Session VIII - Pediatrics
Sat, 10/9/04 Pediatrics, Paper #47, 3:38 pm
Post-Traumatic Stress Symptoms in Pediatric Orthopaedic Trauma Patients
Purpose: The purpose of this study was to determine the prevalence of symptoms of posttraumatic stress disorder (PTSD) in a population of pediatric orthopaedic trauma patients and to investigate whether injury or demographic variables are associated with the development of such symptoms.
Methods: A total of 415 pediatric orthopaedic trauma patients seen for follow-up were asked to complete a 17-item questionnaire, the Child PTSD Symptom Scale [Foa EB, Johnson KM, Feeny NC, Treadwell KH: The Child PTSD Symptom Scale: A Preliminary Examination of its Psychometric Properties. Journal of Clinical Child Psychology 30:376-384, 2001], a self-report indicator of PTSD symptoms in children ages 8 to 18. The average age of the 400 respondents (96.4%) who completed the questionnaire was 11.3 years (range, 8 to 16); 258 were boys and 142 were girls; 161 were white, 114 were Hispanic, 109 were African-American, and 16 belonged to other ethnic groups. The average elapsed time since injury was 36 days (range, 1 day to 925 days). The mechanism of injury was as follows: fall, 158 (114 from standing, 34 from 5 to 10 feet, and 10 from an unspecified height); sports-related, 92; bicycle, 37; all-terrain vehicle, 20; motor vehicle collision, 13; crush, 13; punched object, 11; motor cycle collision, 12; trampoline, 7; motor pedestrian collision, 6; and other, 15. Two patients had a Glasgow Coma Score less than 15 (12 and 14). The average Injury Severity Score (ISS) was 4 (range, 1 to 29), and the average sum of all Extremity Abbreviated Injury Scores (EAIS) was 2 (range, 1 to 5). Fifty-four patients were admitted to the hospital with an average length of stay of 4 days (range, 1 to 38). Two patients were admitted to the Intensive Care Unit for 3 and 7 days, respectively. The 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 symptoms.
Results: Of the respondents, 130 (33%) met criteria for a high level of PTSD symptoms. A significantly higher percentage of patients admitted to the hospital developed high symptom levels (P = 0.03); 46% of the admitted patients had high levels compared with 24% of the patients discharged home. A longer hospital stay did not increase the likelihood of developing symptoms. Although the variables did not reach statistical significance, patients with high levels of symptoms tended to have higher ISS scores (P = 0.10), EAIS scores (P = 0.23), and longer times since injury (P = 0.25). Age, sex, and ethnicity were not significantly associated with high symptom levels. No association between the development of high symptom levels and the six most common ICD-9 codes could be found.
Discussion: Diagnostic criteria for PTSD with specific childhood presentations were not developed until the late 1980s. Furthermore, many orthopaedists focus on the acute physical ailment of the child with concomitant reassurance to the family that children are resilient. Few orthopaedists search for signs of psychological symptoms in their patients. The results of the current study show that high levels of symptoms of PTSD are common in children who sustain musculoskeletal injury, especially whose injury necessitates hospital admission. This appears to be true even for those children who sustain relatively minor injury, as did the majority of our patients. Improved recognition of this problem should lead to better treatment and outcomes for pediatric orthopaedic trauma patients.
Conclusion: High levels of symptoms of PTSD are common after orthopaedic trauma in children. Admission to the hospital increases the risk of symptoms. Also, increased severity of injury and time since injury tend to increase the risk of symptoms. The questionnaire was well accepted by our patients and their families and may be a useful screening tool for PTSD symptoms.