Osteoporosis International

, Volume 16, Issue 6, pp 581–589 | Cite as

Assessment of fracture risk

  • John A. KanisEmail author
  • Frederik Borgstrom
  • Chris De Laet
  • Helena Johansson
  • Olof Johnell
  • Bengt Jonsson
  • Anders Oden
  • Niklas Zethraeus
  • Bruce Pfleger
  • Nikolai Khaltaev


The diagnosis of osteoporosis is based on the measurement of bone mineral density (BMD). There are a number of clinical risk factors that provide information on fracture risk over and above that given by BMD. The assessment of fracture risk thus needs to be distinguished from diagnosis to take account of the independent value of the clinical risk factors. These include age, a prior fragility fracture, a parental history of hip fracture, smoking, use of systemic corticosteroids, excess alcohol intake and rheumatoid arthritis. The independent contribution of these risk factors can be integrated by the calculation of fracture probability with or without the use of BMD. Treatment can then be offered to those identified to have a fracture probability greater than an intervention threshold.


Case-finding Clinical risk factors Fracture probability Intervention threshold 


  1. 1.
    Anonymous (1993) Consensus development conference: diagnosis, prophylaxis and treatment of osteoporosis. Am J Med 94:646–650CrossRefPubMedGoogle Scholar
  2. 2.
    Kanis JA, Delmas P, Burckhardt P, Cooper C, Torgerson D, on behalf of the European Foundation for Osteoporosis and Bone Disease (1997) Guidelines for diagnosis and management of osteoporosis. Osteoporos Int 7:390–406PubMedGoogle Scholar
  3. 3.
    Royal College of Physicians (1999) Clinical guidelines for the prevention and treatment of osteoporosis. RCP, LondonGoogle Scholar
  4. 4.
    National Osteoporosis Foundation (1998) Analyses of the effectiveness and cost of screening and treatment strategies for osteoporosis: a basis for development of practice guidelines. Osteoporos Int 8 (suppl 4):1–88CrossRefGoogle Scholar
  5. 5.
    Kanis JA, Glüer CC for the Committee of Scientific Advisors, International Osteoporosis Foundation (2000) An update on the diagnosis and assessment of osteoporosis with densitometry. Osteoporos Int 11:192–202CrossRefPubMedGoogle Scholar
  6. 6.
    Kanis JA, Black D, Cooper C, Dargent P, Dawson-Hughes B, De Laet C et al. (2002) A new approach to the development of assessment guidelines for osteoporosis. Osteoporos Int 13:527–536CrossRefPubMedGoogle Scholar
  7. 7.
    World Health Organisation (1994) Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Technical Report Series 843. WHO, GenevaGoogle Scholar
  8. 8.
    Kanis JA, Melton LJ, Christiansen C, Johnston CC, Khaltaev N (1994) The diagnosis of osteoporosis. J Bone Miner Res 9:17–1141PubMedGoogle Scholar
  9. 9.
    Kanis JA, Johnell O, Oden A, Jonsson B, De Laet C, Dawson A (2000) Risk of hip fracture according to the World Health Organization criteria for osteoporosis and osteopenia. Bone 27:585–590CrossRefPubMedGoogle Scholar
  10. 10.
    Committee for Proprietary Medicinal Products (CPMP) (1997) Note for guidance on involutional osteoporosis in women. European Agency for the Evaluation of Medicinal Products, London (CPMP/EWP/552/95)Google Scholar
  11. 11.
    World Health Organisation (1998) Guidelines for preclinical evaluation and clinical trials in osteoporosis. WHO, GenevaGoogle Scholar
  12. 12.
