Reasoning GP · Algorithm · 1-page summary
Fractures — suspected or confirmed
For: adults and children with a suspected or confirmed fracture, in primary care. Not for: joint pain without injury (use the hip, knee or ankle pain algorithms); a limping child without clear injury (limping child); osteoporosis treatment detail (osteoporosis protocol).
Core rule: check skin and neurovascular status first, and never let a normal X-ray, a palpable pulse or a patient who walked in overrule high clinical suspicion. Then ask why the bone broke: every fragility fracture needs bone-health follow-up.
0Stop — call 999 now — before X-ray or bloods
- Major trauma or uncontrolled bleeding; open fracture with major bleeding, severe contamination, vascular injury, amputation or mangled limb → 999. ABCDE, control bleeding; cover with saline-soaked sterile gauze + occlusive layer; do not irrigate or probe; splint; check tetanus status.
- Pulseless or ischaemic limb, or suspected compartment syndrome (pain out of proportion, pain on passive stretch, rising analgesic need, tense compartment) → 999 + pre-alert. Loosen tight dressings; limb at about heart level.
- Suspected spinal fracture with neurological deficit, altered consciousness or high-risk mechanism; pelvic fracture with haemodynamic instability → 999. Spinal motion restriction per protocol; no routine rigid board or collar.
- Hip fracture in an older or frail person who cannot safely mobilise; pathological fracture with neurological compromise or cord/cauda equina symptoms → 999. Do not mobilise; no primary-care X-ray first.
1Triage — X-ray? — Ottawa rules (NICE NG38, over 5 years)
| Site | X-ray if any of |
|---|---|
| Ankle | Tender posterior edge or tip of a malleolus (distal 6 cm), or cannot take 4 steps both at injury and now |
| Foot | Tender 5th metatarsal base or navicular, or cannot take 4 steps |
| Knee | Age ≥55; isolated patellar or fibular-head tenderness; flexion <90°; cannot take 4 steps |
| Do not apply | Deformity, dislocation, open wound, neurovascular deficit, unreliable examination |
2Screen — one row is enough
- Other open fracture → Same-day trauma transfer
- Displaced, unstable or intra-articular; suspected hip (even if X-ray negative), scaphoid or physeal → Same-day A&E / fracture clinic
- Altered sensation, weakness, disproportionate pain, rising swelling, or a painful tight cast → Same-day
- Child: story absent or inconsistent, non-mobile, multiple or rib fractures, delay → safeguarding lead, Same-day paediatric safeguarding; no skeletal survey from primary care.
- Known or suspected cancer + minimal trauma (pathological) → Same-day orthopaedics; avoid loading.
- Older person, hip pain, cannot weight-bear, little trauma → no weight-bearing, Same-day orthopaedics
3Assess — once blocks 0–2 are answered
☐ Mechanism: high or low energy, delay ☐ Pulses, capillary refill, motor, sensory; repeat after splint or cast ☐ Skin, wounds ☐ Joint above and below ☐ Child: tender physis = physeal injury ☐ Anticoagulants, steroids, bone risk
X-ray AP + lateral; occult scaphoid or hip → MRI (CT if no MRI within 24 h). Not: X-ray before transfer with vascular compromise, deformity or suspected hip fracture.
4Classify — only if the screen is negative
- Ottawa-negative ankle → RICE, analgesia, physiotherapy.
- Stable undisplaced → minor: buddy taping; needs cast, or 5th metatarsal Jones → Fracture clinic ≤72 h
- Scaphoid — snuffbox or tubercle tenderness, axial thumb pain → immobilise; consider MRI first-line.
- Vertebral compression → analgesia, mobilise; no routine bracing or vertebroplasty.
- Child — torus: often wrist brace; Salter-Harris III–V → paediatric orthopaedics.
- Uncertain — suspicion with normal X-ray: immobilise; MRI or fracture-clinic review.
5Treat today — doses: NICE/SPC, BNF, local formulary
- Analgesia: regular paracetamol; short opioid course if severe. NSAID only after risk check; not routinely in older people with hip or vertebral fracture. Hip fracture: no NSAID.
- Splint; neurovascular check before and after. Never "window" a cast in primary care.
- Driving: no fixed DVLA time; only with safe control incl. emergency stop; cast on right foot → driving assessment. Document; fit note if needed.
6Refer routinely — the bone-health step
- Any fragility fracture → Fracture Liaison Service; calcium, vitamin D.
- DXA (NG259) from age 30 after hip or vertebral fragility fracture, a major one in 2 years, or ≥2; else FRAX/NOGG, selective DXA.
- Bone protection by risk, not T-score; alendronate 70 mg weekly. Never stop denosumab unplanned.
- Aged ≥60, unexplained fracture → offer FBC, calcium, ESR/PV, protein electrophoresis + free light chains (NG12); myeloma? → suspected cancer pathway.
- Falls assessment (NG249); physiotherapy, OT.
7Never reassure by
- A palpable pulse — it does not exclude compartment syndrome.
- A normal X-ray in suspected scaphoid or hip fracture.
- Walking in — some hip fractures do; shortening may be absent.
- Ottawa rules with neuropathy, intoxication or presentation >48 h.
- A negative skeletal survey — it does not exclude abuse.
- Fixing the fracture but forgetting the bone (no FLS).
8Safety-net — say it, then document it
Emergency now “If your fingers or toes go numb, tingly, weak, pale, blue or cold, or the pain is far worse than expected or worse when you move them — go to A&E now or call 999.”
Same day “Pain rising despite painkillers, more swelling or tightness, a smell, discharge, fever, sore skin, or a wet, broken or loose cast — fracture clinic or A&E today. Do not cut the cast yourself.”
✓Safe to leave primary care only if — all five, documented
No block 0–2 row; skin and neurovascular status recorded
Imaging decided; occult fracture immobilised, followed up
Child: story fits development; safeguarding considered
Fragility fracture → FLS, DXA and falls actioned
Analgesia, cast safety-net, driving advice; follow-up set
Summary of the full Reasoning GP fractures algorithm, which holds the classification, examination, specific-fracture management, rehabilitation and evidence. Sources: NICE NG38, NG37, CG124, CG89, NG259 (July 2026), NG12 (updated April 2026), NG249, QS149; NOGG 2024; BOAST open fractures, compartment syndrome and fracture clinic services; MHRA (denosumab); DVLA. Clinical reference — follow local trauma, safeguarding and fracture liaison pathways and check doses: NICE/SPC, BNF.