A Second Fragility Fracture Before Any Bone Health Assessment: A Narrative Review of Fracture Liaison Services and the Care Gap They Exist to Close
DOI:
https://doi.org/10.5281/zenodo.22227636Keywords:
Osteoporosis, Fragility Fracture, Secondary Fracture Prevention, Fracture Liaison Service, Treatment GapAbstract
A fragility fracture is the clearest warning a skeleton can give. It is also, routinely, the one nobody acts on. Most patients who
break a bone after a fall from standing height leave hospital with the fracture treated and the osteoporosis behind it neither
investigated nor named.
Objectives: To review the published evidence on secondary fracture prevention: how large the treatment gap is, why a first
fracture so often passes without assessment, what fracture liaison services change, and what the evidence for them does and does
not establish.
Material and Methods: Narrative review of meta-analyses, cohort studies, population registries, national audits, randomised
trials of anti-osteoporosis therapy and society guidance indexed in PubMed and the major bone, rheumatology and orthopaedic
journals. No new patient data were generated; every estimate quoted is one published by the original investigators.
Results: A prior fracture carried a relative risk of any subsequent fracture of 1.86 across 11 cohorts followed for 250,000
person-years, and the excess risk is concentrated in the first two years. Across 29 European countries in 2019, 71 per cent of
women eligible for treatment received none, leaving 14.0 million untreated; the gap was 55 per cent in 2010, so it has widened.
Pooled against usual care, fracture liaison services increased bone density testing by 24 percentage points, treatment initiation
by 20 and adherence by 22, and reduced absolute re-fracture risk by 5 percentage points and mortality by 3.
Conclusion: The drugs work, the risk is quantified, and the patient is already in the building with a broken bone. What is missing
is a person whose job it is to notice. Fracture liaison services supply exactly that, and the evidence for them is consistent in
direction while resting almost entirely on before-and-after and cohort designs rather than randomised comparison.
Abbreviations: BMD – Bone Mineral Density, DXA – Dual-Energy X-Ray Absorptiometry, FLS – Fracture Liaison Service,
FRAX – Fracture Risk Assessment Tool, IOF – International Osteoporosis Foundation, RR – Relative Risk.
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