Abstract
Background
Posttraumatic stress disorder (PTSD) has been extensively studied in patients who have experienced natural disasters or military conflict, but there remains a substantial gap in knowledge about the prevalence of PTSD after civilian orthopaedic trauma, especially as related to firearms. Gun violence is endemic in the United States, especially in urban centers, and the mental impact is often minimized during the treatment of physical injuries.
Questions/purposes
(1) Do patients who experience gunshot wound (GSW) trauma have higher PTSD screening scores compared with patients with blunt or other trauma (for example, motor vehicle and motorcycle accidents or stab wounds) and those with elective conditions (for example, arthritis, tendinitis, or nerve compression)? (2) Are PTSD scores correlated with pain scores in patients with GSW trauma, those with non-GSW trauma, and patients with elective orthopaedic symptoms?
Methods
We performed a retrospective study of adults older than 18 years of age presenting to an orthopaedic clinic over an 8-month period between August 2021 and May 2022. All patients presenting to the clinic were approached for inclusion (2034 patients), and 630 new or postoperative patients answered study surveys as part of routine care. Patients were divided into three cohorts based on the orthopaedic condition with which they presented, whether gunshot trauma, blunt trauma, or elective orthopaedic symptoms. Overall, the results from 415 patients were analyzed, including 212 patients with elective orthopaedic symptoms, 157 patients with non-GSW trauma, and 46 patients with GSW trauma. Clinical data including demographic information were collected at the time of appointment and abstracted along with results from the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, short screening questionnaire, which uses a 7-item scale scored from 0 to 7 (with higher scores representing worse symptoms), and from the numeric rating scale for pain (range 0 to 10). Both questionnaires were routinely administered by medical assistants at patient intake. The proportions of patients completing PTSD scoring were 45% (95) in the elective group, 74% (116) in the group with non-GSW trauma, and 85% (39) in the group with GSW trauma (p = 0.01). We compared the PTSD scores across the three groups and then dichotomized the scores as a negative versus positive screening result at a value of ≥ 4 with further comparative analysis. The correlation between pain and PTSD scores was also evaluated.
Results
Patients with GSW trauma had higher mean ± SD PTSD scores compared with those who had non-GSW trauma (4.87 ± 4.05 versus 1.75 ± 2.72, mean difference 3.21 [95% CI 1.99 to 4.26]; p < 0.001) and those who presented with elective conditions (4.87 ± 4.05 versus 0.49 ± 1.04, mean difference 4.38 [95% CI 3.50 to 5.26]; p < 0.001). When dichotomized for positive or negative PTSD screening results, patients with GSW trauma had a higher risk of having PTSD (64% [25 of 39]) compared with patients with non-GSW trauma (27% [31 of 116], relative risk 2.40 [95% CI 1.64 to 3.51]; p < 0.001) and compared with patients with elective conditions (4% [4 of 95], relative risk 15.22 [95% CI 5.67 to 40.87]; p < 0.001). Pain scores were correlated with PTSD scores only for patients with non-GSW trauma (ρ = 0.37; p < 0.0001). No correlation with pain scores was present for patients with GSW (ρ = 0.24; p = 0.16) or patients with elective conditions (ρ = -0.04; p = 0.75).
Conclusion
In an orthopaedic clinic population, the prevalence of positive screening for PTSD was highest in the population sustaining gunshot trauma as compared with blunt or other trauma and elective orthopaedic conditions. Interestingly, pain scores correlated with PTSD screening only in the patients with non-GSW trauma. These differences suggest a substantial difference in the populations at risk of PTSD after trauma. Overall, the psychological impacts of gun trauma are poorly understood. The next step would be to prospectively study the differences and timelines of PTSD screening in patients with GSW trauma in comparison with patients with blunt or other trauma to better define the treatment needs in this population.
Level of Evidence
Level III, prognostic study.
Introduction
While the physical impact and outcomes of orthopaedic trauma are well researched, the mental consequences have been studied less. Patients who experience physical trauma manifest acute stress disorder (estimated at 21.7%) or posttraumatic stress disorder (PTSD) (36.1%) after injury [23]. Despite this, acute stress disorder and PTSD are often undiagnosed and unaddressed because of a lack of access to follow-up mental healthcare, insurance issues, or other barriers to access. The ability to recover from psychological trauma can be impacted by many factors such as prior trauma, childhood adversities, and other mental disorders [18]. Previous studies have suggested that approximately 30% of patients hospitalized for trauma develop PTSD 1 month after injury, and 49% present with delayed onset of PTSD 6 months or more after trauma [24]. Evidence has shown that there is increased risk of PTSD in urban environments, civilians in war zones, and in areas with high social deprivation [26].
