Fractures — Assessment & Management

Safety

Red Flags — Open Fracture, Neurovascular Compromise & Pathological Fracture

Done

Fracture with bone visible through wound, or wound near fracture site Open (compound) fracture = fracture communicating with a wound, even if small or remote → contamination and infection risk. Urgent trauma transfer; 999 if unstable, major bleeding, vascularly compromised, severely contaminated, traumatic amputation/mangled limb or otherwise requiring emergency transport. ABCDE + haemorrhage control; document wound and neurovascular status. Remove only readily accessible gross contamination; cover with saline-soaked sterile gauze and an occlusive layer — do not irrigate or perform a "mini-washout" before formal wound excision, do not probe or explore the wound, avoid repeated dressing removal. Realign and splint; tetanus prophylaxis by immunisation status. IV prophylactic antibiotics as soon as possible, ideally within 1 hour, per the regional trauma-network protocol (allergy, contamination, renal function, age) without delaying transfer. Wound excision immediately if highly contaminated or vascularly compromised, within 12 hours for other high-energy and within 24 hours for other open fractures (NICE NG37; BOAST). Photograph only via approved clinical systems.

Fracture + pain out of proportion + pain on passive stretch + rising analgesic need + tense compartment, or a pulseless/ischaemic limb Acute compartment syndrome or vascular injury → emergency transfer and pre-alert the receiving team. Pulselessness, pallor and paralysis are late signs — a palpable pulse does not exclude compartment syndrome. Loosen constrictive dressings where safe; keep the limb at about heart level (not markedly elevated); do not delay for community imaging or bloods. Neurovascular examination before and after any reduction, splint or cast, and at each transfer of care. Urgent orthopaedic assessment; fasciotomy follows the clinical diagnosis and specialist decision without waiting for a pressure result when the diagnosis is clear — hospital pressure measurement only if assessment is uncertain or unreliable (BOAST).

Fracture in a patient with known or suspected malignancy + minimal or no trauma mechanism Pathological fracture through metastatic deposit or primary bone tumour. → emergency (999) if neurovascular compromise, spinal instability, cord/cauda equina symptoms or major trauma; otherwise urgent orthopaedic/oncology assessment and appropriate imaging. Avoid loading the affected bone. Radiograph shows lytic lesion + cortical breach.

Spinal injury — vertebral tenderness after high-energy trauma, or neck pain after road traffic accident Spinal fracture + potential cord injury. → 999 / emergency assessment if neurological deficit, altered consciousness, midline tenderness, high-risk mechanism or unable to assess safely. Spinal motion restriction per current major-trauma/spinal-injury protocol — routine rigid spinal board and collar are not appropriate; avoid prolonged immobilisation.

Fracture in a child with an absent, implausible or inconsistent explanation, injury inconsistent with developmental stage, a non-mobile child, multiple fractures or fractures of different ages, occult/rib fractures, or delayed presentation Non-accidental injury (NAI). → Ensure immediate safety; contact the practice safeguarding lead and follow the local pathway; urgent paediatric/safeguarding assessment. Imaging (including any skeletal survey) is directed by the paediatric/safeguarding team and specialist radiology — not arranged from primary care. No single fracture type proves abuse; consider bone-fragility conditions such as osteogenesis imperfecta and osteopenia of prematurity (NICE CG89). Use "fabricated or induced illness" only where appropriate after specialist assessment.

Stress fracture of femoral neck in elderly osteoporotic patient presenting as hip pain + inability to weight-bear without history of significant trauma Insufficiency/stress fracture — may precede complete fracture. → Avoid weight-bearing + same-day orthopaedic assessment (999 if frail and unable to mobilise safely). X-ray may be normal — MRI generally preferred (CT if MRI unavailable within 24 hours or contraindicated). Fixation depends on fracture location, MRI features, displacement, pain and specialist assessment.

The metaphyseal corner fracture (also called 'bucket handle' fracture) is one of the most specific radiological signs of non-accidental injury in young children — it occurs at the metaphyseal-periosteal junction where the periosteum is stripped away from the metaphysis by forcible traction or twisting of the limb. These fractures are most commonly seen in the distal femur, proximal tibia, and distal tibia in infants under 2 years who are not yet independently mobile. They are rarely caused by accidental trauma in this age group, but no single fracture type proves abuse (NICE CG89). Posterior rib fractures (from squeezing the chest) are another highly specific NAI radiological sign. Any child presenting with a fracture where there is any doubt about the mechanism, or where the mechanism doesn't fit the developmental stage of the child, requires urgent paediatric/safeguarding assessment via the local pathway; any skeletal survey or other imaging is directed by the paediatric/safeguarding team and specialist radiology, not arranged from primary care. A negative skeletal survey does not exclude maltreatment or a bleeding/bone-fragility disorder. The GP should not attempt to investigate NAI themselves — contact the practice safeguarding lead and paediatric safeguarding team.

