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Radiographic signs of the PHPT include a salt-and-pepper pattern skull demineralization, distal clavicle tapering, subperiosteal bone resorption, cysts, and brown tumors. Together, these features are described as osteitis fibrosa cystica and are rarely seen in developed countries where more subtle forms of skeletal involvement are observed. A BMD measured by DXA (dual-energy X-ray absorptiometry) is usually low at the distal 1/3 radius and BMD should be measured at the 1/3 radius site in all individuals with PHPT [23]. An increase in fracture risk at all skeletal sites has been described [24]. High-resolution peripheral quantitative tomography has shown that both trabecular and cortical bone compartments are affected in patients with PHPT [18, 23]. The trabecular bone score, or TBS, which is able to predict the fracture risk independent of BMD [21], is consistent with a deteriorated trabecular microstructure and increased fracture risk [18, 25] in patients with PHPT.