Opportunistic CT screening predicts individuals at risk of major osteoporotic fracture



Millions of CT scans are performed annually and could be also used to opportunistically assess musculoskeletal health; however, it is unknown how well this secondary assessment relates to osteoporotic fracture. This study demonstrates that opportunistic CT screening is a promising tool to predict individuals with previous osteoporotic fracture.


Opportunistic computed tomography (oCT) screening for osteoporosis and fracture risk determination complements current dual X-ray absorptiometry (DXA) diagnosis. This study determined major osteoporotic fracture prediction by oCT at the spine and hip from abdominal CT scans.


Initial 1158 clinical abdominal CT scans were identified from administrative databases and were the basis to generate a cohort of 490 men and women with suitable abdominal CT scans. Participant CT scans met the following criteria: over 50 years of age, the scan had no image artifacts, and the field-of-view included the L4 vertebra and proximal femur. A total of 123 participants were identified as having previously suffered a fracture within 5 years of CT scan date. Fracture cause was identified from clinical data and used to create a low-energy fracture sub-cohort. At each skeletal site, bone mineral density (BMD) and finite element (FE)-estimated bone strength were determined. Logistic regression predicted fracture and receiver-operator characteristic curves analyzed prediction capabilities.


In participants with a fracture, low-energy fractures occurred in 88% of women and 79% of men. Fracture prediction by combining both BMD and FE-estimated bone strength was not statistically different than using either BMD or FE-estimated bone strength alone. Predicting low-energy fractures in women determined the greatest AUC of 0.710 by using both BMD and FE-estimated bone strength.


oCT screening using abdominal CT scans is effective at predicting individuals with previous fracture at major osteoporotic sites and offers a promising screening tool for skeletal health assessment.

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Fig. 1
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Areal bone mineral density


Area under the receiver-operator characteristic curve


Bone mineral density


Computed tomography


Dual X-ray absorptiometry


Finite element


International Classification of Diseases 10th Revision


Kidney, urinary, and bladder


Opportunistic computed tomography


Receiver-operator characteristic curve


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Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.


This study was funded in part by the Bob and Nola Rintoul Chair in Bone and Joint Research and a Discovery Grant from the Natural Sciences and Engineering Council (NSERC) of Canada.

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Corresponding author

Correspondence to S.K. Boyd.

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Ethics approval

Data collection and analyses for this study were approved by the University of Calgary Conjoint Health Research Ethics Board (REB 17-1033) with a waiver of informed consent.

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Supplementary information


Flow diagram of participants to define the study cohort from the CT scan identification to the final defined cohorts, using specific inclusion criteria of each CT scan. The number of participants removed from the total 1158 participant cohort was identified using each criterion, leading to the final defined cohort. Some participants are excluded due to multiple criteria. (PDF 37 kb)


Fracture numbers specified by sex and anatomical region (DOCX 13 kb)


Outcomes from the ROC curves using combined parameters and the complete fracture cohort (DOCX 14 kb)


Outcomes from the ROC curves using individual parameters and the complete fracture cohort (DOCX 15 kb)


Outcomes from the ROC curves using individual parameters and the low energy fracture sub-cohort (DOCX 15 kb)

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Michalski, A., Besler, B., Burt, L. et al. Opportunistic CT screening predicts individuals at risk of major osteoporotic fracture. Osteoporos Int (2021). https://doi.org/10.1007/s00198-021-05863-0

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  • Bone fracture
  • Osteoporosis
  • Patient-specific modeling
  • X-ray computed tomography