Alcohol and Alcoholism Vol. 38, No. 4, pp. 357-359, 2003
© 2003 Medical Council on Alcohol
CASE REPORT: MANAGING FRACTURES IN NON-COMPLIANT ALCOHOLIC PATIENTS — A CHALLENGING TASK
Department of Trauma and Orthopaedics, Manchester Royal Infirmary, Manchester, UK
 |
ABSTRACT |
|---|
 TOPFOOTNOTES ABSTRACT INTRODUCTIONCASE REPORTS AND RESULTSDISCUSSIONREFERENCES |
|---|
Aims: To investigate whether there are extractable conclusions for limb fracture management in dependent alcoholics. Methods: We discuss four cases of dependent alcoholics who presented in our department over a 12-month period, and who developed significant complications owing to non-compliance with treatment. Results: Initial treatment, although appropriate, failed because of non-compliance. This led to further admissions, wound infections and surgery to enable cure. Conclusions: Our case reports indicate that for upper limb fractures of the middle third of the humerus, non-operative treatment or internal fixation with out-patient detoxification is appropriate. Lower limb fractures, on the other hand, should be dealt with by external fixation and in-patient detoxification. It is imperative that the alcohol dependence is addressed if we are to decrease non-compliance.
|
INTRODUCTION |
|---|
|
TOPFOOTNOTESABSTRACTINTRODUCTIONCASE REPORTS AND RESULTSDISCUSSIONREFERENCES |
|---|
Alcohol misuse predisposes to accidents and injuries leading to fractures (Anti-poica and Karaharju, 1988
). Problem drinking may be encountered in up to 20% of in-patients in a general orthopaedic and fracture ward, and in 40% of out-patients attending fracture clinics (Beresford et al., 1982; Diamond et al., 1989; Kankare et al., 1995). Managing fractures in alcoholic patients is a challenging task because alcohol misuse impairs wound healing, inhibits osteoblastic function and diminishes immune defences (De Vernejoul et al., 1983; Redfern et al., 1988; Tonnessen et al., 1991). These patients would also be expected to have problems due to non-compliance with treatment, yet the evidence in the literature supporting this is limited (Karlstrom and Olerud, 1974; Elvy and Gillespie, 1985; MacGregor, 1986; Kankare et al., 1995). In the present paper we describe four alcoholic patients with fractures admitted to our hospital, over a 12-month period, who developed significant complications due to non-compliance with treatment. They illustrate important issues that must be considered in the fracture management of such patients. The potential advantages of conservative and surgical management are discussed. |
CASE REPORTS AND RESULTS |
|---|
|
TOPFOOTNOTESABSTRACTINTRODUCTIONCASE REPORTS AND RESULTSDISCUSSIONREFERENCES |
|---|
Case 1
A 50-year-old man with a history of alcohol misuse (40 units/day) sustained a bimalleolar fracture whilst intoxicated (Fig. 1a
). The medial malleolar fracture was not obvious but was found to be present on an intensified image. He underwent open reduction and internal fixation. He was discharged with a below knee back-slab with non-weight-bearing crutches. Upon discharge, however, he started walking freely on his right ankle and re-presented 10 days later with his medial surgical wound being infected (culture grew anaerobes) and failure of the metal work (Fig. 1b). He was started on intravenous antibiotics and underwent wound debridement with revised internal fixation (the previous metal work was removed and a syndesmosis screw, lateral malleolar plate and medial malleolar screw were inserted). Two days later he self-discharged from hospital. This time, he removed his plaster and started walking on his right foot to re-present whilst alcohol intoxicated with a grossly infected medial malleolar wound and failure of his internal fixation (Fig. 1c). He required debridement of his wounds, removal of all the internal metal work, external fixation (ilizarov) to stabilize the fracture site, and skin grafting (Fig. 1d). Following this, anatomical reduction of the ankle mortise was achieved.
|
Case 2
A 36-year-old man sustained an injury to his right ankle after tripping and falling whilst intoxicated. He had a history of alcohol misuse (about 30 units/day). Radiographs showed a distal fibular fracture with 11-mm talar shift (Fig. 2a
). His ankle was reduced under anaesthesia and reduction maintained with a syndesmosis screw, which achieved anatomical reduction of the ankle mortise. He was discharged home in a below knee back-slab and non-weight-bearing crutches. He presented 2 weeks later with his ankle markedly swollen and clinically infected. The discharge from his surgical wound grew Staphylococcus aureus. He denied weight bearing. Radiographs of his right ankle showed a 10-mm talar shift (Fig. 2b). Seventeen days after his initial procedure the right ankle internal fixation was revised. At operation the diastasis screw was found to be bent, consistent with the patient walking on his foot. A new diastasis screw was applied. His wound infection settled with intravenous antibiotic therapy. He had no further complications.