The hypotheses of this study were that patients sustaining gunshot trauma would have a higher proportion of positive screening results for PTSD when compared with patients with trauma not related to firearms and those with elective conditions, and that pain scores would correlate with PTSD scores in all three groups, as pain has been shown to affect PTSD and vice versa. There is a substantive gap in knowledge on these issues that is important to address given the epidemic of gun violence, its impact on orthopaedic patients, and the need for resources to address the mental outcomes of trauma.
We therefore asked: (1) Do patients who experience gunshot wound (GSW) trauma have higher PTSD screening scores compared with patients with blunt or other trauma (for example, motor vehicle and motorcycle accidents or stab wounds) and those with elective conditions (for example, arthritis, tendinitis, or nerve compression)? (2) Are PTSD scores correlated with pain scores in patients with GSW trauma, those with non-GSW trauma, and patients with elective orthopaedic symptoms?
Patients and Methods
Study Design and Setting
We conducted a retrospective study of orthopaedic patients seen in the outpatient clinic at a single, large, urban academic Level 1 trauma center in a geographic location with high rates of social deprivation.
Patients
Over an 8-month period between August 2021 and May 2022, all patients presenting to the clinic of two orthopaedic surgeons, one specializing in orthopaedic trauma and the other in upper extremity surgery, were approached for inclusion in the study. During this period, there were 2034 visits, and 630 new or postoperative patients provided answers to surveys on PTSD as part of institutional standard-of-care screening. Trauma patients were approached in the outpatient setting after hospitalization. A total of 415 patients older than 18 years of age (an institutional cutoff for adult versus pediatric trauma at this center) were included. The exclusion criterion was age younger than 18 years. Patients included in the study comprised three groups: 46 who sustained gunshot injury, 157 who sustained blunt or other trauma, and 212 with elective conditions. Eighty-five percent (39 of 46) of patients in the GSW group completed PTSD screening compared with 74% (116 of 157) of patients in the non-GSW trauma group and 45% (95 of 212) of patients in the elective group (Table 1).
Table 1.
Characteristics of patients by patient group and PTSD screening completion
| Characteristic | Elective (n = 212) | Elective with PTSD screening (n = 95) | Non-GSW trauma (n = 157) | Non-GSW trauma with PTSD screening (n = 116) | GSW (n = 46) | GSW with PTSD screening (n = 39) | p value |
| Female | 61 (130) | 57 (54) | 52 (82) | 53 (61) | 11 (5) | 10 (4) | < 0.001 |
| Race | |||||||
| Black | 57 (120) | 59 (56) | 58 (91) | 58 (67) | 93 (43) | 92 (36) | |
| White | 34 (72) | 31 (29) | 20 (32) | 27 (31) | 0 (0) | 0 (0) | |
| Multiple | 4 (8) | 3 (3) | 10 (15) | 11 (13) | 7 (3) | 8 (3) | |
| Asian | 2 (5) | 3 (3) | 1 (2) | 2 (2) | 0 (0) | 0 (0) | |
| Unknown | 3 (7) | 4 (4) | 3 (4) | 3 (3) | 0 (0) | 0 (0) | < 0.001 |
| Tobacco use | 13 (27) | 16 (15) | 24 (37) | 25 (29) | 33 (15) | 28 (11) | < 0.001 |
| Age in years | 57 (18-87) | 54 (18-87) | 56 (18-100) | 43 (18-87) | 40 (18-61) | 33 (18-61) | < 0.001 |
| BMI in kg/m2 | 26.3 (15.3-49.8) | 28.5 (18.0-49.8) | 27.5 (17.1-47.4) | 26.2 (17.1-47.4) | 27.4 (19.7-44.3) | 25.9 (19.7-44.3) | 0.25 |
Data presented as % (n) or median (range).
