Association of Smoking, Nutritional Status, and Socioeconomic Factors with Radiographic Evidence of Delayed Fracture Healing

Abstract

Background: Fracture healing is influenced by a complex interaction of biological, behavioral, nutritional, and socioeconomic factors. Other factors such as smoking, which may negatively affect vascularity and osteogenesis, and malnutrition or socioeconomic disadvantage, which may negatively impact on the physiologic processes involved in bone repair, can also adversely affect the healing of fractures.

Objective: To determine the association of smoking, nutritional status, and socioeconomic factors with radiographic evidence of delayed fracture healing.

Methods: This analytical cross-sectional study was conducted at the Rawal Institute of Health Sciences from January 2025 to June 2025. Using non-probability consecutive sampling, a total of 86 cases of adult fractures were included in the study based on the patients' radiographs. Demographic data, smoking habits, nutritional indicators, serum albumin, hemoglobin level, socio-economic status, fracture characteristics, and radiographic healing were obtained. The healing of fractures was evaluated by serial roentgenograms by the methods of callus formation, formation of the bone line, persistence of the fracture line and overall progress toward healing. Chi-square or Fisher's exact test was used for analysis and multivariable binary logistic regression for associations. A p value <0.05 was deemed to be statistically significant.

Results: Delayed radiographic fracture healing was identified in 29 of 86 patients (33.7%). Delayed healing was more frequent among smokers than non-smokers (51.4% vs. 21.6%, p=0.004), among patients who were nutritionally at risk or malnourished compared with well-nourished patients (54.8% vs. 21.8%, p=0.006), and among those with low serum albumin compared with normal albumin levels (61.9% vs. 24.6%, p=0.003). Low socioeconomic status was also significantly associated with delayed healing (p=0.018). On multivariable analysis, current smoking (AOR=3.21, 95% CI: 1.22–8.43), poor nutritional status (AOR=2.84, 95% CI: 1.07–7.56), low serum albumin (AOR=3.47, 95% CI: 1.18–10.20), and low socioeconomic status (AOR=2.73, 95% CI: 1.01–7.39) remained independent predictors of delayed fracture healing.

Conclusion: Smoking, inadequate nutritional status, hypoalbuminemia, and socioeconomic disadvantage were significantly associated with delayed radiographic fracture healing. Early identification and modification of these risk factors may contribute to improved fracture-healing outcomes.