Fracture Liaison Services Save Bones and Lives: Why Every Fragility Fracture Should Trigger Secondary Prevention

A fragility fracture is not an isolated event. It is the skeleton announcing risk, and it is a moment of maximum clinical leverage. UK national audit reporting underlines the “imminent risk” period: over half of subsequent fractures that occur over the next decade happen within the first two years after the initial fracture.

That single fact should change how we practise. If the next fracture is most likely soon, then secondary prevention must start now, not at some indefinite “later”. A Fracture Liaison Service (FLS) exists to make that happen reliably, at scale, for every eligible patient aged 50 and over who presents with a low-trauma fracture.

Fix the fracture, then prevent the next one.

The outcome evidence is now strong enough to end the debate

For years, FLS discussions were dominated by process measures: more patients identified, more DXA scans ordered, more treatment recommendations made. Those matter, but the question that finally settles policy is outcomes: do patients have fewer refractures, and do they live longer?

The 2025 NoFRACT study from Norway shifts the conversation decisively. In a pragmatic, register-supported evaluation involving 100,198 women and men aged 50+ with low-energy fractures, introduction of a standardised FLS model was associated with both lower subsequent fragility fracture risk and lower all-cause mortality during follow-up of up to 4.7 years. Fracture risk fell by 13% in women (HR 0.87, 95% CI 0.83–0.92) and 10% in men (HR 0.90, 95% CI 0.81–0.99), while mortality fell by 18% in women (HR 0.82, 95% CI 0.79–0.86) and 15% in men (HR 0.85, 95% CI 0.81–0.89).

This is not a small signal. It is large-scale, real-world evidence linking FLS delivery to outcomes that matter most to patients and systems: fewer fractures and fewer deaths.

The pooled literature reinforces this. A 2024 systematic review and meta-analysis found moderate-certainty evidence that FLS reduces secondary fragility fractures at two years or more, with a relative risk of 0.68 (95% CI 0.55–0.83) versus non-FLS care.

Earlier meta-analytic work also shows fewer subsequent fractures associated with FLS (odds ratio around 0.70 overall, with stronger effects when follow-up exceeds two years), and mortality reductions reported particularly in before-and-after implementation studies.

Why usual care fails after a fracture

Acute fracture care is usually excellent. The failure happens afterwards. Too often, the system treats the injury but not the disease that caused it: osteoporosis, frailty, falls risk, medication contributors, and the adherence barriers that quietly dismantle any plan written at discharge.

UK audit data makes this gap visible. The FLS-DB Annual Report 2025 (reporting care for fractures in 2023) shows that only 35.4% of patients had commenced or continued anti-osteoporosis medication within 16 weeks of fracture, and confirmed adherence at 12 months was 11.9%.

The same report and programme summary emphasise that improving timely treatment initiation for high-risk patients remains a priority, even as some indicators improve.

This is not about blaming clinicians. It is about recognising that an opportunistic, unowned pathway produces predictable harm. Secondary prevention requires a service model designed to deliver it.

What a high-quality FLS does (and why it works)

FLS is not “an osteoporosis clinic”. It is a quality-and-safety system embedded into fracture pathways, designed to close the care gap with defined steps, timeframes, and accountability.

The Royal Osteoporosis Society Clinical Standards describe a whole-pathway approach: Identify, Investigate, Inform and Involve, Intervene, Integrate, and Quality. This is not bureaucracy. It is the minimum structure needed to turn a missed opportunity into prevented harm.

1) Identify every eligible patient, reliably

A good FLS systematically case-finds adults aged 50+ with fragility fractures, including newly identified vertebral fractures and fractures that occur while a patient is already taking osteoporosis medication. This matters because vertebral fractures are often missed and carry high future fracture risk.

2) Investigate fracture risk, falls risk, and secondary causes promptly

The ROS standards emphasise completing assessment within 12 weeks of fracture diagnosis, using fracture risk tools (such as FRAX/QFracture) and quality-assured DXA where indicated, alongside appropriate tests to assess secondary causes and guide safe treatment decisions. Falls risk assessment is a core component, especially for adults aged 65+.