Outcomes Tools and Data Sources
All patients in our clinics are asked to complete the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), short screening questionnaire, which is a validated PTSD instrument [3] that uses seven focused questions and is scored on a scale from 0 to 7, with higher scores indicating a higher risk of a PTSD diagnosis (Appendix 1; http://links.lww.com/CORR/B313). Completion of the DSM-IV is part of the routine triage process during clinic intake. We screened all patients to evaluate for baseline proportion of PTSD in the patient population, geographically located in an area with high rates of gun violence. A score of ≥ 4 is considered a positive screening. The DSM-IV questionnaire was developed for use in busy clinical environments and excludes lifetime exposure to trauma to measure current mental status.
Results from the numeric rating scale (NRS) for pain at the time of presentation to the clinic were also recorded. The NRS pain score is a validated measure of current pain [15], with a scale of 0 to 10, 10 being the highest level of pain, and a minimum clinically important difference of 2 [5]. It applies to patients at all stages of care including new evaluation, postoperative follow-up, and follow-up after conservative care. All scores were collected in the electronic medical record as pain at the time of arrival, at the first clinic follow-up, within 6 weeks of injury, or at presentation and concurrently with PTSD screening for patients with elective conditions.
All patients meeting inclusion criteria underwent manual chart review. Demographic and clinical data were extracted, including age, patient-reported gender and race, BMI, tobacco use, NRS pain scores, injury details, and surgical procedures. Patients were divided into the following three groups based on the reason that they presented to the clinic: those treated for elective musculoskeletal problems, those treated for GSW trauma, and those treated for blunt or other traumatic injuries (Table 2). The elective cohort consisted of patients with symptoms not resulting from a traumatic event or acute injury. This included patients presenting for overuse injuries and related nontraumatic orthopaedic conditions such as carpal tunnel syndrome, tendinitis, trigger digits, osteoarthritis, nerve compressive disorders, and similar conditions (Table 3). Patients with traumatic injuries consisted of two groups: gunshot trauma and blunt or other trauma (to include stab wounds, motor vehicle accidents, and falls), with screening performed at the first postoperative visit up to 6 weeks after surgery or injury.
Table 2.
Mechanism of injury for the trauma population
| Mechanism of injury | Total trauma population (n = 203) |
| GSW | 23 (46) |
| General trauma | 9 (18) |
| Fall | 33 (67) |
| Assault | 1 (2) |
| MVA | 34 (70) |
Data presented as % (n).
Table 3.
Sites of chief complaint for the elective population
| Location | Total elective population (n = 212) |
| Bone | |
| Clavicle | 0.5 (1) |
| Shoulder | 11 (24) |
| Elbow | 2 (5) |
| Forearm | 5 (10) |
| Wrist | 8 (17) |
| Hand | 7 (14) |
| Finger | 12 (25) |
| Hip | 2 (5) |
| Knee | 3 (7) |
| Ankle | 1 (2) |
| Foot | 1 (2) |
| Nerve | |
| Carpal tunnel | 11 (23) |
| Cubital tunnel | 2 (4) |
| Soft tissue | 17 (37) |
| Tendon | 13 (28) |
| Other | 3 (7) |
| Cervical/spine | 0.5 (1) |
Data presented as % (n).
Descriptive Data
Within the three cohorts, there were notable and expected differences. Patients presenting with elective conditions were more likely to be women (61% [130 of 212]; p < 0.001) and older (≥ 45 years) in age (67% [142 of 212]; p < 0.001) compared with the patients presenting with trauma (men 57% [116 of 203]; p < 0.001; < 45 years of age 56% [113 of 203]; p < 0.001). These differences match the findings of previous studies demonstrating an inherent difference between patient populations who have experienced trauma and those who have not. Patients who have experienced trauma have been shown previously to be younger, with a prevalence of male patients and differences in mechanism [27, 29]. The demographic characteristics of patients with completed PTSD scores and those with missing data were not different (Table 1).
Primary Outcome
Our primary outcome was PTSD screening score, obtained using the DSM-IV short screening questionnaire. The PTSD scores were dichotomized as a negative versus positive screening result using the predetermined cut point at a value of ≥ 4 [3].
Secondary Outcome
Our secondary study goal was the correlation between pain scores and PTSD screening scores, which was measured by statistical analysis of NRS scores and an evaluation of PTSD scores stratified by each of the three groups.
