ORIGINAL ARTICLE
Posttraumatic Stress Disorder Associated With Orthopaedic Trauma: A Study in Patients With Extremity Fractures Chang Hoon Lee, MD,* Choong Hyeok Choi, MD,* Sang-Young Yoon, PhD,† and Jin Kyu Lee, MD*
Objective: The aims of this prospective study were to determine the prevalence of posttraumatic stress disorder (PTSD) in a population of young male military conscripts who experienced an extremity long-bone fracture, and to evaluate whether injury-related variables are associated with the development of PTSD.
Design: Prospective, nonrandomized comparative study. Setting: Level 1 trauma center. Patients and Methods: A total of 148 men (age older than 18 years) who had 1 or more acute long-bone extremity fractures within 12 months and were seen at the Seoul Regional Military Manpower Center for examination of military conscripts from March 2013 to March 2014, were enrolled. The Korean version of the posttraumatic disorder scale was used to identify aspects of PTSD. The injuryrelated variables assessed included injury mechanism, fracture location and multiplicity, fracture severity, and the occurrence of joint ankylosis and secondary osteoarthritis. Results: Of the 148 participants, 40 (27.0%) met the criteria for the diagnosis of PTSD. Multivariate logistic linear analysis confirmed that lower extremity fracture, multiple fractures, and a higher pain visual analog scale score were significantly (P = 0.042, P = 0.043 and P , 0.001, respectively) related to the occurrence of PTSD. Conclusions: Lower extremity fracture, multiple extremity fractures, and higher pain visual analog scale scores were significantly related to the occurrence of PTSD. To achieve an optimal recovery after orthopaedic injury, clinicians must address both physical and psychologic needs of their patients. Key Words: posttraumatic stress disorder, orthopaedic trauma, fracture, risk factors, trauma
Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence. (J Orthop Trauma 2015;29:e198–e202)
Accepted for publication October 30, 2014. From the *Department of Orthopaedic Surgery, Hanyang University College of Medicine, Seoul, Korea; and †Department of Physical Education, Kyonggi University, Suwon-si, Gyeonggi-do, Korea. The authors report no conflict of interest. Reprints: Jin Kyu Lee, MD, Department of Orthopaedic Surgery, Hanyang University College of Medicine, 222 Wangsimni-ro, seongdong-gu, Seoul, 133-792, Korea (e-mail: [email protected]). Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.
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INTRODUCTION Posttraumatic stress disorder (PTSD) is a mental illness that can occur after a trauma or life-threatening event.1 PTSD is often described among soldiers who have experienced severe emotional or physical stress during combat but is also recognized among the civilian trauma population.2,3 The symptoms of PTSD can be divided into 3 categories: intrusion (flashbacks of the event), avoidance (social withdrawal), and hyperarousal (anxiety).4 A diagnosis of PTSD is made when: (1) the individual has experienced, either directly or indirectly, an event involving serious injury or a threat to the physical integrity of the individual or another person; (2) the distress substantially impairs social, occupational, or other areas of functioning; and (3) the symptoms have lasted for longer than 1 month.4 The lifetime prevalence of PTSD in the general population is estimated to range from 1% to 14%.4,5 However, recent studies have noted a highly variable rate (2%–51%) of psychologic distress among adult orthopaedic trauma patients.3–8 Furthermore, clinically relevant depression was found in 45% of patients with orthopaedic trauma and was strongly correlated with global disability.9 Studies looking at the potential predictors of PTSD after physical trauma have shown considerable variations owing to inconsistencies in methodologic factors and inhomogeneous selection of patient groups, such as including both men and women with a range of ages, education levels, injury severities or locations, and psychosocial variables. Various risk factors for PTSD have also been reported, including female sex, intense or long-lasting trauma, low level of education, trauma earlier in life, and previous mental illness.3,10–14 Furthermore, only a few studies have investigated the association between the development of PTSD and injury characteristics (location or severity) in patients experiencing orthopaedic trauma.5,8 The aims of this prospective study were to determine the prevalence of PTSD in a population of young male military conscripts who experienced extremity long-bone fracture, and to evaluate whether injury-related variables are associated with the development of PTSD. We hypothesized that patients with multiple long-bone fractures and open fracture would be significantly associated with occurrence of PTSD.
PATIENTS AND METHODS A total of 447 men (age older than 18 years) who had 1 or more acute long-bone extremity (ie, humerus, radius with or without ulna, femur or tibia with or without fibula) J Orthop Trauma Volume 29, Number 6, June 2015
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J Orthop Trauma Volume 29, Number 6, June 2015
fractures that had been treated operatively within 12 months of recruitment and who were seen consecutively at the Seoul Regional Military Manpower Center for examination of military conscripts from March 2013 to March 2014, were assessed for enrollment to the study. Individuals who had experienced an acute injury within 6 months were asked to revisit the center after 6–12 months of follow-up. The exclusion criteria were as follows: (1) preexisting psychologic disorders [disapproved by military service using a Symptom Checklist-90-R (SCL-90-R), which is a brief self-report psychometric questionnaire designed to evaluate a broad range of symptoms of psychopathology15 and interview with an army psychiatrist or confirmed from medical records]; (2) traumatic head injury, including a skull fracture or brain hemorrhage; (3) chest or abdominal injury requiring hospital treatment; (4) spine or pelvic bone fracture; (5) extremity fracture occurring in the hand or foot; and (6) completion of elementary or middle school only. Of the 447 individuals approached, 169 individuals satisfied the inclusion criteria and possessed none of the exclusion criteria. These 169 individuals were asked to complete a Korean version of the posttraumatic disorder scale (PDS) questionnaire. The Korean version of the PDS has demonstrated high internal consistency (Cronbach alpha coefficients of total score = 0.90), high test–retest reliability (r = 0.81), and high consistency with diagnosis by the Structured Clinical Interview for DSM-IV (r = 0.84).16 However, 13 eligible individuals refused to participate and 8 were eliminated from the study because of incomplete questionnaires that were missing most of the data. Thus, a total of 148 individuals were finally enrolled in the study. The institutional review board of the armed force medical command approved this study (AFMC-13-IRB-065), and all participants provided informed consent. The PDS is a useful diagnostic tool for evaluating diagnostic criteria and the severity of symptoms related to PTSD, and several studies have confirmed its validity and reliability.17,18 The questionnaire assesses the 17 PTSD symptoms listed in the DSM-IV.4 It contains 7 questions concerning symptoms of avoidance and 5 questions concerning symptoms of hyperarousal and reexperiencing. Each item in the survey is scored on a 4-point Likert scale (0 = not at all; 1 = once per week; 2 = 2–4 times per week; 3 = almost always). The total possible score is 51 points, and a score of 20 points or more is considered to indicate the presence of PTSD. The PDS includes a symptom severity score, which ranges from 0 to 51, with a higher number of points indicating more severe symptoms.18 To evaluate possible injury-related variables of PTSD, demographic and clinical data were collected from the participants’ medical certificates and medical records. The injury-related variables assessed included injury mechanism, fracture location and multiplicity, fracture severity (ie, closed vs. open, extraarticular vs. intraarticular), and the occurrence of joint ankylosis and secondary osteoarthritis (if a joint was involved). Multiple fractures were defined as fractures involving 2 or more long bones. However, both bone forearm (radius combined with ulnar) fracture and tibia fracture combined with fibular fracture were counted as a single fracture. Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.
