Archives of Osteoporosis

, 14:107 | Cite as

Impact of reference point selection on DXA-based measurement of forearm bone mineral density

  • Wei YuEmail author
  • Qifeng Ying
  • Wenmin Guan
  • Qiang Lin
  • Zaizhu Zhang
  • Jianfeng Chen
  • Klaus Engelke
  • Evelyn Hsieh
Original Article



Few studies have systematically evaluated the technical aspects of forearm bone mineral density (BMD) measurement. We found that BMD remained stable regardless of the reference point; however, the ROI identified was not always consistent. Our study highlights the importance of using the same reference point for serial measurements of forearm BMD.


Forearm fractures are clinically important outcomes from the perspective of morbidity, health care costs, and interruption of work. BMD of the forearm, as derived by dual-energy x-ray absorptiometry (DXA), is a better predictor of fracture at the forearm compared with BMD measured at other sites. However, very few studies have evaluated the technical aspects of selecting the ROI for forearm BMD measurement. This study aimed to compare the BMD values measured at the 1/3 radius site using three different reference points: the ulnar styloid process, the radial endplate, and the bifurcation of the ulna and radius.


Healthy Chinese patients participating in the control group of an ongoing study at Zhejiang Provincial People’s Hospital were recruited for this study. For each patient, a DXA scan (GE Lunar Prodigy) of the forearm was performed and BMD values were separately calculated using each of the three reference points to identify the ROI. Pearson correlation coefficients were calculated to examine the correlation between the BMD measures derived from each reference point. The F test and independent t test were applied for more robust analysis of the differences in the variances and means.


Sixty-eight healthy Chinese volunteers agreed to participate in this study. The root mean square standard deviation (RMS-SD) percentages of BMD values measured at the 1/3 radius site were 2.19%, 2.23%, and 2.20% when using the ulnar styloid process, radial endplate, and the bifurcation of the ulna and radius as the reference points, respectively. Pearson’s correlation coefficients for all pairwise comparisons among these three groups were greater than 0.99. F tests and independent t tests showed p values ranging from 0.92 to 0.99. However, we observed that among 10% of patients, choosing an ROI at the ulnar styloid process led to an inability to accurately determine the BMD at the ultra-distal radius.


Given equal ability to determine BMD at the 1/3 radius accurately, the radial endplate or the bifurcation of the ulna and radius should be preferentially selected as the reference point for routine forearm BMD measurements in order to avoid situations in which the ultra-distal radius BMD cannot be determined.


Forearm Dual-energy X-ray absorptiometry Bone mineral density Regions of interest Precision One-third radius 



We would like to express our sincere gratitude to Professor Harry K. Genant for his scientific advice and suggestions. Dr. Hsieh is supported by NIH/Fogarty International Center K01TW009995.

Compliance with ethical standards

Conflicts of interest


Supplementary material

11657_2019_658_MOESM1_ESM.docx (69 kb)
ESM 1 (DOCX 68 kb)


