Background: Osteoporosis leads to decreased bone mass, skeletal fragility, and fractures. Osteoporosis affects at least 1.4 million Canadians, 25% of women and 12% of men >60 years of age. The most common osteoporotic fractures are vertebral (spinal), two-thirds of which are asymptomatic. Irrespective of symptoms, these "silent" fractures cause disability, deformity, and death. Compared to those with normal bones and no fracture, the patient with osteoporosis and vertebral fracture has a 20-fold increased risk of future fracture. Guidelines recommend aggressive treatment because rate of re-fracture is 20% within 1 year and treatment reduces risk by 40-50%. Guidelines do not, however, recommend population screening for vertebral fractures. We reported (Arch Intern Med, 2005) that chest radiographs performed in the Emergency Department detected "incidental" fractures in 16% of elderly patients, although only 25% of patients were treated for osteoporosis. The care gap between evidence-based best practice and usual care needs to be urgently addressed.