    Liu, Z, Piao J, Pang L, Qing X et al. (2002) The diagnostic criteria for primary osteoporosis and the incidence of osteoporosis in China. J Bone Miner Metab 20:181–189CrossRefPubMedGoogle Scholar
  13. 13.
    Kanis JA, Johnell O, Oden A, De Laet C, Mellstrom D (2001) Diagnosis of osteoporosis and fracture threshold in men. Calcif Tissue Int 69:218–221PubMedGoogle Scholar
  14. 14.
    DeLaet CEDH, Van Hout BA, Burger H, Hofman A, Weel AEAM, Pols HAP (1998) Hip fracture prediction in elderly men and women: validation in the Rotterdam Study. J Bone Miner Res 13:1587–1593PubMedGoogle Scholar
  15. 15.
    Ross P, Huang C, Davis J, Imose K, Yates J, Vogel J, Wasnich R (1995) Predicting vertebral deformity using bone densitometry at various skeletal sites and calcaneous ultrasound. Bone 16:325–332CrossRefPubMedGoogle Scholar
  16. 16.
    Lunt M, Felsenberg D, Reeve J, Benevolenskaya L, Cannata J, Dequeker J (1997) Bone density variation and its effect on risk of vertebral deformity in men and women studied in thirteen European Centres: the EVOS Study. J Bone Miner Res 12:1883–1894PubMedGoogle Scholar
  17. 17.
    Faulkner KG, von Stetten E, Miller P (1999) Discordance in patient classification using T-scores. J Clin Densitom 2:343–350CrossRefPubMedGoogle Scholar
  18. 18.
    Arlot ME, Sornay-Rendu E, Garnero P, Vey-Marty B, Delmas PD (1997) Apparent pre- and postmenopausal bone loss evaluated by DXA at different skeletal sites in women: the OFELY cohort. J Bone Miner Res 12:683–690Google Scholar
  19. 19.
    Marshall D, Johnell O, Wedel H (1996) Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ 312:1254–1259PubMedGoogle Scholar
  20. 20.
    Cooper C, Aihie A (1994) Osteoporosis: recent advances in pathogenesis and treatment. Q J Med 87:203–209PubMedGoogle Scholar
  21. 21.
    Kanis JA, Johnell O, Oden A, De Laet C, Jonsson B, Dawson A (2001) Ten year risk of osteoporotic fracture and the effect of risk factors on screening strategies. Bone 30:251–258CrossRefGoogle Scholar
  22. 22.
    Kanis JA, Johnell O, Oden A, Jonsson B, Dawson A, Dere W (2000) Risk of hip fracture in Sweden according to relative risk: an analysis applied to the population of Sweden. Osteoporos Int 11:120–127PubMedGoogle Scholar
  23. 23.
    Kanis JA, Johnell O, Oden A, Jonsson B, DeLaet C, Dawson A (2000) Prediction of fracture from low bone mineral density measurements overestimates risk. Bone 26:387–391CrossRefPubMedGoogle Scholar
  24. 24.
    Oden A, Dawson A, Dere W, Johnell O, Jonsson B, Kanis JA (1999) Lifetime risk of hip fracture is underestimated. Osteoporos Int 8:599–603CrossRefGoogle Scholar
  25. 25.
    Hui SL, Slemenda CW, Johnston CC (1988) Age and bone mass as predictors of fracture in a prospective study. J Clin Invest 81:1804–1809PubMedGoogle Scholar
  26. 26.
    Kanis JA, Johnell O, Oden A, Dawson A, De Laet C, Jonsson B (2001) Ten year probabilities of osteoporotic fractures according to BMD and diagnostic thresholds. Osteoporos Int 12:989–995CrossRefPubMedGoogle Scholar
  27. 27.
    Kanis JA (2002) Diagnosis of osteoporosis and assessment of fracture risk. Lancet 359:1929–1936CrossRefPubMedGoogle Scholar
  28. 28.
    Johnell O, Gullberg B, Kanis JA et al. (1995) Risk factors for hip fracture in European women: the MEDOS Study. J Bone Miner Res 10:1802–1815PubMedGoogle Scholar
  29. 29.
