Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Falls assessment after fragility fracture
Musculoskeletal medicine and orthopaedics · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
!
Do not label collapse as a simple fall
Ongoing neurological deficit, chest pain, arrhythmia, severe postural hypotension, significant head injury, sepsis, hypoglycaemia or recurrent unexplained loss of consciousness needs urgent cause-specific assessment.
Action: Stabilise with ABCDE, check bedside glucose and appropriate observations, investigate the time-critical alternative and protect the fracture while the fall history is reconstructed.
Role and principles
Reconstruct why a fall occurred, identify modifiable recurrence risks and link fracture treatment to tailored falls, bone-health and functional interventions before another injury occurs.
Begin with the patient's narrative before adopting labels from the ambulance or referral. Ask what they were doing, whether they tripped, the direction of fall, lighting, surface, footwear and walking aid. Establish prodrome: dizziness, rotational vertigo, visual dimming, nausea, palpitations, chest pain, breathlessness, focal symptoms or no warning. Clarify memory, witness account, abnormal movements, tongue injury, incontinence, recovery and whether lying or sitting prevents symptoms. Determine time on the floor and how help was summoned.
Treat acute consequences in parallel. Use a trauma approach where indicated, assess head injury and anticoagulation, examine the painful region and document skin and distal neurovascular status. Check temperature, oxygen saturation and bedside glucose; investigate infection, anaemia, electrolyte disturbance, dehydration or drug toxicity when the clinical picture supports them. A fracture after apparently minor force can be pathological, so pain preceding the fall, destructive imaging, weight loss or hypercalcaemia requires a different route.
Assessment and patient selection
Mechanical trip pattern
A clear environmental obstacle, preserved awareness and immediate recall supports a trip but does not remove underlying gait or vision risks.
Orthostatic pattern
Symptoms after standing, meals or medicines with a reproducible pressure fall suggests postural hypotension that requires cause assessment.
Cardiac syncope warning
Abrupt collapse without prodrome, exertional or supine events, palpitations and structural heart disease increase concern for arrhythmia.
Neurological alternative
Persistent focal deficit, prolonged post-event confusion or witnessed seizure features should not be absorbed into a generic falls label.
Frailty-linked recurrence
Slow gait, weak transfers, low intake, polypharmacy and dependence often interact rather than providing one isolated cause.
Long-lie injury
Pressure damage, dehydration, hypothermia and muscle tenderness after hours on the floor require additional physiological assessment.
Red flags requiring action
Loss of consciousness during exertion, while supine or with chest pain, palpitations or a family history of sudden death requires urgent cardiovascular evaluation.
Persistent focal weakness, speech disturbance, severe new headache or inability to coordinate after the event needs an acute neurological and head-injury pathway.
Baseline assessment
01First-line comprehensive falls assessmentFirst stepFirst line
Why
Identify the person's cardiovascular, neurological, sensory, functional, medication, environmental and psychological risk factors.
Interpretation and limitations
Use each positive finding to generate a tailored intervention; a total score cannot replace this causal approach.
02Lying and standing blood pressure
Why
Assess postural hypotension in relation to symptoms, hydration, autonomic disease and medicines.
Interpretation and limitations
Reproduce measurements with documented timing and pulse; an asymptomatic single change needs context while symptomatic decline requires action.
03Twelve-lead ECG for possible syncope
Why
Identify rhythm, conduction, repolarisation or structural-disease clues when transient loss of consciousness may have occurred.
Interpretation and limitations
Abnormal or high-risk features prompt urgent cardiovascular evaluation; a normal brief ECG does not exclude intermittent arrhythmia.
04Targeted blood tests
Why
Investigate suspected anaemia, infection, electrolyte disturbance, kidney injury, hypoglycaemia or rhabdomyolysis rather than screen indiscriminately.
Interpretation and limitations
Select FBC, renal profile, CRP, glucose, CK or other tests from history, examination and time on the floor.
