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.