Diagnose

Fracture Types, Ottawa Rules & Classification

Done

Fracture classification

Complete vs incomplete (greenstick in children). Open (compound) vs closed. Displaced vs undisplaced. Comminuted (>2 fragments). Intra-articular vs extra-articular. Stress/insufficiency fracture (repetitive loading — no acute trauma). Pathological (through abnormal bone). Avulsion (tendon or ligament pulls off bony attachment). Compression (vertebral — osteoporotic wedge). Angulation, rotation, shortening (describe displacement). Growth plate fractures in children: Salter-Harris I-V classification — I (through physis), II (physis + metaphysis — most common), III (physis + epiphysis), IV (physis + metaphysis + epiphysis), V (crush injury to physis — growth arrest risk).

Ottawa Ankle Rules (X-ray required if)

NICE NG38: use the Ottawa ankle and foot rules for people over 5 years. Ankle X-ray if bony tenderness at the posterior edge or tip of either malleolus (distal 6cm) OR inability to take four steps both immediately after injury and at assessment. Foot X-ray if bony tenderness at the base of the 5th metatarsal OR over the navicular OR inability to take four steps immediately after injury and at assessment. The rules do not replace clinical judgement — do not apply with gross deformity, suspected dislocation, open injury, neurovascular compromise, altered sensation or unreliable examination, or children who cannot reliably participate.

Ottawa Knee Rules (separate knee rule — the age criterion is not part of the ankle/foot rules)

Knee X-ray if: age ≥55 OR isolated patellar tenderness OR tenderness at fibular head OR inability to flex ≥90° OR inability to weight-bear 4 steps → X-ray.

Cervical spine

Use the Canadian C-spine rule or NICE spinal-injury guidance in full (age ≥65 is one Canadian C-spine high-risk factor, not an Ottawa criterion). High-risk mechanism, neurological symptoms, midline tenderness, altered consciousness or inability to assess safely → spinal motion restriction and emergency assessment per local trauma protocol; routine rigid board and collar are not appropriate.

5th metatarsal & scaphoid

5th metatarsal base fracture (Jones fracture vs pseudo-Jones): Jones = at the metaphyseal-diaphyseal junction (poor blood supply, may need fixation); pseudo-Jones = avulsion of styloid process at base (good prognosis, conservative). Scaphoid fracture: suspect with anatomical snuffbox or scaphoid-tubercle tenderness, pain on axial thumb loading or pain on wrist movement after a fall on the outstretched hand. NICE NG38: consider MRI as first-line imaging after thorough examination; if MRI is not immediately available, immobilise per local practice and arrange prompt fracture-clinic/imaging review. Plain radiographs may miss an acute scaphoid fracture — do not dismiss the diagnosis because initial X-rays are normal. Missing scaphoid fracture → avascular necrosis risk.

The Ottawa Rules are one of the most rigorously validated clinical decision rules in emergency medicine — their high sensitivity for clinically significant ankle and foot fractures means that applying them safely reduces unnecessary X-rays. The key word is 'clinically significant' — not every crack counts, only fractures requiring immobilisation or surgery. GPs in primary care who see acute ankle injuries can apply the Ottawa Rules to decide whether an X-ray is clinically necessary before referring to A&E or requesting plain X-ray through direct access. An ankle sprain with no malleolar tenderness and ability to weight-bear does not need X-ray. However, Ottawa Rules have reduced reliability in: children who cannot reliably participate (NICE NG38 applies them over 5 years), patients with peripheral neuropathy, patients with intoxication or distracting injuries, and patients who present late (>48h post-injury when bruising and swelling obscure tenderness). In these groups, a lower threshold for X-ray is appropriate.

