Insights 01/05/2026
Can DXA alone capture the full picture of fracture risk?
Each May, Osteoporosis awareness month serves as a critical reminder: osteoporosis is often silent, until a fracture occurs.
Despite widespread use of dual-energy X-ray absorptiometry (DXA) as the standard for bone mineral density (BMD) measurement, a significant gap remains in identifying patients truly at risk.
The reality is straightforward: many patients who experience fragility fractures were never classified as high risk by BMD alone¹.
This raises an important question for clinicians: Are we missing patients who need intervention?
The limitations of DXA in osteoporosis screening
DXA has long been the foundation of osteoporosis diagnosis. It provides a quantitative measure of bone mineral density, which is essential—but leaves a gap.
| What DXA does well | Where the gap remains |
| Standardized BMD measurement | Does not assess bone quality |
| Widely available | Cannot fully capture fracture risk independently |
| Established thresholds | May not fully identify many at-risk patients |
Studies have consistently shown that approximately 50–70% of fragility fractures occur in individuals who do not meet the densitometric definition of osteoporosis (T-score ≤ -2.5)²& ³.
This gap highlights a fundamental issue: Bone strength is not defined by density alone.
Understanding the missing piece: Bone Microarchitecture
Bone strength is driven by two factors:
Bone density (quantity) & Bone microarchitecture (quality)
While DXA measures density, it does not evaluate the internal structure of bone—specifically, the trabecular network that contributes to bone resilience⁴.
What is Trabecular Bone Score (TBS)?
Trabecular Bone Score (TBS) is a validated technology that analyzes DXA images to assess bone microarchitecture.
Unlike BMD, TBS evaluates textural patterns within lumbar spine DXA images, providing insight into bone quality without requiring additional imaging⁵.
Key advantages of TBS:
• Complements existing DXA scans (no additional equipment or scanning required)
• Provides independent fracture risk information
• Enhances clinical decision-making alongside BMD and FRAX
• Seamlessly integrates into current DXA workflows
TBS has been shown to be independently associated with fracture risk and to improve risk prediction when combined with BMD and clinical risk factors⁶ & ⁷.
Guideline perspective: where TBS fits in clinical practice
According to the International Osteoporosis Foundation (IOF), TBS is recognized as a validated measure of bone microarchitecture derived from DXA images⁸.
IOF position statements highlight that:
• TBS provides independent and complementary information to BMD in fracture risk assessment⁸
• TBS can be used alongside clinical risk factors to enhance patient risk stratification⁸
• TBS-adjusted fracture probability can improve risk estimation when integrated with tools like FRAX⁷ & ⁸
This reinforces an important clinical shift: Fracture risk assessment is most effective when both bone quantity and bone quality are considered.
Why TBS Osteo matters in 2026
As healthcare shifts toward preventive care and risk stratification, the need for more precise tools has never been greater.
By going beyond BMD, TBS Osteo empowers clinicians to detect high-risk patients earlier, enhance fracture risk stratification, and make more proactive treatment decisions—helping drive better outcomes in a value-based care environment.
Incorporating TBS into assessment has been shown to reclassify fracture risk in a meaningful proportion of patients, particularly those with osteopenia⁶.
Bridging the gap in fracture risk assessment
The combination of:
- BMD (DXA)
- Clinical risk factors (e.g., FRAX)
- Bone microarchitecture (TBS)
creates a more complete and clinically actionable view of patient risk. The FRAX model itself has been enhanced to incorporate TBS adjustments, further improving fracture prediction accuracy⁷.
This integrated approach is particularly important for:
Osteoporosis Awareness Month is not just about education—it’s about action.
| Opportunity for Healthcare Providers | Key Questions to Consider |
| Reevaluate current screening protocols | Are patients being fully assessed for fracture risk? |
| Expand beyond BMD-only assessments | Are current tools capturing both bone quantity and quality? |
| Adopt tools that improve early detection | Could additional insights change treatment decisions? |
Looking ahead: smarter screening for better outcome
Osteoporosis care is evolving—not by replacing DXA, but by strengthening it. Integrating tools like TBS Osteo into routine practice enables earlier detection of at-risk patients, greater confidence in clinical decision-making, and a meaningful reduction in fractures and their associated costs.
Conclusion
This Osteoporosis Awareness Month, the message is clear:
DXA is essential—but it’s only part of the picture. To truly understand fracture risk, clinicians must look beyond bone density and incorporate tools that assess bone quality.
Because preventing the first fracture starts with seeing the full story.
References
- National Osteoporosis Foundation. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporos Int. 2014.
- Siris ES, Chen YT, Abbott TA, et al. Bone mineral density thresholds for pharmacological intervention to prevent fractures. Arch Intern Med. 2004;164(10):1108–1112.
- Pasco JA, Seeman E, Henry MJ, et al. The population burden of fractures originates in women with osteopenia, not osteoporosis. Osteoporos Int. 2006;17:1404–1409.
- Seeman E, Delmas PD. Bone quality — the material and structural basis of bone strength. N Engl J Med. 2006;354:2250–2261.
- International Osteoporosis Foundation. Trabecular Bone Score (TBS): Clinical Use and Applications.
- McCloskey EV, Odén A, Harvey NC, et al. A meta-analysis of trabecular bone score in fracture risk prediction. Osteoporos Int. 2016;27:517–530.
- McCloskey EV, Odén A, Harvey NC, Leslie WD, Hans D, Kanis JA. Adjusting fracture probability by trabecular bone score. J Bone Miner Res. 2015;30(5):940–948.
- International Osteoporosis Foundation. Trabecular Bone Score (TBS): Position Statements and Clinical Guidance. 2023.