Posttraumatic Stress Disorder
Open fractures were classified using the classification suggested by Gustilo–Anderson.19 Ankylosis of an involved joint was defined according to the McBride disability evaluation system.20 The existence of intraarticular involvement was based on computed tomography evaluation before surgery and was further divided into weight bearing (ie, hip, knee, ankle) and non–weight bearing (ie, shoulder, elbow, wrist) joints. Posttraumatic osteoarthritis was diagnosed by the agreement of 2 board-certificated radiologists, using the classification of Marsh et al21 for the knee and that of Morrey and Wiedemann22 for the ankle. Participants were asked to score their pain on a 100-mm visual analog scale (VAS) according to the degree of the most severe pain at the involved site during the last few weeks. The Extremity Abbreviated Injury Scale (EAIS) was used to represent the degree of critical illness experienced by each participant.23 The Abbreviated Injury Scale classifies each injury into body regions according to its relative severity on a 6-point scale (1 = minor, 2 = moderate, 3 = serious, 4 = severe, 5 = critical, 6 = maximum).
Statistical Analysis All continuous variables are reported as medians and ranges for nonnormal distributions, whereas categorical variables are presented as numbers or percentages. Statistical analysis was performed using SAS 9.2 (SAS Institute Inc, Cary, NC). A P , 0.05 was considered statistically significant. We used univariate and multivariate logistic regression models to determine independent predictors of PTSD. Fracture location, multiple fracture, open fracture, joint involvement, VAS score, and the average sum of all EAIS were selected as independent variables for the multivariable analysis model. Multivariate analyses were performed using forward logistic regression analysis.
RESULTS The mean age of participants was 20.9 (range, 18–25) years at the time of presentation. The average time since injury was 12.37 (range, 6–15) months. Of the 148 participants, 40 (27.0%) met the criteria for the diagnosis of PTSD. Table 1 presents basic demographic data. Table 2 shows the orthopaedic diagnoses and Table 3 presents the injury-related variables of the participants. The mechanism of injury was a slip for 72 individuals, fall for 11, motorcycle collision for 33, motor vehicle collision for 21, and motor vehicle–pedestrian collision for 11. A total of 122 individuals suffered an isolated long-bone extremity fracture, whereas the remaining 26 individuals had 2 or more longbone fractures. Of these 26 individuals, 23 (88.5%) experienced multiple long-bone fractures at lower extremities, whereas remaining 3 experienced multiple fractures involving upper extremities. According to Gustilo–Anderson’s open fracture classification, there were 6 Grade I, 6 Grade II, 6 Grade IIIA, and 4 Grade IIIB open fractures. A total of 24 individuals had intraarticular involvement (6 distal radius, 3 proximal tibia, and 15 distal tibia). Of these 24 individuals, 16 experienced radiologically evident secondary osteoarthritis (3 knee and 13 ankle). In addition, 24 individuals experienced partial ankylosis in 24 joints (3 elbow, 2 wrist, 9 knee, and 10 ankle). www.jorthotrauma.com |
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Lee et al
TABLE 1. General Characteristics of Study Subjects Total, n = 148
Factors Age (SD), y Height (SD), cm Weight (SD), kg Body mass index (SD), kg/m2 Time from injury (SD), mo
20.98 174.48 72.84 23.93 12.37
No PTSD, n = 108
(1.77) (5.02) (13.03) (4.17) (2.19)
21.09 174.3 72.43 23.85 12.40
Multivariate, logistic linear analysis with adjustment for possible confounding factors confirmed that lower extremity fracture, multiple fractures, and a higher pain VAS score were significantly (P = 0.042, P = 0.043, and P , 0.001, respectively) related to the occurrence of PTSD (Table 4).
DISCUSSION It is clear that civilian patients who experience orthopaedic trauma can suffer from PTSD.2,3 It is known that serious injury to an extremity has a negative impact on the quality of life, and that poor physical function after a lower extremity injury is strongly predictive of psychologic distress.5 Orthopaedic surgeons need to be aware of conditions that might lead to psychologic distress; however, data are lacking with respect to which injury-related variables are associated with a high risk of PTSD. Accordingly, this study reports on the prevalence of PTSD among young male military conscripts who had suffered an acute long-bone extremity fracture, and the impact of injury-related variables associated with the development of PTSD. In this study, the prevalence of PTSD was 27.0% (40 of 148 individuals) and, according to multivariate regression analysis, lower extremity fracture, multiple fractures, and higher pain scores on VAS were significantly related to PTSD. The early detection and treatment of PTSD is very important for the prognosis of patients with PTSD-associated orthopaedic fractures. Even with satisfactory surgical treatment, the presence of such psychologic distress might have
TABLE 2. Orthopaedic Diagnoses Diagnosis Humerus, shaft Humerus, distal Radius, proximal Forearm, both bone Ulna, shaft Radius, distal Femur, proximal Femur, shaft Femur, distal Tibia, proximal Tibia, shaft Lateral malleolar Bimalleodlar Trimalleoloar
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No. Cases 3 4 4 4 5 20 6 32 14 2 7 39 23 11
PTSD, n = 40
(1.68) (5.42) (13.18) (4.24) (2.21)
20.68 174.9 73.95 24.17 12.30
P
(2.01) (3.77) (12.70) (4.00) (2.16)
0.2047 0.5234 0.5292 0.6770 0.8096
a substantial negative effect on surgical outcome. In addition, such distress conditions can have a substantial negative effect on the patient’s report of outcomes. Unfortunately, it is known that about half of patients with PTSD undergo a chronic progression, and that PTSD takes approximately 3 years to remit. Furthermore, a third of PTSD patients suffer from PTSD-related symptoms for more than 10 years.24 Studies investigating PTSD related to natural disasters have reported the highest mean remission rate (60.0%), whereas those related to physical disease have reported the lowest remission rate (31.4%).25
TABLE 3. Injury-Related Variables of Study Subjects
Factors Injury mechanism* Slip or fall Motorcycle collision Motor vehicle collision Motor vehicle– pedestrian collision Fracture location* and multiplicity Single UE Single LE Multiple Open fracture* Grade I Grade II Grade IIIA or B Intraarticular involvement* NWB joint WB joint Ankylosis* Secondary OA* Pain VAS, mean† (SD) Sum of EAIS, mean† (SD)
Total, n = 148, n (%)
No PTSD, n = 108, n (%)
PTSD, n = 40, n (%)
P 0.0002
83 (56.1) 33 (22.3)
71 (65.7) 22 (20.3)
12 (30) 11 (27.5)
21 (14.1)
8 (7.5)
13 (32.5)
11 (7.5)
7 (6.5)
4 (10)
0.0005 34 (22.9) 88 (59.5) 26 (17.6)
31 (28.7) 65 (60.1) 12 (11.2)
3 (7.5) 23 (57.5) 14 (35)
6 (4) 6 (4) 10 (6.7)
5 (4.6) 5 (4.6) 5 (4.6)
1 (2.5) 1 (2.5) 5 (12.5)
0.4174
0.9254 6 18 24 16 3.09
(4) (12.1) (16.2) (10.8) (1.94)
3.48 (1.98)
4 13 19 11 2.66
(3.7) (12.0) (17.5) (10.1) (2.05)
3.19 (1.71)
2 5 5 5 4.28
(5) (12.5) (12.5) (12.5) (0.85)
0.6203 0.7667 ,0.0001
4.28 (0.42)
0.0114
*x2 test. †Student’s t test. LE, lower extremity, NWB, non–weight bearing; OA, osteoarthritis; UE, upper extremity; WB, weight bearing.