    Cummings SR, Nevitt MC, Browner WS, Stone K, Fox KM, Ensrud KE, Cauley J, Black D, Vogt TM (1995) Risk factors for hip fracture in white women. N Engl J Med 332:767–773CrossRefPubMedGoogle Scholar
  30. 30.
    Compston JE (1992) Risk factors for osteoporosis. Clin Endocrinol 36:223–224Google Scholar
  31. 31.
    Ribot C, Pouilles JM, Bonneu M, Tremollieres F (1992) Assessment of the risk of postmenopausal osteoporosis using clinical risk factors. Clin Endocrinol 36:225–228Google Scholar
  32. 32.
    Kanis JA, Johnell O, Gullberg B, Allander A, Elffors L, Dequeker J et al. (1999) Risk factors for hip fracture in European men. The MEDOS study. Osteoporos Int 9:45–54CrossRefPubMedGoogle Scholar
  33. 33.
    Nguyen T, Sambrook SP, Kelly P, Jones G, Freund J, Eisman J (1993) Prediction of osteoporotic fractures by postural instability and bone density. BMJ 307:1111–1115PubMedGoogle Scholar
  34. 34.
    Poor G, Atkinson EJ, O’Fallon WM, Melton LJ III (1995) Predictors of hip fractures in elderly men. J Bone Miner Res 10:1900–1907PubMedGoogle Scholar
  35. 35.
    Kanis JA, McCloskey EV (1996) Evaluation of the risk of hip fracture. Bone 18:127–132CrossRefGoogle Scholar
  36. 36.
    Kanis JA, De Laet C, Delmas P, Garnero P, Johansson H, Johnell O, Kroger H, McCloskey EV, Mellstrom D, Melton LJ, Oden A, Pols H, Reeve J, Silman A, Tenenhouse A (2004) A meta-analysis of previous fracture and fracture risk. Bone 35:375–382CrossRefGoogle Scholar
  37. 37.
    Kanis JA, Johansson H, Oden A, Johnell O, De Laet C, Melton LJ, Tenenhouse A, Reeve J, Silman AJ, Pols HAP, Eisman JA, McCloskey EV, Mellstrom D (2004) A meta-analysis of prior corticosteroid use and fracture risk. J Bone Miner Res 19:893–899PubMedGoogle Scholar
  38. 38.
    Kanis JA, Johnell O, Oden A, Johansson H, De Laet C, Eisman JA, Fujiwara S, Kroger H, McCloskey EV, Mellstrom D, Melton LJ, Pols H, Reeve J, Silman AJ, Tenenhouse A (2004) Smoking and fracture risk: a meta-analysis. Osteoporos Int (in press)Google Scholar
  39. 39.
    Kanis JA, Johansson H, Oden A, Johnell O, De Laet C, Eisman JA, McCloskey EV, Mellstrom D, Melton LJ, Pols HAP, Reeve J, Silman AJ, Tenenhouse A (2004) A family history of fracture and fracture risk: a meta-analysis. Bone (in press)Google Scholar
  40. 40.
    De Laet C, Kanis JA, Oden A, Johansson H, Johnell O, Delmas P et al. (2004) Body mass index as a predictor of fracture risk: A meta-analysis. Osteoporos Int (in press)Google Scholar
  41. 41.
    Kanis JA, Johansson H, Johnell O, Oden A, De Laet C, Eisman JA, Pols H, Tenenhouse A (2004) Alcohol intake as a risk factor for fracture. Osteoporos Int (in press)Google Scholar
  42. 42.
    Van Staa TP, Leufkens HGM, Abenhaim L, Zhang B, Cooper C (2001) Use of oral corticosteroids and risk of fractures. J Bone Miner Res 15:993–1000Google Scholar
  43. 43.
    Van Staa TP, Leufkens HGM, Cooper C (2002) The epidemiology of corticosteroid-induced osteoporosis: a meta-analysis. Osteoporos Int 13:777–787PubMedGoogle Scholar
  44. 44.
    Klotzbuecher CM, Ross PD, Landsman PB, Abbot TA, Berger M (2000) Patients with prior fractures have increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res 15:721–727PubMedGoogle Scholar
  45. 45.
    Ross PD, Genant HK, Davis JW, Miller PD, Wasnich RD (1993) Predicting vertebral fracture incidence from prevalent fractures and bone density among non black, osteoporotic women. Osteoporos Int 3:120–126PubMedGoogle Scholar
  46. 46.