Diagnose

Assessment — History, Examination & Investigations

Done

Fracture history

Mechanism: high energy (RTA, fall from height — high risk of multiple injuries + spinal injury) vs low energy (fall from standing — consider osteoporosis, pathological fracture). Direct vs indirect force (twisting → spiral fracture; axial loading → compression). Time of injury. Any previous X-ray or assessment. Current neurovascular symptoms: numbness, tingling, weakness distal to fracture. Tetanus immunisation status (open fractures). Time of injury and any delay in presentation; crush or fall from height; pain, deformity, loss of function and ability to weight-bear or use the limb; colour change. Anticoagulants, antiplatelets, steroids and relevant comorbidity. Osteoporosis risk factors: age, previous fracture, steroid use, low BMI, smoking, alcohol, premature menopause, parental hip fracture and secondary causes. Children: developmental mobility, exact mechanism, witnesses, delay in presentation and whether the explanation fits the injury.

Examination (ABCDE for high-energy trauma first)

Soft tissue: swelling, bruising, deformity, shortening, skin compromise. Neurovascular: distal pulse palpation, capillary refill, temperature and colour, motor and sensory function in named nerve distributions, tendon function where relevant. Skin integrity and any wound near the fracture. Compartment assessment: pain out of proportion, pain on passive stretch (passive extension of fingers/toes), tense compartment — a clinical diagnosis; hospital pressure measurement only if assessment is uncertain or unreliable. Spinal examination and full trauma assessment where indicated. Repeat and record the neurovascular examination after manipulation/reduction, after a splint, cast or backslab, and at each transfer of care. Joint above and below fracture: always assess for ligamentous injury. Growth plate in children: palpate physis — if tender, assume physis involved even if X-ray normal.

Investigations

X-ray (2 views — AP + lateral minimum) (primary investigation — all suspected fractures; note: normal X-ray does not exclude occult fracture in scaphoid, femoral neck stress fracture, occult hip fracture; do not delay transfer for X-ray if vascular compromise, obvious deformity or suspected hip fracture) · MRI (consider first-line for suspected scaphoid fracture; occult hip or femoral neck stress fracture — CT if MRI unavailable within 24 hours or contraindicated; vertebral marrow oedema, soft tissue + ligament) · CT (complex fractures — tibial plateau, pilon, acetabulum, spine; pre-operative planning) · FBC + group and save (significant blood loss, e.g. femoral fracture) · DEXA scan (offer from age 30 after a hip or vertebral fragility fracture, a major osteoporotic fragility fracture in the last 2 years, or 2 or more fragility fractures (NICE NG259); otherwise selective — when FRAX/NOGG risk is near a treatment threshold or the result will alter management; treatment need not wait for DXA when risk is clearly high)

The scaphoid fracture occult diagnosis is the most important missed fracture in primary care — the scaphoid is the most commonly fractured carpal bone, typically from a fall on an outstretched hand (FOOSH), and plain radiographs may miss an acute scaphoid fracture. The consequence of missing a scaphoid fracture: the scaphoid has a retrograde blood supply (from the distal pole proximally), meaning an undisplaced proximal or waist scaphoid fracture can cause avascular necrosis (AVN) of the proximal pole if not immobilised, leading to carpal collapse and lifelong pain and reduced grip. The clinical standard: any patient with snuffbox tenderness (dorsoradial wrist pain on palpation of the anatomical snuffbox between EPL and APB tendons at the base of the thumb) after a FOOSH mechanism should be treated as a scaphoid fracture until proved otherwise — immobilise per local practice and consider MRI as first-line imaging (NICE NG38), with prompt fracture-clinic or imaging review if MRI is not immediately available, regardless of initial X-ray result. Do not discharge a FOOSH with snuffbox tenderness as a 'sprained wrist' based on a normal X-ray.

Diagnose

Fragility Fractures, FRAX & Osteoporosis Assessment

Done

Fragility fracture definition and implications

A fragility fracture is a fracture resulting from a fall from standing height or less (or minimal trauma), although clinical judgement is needed — it suggests possible osteoporosis. High-energy trauma does not exclude osteoporosis but should not automatically be labelled a fragility fracture. Common sites: distal radius (Colles' fracture — most common first fragility fracture), vertebral body (compression fracture — often painless), hip (neck of femur or intertrochanteric — most consequential, with high early mortality), proximal humerus, ankle. Any fragility fracture → refer to, or capture by, the local Fracture Liaison Service to assess fracture risk, falls risk, secondary causes, calcium and vitamin D status, need for drug treatment, adherence and future fracture prevention (NICE QS149). Aged ≥60 with persistent bone pain, particularly back pain, or an unexplained fracture → offer FBC, calcium, ESR or plasma viscosity, serum protein electrophoresis and serum free light chains, all together (urine Bence Jones protein if free light chain testing is not available), and use a suspected cancer pathway referral if the results suggest myeloma (NICE NG12, updated April 2026).

