8.8 Fracture History, Clinical Risk & Imaging

Build a fracture and risk history

Record the site, age at fracture, date, mechanism and any suggestion of a local lesion. Ask about previous imaging because vertebral fractures may be identified on studies done for another reason. Ask about parental hip fracture separately from the patient's own prior fracture. Dates, sites and the number of prior fractures matter for clinical assessment even when a risk calculator uses a single yes/no field.

The same measured BMD does not imply the same risk at different ages. Record age, sex and menopausal history, and choose the population model and reference appropriate to the question. A DXA diagnostic reference population differs from a fracture risk model. ISCD uses a uniform female hip T-score reference for eligible adults and may use self-reported ethnicity for the Z-score when adequate population data exist. A risk model's population calibration reflects observed fracture rates and mortality, rather than an individual's inherited destiny. Record the model and the actual clinical inputs. Age and menopausal history also affect how the DXA result should be expressed and interpreted.

Ask about current smoking, alcohol quantity and pattern, dietary calcium and vitamin D sources, and activity level. Collect current smoking and alcohol in the way the calculator defines them. Past smoking, nutrition, activity and falls can still matter clinically even when a field does not accept them. Review medicines, including prednisone dose and duration, and conditions such as rheumatoid arthritis, endocrine disorders, and impaired absorption. Distinguish falls due to a trip from episodes associated with loss of consciousness or new weakness. Those histories can lead to different clinical assessments.

Select imaging based on the question

Use DXA for valid skeletal BMD and clinical fracture risk assessment. Lateral spine radiographs or DXA-based vertebral fracture assessment (VFA) answer a different question about vertebral shape and fracture. Inspect prior studies and note the limitations of any existing images. A deformity in the setting of known relevant malignancy, unexplained focal pain or a lytic or sclerotic lesion can warrant additional diagnostic imaging. The method depends on the concern. A DXA T-score cannot establish a focal diagnosis or distinguish an acute fracture from a chronic deformity.

Worked height-loss assessment

A 71-year-old woman now measures 159.0 cm using a stadiometer. Her documented young-adult height was 164.5 cm and her height two years earlier was 161.5 cm. Historical loss is 5.5 cm. Prospective loss is 2.5 cm. Her valid femoral neck T-score is −1.6. Under the ISCD adult position, she meets the T-score criterion and the age and historical height triggers for lateral spine imaging. In the BHOF guidance, prospective height loss of at least 0.8 inches is a separate reason to consider vertebral imaging in the relevant population.

Measure standing height consistently and record the source of the comparison. Use a stadiometer when feasible and note when posture, inability to stand or a different measurement method limits the comparison. Historical loss uses the best available peak-height estimate. Prospective loss requires a previous measured height, so document the dates and methods if known. Postural and musculoskeletal findings, including kyphosis, can raise suspicion but do not diagnose fracture. In another patient whose only finding is prospective height loss, do not count it as the ISCD historical height trigger. Check the applicable guidance and clinical context. If imaging confirms a vertebral fragility fracture, reassess clinical risk without relabeling the original T-score as a different densitometric category.

ISCD Adult Official Positions · U.S. BHOF Clinician’s Guide · FRAXplus questionnaire · High-trauma fracture cohort · ACR vertebral compression fracture guidance