  1. 1.
    WHO (1994) Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Technical Report Series 843 WHO, GenevaGoogle Scholar
  2. 2.
    Baim S, Binkley N, Bilezikian JP, Kendler DL, Hans DB, Lewiecki EM, Silverman S (2008) Official positions of the International Society for Clinical Densitometry and executive summary of the 2007 ISCD Position Development Conference. J Clin Densitom 11(1):75–91CrossRefGoogle Scholar
  3. 3.
    O'Neill TW, Cooper C, Finn JD, Lunt M, Purdie D, Reid DM, Rowe R, Woolf AD, Wallace WA, Group UKCFS (2001) Incidence of distal forearm fracture in British men and women. Osteoporos Int 12(7):555–558CrossRefGoogle Scholar
  4. 4.
    Thompson PW, Taylor J, Dawson A (2004) The annual incidence and seasonal variation of fractures of the distal radius in men and women over 25 years in Dorset, UK. Injury 35(5):462–466. CrossRefPubMedGoogle Scholar
  5. 5.
    Yu W, Gluer CC, Fuerst T, Grampp S, Li J, Lu Y, Genant HK (1995) Influence of degenerative joint disease on spinal bone mineral measurements in postmenopausal women. Calcif Tissue Int 57(3):169–174CrossRefGoogle Scholar
  6. 6.
    Abrahamsen B, Jorgensen NR, Schwarz P (2015) Epidemiology of forearm fractures in adults in Denmark: national age- and gender-specific incidence rates, ratio of forearm to hip fractures, and extent of surgical fracture repair in inpatients and outpatients. Osteoporos Int 26(1):67–76. CrossRefPubMedGoogle Scholar
  7. 7.
    Jerrhag D, Englund M, Karlsson MK, Rosengren BE (2017) Epidemiology and time trends of distal forearm fractures in adults - a study of 11.2 million person-years in Sweden. BMC Musculoskelet Disord 18(1):240. CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Miller PD, Siris ES, Barrett-Connor E, Faulkner KG, Wehren LE, Abbott TA, Chen YT, Berger ML, Santora AC, Sherwood LM (2002) Prediction of fracture risk in postmenopausal white women with peripheral bone densitometry: evidence from the National Osteoporosis Risk Assessment. J Bone Miner Res 17(12):2222–2230CrossRefGoogle Scholar
  9. 9.
    Greenspan S, Maitland-Ramsey L, Myers E (1996) Classification of osteoporosis in the elderly is dependent on site-specific analysis. Calcif Tissue Int 58:409–414CrossRefGoogle Scholar
  10. 10.
    Saleem TF, Horwith M, Stack BC Jr (2004) Significance of primary hyperparathyroidism in the management of osteoporosis. Otolaryngol Clin N Am 37(4):751–761, viii-ix. CrossRefGoogle Scholar
  11. 11.
    Macfarlane DP, Yu N, Leese GP (2015) Asymptomatic and mild primary hyperparathyroidism. Ann Endocrinol (Paris) 76(2):120–127. CrossRefGoogle Scholar
  12. 12.
    Silverberg SJ, Gartenberg F, Jacobs TP, Shane E, Siris E, Staron RB, Bilezikian JP (1995) Longitudinal measurements of bone density and biochemical indices in untreated primary hyperparathyroidism. J Clin Endocrinol Metab 80(3):723–728. CrossRefPubMedGoogle Scholar
  13. 13.
    Shepherd JA, Schousboe JT, Broy SB, Engelke K, Leslie WD (2015) Executive summary of the 2015 ISCD Position Development Conference on Advanced Measures From DXA and QCT: Fracture Prediction Beyond BMD. J Clin Densitom 18(3):274–286CrossRefGoogle Scholar
  14. 14.
    Wood K, Dhital S, Chen H, Sippel RS (2012) What is the utility of distal forearm DXA in primary hyperparathyroidism? Oncologist 17(3):322–325. CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Silverberg SJ, Walker MD, Bilezikian JP (2013) Asymptomatic primary hyperparathyroidism. J Clin Densitom 16(1):14–21. CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Nakayama H, Toho H, Sone T (2018) Utility of radius bone densitometry for the treatment of osteoporosis with once-weekly teriparatide therapy. Osteoporos Sarcopenia 4(1):29–32. CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Urushibara N, Kato N, Adachi R, Nakamura Y, Mihara A, Uzawa T, Kitagawa S, Hayashi M, Kuroda T, Sone T (2014) Once-weekly teriparatide increases bone mineral density in the distal 1/10 radius, but not in the distal 1/3 radius. Springerplus 3:238. CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Sugimoto T, Shiraki M, Fukunaga M, Hagino H, Sone T, Nakano T, Kishimoto H, Ito M, Yoshikawa H, Kishida M, Irie C, Nakamura T (2017) 24-month open-label teriparatide once-weekly efficacy research trial examining bone mineral density in subjects with primary osteoporosis and high fracture risk. Adv Ther 34(7):1727–1740. CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Neer RM, Arnaud CD, Zanchetta JR, Prince R, Gaich GA, Reginster JY, Hodsman AB, Eriksen EF, Ish-Shalom S, Genant HK, Wang O, Mitlak BH (2001) Effect of parathyroid hormone (1-34) on fractures and bone mineral density in postmenopausal women with osteoporosis. N Engl J Med 344(19):1434–1441CrossRefGoogle Scholar
  20. 20.
    Michalska D, Luchavova M, Zikan V, Raska I Jr, Kubena AA, Stepan JJ (2012) Effects of morning vs. evening teriparatide injection on bone mineral density and bone turnover markers in postmenopausal osteoporosis. Osteoporos Int 23(12):2885–2891. CrossRefPubMedGoogle Scholar