FRAX and DEXA assessment

FRAX (fracture risk assessment tool — WHO): estimates 10-year probability of major osteoporotic fracture + hip fracture. Inputs: age, sex, BMI, smoking, alcohol, steroid use, RA, secondary osteoporosis, parental hip fracture, previous fracture. Available at: shef.ac.uk/FRAX. Fracture risk assessment (NICE NG259, July 2026; replaced CG146): consider in all women ≥65 and men ≥75, and in younger people with risk factors, using FRAX or QFracture (QFracture only at 30–39; keep to one tool for each person); offer DXA directly (with or without a risk tool) from age 30 after a hip or vertebral fragility fracture, a major osteoporotic fragility fracture in the last 2 years, or 2 or more fragility fractures; otherwise arrange DEXA when the result is close to a NOGG intervention threshold or before starting treatment where needed. Interpretation: T-score ≥ -1.0 = normal; T-score -1.0 to -2.5 = osteopenia; T-score ≤ -2.5 = osteoporosis. Treatment follows FRAX/NOGG risk, fracture site, age, renal function and contraindications — not the T-score alone; treatment may be appropriate without DXA where scanning is impractical or would not alter management (NOGG 2024). Do not use FRAX to monitor treatment response. Consider vertebral imaging with height loss, kyphosis, acute back pain, long-term glucocorticoids or low BMD.

Children's fractures — growth plate and NAI considerations

Consider maltreatment (NICE CG89) when the injury is inconsistent with developmental stage, the child is not independently mobile, there are multiple fractures or fractures of different ages, occult or rib fractures in infants, an absent/implausible/inconsistent explanation or delayed presentation — and consider bone-fragility conditions. Address possible non-accidental injury before discharge in all children with femoral fractures, particularly non-walking or non-verbal children (NICE NG38). Do not discharge a child with unresolved safeguarding concerns without senior paediatric/safeguarding discussion. Salter-Harris classification: type I and II (most common) — generally good prognosis. Type III-V: involve the articular surface or damage the growth plate — risk of growth arrest, angular deformity. Salter-Harris V (physeal crush): may appear normal initially; progressive growth arrest noticed months later. Children's bone remodels — some angulation acceptable (depends on proximity to growth plate, age, site). Refer to paediatric orthopaedics for all types III-V and any NAI concern.

The FRAX tool with DEXA integration provides the most clinically precise fracture risk assessment available in primary care — the combination of clinical risk factors (FRAX without DEXA) + T-score from DEXA allows calculation of the absolute 10-year fracture risk, which then guides the treatment decision. UK treatment decisions use the NOGG age-dependent intervention thresholds (FRAX result plotted against the NOGG thresholds at nogg.org.uk) — not the fixed US cut-offs of hip ≥3% / major ≥20%. In practice, bone protection (commonly alendronate 70 mg once weekly first-line) is offered according to NOGG risk, fracture site, renal function, contraindications and patient preference — not on the T-score alone. The Fracture Liaison Service (FLS) — available in most UK NHS trusts — systematically identifies patients with fragility fractures (particularly hip, vertebral, and distal radius) and coordinates DEXA, FRAX, and treatment initiation. GP referral to FLS for any new fragility fracture helps reduce secondary fractures.

Refer

Referral Pathways

Done

999

Uncontrolled haemorrhage or major trauma · Open fracture with major bleeding, severe contamination, vascular injury, traumatic amputation or mangled limb · Ischaemic or pulseless limb · Suspected acute compartment syndrome · Fracture-dislocation threatening skin or neurovascular status · Suspected spinal fracture with neurological deficit, altered consciousness or high-risk mechanism · Suspected pelvic fracture with haemodynamic instability · Hip fracture in an older or frail person who cannot safely mobilise · Suspected pathological fracture with neurological compromise or cord/cauda equina symptoms

A&E / fracture clinic (same-day)

Other open fractures → urgent trauma/orthopaedic transfer · Any displaced, angulated, unstable or intra-articular fracture · Suspected hip fracture, even if initial X-ray negative (avoid unnecessary mobilisation) · Suspected scaphoid fracture · Suspected physeal fracture in a child · Fracture with abnormal sensation, weakness, disproportionate pain or increasing swelling · Cast or splint with increasing pain, paraesthesia, swelling, colour change or reduced movement · Possible pathological fracture without acute neurovascular compromise · Any fracture with safeguarding concerns