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Posttraumatic Stress Disorder
TABLE 4. Multivariate Analysis of Predictors of PTSD Factors Fracture location and multiplicity Single UE Single LE Multiple Open fracture Closed Grade I Grade II Grade IIIA or B Intraarticular involvement None NWB joint WB joint Ankylosis None Partial Secondary OA None Evident Pain VAS Sum of EAIS
Odds Ratio (95% CI)
P
Reference 5.240 (1.056–25.998) 9.291 (1.071–80.573)
— 0.0427 0.0431
Reference 0.306 (0.029–3.260) 0.282 (0.024–3.352) 1.019 (0.197–5.266)
— 0.3264 0.3160 0.9816
Reference 0.995 (0.180–5.489) 2.980 (0.277–32.088)
— 0.9953 0.3679
Reference 0.574 (0.172–1.911)
— 0.3654
Reference 0.925 (0.169–5.066) 1.565 (1.206–2.029) 1.022 (0.754–1.387)
— 0.9288 0.0007 0.8872
CI, confidence interval; LE, lower extremity, NWB, non–weight bearing; OA, osteoarthritis; UE, upper extremity.
Only a few studies have reported on the prevalence of and risk factors for PTSD in the field of orthopaedic trauma, and the topic has received little attention in the orthopaedic literature. McCarthy et al5 evaluated the association of severe lower-limb injury with psychologic distress and concluded that 48% of patients screened positive for likely psychologic distress at 3 months after the injury. They also noted that poor physical heath after severe lower-limb injury is strongly predictive of psychologic distress. Starr et al8 also evaluated the symptoms and prevalence of PTSD after orthopaedic trauma and reported a PTSD prevalence of 51%. They also noted that patients with PTSD had significantly higher injury-severity scores, a higher sum of EAIS scores, and longer duration since the injury than those without PTSD. However, none of the injury-related variables demonstrated the ability to discriminate between patients with and without PTSD. PTSD is known to have a negative impact on physical and mental aspects of health. Psychologic factors are strongly associated with pain density and disability in patients recovering from musculoskeletal trauma.7 Increased pain density disturbs early rehabilitation and can lead to the persistence of functional impairment. In addition, psychologic stress adversely affects the immune system and impairs early wound repair after surgery. Peripheral blood leukocytes of patients with psychologic stress have been reported to produce significantly less interleukin-1b mRNA in response to lipopolysaccharide than control cells.26 Delayed wound healing can delay the start of range-of-motion exercises and lead to ankylosis.27 Patients with severe infections can experience delayed union or nonunion and long-lasting functional impairment. Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.
In this study, multivariate regression analysis revealed lower extremity fracture, multiple fractures, and higher pain VAS scores to be significantly related to PTSD. Multiple extremity fracture may be a predictor for PTSD, although it does not always represent a major trauma. Fern et al28 reported that patients with multiple extremity injuries tended to have greater long-term disability, based on Short-Form 36 (SF-36) scores, and a lower return to productivity. They also noted poor mental and physical health scores on the SF36 in patients with multiple extremity injuries than in other body regions and only minor injury affecting extremities despite similar injury-severity scores. In this study, lower extremity fracture and multiple extremity fractures were significantly related to the occurrence of PTSD. We believe that patients with lower extremity fracture and multiple lower extremity fractures (as most of our cases with multiple fractures were lower extremity fractures) may have experienced more distress as a result of a longer period of limited weight bearing and exercise compared with those with a single fracture or upper extremity fractures. However, open fracture was not found to be a significant predictor of PTSD, in this study, negating our hypothesis. We believe that this was due to the small number of open fractures (22 cases) enrolled, because all amputees (who would probably have experienced severe open extremity fracture) are exempted from military service, and thus were not available for enrollment in this study. Other studies have reported that psychologic factors are strongly and significantly intercorrelated with pain density and symptoms of PTSD.7,29 Ring et al30 reported that psychologic factors such as low pain self-efficacy and greater symptoms of depression were consistent and strong predictors of upper extremity-specific disabilities. Although it is not clear which comes first—severe pain or psychologic distress—it is clear that these factors are strongly intercorrelated. Therefore, orthopaedic surgeons need to pay attention to the neuropsychologic health of patients complaining of chronic pain. If needed, early, cognitive behavioral therapy could be helpful in decreasing pain intensity and the prevalence of PTSD. The results of our study should be considered in light of the following limitations. First, the results of this study cannot be generalized to the general population, because only young men were enrolled. However, this can also be taken as a strength of our study, because it minimized the heterogeneity of the study population. Second, the evaluation of PTSD was performed at a mean of 12.37 (range, 6–15) months from the initial injury. However, because many patients with PTSD undergo chronic progression and remission takes about 3 years, we believe it was reasonable to evaluate patients for PTSD at a mean of 12 months.22 Third, this study does not represent all extremity fractures, because we excluded patients with hand or foot fractures. Fourth, although posttraumatic osteoarthritis was diagnosed by the agreement of 2 board-certificated radiologists focusing on knee and ankle joints, there are no universally accepted criteria for grading posttraumatic osteoarthritis covering all joints, and therefore we could not apply the same criteria for all joints involved. Fifth, the sample size of subjects who had open fracture was rather small because amputees (who probably had experienced severe open fracture) were not included in this study. www.jorthotrauma.com |
