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Journal of Orthopaedic and Rehabilitation 2015 Jult-Sep; 1(2): 13-16

IntroductionA Cohort Study consisting of 298 patients with compound fractures (Grade II and Grade III; Gustilo Andersons Classification4) admitted at our hospital during 2008-2012.Diagnostic criteria: PTSD (DSM IV): PTSD patients experience 1) disturbing repetitive thoughts, 2) recurrent

nightmares of the accident or 3) feel detached from the community and 4) inability to adapt and experience emotional numbing. Patients might experience hyper arousal, insomnia and changes in sleep cycle. These symptoms must at least have duration of one month for the diagnosis of PTSD.3.All the patients with compound fractures are interviewed with PC-PTSD screen5 and the positively screened patients are further interviewed with Clinician-Administered PTSD Scale (CAPS)6 and their socio-demographic variables are analyzed. The questionnaire included demographic parameters; nature of the accident; social adjustment in the

Post Traumatic Stress Disorder in Patients with

Compound Fractures – Pr imary Care-pat ients

Screening Tool in Orthopaedic Practice

Abstract

Objective: Incidence of compound fractures resulting from high energy trauma has increased. Many

of these patients develop significant post-traumatic psychiatric morbidity. While the physical

consequences of such compound fractures are obvious, the psychological consequences are often not

apparent. P T S D is a serious and chronic psychiatric disorder that follows overwhelmingly stressful

events such as road traffic accidents, natural disasters, combat exposure and other high energy

trauma causing compound fractures.1-2 Given the high prevalence and lack of attention to

identification, it is no surprise that P T S D is the most frequently under recognized and untreated

anxiety disorder in orthopaedic practice. Identification of these patients is critical to allow for

intervention and prevent greater impairment and restriction and also to help the patient regain

confidence to perform daily activities.2. However, the first month following injury appears to be the

critical period for development of P T S D .3. The treating orthopaedic surgeon himself would be in an

ideal position to identify, assure or refer patients with traumatic responses to compound fractures.

Existing measures for P T S D are largely inappropriate for use in orthopaedic practice as they are time

consuming. The present study tries to evaluate a better screening tool for an orthopaedic surgeon in

daily ward rounds to identify such patients in time and refer for psychiatry services. Aim of the study

is to analyze post traumatic stress disorders in compound fractures and their outcome and to assess

four point “Primary care P T S D Screen (P C -P T S D tool) in orthopaedic patients.

Keywords: compound fractures, post traumatic stress disorder, P C -P T S D Screen.

1Siddaram N Patil

1Department Orthopaedics, Mamata Medical College & Hospital, Khammam,

AP, India.

Address of Correspondence

Dr. Siddaram.N.Patil

Professor in Orthopaedics, Mamata medical college & general hospital, Rotary

Nagar, Khammam-507002.

Email: drsnp_2006@yahoo.co.in

Journal of Orthopaedic and Rehabilitation | Volume 1 | Issue 2 | July - Sep 2015 | Page 13-16

Patil SN et al

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Table 1: PTSD – Post Traumatic Stress Disorder Group; NPTSD – Non

Post traumatic stress disorder group

Journal of Orthopaedic and Rehabilitation | Volume 1 | Issue 2 | July - Sep 2015 | Page 13-16

month before the accident (semi structure interview covering psychiatric symptoms, work, leisure, family life, social life, and financial circumstances). Additional information was obtained from patients attendants. The PC PTSD screen was administered to all the included patients weekly during hospital stay and at every monthly follow up visit. All the positively screened patients are administered with Clinician-Administered PTSD Scale (CAPS). Severity of injury was rated by the Gustilo Anderson classification of compound fractures.4. Patients with only soft tissue wounds , Gustilo Anderson grade I compound fractures and fracture non unions with infected wounds or sinuses are excluded from study. Patients who sustained head injury were also excluded.