Fracture clinic (within 72 hours)

Undisplaced distal radius fracture for plaster · Undisplaced ankle fracture for immobilisation · 5th metatarsal Jones fracture (poor healing — may need fixation) · Undisplaced clavicle fracture (sling + review). BOAST: new fracture-clinic review within 72 hours for significant injuries, with a written management plan and a route for rapid re-access

Osteoporosis management

Any fragility fracture → Fracture Liaison Service (FLS) referral; DXA per NICE NG259 (directly after a hip or vertebral fragility fracture, a major osteoporotic fragility fracture in the last 2 years, or 2 or more fragility fractures; otherwise FRAX/NOGG risk assessment with selective DXA). Primary care may initiate alendronate 70 mg weekly when the treatment indication and local pathway are clear — not solely on the T-score. Encourage adequate dietary calcium; vitamin D where deficient or at risk.

GP management

Ottawa rules negative ankle injury: RICE (Rest, Ice, Compression, Elevation) + analgesia (NSAID only after individual assessment of age, renal, GI, cardiovascular and bleeding risk) + physiotherapy referral. Minor stable undisplaced fracture (confirmed by X-ray): strapping/buddy taping + analgesia + safety-net.

The hip fracture 30-day and 1-year mortality data places it among the highest-priority surgical emergencies in elderly care — hip fracture carries high early and 1-year mortality, especially in frail people and care-home residents. A GP who identifies an elderly patient with hip pain and inability to weight-bear after a fall must act immediately: arrange 999 transfer, ensure the patient is not attempting to walk, provide analgesia (IV or IM morphine 2.5-5 mg if available), check limb neurovascular status, and document the fall mechanism and any anticoagulant use (which affects surgical timing). The clinical sign of hip fracture: shortened + externally rotated lower limb; inability to straight leg raise; pain on axial loading of the hip (grinding heel). Some minimally displaced hip fractures may walk into the GP surgery — any elderly patient with new hip pain after a fall who cannot fully weight-bear requires same-day hospital assessment — do not delay transfer for primary-care radiography. Shortening and external rotation may be absent.

Treat

Fracture Immobilisation, Analgesia & Osteoporosis Treatment

Done

Fracture analgesia

Multimodal approach: (1) paracetamol 1g QDS (regular, not PRN — maintains plasma levels); (2) NSAID only after individual assessment — avoid routinely in older people with hip/vertebral fracture and in renal disease, peptic ulcer disease, heart failure, cardiovascular or high bleeding risk; NICE does not recommend NSAIDs for peri-operative hip-fracture analgesia; (3) short-course opioid for severe pain, e.g. codeine 30-60 mg QDS PRN, with constipation and falls-risk precautions. Review analgesic need frequently and reduce as pain improves. Stronger opioid (significant fracture — femur, pelvis, hip): morphine 2.5-5 mg PRN (titrate to pain — elderly patients: lower dose, longer interval).

Osteoporosis first-line treatment

Alendronate 70 mg once weekly (empty stomach, with plain water, remain upright at least 30 min after; not with calcium, food or other medicines — prevent oesophageal ulceration). Not solely on T-score: consider fracture risk and site, renal function (check SPC thresholds), calcium and vitamin D status, oesophageal disease or inability to remain upright, dental/jaw risk, pregnancy potential, preference and adherence. Reduces vertebral, non-vertebral and hip fracture risk. Review oral bisphosphonate after approximately 5 years (IV zoledronate after approximately 3 years), continuing or pausing according to current fracture risk; DXA only when it will inform management. Very high risk (recent or multiple vertebral fractures, very low BMD, high-dose glucocorticoids) → specialist assessment for anabolic or parenteral treatment (NOGG 2024). Side effects: upper GI (oesophagitis — contra if Barrett's, significant GORD, inability to remain upright). Alternative if oral bisphosphonate intolerant: risedronate 35 mg once weekly or IV zoledronate 5 mg yearly. Encourage adequate dietary calcium; supplement vitamin D (± calcium) where deficiency or risk is present, per local guidance.