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Finally, psychologic factors, other than pain, were not considered in association with PTSD, and this should be addressed in future studies. In conclusion, the prevalence of PTSD after an extremity fracture in young men was 27.0% (40 of 148 individuals) and, according to multivariate logistic regression analysis, lower extremity fracture, multiple extremity fractures, and higher pain VAS scores were significantly related to the occurrence of PTSD. To achieve an optimal recovery after orthopaedic injury, clinicians must address both the physical and psychologic needs of their patients. Early use of psychologic intervention such as cognitive behavioral therapy could be beneficial in decreasing the intensity of pain and the prevalence of PTSD. 1. Yehuda R. Post-traumatic stress disorder. N Eng J Med. 2002;346: 108–114. 2. Yehuda R, McFarlane AC, Shalev AY. Predicting the development of post-traumatic stress disorder from the acute response to a traumatic event. Biol Psychiatry. 1998;44:1305–1313. 3. Zatzick DF, Jurkovich GJ, Gentilello L, et al. Posttraumatic stress, problem drinking, and functional outcomes after injury. Arch Surg. 2002;137: 200–205. 4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). 4th ed. Washington, DC: American Psychiatric Association; 1994. 5. McCarthy ML, MacKenzie EJ, Edwin D, et al. Psychological distress associated with severe lower-limb injury. J Bone Joint Surg Am. 2003; 85:1689–1697. 6. Maselesele VM, Idemudia ES. The role of social support in the relationship between mental health and posttraumatic stress disorder amongst orthopedic patients. Curationis. 2013;36:E1–E7. 7. Vranceanu AM, Bachoura A, Weening A, et al. Psychological factors predict disability and pain intensity after skeletal trauma. J Bone Joint Surg Am. 2014;96:1–6. 8. Starr AJ, Smith WR, Farwley WH, et al. Symptoms of posttraumatic stress disorder after orthopaedic trauma. J Bone Joint Surg Am. 2004; 86:1115–1121. 9. Crichlow RJ, Andres PL, Morrison SM, et al. Depression in orthopaedic patients. Prevalence and severity. J Bone Joint Surg Am. 2006;88: 1927–1933. 10. Sanders MB, Starr AJ, Frawley WH, et al. Posttraumatic stress symptoms in children recovering from minor orthopaedic injury and treatment. J Orthop Trauma. 2005;19:623–628. 11. Harris IA, Young JM, Rae H, et al. Predictors of post-traumatic stress disorder following major trauma. ANZ J Surg. 2008;78:583–587. 12. Blaszczynski A, Gordon K, Silove D, et al. Psychiatric morbidity following motor vehicle accidents: a review of methodological issues. Compr Psychiatry. 1998;39:111–121.
13. O’Donnell ML, Creamer M, Bryant RA, et al. Posttraumatic disorders following injury: an empirical and methodological review. Clin Psychol Rev. 2003;23:587–603. 14. Silove D, Blaszczynski A, Manicavasager V, et al. Capacity of screening questionnaires to predict psychiatric morbidity 18 months after motor vehicle accidents. J Nerv Ment Dis. 2003;191:604–610. 15. Schmitz N, Kruse J, Heckrath C, et al. Diagnosing mental disorder in primary care: the General Health Questionnaire (GHQ) and the Symptom Check List (SCL-90-R) as screening instruments. Soc Psychiatry Psychiatr Epidemiol. 1999;34:360–366. 16. Nam B, Kwon HI, Kwon JH. Psychometric qualities of the Korean version of the Post-traumatic Diagnosis Scale (PDS-K). Korean J Clin Psychol. 2010;29:147–167. 17. Foa EB, Cashman L, Jaycox L, et al. The validation of a self-report measure of posttraumatic stress disorder: the posttraumatic diagnostic scale. Psychol Assess. 1997;9:445–451. 18. Sheeran T, Zimmerman M. Screening for posttraumatic stress disorder in general psychiatric outpatient setting. J Consult Clin Psychol. 2002;70: 961–966. 19. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58:453–458. 20. McBride ED. Disability Evaluation and Principles of Treatment of Compensable Injuries. 6th ed. Philadelphia, PA: JB Lippincott CO; 1963:68–103. 21. Marsh JL, Smith ST, Do TT. External fixation and limited internal fixation for complex fracture of the tibial plateau. J Bone Joint Surg Am. 1995;77:661–673. 22. Morrey BF, Wiedemann GP. Complications and long-term results of ankle arthrodesis following trauma. J Bone Joint Surg Am. 1980;62: 777–784. 23. Association for the Advancement of Automotive Medicine. The Abbreviated Injury Scale; 1990 revision. Des Plaines, IL: Association for the Advancement of Automotive Medicine. 24. Fairbank JA, Ebert L, Costello EJ. Epidemiology of traumatic events and post-traumatic stress disorder. In: Nutt D, Davidson JRT, Zohar J, eds. Post-traumatic Stress Disorder: Diagnosis, Management and Treatment. London, United Kingdom: Martin Dunitz; 2000:17–28. 25. Morina N, Wicherts JM, Lobbrecht J, et al. Remission from posttraumatic stress disorder in adults: a systemic review and meta-analysis of long term outcome studies. Clin Psychol Rev. 2014;34:249–255. 26. Kiecolt-Glaser JK, Marucha PT, Malarkey WB, et al. Slowing of wound healing by psychological stress. Lancet. 1995;346:1194–1196. 27. Broadbent E, Petrie KJ, Alley PG, et al. Psychological stress impairs early wound repair following surgery. Psychosom Med. 2003;65: 865–869. 28. Fern KT, Smith JT, Zee B, et al. Trauma patients with lower extremity injuries: resource utilization and long term outcomes in relation to injury severity scores. J Trauma. 1998;45:489–494. 29. Otis JD, Keane TM, Kerns RD. An examination of the relationship between chronic pain and post-traumatic stress disorder. J Rehabil Res Dev. 2003;40:397–405. 30. Ring D, Kadzielski J, Malhota L, et al. Psychological factors associated with idiopathic arm pain. J Bone Joint Surg Am. 2005;87:374–380.
