CCFP priority topic 71 of 105
Osteoporosis on the CCFP exam
7 key features, the mistakes that cost marks, and a practice question.
Checked by a Canadian family physician, MD, CCFP. Updated October 20, 2026.
What the exam tests
Key features
The CFPC’s 7 key features for Osteoporosis. Each one below has how the exam asks it, the common mistakes and the approach.
Practice question
Try one before you read
A real case from the bank, in the new short-menu format. Answer it first. Then read the key features.
Key feature 1 of 7
Risk at every checkup
Check each adult's chance of breaking a bone during routine preventive visits.
CFPC skill Clinical reasoningPhase Hypothesis generation, diagnosisSources Osteoporosis Canada 2023, Osteoporosis Canada 2023, Canadian Task Force on Preventive Health Care 2023
On the exam
A routine checkup with a long history. Expect a short menu (pick several from a list) of what raises risk.
Pick the history that raises fracture risk.
Common mistakes
Ticking every chronic illness. High blood pressure, osteoarthritis and gout are not on the risk list. Neither is smoking that stopped decades ago, or one drink at weekends.
Approach
- Use the Canadian FRAX tool (Fracture Risk Assessment Tool). It gives the 10-year risk of a major fracture.
- Know the risk factors: a fragility fracture after 40, a parent's hip fracture, current smoking, and 3 or more drinks a day.
- Also on the list: body mass index under 20, 2 or more falls in the last year, and bone loss caused by another disease.
- Glucocorticoids count after more than 3 months in the last year at over 5 mg of prednisone a day.
- A fragility fracture comes from a fall at standing height or less. A car crash does not count.
- Look for hidden spine fractures: measured height loss over 2 cm, or over 6 cm by history.
- The Task Force advises this risk check first, without a scan, for women 65 and older.
Key feature 2 of 7
When to scan
Order bone density scans only where a guideline backs them, never for everyone.
CFPC skill Selectivity, professionalismPhase Investigation, follow-upSources Canadian Task Force on Preventive Health Care 2023, Osteoporosis Canada 2023, Choosing Wisely Canada
On the exam
A healthy woman of 52 asks for a bone scan to be safe. Expect one best answer.
Pick the right test, or no test.
Common mistakes
Scanning her because she asks: neither Canadian guideline supports it. Refusing a man assessment after a fragility fracture, because the Task Force advises against screening men, is wrong too.
Approach
- Name the guideline you follow. The Task Force and Osteoporosis Canada differ (table below).
- The test is a DXA scan (dual-energy X-ray absorptiometry). It measures bone mineral density.
- The result is a T-score: how far density sits below a young adult's. A T-score of −2.5 or lower means osteoporosis.
- A fragility fracture is not screening. From age 50 it calls for assessment; the Task Force advice against screening does not apply.
- A hip or spine fragility fracture already qualifies for treatment. A scan is not needed to decide.
- Choosing Wisely Canada: do not order a screening DXA for low-risk patients.
| Canadian Task Force, 2023 | Osteoporosis Canada, 2023 | |
|---|---|---|
| Women 65 and older | FRAX without a scan first, then a shared decision. Scan the femoral neck only if a drug is being considered. | Scan at 65 to 69 with 1 risk factor. Scan everyone 70 or older. |
| Women 40 to 64 | Don't screen (strong) | After menopause, from 50: scan after a fragility fracture or with 2 or more risk factors |
| Men | Don't screen men 40 or older (strong) | Same ages and risk rules as women, from 50 |
| Repeat scan | Within 8 years does not look useful | Every 5 to 10 years if 10-year risk is under 10%, 5 years at 10 to 15%, 3 years above 15% |
Key feature 3 of 7
Bone health for all
Advise every patient how to build and keep strong bones, with extra care where risk runs high.
CFPC skill Clinical reasoning, communicationPhase TreatmentSources Osteoporosis Canada 2023, Osteoporosis Canada 2023
On the exam
A 19-year-old runner with a body mass index of 18 and no periods for months. Expect a short menu (pick several from a list) of advice.
Pick the advice that protects her bones.
Common mistakes
A calcium pill as the whole plan. Supplements add little when food meets the need. Missing her low weight misses her real risk.
Approach
- Watch for low weight in young athletes. A body mass index under 20 is a risk factor. Ask about disordered eating, and eating too little for the training load.
- Calcium from food first. If food meets the daily need, Osteoporosis Canada suggests no supplement to prevent fractures.
- Adults over 50: a 400 IU vitamin D supplement daily, plus foods rich in vitamin D.
