Osteoporotic fractures are related not only to bone mineral density (BMD) but also to bone structure or microarchitecture, which is not assessed routinely with currently available methods. We have developed radiographic texture analysis (RTA) for calcaneal images from a peripheral densitometer as an easy, noninvasive method for assessing bone structure. We conducted a cross-sectional study of the relationship between RTA and prevalent vertebral fractures (n = 148) among 900 subjects (ages 19 to 99 years, 94 males) referred for bone densitometry as part of their routine medical care. RTA features were derived from Fourier-based image analysis of the radiographic texture pattern (including root mean square, first moment, and power spectral analyses). RTA features were associated with age, weight, gender, and race, as well as glucocorticoid use. When controlling for clinical risk factors and BMD (or a summary measure calculated using FRAX algorithms), RTA features were significantly different for subjects with and without prevalent vertebral fractures [adjusted odds ratio (OR) = 1.5 per 1 standard deviation (SD) decrease in RTA feature beta, 95% confidence interval (CI) 1.2-1.8, p = .001]. Gender and use of pharmacologic therapy for osteoporosis did not significantly affect this association, suggesting that RTA can be applied to a wide range of densitometry patients. We conclude that RTA obtained using a portable instrument has a potential as a noninvasive method to enhance identification of patients at increased risk of osteoporotic fractures.