|
Case 3
A 76-year-old man with a history of alcohol misuse (about 20 units/day) had a mechanical fall whilst intoxicated and sustained a closed displaced right humeral mid-shaft fracture. His right upper limb was neurovascularly intact and was treated in a U-slab plaster. As the patient was unsteady on his feet he was admitted for rehabilitation. On two occasions whilst in hospital the patient removed his U-slab, and kept moving his arm. This caused the skin at the fracture to break down leaving a 5 x 5-cm infected wound with a bone spike visible through it. Wound cultures grew ß-haemolytic streptococci and coliforms. Thirty-three days after the initial injury he underwent wound debridement and unilateral external fixation. Anatomical reduction and stabilization were achieved. The wound infection settled, but 20 days later the patient took off his external fixator whilst confused in the ward. At this point the fracture site had clinically united and no further intervention was deemed necessary.
Case 4
A 51-year-old man was hit by a car whilst a pedestrian. He was alcohol intoxicated. He had a history of epilepsy and alcohol misuse (42 units/week). He sustained a closed displaced spiral left humeral mid-shaft fracture. His upper limb was neurovascularly intact. This was immobilized in a U-slab plaster. A week after the initial injury he fell again whilst alcohol intoxicated and sustained an undisplaced left distal radius fracture treated in plaster. One month later, whilst in hospital for haematemesis and melaena he complained of increasing pain in his left elbow and wrist. On examination, he had sensory loss in the radial nerve distribution on the dorsum of his left hand, and wrist drop. Radiographs showed further displacement of his fracture site. He underwent exploration of the radial nerve, open reduction and antegrade intramedullary nailing of his left humerus. The radial nerve was intact but trapped in fibrous tissue around the fracture site. Four months later, sensation on the dorsum of his hand was restored, but he still has reduced power (4/5) in finger extension.
|
DISCUSSION |
|---|
|
TOPFOOTNOTESABSTRACTINTRODUCTIONCASE REPORTS AND RESULTSDISCUSSIONREFERENCES |
|---|
Managing fractures in alcoholic patients is a challenging task as alcohol misuse predisposes to osteoporosis, slows bone and wound healing and impairs immune defences (De Vernejoul et al., 1983
; Redfern et al., 1988; Tonnessen et al., 1991). Such patients may also suffer severe complications due to non-compliance with treatment. They often pay little attention to instructions, thereby increasing their risk of infection and refracture. Alcohol intoxication increases the risk of further accidents, impairs judgement and decreases the pain inhibition that would make a normal patient more careful. A high incidence of complications (infections, plate breaking, refracture) in internally fixed tibial (Karlstrom and Olerud, 1974), clavicular (Elvy and Gillespie, 1985) and ankle (Bostman et al., 1997) fractures has been reported. These were partly attributed to non-compliance. Kankare et al.(1995) internally fixed malleolar fractures in 16 alcoholic patients with biodegradable screws in an attempt to avoid significant complications. In this latter study 6/16 patients underwent reoperation owing to redisplacement of the fracture. This highlights the importance of identifying and dealing with the dual pathology that these patients present with, namely alcohol dependence and orthopaedic pathology. Our four patients had significant complications due to non-compliance and required multiple surgical interventions. The first two patients had ankle fractures, which were initially internally fixed. Both presented with failure of their internal fixation due to walking on their injured ankles, against medical advice and whilst intoxicated. Our experience questions whether such fractures should be internally fixed or be treated conservatively with manipulation and immobilization in plaster. Initial conservative management with fracture reduction under a general anaesthetic and immobilization in plaster is likely to fail if the patient weight-bears, but the risk of infection of metal work and surgical wounds would be avoided. Use of external fixators may also be advocated as a more rigid way of fracture stabilization. However, such patients might further injure themselves or others with the fixator whilst intoxicated. Admission to a rehabilitation ward until the fracture site has consolidated in those where internal fixation is employed might be an alternative approach. On the basis of our cases and prior experience, we suggest that dependent drinkers with lower limb fractures should be dealt with by non-operative treatment or external fixation and in-patient detoxification.
