To critically assess recent evidence concerning osteoporosis fracture risk.

Robust instruments exist for predicting factures incorporating well-documented risk factors especially prior fracture whose magnitude varies with site, occurrence time, and age. Stratifying time-since-prior fracture has resulted in the concept of imminent fracture risk and increased focus on secondary fracture prevention. Secondary fracture prevention recommendations include fracture liaison service, pharmacologic and non-pharmacologic multidisciplinary intervention, and communicating that fractures in older adults are the predictable consequence of underlying osteoporosis rather than unfortunate accidents. Quality improvement in osteoporosis care includes diagnosing osteoporosis on the basis of clinical fractures rather than exclusively relying on bone density testing; applying diagnostic rather than screening approaches to patients with prior fractures; regularly updating fall and fracture histories; performing a physical exam focused on spinal curvature, posture, and musculoskeletal function; reviewing images to identify prevalent fractures that may have been missed; and general use of fracture risk algorithms at all stages of osteoporosis management. Communicating effectively with patients about osteoporosis and fractures, their consequences, and pharmacological and non-pharmacological management is the cornerstone of high-value care.