NICE publishes guideline on assessing risk of fragility fracture in adults

The National Institute for Health and Care Excellence (NICE) today (8 August) publishes final guidance on assessing the risk of fragility fracture in adults. The short clinical guideline advises on methods to help clinicians assess who might be at risk of a fragility fracture, and will support them in identifying who will benefit from treatments that help prevent such fractures occurring.

Fragility fractures are often linked to osteoporosis - the condition where bone tissue deteriorates and the bone density is lower than normal. This can lead to the bone fracturing as a result of a force that wouldn't normally cause a break in a healthy bone, such as a fall from a standing height or less. Each year in the UK over 300,000 people are seen in hospital because of fragility fractures, with the most common sites for these fractures being the spinal vertebrae, hip and wrist.

Osteoporotic fragility fractures can cause a great deal of pain, disability and reduction in quality of life. These fractures can also be linked with decreased life expectancy: about 10% of people with a hip fracture die within 1 month, although most of the deaths are due to associated conditions and not to the fracture itself.

Recommendations in the short clinical guideline include:

  • Estimate absolute risk when assessing risk of fracture (for example, the predicted risk of major osteoporotic or hip fracture over 10 years, expressed as a percentage)
  • Use either FRAX[1](without a bone mineral density [BMD] measurement[2]) or QFracture[3], within their allowed age ranges, to estimate 10-year predicted absolute fracture risk when assessing risk of fracture. Above the upper age limits defined by the tools, consider people to be at high risk
  • Interpret the estimated absolute risk of fracture in people aged over 80 years with caution, because predicted 10-year fracture risk may underestimate their short-term fracture risk
  • Do not routinely measure BMD to assess fracture risk without prior assessment using FRAX (without a BMD value) or QFracture
  • Measure BMD to assess fracture risk in people aged under 40 years who have a major risk factor, such as history of multiple fragility fractures, major osteoporotic fracture, or current or recent use of high-dose oral or high-dose systemic glucocorticoids (more than 7.5 mg prednisolone or equivalent per day for 3 months or longer).

Professor Mark Baker, Director of the Centre for Clinical Practice, commented: “Fragility fractures can cause substantial pain and severe disability, so we‘re pleased to be publishing this new short clinical guideline to help in assessing the risk of fragility fractures in adults. The guideline will help provide clarity for health professionals on which risk assessment tools to use to predict the likelihood of fragility fracture in adults over a period of time. This will assist in overcoming the difficulties in identifying who might benefit from treatment to help prevent fractures linked to bone tissue deterioration. We hope that this new guideline will help in supporting the care of people at risk of fragility fractures.”

Dr Peter Barry, Chair of the Guideline Development Group, said: “This guideline is an important step forward in the care for people at risk of fragility fracture. As well as clarity on the strengths of the QFracture and FRAX tools, the guideline also highlights common and important factors that should alert health professionals to consider risk assessment. Following the recommendations will help ensure that the most appropriate risk assessment tool is used for different people depending on factors such as their clinical history and age, so that well-informed decisions can be made about their future care.”


For more information call Dr Tonya Gillis at the NICE press office on 0845 003 7782.

Notes to Editors

About this short clinical guideline

1. The short clinical guideline ‘Osteoporosis: assessing the risk of fragility fracture' is available at: from Weds 8th August.

2. The main risk factor for fragility fractures is reduced bone density, and other factors that can increase the risk of fracture include age, sex, previous fractures, using glucocorticoids, heavy smoking and drinking and family history of osteoporosis.

3. Direct medical costs from fragility fractures to the UK healthcare economy were estimated at £1.8 billion in 2000, with the potential to rise to £2.2 billion by 2025 with most of these costs relating to hip fracture care.

About other published NICE guidance on preventing osteoporotic fracture

4. NICE has published technology appraisal guidance on the primary prevention of osteoporotic fracture, available at: ta160 and guidance on the secondary prevention of osteoporotic fracture, available at: ta161.

NICE has also separately recommended denosumab (Prolia) as a treatment option for certain postmenopausal women who are at increased risk of primary and secondary osteoporotic fractures if other treatments available on the NHS are unsuitable. This guidance is available at: ta204.

About NICE

5. The National Institute for Health and Care Excellence (NICE) is the independent organisation responsible for providing national guidance and standards on the promotion of good health and the prevention and treatment of ill health.

6. NICE produces guidance in three areas of health:

  • public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
  • health technologies - guidance on the use of new and existing medicines, treatments, medical technologies (including devices and diagnostics) and procedures within the NHS
  • clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.

7. NICE produces standards for patient care:

  • quality standards - these reflect the very best in high quality patient care, to help healthcare practitioners and commissioners of care deliver excellent services
  • Quality and Outcomes Framework - NICE develops the clinical and health improvement indicators in the QOF, the Department of Health scheme which rewards GPs for how well they care for patients
  • Commissioning Outcomes Framework - NICE develops the potential indicators for the COF, the scheme starting in 2013, which will help measure the health outcomes and quality of care commissioned by Clinical Commissioning Groups.

8. NICEprovides advice and support on putting NICE guidance and standards into practice through its implementation programme, and it collates high quality guidance and evidence-based information to help professionals deliver the best patient care through NHS Evidence.

[1] FRAX, the WHO fracture risk assessment tool, is available from It can be used for people aged between 40 and 90 years, either with or without BMD values, as specified.

[2] Bone mineral density measurements indicate the amount of calcium in bones, and are determined using a type of X-ray scan

[3] QFracture is available from It can be used for people aged between 30 and 84 years. BMD values cannot be incorporated into the risk algorithm.

This page was last updated: 07 August 2012