Osteoporosis has a frustrating habit of staying quiet. There may be no pain, no obvious symptoms and no clear warning that bone strength is declining. For many people, the first real indication that something is wrong is a fracture — often after a fall or incident that would not normally be expected to cause a healthy bone to break.
That is why osteoporosis care is not only about asking whether someone has low bone density. Increasingly, the more useful question is: How likely is this person to sustain a fracture?
This November, NOFSA is focusing on Know Your Risk. FRAX It. The aim is simple: to encourage people to understand that fracture risk is personal, influenced by a number of different factors, and worth discussing before the first — or next — fracture occurs. One of the tools healthcare professionals can use to help answer that question is FRAX®, the Fracture Risk Assessment Tool.
Looking beyond bone density
Bone mineral density remains an important part of osteoporosis assessment, but it is only one part of the picture. Two people can have similar bone-density results and still have very different fracture risks. Age matters. A previous fracture matters. Family history matters. Certain medications and medical conditions matter too.
FRAX brings several of these factors together to estimate a person’s 10-year probability of sustaining a hip fracture or a major osteoporotic fracture.
Major osteoporotic fractures include fractures of the hip, spine, forearm and shoulder. This broader way of looking at fracture risk is important because osteoporosis is not simply a number on a DXA report. What ultimately matters is the likelihood that fragile bones will result in a fracture that affects mobility, independence and quality of life.
What does FRAX take into account?
The FRAX calculation considers a combination of clinical information.This includes age, sex, height and weight, whether a person has had a previous fracture, whether a parent fractured a hip, current smoking, glucocorticoid use, rheumatoid arthritis, causes of secondary osteoporosis and higher alcohol intake. Femoral-neck bone mineral density can also be included when it is available.
Together, these factors help provide a more individualised picture of fracture probability. FRAX is generally used in people between the ages of 40 and 90. Importantly, it is a risk-assessment tool — not a diagnosis. A FRAX result does not replace a medical consultation, DXA scan when indicated, or the clinical judgement of a healthcare professional.
You do not necessarily need a DXA scan first
One useful feature of FRAX is that it can be calculated with or without a bone-density result. That means a healthcare professional may first use clinical risk factors to estimate fracture probability and then decide whether a DXA scan would add useful information.
In some patients, the initial FRAX result may place them in an intermediate-risk category. A DXA scan can then be performed and the calculation repeated with bone mineral density included, helping to refine the assessment. Other patients may already have clinical circumstances that place them at higher risk and require a different approach. This is why fracture-risk assessment should not be treated as a DIY score or a single number to interpret in isolation. It is part of a bigger clinical decision-making process.
One previous fracture can change the conversation
A fracture after the age of 50 deserves attention — particularly if it occurred after a relatively minor fall or low-impact incident. Too often, the broken bone is treated successfully while the reason behind the fracture is never explored. Yet a previous fragility fracture is one of the strongest warning signs that future fracture risk may be increased.
If you have fractured after a minor fall, it is worth asking: Could osteoporosis have contributed to this fracture? And just as importantly: What is my risk of another one?
A fracture should not automatically be dismissed as bad luck or an inevitable part of ageing. In some cases, it may be an opportunity to identify underlying bone fragility and take action before another fracture occurs.
Family history matters more than many people realise
Your own medical history is important, but so is your family history. FRAX specifically takes a parental history of hip fracture into account. If your mother or father fractured a hip, particularly later in life, that information may be relevant to your own risk assessment. It is a good reminder that family medical history is not just something to discuss when talking about heart disease, diabetes or cancer. Bone health belongs in that conversation too.
“But I feel healthy” This is one of the challenges with osteoporosis. Feeling well does not necessarily mean that your bones are strong.You cannot feel declining bone mineral density. You may still exercise, work, travel and live an active life while changes in bone strength are happening silently.
That is why waiting for symptoms is not an effective bone-health strategy. Risk assessment is about looking ahead — identifying factors that could increase the likelihood of fracture and deciding whether further investigation or intervention is appropriate.
FRAX does not capture everything
No risk-assessment tool can tell the whole story. FRAX is valuable, but clinical judgement remains essential.
For example, frequent falls can have a significant impact on someone’s real-life fracture risk. The number of previous fractures and how recently they occurred may also matter. Certain medical conditions, medication doses and other factors may require additional consideration. Newer developments such as FRAXplus allow some of these additional factors to be taken into account. The important message for patients is that a FRAX percentage is not the final answer.
It is information that helps guide the next conversation.
What happens after your risk is calculated?
Once fracture probability has been estimated, a healthcare professional can interpret the result together with your medical history, clinical risk factors and, where appropriate, your DXA result. Depending on the outcome, a person may be considered at low, intermediate, high or very high fracture risk. For someone at low risk, lifestyle guidance and future reassessment may be appropriate. Someone at intermediate risk may benefit from a DXA scan to refine the assessment further.
Patients at higher or very high risk may require further investigation, treatment or specialist input. The decision is individual. A number alone should never determine treatment without the wider clinical context.
Knowing your risk gives you something to act on
Fracture-risk assessment is not only about medication. Understanding your risk can lead to important conversations about the things that help support stronger bones and reduce the likelihood of falls and fractures. That may include weight-bearing and muscle-strengthening exercise, balance training, adequate calcium and protein intake, vitamin D, smoking cessation, alcohol intake, maintaining a healthy body weight and reviewing medications that may affect bone health.
Some risk factors cannot be changed. You cannot change your age, your family history or the fact that a previous fracture has already happened. But knowing those factors exist can help you and your healthcare provider make better decisions about the factors that can be addressed.
We monitor so many things — why not fracture risk?
Many people know their blood pressure. They know their cholesterol levels. Some regularly check blood glucose or monitor other indicators of long-term health. Yet very few people could answer the question:
What is my risk of breaking a bone over the next 10 years?
For a condition that often remains silent until a fracture happens, that is a question worth asking. This November, NOFSA is encouraging South Africans to become more aware of their osteoporosis risk factors and to speak to a healthcare professional about fracture-risk assessment where appropriate. If you are between the ages of 40 and 90, particularly if you have additional risk factors, ask whether FRAX may form part of your assessment.
And if you have already experienced a fragility fracture, do not assume that treating the break is the end of the story. The fracture may be telling you something important about your bone health.
Know your risk. Ask the question. FRAX it.
Because understanding your fracture risk today may help protect your mobility, independence and quality of life tomorrow. For more information on osteoporosis, fracture prevention and bone health, visit www.osteoporosis.org.za.
This article is intended for educational purposes and does not replace individual assessment, diagnosis or treatment by a qualified healthcare professional.
