{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,5]],"date-time":"2026-10-05T16:56:30Z","timestamp":1791219390147,"version":"4.1.0"},"reference-count":149,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,10,5]],"date-time":"2026-10-05T00:00:00Z","timestamp":1791158400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Endocrinol."],"abstract":"<jats:p>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.<\/jats:p>","DOI":"10.3389\/fendo.2026.1916830","type":"journal-article","created":{"date-parts":[[2026,10,5]],"date-time":"2026-10-05T16:10:30Z","timestamp":1791216630000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Advancing fracture risk prediction: established assessment tools and emerging HR-pQCT-based approaches"],"prefix":"10.3389","volume":"17","author":[{"given":"Raveen K.","family":"Sidhu","sequence":"first","affiliation":[{"name":"McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary","place":["Calgary, AB, Canada"]},{"name":"Department of Biomedical Engineering, Schulich School of Engineering, University of Calgary","place":["Calgary, AB, Canada"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Meghan G.","family":"Donaldson","sequence":"additional","affiliation":[{"name":"McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary","place":["Calgary, AB, Canada"]},{"name":"Department of Radiology, Cumming School of Medicine, University of Calgary","place":["Calgary, AB, Canada"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Steven K.","family":"Boyd","sequence":"additional","affiliation":[{"name":"McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary","place":["Calgary, AB, Canada"]},{"name":"Department of Biomedical Engineering, Schulich School of Engineering, University of Calgary","place":["Calgary, AB, Canada"]},{"name":"Department of Radiology, Cumming School of Medicine, University of Calgary","place":["Calgary, AB, Canada"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,10,5]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","DOI":"10.7861\/clinmedicine.14-2-187","article-title":"Osteoporosis and fracture risk in older people","volume":"14","author":"Coughlan","year":"2014","journal-title":"Clin Med"},{"key":"B2","doi-asserted-by":"publisher","first-page":"61","DOI":"10.1177\/1759720X11430858","article-title":"Aging and bone loss: new insights for the clinician","volume":"4","author":"Demontiero","year":"2012","journal-title":"Ther Adv Musculoskelet Dis"},{"key":"B3","doi-asserted-by":"publisher","DOI":"10.1503\/cmaj.221647","article-title":"Clinical practice guideline for management of osteoporosis and fracture prevention in Canada: 2023 update","volume":"195","author":"Morin","year":"2023","journal-title":"Can Med Assoc J"},{"key":"B4","doi-asserted-by":"publisher","DOI":"10.1038\/bonekey.2012.102","article-title":"Aging mechanisms in bone","volume":"1","author":"Almeida","year":"2012","journal-title":"BoneKEy Rep"},{"key":"B5","doi-asserted-by":"publisher","DOI":"10.1002\/jbmr.1952","article-title":"Progressively increasing fracture risk with advancing age after initial incident fragility fracture: The Troms\u00f8 Study","volume":"28","author":"Ahmed","year":"2013","journal-title":"J Bone Miner Res"},{"key":"B6","doi-asserted-by":"publisher","DOI":"10.1093\/jbmr\/zjae119","article-title":"Goal-directed osteoporosis treatment: ASBMR\/BHOF task force position statement 2024","volume":"39","author":"Cosman","year":"2024","journal-title":"J Bone Miner Res"},{"key":"B7","doi-asserted-by":"publisher","first-page":"37","DOI":"10.1007\/s11657-020-0699-6","article-title":"Quality of life after fragility fracture in the Russian Federation: results from the Russian arm of the International Cost and Utility Related to Osteoporotic Fractures Study (ICUROS)","volume":"15","author":"Lesnyak","year":"2020","journal-title":"Arch Osteoporos"},{"key":"B8","doi-asserted-by":"publisher","DOI":"10.1002\/jbmr.3666","article-title":"Incident fragility fractures have a long-term negative impact on health-related quality of life of older people: the canadian multicentre osteoporosis study","volume":"34","author":"Borhan","year":"2019","journal-title":"J Bone Miner Res"},{"key":"B9","doi-asserted-by":"publisher","DOI":"10.1007\/s00198-017-4317-4","article-title":"Quality of life for up to 18 months after low-energy hip, vertebral, and distal forearm fractures\u2014results from the ICUROS","volume":"29","author":"Svedbom","year":"2018","journal-title":"Osteoporos Int"},{"key":"B10","doi-asserted-by":"publisher","DOI":"10.1016\/j.injury.2026.113195","article-title":"Encouraging recovery or avoiding risk? 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