- Exercise: balance, functional and resistance training, each at least twice a week.
- Help smokers quit. Current smoking is a fracture risk factor.
- Keep alcohol under 3 drinks a day. Three or more is a risk factor.
| Group | Calcium | Vitamin D |
|---|---|---|
| Women over 50 | 1,200 mg | 600 IU to age 70, 800 IU over 70 |
| Men 51 to 70 | 1,000 mg | 600 IU |
| Men over 70 | 1,200 mg | 800 IU |
Key feature 4 of 7
Around menopause
Give women near or after menopause a full plan to avoid fractures, beyond supplements.
CFPC skill Clinical reasoning, communicationPhase Treatment, hypothesis generationSources Osteoporosis Canada 2023, Osteoporosis Canada 2023
On the exam
A woman of 58, recently through menopause, asks which supplements to take. Expect a short menu (pick several from a list) of advice.
Pick the advice that lowers her fracture risk.
Common mistakes
Stopping at supplements, or prescribing walking alone. Walking does not replace balance and strength work. Missing her drinking, smoking or abuse at home misses real causes of fractures.
Approach
- Prescribe balance and functional training at least twice a week. It lowers falls.
- Add progressive resistance training at least twice a week, including back and core exercises. Progressive means the load gets harder over time.
- Walking, yoga or Pilates are fine on top, not instead.
- Ask about alcohol and smoking. Three or more drinks a day and current smoking are both risk factors. Help her cut down or quit.
- Ask about falls: 2 or more in the last year is a risk factor. Check the home for hazards such as loose rugs and poor lighting.
- Ask her, alone, whether anyone at home hurts her. Abuse can explain falls and fractures.
- Hormone therapy can replace a bisphosphonate if she has strong menopause symptoms and is under 60 or within 10 years of menopause.
Key feature 5 of 7
Medicines and falls
When bones are already thin, steer clear of drugs that make a fall more likely.
CFPC skill Clinical reasoningPhase Hypothesis generation, treatmentSources Choosing Wisely Canada, Osteoporosis Canada 2023
On the exam
A woman of 81 broke her hip in a night-time fall. She asks you to renew her lorazepam. Expect one best answer.
Pick the best plan for her sleeping pill.
Common mistakes
Renewing it because years of use felt safe. Stopping it overnight is wrong too. Swapping to zopiclone is no fix: it is a sedative-hypnotic, and the same advice covers it.
Approach
- Benzodiazepines can more than double falls and hip fractures in older adults. Do not make any sedative-hypnotic the first choice for sleep.
- That means benzodiazepines and the other sedative-hypnotics, a class that includes zopiclone.
- Plan a slow taper with her. Tapering protocols help people come off. Stopping suddenly after long use risks withdrawal.
- Offer cognitive behavioural therapy for insomnia. It also helps people stop the pill.
- Review every medicine that sedates her or drops her blood pressure when she stands.
- Ask about falls at every visit, and check for new fractures.
Key feature 6 of 7
Men break bones too
Counsel older men on avoiding fractures, since their bones thin with age as well.
CFPC skill Clinical reasoningPhase Hypothesis generation, treatmentSources Canadian Task Force on Preventive Health Care 2023, Osteoporosis Canada 2023, Osteoporosis Canada 2023
On the exam
A 74-year-old man broke his wrist tripping on a curb. Expect a short menu (pick several from a list) of next steps.
Pick the next steps for his bones.
Common mistakes
Skipping assessment because the Task Force advises against screening men. A fragility fracture is not screening; it calls for assessment.
Approach
- Name the framework. The Task Force advises against screening men. Osteoporosis Canada suggests a bone density test for men from 50 by risk, and for all at 70.
- A fracture from standing height or less after 50 calls for assessment and a bone density test.
- After a recent fracture, refer to a fracture liaison service where one exists.
- Check his risk factors as for women: glucocorticoids, 3 or more drinks a day, current smoking, low weight and falls.
- Give the same advice as for women: balance and resistance training, a 400 IU vitamin D supplement, and calcium from food.
- His calcium need is 1,000 mg a day at 51 to 70, and 1,200 mg over 70.
- Men get the same treatment rules as women from age 50.
Key feature 7 of 7
Treat men and women alike
Start treatment for proven osteoporosis in men just as you would in women.
CFPC skill Clinical reasoningPhase Hypothesis generation, treatmentSources Osteoporosis Canada 2023
On the exam
A man of 68 had a low-trauma hip fracture and has no bone scan on file. Expect one best answer for treatment.
Pick the first-line drug and when to start.
