The physical, psychological and social impact of long bone fractures on adults: A review

Background Long bone fractures are common injuries caused by trauma and are a common cause for referral to hospitals. Little consideration has been given to the impact of long bone fractures in adults despite the World Health Organization’s statement that such injuries cause substantial morbidity in low- and middle-income countries. Aim This review targeted published studies conducted from 1990 to 2017 that examined the impact of long bone fractures on the psychological, social, financial, occupational and physical health of adults. Method This scoping review involved a systematic literature search using key terms in Science Direct, Cochrane Library, BMJ Online, PubMed, Jstor, SpringerLink, Emerald Insight and Ebscohost Research databases and Google Scholar. Results From a total of 297 publications, 19 met the inclusion criteria: four publications focused on the impact of fractures of the humerus, one publication looked at ulna fractures, six publications focused on distal radius fractures, five looked at femur fractures and three focused on tibial fractures. Conclusion Long bone fractures have a considerable impact on many facets of a patient’s life. In some cases, the fracture prevents patients from working and meeting financial obligations. The injury limited previously normal social interactions and pre-injury functioning. Future research should examine the impact of long bone fractures in Africa, as there were very limited studies, which were identified.


Introduction
Numerous studies and reports by the World Health Organisation indicate that injury is a substantial cause of morbidity and mortality in low-and middle-income countries (LMICs). 1 The 2013 Global Burden of Disease and Injury study shows that road injuries are the seventh most common cause of disability adjusted life years. 2 The Centres for Disease Control and Prevention indicates that fractures feature in the top-20 first-line diagnoses presenting to emergency departments. 3 A fracture is 'any loss in the continuity of bone'. 4 Over the last several years, long bone fractures are becoming increasingly common, particularly because of road traffic injuries. More than 90% of injuries, particularly fractures of the extremity, occur in LMICs. 2 Some studies have indicated that road traffic accidents cause 68.14% of fractures in some LMIC countries. Falls are also a serious public health problems worldwide because they can also cause re-injury. Some studies have demonstrated that falls have a prevalence of 21.8% and 35.1%. 5 The burden of long bone fractures impacts society through the loss of productivity, the direct and indirect costs of treatment and the additional contribution to morbidity and mortality. The management and treatment of long bone fractures add significantly to the expenses of any health care system because of the cost of surgery, possible rehospitalisation and the physical rehabilitation of patients. 6 http://www.phcfm.org Open Access

Search strategy
Literature searches were conducted in Science Direct, Cochrane Library, BMJ Online, PubMed, Jstor, SpringerLink, Emerald Insight Ebscohost Research databases and Google Scholar to avoid missing other relevant articles not published in a journal.
The reference lists of all chosen publications were also searched to source additional publications that may not have appeared in the search results. The search terms used were the following: impact of long bone fractures and/or psychological impact of long bone fractures and/or social impact of long bone fractures and/or financial impact of long bone fractures and/or occupational impact of long bone fractures and/or physical impact of long bone fractures and/or impact of humerus fractures and/or impact of radius fractures and/or impact of ulna fractures and/or impact of femur fractures, impact of tibia fractures and/or impact of fibula fractures.
Publications that were published in English only were included in the review. The inclusion criteria concentrated on studies that included participants aged 18 years and older who sustained one long bone fracture because of injury or pathology. For this review, only six long bones were included: the humerus, radius, ulna, femur, tibia or fibula. Both qualitative and quantitative studies published in English were included.
The study needed at least one outcome, that is, the psychological, social, financial, occupational or physical impact of the long bone fracture. Studies conducted before 1990, or those that did not reveal the age of participants or the name of the fractured bone, were excluded from the study.
To reduce bias, both authors (S.S. and M.N.) screened all titles and abstracts while being guided by the inclusion and exclusion criteria. Disagreement was resolved through discussion and final consensus. Publication bias was reduced by considering studies with limited sample sizes and studies with non-statistically significant results. Google Scholar was also searched to source grey literature.

Review results
The study selection involved three steps: In the first step, keywords and screening of titles were searched that returned 286 publications. Eleven publications were identified through a search of the reference lists. A total of 297 publications were included after exclusion criteria and duplicates were excluded.
The second step was the screening of the titles and abstracts, which was performed by the second reviewer that resulted in 267 publications being excluded. Five additional publications were excluded by the second reviewer after screening of the titles and abstracts.
Full-text screening was performed on 30 records. After fulltext screening, five publications were excluded. This resulted in 25 publications having been assessed using the mixedmethods appraisal tool (MMAT) version 2018, a reliable critical appraisal tool that allows researchers to assess the methodological quality of publications because critical appraisal is an important aspect of scoping reviews. 8,9 The MMAT is presented in Appendix 1. Only studies with a score of 50% or more were included. Six publications were excluded after being assessed using MMAT. Approximately 25 minutes was spent on the appraisal of each article. Finally, 19 eligible publications were included in the analysis.

