fracture risk assessment (how to assess)

Last reviewed 08/2020

Methods of fracture risk assessment

  • estimate absolute risk when assessing risk of fracture (for example, the predicted risk of major osteoporotic or hip fracture over 10 years, expressed as a percentage)

  • NICE suggest that clinicians use either FRAX (without a bone mineral density [BMD] value if a dual energy X-ray absorptiometry [DXA] scan has not previously been undertaken) or QFracture, within their allowed age ranges, to estimate 10-year predicted absolute fracture risk when assessing risk of fracture
    • consider people to be at high risk if above the upper age limits defined by the tools (1)

  • interpret the estimated absolute risk of fracture in people aged over 80 years with caution, because predicted 10-year fracture risk may underestimate their short-term fracture risk (1)

  • measurement of BMD should not be routinely used to assess fracture risk without prior assessment using FRAX (without a BMD value) or QFracture

  • following risk assessment with FRAX (without a BMD value) or QFracture, consider measuring BMD with DXA in people whose fracture risk is in the region of an intervention threshold for a proposed treatment, and recalculate absolute risk using FRAX with the BMD value

  • before starting treatments that may have a rapid adverse effect on bone density (for example, sex hormone deprivation for treatment for breast or prostate cancer) then consider measuring BMD with DXA

  • measure BMD to assess fracture risk in people aged under 40 years who have a major risk factor, such as history of multiple fragility fracture, major osteoporotic fracture, or current or recent use of high-dose oral or high-dose systemic glucocorticoids (more than 7.5 mg prednisolone or equivalent per day for 3 months or longer)

  • consider recalculating fracture risk in the future:
    • if the original calculated risk was in the region of the intervention threshold for a proposed treatment and only after a minimum of 2 years, or when there has been a change in the person's risk factors

  • when assessing risk score results then take into account that risk assessment tools may underestimate fracture risk in certain circumstances, for example if a person:
    • has a history of multiple fractures
    • has had previous vertebral fracture(s)
    • has a high alcohol intake
    • is taking high-dose oral or high-dose systemic glucocorticoids (more than 7.5 mg prednisolone or equivalent per day for 3 months or longer)
    • has other causes of secondary osteoporosis
      • causes of secondary osteoporosis include
        • endocrine (hypogonadism in either sex including untreated premature menopause and treatment with aromatase inhibitors or androgen deprivation therapy; hyperthyroidism; hyperparathyroidism; hyperprolactinaemia; Cushing's disease; diabetes),
        • gastrointestinal (coeliac disease; inflammatory bowel disease; chronic liver disease; chronic pancreatitis; other causes of malabsorption),
        • rheumatological (rheumatoid arthritis; other inflammatory arthropathies),
        • haematological (multiple myeloma; haemoglobinopathies; systemic mastocytosis),
        • respiratory (cystic fibrosis; chronic obstructive pulmonary disease),
        • metabolic (homocystinuria),
        • chronic renal disease and
        • immobility(due for example to neurological injury or disease)

    • also consider that fracture risk can be affected by factors that may not be included in the risk tool, for example living in a care home or taking drugs that may impair bone metabolism (such as anti-convulsants, selective serotonin reuptake inhibitors, thiazolidinediones, proton pump inhibitors and antiretroviral drugs


  • FRAX, the WHO fracture risk assessment tool, can be used for people aged between 40 and 90 years, either with or without BMD values, as specified

  • QFracture can be used for people aged between 30 and 84 years. BMD values cannot be incorporated into the risk algorithm

  • An intervention threshold is the level of risk at which an intervention is recommended