PTSD Common in Children with Orthopaedic Injuries

More than one third of patients in study had posttraumatic stress disorder

Jennie McKee

The fact that trauma has more than just a physical effect on the patient and the patient’s family is something we, as surgeons, are becoming increasingly aware of,” noted the authors of a study presented yesterday.

The study evaluated 76 children between the ages of 8 and 18 years; 44 patients were treated for traumatic orthopaedic injuries (44 patients) and 32 patients had isolated, upper extremity (UE) fractures and were treated nonsurgically. More than one third of study participants had symptoms of posttraumatic stress disorder (PTSD) resulting from their injury.

The psychological repercussions of a traumatic injury, noted the researchers, can “represent a life-altering experience and have lasting implications on extracurricular activities, school, future education plans, and family relationships,” and can “interfere with emotional, social, and cognitive development.”

Because they did not find any factors significantly associated with or predictive of PTSD, the investigators emphasized that orthopaedic surgeons should be alert to the possibility of PTSD development in a pediatric trauma patient.

Collecting data
PTSD can be divided into the following three categories:

  • reexperiencing symptoms, such as having intrusive thoughts or flashbacks
  • avoidance symptoms, including physical and psychological avoidance of reminders of the trauma
  • arousal symptoms, such as difficulty sleeping or concentrating

The study focused on determining whether, 3 months after the injury, pediatric trauma patients who sustained high-energy orthopaedic injuries have a higher incidence of PTSD than children who sustained a lower energy, isolated UE fracture treated nonsurgically.

The researchers’ hypothesis was that those who sustain high-energy orthopaedic injuries—compared to those who sustain low-energy, UE fractures treated nonsurgically—would have significant emotional and/or psychological symptoms resulting from their trauma. They also hypothesized that patients with parents who have higher stress levels would have higher rates of PTSD.

The Institutional Review Board–approved, retrospective study used prospectively collected data (October 2009 through May 2010) from a pediatric Level 1 trauma center. Researchers identified patients for possible inclusion from their daily clinic schedules based on age (8 to 18 years old), injury (traumatic or isolated UE fracture), and time since injury. Average time since injury was 8.5 months (range: 3 months to 89 months). Mechanism of injury included the following: fall from height, low-energy fall, sports, motor vehicle collision, all-terrain vehicle crash, motor vehicle versus pedestrian crash, lawn mower cuts, and dog bite.

The following patients were excluded: those who were younger than 8 years old or older than 18 years old; those with preexisting psychological disorders reported by themselves or by their parents/guardians; patients with a traumatic brain injury with a hospital discharge Glasgow Coma Score of less than 15; and patients whose primary language was not English.

The investigators obtained demographic data for the patients and had the children complete the Child PTSD Symptom Scale, a validated survey of PTSD symptoms for children ages 8 to 18 years, during their scheduled office visit. The survey also poses questions about functional impairment.

In addition, the parent/guardian completed the Parent Stress Index (PSI) during the office visit to assess his or her stress. If the surveys could not be completed during the office visit, the child and parent/guardian were allowed to mail in the completed surveys.

Researchers conducted statistical analysis of the data, setting the P value at < 0.05. They performed post-hoc analysis using a Tukey test, and used chi square testing for categorical data. In addition, post hoc analysis of categorical data was performed using a Kruskall-Wallis test or a Mann-Whitney test.

Overall, the researchers found that 32.9 percent of the study participants (including 7 children in the upper extremity group and 18 children in the trauma group) had Child PTSD Symptom Scale scores indicative of PTSD. No significant difference was found in the prevalence of PTSD between the high-energy trauma patients and the low-energy, UE injury patients treated nonsurgically (P = 0.22).

Functional impairment scores, noted the researchers, were significantly different between the non-PTSD group and the PTSD group, which may indicate that everyday function of children with PTSD may be impaired.

“One may expect the parents/guardians to be affected by the trauma of their child,” noted the researchers. “However, in our study we did not find any association between the stress of the parent/guardian and the presence of PTSD in the children.”

They also found that involvement in music was significant between patients with and without PTSD (P = 0.037), suggesting that music might have a protective effect against PTSD.

The risk for PTSD
The researchers concluded that “PTSD commonly affects pediatric patients who sustain injuries as a result of a traumatic event, whether through low- or high-energy mechanisms.”

“Many times, as orthopaedic surgeons we are so concentrated on the child’s physical injuries that we forget or are not aware of the psychological effects that the child and/or the child’s family are experiencing,” they noted. “Thus, we do not ask them questions regarding the psychological aspects of the trauma and its effects on the patient and their family.”

Although they did not find any factors significantly associated with or predictive of PTSD nor did they find an association of PTSD with parent stress, the investigators emphasized that orthopaedists “need to maintain a high index of suspicion in pediatric trauma patients, regardless of the energy associated with the traumatic event.”

Based on the study’s findings, they noted, “it appears a child who sustains an orthopaedic injury, no matter how serious, is at risk for PTSD.”

Maegen Wallace, MD, is the lead author of “Prospective Evaluation of Post Traumatic Stress and Parent Stress in Pediatric Orthopaedic Trauma Patients.” Coauthors include Aki Puryear, MD (Globus Medical, Medicrea, and K2M); and Lisa K. Cannada, MD (Smith & Nephew, Zimmer, Synthes, Department of Defense, and Southeastern Fracture Consortium). Dr. Wallace declared no conflicts. The authors acknowledge Heidi Israel, PhD, for her assistance with the statistics in this study.