Ethical Approval
Ethical approval for this study was obtained from the University of Chicago Biological Sciences Division/University of Chicago Medical Center (Protocol IRB18-1370-CR005).
Statistical Analysis
We described the demographic characteristics of the patients by group using frequencies and percentages by means of a Fisher exact test. We also used frequencies and percentages and a Fisher exact test to determine whether PTSD screening was completed. PTSD scores were compared across groups visually using scatter plots, and then the statistical significance of between-group differences was assessed using Kruskal-Wallis and Wilcoxon rank sum tests, with the threshold of significance set at p = 0.05. Finally, we assessed the correlation between PTSD screening score and NRS score using Spearman rho for each patient group, and we used box plots and Wilcoxon rank sum testing to compare NRS scores for patients with a positive versus negative PTSD screening result.
Results
Distribution of PTSD Screening Scores for Patients Presenting for Outpatient Orthopaedic Care
With PTSD screening completed by 60% (250 of 415) of the patients eligible, there was a substantially increased proportion of PTSD in the population with gunshot trauma compared with the group with blunt or other trauma and the group presenting for elective treatment. Broken down by mechanism, patients with gunshot trauma were more likely to have completed PTSD screening (85% [39 of 46]) compared with patients with elective conditions (45% [95 of 212]; p < 0.001) and patients with non-GSW trauma (74% [116 of 157]; p = 0.13).
Patients who sustained GSW trauma had higher mean ± PTSD scores compared with those who had non-GSW trauma (4.87 ± 4.05 versus 1.75 ± 2.72, mean difference 3.21 [95% CI 1.99 to 4.26]; p < 0.001) and those who presented for elective treatment (4.87 ± 4.05 versus 0.49 ± 1.04, mean difference 4.38 [95% CI 3.50 to 5.26]; p < 0.001) (Fig. 1). When dichotomized for positive or negative PTSD screening results, patients with GSW trauma had a higher risk of having PTSD (64% [25 of 39]) compared with patients with non-GSW trauma (27% [31 of 116], relative risk 2.40 [95% CI 1.64 to 3.51]; p < 0.001) and compared with patients with elective conditions (4% [4 of 95], relative risk 15.22 [95% CI 5.67 to 40.87]; p < 0.001). The baseline PTSD screening score, which was positive in 4% of the overall elective population, reflects a low but present level of PTSD risk in an urban population center [23, 24].
Fig. 1.
This box plot shows PTSD scores by patient type; GSW = gunshot wound.
Correlation of PTSD Scores With Pain Scores in the GSW, Non-GSW Trauma, and Elective Groups
Pain score was correlated with PTSD score only in patients with non-GSW trauma (ρ = 0.37; p < 0.001), whereas there was no correlation in patients with GSW trauma (ρ = 0.24; p = 0.16) and patients with elective conditions (ρ = -0.04; p = 0.75) (Fig. 2). A total of 341 patients reported an NRS pain score; the mean score was 3 (range 0 to 10). Within this group, 73% (250 of 341) also completed PTSD screening scores. Interestingly, NRS pain scores were similar across patient groups (Fig. 2). When the NRS pain scores were compared with positive PTSD screening results, the associations were present for the groups of patients who had either GSW trauma (p = 0.01) or non-GSW trauma (p = 0.002).
Fig. 2.
This scatter plot shows correlations between PTSD screening scores and pain scores for the (A) elective, (B) non-GSW trauma, and (C) GSW trauma groups; GSW = gunshot wound.
Discussion
The prevalence of PTSD in patients with orthopaedic trauma has been shown to be higher than population norms up to 3 years after injury, highlighting the mental impact of musculoskeletal trauma [11, 20, 21]. The impact of the mechanism of trauma on PTSD is less well understood. There is a substantial gap in knowledge about the prevalence of PTSD after civilian orthopaedic trauma, especially as related to firearms. As gun violence is endemic in the United States, especially in urban centers, the impact of this injury mechanism on the mental state of patients with orthopaedic trauma is critical to understand to optimize the mental and physical treatment of these injuries. The current study demonstrated that patients with GSW injuries had overall higher PTSD screening scores and were more likely to screen positive for PTSD than patients with non-GSW trauma or elective conditions. These results suggest that healthcare providers should have a high index of suspicion for potential PTSD in patients who present after experiencing GSW trauma.
