Standard radiography: untapped potential in the assessment of osteoporotic fracture risk

Abstract

Background: Assessment of osteoporotic fracture risk is based primarily on bone mineral density (BMD) measurements using dual X-ray absorptiometry (DXA).

Methods: However, recent evidence indicates that the method is insufficient for accurate individual risk assessment; in addition to methodological inaccuracies related to DXA, the mechanical strength of bone is influenced not only by low BMD but also by other factors that are not captured by DXA.

Results: DXA-based BMD can provide information on the amount of bone but does not elucidate bone structure, which is significant for bone mechanical strength and for fracture risk. In order to achieve more a comprehensive assessment of fracture risk, recent efforts have been directed toward imaging techniques by which bone structural changes can be observed. In addition to novel three-dimensional imaging techniques, analysis of plain radiographs has also been investigated with promising results.

Conclusion: As plain radiographs are cheap and widely available, it was considered of interest to discover how well plain radiography could be utilised for the assessment of bone mechanical competence and fracture risk. In this article, we review studies related to radiographic assessment of fracture risk in order to show the potential of this conventional methodology for screening subjects at risk.

Key points: • Conventional radiography has sufficient theoretical requirements for assessment of bone structure. • Bone geometry and trabecular structure can be depicted by and evaluated from standard radiographs. • Texture-based analysis of radiographs discriminates postmenopausal women with and without fractures. • Such analysis can also predict fractures in individuals without frank osteoprosis. • Imaging and subsequent analysis should become more standardised to allow structural quantification.