Pearls of Wisdom: Smoking and Fractures
Mark is a very active man in his mid-40s who was playing racquetball with his 19-year-old son 3 days ago. He did a rotational maneuver on a fixed foot, resulting in a fractured tibia.
He returns to your office for follow-up with no concerns, except for 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, and he has not experienced any major medical maladies and has only sought medical care for incidental short-term illnesses (eg, upper respiratory tract infection, poison ivy, laceration repair).
He has been smoking since he was a teenager, and he has not been receptive to cessation advice. He was frank enough to say to you, "Well, Doc, the problems that might come from smoking are far enough away that 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.
Using the "Stages of Change" model, Mark is perhaps at the precontemplation stage. He has a pack of cigarettes in his shirt pocket at today's visit.
For a male smoker at age 46, does smoking status have a meaningful impact on fracture healing?
A. No. Because men have greater bone mineral density (BMD) than women do, smoking would have no impact.
B. No. Even though smoking does impact BMD and bone healing, it does so only later in life.
C. Yes. Smoking increases the risk of non-union by about 10%.
D. Yes. Smoking can delay fracture healing by as much as 6 weeks or even more.
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. These “Pearls of Wisdom” often highlight studies that may not have gotten traction within the clinical community and/or may have been overlooked since their time of publishing, but warrant a second look.
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Answer: Yes. Smoking can delay fracture healing by as much as 6 weeks or even more.
In my experience, the invulnerability of young men begins to falter at about age 55. Between the ages of 15 and 55, many men seek health care only if their parts are falling off in the street, or if their significant other insists on 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 father may have experienced a decline in exercise capacity, a decreased sensation of taste and smell, some degree of erectile dysfunction, and other maladies related to smoking, none of those would necessarily be evident to Mark. Although the death of his dad in his 70s might seem to Mark to have been a "ripe old age," perhaps his father could have enjoyed life well into his 80s without the cigarettes!
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Right now, the consequences of cigarette smoking seem distant to Mark. But what if you could prove to him that the consequences of his smoking are already visible right now?
Research
In a study of 85 adults (mean age, 46 years) with a tibial fracture,1 Moghaddam and colleagues evaluated the effects of cigarette smoking on time to healing, time off of work, and likelihood of non-union in smokers compared with nonsmokers. 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 (4.0% vs 7.7%), and incurred an extended absence from work (26 weeks vs 31 weeks) compared with nonsmokers.
Smokers often need a loud knock at their own door that sensitizes them to risk. This injury might be a golden opportunity for Mark.
What's the "Take Home"?
We need to take every appropriate opportunity available to us to make smokers cognizant of the risks that smoking incurs. 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 a meaningful negative impact on fracture healing time, union, and time away from work. A concrete demonstration of such risks may sway a patient in the direction of better health habits.
Reference:
1. Moghaddam A, Zimmermann G, Hammer K, Bruckner T, Grützner PA, von Recum J. Cigarette smoking influences the clinical and occupational outcome of patients with tibial shaft fractures. Injury. 2011;42(12):1435-1442.