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AAOS Now

Published 5/1/2011
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Maureen Leahy

PTSD: An underrecognized complication

When left untreated, PTSD leads to poor orthopaedic outcomes

Posttraumatic stress disorder (PTSD) is an anxiety disorder that may occur in people who have been exposed to a traumatic event. People with PTSD persistently experience nightmares or flashbacks, emotional numbing, and hyperarousal (eg, insomnia, inability to concentrate); they purposely avoid all stimuli associated with the trauma. Symptoms typically begin to develop within 3 months of the event.

Due to the prevalence of traumatic stress in soldiers, much of the research on PTSD has been in military populations. PTSD, however, is also a potential complication for musculoskeletal trauma patients and may have considerable negative effects on outcomes.

Daniel L. Aaron, MD, of Rhode Island Hospital, Providence, R.I., and his coauthors discuss “Posttraumatic Stress Disorders in Civilian Orthopaedics,” in the May issue of the Journal of the AAOS. AAOS Now spoke with Dr. Aaron to learn more about the phenomenon.

AAOS Now: How prevalent is PTSD in the civilian orthopaedic population? Who is at risk?

Dr. Aaron: PTSD among orthopaedic patients is more prevalent than people realize because many physicians don’t know how to recognize it. The literature reports that PTSD occurs in up to 51 percent of patients who have sustained serious orthopaedic trauma. More typical percentages range from 18 percent to 20 percent, at 6 months to 12 months following injury.

Risk factors for PTSD include young age—although the definition of “young” varies, female sex, poor education, lower socioeconomic status, and the use of drugs and alcohol. One study that examined PTSD and ethnicity found a higher risk of PTSD symptoms among people of Hispanic origin.

PTSD is associated with higher energy trauma, which tends to result in open fractures or pelvic injuries, although PTSD is not limited to these types of injuries. Mechanisms of injury often include motor vehicle accidents, motorcycle accidents, and falls from heights such as from a ladder or roof.

AAOS Now: How can orthopaedic surgeons recognize patients who are at risk for PTSD?

Dr. Aaron: Orthopaedic surgeons are in a position to recognize and help prevent the development of PTSD because they frequently provide primary care to patients after a traumatic injury. PTSD adversely affects both the patient’s emotional health and his or her physical outcome and is, therefore, detrimental to the orthopaedic surgeon’s efforts to restore patients to function after injury. Patients with PTSD have a lower rate of return to work, a lower rate of return to their original physical function, and a decreased ability to perform activities of daily living (ADL) such as eating and bathing, as well as instrumental ADLs like shopping and preparing meals.

Orthopaedic surgeons should familiarize themselves with the risk factors of PTSD. It may also be helpful to question patients during the initial physical exam about how their injury will likely affect them emotionally and physically. One group of researchers found that patients who responded to being more affected by the emotional fallout of their injury, compared to the physical fallout, were at a higher risk for PTSD.

Recent studies suggest that patients with acute stress disorder, which has many of the same signs and symptoms as PTSD and occurs within the patient’s initial hospitalization for injury, are predisposed to development of PTSD. Certain outcome measurement instruments can also be used to evaluate patients (Table 1).

AAOS Now: How is PTSD managed?

Dr. Aaron: Once an at-risk patient is identified, prevention strategies can be implemented. Pharmacologic prevention methods involve selective serotonin reuptake inhibitors (eg, fluoxetine, sertraline) and antidepressant and anti-anxiety medications and are best managed by psychiatrists.

Psychiatric referral is imperative if the problem continues. Some of the same medications that may be useful in preventing PTSD have been proven effective in treating the disorder. A psychiatrist may also initiate nonpharmacologic management, such as cognitive behavioral therapy.

AAOS Now: How long should orthopaedists stay involved in the care of the patient with PTSD?

Dr. Aaron: That is a critical issue, which warrants further research. I think all orthopaedists would agree that we should stay involved until physical healing is complete, but patients with PTSD may warrant fruther orthopaedic involvement as their functional rehabilitation begins to improve.

Dr. Aaron’s coauthors of “Posttraumatic Stress Disorders in Civilian Orthopaedics,” are Paul D. Fadale, MD; Colin J. Harrington, MD; and Christopher T. Born, MD.

Disclosure information: Dr. Aaron—Orthopaedic Research and Reviews; Dr. Fadale—Sports Medicine & Arthroscopy Review, Arthroscopy Association of North America Learning Center Committee; Dr. Born—Stryker; Illuminoss; Biointraface; Journal of the AAOS; Clinical Orthopaedics and Related Research; Journal of Orthopaedic Trauma; Journal of Trauma; American College of Surgeons; Orthopaedic Trauma Association; AAOS; Foundation for Orthopaedic Trauma; Dr. Harrington—no disclosures.

Bottom line

  • PTSD is underrecognized in civilian orthopaedic patients.
  • Orthopaedic outcomes in rehabilitation can be adversely affected in patients with PTSD.
  • Orthopaedic surgeons can learn to recognize at-risk patients and help prevent the development of PTSD.
  • Research evaluating the correlation between successful management of PTSD’s emotional symptoms and improved physical outcomes is needed.

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at leahy@aaos.org

References:

  1. Starr AJ, Smith WR, Frawley WH, et al: Symptoms of posttraumatic stress disorder after orthopaedic trauma. J Bone Joint Surg Am 2004;86(6):1115-1121.
  2. Williams AE, Smith WR, Starr AJ, et al: Ethnic differences in posttraumatic stress disorder after musculoskeletal trauma. J Trauma 2008;65(5):1054-1065.