    Delmas PD (ed) (2000) The use of biochemical markers of bone turnover in the management of post-menopausal osteoporosis. Osteoporosis Int 11:S1–S76CrossRefGoogle Scholar
  47. 47.
    Garnero P, Sornay-Rendu E, Claustrat B, Delmas PD (2000) Biochemical markers of bone turnover, endogenous hormones and the risk of fractures in postmenopausal women. The Ofely study. J Bone Miner Res 15:1526–1536PubMedGoogle Scholar
  48. 48.
    Garnero P, Hauser E, Chapuy MC, Marcelli C, Grandjean H, Muller C, Cormier C, Breard G, Meunier PJ, Delmas PD (1996) Markers of bone turnover predict hip fractures in elderly women. The EPIDOS prospective study. J Bone Miner Res 11:1531–1538PubMedGoogle Scholar
  49. 49.
    Hansen M, Overgaard K, Riis B, Christiansen C (1991) Role of peak bone mass and bone loss in postmenopausal osteoporosis: 12 year study. BMJ 303:961–964PubMedGoogle Scholar
  50. 50.
    Johnell O, Oden A, DeLaet C, Garnero P, Delmas PD, Kanis JA (2002) Biochemical indices of bone turnover and the assessment of fracture probability. Osteoporos Int 13:523–526CrossRefPubMedGoogle Scholar
  51. 51.
    Dyslipidaemia Advisory Group on behalf of the Scientific Committee of the National Heart Foundation of New Zealand (1996) National Heart Foundation Clinical Guidelines for the assessment and management of dyslipidaemia. N Z Med J 109:224–232PubMedGoogle Scholar
  52. 52.
    Kanis JA, Dawson A, Oden A, Johnell O, De Laet C, Jonsson B (2001) Cost-effectiveness of preventing hip fracture in the general female population. Osteoporos Int 12:356–361CrossRefPubMedGoogle Scholar
  53. 53.
    Kanis JA, Johnell O, Oden A, Borgstrom F, Zethraeus N, De Laet C, Jonsson B (2004) The risk and burden of vertebral fractures in Sweden. Osteoporos Int 15:20–26CrossRefPubMedGoogle Scholar
  54. 54.
    Kanis JA, Oden A, Johnell O, Jonsson B, De Laet C, Dawson A (2001) The burden of osteoporotic fractures: a method for setting intervention thresholds. Osteoporos Int 12:417–427CrossRefPubMedGoogle Scholar
  55. 55.
    Kanis JA, Johnell O, Oden A, De Laet C, Oglesby A, Jonsson B (2002) Intervention thresholds for osteoporosis. Bone 13:26–31Google Scholar
  56. 56.
    Kanis JA, Barton IP, Johnell O (2004) Risedronate decreases fracture risk in patients selected solely on the basis of prior vertebral fracture. Osteoporos Int (in press)Google Scholar
  57. 57.
    Johansson H, Oden A, Johnell O, Jonsson B, De Laet C, Oglesby A, McCloskey EV, Kayan K, Jalava T, Kanis JA (2004) Optimisation of BMD measurements to identify high risk groups for treatment—a test analysis. J Bone Miner Res 19:906–913PubMedGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2004

Authors and Affiliations

  • John A. Kanis
    • 1
    Email author
  • Frederik Borgstrom
    • 2
  • Chris De Laet
    • 3
  • Helena Johansson
    • 4
  • Olof Johnell
    • 5
  • Bengt Jonsson
  • Anders Oden
    • 4
  • Niklas Zethraeus
    • 6
  • Bruce Pfleger
    • 7
  • Nikolai Khaltaev
    • 8
  1. 1.Centre for Metabolic Bone Diseases (WHO Collaborating Centre)University of Sheffield Medical SchoolSheffieldUK
  2. 2.Stockholm Health EconomicsStockholmSweden
  3. 3.Scientific Institute of Public HealthBrusselsBelgium
  4. 4.RomelandaSweden
  5. 5.Department of OrthopaedicsMalmo General HospitalMalmoSweden
  6. 6.Centre for HealthStockholm School of EconomicsStockholmSweden
  7. 7.AtlantaUSA
  8. 8.GenevaSwitzerland

Personalised recommendations