Recent U.S. military operations in Iraq and Afghanistan have resulted in nearly 15,000 U.S. service members being evacuated from combat zones with battle-related injuries. Among those injured, approximately 1,200 have sustained at least one battle-related, major amputation (excluding the digits).

Much has been published regarding the characterization of extremity war injuries, the resultant long-term disability associated with combat wounds, and the characterization of combat amputations. Overall, however, these epidemiologic studies have not examined the various demographics of service members. Specifically, the course of care of the female veteran following combat injury is not understood. Evidence supports a different reaction by female veterans compared to male military or female civilians who are exposed to war. All-cause fatality rates also appear to be higher among female veterans.

Female veterans represent the fastest growing population of Veterans Health Administration (VA) users, with 44 percent of female veterans from Iraq and Afghanistan matriculating to VA health care. A review of healthcare utilization in the VA indicated that female veterans use primary care and mental health services more frequently than male veterans. Additionally, female veterans are more likely than males to experience musculoskeletal disorders and depression. Female veterans have a higher odds ratio of musculoskeletal conditions, especially back and joint problems. The musculoskeletal pain reported by female veterans increases annually following injury compared to male veterans.

These studies suggest that musculoskeletal conditions have an impact on female veterans and highlight the importance of pain and mental health outcomes for female veterans. Additionally, the most common injury sustained in combat is a musculoskeletal injury and the most common cause for medical evacuation of female service members is mental health conditions. Therefore, the potential link of these types of conditions with regard to long-term outcomes cannot be ignored and needs investigation.

One mental health condition that has received a lot of attention is posttraumatic stress disorder (PTSD). Studies on PTSD have been mixed with regard to rates between men and women, although most studies include a mixed population of service members from variable occupational roles and injury severities. A recent effort to determine disability outcomes for a discrete subset of injured service members explored military-associated disability following combat-related amputation. Among the cohort of combat amputees from recent U.S. conflicts, as identified in the Department of Defense Trauma Registry and the Military Orthopaedic Trauma Registry (MOTR), 24 are women.

None of the women who were able to continue on active duty status received a disability rating for PTSD. However, women service members were found to have PTSD more frequently than men, and women’s disability from PTSD tended to be rated higher than men’s.

Although the literature on PTSD and the female veterans remains mixed, evidence exists to support that PTSD, as well as other mental health outcomes, are important considerations when treating female veterans with orthopaedic injuries. These mental health outcomes can have an adverse effect on their ability to pursue employment or continue on active-duty status.

A holistic view
In a holistic view of a patient’s orthopaedic trauma experience, the trauma, the subsequent coping mechanisms, and the patient’s mental health status are important. How men and women experience trauma and deal with that experience may vary.

One phenomenological study of female veterans with amputations made an effort to determine the psychological adjustment employed following limb loss. Each of the female participants admitted that her adjustment to her physical disability was affected by concerns for her personal safety. Female veterans also expressed concern that their psychological adjustment was influenced by social perceptions and personal body image issues, which they felt were more significant for women than for men with similar injuries.

One veteran expressed frustration that, among a group of other wounded service members, she was commonly not identified as a wounded veteran because she is female. Each woman identified protective factors such as mental toughness and strong social support as vitally important for her psychosocial adjustment.

Although these factors may seem to be out of the realm of orthopaedics, orthopaedic surgeons do have the opportunity to allow patients to talk about these concerns and can direct patients to peer support, mental health, and occupational health services as part of an integrated, interprofessional recovery program. This practice is currently employed within the military health system at the U.S. Army Institute of Surgical Research – Burn Center, the Center for the Intrepid, and the Brain Injury Rehabilitation Service within the Department of Orthopaedics & Rehabilitation at Ft. Sam Houston, Texas.

As the current generation of veterans moves from the military healthcare system to the VA and civilian health care, healthcare providers have a responsibility to take into account the effects of injury beyond the acute stabilization and initial recovery. The recent literature on the female veteran suggests that these considerations should be approached differently for men and women veterans to provide the best care possible.

The female military veteran amputee is one example of a population that faces challenges beyond the musculoskeletal injury. Psychological adjustments, social adjustments, and comorbid physical and mental health conditions affect the outcomes of the female trauma patient. Both veterans’ health policy and civilian trauma health care should include study of and best practice guidelines for treating sex-specific outcomes in this population.

Disclaimer: The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.

Maj. Jessica C. Rivera, MD, is assigned to the United States Army Institute of Surgical Research with duty at the department of orthopaedics & rehabilitation (DOR), San Antonio Military Medical Center (SAMMC) and is the associate custodian for MOTR; Lt. Col. Anthony E. Johnson, MD, is the MOTR custodian and the current chair of the DOR, SAMMC.

Putting sex in your orthopaedic practice
This quarterly column from the AAOS Women’s Health Issues Advisory Board and the Ruth Jackson Orthopaedic Society provides important information for your practice about issues related to sex (determined by our chromosomes) and gender (how we present ourselves as male or female, which can be influenced by environment, families and peers, and social institutions). It is our mission to promote the philosophy that male and female patients experience and react to musculoskeletal conditions differently; when it comes to patient care, surgeons should not have a one-size-fits-all mentality.

Bottom Line

• Female veterans have a different response to war than their male colleagues and female civilians.
• Female veterans use primary care and mental health services more frequently than male veterans and are more likely than males to experience musculoskeletal disorders and depression.
• In addition to their musculoskeletal injury, female veteran amputees face challenges that include psychological adjustments, social adjustments, and comorbid physical and mental health conditions that differ from those faced by their male colleagues.

References:

1. Carter JK. Traumatic amputation: psychosocial adjustment of six Army women to loss of one of more limbs. J Rebah Research Develop 2012; 49 (10): 1443-1456.
2. Cross JD, Johnson AE, Wenke JC, Bosse MJ, Ficke JR. Mortality in female war veterans of Operations Enduring Freedom and Iraqi Freedom. Clin Orthop Relat Res 2011; 469: 1956-1961.
3. Haskell SG, Mattocks K, Goulet JL, Krebs EE, Skanderson M, Leslie D, et al. The burden of illness in the first year home: do male and female VA users differ in health conditions and healthcare utilization. Womens Health Issues 2011; 21(1): 92-97.
4. Haskell SG, Ning Y, Krebs E, Goulet J, Mattocks K, Kerns R, et al. Prevalence of painful musculoskeletal conditions in female and male veterans in 7 years after return from deployment in Operation Enduring Freedom/Operation Iraqi Freedom. Clin J Pain 2012; 28: 163-167.
5. Rivera JC, Johnson AE. Female veterans of Operations Enduring and Iraqi Freedom: status and future directions. Mil Med 2014; 179: 133-6.