The management of osteoporosis has been transformed over the past quarter century. The advent of non-invasive methods for assessing bone mineral density (BMD), coupled with the emergence of agents that retard involutional bone loss and prevent fracture, have promoted a disorder that was thought to be an inevitable consequence of ageing to the ranks of those amenable to effective targeted intervention. The linked paper by Hippisley-Cox and Coupland (doi:10.1136/bmj.e3427) evaluates a new tool for assessing the risk of osteoporotic fracture.1 What role do such tools play in helping prevent osteoporosis and its consequences?

In 1994 the World Health Organization generated a clinical definition of osteoporosis based on a BMD T score of −2.5 or lower.2 Although this definition performs well at a population level, the multifactorial nature of fracture pathogenesis and the fact that many people with fractures have a T score above −2.5 meant that initial algorithms for targeting treatment (such as those developed by the Royal College of Physicians) indicated intervention for some patients at relatively low risk of fracture. A major step forward was the publication in 2008 of a WHO algorithm (FRAX),3 which estimated the 10 year …