Bone involvement in primary hyperparathyroidism (PHPT) is characterized by reduced bone mineral density (BMD) using dual X-ray absorptiometry (DXA). A hallmark of PHPT is BMD loss at cortical sites while trabecular bone remains relatively preserved. PHPT is associated with increased fracture risk at both trabecular and cortical skeletal sites, which cannot be explained based on BMD values alone. The application of the trabecular bone score (TBS), an index of the lumbar spine DXA bone microarchitecture, showed lower TBS values and increased risk of fractures in PHPT patients, independent of BMD. Although further prospective studies are needed, promising data have been published with the use of TBS and some advanced DXA-based imaging modalities in patients with PHPT.