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. Their specificity for NAI approaches 80-90% — they are almost never caused by accidental trauma in this age group. 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 a full skeletal survey (a standardised radiological series of all long bones + spine + skull + ribs) and immediate safeguarding referral. The GP should not attempt to investigate NAI themselves — contact the paediatric safeguarding team.

The Ottawa Rules are one of the most rigorously validated clinical decision rules in emergency medicine — their sensitivity of approximately 97-99% for clinically significant ankle and foot fractures means that applying them reduces the number of X-rays ordered by approximately 30-40% without missing any fractures that would change management. 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 sensitivity in: patients under 18, 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.

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 has a false-negative rate of approximately 20% on initial X-ray. 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 — thumb spica cast + MRI within 3-5 days (or bone scan if MRI unavailable) regardless of initial X-ray result. Do not discharge a FOOSH with snuffbox tenderness as a 'sprained wrist' based on a normal X-ray.

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. The NICE NG187 thresholds for treatment: if 10-year hip fracture probability ≥3% (from FRAX) or 10-year major fracture probability ≥20%, treatment is indicated. In practice, this means: first-line bisphosphonate (alendronate 70 mg once weekly) should be offered to any woman over 70 with a fragility fracture, and to younger patients if FRAX exceeds the intervention threshold for their age. 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 dramatically reduces secondary fracture rates.

The hip fracture 30-day and 1-year mortality data places it among the highest-priority surgical emergencies in elderly care — approximately 76,000 hip fractures occur annually in the UK, with a 30-day mortality of approximately 8% and a 1-year mortality of approximately 25-35% (higher in nursing 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 X-ray and orthopaedic assessment.

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.

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 the current NICE guidance (2013, under review) does not recommend vertebroplasty routinely outside of specialist centres or clinical trials. 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 (alendronate + calcium/D3 immediately), early mobilisation, physiotherapy, and DEXA. Referral to specialist spine service only if: persistent severe pain at 6 weeks despite adequate treatment.

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 without a transition plan to 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.

The secondary fracture prevention pathway after a first fragility fracture is where the largest gap between evidence and practice exists in UK primary care — a BMJ audit (2020) found that fewer than 30% of patients who suffered a hip fracture received osteoporosis treatment within 12 months of 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 fracture rates by approximately 40% 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), offered DEXA scan, started on calcium + vitamin D supplementation, and offered alendronate 70 mg weekly if T-score ≤ -2.5. 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.