3) Inform and involve patients, because adherence is the real battleground

Effective prevention depends on shared decision-making and patient understanding of benefits, risks, and practicalities. The ROS standards explicitly prioritise tailored information, clear communication with primary care, and support that makes treatment persistence more likely.

4) Intervene quickly, especially in very high-risk groups

The ROS standards state that people willing to take drug treatment should be offered appropriate osteoporosis medication within 16 weeks of fracture diagnosis, alongside timely falls prevention referral where needed.

NoFRACT shows how this translates into operational design: systematic identification; structured risk assessment; lifestyle and falls prevention advice; and direct initiation of anti-osteoporosis drugs for very high-risk patients such as hip and vertebral fractures.

5) Integrate across hospital and primary care so the plan survives discharge

Secondary prevention collapses when responsibility is vague. The ROS standards require integration with the wider system: clear management plans, referral pathways, and communication that supports long-term management and annual medication review in primary care.

6) Measure quality and continuously improve

FLS should be auditable. The ROS standards emphasise governance and continuous improvement, including participation in national audit systems such as the FLS-DB.

The FLS-DB exists precisely to benchmark care and expose where systems fail patients: identification, assessment timeliness, DXA access, treatment initiation within 16 weeks, and adherence at 12 months.

Global consensus: FLS is the preferred model for secondary fracture prevention

The International Osteoporosis Foundation’s Capture the Fracture initiative was created to break the fragility fracture cycle by promoting post-fracture care coordination programmes like FLS and by defining globally endorsed best practices through its Best Practice Framework. It also provides a recognition and benchmarking mechanism that encourages services to standardise and improve.

This matters because “having an FLS” is not the same as delivering effective FLS. Outcomes follow from fidelity: case-finding that actually reaches patients, timely assessment, rapid initiation for high-risk groups, and follow-up that protects adherence. Standards and benchmarking exist to drive that fidelity.

The bottom line

In modern fracture care, fixing the bone is not enough. The first fragility fracture is the clearest warning the healthcare system will ever get, and the risk of the next fracture is front-loaded into the first two years.

The evidence is now difficult to ignore. NoFRACT links standardised FLS delivery to fewer subsequent fragility fractures and lower mortality. Meta-analyses show meaningful reductions in refracture risk, especially beyond two years. National UK audit data shows the treatment and adherence gap that still leaves patients exposed.

So the standard should be non-negotiable: every fragility fracture should trigger secondary prevention, and the best system to deliver it is a high-quality Fracture Liaison Service.

A fragility fracture is a warning sign, not just an injury. Fracture Liaison Services find high-risk patients, start bone protection, improve follow-up and adherence, and are linked to fewer repeat fractures and lower mortality.

References

1. Andreasen C, Dahl C, Frihagen F, et al. Fracture liaison service (FLS) is associated with lower subsequent fragility fracture risk and mortality: NoFRACT (the Norwegian Capture the Fracture initiative). Osteoporosis International. 2025. DOI: 10.1007/s00198-024-07376-y.

2. Danazumi MS, Lightbody N, Dermody G. Effectiveness of fracture liaison service in reducing the risk of secondary fragility fractures in adults aged 50 and older: a systematic review and meta-analysis. Osteoporosis International. 2024;35(7):1133–1151. DOI: 10.1007/s00198-024-07052-1.

3. Royal College of Physicians / HQIP. FLS-DB Annual Report 2025: You’ve had a fracture; how can we prevent another? (Data 1 Jan–31 Dec 2023).

4. International Osteoporosis Foundation. Capture the Fracture: Best Practice Framework.

5. Royal Osteoporosis Society. Effective Secondary Prevention of Fragility Fractures: Clinical Standards for Fracture Liaison Services (Version 3; publication date September 2025).

6. Li N, Hiligsmann M, Boonen A, et al. The impact of fracture liaison services on subsequent fractures and mortality: a systematic literature review and meta-analysis. Osteoporosis International. 2021;32:1517–1530.