Can a 79-year-old female patient with a history of compression fracture, osteopenia, and a recent fall be diagnosed with osteoporosis despite having a normal current Dual-Energy X-ray Absorptiometry (DEXA) scan?

Can a Patient with Normal DEXA and Fragility Fracture Be Diagnosed with Osteoporosis?

Yes, a 79-year-old woman with a compression fracture can and should be diagnosed with osteoporosis despite having a normal current DEXA scan, because the presence of a low-trauma major osteoporotic fracture (including vertebral compression fractures) establishes the diagnosis of osteoporosis independent of bone mineral density measurements. 1

Diagnostic Framework

Fragility Fracture as Standalone Diagnostic Criterion

The most recent guidelines from the European Association of Nuclear Medicine (EANM), American Society for Bone and Mineral Research (ASBMR), and Canadian Society of Endocrinology and Metabolism (CSEM) pragmatically recognize that osteoporosis may be presumed in the presence of a prior low-trauma major osteoporotic fracture, even with normal BMD. 1 This represents an evolution beyond the traditional WHO T-score-only definition.

• Vertebral compression fractures are specifically included as qualifying fractures for this diagnosis, along with hip, forearm, humerus, and pelvis fractures. 1

• The National Bone Health Alliance Working Group similarly recommends that postmenopausal women who have experienced vertebral fractures with osteopenia (or even normal BMD) should receive an osteoporosis diagnosis due to their demonstrably elevated fracture risk. 2

Why Normal DEXA Doesn't Exclude Osteoporosis

Several critical factors explain this apparent paradox:

• Vertebral fractures are the strongest predictor of future fractures, multiplying the risk of new vertebral fractures by 5-fold and fractures at other sites by 2- to 3-fold, regardless of current BMD. 3

• Bone quality encompasses more than just density—microarchitectural deterioration, bone turnover rates, and collagen integrity contribute to fracture risk but aren't captured by DEXA T-scores alone. 4

• The fracture itself is clinical evidence that bone strength was insufficient to withstand the applied force, which by definition indicates osteoporosis when the trauma was minimal. 2

Important Caveats About the Fracture History

You must verify that the compression fracture was truly low-trauma (fragility) in nature. 1 Historical information is valuable to clarify whether the vertebral fracture occurred:

• Spontaneously or with minimal trauma (lifting, bending, coughing)
• With significant trauma that would fracture normal bone

If the fracture resulted from significant trauma, the diagnosis becomes less certain and requires additional clinical judgment. 1

Clinical Implications for This Patient

Immediate Diagnostic Classification

For documentation purposes, this 79-year-old woman with a history of compression fracture meets diagnostic criteria for osteoporosis based on the fracture history alone, assuming it was low-trauma. 1, 2

• Her age (79 years) places her in the highest risk category for osteoporotic fractures. 1
• The recent fall further emphasizes her elevated fracture risk and need for intervention. 4

Treatment Implications

The presence of a vertebral fracture automatically establishes the need for pharmacologic treatment, regardless of FRAX scores or current T-scores. 5, 6

• First-line treatment options include oral bisphosphonates (alendronate, risedronate, ibandronate). 7, 8
• Alternative options include denosumab 60 mg subcutaneously every 6 months if bisphosphonates are contraindicated or not tolerated. 5, 6
• All patients require calcium supplementation (1000-1200 mg daily) and vitamin D (800-1000 IU daily). 5, 6, 3

Monitoring Strategy

• Repeat DEXA scanning should occur in 1-2 years on the same machine using identical protocols, comparing absolute BMD values (g/cm²) rather than T-scores. 1
• Consider vertebral fracture assessment (VFA) imaging, as vertebral fractures are often asymptomatic and the strongest predictor of future fractures. 5

Common Pitfalls to Avoid

Do not withhold the osteoporosis diagnosis or delay treatment simply because the current DEXA shows normal or osteopenic T-scores—this represents a critical care gap that leaves high-risk patients untreated. 3, 2

Do not assume the previous compression fracture is irrelevant because it occurred in the past—the diagnosis of osteoporosis persists even if subsequent DEXA T-scores normalize, as the disease is not cured by achieving normal BMD. 3

Do not overlook fall prevention strategies in addition to pharmacotherapy, as hip fractures result from the combination of low bone mass and falls. 4