FRAX® Score: A Practical Guide for Doctors
A quick clinical guide to estimating 10-year fracture probability, understanding key risk factors, and deciding when further bone health assessment may be appropriate.
This page is for clinician education only. It does not replace clinical judgement, local guidelines, DXA interpretation, or specialist assessment.
What FRAX estimates
- 10-year probability of major osteoporotic fracture
- 10-year probability of hip fracture
- Calculated with or without femoral neck BMD
- Applicable to adults aged 40 to 90
What is FRAX?
FRAX is a fracture risk assessment tool developed to estimate a patient's 10-year probability of a major osteoporotic fracture and of hip fracture.
It combines clinical risk factors, with or without femoral neck BMD, to produce an individualised estimate that can be used alongside local guidelines to guide further assessment and management.
When to consider using FRAX
FRAX is most useful when a patient has risk factors for osteoporosis or when bone health needs to be formally assessed.
Postmenopausal women
Men aged 50 and above
Patients with osteopenia on DXA
Clinical risk factors for osteoporosis
Previous low-trauma fracture
Long-term oral glucocorticoid use
Rheumatoid arthritis or secondary osteoporosis risk
Data needed before calculating
Gather these items before opening the official calculator. Most can be obtained from a focused history and basic examination.
- Country / population reference
- Age
- Sex
- Weight
- Height
- Previous adult fragility fracture
- Parental history of hip fracture
- Current smoking
- Oral glucocorticoid exposure
- Confirmed rheumatoid arthritis
- Secondary osteoporosis
- Alcohol intake of 3 or more units daily
- Femoral neck BMD or T-score, if available
Risk factor definitions to be careful with
Precise data entry matters. Misclassification of these variables is a common source of error.
How to interpret FRAX results
Treatment thresholds vary by country and guideline. Interpret FRAX in the context of the patient's clinical picture and local recommendations.
Low risk
- Optimise lifestyle
- Adequate calcium and vitamin D
- Falls prevention
- Reassess if risk changes
Intermediate risk
- Consider DXA if not done
- Review risk modifiers
- Apply clinical judgement
High risk
- Consider osteoporosis treatment pathway
- Evaluate secondary causes
- Consider specialist referral
Situations where FRAX may underestimate risk
- Recent fracture within the past 2 years
- Multiple previous fractures
- Prior hip or clinical vertebral fracture
- Very high-dose or prolonged glucocorticoid exposure
- High falls risk or frailty
- Very low lumbar spine BMD compared with femoral neck
- Poorly controlled inflammatory disease
- Patients with strong secondary osteoporosis drivers
FRAX and rheumatoid arthritis
RA is an independent fracture risk factor in FRAX. Inflammatory burden, glucocorticoid exposure, reduced mobility, menopause, nutrition, and falls risk may all contribute. Only tick RA when there is a confirmed clinical diagnosis.
Osteoarthritis is not the same as RA and should not be entered as RA.
FRAX and glucocorticoid use
FRAX treats glucocorticoids as a yes or no variable based on average exposure. Apply additional clinical judgement when assessing:
- Higher dose prednisolone
- Long duration exposure
- Repeated courses
- Current inflammatory disease activity
- Additional concurrent risk factors
Suggested doctor workflow
- 1Identify the patient at risk
- 2Take fracture and medication history
- 3Check RA and secondary osteoporosis risk factors
- 4Calculate FRAX with available data
- 5Add femoral neck BMD if DXA is available
- 6Interpret against local thresholds
- 7Consider secondary workup where indicated
- 8Discuss bone protection, falls risk and treatment options
- 9Refer when risk is high, complex or uncertain
When to refer for specialist review
- Fragility fracture, especially hip or vertebral
- Multiple fractures
- Very low BMD
- Ongoing or planned long-term glucocorticoids
- Confirmed RA with fracture risk concerns
- Premature menopause or hypogonadism
- Chronic kidney disease, malabsorption or complex secondary causes
- Unclear diagnosis or discordant DXA / clinical picture
- Treatment failure or fracture while on therapy
- Complex decision around antiresorptive or anabolic therapy
FRAX Quick Reference for Clinics
A printable handout covering the input checklist, risk factor definitions, underestimation cautions and referral triggers.
Frequently asked questions
FRAX® and FRAXplus® are registered trademarks of Osteoporosis Research Ltd. This page is an educational guide and links to the official FRAX tool. It is not affiliated with, endorsed by, or a replacement for the official FRAX calculator.