Limitations
This study had several limitations. The survey-based study design is subject to potential survey completion bias, which may have underrepresented those with potential PTSD who elected not to complete the survey. Although survey completion was requested of all patients, there may have been many reasons patients did not complete the questionnaire, including time, interest, or concern over the content. The completion rates among trauma patients were higher than for patients with elective conditions, which may have artificially suggested a larger difference between groups. This discrepancy in survey completion by diagnosis is an important caveat in the interpretation of the study findings; however, rates of completion for both trauma cohorts were high (74% and 87%), which suggests that for our primary outcome, frequency of PTSD based on trauma mechanism, the impact of differential completion was likely minimized. Furthermore, patient diagnosis itself is a potential confounder as the patient groups are inherently different based on the conditions with which they presented. The impact of any diagnosis on a patient’s psychological response to and recovery from injury is the crux of the current investigation. The inclusion of patients with elective conditions was intentional, to provide a comparative baseline to assess the correlation of trauma exposure itself. The differences in underlying diagnosis between the patients exposed to GSW trauma and non-GSW trauma, while potentially present, were similarly matched by anatomic location; previous work has suggested that injury-related factors may not have a large effect on psychological and health outcomes [4]. While PTSD scores were collected as close as possible to the time of the traumatic injury, positive screening may or may not be referable to that injury. We did not specifically collect data on variables that may have contributed to a greater understanding of this population, including Injury Severity Scores, history of substance abuse, or other social determinants of health. Because our study was conducted at a single urban Level 1 trauma center, our results may only be generalizable to similar institutions and patient populations, and thus, wider generalizability may not apply.
Distribution of PTSD Screening Scores for Patients Presenting for Outpatient Orthopaedic Care
Patients with GSW trauma have higher PTSD scores and a higher risk of screening positive for PTSD. In the study population, 64% of patients screened positive for PTSD, suggesting that screening and identification of at-risk patients is important, particularly in the population of patients with gunshot trauma. PTSD has been shown to have adverse effects on patient recovery and outcomes and is a common sequela of traumatic injury [10], but PTSD in patients with orthopaedic trauma, especially that due to penetrating causes, has not been studied in depth. As gunshot trauma presents an ongoing public health issue, especially in urban centers [19], the identification and treatment of PTSD is critical. The results of the current study confirm that PTSD screening scores for traumatic orthopaedic injuries, especially firearm-related injuries, are higher than those in the elective patient population. The population of patients with GSW trauma is at risk for the well-established physical and psychological consequences of PTSD if untreated [14]. Effective identification and management may provide opportunities for intervention and improve outcomes and reduce readmission after trauma [12, 22]. Previous work has similarly found a high proportion of positive screening results for PTSD in the trauma population (as high as 30%); however, no studies have specifically evaluated patients with orthopaedic trauma and the impact of GSW injuries specifically [6, 13, 17, 21, 28]. Interestingly, a previous National Epidemiologic Survey, conducted between 2012 and 2013, reported the lifetime prevalence of PTSD in the United States as 6.11%, while other studies of populations in urban centers have suggested a community proportion of up to 30% [8, 17]. Our study showed that a low overall proportion (4%) of patients screened positive for PTSD in the elective population presenting for orthopaedic care at our Level 1 trauma center. While this finding also could be attributed to acute stress disorder or to other reasons in the general population, previous work has suggested that those with exposure to violence or with comorbid psychiatric disorders and recent immigrants and socioeconomically disadvantaged patients are most at risk [6, 16].
Correlation of PTSD Scores With Pain Scores in the GSW, Non-GSW Trauma, and Elective Groups
In evaluating the relationship between pain and positive screening results for PTSD, we noted a statistically meaningful correlation in the patients sustaining blunt or other trauma only (ρ = 0.37; p < 0.001). Although the elective cohort reported higher levels of pain overall, this did not correlate with PTSD screening results. There is compelling evidence that pain levels impact PTSD severity. Warren et al. [25], in a study of patients with orthopaedic trauma, noted that a pain score of ≥ 5 was one factor increasing the risk of PTSD 6 months after injury. Another prospective study of 213 patients with trauma showed that pain at hospital discharge was associated with PTSD and depression at 1 year [1]. As pain and PTSD often co-occur after injury and influence each other [7], it is important to measure both in considering treatment options. Our findings suggest that while pain itself may not be sufficient to induce or predict positive PTSD screening results, pain is a component of the risk factors that may heighten prevalence of PTSD. However, the relationship between pain and PTSD is multifactorial and can be influenced by other comorbidities [9], social determinants of health [2], and degree of resilience [20].
