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Factors Affecting Fracture Healing

Rina Pandya, PT, DPT, PGCert LTHE, AFHEA

March 1, 2023

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Question

What factors, including medications, delay the healing of fractures?  

Answer

Many factors can affect the healing of a fracture. 

Here is a partial list: 

  • Age of patient
  • Type of bone
  • Pattern of fractures
  • Disturbed pathoanatomy
  • Type of reduction
  • Immobilization  
  • Open fracture-more prone to infection
  • Compression at the fracture site

Smoking leads to low bone density (reduces by two percent yearly in a smoker).  This, in turn, leads to reduced absorption of vitamin D and Calcium that can delay bone healing, even if they have already stopped smoking. In addition, smoking at a young age basically leads to unfavorable bone geometry and density. Similarly, with diabetes, there is a higher risk of impaired fracture healing. The pathophysiology of how diabetes affects microcirculation leads to reduced vasculature, which slows healing and can increase osteoporosis. Diabetes can impair fracture healing in the lower extremities and short bones. Diabetes can also cause osteoporotic unrelated fracture possibilities, increasing the risk in both males and females.  Osteoporotic fractures have been seen in the femur, spine, humerus, and forearm. 

Medications

Corticosteroids and non-steroidal drugs (NSAIDs) alter the mineralization of the current bone and the new bone being put into place. High rates of non-union are seen in patients who have taken NSAIDs for a prolonged period of time or who are on a higher level of NSAID. NSAIDs are also linked to heterotrophic bone formation.  Chemotherapeutic agents, anticoagulants, and antibiotics are not going to be any help if you're looking into fracture heating. Glucocorticoids can decrease callus formation, retard healing, and alter callus mineralization. Higher rates of non-union have been found with higher doses and with the prolonged postoperative use of NSAIDs. NSAIDs are linked to reduced heterotopic bone formation after a hip surgery. If your patient has these medications on the chart, you know that it may take a little while for the fracture to heal, perhaps longer than normal. 

Finally, rapid revascularization and bone healing depend on minimizing shearing movements of the healing zone. So basically, that's why we undergo stabilization and immobilization with those with a fracture.  


rina pandya

Rina Pandya, PT, DPT, PGCert LTHE, AFHEA

Dr. Rina Pandya, PT, DPT, has an extensive physical therapy career that spans over 20 years, through the UK, the USA, and the Middle East. She has worked in NHS (National Health Service), American health care providing PT services in acute care, in-patient rehab, skilled nursing facility, home healthcare, and outpatient clinic. In addition to being a clinician, she has developed specialty programs based on evidence-based practice in her role as a project manager. She has also managed a Physical Therapy department as Department Head in a premier private hospital in Oman. Currently, Dr. Rina is a senior lecturer of physiotherapy (musculoskeletal physiotherapy) at the University of West England, Bristol, UK, and an author of a pocket book series titled Orthopedic Assessments Made Easy.  

Rina graduated from Manipal University, India, in 2000, as well as the University of Michigan, in 2018 with a Doctor of Physical Therapy. Rina has been awarded a postgraduate certificate in learning and teaching in higher education (PGCert LTHE) and is an associate fellow in higher education (AFHEA). She is also a member of the APTA, HCPC-UK, and OAP-Oman. 


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