- Email: [email protected]
Lower limb trauma and posttraumatic stress disorder: A single UK trauma unit's experience
Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) 67, 555e560
Lower limb trauma and posttraumatic stress disorder: A single UK trauma unit’s experience* Waseem Bhat*, Sergio Marlino, Victoria Teoh, Salman Khan, Umraz Khan Department of Reconstructive Plastic Surgery, Frenchay Hospital, Bristol BS16 1LE, UK Received 20 October 2013; accepted 21 December 2013
KEYWORDS Lower limb trauma; PTSD; Outcomes in trauma
*
Summary Introduction: The incidence and factors influencing posttraumatic stress disorder (PTSD) in victims of severe lower extremity injuries are largely unknown. We studied a cohort of patients treated in a specialist centre to try and elucidate these unknowns. Materials and methods: The Posttraumatic Stress Disorder Checklist Scale (PCL-S) was used as a reliable and reproducible patient-reported outcome measure (PROM) assessing all patients for PTSD. Sixty patients were included in the study. This was a prospective analysis of the progression of the PCL-S scores. The data were analysed using a non-parametric Wilcoxon test. Results: Sixty patients were recruited into the study cohort. We found that the incidence in this cohort of PTSD was 30%. We found that age had an influence on outcome. Those who were 50 years old or over had a significantly lower incidence of PTSD according to the PCL-S scores and appeared to recover from it significantly more effectively. Conclusions: Up to a third of patients suffering from a severe lower extremity injury will develop PTSD. Patients of the younger age group are more severely affected and will need psychological support to overcome their distress. ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Presented at the Summer Scientific Meeting for the British Association of Plastic, Reconstructive and Aesthetic Surgeons, Newcastle, UK on Friday 13th July, 2012. * Corresponding author. E-mail address: [email protected] (W. Bhat).
Severe lower limb injuries, even when expertly treated, are known to induce a considerable drain on the patient’s physiology. There are now well-established ‘major trauma responses’ that have been studied.1 The physical stresses that the human body goes through during the various timelines after major trauma can be studied with various surrogate markers of improvement.2 The restoration of physical well-being is the ultimate aim of treatment protocols. There are many areas in major trauma that are well
1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.12.039
556 studied, in particular, head trauma, spinal cord injury, burns and gunshot injures. What is not entirely known is if there is also a resultant deep psychological cost. The mental stresses are often overlooked in the acute major trauma setting. Posttraumatic stress disorder (PTSD) is a disabling, long-term consequence of severe trauma. An analysis of factors important in leading to PTSD among this group has not been done. Certain demographics of the victims of high-energy lower extremity trauma are becoming clearer. It often, for example, results from motor-vehicle accidents and it tends to affect young males. The assessment of mental well-being can be done using various techniques including an interview-based assessment of questionnaire scale bases such as the Hamilton rating scale and Patient Health Questionnaire (PHQ-9) for depression. The questionnaire-based assessments are the least intrusive and most easy to administer. They can also be either doctor or patient administered, making their use attractive in major trauma. The Posttraumatic Stress Disorder Checklist Scale (PCL-S) has been reliably used in one major study assessing the factors influencing outcomes after orthopaedics surgery.1 PTSD has been a recognised distinct entity for anxiety that can develop after exposure to any event that results in psychological trauma. Although it was recognised that stresses of combat could cause long-lasting psychological effects, it was not until 1980 that PTSD was defined and first appeared in the Diagnostic and Statistical Manual of Mental Disorders (DSM III). The salient symptoms are: Reliving trauma, avoidance behaviour, numbing of emotion and/or physiological hyperarousal symptoms such as anger or hypervigilence. We used a reliable and reproducible method to assess the incidence of PTSD in patients with limb-threatening injuries who had undergone limb salvage. Associations between patient demographics, injury severity and duration of hospital stay were reviewed to see if there was a correlation between these factors and the incidence of PTSD.
Materials and methods Data were collected prospectively with strict inclusion criteria. After ethics approval, all patients attending a specialist clinic in a single trauma centre were considered in the study. We used the PCL-S questionnaire as an indication of the extent of mental distress. The PCL-S was described by Weather in 1993 to look at diagnosing, screening and monitoring PTSD.3 It has been shown that the PCL-S is reliable in many study settings and can be reproducible when studying the gravity of PTSD.4,5 The PCL-S thus provided us with an ideal tool. The study period was between April 2010 and December 2011 and patients were screened for study eligibility. Eligible patients were English speaking, had definitive orthoplastic reconstruction within 1 week of injury, were under active review in a specialist clinic and cognitively able to complete the questionnaire. All consenting patients completed a baseline assessment which included a limb function outcome and a PCL-S. At least two recordings at 2 and again at 4 months after discharge of PCL-S were necessary for inclusion into the study.
W. Bhat et al.
Study design We conducted a prospective study of all patients treated at one tertiary lower limb trauma centre attending the combined orthoplastics follow-up clinic from April 2010 to December 2011. Eligible patients were those who received treatment for lower limb injuries, all receiving definitive orthoplastic treatment within a week from the time of injury. They were all under active follow-up in a specialist clinic and of adequate cognition to complete the questionnaire and provide informed consent.