  21. 21.
    Macdonald HM, Nishiyama KK, Hanley DA, Boyd SK (2011) Changes in trabecular and cortical bone microarchitecture at peripheral sites associated with 18 months of teriparatide therapy in postmenopausal women with osteoporosis. Osteoporos Int 22(1):357–362. CrossRefPubMedGoogle Scholar
  22. 22.
    Nakamura T, Sugimoto T, Nakano T, Kishimoto H, Ito M, Fukunaga M, Hagino H, Sone T, Yoshikawa H, Nishizawa Y, Fujita T, Shiraki M (2012) Randomized Teriparatide [human parathyroid hormone (PTH) 1-34] Once-Weekly Efficacy Research (TOWER) trial for examining the reduction in new vertebral fractures in subjects with primary osteoporosis and high fracture risk. J Clin Endocrinol Metab 97(9):3097–3106. CrossRefPubMedGoogle Scholar
  23. 23.
    Zanchetta JR, Bogado CE, Ferretti JL, Wang O, Wilson MG, Sato M, Gaich GA, Dalsky GP, Myers SL (2003) Effects of teriparatide [recombinant human parathyroid hormone (1–34)] on cortical bone in postmenopausal women with osteoporosis. J Bone Miner Res 18(3):539–543. CrossRefPubMedGoogle Scholar
  24. 24.
    McClung MR, San Martin J, Miller PD, Civitelli R, Bandeira F, Omizo M, Donley DW, Dalsky GP, Eriksen EF (2005) Opposite bone remodeling effects of teriparatide and alendronate in increasing bone mass. Arch Intern Med 165(15):1762–1768. CrossRefPubMedGoogle Scholar
  25. 25.
    Zhao J, Xing Y, Zhou Q, Jin W, Wacker W, Barden HS (2010) Can forearm bone mineral density be measured with DXA in the supine position? A study in Chinese population. J Clin Densitom 13(2):147–150. CrossRefPubMedGoogle Scholar
  26. 26.
    Hongsdusit N, von Muhlen D, Barrett-Connor E (2006) A comparison between peripheral BMD and central BMD measurements in the prediction of spine fractures in men. Osteoporos Int 17(6):872–877. CrossRefPubMedGoogle Scholar
  27. 27.
    Orlic L, Crncevic Z, Pavlovic D, Zaputovic L (2010) Bone mineral densitometry in patients on hemodialysis: difference between genders and what to measure. Ren Fail 32(3):300–308. CrossRefPubMedGoogle Scholar
  28. 28.
    Engelke K, Libanati C, Liu Y, Wang H, Austin M, Fuerst T, Stampa B, Timm W, Genant HK (2009) Quantitative computed tomography (QCT) of the forearm using general purpose spiral whole-body CT scanners: accuracy, precision and comparison with dual-energy X-ray absorptiometry (DXA). Bone 45(1):110–118. CrossRefPubMedGoogle Scholar
  29. 29.
    El Hage R, El Hage Z, Jacob C, Moussa E, Theunynck D, Baddoura R (2011) Bone mineral content and density in overweight and control adolescent boys. J Clin Densitom 14(2):122–128. CrossRefPubMedGoogle Scholar
  30. 30.
    Bonnick SL (2004) Bone densitiometry in clinical practice. Densitiometry techniques, 2nd edn. Humana Press, TotowaGoogle Scholar
  31. 31.
    Augat P, Fuerst T, Genant HK (1998) Quantitative bone mineral assessment at the forearm: a review. Osteoporos Int 8(4):299–310CrossRefGoogle Scholar
  32. 32.
    Rosen EO, McNamara EA, Whittaker LG, Malabanan AO, Rosen HN (2018) Effect of positioning of the ROI on BMD of the forearm and its subregions. J Clin Densitom 21(4):529–533. CrossRefPubMedGoogle Scholar
  33. 33.
    Gluer CC, Blake G, Lu Y, Blunt BA, Jergas M, Genant HK (1995) Accurate assessment of precision errors: how to measure the reproducibility of bone densitometry techniques. Osteoporos Int 5(4):262–270CrossRefGoogle Scholar
  34. 34.
    Pearson D, Horton B, Green DJ (2007) Cross calibration of Hologic QDR2000 and GE Lunar Prodigy for forearm bone mineral density measurements. J Clin Densitom 10(3):306–311. CrossRefPubMedGoogle Scholar
  35. 35.
    Chang YJ, Yu W, Lin Q, Yao JP, Zhou XH, Tian JP (2012) Forearm bone mineral density measurement with different scanning positions: a study in right-handed Chinese using dual-energy X-ray absorptiometry. J Clin Densitom 15(1):67–71. CrossRefPubMedGoogle Scholar
  36. 36.
    Wahner HW, Eastell R, Riggs BL (1985) Bone mineral density of the radius: where do we stand? J Nucl Med 26(11):1339–1341PubMedGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2019

Authors and Affiliations

  • Wei Yu
    • 1
    Email author
  • Qifeng Ying
    • 2
  • Wenmin Guan
    • 1
  • Qiang Lin
    • 1
  • Zaizhu Zhang
    • 1
  • Jianfeng Chen
    • 3
  • Klaus Engelke
    • 4
    • 5
  • Evelyn Hsieh
    • 6
  1. 1.Department of Radiology, Perking Union Medical College HospitalChinese Academy of Medicine SciencesBeijingChina
  2. 2.Department of RadiologyZhejiang Provincial People’s HospitalZhejiangChina
  3. 3.Department of Radiology, Feinberg School of MedicineNorthwestern UniversityChicagoUSA
  4. 4.Institute of Medical PhysicsUniversity of ErlangenErlangenGermany
  5. 5.Bioclinica, Inc.HamburgGermany
  6. 6.Section of Rheumatology, Allergy and Immunology, Department of Internal MedicineYale School of MedicineNew HavenUSA

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