Fracture Liaison Services — The Handover That Keeps You From Breaking Again

• What "liaison" means and what an FLS actually connects
• Why the handover after a fracture is so easy to lose
• Who the people are that you would meet
• What the evidence does — and does not — show
• How Japan has built this into its insurance system
• How to find out whether your hospital runs one

Osteoporosis care has an uncomfortable, well-documented weak point. It is usually called the care gap or the treatment gap: the space between having a fragility fracture and actually being assessed and treated for the bone disease that caused it.

The gap is not caused by anyone being careless. It is structural:

• The fracture itself is what hurts, so all the attention — the patient's and the family's — goes there
• The surgeon's role tends to end when the bone has united
• When care passes back to a family doctor, "this person broke a bone" is communicated, but "therefore this person needs osteoporosis treatment" often is not
• Osteoporosis causes no symptoms, so there is nothing to make it feel urgent

Nobody's job description contains the handover. That is precisely why it gets lost — and why the solution has to be a system rather than good intentions.

Liaison comes from French, meaning a connection or a linking-up. It describes the service well, because an FLS is not defined by a treatment. It is defined by the joins it makes:

Treating the broken bone (surgery, fixation, rehabilitation)
        ↓  ← the join that tends to break
Treating the osteoporosis (preventing the next fracture)

And it links in more than one direction:

• Between professions — surgeons, nurses, pharmacists, physiotherapists, dietitians, radiographers
• Between institutions — the hospital that operated, the rehabilitation unit, the family doctor you return to
• Across time — from the ward, to discharge, to follow-up measured in years

Most services follow the same broad sequence:

• Finds patients who have had a fragility fracture — often by systematically screening admissions rather than waiting for a referral
• Assesses bone health with bone density testing and fracture risk assessment
• Starts treatment where it is indicated, including calcium and vitamin D
• Coordinates follow-up so that treatment is actually continued
• Addresses falls as well as bones — a fracture usually needs both a fragile bone and a fall
• Explains the condition to the patient, which is often the step that makes the rest stick

📖 For the underlying reason all of this matters, see The Fracture Cascade.

The striking thing about an FLS, if you have one, is that the person coordinating your care is usually not a doctor. In most services it is a specialist nurse.

Around that coordinator sits a wider team — pharmacists who sort out how and when to take a medication that has awkward rules, physiotherapists who restore the confidence that a fracture takes away, dietitians, radiographers who perform the bone density scan.

If you have ever thought "this isn't worth bothering the doctor about" — those questions are exactly what this team is there for. How to take the tablet. Whether the pain is normal. When you can go back to walking. Ask them.

Here it is worth being precise, because the evidence is strong in one place and weaker in another.

What is well established

A synthesis of 74 controlled studies found substantial differences where an FLS was in place:

These are differences of roughly 20 percentage points. That an FLS gets people assessed, treated, and keeping to treatment is not seriously in doubt.

What is likely, with caveats

Fewer subsequent fractures. Pooled analyses point in that direction (odds ratio 0.70, 95% confidence interval 0.52–0.93). The effect is clearer in studies that followed people for more than two years; within two years the difference is not reliably detectable.

What cannot yet be claimed

A reduction in deaths has not been established. Some analyses appear to show one, but when the comparison is restricted to hospitals with an FLS versus hospitals without, the difference stops being statistically significant (odds ratio 0.73, 95% confidence interval 0.49–1.09). It reaches significance only in before-and-after studies within a single hospital — the design most vulnerable to simply picking up general improvements in medical care over the same period.

It is also worth knowing that most of this evidence is observational rather than randomized, and a large share compares a hospital to its own earlier self. That design tends to flatter the intervention.

We have set this out in detail rather than quoting only the encouraging numbers. An FLS reliably improves the odds that you are assessed and treated — you can rely on that. Beyond that, the research is still catching up.

If you are reading this in Japan, there are some specifics worth knowing.

Japan uses two related terms, and both are current:

OLS is the broader term; FLS is the part of it that begins after a fracture.

Since 2022, Japan's health insurance system has formally recognized this work. Where a patient has had surgery for a hip fracture (大腿骨近位部骨折), continuing osteoporosis assessment and treatment is reimbursed in stages — through the acute hospital, the rehabilitation ward, and then outpatient follow-up. When the measure was introduced, the proportion of patients discharged on osteoporosis medication rose by roughly 20 percentage points almost immediately, after years of moving barely at all.

[!note] Which fractures the Japanese scheme covers The insurance measure currently applies to hip fracture treated surgically. Spine and wrist fractures are not included. This is a rule about reimbursement, not a statement that people with spinal or wrist fractures do not need osteoporosis treatment. A spinal fracture in particular is an important warning sign. Please discuss assessment and treatment with your doctor regardless of which bone you broke.