The considerations for managing upper limb fractures in non-compliant alcoholic patients may differ. As illustrated by our last two cases, alcohol-intoxicated patients with humeral fractures may take off their casts and move their arms causing further displacement of the fracture site. One of our patients fell and injured the same limb whilst alcohol intoxicated, eventually developing radial nerve palsy, whereas the other kept removing his plaster and moving his arm until the bone ends penetrated through the skin. On the basis of such problems, immobilization by surgical fixation may be advocated in potentially non-compliant patients. Internal fixation by intramedullary nailing or plating may be rigid enough to allow early mobilization. As demonstrated by one of our cases, the use of an external fixator may not be the best option as this may be removed by the confused intoxicated patient, or be used as a tool for self-harm or injuring others. We thus suggest that, for the dependent drinker with upper limb fractures, internal fixation and out-patient detoxification is the treatment of choice.
The importance of identifying and dealing with alcohol dependence cannot be overemphasized. The poor outcomes of these patients following trauma have tremendous individual and economic consequences. One can begin to appreciate the cost implications when one takes into account that a theatre episode costs £85, overnight stay £110, an out-patient appointment £52, a physiotherapy session £20, staff wages (daily review, A&E triage and clerking, theatre session and clinic) £100, and consumables (anaesthetic consumables, medication, radiographs, dressings, microbiology consumables) £40.
In conclusion, four cases of alcoholic patients with complicated ankle and humeral fractures due to non-compliance have been presented. They suggest that careful consideration must be taken in managing fractures in such patients. The site of the fracture and the potential complications should guide conservative treatment or surgical fixation if the patient is non-compliant. Furthermore, the orthopaedic surgeon should be on the lookout for alcohol dependence and arrange for the patient to have a detoxification programme either as an in-patient or out-patient, depending on the circumstances, the facilities available, local and patient preferences, and type of fracture.
|
FOOTNOTES |
|---|
|
TOPFOOTNOTESABSTRACTINTRODUCTIONCASE REPORTS AND RESULTSDISCUSSIONREFERENCES |
|---|
* Author to whom correspondence should be addressed at: F204, 159 Hathersage Road, Manchester M13 0HX, UK.
|
REFERENCES |
|---|
|
TOPFOOTNOTESABSTRACTINTRODUCTIONCASE REPORTS AND RESULTSDISCUSSIONREFERENCES |
|---|
Anti-poica, I. and Karaharju, E. (1988) Heavy drinking and accidents. A prospective study. Injury 19, 198–200.[CrossRef][ISI][Medline]
Beresford, T., Low, D., Adduci, R. and Goggans, F. (1982) Alcoholism assessment in an orthopaedic surgery service. Journal of Bone and Joint Surgery (Am) 64, 730–733.
Bostman, O., Manninen, M. and Pihlajamaki, H. (1997) Complications of plate fixation in fresh displaced mid-clavicular fractures. Journal of Trauma 43, 778–783.[ISI][Medline]
De Vernejoul, M. C., Bielakoff, J. and Herve, M. (1983) Evidence for defective osteoblastic function: a role for alcohol and tobacco smoking in osteoporosis in middle aged men. Clinical Orthopaedics 179, 107–115.
Diamond, T., Stiel, D., Lunzer, M. and Posen, S. (1989) Ethanol reduces bone formation and may cause osteoporosis. American Journal of Medicine 86, 282–288.[CrossRef][ISI][Medline]
Elvy, G. A. and Gillespie, W. J. (1985) Problem drinking in orthopaedic patients. Journal of Bone and Joint Surgery (Br) 67, 478–481.
Kankare, J., Hirvensalo, E. and Rokkanen, P. (1995) Malleolar fractures in alcoholics treated with biodegradable internal fixation. Acta Orthopaedica Scandinavica 66, 524–528.[ISI][Medline]
Karlstrom, G. and Olerud, S. (1974) The management of tibial fractures in alcoholics and mentally disturbed patients. Journal of Bone and Joint Surgery (Br) 54, 730–734.
MacGregor, R. R. (1986) Alcohol and immune defence. Journal of the American Medical Association 256, 1474–1479.[CrossRef][ISI][Medline]
Redfern, T. R., Rees, D. and Owen, R. (1988) The impact of alcohol ingestion on the orthopaedic and accident service. Alcohol and Alcoholism 23, 415–419.
Tonnessen, H., Pedersen, A., Jensen, M., Moler, A. and Madsen, J. (1991) Ankle fractures and alcoholism. Journal of Bone and Joint Surgery 73B, 511–513.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||