Data extraction and analysis
The PRISMA 2009 flow diagram tool was used to demonstrate the search process (see Figure 1). A standardised data extraction template was used to obtain data from the publications using the population, intervention, comparison, outcome and study   Tables 1 and 2). A metaanalysis was unsuitable because of the heterogeneity of the study variables and research designs. Content analysis was used to identify categories and report on findings. Content on the psychological, social, financial, occupational and physical impact was extracted from each publication.

Ethical considerations
This review is part of a PhD thesis, which has been reviewed by the Biomedical Research Ethics Committee, under the protocol reference number BE 583/16. The title of the thesis is 'The perceived psychological, social, financial, occupational and physical impact of long bone fractures in adults in KwaZulu-Natal'. The study enrolled 821 research participants from nine hospitals. To our knowledge, there is no other study investigating this topic. The purpose of this review is to gather information on this topic.

Study characteristics
The average age of participants in all studies was 63.7 years. The earliest study was conducted in 1997 and the latest study

Extent and trend of the studies
The sample size ranged from 9 to 609 respondents per study.
In some studies, the respondents had a surgical orthopaedic intervention.

The biopsychosocial approach to long bone fractures
The World Health Organization states that 'health is a complete state of physical, mental and social well-being and not merely the absence of disease or infirmity'. 32,33 The biopsychosocial model (BPSM) offers a broader and holistic approach for healthcare professionals to understand human behaviour, disease and infirmities. 32,33 The biopsychosocial approach should be applied after a patient sustains a fracture and this may aid in addressing other factors that might influence an individual's recovery. The BPSM comprises three dimensions that can be used to assess post-fracture outcomes: biological, psychological and social factors. The biological dimension deals with the physical impact of the fracture. 33 The psychological dimension comprises the psychodynamic factors affecting patients after the fracture and the social dimension examines the external influences such as support from family and friends, financial influences and possible changes to job or loss of income after the fracture. Research from high-income countries suggests that timely and adequate treatment leads to quicker recovery. Various authors have suggested that health care resources and finances of the patient also influence a patient's recovery. 34 To accurately understand the impact of long bone fractures, the BPSM was adopted as the analytical framework. The literature supports this framework as fractures affect the biological, psychological and social aspects of a patient's life (see Figure 2).
The results will therefore be presented under three headings, namely, psychological and social, financial and occupational and physical impact of long bone fractures.

Psychological and social impact of long bone fractures
Psychological sequelae are common after long bone fractures and include post-traumatic stress disorder, depression and anxiety. 35 Depression is common following injury and may adversely affect clinical outcomes. Further to this, a failure to return to the level of functioning before the fracture may cause symptoms of depression. 35 Trickett and colleagues' 27 qualitative study described how patients felt after an open tibial fracture. All patients were fearful of falling and were conscious of the aesthetic appearance of the fractured limb. Two patients described using alcohol as a means of coping with the circumstances surrounding the injury. In contrast, MacDermid and colleagues 14 found that distal radius fractures had minimal effect on the patient's psychological state. In a 2017 study by Grenier et al. 36 it was found that the presence of a fear of falling causes dysfunction in the neural networks connected to motor imagery abilities, and therefore these patients are more susceptible to re-injury. Fearful patients may not comply with the physical rehabilitation which may reduce one's ability to complete activities of daily living leading to an increase in patient dependency. Glover and colleagues 37 advise that the most effective approach to managing fear of falls is psychological and physical intervention. Kammerlander et al. 22 found that 23% of patients were physically unable to leave their home after sustaining a distal femoral fracture and as a result were not able to socialise. In 2012, Trickett and colleagues 27 also confirmed that a tibial fracture prevented previously normal social interactions. This lack of social support may contribute to injury reoccurrence, rehospitalisation and higher personal and societal health care costs. The use of caregivers with a health care background is a useful way of lending emotional support to patients to reach their recovery goals. 38

Financial and occupational impact of long bone fractures
Volgas and colleagues 28 examined the financial implications of tibial fractures after 6-20 months and found that 29% of patients returned to work at the anticipated time of recovery, 36.8% reported selling possessions to pay their expenses and 42.1% used social welfare initiatives. It was noted that all patients in white-collar jobs returned to work sooner than others, whereas only 14.3% of blue-collar workers returned to work at the last follow-up visit. Forty-two percent of patients used friends and family as a source of financial aid. Only 29.2% of patients returned to work at a mean follow-up of 11.8 months. 28 Trickett and colleagues 27 described how the inability to work, following a tibial fracture, led to financial implications. Larsen and colleagues 39 suggest that fractures of the lower extremity limit positive results, such as returning to work and performing activities of daily living independently.
Returning to work is regarded as an important outcome in orthopaedic treatment. Mackenzie et al. state that patients who return to work sooner are usually younger and have higher social support. 40 Coulibaly and colleagues 20 found that in isolated ulna shaft fractures, 87% of patients returned to a pre-fracture level of activity or work. MacDermid and colleagues 17 described the days lost from work following a distal radius fracture. Patients with a limited range of motion were less likely to return to work. The average number of weeks lost from work was 9.5. Trickett and colleagues 27 indicated that many non-retired patients wanted to return to work soon after a tibial fracture because of the inability to financially provide for themselves and to return to normality. One patient described how he had to adapt his duties and hours of work after the injury to remain involved at work.
Sluys and colleagues 41 confirm that patients with fractures of the lower extremity return to work later compared to those with fractures of the upper extremity.