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REFERENCES
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Posttraumatic Stress Disorder Associated With Orthopaedic Trauma: A Study in Patients With Extremity Fractures Chang Hoon Lee, MD,* Choong Hyeok Choi, MD,* Sang-Young Yoon, PhD,† and Jin Kyu Lee, MD*
Objective: The aims of this prospective study were to determine the prevalence of posttraumatic stress disorder (PTSD) in a population of young male military conscripts who experienced an extremity long-bone fracture, and to evaluate whether injury-related variables are associated with the development of PTSD.
Design: Prospective, nonrandomized comparative study. Setting: Level 1 trauma center. Patients and Methods: A total of 148 men (age older than 18 years) who had 1 or more acute long-bone extremity fractures within 12 months and were seen at the Seoul Regional Military Manpower Center for examination of military conscripts from March 2013 to March 2014, were enrolled. The Korean version of the posttraumatic disorder scale was used to identify aspects of PTSD. The injuryrelated variables assessed included injury mechanism, fracture location and multiplicity, fracture severity, and the occurrence of joint ankylosis and secondary osteoarthritis. Results: Of the 148 participants, 40 (27.0%) met the criteria for the diagnosis of PTSD. Multivariate logistic linear analysis confirmed that lower extremity fracture, multiple fractures, and a higher pain visual analog scale score were significantly (P = 0.042, P = 0.043 and P , 0.001, respectively) related to the occurrence of PTSD. Conclusions: Lower extremity fracture, multiple extremity fractures, and higher pain visual analog scale scores were significantly related to the occurrence of PTSD. To achieve an optimal recovery after orthopaedic injury, clinicians must address both physical and psychologic needs of their patients. Key Words: posttraumatic stress disorder, orthopaedic trauma, fracture, risk factors, trauma
Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence. (J Orthop Trauma 2015;29:e198–e202)
Accepted for publication October 30, 2014. From the *Department of Orthopaedic Surgery, Hanyang University College of Medicine, Seoul, Korea; and †Department of Physical Education, Kyonggi University, Suwon-si, Gyeonggi-do, Korea. The authors report no conflict of interest. Reprints: Jin Kyu Lee, MD, Department of Orthopaedic Surgery, Hanyang University College of Medicine, 222 Wangsimni-ro, seongdong-gu, Seoul, 133-792, Korea (e-mail: [email protected]). Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.
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INTRODUCTION Posttraumatic stress disorder (PTSD) is a mental illness that can occur after a trauma or life-threatening event.1 PTSD is often described among soldiers who have experienced severe emotional or physical stress during combat but is also recognized among the civilian trauma population.2,3 The symptoms of PTSD can be divided into 3 categories: intrusion (flashbacks of the event), avoidance (social withdrawal), and hyperarousal (anxiety).4 A diagnosis of PTSD is made when: (1) the individual has experienced, either directly or indirectly, an event involving serious injury or a threat to the physical integrity of the individual or another person; (2) the distress substantially impairs social, occupational, or other areas of functioning; and (3) the symptoms have lasted for longer than 1 month.4 The lifetime prevalence of PTSD in the general population is estimated to range from 1% to 14%.4,5 However, recent studies have noted a highly variable rate (2%–51%) of psychologic distress among adult orthopaedic trauma patients.3–8 Furthermore, clinically relevant depression was found in 45% of patients with orthopaedic trauma and was strongly correlated with global disability.9 Studies looking at the potential predictors of PTSD after physical trauma have shown considerable variations owing to inconsistencies in methodologic factors and inhomogeneous selection of patient groups, such as including both men and women with a range of ages, education levels, injury severities or locations, and psychosocial variables. Various risk factors for PTSD have also been reported, including female sex, intense or long-lasting trauma, low level of education, trauma earlier in life, and previous mental illness.3,10–14 Furthermore, only a few studies have investigated the association between the development of PTSD and injury characteristics (location or severity) in patients experiencing orthopaedic trauma.5,8 The aims of this prospective study were to determine the prevalence of PTSD in a population of young male military conscripts who experienced extremity long-bone fracture, and to evaluate whether injury-related variables are associated with the development of PTSD. We hypothesized that patients with multiple long-bone fractures and open fracture would be significantly associated with occurrence of PTSD.
PATIENTS AND METHODS A total of 447 men (age older than 18 years) who had 1 or more acute long-bone extremity (ie, humerus, radius with or without ulna, femur or tibia with or without fibula) J Orthop Trauma Volume 29, Number 6, June 2015
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J Orthop Trauma Volume 29, Number 6, June 2015
fractures that had been treated operatively within 12 months of recruitment and who were seen consecutively at the Seoul Regional Military Manpower Center for examination of military conscripts from March 2013 to March 2014, were assessed for enrollment to the study. Individuals who had experienced an acute injury within 6 months were asked to revisit the center after 6–12 months of follow-up. The exclusion criteria were as follows: (1) preexisting psychologic disorders [disapproved by military service using a Symptom Checklist-90-R (SCL-90-R), which is a brief self-report psychometric questionnaire designed to evaluate a broad range of symptoms of psychopathology15 and interview with an army psychiatrist or confirmed from medical records]; (2) traumatic head injury, including a skull fracture or brain hemorrhage; (3) chest or abdominal injury requiring hospital treatment; (4) spine or pelvic bone fracture; (5) extremity fracture occurring in the hand or foot; and (6) completion of elementary or middle school only. Of the 447 individuals approached, 169 individuals satisfied the inclusion criteria and possessed none of the exclusion criteria. These 169 individuals were asked to complete a Korean version of the posttraumatic disorder scale (PDS) questionnaire. The Korean version of the PDS has demonstrated high internal consistency (Cronbach alpha coefficients of total score = 0.90), high test–retest reliability (r = 0.81), and high consistency with diagnosis by the Structured Clinical Interview for DSM-IV (r = 0.84).16 However, 13 eligible individuals refused to participate and 8 were eliminated from the study because of incomplete questionnaires that were missing most of the data. Thus, a total of 148 individuals were finally enrolled in the study. The institutional review board of the armed force medical command approved this study (AFMC-13-IRB-065), and all participants provided informed consent. The PDS is a useful diagnostic tool for evaluating diagnostic criteria and the severity of symptoms related to PTSD, and several studies have confirmed its validity and reliability.17,18 The questionnaire assesses the 17 PTSD symptoms listed in the DSM-IV.4 It contains 7 questions concerning symptoms of avoidance and 5 questions concerning symptoms of hyperarousal and reexperiencing. Each item in the survey is scored on a 4-point Likert scale (0 = not at all; 1 = once per week; 2 = 2–4 times per week; 3 = almost always). The total possible score is 51 points, and a score of 20 points or more is considered to indicate the presence of PTSD. The PDS includes a symptom severity score, which ranges from 0 to 51, with a higher number of points indicating more severe symptoms.18 To evaluate possible injury-related variables of PTSD, demographic and clinical data were collected from the participants’ medical certificates and medical records. The injury-related variables assessed included injury mechanism, fracture location and multiplicity, fracture severity (ie, closed vs. open, extraarticular vs. intraarticular), and the occurrence of joint ankylosis and secondary osteoarthritis (if a joint was involved). Multiple fractures were defined as fractures involving 2 or more long bones. However, both bone forearm (radius combined with ulnar) fracture and tibia fracture combined with fibular fracture were counted as a single fracture. Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.
