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Clinical practice guideline for management of osteoporosis and fracture prevention in Canada: 2023 update

Author/s: 
Suzanne N. Morin, Sidney Feldman, Larry Funnell, Lora Giangregorio, Sandra Kim, Heather McDonald-Blumer, Nancy Santesso, Rowena Ridout, Wendy Ward

Fracture risk increases with advancing age, as a result of declining skeletal strength and increased risk of falling. In Canada, more than 2 million people live with osteoporosis.1 Every year in Canada, about 150 people per 100 000 suffer a hip fracture, which is considered among the most serious fractures associated with osteoporosis. Fractures lead to increased morbidity, excess mortality, decreased quality of life and loss of autonomy.2 Although osteoporosis is often considered a disease of older females, males are remarkably underevaluated and undertreated for the condition despite suffering worse outcomes following fracture,3 highlighting the importance of providing guidance in males.

Osteoporosis, defined as a bone mineral density (BMD) of 2.5 or more standard deviations below the peak bone mass (i.e., T-score ≤ −2.5), is an indicator of increased fracture risk; this risk is modified by age, sex and other factors.4 A clinical diagnosis of osteoporosis can be made in people aged 50 years and older if they have sustained a low-trauma hip, vertebral, humerus or pelvic fracture after the age of 40 years, or if they have an absolute fracture risk of 20% or more over the next 10 years, using a fracture risk assessment tool (FRAX or the Canadian Association of Radiologists and Osteoporosis Canada [CAROC]).5–7

Advances in risk assessment and nonpharmacologic and pharmacologic management warranted an update to the Osteoporosis Canada 2010 clinical practice guideline for the diagnosis and management of osteoporosis in Canada

Keywords 
quality of life fracture

Approach to nail trauma for primary care physicians

Author/s: 
Knox, Aaron, Lafreniere, Ann-Sophie, Misati , Griffins

Objective: To provide an overview and approach to common nail bed injuries seen by primary care practitioners.

Sources of information: An Ovid MEDLINE literature search was performed using search terms and studies were graded based on level of evidence.

Main message: Nail trauma is common in primary care practice and requires proper and prompt treatment to avoid lasting effects on finger function and cosmesis. When presented with a fingernail injury, primary care physicians should perform a thorough physical examination to determine extent of injury; take a history to rule out notable risk factors; perform a comprehensive neurovascular examination to assess pulp capillary refill, to do a 2-point discrimination, and to compare with an uninjured digit; and evaluate range of motion. Clinical evaluation may require local anesthesia and a tourniquet. Nail bed trauma can present in different ways and includes subungual hematomas, distal phalanx fractures, Seymour fractures, and-in more severe cases-fragmentation or avulsion of the nail bed. Treatment for subungual hematomas where the nail plate is intact does not require nail plate removal and nail bed exploration; however, exploration and repair are indicated for a nail plate injury, a proximal fracture involving the germinal matrix, and a distal phalanx fracture requiring stabilization.

Conclusion: Fingertips are essential to normal hand function. Nail trauma is common and can be managed by primary care physicians. Shared decision making concerning management is based on the mechanism and extent of the injury and aims to prevent secondary deformities.

Keywords 
fingers nails primary care
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