Bone fracture is related to bone strength. In current clinical practice, bone mineral density (BMD) is used as the prime indicator of bone strength, not infrequently at the neglect of an even more pertinent measure of reduced bone strength, namely the radiographic presence of an insufficiency fracture. Bone strength depends not just on BMD but also on bone quality, which relates to such factors as bone architecture, turnover, mineralization, and cellularity. The high resolution available from current imaging techniques, particularly computed tomography and magnetic resonance imaging, along with advanced analytical software has greatly enhanced evaluation of bone architecture and strength. This has improved our knowledge of the pathophysiological processes behind osteoporosis and its treatment beyond that provided by BMD measurement alone. Although still in the experimental stage, these techniques will no doubt be incorporated into clinical practice, leading to a more tailored approach to the screening, monitoring, and treatment of osteoporosis.