Colles' fracture (distal radius) conservative management

Undisplaced: below-elbow plaster of Paris (POP) or synthetic cast for 6 weeks. Displaced: manipulation under LA block (haematoma block — 10 mL lidocaine 1% into fracture haematoma) + closed reduction + plaster. Check post-reduction X-ray. Physiotherapy after cast removal: wrist mobilisation, grip strengthening. Review at 1-2 weeks in fracture clinic.

Alendronate oesophageal compliance counselling is one of the most important patient education points for bisphosphonate therapy — bisphosphonates must be taken under very specific conditions to avoid oesophageal erosions, which can be severe. The mandatory instructions: take on waking in the morning before eating or drinking anything; take with a FULL glass of water (not tea, coffee, juice, or mineral water — these reduce absorption); remain completely upright (sitting or standing — not lying down) for at least 30 minutes after taking; do not take any other medications for 30 minutes. The pharmacological reason: bisphosphonates are poorly absorbed and require an empty stomach + full upright posture to transit the oesophagus rapidly before the tablet dissolves and contacts the oesophageal mucosa. Patients who take alendronate with a half-glass of water and go back to bed develop alendronate-related oesophageal ulceration — a significant adverse effect that can cause severe dysphagia and haemorrhage. GPs should review these instructions at every prescription and document that compliance counselling has been given.

Treat

Specific Fractures — Clinical Management

Done

Hip fracture — primary care management before transfer

Immediate: appropriate analgesia (NICE CG124: regular paracetamol + immediate-release opioid if required; NSAIDs not recommended) ± anti-emetic; avoid unnecessary mobilisation; emergency transfer — do not delay for primary-care radiography. Examination: shortened + externally rotated limb (may be absent), pain on gentle passive movement, neurovascular check. Cannula + IV fluids (maintenance if prolonged wait). Document: last food/drink (anaesthetic planning), anticoagulants/antiplatelets, baseline cognitive status. NICE CG124: surgery on the day of, or the day after, admission, with early orthogeriatric and multidisciplinary care. If hip X-rays are negative but suspicion remains → MRI (CT if MRI unavailable within 24 hours or contraindicated). Document baseline mobility. Hip fracture anaemia: transfusion per NICE NG24 restrictive thresholds (Hb <70 g/L; <80 g/L with acute coronary syndrome). Post-operatively: immediate mobilisation + FLS for osteoporosis treatment.

Vertebral compression fracture

Presentation: acute or subacute focal back pain, worse on movement, coughing or changing position; height loss, kyphosis, known osteoporosis or new back pain on long-term glucocorticoids. Assess for neurological deficit, bowel or bladder disturbance, saddle anaesthesia, fever/infection, history of malignancy and features of metastatic spinal cord compression → emergency spinal/oncology assessment for suspected cord compression or cauda equina. Treatment: oral analgesia where possible (caution with NSAIDs in older people — if used, gastroprotection and renal, GI and cardiovascular monitoring); mobilise as tolerated and avoid prolonged bed rest. A compression fracture alone does not automatically need bracing, vertebroplasty/kyphoplasty or urgent surgery — individualise with specialist spinal review. Start or review osteoporosis treatment according to fracture risk.

Child fracture — growth plate and remodelling

Salter-Harris I + II: conservative management (cast x 3-6 weeks) + paediatric orthopaedic follow-up. Monitor for growth arrest at 6 months + 12 months post-injury. Clavicle fracture: sling for 3-4 weeks (children) — excellent remodelling. Greenstick fracture: cast for stability. Torus (buckle) fracture: often treated with wrist brace + analgesia; cast not always required.

Next steps: see Osteoporosis

The vertebral augmentation debate (vertebroplasty/kyphoplasty) has evolved significantly — the VAPOUR trial (JAMA 2016) and VERTOS II trial showed conflicting results compared to the original INVEST and VERTOS I trials, and NICE TA279 (2013) recommends vertebroplasty or balloon kyphoplasty only for severe ongoing pain after a recent, unhealed osteoporotic vertebral fracture despite optimal pain management. The current role: vertebroplasty (cement injection) and kyphoplasty (balloon + cement) may be offered to selected patients with acute vertebral fractures (within 6 weeks) who have severe pain not controlled by analgesia, confirmed fracture with marrow oedema on MRI, no neurological deficit, and appropriate anatomy. GPs should not refer all vertebral fractures for augmentation — the evidence is insufficient to support routine use. The primary GP management is: adequate analgesia, mobilisation as tolerated, physiotherapy, and fracture-risk assessment with osteoporosis treatment according to risk. Referral to specialist spine service only if: persistent severe pain at 6 weeks despite adequate treatment.