DiscussionThe PC-PTSD Screen was designed to detect PTSD diagnosis in busy primary care clinics, where doctor's time and resources are limited. This 4 screen tool reflects these four factors characteristic of PTSD: 1) Re-experiencing 2) Numbing 3) Avoidance 4) Hyper arousal.5. PTSD diagnosis was assessed using the CAPS. This is a structured clinical interview that assessed PTSD as defined by Diagnostic and statistical manual of mental disorders-IV. The CAPS has excellent reliability and validity.6-7.A positive response to the Primary Care Post-Traumatic Stress Disorder (PC-PTSD) Screen does not necessarily indicate that a patient has post-traumatic stress disorder (PTSD). However, a positive response does indicate that a patient may have PTSD or trauma-related problems, and further investigation of trauma symptoms by CAPS Tool to rule out PTSD by a psychiatric professional is carried out.8. This 4 point screening tool gives an easy assessment for an orthopaedic surgeon to identify at risk patients and further evaluation. If 3 or 4 of the 4 questions are answered in the affirmative, the score is deemed a positive score.5.

ResultThere were 298 participants with Gr II and Gr III Gustilo Anderson compound fractures in the present study. Twelve patients were lost to follow up and 6 died. The age range of the study population was 19 to 73 years, and the mean age was 33.61 ± 9.18 years. There was no significant relation to

financial circumstances of the injured patient.Prevalence and distribution of PTSD among victims of compound fractures: Among the 282 compound fracture victims interviewed, 37 (13.12%) experienced PTSD. Of the 37, males were 26 (12.8%) and females were 11 (13.92%). Men experienced more traumatic events, whereas exposure is associated with more severe psychiatric disorders among women.Prevalence of PTSD increased with increasing intensity of injury. Compound grade IIIC Gustilo Anderson fractures with neurovascular defect had higher prevalence (4.25%) among the rest.Limitations of the study:We did not use a structured diagnostic interview for identifying preexisting psychiatric pathology. Had we done so, we would have solved the methodological problem of effect of pretraumatic psychopathology in the immediate posttraumatic stage. It is possible that some patients suffered from mental disorders before their accident. Therefore, preexisting psychopathology cannot be excluded as an etiologic factor for the development of PTSD in this group.

ConclusionThe results of this study suggest that PTSD is a frequent psychiatric disorder following high energy injuries sustaining compound fractures. Compound fractures related PTSD can have devastating effects on patient’s quality of life and functional outcome of orthopaedic surgery. Literature review findings revealed higher prevalence of PTSD in patients with RTA. The results are consistent with previous studies where men experience more traumatic events, whereas exposure is associated with more severe psychiatric disorders among women.13. There was no significant relation to socio economic status of the injured patient to PTSD. The prevalence of PTSD in high-energy trauma patients was more, but it commonly affects those who sustain injuries as a result of trauma. Hence, the findings of this study point to the need of promoting counseling services and necessary consultation-liaison psychiatry services in tertiary care trauma units.Orthopedic surgeon has the opportunity to help such identified patients. The PC-PTSD screen is distinguishable from other lengthy PTSD measures in its ease of completion, scoring pattern. It is the shortest screen available and the only one that utilizes a simple binary response format (Yes/No). The sensitivity and specificity and diagnostic accuracy (85%) is similar to other longer measures of PTSD.Because of significant relation between PTSD and morbidity, detection of PTSD secondary to high energy injuries is

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Figure 1: Figure : Prevalence of PTSD in compound fractures

Patil SN et al

Journal of Orthopaedic and Rehabilitation | Volume 1 | Issue 2 | July - Sep 2015 | Page 13-16 16

essential. Hence, PC-PTSD screen should be adopted in orthopaedic pract ice, where t ime ef f iciency and identification of potentially traumatized patients is of utmost importance.

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How to Cite this Article

Patil SN. Post Traumatic Stress Disorder in Patients with Compound Fractures – Primary Care-patients Screening Tool in Orthopaedic Practice. Journal of Orthopaedic and Rehabilitation 2015 Jult-Sep; 1(2): 13-16

Conflict of Interest: Nil Source of Support: None

Patil SN et al