Posttraumatic Stress Disorder
Open fractures were classified using the classification suggested by Gustilo–Anderson.19 Ankylosis of an involved joint was defined according to the McBride disability evaluation system.20 The existence of intraarticular involvement was based on computed tomography evaluation before surgery and was further divided into weight bearing (ie, hip, knee, ankle) and non–weight bearing (ie, shoulder, elbow, wrist) joints. Posttraumatic osteoarthritis was diagnosed by the agreement of 2 board-certificated radiologists, using the classification of Marsh et al21 for the knee and that of Morrey and Wiedemann22 for the ankle. Participants were asked to score their pain on a 100-mm visual analog scale (VAS) according to the degree of the most severe pain at the involved site during the last few weeks. The Extremity Abbreviated Injury Scale (EAIS) was used to represent the degree of critical illness experienced by each participant.23 The Abbreviated Injury Scale classifies each injury into body regions according to its relative severity on a 6-point scale (1 = minor, 2 = moderate, 3 = serious, 4 = severe, 5 = critical, 6 = maximum).
Statistical Analysis All continuous variables are reported as medians and ranges for nonnormal distributions, whereas categorical variables are presented as numbers or percentages. Statistical analysis was performed using SAS 9.2 (SAS Institute Inc, Cary, NC). A P , 0.05 was considered statistically significant. We used univariate and multivariate logistic regression models to determine independent predictors of PTSD. Fracture location, multiple fracture, open fracture, joint involvement, VAS score, and the average sum of all EAIS were selected as independent variables for the multivariable analysis model. Multivariate analyses were performed using forward logistic regression analysis.
RESULTS The mean age of participants was 20.9 (range, 18–25) years at the time of presentation. The average time since injury was 12.37 (range, 6–15) months. Of the 148 participants, 40 (27.0%) met the criteria for the diagnosis of PTSD. Table 1 presents basic demographic data. Table 2 shows the orthopaedic diagnoses and Table 3 presents the injury-related variables of the participants. The mechanism of injury was a slip for 72 individuals, fall for 11, motorcycle collision for 33, motor vehicle collision for 21, and motor vehicle–pedestrian collision for 11. A total of 122 individuals suffered an isolated long-bone extremity fracture, whereas the remaining 26 individuals had 2 or more longbone fractures. Of these 26 individuals, 23 (88.5%) experienced multiple long-bone fractures at lower extremities, whereas remaining 3 experienced multiple fractures involving upper extremities. According to Gustilo–Anderson’s open fracture classification, there were 6 Grade I, 6 Grade II, 6 Grade IIIA, and 4 Grade IIIB open fractures. A total of 24 individuals had intraarticular involvement (6 distal radius, 3 proximal tibia, and 15 distal tibia). Of these 24 individuals, 16 experienced radiologically evident secondary osteoarthritis (3 knee and 13 ankle). In addition, 24 individuals experienced partial ankylosis in 24 joints (3 elbow, 2 wrist, 9 knee, and 10 ankle). www.jorthotrauma.com |
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J Orthop Trauma Volume 29, Number 6, June 2015
Lee et al
TABLE 1. General Characteristics of Study Subjects Total, n = 148
Factors Age (SD), y Height (SD), cm Weight (SD), kg Body mass index (SD), kg/m2 Time from injury (SD), mo
20.98 174.48 72.84 23.93 12.37
No PTSD, n = 108
(1.77) (5.02) (13.03) (4.17) (2.19)
21.09 174.3 72.43 23.85 12.40
Multivariate, logistic linear analysis with adjustment for possible confounding factors confirmed that lower extremity fracture, multiple fractures, and a higher pain VAS score were significantly (P = 0.042, P = 0.043, and P , 0.001, respectively) related to the occurrence of PTSD (Table 4).
DISCUSSION It is clear that civilian patients who experience orthopaedic trauma can suffer from PTSD.2,3 It is known that serious injury to an extremity has a negative impact on the quality of life, and that poor physical function after a lower extremity injury is strongly predictive of psychologic distress.5 Orthopaedic surgeons need to be aware of conditions that might lead to psychologic distress; however, data are lacking with respect to which injury-related variables are associated with a high risk of PTSD. Accordingly, this study reports on the prevalence of PTSD among young male military conscripts who had suffered an acute long-bone extremity fracture, and the impact of injury-related variables associated with the development of PTSD. In this study, the prevalence of PTSD was 27.0% (40 of 148 individuals) and, according to multivariate regression analysis, lower extremity fracture, multiple fractures, and higher pain scores on VAS were significantly related to PTSD. The early detection and treatment of PTSD is very important for the prognosis of patients with PTSD-associated orthopaedic fractures. Even with satisfactory surgical treatment, the presence of such psychologic distress might have
TABLE 2. Orthopaedic Diagnoses Diagnosis Humerus, shaft Humerus, distal Radius, proximal Forearm, both bone Ulna, shaft Radius, distal Femur, proximal Femur, shaft Femur, distal Tibia, proximal Tibia, shaft Lateral malleolar Bimalleodlar Trimalleoloar
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No. Cases 3 4 4 4 5 20 6 32 14 2 7 39 23 11
PTSD, n = 40
(1.68) (5.42) (13.18) (4.24) (2.21)
20.68 174.9 73.95 24.17 12.30
P
(2.01) (3.77) (12.70) (4.00) (2.16)
0.2047 0.5234 0.5292 0.6770 0.8096
a substantial negative effect on surgical outcome. In addition, such distress conditions can have a substantial negative effect on the patient’s report of outcomes. Unfortunately, it is known that about half of patients with PTSD undergo a chronic progression, and that PTSD takes approximately 3 years to remit. Furthermore, a third of PTSD patients suffer from PTSD-related symptoms for more than 10 years.24 Studies investigating PTSD related to natural disasters have reported the highest mean remission rate (60.0%), whereas those related to physical disease have reported the lowest remission rate (31.4%).25
TABLE 3. Injury-Related Variables of Study Subjects
Factors Injury mechanism* Slip or fall Motorcycle collision Motor vehicle collision Motor vehicle– pedestrian collision Fracture location* and multiplicity Single UE Single LE Multiple Open fracture* Grade I Grade II Grade IIIA or B Intraarticular involvement* NWB joint WB joint Ankylosis* Secondary OA* Pain VAS, mean† (SD) Sum of EAIS, mean† (SD)
Total, n = 148, n (%)
No PTSD, n = 108, n (%)
PTSD, n = 40, n (%)
P 0.0002
83 (56.1) 33 (22.3)
71 (65.7) 22 (20.3)
12 (30) 11 (27.5)
21 (14.1)
8 (7.5)
13 (32.5)
11 (7.5)
7 (6.5)
4 (10)
0.0005 34 (22.9) 88 (59.5) 26 (17.6)
31 (28.7) 65 (60.1) 12 (11.2)
3 (7.5) 23 (57.5) 14 (35)
6 (4) 6 (4) 10 (6.7)
5 (4.6) 5 (4.6) 5 (4.6)
1 (2.5) 1 (2.5) 5 (12.5)
0.4174
0.9254 6 18 24 16 3.09
(4) (12.1) (16.2) (10.8) (1.94)
3.48 (1.98)
4 13 19 11 2.66
(3.7) (12.0) (17.5) (10.1) (2.05)
3.19 (1.71)
2 5 5 5 4.28
(5) (12.5) (12.5) (12.5) (0.85)
0.6203 0.7667 ,0.0001
4.28 (0.42)
0.0114
*x2 test. †Student’s t test. LE, lower extremity, NWB, non–weight bearing; OA, osteoarthritis; UE, upper extremity; WB, weight bearing.
