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In this issue of JBMR, Ensrud and colleagues report the incidence of clinical and radiographic vertebral fractures in the prospective MrOs study.(1) Vertebral fractures (VFs) are the classic hallmark of osteoporosis; they are the paradigm of osteoporotic fractures because of at least five differences with non‐vertebral fractures.

First, VFs can occur without injury; a fall is associated with all non‐vertebral fractures. Substantial differences in risk profiles are well known among the fractures; in the GLOW study, conducted in women aged ≥55 years, baseline falling is associated with increased risk in almost all fractures, except spine.(2) In the prospective study of 5995 men at least 65 years of age, the incidence of clinical thoracic and lumbar VFs was 1.9/1000 person‐years. A fall from standing height or less was noted in 41% of the participants; thus, a proportion of clinical VFs occur without a fall, ie, routine everyday activity.(3) The rate of clinical VF related to high trauma is twofold greater in men than in women,(3) but 1 in 5 incident fracture patients presents with back pain without known injury.(4) Second, low areal bone mineral density (aBMD) is a determinant of the risk of fracture in elderly men, although a T‐score < –2.5 is present in a minority of men with fractures. In a cross‐sectional study, men with VFs have thinner cortex and lower cortical volumetric bone density assessed by high‐resolution peripheral quantitative computed tomography than men without VF, after adjustment for density measured by dual‐energy X‐ray absorptiometry.(5) Risk factors for men with multiple vertebral deformities are consistent with those well known for osteoporotic women. This is not true for men with single/dual deformities; in this population, the association with low aBMD is lower, suggesting that a single VF in men may be ascribed to less severe osteoporosis or activity‐related trauma or both.(6) Third, a VF is not an all‐or‐non phenomenon; VFs can be of different grades of severity. Changes in vertebral body shape can occur in a continuous or step‐wise fashion, and this may be associated with a different severity of clinical symptoms. Interestingly, there is a relationship between the severity of VFs and the deterioration of microstructure in transiliac bone biopsies: the more severe are the VFs, whereas the lower are the trabecular number and connectivity in women(7) and men.(8, 9) Fourth, there is no possibility of restoration of shape after a VF, ie, expansion of vertebral body to its normal height and volume, in contrast to the results of surgical repair of non‐vertebral fractures. Fifth, all anti‐osteoporotic treatments have a greater effect on vertebral fracture risk than on non‐vertebral fracture risk in postmenopausal women; the anti‐fracture efficacy of treatments in men is mainly inferred from bridging studies from data in women.

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