Japan also certifies the staff who do this work. The Japan Osteoporosis Society's Osteoporosis Manager (骨粗鬆症マネージャー) qualification has been awarded to roughly 6,000 people; about half are nurses, with physiotherapists, pharmacists, radiographers and dietitians making up most of the rest. Doctors are deliberately not eligible — it is a credential for the wider team. A separate certification for nurses, FLS Coordinator, also exists.

Honestly: there is no convenient public directory. In Japan the professional society's list of certified staff is restricted to members. The International Osteoporosis Foundation's Capture the Fracture program maps registered services worldwide — over 1,300 across 65 countries, including about 150 in Japan — but registration is voluntary and the site is in English.

So asking is more reliable than searching. Useful questions:

• "After this fracture, will my osteoporosis be assessed and treated?"
• "Is there a fracture liaison service, or someone who coordinates bone health here?"
• "Where should I continue bone treatment after I'm discharged?"

A hospital's patient liaison or social work office can answer these as well as the doctor can.

If there is no service where you are, you can still cover the same ground yourself:

• Ask for bone density testing after any fragility fracture
• Ask whether osteoporosis treatment should be started before you are discharged, not months later
• Make sure the referral back to your family doctor says explicitly that osteoporosis needs managing
• Treat falls prevention as part of the same plan — see Preventing Falls

[!warning] Please note Do not change or stop any prescribed medication on your own judgement. If something concerns you, speak to your doctor first.

• If you have ever had a fracture, check whether osteoporosis treatment was actually started. Your medication list will tell you. If there is nothing for bone, raise it at your next appointment.
• If a family member is in hospital with a fracture, ask during the admission where bone treatment will continue after discharge. It is much harder to arrange once discharge day arrives.
• If you are transferred between hospitals, ask that bone treatment be included in the handover letter.
• Talk to the nurses and pharmacists, not only the doctor. In this particular part of medicine, they are usually the ones holding the thread.

My hospital never mentioned any of this. Does that mean they don't do it?

Not necessarily. Many hospitals do the same work without using the name, and services have expanded a great deal in recent years. If you are unsure, ask — asking is exactly what the system is designed to prompt.

I broke my wrist, not my hip. Is this relevant to me?

Yes. A wrist fracture from a minor fall is a classic early warning sign, often arriving years before a more serious fracture. Reimbursement rules in some countries are narrower than the medical need — the medical need applies to you.

Is an Osteoporosis Manager a kind of doctor?

No. It is a certification for nurses, pharmacists, physiotherapists, dietitians and radiographers. Doctors are not eligible. Think of them as the person you can ask the questions you did not get to in a short consultation.

Should I move to a hospital that has a service like this?

Usually there is no need. What matters is not the name of the program but whether your osteoporosis treatment has started and is continuing. If your current doctor is doing that, that is what counts.

Does it cost extra?

This work sits within normal insured care rather than being billed separately to you. For how osteoporosis costs work more generally, see The Cost of Osteoporosis Care.

• The Fracture Cascade — why the first fracture matters most
• Bone Density Testing (DEXA) — the assessment an FLS would arrange
• Preventing Falls — the other half of preventing the next fracture
• How Family Can Help — practical support after a fracture
• The Cost of Osteoporosis Care — what treatment costs in Japan

• Japan Osteoporosis Society. Osteoporosis Liaison Service (OLS) and the Osteoporosis Manager certification. http://www.josteo.com/medical/liaison/
• Japan Osteoporosis Society and Fragility Fracture Network Japan. Clinical Standards for Fracture Liaison Services in Japan (日本版 二次骨折予防のための骨折リエゾンサービス クリニカルスタンダード). 2019.
• Wu CH, et al. Fracture liaison services improve outcomes of patients with osteoporosis-related fractures: a systematic literature review and meta-analysis. Bone. 2018;111:92-100.
• Li N, et al. Effectiveness of fracture liaison services in reducing subsequent fractures and mortality: a systematic review and meta-analysis. Osteoporosis International. 2021;32(8):1517-1530.
• Takegami Y, et al. Impact of the secondary fracture prevention fee on osteoporosis treatment initiation: an interrupted time-series analysis. Osteoporosis International. 2025;36(12):2509-2518.
• Nakatoh S, et al. Insufficient persistence of osteoporosis treatment after fragility fracture: analysis of the National Database of Health Insurance Claims. Archives of Osteoporosis. 2021;16(1):130.
• Åkesson K, Marsh D, et al. Capture the Fracture: a Best Practice Framework and global campaign to break the fragility fracture cycle. Osteoporosis International. 2013;24(8):2135-2152.
• International Osteoporosis Foundation. Capture the Fracture. https://www.capturethefracture.org/

This article provides general medical information and is not intended as a substitute for professional medical advice. If you have concerns about continuing your treatment after a fracture, please consult your doctor.