Conclusion
In this study, we demonstrated that patients with gunshot trauma are at particularly high risk for PTSD based on screening criteria compared with those with non-GSW trauma and elective orthopaedic conditions in a retrospectively evaluated cohort. The prevalence of high PTSD screening scores in the GSW trauma group indicates that these patients should be routinely evaluated for PTSD during recovery. Possible resources for patients sustaining GSW trauma might include access to focused therapy and programming on violence prevention. The next step is a prospective study to compare PTSD screening measurements in patients with GSW trauma with those with blunt or other trauma over time with evaluation of the impact of injury severity, social determinants of health, and pain control to help stratify interventions.
Footnotes
Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.
Ethical approval for this study was obtained from the University of Chicago Biological Sciences Division/University of Chicago Medical Center (Protocol IRB18-1370-CR005).
This work was performed at the University of Chicago Medicine, Chicago, IL, USA.
Contributor Information
Fatima Bouftas, Email: fatima.bouftas@uchicagomedicine.org.
David C. Landy, Email: landyarthroplasty@gmail.com.
Jason A. Strelzow, Email: jstrelzow@bsd.uchicago.edu.
References
- 1.Archer KR, Abraham CM, Song Y, Obremskey WT. Cognitive-behavioral determinants of pain and disability two years after traumatic injury: a cross-sectional survey study. J Trauma Acute Care Surg . 2012;72:473-479. [DOI] [PubMed] [Google Scholar]
- 2.Bell TM, Gilyan D, Moore BA, et al. Long-term evaluation of a hospital-based violence intervention program using a regional health information exchange. J Trauma Acute Care Surg. 2018;84:175-182. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Breslau N, Peterson EL, Kessler RC, Schultz LR. Short screening scale for DSM-IV posttraumatic stress disorder. Am J Psychiatry. 1999;156:908-911. [DOI] [PubMed] [Google Scholar]
- 4.Cahill SP, Pontoski K, D’Olio CM. Posttraumatic stress disorder and acute stress disorder II: considerations for treatment and prevention. Psychiatry (Edgmont). 2005;2:34-46. [PMC free article] [PubMed] [Google Scholar]
- 5.Farrar JT, Portenoy RK, Berlin JA, Kinman JL, Strom BL. Defining the clinically important difference in pain outcome measures. Pain. 2000;88:287-294. [DOI] [PubMed] [Google Scholar]
- 6.Gillikin C, Habib L, Evces M, Bradley B, Ressler KJ, Sanders J. Trauma exposure and PTSD symptoms associate with violence in inner city civilians. J Psychiatr Res. 2016;83:1-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Giummarra MJ, Reeder S, Williams S, et al. Stepped collaborative care for pain and posttraumatic stress disorder after major trauma: a randomized controlled feasibility trial. Disabil Rehabil. 2023:1-17. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Goldstein RB, Smith SM, Chou SP, et al. The epidemiology of DSM-5 posttraumatic stress disorder in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions-III. Soc Psychiatry Psychiatr Epidemiol. 2016;51:1137-1148. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Joseph NM, Benedick A, Flanagan CD, et al. Prevalence of posttraumatic stress disorder in acute trauma patients. OTA Int. 2020;3:e056. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Kravets V, McDonald M, DeRosa J, et al. Early identification of post-traumatic stress disorder in trauma patients: development of a multivariable risk prediction model. Am Surg. 2023;89:4542-4551. [DOI] [PubMed] [Google Scholar]
- 11.LaRose M, Cunningham D, Paniagua A, Gage MJ. Long-term post-traumatic stress disorder after orthopaedic injury: prevalence and risk factors. J Orthop Trauma. 2022;36:e122-e128. [DOI] [PubMed] [Google Scholar]
- 12.Lumbard DC, Richardson CJ, Endorf FW, Nygaard RM. Firearm injury survival is only the beginning: the impact of socioeconomic factors on unplanned readmission after injury. Injury. 2023;54:110893. [DOI] [PubMed] [Google Scholar]