Lifestyle

Fracture Prevention, Bone Health & Rehabilitation

Done

Falls prevention for fragility fracture risk NICE NG249 (Falls, 2025): comprehensive multifactorial assessment for people aged 65 and over, or 50–64 with relevant risk factors, who have fallen and meet its criteria, including those with a fall-related fragility fracture — do not use a falls-risk prediction score alone. Assess gait, balance, mobility, strength, postural BP and cardiovascular symptoms, hearing, cognition, mood, footwear and foot health, continence, dizziness, nutrition and weight loss, osteoporosis risk. Components: medication review (stop sedatives, reduce antihypertensives causing postural hypotension), vision assessment (cataract surgery), vestibular assessment, environment hazard removal (loose rugs, grab rails, night lights), tailored strength and balance exercise (e.g. Tai Chi or Otago-type programmes), home-hazard intervention and medication review.

Bone health nutrition Calcium: 700-1000 mg/day dietary calcium (dairy; fortified plant milks; leafy greens; tinned fish with bones). Encourage adequate dietary calcium; supplement only if intake is inadequate, per local guidance. Vitamin D: supplement where deficiency or risk is present (e.g. housebound, full body covering, dark skin), per local guidance. Check 25-OH-vitamin D before supplementing high doses. Protein: adequate dietary protein (1 g/kg/day) essential for bone matrix formation and muscle mass (sarcopenia worsens falls risk).

Exercise for bone health Weight-bearing and resistance exercise stimulates osteoblast activity and maintains bone density. Walking 30 min daily (moderate benefit). High-impact activities (dancing, jogging) provide greater bone stimulus but must be balanced against falls risk. Resistance training (gym or physiotherapy — supervised): 2x/week, large muscle groups — helps maintain bone density and muscle strength. Swimming and cycling: cardiovascular benefit but NON-weight-bearing — minimal bone density benefit.

Smoking cessation and bone health Smoking reduces bone density, increases fracture risk, impairs fracture healing (reduces periosteal blood supply + osteoblast activity), and causes early menopause (accelerating osteoporosis in women). NHS Stop Smoking Services. The combined effect of smoking + low BMI + steroid use significantly elevates fracture risk — assess fracture risk with FRAX or QFracture, with DXA where it will alter management.

Rehabilitation after fracture Physiotherapy post-cast: ROM exercises, progressive resistance, proprioceptive retraining. Hip fracture: intensive physiotherapy from day 1 post-operatively — stand and mobilise within 24h. Colles' fracture: wrist extension, pronation/supination exercises from week 2 post-cast. OT assessment: for ADL difficulties, home adaptations, equipment (grab rails, shower stool). Mobilise when clinically safe and permitted by the orthopaedic team. Assess function, work, driving, home safety and equipment needs. Fracture clinic should provide a written plan and a route for rapid re-access if recovery is not as expected. Goal-setting with patient: return to previous function + prevent second fracture.

DEXA and bisphosphonate monitoring Alendronate: baseline renal function, calcium and vitamin D assessment and contraindication check (SPC renal thresholds); routine FBC/LFT monitoring is not required. Treatment review at approximately 5 years for oral bisphosphonates and 3 years for IV zoledronate, with DXA only when it will inform management. Zoledronate: calcium + vitamin D supplementation mandatory (hypocalcaemia post-infusion). Denosumab is not a simple alternative bisphosphonate to start or stop in primary care: 60 mg SC every 6 months. Before starting, ensure a clear long-term plan, corrected calcium and vitamin D adequacy, renal and hypocalcaemia risk assessment, six-monthly administration and recall, and a documented transition plan. Do not delay or stop without specialist advice — stopping or delaying increases the risk of multiple vertebral fractures; an alternative antiresorptive is required (MHRA). Strontium ranelate: withdrawn in UK (cardiovascular risk).

Return to driving after fracture DVLA requirements: patients must not drive if fracture prevents safe vehicle control. There is no fixed DVLA time rule after fracture: individual safe-driving assessment — the patient must be able to control the vehicle safely, including an emergency stop, and should check insurer and DVLA requirements where relevant. Upper limb fracture — must have adequate steering control. Cast on the right foot: always seek driving assessment. GP documentation: advise patient verbally + in writing about driving restriction + document in notes.

