Half of orthopedic trauma patients experience PTSD

Link between PTSD and injury discovered

Ever seen an orthopedic patient with great X-rays who still complains of terrible pain and can’t get back to work? If you’ve ever faced this puzzling situation, researchers at the University of Texas might have the answer for you: post-traumatic stress disorder (PTSD).

As many as 52% of patients who experience orthopedic trauma suffer from PTSD, a disorder more commonly associated with war veterans, according to a recent study by Adam Starr, MD, assistant professor of orthopedic surgery at the University of Texas Southwestern Medical Center in Dallas. "Psychological distress after trauma has a bigger impact than we think," Starr says. "I think it is the most important factor in determining outcome."

Starr, who is also a trauma surgeon at Parkland Memorial Hospital in Dallas, says it’s common in orthopedics to see patients whose X-rays indicate they should be fully recovered but who still experience pain and are unable to get back to daily activities. "It just doesn’t make any sense," says Starr, who presented the results of his research at the February meeting of the Rosemont, IL-based American Academy of Orthopaedic Surgeons. "So we started asking people why they weren’t better, and what we heard is, I’m having nightmares’ or I’m terrified about getting back up on that ladder’ or I can’t get in my car.’ A lot of times the wife will come in with the patient and say her husband is angry all the time and yells at the kids or he wakes up in the middle of the night crying or shaking. Those symptoms don’t have anything at all to do with orthopedic trauma. They’re psychological symptoms. It sounded like PTSD."

Starr began to search the literature to see if anything had been written about PTSD in orthopedic patients. He came up with some studies on PTSD in general surgery, which put the PTSD rate at 20% to 30% of patients, but nothing in orthopedics. So Starr and his colleagues gave 330 orthopedic trauma follow-up patients the Revised Civilian Mississippi Scale for PTSD, a self-report questionnaire that is widely used in the mental health industry. The team created one additional question asking whether emotional aspects resulting from the injury were more difficult to cope with than the physical problems. Causes of patient injuries included in the study were motor vehicle collision, motor-pedestrian collision, motorcycle collision, crush injuries, horseback riding injuries, and gunshot wounds, with an average time elapsed since injury of 14 months.

"Most of my patients have had some bone broken, and I think there’s something inherently horrible about seeing a piece of your body flop around broken," Starr says. "If you have a spleen rupture or a liver laceration, you don’t see it. Orthopedic injuries are painful, horrible injuries. Orthopedic trauma for adults is a life-changing event."

To merit a diagnosis of PTSD according to the Diagnostic and Statistical Manual of Mental Disorders, patients must show a specific number of symptoms in each of these categories: intrusion symptoms, such as recurring recollections of the event; avoidance symptoms, such as efforts to avoid certain activities, places, or thoughts related to the event; and arousal symptoms, such as excessive vigilance, outbursts of anger, or sleeplessness. Surprised that 52 percent of the patients met this criteria, Starr sent the protocol for the study to a colleague at the Denver Health Medical Center, who repeated the study and got similar results.

"Most people in my job are trained to focus on making the bone straight again, to get that bone to heal so the patient can walk and get back to work. We tend not to pay a whole lot of attention to other stuff," Starr says. "But this shows we’ve got this disease that we have to treat."

The main step providers need to take is to ask patients who aren’t recovering as quickly as expected if psychological problems have been more difficult than the physical problems caused by their injury. "If they say the psychological problems have been worse, that may indicate PTSD," Starr says. "The thing you have to watch out for is that asking this question is like opening Pandora’s Box. You can take what would be a five- or ten-minute office visit and turn it into a half-hour-long hand-holding session. If you ask them about it, they sure will tell you. If you start going down that road, it validates it for them and they see that it’s OK to talk about it."

But asking the question can save you time in the long run if you can get the patient some psychological help that will improve the situation. "You have to ask yourself what your goal is. If your goal is to make the patient better, then you have to ask the question," Starr says. "The reason this has gone unrecognized in orthopedics for so long is that nobody ever asks about it. I’m not trained to ask people how they’re sleeping or if they’re eating OK. We ask, How does your knee feel? What’s your range of motion like?’"

One of the biggest problems with this issue is that there aren’t a lot of psychologists who are willing or able to treat these patients, Starr says. "You can count on one hand the number of psychologists in Dallas who have any interest in this stuff at all," he says. "Now that we’ve recognized that we’ve got this disease that we have to treat, we’ve got to actually go out and treat it. I’m sure not trained to treat it. I want to send them to somebody who’s trained to treat it, and that’s hard to find."

The next step for Starr and his colleagues is a prospective study with orthopedic trauma patients to determine whether psychological intervention alters their outcomes. "In orthopedics, like most areas of medicine now, there is this revolution going on in how we assess what we do. The government and insurance carriers and HMOs are all asking us to use outcome measures," Starr says. "So we give patients these outcome questionnaires about their specific problem without realizing that what drives their responses is probably their mental health more than anything. If you have some guy who’s having nightmares every night and flashbacks every day and is scared to death of getting behind the wheel of his car, he’s not going to say his treatment was a complete success, even if his knee feels fine."

Need More Information?
  • Adam Starr, MD, Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390. Telephone: (214) 648-6428. E-mail: adam.starr@utsouthwestern.edu.