Interventions
01ImmediateStabilise injury and exclude collapseFirst stepA fall causes a suspected fragility fracture or physiological deterioration.+
1Use ABCDE and trauma assessment, provide analgesia and protect the injured region.
2Check bedside glucose, observations and neurological status and examine for head injury and complications of a long lie.
3Reconstruct warning symptoms, awareness and witness account before calling the event mechanical.
4Activate cardiac, neurological, infectious or other urgent pathways when red flags are present.
02Comprehensive assessmentFind interacting recurrence driversThe fall required medical or surgical treatment for injury.+
1Complete the NICE NG249 domains, including lying and standing pressure, cognition, mood, sensory function, continence, gait and strength.
Targets, monitoring and follow-up
Record subsequent falls and near-falls with context rather than only counting completed fractures.
Repeat gait, balance, strength and confidence measures during the tailored exercise programme and progress difficulty safely.
Review symptomatic postural observations after hydration or medicine changes and monitor seated or supine hypertension where relevant.
Track whether cataract, cardiac, foot, continence, nutrition and home-hazard referrals were completed and changed the identified risk.
Reassess psychotropic tapering for withdrawal, relapse and falls rather than treating cessation as a one-off intervention.
Follow bone-health treatment, adherence, new fractures and fracture-liaison handover alongside the falls plan.
Special situations
A trip can have causes
An obstacle may be the final trigger while poor vision, weak balance and sedating medicines created susceptibility.
One normal ECG is limited
Intermittent arrhythmia may require monitoring selected by event frequency and risk after a normal resting trace.
Fear itself reduces reserve
Avoiding movement after fracture weakens strength and confidence, so graded supported activity is part of prevention.
Vitamin D is not a falls cure
NICE does not support supplementation solely to reduce falls, although NHS advice for bone and muscle health still applies.
Assessment must produce action
Documenting fifteen risk domains has little value unless referrals, modifications and review responsibility are completed.
Common pitfalls
01
Calling an unwitnessed collapse mechanical without asking about prodrome, awareness and recovery.
02
Using a falls-risk score in place of comprehensive inpatient assessment and tailored intervention.
03
Stopping multiple long-term medicines abruptly to reduce polypharmacy.
04
Assuming a fragility fracture requires DXA confirmation before secondary prevention begins.
05
Prescribing generic exercise without assessing balance, strength, goals and the person's ability to participate.
06
Discharging with referrals listed but no named owner, appointment route or method to obtain help after another fall.
Practice
Two practice questions
Your practice draft is saved in this browser.
Question 1 of 2
0 correct
Musculoskeletal medicine and orthopaedicsOriginal SBA
Assessment after injurious fall
A 78-year-old sustains a distal-radius fragility fracture after a fall and needs hospital treatment. What falls intervention does NICE NG249 support?
Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Complete NICE NG249 comprehensive assessment because the fall caused a medically treated injury. Measure lying and standing blood pressure using a repeatable protocol and relate any fall to symptoms and medicines. Examine pulse and heart, cognition, delirium, mood, neurological function, vision, hearing, feet, footwear, continence, gait, balance, mobility and muscle strength. Assess diet, fluids, weight loss, alcohol and long-term conditions. Ask about fear of falling and perceived function because self-restriction can accelerate deconditioning.
Medication review is causal, not a box tick. Reconcile recent changes and timing of antihypertensives, diuretics, opioids, benzodiazepines, Z-drugs, antidepressants, antipsychotics, antiepileptics, hypoglycaemics and anticholinergics. Identify cumulative sedation and postural effects. Discuss psychotropic-associated risk and plan supervised reduction where appropriate, involving mental-health teams when needed. Do not abruptly stop long-term benzodiazepines, antidepressants, antiepileptics or steroids, and do not remove beneficial cardiovascular treatment without understanding the indication.
