Among vertebral deformities, the prevalence of wedge fractures is about twice that of endplate (biconcave) deformities, both of which are greater than that of crush deformities. The anterior cortex is, therefore, a site of interest for understanding mechanisms of vertebral fracture. Despite its importance to vertebral mechanics, there are limited data describing the role of cortical shell, microdamage, and bone matrix parameters in vertebral fragility. This review of literature emphasizes the translational aspects of bone quality and demonstrates that a greater understanding of bone fractures will be gained through bone quality parameters related to both cortical and cancellous compartments as well as from microdamage and bone matrix parameters. In the context of vertebral fractures, measures of cortical shell and bone matrix parameters related to the organic matrix (advanced glycation products and a/ߠCTX ratio) are independent of BMD measurements and can therefore provide an additional estimate of fracture risk in older patients.