Ten-year fracture risk predicted by proximal femur Hounsfield units

D. L. Christensen, K. E. Nappo, J. A. Wolfe, J. G. Tropf, M. J. Berge, B. M. Wheatley, S. Saxena, B. G. Yow, S. M. Tintle*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

10 Scopus citations


Summary: Colon cancer screening occurs at younger ages than osteoporosis screening. Bone density measurements using virtual colonoscopy performed for colon cancer screening can provide an early warning sign of patients at potential risk for osteoporosis-related fractures. Earlier identification may improve treatment and potentially fracture prevention. Introduction: Opportunistic osteoporosis screening with computed tomography colonography (CTC) offers an opportunity to capitalize on earlier colorectal cancer screening to identify patients at risk of future fractures. The purpose of this study is to evaluate 10-year fracture and specifically hip fracture risk based on Hounsfield units (HU) obtained from CTC. Methods: We identified all CTC scans between 2004 and 2007 of patients 40 years and older with 10 years minimum follow-up. Hounsfield units were measured within the proximal femur and fractures identified via worldwide military records. Patients were stratified into two cohorts based on the presence or lack of a fracture in the wrist, spine, hip, or proximal humerus. Hounsfield unit measurements were compared between groups using Student’s t test and the HU threshold was calculated that best approximated an 80% sensitivity to optimally screen patients for fracture risk. The odds ratio, negative predictive value, 10-year incidence of fracture, and survival curves were calculated. Results: We identified 3711 patients with 183 fractures over 10 years. The HU threshold that corresponded with an 80% sensitivity to identify fractures was 112 HU. The negative predictive value (NPV) for overall fractures and hip fractures was over 97%. The 10-year fracture incidence was higher in patients below 112 HU compared to those above for both overall fractures (6.3% vs 1.7%) and hip fractures (2.7% vs 0.07%). The 112 HU threshold corresponds with an odds ratio for overall fracture and hip fractures of 2.5 (95% confidence interval (CI), 1.7–3.6) and 24.5 (95% CI, 3.3–175.5), respectively. Conclusion: In the 10 years following CTC, patients who experienced a fracture had lower hip HU. Decreasing HU on CTC may be an early warning sign of fracture potential.

Original languageEnglish
Pages (from-to)2123-2130
Number of pages8
JournalOsteoporosis International
Issue number11
StatePublished - 1 Nov 2020
Externally publishedYes


  • Computed tomography colonoscopy
  • Fracture prevention
  • Fragility fracture
  • Hip fracture
  • Opportunistic screening
  • Osteoporosis
  • Virtual colonoscopy


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