Advancing fracture risk prediction: established assessment tools and emerging HR-pQCT-based approaches

Osteoporotic fractures, or fragility fractures, pose a substantial global healthcare burden. Individuals who experience them report significant declines in their quality of life. Identifying individuals at risk of fragility fractures is key to reducing the future fracture burden. However, due to demographic shifts, the proportion of older adults is growing globally. As fracture risk rises with age, an increase in the incidence of osteoporotic fractures is also anticipated. However, existing screening initiatives and fracture risk assessment tools remain challenged in identifying individuals at risk of experiencing osteoporotic fractures. To adapt to the predicted incidence of fragility fractures, knowledge of established fracture risk tools and emerging approaches is needed to inform the development of future fracture prediction tools. Correspondingly, this narrative review presents an overview of established fracture risk assessment tools, including FRAX, FRAXplus, CAROC, Garvan, and QFracture, which use clinical risk factors and frequently, bone mineral density estimates, to produce fracture risk prediction scores. We review methods, advantages, limitations, and performance of the established tools in detail. Later, we highlight emerging fracture risk assessment tools that integrate direct assessment of bone using high-resolution peripheral quantitative computed tomography (HR-pQCT). The advantages and limitations of the emerging HR-pQCT-based fracture risk assessment models are also reviewed in detail. Finally, future directions for fracture risk assessment tool development are discussed.