Translate findings into tailored action: treat cataract, symptomatic arrhythmia, postural hypotension or foot pain; improve hydration and nutrition; provide the correct aid; prescribe progressive strength, balance, coordination and power work; and arrange validated home-hazard assessment and modification. Review osteoporosis and initiate secondary fracture prevention. Plan personal alarms or methods to summon help after a fall. Agree goals with the patient and carers and communicate named referrals, because a long list of risks without completed interventions does not prevent recurrence.
Key points
A fragility fracture is a sentinel event: treat the injury, but also investigate the fall, future fracture risk, bone health and the person's ability to recover safely.
Under NICE NG249, a fall causing injury that needed medical or surgical treatment qualifies for comprehensive falls assessment and management.
First-line history reconstructs activity, direction, warning symptoms, loss of consciousness, time on the floor, footwear, alcohol, medicines, previous falls and witness account.
Comprehensive assessment includes cardiovascular examination with lying and standing blood pressure, cognition and mood, gait, balance, strength, vision, hearing, feet, continence, nutrition, neurological examination and osteoporosis risk.
Do not use a numerical falls-risk prediction score to decide who receives inpatient assessment; address the person's observed and identified factors.
Perform structured medication review, especially psychotropics, sedatives and blood-pressure-lowering medicines, but taper or adjust safely rather than abruptly stopping necessary treatment.
Offer a progressive, tailored falls-prevention exercise programme and home-hazard assessment when indicated; occupational-therapy delivery of home assessment should be considered.
Initiate or hand over secondary fracture prevention through a named fracture liaison or bone-health pathway rather than treating the fracture as an isolated accident.
Fever, hypotension, hypoxia, acute confusion or markedly reduced intake suggests illness precipitated the fall and needs treatment alongside fracture care.
A prolonged lie, inability to rise, pressure injury, hypothermia, dehydration or dark urine raises concern for rhabdomyolysis, kidney injury and safeguarding needs.
Repeated falls with bruises of different ages, fearfulness, neglect or an inconsistent mechanism should prompt sensitive safeguarding assessment.
New back pain, weakness, saddle sensory change or bladder or bowel dysfunction after a fragility event requires emergency spinal assessment.
05Gait, balance, strength and home assessment
Why
Measure functional deficits and environmental barriers that can be changed through therapy, aids and modification.
Interpretation and limitations
Performance must resemble real tasks; a safe short ward walk may not establish stair or night-toilet safety at home.
06Osteoporosis risk and fracture liaison assessment
Why
Estimate future fracture risk, identify vertebral injury and secondary causes and plan bone-protective treatment.
Interpretation and limitations
Do not let DXA delay indicated secondary prevention after a high-risk fragility fracture.
2
Reconcile medicines and identify cumulative psychotropic, sedative, hypotensive and hypoglycaemic burden.
3Assess nutrition, hydration, alcohol, feet, footwear, home hazards, fear of falling and ability to summon help.
4Link the fracture to osteoporosis and fracture-liaison assessment before discharge.
03Tailored preventionConvert findings into completed actionModifiable risk factors are identified after assessment.+
1Treat specific disease and adjust medicines through shared, supervised plans that preserve essential indications.
2Offer progressive strength and balance exercise matched to ability and goals.
3Arrange validated home-hazard intervention, considering occupational-therapy delivery, and provide appropriate aids.
4Communicate referrals, owners and review dates to the patient, carers, GP and community teams.
04Recurrent unexplained fallsEscalate the diagnostic searchEscalationFalls continue despite initial interventions or involve unexplained loss of consciousness.+
1Revisit the original event history and obtain collateral information or device data where available.
2Assess intermittent arrhythmia, carotid sinus hypersensitivity, seizure, vestibular and neurological causes according to phenotype.
3Review adherence, new medicines, illness and whether interventions were actually delivered.
4Use specialist falls, geriatric, cardiology or neurology services according to the unresolved pattern.