- 13.Nehra D, Bulger EM, Maier RV, et al. A prospective US national trauma center study of firearm injury survivors weapon carriage and posttraumatic stress disorder symptoms. Ann Surg. 2021;274:e364-e369. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Nguyen J, Whiteside LK, Bulger EM, et al. Post-traumatic stress disorder (PTSD) symptoms and alcohol and drug use comorbidity at 25 US level I trauma centers. Trauma Surg Acute Care Open. 2022;7:e000913. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Price DD, Bush FM, Long S, Harkins SW. A comparison of pain measurement characteristics of mechanical visual analogue and simple numerical rating scales. Pain. 1994;56:217-226. [DOI] [PubMed] [Google Scholar]
- 16.Rahman S, Zammit S, Dalman C, Hollander AC. Epidemiology of posttraumatic stress disorder: a prospective cohort study based on multiple nationwide Swedish registers of 4.6 million people. Eur Psychiatry. 2022;65:e60. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Raman U, Bonanno PA, Sachdev D, et al. Community violence, PTSD, hopelessness, substance use, and perpetuation of violence in an urban environment. Community Ment Health J. 2021;57:622-630. [DOI] [PubMed] [Google Scholar]
- 18.Rosellini AJ, Liu H, Petukhova MV, et al. Recovery from DSM-IV post-traumatic stress disorder in the WHO World Mental Health surveys. Psychol Med. 2018;48:437-450. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Silver JH, Ramos TA, Stamm MA, Gladden PB, Martin MP, Mulcahey MK. Examining the healthcare and economic burden of gun violence in a major US metropolitan city. J Am Acad Orthop Surg Glob Res Rev. 2023;7:e22.00158. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Srivastava AV, Brown R, Newport DJ, et al. The role of resilience in the development of depression, anxiety, and post-traumatic stress disorder after trauma in children and adolescents. Psychiatry Res. 2024;334:115772. [DOI] [PubMed] [Google Scholar]
- 21.Vasan A, Mitchell HK, Fein JA, Buckler DG, Wiebe DJ, South EC. Association of neighborhood gun violence with mental health-related pediatric emergency department utilization. JAMA Pediatr. 2021;175:1244-1251. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Vella MA, Warshauer A, Tortorello G, et al. Long-term functional, psychological, emotional, and social outcomes in survivors of firearm injuries. JAMA Surg. 2020;155:51-59. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Visser E, Den Oudsten BL, Lodder P, Gosens T, De Vries J. Psychological risk factors that characterize acute stress disorder and trajectories of posttraumatic stress disorder after injury: a study using latent class analysis. Eur J Psychotraumatol. 2022;13:2006502. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Visser E, Gosens T, Den Oudsten BL, De Vries J. The course, prediction, and treatment of acute and posttraumatic stress in trauma patients: a systematic review. J Trauma Acute Care Surg. 2017;82:1158-1183. [DOI] [PubMed] [Google Scholar]
- 25.Warren AM, Jones AL, Bennett M, et al. Prospective evaluation of posttraumatic stress disorder in injured patients with and without orthopaedic injury. J Orthop Trauma. 2016;30:e305-311. [DOI] [PubMed] [Google Scholar]
- 26.White J, Pearce J, Morrison S, Dunstan F, Bisson JI, Fone DL. Risk of post-traumatic stress disorder following traumatic events in a community sample. Epidemiol Psychiatr Sci. 2015;24:249-257. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Zhang J, Bradshaw F, Duchniewicz M, Karamatzanis I, Fernandes FW, Krkovic M. Epidemiology and incidence of upper limb fractures: a UK level 1 trauma center perspective. Cureus. 2024;16:e54961. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Zimmerman GM, Posick C. Risk factors for and behavioral consequences of direct versus indirect exposure to violence. Am J Public Health. 2016;106:178-188. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Zwemer C, Kartiko S, Forssten MP, et al. Firearms-related injury and sex: a comparative National Trauma Database (NTDB) study. Trauma Surg Acute Care Open. 2023;8:e001181. [DOI] [PMC free article] [PubMed] [Google Scholar]