Pearls of Wisdom: Smoking and Fractures
Question: Mark is a very active man in his mid-40s who was playing racquetball with his 19-year-old son last Friday (3 days ago). He did a rotational maneuver on a fixed foot and ended up fracturing his tibia.
He returns to your office Monday morning for follow-up, with no complaints except the inconvenience of the cast that he is expecting to wear for the next 6 weeks.
Mark has been in your practice since he was a college student himself, but has not suffered any major medical maladies and has only sought medical care for incidental short-term illnesses (eg, URI, poison ivy, laceration repair).
You know he has been smoking since he was a teenager, but he has not been receptive to cessation advice, and was frank enough to say to you, “Well Doc, the problems that might come from smoking are far enough away I think I’ll worry about that later.” He even goes on to remind you that lung cancer screening can be done for early detection now, and he intends to consider that when he enters the right age group.
From the perspective of the “Stages of Change” model, Mark is perhaps at the precontemplation stage. He his a pack of Marlboro in his shirt pocket today.
For a male smoker at age 46, does smoking status make a meaningful impact upon fracture healing?
A. No. Because men have greater bone mineral density (BMD) than women, smoking would have no impact.
B. No. Even though smoking does impact BMD and bone healing, it occurs only later in life.
C. Yes. It increases the risk of non-union by about 10%.
D. Yes. Fracture healing is delayed as much as 6 weeks or more by smoking.
What is the correct answer?
(Answer and discussion on next page)
Louis Kuritzky. MD, has been involved in medical education since the 1970s. Drawing upon years of clinical experience, he has crafted each year for almost 3 decades a collection of items that are often underappreciated by clinicians, yet important for patients. His “Pearls of Wisdom” as we like to call them, have been shared with primary care physicians annually in an educational presentation entitled 5TIWIKLY (“5 Things I Wish I Knew Last Year”…. or the grammatically correct, “5 Things I Wish I’d Known Last Year”).
Now, for the first time, Dr Kuritzky is sharing with the Consultant360 audience. Sign up today to receive new advice each week.
Answer: Yes. Fracture healing is delayed as much as 6 weeks or more by smoking.
In my experience, the invulnerability of young men begins to show chinks in the armor at about age 55; between ages 15-55, men only seek health care if parts are falling off in the street, or their significant other insists upon it. Our patient, Mark, is probably no different.
Like many smokers, he has had the life experience of seeing family members enjoy long lives untainted by any visible consequences of smoking. Although his dad may have suffered a decline in exercise capacity, decreased sensation of taste and smell, lesser erectile dysfunction, and other maladies related to smoking, none of those would necessarily be evident to Mark. Even though the loss of his dad in his 70s might seem to Mark to be a “ripe old age,” perhaps his dad could have enjoyed life into his 80s without the cigarettes!
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Right now, consequences of cigarette smoking seem distant to Mark. But what if you could prove to him that the consequences of his smoking might be visible right now?
Research
In a study of adults (mean age of 46) with tibial fracture (n=85), Mgohaddam et al1 evaluated the effects of cigarette smoking on time to healing, time off work, and likelihood of non-union by comparison to non-smokers. The differences in outcome were not the least bit subtle: Smokers took 1.5 times as long to heal (6 weeks longer), had twice the rate of delayed union (4% vs 7.7%), and incurred an extended absence from work (26 weeks vs 31 weeks) compared to non-smokers.
Smoking Impairs Fx Healing1
Smokers often need a loud knock at their own door that sensitizes them to risk. This injury might be a golden opportunity.
What’s the “Take Home”?
We need to take every appropriate opportunity that is available to us to make smokers cognizant of the risks they incur. For young men who may feel invincible, pragmatic messages that are pertinent to the now rather than the distant future may catch their attention. Smoking incurs meaningful negative impact on fracture healing time, delayed union, and missed work. Concrete demonstration of such risks may sway a patient in the direction of better health habits.
Reference:
1. Moghaddam A, Zimmerman G, Hammer K, et al. Cigarette smoking influences the clinical and occupational outcome of patients with tibial shaft fractures. J Injury. 2011;42(12):1435-1442.