Workplace and school absence after fracture Fit note (MED3): issue immediately for significant fractures preventing work. Duration depends on the fracture, its treatment and the job; use the fracture-clinic plan. Phased return to work: start date + reduced hours + adjusted duties — document on fit note. School absence: inform school in writing. Children with femoral fracture: may need wheelchair + educational support for extended period.

The denosumab discontinuation rebound vertebral fracture risk is a critical patient safety issue — denosumab (Prolia 60 mg SC every 6 months) inhibits RANK ligand, thereby reducing osteoclast activity and increasing bone density. When denosumab is stopped (for any reason — patient preference, financial, side effects), there is a rapid rebound increase in bone resorption within 6-12 months, which can cause multiple vertebral fractures in patients who were previously fracture-free. This is a class effect related to the mechanism of action, distinct from bisphosphonates. The patient safety principle: denosumab should NEVER be stopped or delayed without specialist advice and a transition plan to an alternative antiresorptive (usually bisphosphonate) therapy. At least 1 year of bisphosphonate (zoledronate IV preferred, or alendronate oral) should be given after stopping denosumab to maintain the anti-fracture protection. GPs reviewing denosumab prescriptions who consider stopping it (e.g., after 5 years) must consult with a specialist and ensure a bisphosphonate bridge is in place.

Safety

Follow-Up, Monitoring & Secondary Prevention

Done

Post-fracture standard of care

Any fragility fracture → Fracture Liaison Service referral; DXA per NICE NG259 (directly after a hip or vertebral fragility fracture, a major osteoporotic fragility fracture in the last 2 years, or 2 or more fragility fractures; otherwise FRAX/NOGG risk assessment with selective DXA); calcium and vitamin D status; bone protection according to risk, fracture site and contraindications (not on T-score alone). Review at 6 weeks: pain, function, range of motion, cast comfort. Review at 3 months: fracture healing (X-ray), occupational and physiotherapy progress.

Cast complications

Advise same-day review (fracture clinic or A&E) for increasing pain despite analgesia, new numbness, paraesthesia or weakness, blue/pale/cold digits, increasing swelling or tightness, inability to move fingers or toes, pain on passive stretch, foul odour, discharge, fever or skin breakdown, or a wet, broken, loose or displaced cast. Cast removal, splitting or modification must be performed by trained staff — emergency assessment now if neurovascular or compartment symptoms are present. Do not "window" a cast in primary care.

NAI — safety in children

Any fracture with NAI concern: do NOT discharge. Paediatric safeguarding referral immediately. If child is at home risk: MASH referral (Multi-Agency Safeguarding Hub). Contact the practice safeguarding lead. Imaging (including any skeletal survey) is directed by the paediatric/safeguarding team, not arranged from primary care. Document the history verbatim where relevant, examination, developmental stage and mechanism (body maps; photographs only via approved systems).

999 / Same-day

Open fracture · Vascular compromise (pulseless limb) · Compartment syndrome signs · High-energy trauma · Spinal injury · Hip fracture (elderly) · Any NAI concern · Suspected scaphoid or physeal fracture · Cast with increasing pain, paraesthesia, swelling, colour change or reduced movement

Fracture clinic within 72 hours

Any stable undisplaced fracture requiring cast or immobilisation (BOAST: new fracture-clinic review within 72 hours for significant injuries). Suspected scaphoid fracture is same-day (above): immobilise and arrange MRI first-line or same-day fracture-clinic review.

The secondary fracture prevention pathway after a first fragility fracture is where the largest gap between evidence and practice exists in UK primary care — many patients who suffer a hip fracture do not receive osteoporosis treatment after discharge. The Fracture Liaison Service (FLS) model (which systematically identifies patients with fragility fractures through hospital and primary care records, coordinates DEXA scanning, and initiates treatment) reduces secondary fractures and is cost-effective by NHS standard cost-effectiveness thresholds. Every GP practice should ensure that all patients with fragility fractures (hip, vertebral, Colles', humerus) who are not already on bisphosphonate therapy are: referred to FLS (where available), assessed per NICE NG259 (DXA directly after a hip or vertebral fragility fracture, a major osteoporotic fragility fracture in the last 2 years, or 2 or more fragility fractures; otherwise FRAX/NOGG with DXA where it will alter management), checked for calcium and vitamin D status, and offered bone protection according to risk, fracture site and contraindications. This is a core quality standard — the primary responsibility for initiating osteoporosis treatment after fragility fracture rests with the GP if FLS is not available or does not follow up.