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Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Orthop Trauma Volume 29, Number 6, June 2015
Posttraumatic Stress Disorder
TABLE 4. Multivariate Analysis of Predictors of PTSD Factors Fracture location and multiplicity Single UE Single LE Multiple Open fracture Closed Grade I Grade II Grade IIIA or B Intraarticular involvement None NWB joint WB joint Ankylosis None Partial Secondary OA None Evident Pain VAS Sum of EAIS
Odds Ratio (95% CI)
P
Reference 5.240 (1.056–25.998) 9.291 (1.071–80.573)
— 0.0427 0.0431
Reference 0.306 (0.029–3.260) 0.282 (0.024–3.352) 1.019 (0.197–5.266)
— 0.3264 0.3160 0.9816
Reference 0.995 (0.180–5.489) 2.980 (0.277–32.088)
— 0.9953 0.3679
Reference 0.574 (0.172–1.911)
— 0.3654
Reference 0.925 (0.169–5.066) 1.565 (1.206–2.029) 1.022 (0.754–1.387)
— 0.9288 0.0007 0.8872
CI, confidence interval; LE, lower extremity, NWB, non–weight bearing; OA, osteoarthritis; UE, upper extremity.
Only a few studies have reported on the prevalence of and risk factors for PTSD in the field of orthopaedic trauma, and the topic has received little attention in the orthopaedic literature. McCarthy et al5 evaluated the association of severe lower-limb injury with psychologic distress and concluded that 48% of patients screened positive for likely psychologic distress at 3 months after the injury. They also noted that poor physical heath after severe lower-limb injury is strongly predictive of psychologic distress. Starr et al8 also evaluated the symptoms and prevalence of PTSD after orthopaedic trauma and reported a PTSD prevalence of 51%. They also noted that patients with PTSD had significantly higher injury-severity scores, a higher sum of EAIS scores, and longer duration since the injury than those without PTSD. However, none of the injury-related variables demonstrated the ability to discriminate between patients with and without PTSD. PTSD is known to have a negative impact on physical and mental aspects of health. Psychologic factors are strongly associated with pain density and disability in patients recovering from musculoskeletal trauma.7 Increased pain density disturbs early rehabilitation and can lead to the persistence of functional impairment. In addition, psychologic stress adversely affects the immune system and impairs early wound repair after surgery. Peripheral blood leukocytes of patients with psychologic stress have been reported to produce significantly less interleukin-1b mRNA in response to lipopolysaccharide than control cells.26 Delayed wound healing can delay the start of range-of-motion exercises and lead to ankylosis.27 Patients with severe infections can experience delayed union or nonunion and long-lasting functional impairment. Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.
In this study, multivariate regression analysis revealed lower extremity fracture, multiple fractures, and higher pain VAS scores to be significantly related to PTSD. Multiple extremity fracture may be a predictor for PTSD, although it does not always represent a major trauma. Fern et al28 reported that patients with multiple extremity injuries tended to have greater long-term disability, based on Short-Form 36 (SF-36) scores, and a lower return to productivity. They also noted poor mental and physical health scores on the SF36 in patients with multiple extremity injuries than in other body regions and only minor injury affecting extremities despite similar injury-severity scores. In this study, lower extremity fracture and multiple extremity fractures were significantly related to the occurrence of PTSD. We believe that patients with lower extremity fracture and multiple lower extremity fractures (as most of our cases with multiple fractures were lower extremity fractures) may have experienced more distress as a result of a longer period of limited weight bearing and exercise compared with those with a single fracture or upper extremity fractures. However, open fracture was not found to be a significant predictor of PTSD, in this study, negating our hypothesis. We believe that this was due to the small number of open fractures (22 cases) enrolled, because all amputees (who would probably have experienced severe open extremity fracture) are exempted from military service, and thus were not available for enrollment in this study. Other studies have reported that psychologic factors are strongly and significantly intercorrelated with pain density and symptoms of PTSD.7,29 Ring et al30 reported that psychologic factors such as low pain self-efficacy and greater symptoms of depression were consistent and strong predictors of upper extremity-specific disabilities. Although it is not clear which comes first—severe pain or psychologic distress—it is clear that these factors are strongly intercorrelated. Therefore, orthopaedic surgeons need to pay attention to the neuropsychologic health of patients complaining of chronic pain. If needed, early, cognitive behavioral therapy could be helpful in decreasing pain intensity and the prevalence of PTSD. The results of our study should be considered in light of the following limitations. First, the results of this study cannot be generalized to the general population, because only young men were enrolled. However, this can also be taken as a strength of our study, because it minimized the heterogeneity of the study population. Second, the evaluation of PTSD was performed at a mean of 12.37 (range, 6–15) months from the initial injury. However, because many patients with PTSD undergo chronic progression and remission takes about 3 years, we believe it was reasonable to evaluate patients for PTSD at a mean of 12 months.22 Third, this study does not represent all extremity fractures, because we excluded patients with hand or foot fractures. Fourth, although posttraumatic osteoarthritis was diagnosed by the agreement of 2 board-certificated radiologists focusing on knee and ankle joints, there are no universally accepted criteria for grading posttraumatic osteoarthritis covering all joints, and therefore we could not apply the same criteria for all joints involved. Fifth, the sample size of subjects who had open fracture was rather small because amputees (who probably had experienced severe open fracture) were not included in this study. www.jorthotrauma.com |
