Vertebral deformities may be caused by a variety of conditions, such as osteoporosis, severe trauma, congenital deformities, Scheuermann's disease, osteoarthritis, and multiple myeloma. For the individual patient, the correct diagnosis of an osteoporotic fracture is a prerequisite for the choice of optimal treatment and will be ensured by careful differential diagnosis based on a spinal radiograph and additional diagnostic procedures. Evaluation of radiographs by experienced radiologists is crucial for the correct diagnosis of vertebral fractures. For clinical trials and epidemiological studies of osteoporosis, qualitative radiological evaluation of radiographs has proven to be insufficient, since results lack reproducibility. Therefore, objective morphometric methods based on vertebral height measurements have been developed for fracture identification and quantification in scientific settings. Satisfactory sensitivity of these methods is usually reached at the expense of specificity, leading to a high number of false positives. With some differences in methodology, most of the morphometric approaches are of comparable validity. However, none of the morphometric methods allows any subclassification of vertebral deformities with respect to etiology. A combined approach based on morphometry as well as standardized radiological evaluation by experts appears to be the most promising solution to the problem. Further efforts are needed to standardize radiological criteria to yield comparable results between individual readers and different studies. It has to be evaluated whether the combined approach (clinical reading and morphometry) is necessary during follow-up evaluation, as morphometry may be sufficient for monitoring once the diagnosis has been established at baseline.