Session III - Polytrauma

Symptoms of Post-Traumatic Stress Disorder after Orthopaedic Trauma

Adam J. Starr, MD; Drake S. Borer, MD; Charles M. Reinert, MD; Maxine Mendoza-Welch, PA-C; William H. Frawley, PhD; University of Texas Southwestern Medical Center, Dallas, Texas, USA

Purpose: The purpose of this study was to determine the prevalence of the symptoms of post-traumatic stress disorder (PTSD) in a population of orthopaedic trauma patients and to investigate whether injury or demographic variables are associated with later development of PTSD.

Methods: A total of 330 orthopaedic trauma patients seen for follow-up after treatment were asked to complete a 31-item questionnaire, the Revised Civilian Mississippi Scale for PTSD [Norris FH, Perilla JL: The Revised Civilian Mississippi Scale for PTSD: Reliability, Validity, and Cross-Language Stability. Journal of Traumatic Stress 9:285-298, 1996], a previously validated self-report indicator of PTSD. The average age of the 310 respondents (94%) who completed the questionnaire was 40 years (range, 14 to 90); 120 were women; 160 were married, 29 were divorced, 118 were single, and 3 were widows or widowers. Of the respondents, 148 were seen in a clinic for indigent patients, 162 were seen in a clinic for insured patients, and 43 completed a Spanish version of the questionnaire. The average time elapsed since injury was 14 months (range, 2 days to 64 years). The mechanism of injury was as follows: motor vehicle collision, 101; fall, 96; motor vehicle-pedestrian collision, 18; motorcycle collision, 17; crush injury, 15; horseback riding injury, 9; bicycle injury, 9; gunshot wound, 7; and other, 38. The average Glasgow Coma Scale (GCS) score on arrival was 14.7 (range, 3 to 15), and the average Injury Severity Score (ISS) was 8.3 (range, 1 to 36). The average intensive-care-unit length of stay was 0.5 days (range, 0 to 25). The average sum of all Extremity Abbreviated Injury Scores (EAIS) was 4 (range, 1 to 18). ICD-9 diagnoses for orthopaedic injuries were collected. Patient responses to the questionnaire were tabulated, and the patient variables noted above were tested to see if any were associated with the development of PTSD.

Results: Of the respondents, 163 (52%) met the criteria for a diagnosis of PTSD. Patients with PTSD had significantly higher Injury Severity Scores (P = 0.002) and had a higher sum of EAIS scores (P = 0.025). Additionally, those with PTSD were further from the time of their injury than those without PTSD (P = 0.026). Contrary to our expectation, more elapsed time since injury seemed to raise the risk of PTSD rather than decrease it. Patients with PTSD tended to be younger, but this difference was not significant (P = 0.079). Marital status, GCS score, ICU length of stay, and injury mechanism were not significantly associated with later development of PTSD. Likewise, sex, language preference, and whether the patient was seen in an indigent or at a private clinic were not significantly associated with PTSD. No association between the development of PTSD and any of 20 specific ICD-9 diagnosis codes tested could be found.

Discussion: Orthopaedic surgeons tend to make diagnoses based on objective information, such as physical examination or radiographic findings. Many traumatized patients will not voice complaints about psychological symptoms, either because they do not realize that their mental illness is linked to a traumatic event, or because they fear they will be seen as emotionally unstable or "crazy." Symptoms of PTSD can have a profound effect on a patient's life, even though these symptoms may never be discussed in a routine orthopaedic office visit. Because doctors do not usually ask about psychological symptoms and patients are often ashamed or embarrassed to discuss such problems, PTSD is rarely diagnosed with orthopaedic trauma patients. The results of this study show that, far >from being rare, PTSD is common among people who sustain musculoskeletal injury. Increased recognition and treatment of PTSD should lead to better outcomes for orthopaedic trauma patients.

Conclusion: Development of the symptoms of PTSD after orthopaedic trauma is common, and increased severity of injury raises the risk of PTSD. In this study, patients who were further out from the time of their injury had an increased risk of PTSD. It is unclear whether this finding indicates that the risk of PTSD increases with time after injury or if patients with PTSD symptoms are more likely to seek medical attention over time, thus raising the apparent prevalence rate of PTSD. The questionnaire was well accepted by our patients and may be useful as a screening tool for PTSD.