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Summary   The WHO fracture risk assessment (FRAX) and Canadian Association of Radiologists and Osteoporosis Canada (CAROC) tools can both be used to determine an individual’s 10-year risk of osteoporotic fracture. However, these tools differ in their risk calculation. For participants <65 years with a wrist fracture, FRAX provides a lower fracture risk estimate than CAROC resulting in fewer decisions to initiate therapy.    Purpose  The purpose of the current report is to compare fracture risk prediction rates using the CAROC and the FRAX® tools.    Methods  Individuals ≥50 years with a distal radius fracture resulting from a fall from standing height or less were recruited from a single orthopedic clinic. Participants underwent a DXA scan of their lumbar spine and hip. Femoral neck (FN) bone mineral density (BMD) and fracture risk factors were used to determine each participant’s 10-year fracture risk using both fracture risk assessment tools. Participants were categorized as low (<10 %), moderate (10–20 %), or high (>20 %) risk. Stratified by age (<65 years, >65 years), the proportion of participants in each category was compared between the tools.    Results  Analyses included 60 participants (mean age 65.7 ± 9.6 years). In those <65 years ( n  = 26), the proportion of individuals at low, moderate, and high risk differed between the FRAX and CAROC tools ( p  < 0.0001). FRAX categorized 69 % as low (CAROC 0 %) and 3 % as high (CAROC 12 %) risk. For individuals >65 years, almost all were at least at moderate risk (FRAX 79 %, CAROC 53 %), but fewer were at high risk using FRAX (18 vs. 47 %,  p  < 0.0003).    Conclusion  For participants <65 years with a wrist fracture, FRAX provides a lower estimate of 10-year fracture risk than CAROC resulting in fewer decisions to initiate therapy. However, almost all participants >65 years were at moderate or high risk under both FRAX and CAROC and should at least be considered for pharmacotherapy.

Estimating osteoporotic fracture risk following a wrist fracture: a tale of two systems