Common mistakes
Waiting for a scan or for recovery: the next fracture is likeliest soon after this one. Raloxifene is for women only. Calcium alone leaves him untreated.
Approach
- The rules for starting a drug are the same for men and women (table below).
- First line: a bisphosphonate (alendronate, risedronate or zoledronic acid). Pills may be preferred.
- Denosumab if a bisphosphonate cannot be used. Do not delay a dose by more than a month, or stop it without a plan.
- Start soon after a fracture. The risk of another one is highest early.
- Raloxifene is only for women after menopause who cannot take the others.
- First bisphosphonate course: 3 to 6 years. Give the full 6 years after a hip, spine or several fractures. Do not consider a drug holiday before the course ends.
- Repeat bone density 3 years after starting.
| Finding | Start a drug? | Strength |
|---|---|---|
| Hip or spine fragility fracture, or 2 or more fragility fractures | Yes | Strong |
| 10-year major fracture risk of 20% or more | Yes | Strong |
| Age 70 or older with a T-score of −2.5 or lower | Yes | Strong |
| 10-year risk of 15 to 19.9%, or under 70 with a T-score of −2.5 or lower | Suggested. A fracture in the past 2 years weighs more. | Conditional |
Flashcards
Answer it first, then check.
KF 1A woman of 66 quit smoking 30 years ago. Is that a fracture risk factor?
No. Only current smoking counts. Alcohol counts at 3 or more drinks a day. Source: Osteoporosis Canada 2023
KF 2A healthy 55-year-old woman with no risk factors wants a bone scan. Order it?
No. Neither Canadian guideline supports it. The Task Force advises against screening women under 65. Source: Canadian Task Force on Preventive Health Care 2023, Osteoporosis Canada 2023
KF 3A 60-year-old woman gets 1,200 mg of calcium a day from food. Add a pill?
No. When food meets her need, Osteoporosis Canada suggests no supplement to prevent fractures. Source: Osteoporosis Canada 2023
KF 4Which exercise lowers falls after menopause, and how often?
Balance and functional training, at least twice a week. Walking is fine on top, not instead. Source: Osteoporosis Canada 2023
KF 5After a hip fracture, an 81-year-old asks you to renew her lorazepam. Your plan?
A slow taper, with sleep therapy. Benzodiazepines can more than double falls and hip fractures in older adults. Source: Choosing Wisely Canada
KF 6A 72-year-old man has no risk factors. Does Osteoporosis Canada suggest a bone scan?
Yes, for everyone 70 or older. The Task Force advises against screening men, so name your framework. Source: Osteoporosis Canada 2023, Canadian Task Force on Preventive Health Care 2023
KF 7A 68-year-old man had a low-trauma hip fracture. Which drug first?
A bisphosphonate: alendronate, risedronate or zoledronic acid. The fracture alone qualifies him; no scan is needed first. Source: Osteoporosis Canada 2023
KF 7One year into alendronate after a hip fracture, he asks to stop. Your answer?
Not yet. The first course runs 3 to 6 years, and 6 after a hip fracture. Source: Osteoporosis Canada 2023
FAQ
Which guideline does the exam follow for bone scans?
The CFPC does not say. Name your framework: the Task Force for screening people with no fracture, Osteoporosis Canada for testing by age and risk. A fragility fracture always needs assessment.
Do I need a bone scan before treating a hip fracture?
No. Osteoporosis Canada treats a hip or spine fragility fracture after 50 as enough to start a drug. Do not let a missing scan delay treatment.
Should every older patient take a calcium pill?
No. Get calcium from food first. Osteoporosis Canada suggests no supplement when diet meets the need. Adults over 50 should take 400 IU of vitamin D a day.
How long does a bisphosphonate course last?
Three to 6 years at first, then reassess. Continue for the full 6 years after a hip, spine or several fractures, or with ongoing risk. Repeat bone density 3 years after starting.
Sources
Written from the CFPC Assessment Objectives and Canadian guidelines first. Checked by a Canadian family physician, MD, CCFP.
Last reviewed October 20, 2026For exam study. Not advice for a patient in front of you.
- Assessment Objectives for Certification in Family Medicine, 2nd editionCollege of Family Physicians of Canada · 2020
- Clinical practice guideline for management of osteoporosis and fracture preventionOsteoporosis Canada · 2023
- Osteoporosis and fracture prevention guidelineOsteoporosis Canada · 2023
- Fragility fracture prevention screeningCanadian Task Force on Preventive Health Care · 2023
- Choosing Wisely recommendationsChoosing Wisely Canada