Physical impact of long bone fractures
Pain is one of the main symptoms of a fracture that causes the patient to seek medical attention after the initial injury. Swelling, reduced mobility of the affected joint and deformity of the limb are common causes of pain. Some fractures are associated with less pain, resulting in some patients presenting late for treatment. 4,42 The possible implications of not receiving appropriate and timely treatment after sustaining a fracture are malunion, avascular necrosis, fat embolism syndrome and prolonged immobility. 4 Fractures with injury extension to the soft tissue, nerve or vasculature may cause complex regional pain syndrome. 43 An important consideration in the initial management of fractures is a clinical pathway for pain management. Pain is often dependent on a host of factors that may or may not be because of the severity of the fracture. Good pain management facilitates patient comfort and reduces anxiety, allowing for a better orthopaedic assessment and compliance with the rehabilitation plan. 4,42 Upper extremity long bone fractures often affect activities such as personal hygiene, eating and writing, especially if the dominant limb is fractured. Frail geriatrics may require additional support during the period of immobilisation. Swelling following fracture is a common contributor of pain that is exacerbated by a tight plaster cast, but this could be managed by elevation of the arm and monitoring the swelling. Lower limb long bone fractures often result in an inability to carry out activities of daily living and usually affect employment, especially if the patient requires mobility in their occupation. Many patients with lower limb fractures require hospitalisation. 4,39,42 Osteoarthritis is a long-term complication of fractures, especially in the lower limbs, and can lead to chronic pain. Approximately 12% of all patients seeking treatment for symptomatic arthritis reported previous injury to the joint. 44 There can be significant joint degeneration after severe joint injury such as an articular fracture. 4

Discussion
This scoping review aimed to investigate the impact of long bone fractures on the psychological, social, financial, occupational and physical health of adults. The psychological impact of long bone fractures includes fear of falling and, therefore, limiting participation in physical activities, being conscious of the aesthetic appearance of the affected limb, post-traumatic stress disorder, acute stress disorder, depression and anxiety. Fractures can also impact the patient's social life because of limited mobility that compromises social activity. Patients reported selling possessions and making use of social assistance programmes to pay for expenses incurred as a direct result of the fracture. Some used friends and family as a source of financial aid. Physical discomfort, pain, immobilisation, deformity and the nature of some fractures result in prolonged absence from work. Patients with limited range of motion were less likely to return to work without vigorous physical rehabilitation. Those who were gainfully employed expressed a need to return to work to honour their financial obligations and as a signal of the gradual return to normality.
The fracture prevented patients from returning to previous level of activity for many months, with pain being the common reason for this.
The public health impact of fractures includes increases in physical impairments and psychological symptoms of fear of re-injury and post-traumatic stress disorder. 45 Further to this, equal access to orthopaedic care and surgery in many African countries remains a challenge because of the shortage of health care practitioners and limited resources.
As many countries in Africa are already struggling with poverty, human immunodeficiency virus and a shortage of health care workers, sustaining an injury can place an added burden on patients. 46 Another important public health consideration is that in some instances, a proximal femur fracture places the individual at a high risk of sustaining another fracture. This may create additional costs to the individual because of possible rehospitalisation and loss of work. 45

Study limitations
This review only included studies published in English as it would have been costly and time-consuming to enlist the services of many translators for various languages. This review shows the need for studies that include younger participants. We acknowledge that we may have missed important evidence because of our inclusion and exclusion criteria.

Implications and recommendations
According to the World Health Organization, 90% of injuries occur in LMICs, such as those in Africa. Therefore, there is a need for more studies to assess the financial, occupational, social and psychological impacts of long bone fractures because there are many studies that only have documented the physical impact of long bone fractures, particularly in Africa. The impact of fractures in LMICs could be magnified because of poorly developed trauma care and limited social infrastructure.

Conclusion
Long bone fractures have a considerable impact on the physical outcome of patients. In some cases, the fracture prevents patients from working and meeting financial obligations. In many cases, the injury limited previously normal social interactions and pre-injury functioning. The findings should be considered while training health workers and providing counselling to orthopaedic patients.