The operational definition of osteoporosis used in clinical practice is based on central areal bone mineral density (aBMD) measured at the spine and hip by dual-energy X-ray absorptiometry (DXA). The Fracture Risk Assessment Tool (FRAX) combines femoral neck (FN) aBMD with clinical risk factors. However, about half of fragility fractures occur in individuals not qualified at high risk of fracture with these tools, that is, with nonosteoporotic status on central DXA or with FRAX score below the intervention threshold for age. High-resolution peripheral quantitative computed tomography has been used for noninvasive quantification of the geometric, microarchitectural, densitometric, and mechanical properties of distal radius and tibia cortical and trabecular bone. Cross-sectional and prospective studies demonstrated that peripheral bone microstructure and strength are associated with fractures and might improve the identification of people at the highest risk of fracture beyond FN BMD and FRAX. The value of alternative and more accessible noninvasive imaging techniques to predict fractures are also discussed in this chapter.