CORR Insights®: Gunshot Trauma Patients Have Higher Risk of PTSD Compared With Blunt Trauma and Elective Populations: A Retrospective Comparative Study of Outpatient Orthopaedic Care

Where Are We Now?

Looking at a radiograph with callus formation surrounding a comminuted forearm fracture, I explained to my patient, John, how pleased I was with his healing. His demeanor told me that his greatest concerns pertained to something else entirely. His focus was not on fracture healing, nor even on the physical pain related to his open forearm fracture, as I expected. Rather, he was experiencing emotional distress in the wake of his trauma. John helped me realize that the treatment I had been providing to him and other patients like him was inadequate to help him fully heal.

Posttraumatic stress disorder (PTSD) affects more than 25% of patients after an acute orthopaedic injury [8]. The American College of Surgeons (ACS) recommends that certified trauma centers implement a screening protocol for mental illness and treatment for patients who have a positive screening [1]. And it makes sense to do so: Studies consistently demonstrate the important effects of mental health on patients’ clinical outcomes [4, 7, 9, 11].

In this issue of Clinical Orthopaedics and Related Research®, Wolf et al. [12] caution us about the high prevalence of PTSD among patients who have experienced orthopaedic trauma, especially those with a history of gunshot wounds (GSWs). In this retrospective review of 250 patients who completed a 7-item scale screen for PTSD, the authors found higher scores for PTSD symptoms in patients with GSWs than in patients with blunt trauma or those who hadn’t experienced trauma. They found that 64% (25 of 39) of patients with GSWs screened positive for PTSD. These results suggest that all patients who have experienced a GSW should be screened for PTSD, and that healthcare professionals should have a high index of suspicion for PTSD when caring for patients after GSW trauma.

Where Do We Need To Go?

Following the newest ACS clinical guideline for mental health, trauma centers throughout the country are implementing programs to help screen and treat PTSD [1]; however, the guideline does not specify how screening should be performed. Even though orthopaedic trauma surgeons are skilled at fixing broken bones, most of us have not received much training in mental health. Thus, many partner with other team members with expertise in mental health to form support programs that provide screening and treatment for symptomatic patients.

These support programs during trauma recovery deliver benefits to patients and hospital systems, including reduced rates of PTSD, reduced rates of unplanned hospital admissions, improved patient satisfaction, and improved compliance with medical treatment [6, 9, 11, 13]. However, implementing those kinds of programs is challenging, and there remain numerous obstacles and unanswered questions on that topic. Numerous screening tests for acute stress disorder and PTSD are available, but it is unclear which test is best suited for patients who have experienced orthopaedic trauma [1]. It would be interesting if future studies could identify the most effective screening test for patients after acute orthopaedic trauma. Moreover, who will provide screening for patients in hospitals and clinics and when it will take place? Wolf et al. [12] found the response rate for their screening questionnaire was between 45% and 85%, underscoring the limitation that many patients did not complete the screening. Future studies are needed to identify barriers to completion of the current screening tests to improve the response rate and to ensure that all at-risk patients are screened appropriately. Other questions include how we can best incorporate PTSD treatment into a recovery course of musculoskeletal injuries in patients with limited mobility. The findings of Wolf et al. [12], along with the growing evidence on mental health, underscore the importance of PTSD among orthopaedic trauma patients, but these results stopped short of presenting a comprehensive, reproducible program that would benefit the group of at-risk patients the most [8]. Based on that, future studies must define the important elements that will shape the most effective support program for patients after orthopaedic trauma.

How Do We Get There?

Different programs that incorporate mental health support have been shown to improve patients’ functional outcomes and reduce symptoms of PTSD and depression [2, 3, 9]. The ACS practice guideline identifies several programs with a range of complexity and cost [1]. Recent evidence suggests a dose-dependent effect of mental health interventions for patients after trauma [13]. Thus, a comprehensive program like the Collaborative Care Model, which includes a mental health counselor, a trauma educator, and a nurse coordinator, may result in more downstream gains for hospitals than a lower cost program with basic screening and treatment like the Multi-Tier Approach to Psychological Intervention after Traumatic Injury [2, 4, 14]. However, when applied broadly to all patients, the effect may be diluted; some studies found no difference in 1-year outcomes leading to dissolution of programs over time [5, 15]. Wolf et al. [12] identified a high-risk group of patients who had experienced violent trauma from GSWs and serious musculoskeletal injuries that are associated with a long recovery course, 64% of whom developed PTSD compared with 25% of patients with other trauma types identified in previous research [8]. This is the group of trauma patients who are the most likely to develop PTSD and are likely to benefit the most from comprehensive intervention. Head-to-head comparison studies are needed to determine the most effective program for this patient group.

Recovering after orthopaedic trauma requires healing more from physical wounds. Symptoms of PTSD can develop anytime during the recovery course and often emerge after the initial hospital stay. When the rate of PTSD is 64% for a group of patients, we can no longer rely on professionals to pick up cues during a 15-minute clinic visit [12]. A streamlined program of appropriate screening and treatment is essential in the high-risk group of patients. Establishing a program that supports mental health during trauma recovery requires collaborative efforts and buy-in from multiple stakeholder groups, including hospital administrations, healthcare professionals who care for patients who’ve experienced serious trauma, as well as patients and their at-home caregivers.

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Although building a program that supports mental health is critical for all trauma programs, individual surgeons can adopt the below practice in clinics:

• Several approaches have been suggested to screen patients for acute stress or PTSD in outpatient clinics. The Traumatic Injuries Distress Scale is an example survey that can accomplish this task in less than 3 minutes and does not require additional staff to administer [7].

• PTSD is common in the patients we treat after trauma, and it can be diagnosed at any point more than 3 months after the initial trauma experience. Patients who endorse “The emotional problems caused by the injury have been more difficult than the physical problems” may meet diagnostic criteria for PTSD and should be evaluated further [10].