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Finally, psychologic factors, other than pain, were not considered in association with PTSD, and this should be addressed in future studies. In conclusion, the prevalence of PTSD after an extremity fracture in young men was 27.0% (40 of 148 individuals) and, according to multivariate logistic regression analysis, lower extremity fracture, multiple extremity fractures, and higher pain VAS scores were significantly related to the occurrence of PTSD. To achieve an optimal recovery after orthopaedic injury, clinicians must address both the physical and psychologic needs of their patients. Early use of psychologic intervention such as cognitive behavioral therapy could be beneficial in decreasing the intensity of pain and the prevalence of PTSD. 1. Yehuda R. Post-traumatic stress disorder. N Eng J Med. 2002;346: 108–114. 2. Yehuda R, McFarlane AC, Shalev AY. Predicting the development of post-traumatic stress disorder from the acute response to a traumatic event. Biol Psychiatry. 1998;44:1305–1313. 3. Zatzick DF, Jurkovich GJ, Gentilello L, et al. Posttraumatic stress, problem drinking, and functional outcomes after injury. Arch Surg. 2002;137: 200–205. 4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). 4th ed. Washington, DC: American Psychiatric Association; 1994. 5. McCarthy ML, MacKenzie EJ, Edwin D, et al. Psychological distress associated with severe lower-limb injury. J Bone Joint Surg Am. 2003; 85:1689–1697. 6. Maselesele VM, Idemudia ES. The role of social support in the relationship between mental health and posttraumatic stress disorder amongst orthopedic patients. Curationis. 2013;36:E1–E7. 7. Vranceanu AM, Bachoura A, Weening A, et al. Psychological factors predict disability and pain intensity after skeletal trauma. J Bone Joint Surg Am. 2014;96:1–6. 8. Starr AJ, Smith WR, Farwley WH, et al. Symptoms of posttraumatic stress disorder after orthopaedic trauma. J Bone Joint Surg Am. 2004; 86:1115–1121. 9. Crichlow RJ, Andres PL, Morrison SM, et al. Depression in orthopaedic patients. Prevalence and severity. J Bone Joint Surg Am. 2006;88: 1927–1933. 10. Sanders MB, Starr AJ, Frawley WH, et al. Posttraumatic stress symptoms in children recovering from minor orthopaedic injury and treatment. J Orthop Trauma. 2005;19:623–628. 11. Harris IA, Young JM, Rae H, et al. Predictors of post-traumatic stress disorder following major trauma. ANZ J Surg. 2008;78:583–587. 12. Blaszczynski A, Gordon K, Silove D, et al. Psychiatric morbidity following motor vehicle accidents: a review of methodological issues. Compr Psychiatry. 1998;39:111–121.
13. O’Donnell ML, Creamer M, Bryant RA, et al. Posttraumatic disorders following injury: an empirical and methodological review. Clin Psychol Rev. 2003;23:587–603. 14. Silove D, Blaszczynski A, Manicavasager V, et al. Capacity of screening questionnaires to predict psychiatric morbidity 18 months after motor vehicle accidents. J Nerv Ment Dis. 2003;191:604–610. 15. Schmitz N, Kruse J, Heckrath C, et al. Diagnosing mental disorder in primary care: the General Health Questionnaire (GHQ) and the Symptom Check List (SCL-90-R) as screening instruments. Soc Psychiatry Psychiatr Epidemiol. 1999;34:360–366. 16. Nam B, Kwon HI, Kwon JH. Psychometric qualities of the Korean version of the Post-traumatic Diagnosis Scale (PDS-K). Korean J Clin Psychol. 2010;29:147–167. 17. Foa EB, Cashman L, Jaycox L, et al. The validation of a self-report measure of posttraumatic stress disorder: the posttraumatic diagnostic scale. Psychol Assess. 1997;9:445–451. 18. Sheeran T, Zimmerman M. Screening for posttraumatic stress disorder in general psychiatric outpatient setting. J Consult Clin Psychol. 2002;70: 961–966. 19. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58:453–458. 20. McBride ED. Disability Evaluation and Principles of Treatment of Compensable Injuries. 6th ed. Philadelphia, PA: JB Lippincott CO; 1963:68–103. 21. Marsh JL, Smith ST, Do TT. External fixation and limited internal fixation for complex fracture of the tibial plateau. J Bone Joint Surg Am. 1995;77:661–673. 22. Morrey BF, Wiedemann GP. Complications and long-term results of ankle arthrodesis following trauma. J Bone Joint Surg Am. 1980;62: 777–784. 23. Association for the Advancement of Automotive Medicine. The Abbreviated Injury Scale; 1990 revision. Des Plaines, IL: Association for the Advancement of Automotive Medicine. 24. Fairbank JA, Ebert L, Costello EJ. Epidemiology of traumatic events and post-traumatic stress disorder. In: Nutt D, Davidson JRT, Zohar J, eds. Post-traumatic Stress Disorder: Diagnosis, Management and Treatment. London, United Kingdom: Martin Dunitz; 2000:17–28. 25. Morina N, Wicherts JM, Lobbrecht J, et al. Remission from posttraumatic stress disorder in adults: a systemic review and meta-analysis of long term outcome studies. Clin Psychol Rev. 2014;34:249–255. 26. Kiecolt-Glaser JK, Marucha PT, Malarkey WB, et al. Slowing of wound healing by psychological stress. Lancet. 1995;346:1194–1196. 27. Broadbent E, Petrie KJ, Alley PG, et al. Psychological stress impairs early wound repair following surgery. Psychosom Med. 2003;65: 865–869. 28. Fern KT, Smith JT, Zee B, et al. Trauma patients with lower extremity injuries: resource utilization and long term outcomes in relation to injury severity scores. J Trauma. 1998;45:489–494. 29. Otis JD, Keane TM, Kerns RD. An examination of the relationship between chronic pain and post-traumatic stress disorder. J Rehabil Res Dev. 2003;40:397–405. 30. Ring D, Kadzielski J, Malhota L, et al. Psychological factors associated with idiopathic arm pain. J Bone Joint Surg Am. 2005;87:374–380.
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REFERENCES
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