Patient assessment During each visit to the clinic, patients were screened for eligibility. Those included in the study all completed a baseline assessment PCL-S form, a 17-item brief and selfreport questionnaire (Figure 1), in which the patient gives a rating of 1e5 for each of the 17 items on the questionnaire. The score ranges from 17 to 85. A score of 30 or above is considered to be PTSD positive for the general population as well as military populations.4 The initial assessment included the following demographic information: age, sex, occupation, social habits (i.e., smoking and alcohol use), additional injuries, orthoplastic reconstruction, co-morbidities, complications and outcomes. The PCL-S scores were recorded at 2- and again at 4-month follow-up. The PCL-S is useful because the symptoms endorsed are usually linked to a specified event. It has been internationally recognised as a means of evaluating the severity of the three main sub-types of PTSD, screening individuals for PTSD and monitoring symptom change during and after treatment. The PCL-S has been evaluated in psychiatric patients and in patients with the most major medical surgical conditions.6,7 Our decision to use the PCL-S was based on its ease of application and on the considerable data supporting its reliability and validity. When looking at any effect of age, we subdivided the patients according to age as is suggested: 0e25, 25e50 and 50e75.
Results Sixty patients were included in the study. The age ranged from 9 to 88 years. The mean ages of male and female patients were 46 and 48 years, respectively. Two-thirds of the patients were male, representing the trend that more males are involved in major road traffic accidents (RTAs). The most common cause of lower limb injuries amongst our cohort of patients was RTAs, followed by falls from height and sports (Figure 2). The type of reconstruction was primarily governed by the nature of the injury. The most common flap used was the parascapular and scapular flaps (Table 1). Sixty percent of patients had complex reconstructions (free flap). In 30% of patients, the reconstruction was of moderate difficulty (local flap reconstruction). Fourteen patients experienced complications. Six patients had minor wound infections which all resolved
Lower limb trauma and PTSD
557
Figure 1
PTSD checklist given to patients at follow-up clinic.
following courses of antibiotics. Two patients had deep vein thromboses; amputation was performed in only one patient. This was done as a primary procedure as a result of the extent of the injury.
Three patients developed infected non union, two patients had free-flap failures from their initial surgery but later had successful flap coverage on subsequent surgery. Both these patients were young (<35 years old), heavy
Table 1
Figure 2
Chart showing causes of lower limb trauma.
Type of reconstructions utilised.
Reconstruction
Number of patients (n Z 60)
Free scapular/parascapular ALT free flap Local fasciocutaneus flap Radial forearm free flap Free gracilis flap Gastocnemius (local) Free groin flap Free medial plantar flap Primary amputation (acute)
20 15 8 6 5 3 1 1 1
558
W. Bhat et al.
smokers, alcoholics and ex-intravenous drug abusers, who refused to comply with early postoperative instructions (Table 2). Patients (aged >50) had statistically lower PCL-S scores than younger patients. The difference observed on the chisquared test at 2 months was 0.054. With respect to age variance, Fisher’s exact test showed a P value of 0.013. A Wilcoxon test demonstrated that subsequent scores at the 4-month follow-up were lower than the scores at 2 months in all age groups and this was statistically significant (P value of 0.021).
PCL-S score with age Of the 60 patients included in the study, 33 were >50 years old and 27 were <50 years old. When assessed at 2 months in the outpatient clinic, >26 patients in the 50-year-old age group had PCL-S scores <30 and only seven patients scored >30 on the checklist. In the under-50-year-old age group, 15 patients scored <30 and 12 patients >30 (Table 3). The difference observed on the chi-squared test at 2 months was 0.054.
Trends in PCL-S Trends across the four age groups were analysed (Table 4). In all age groups, higher scores were noted at the 2-month follow-up and this was significantly less at the 4-month follow-up. The Wilcoxon test demonstrated that scores at the 4month follow-up were lower as compared to scores at the 2-month follow-up regardless of age; this was statistically significant (P Z 0.021). The under-25-year-old age group scored significantly higher than those in the older age groups. This may in part be due to the fact that younger patients are more likely to be involved in significant high-energy injuries, and this was reflected in higher scores. Fisher’s exact test showed P Z 0.013 for age variance at 2 months. This was used as it is similar to the chi-squared test but more accurate for small sample sizes. Correlations were drawn between the PCL-S scores and length of hospital stay, complications and age of patients. With regard to hospital stay, there was a strong positive correlation between high PCL-S scores and length of hospital stay (correlation þ0.419). This positive correlation was also observed with respect to correlation with associated complications. The age of the patient was negatively correlated with the PCL-S score correlation 0.277. The older the patient, the less likely they were to have scored >30 on the PCL-S. Table 2 Complications in patients that underwent reconstructive surgery. Complication
Number of patients (n Z 60)
Wound infection Non union (osteomylitis) Flap loss Deep vein thrombosis Amputation
6 3 2 2 1
Table 3
PCL-S scores relating to age.
<50 years old >50 years old Total
Score <30
Score >30
15 26 41
12 7 19
PCL-S scores were subsequently lower at 4 months (correlation 0.956). Nineteen patients rated their PCL-S scores >30; of these patients, 30% lacked social support networks and were unemployed, supporting the fact that lack of support and substance dependence may correlate with an increased likelihood of PTSD following trauma.
Discussion Our review of the 60 patients in our study found the following: One in three patients met the criteria for PTSD. Patients’ PCL-S component summary scores were significantly associated with younger age groups and recovery is longer. Patients with high PCL-S scores were significantly associated with ongoing treatment, complex surgery and complications. Higher scores were associated with long hospital stay. PCL-S scores were significantly lower at subsequent follow-up. The scores of older patients improved quicker. Our finding that 33% of the patients with lower limb injuries met the criteria for psychological illness is consistent with previous reports.8 The most remarkable finding was that the younger age groups scored higher at both the 2- and 4-month follow-ups. This may have been related to the fact that injuries among the younger age groups tended to be of a higher velocity such as RTAs compared to the higher proportion of older patients sustaining injures by trivial slips/falls. As a result, it can be seen that those injuries were more likely to
Table 4
Trends in PCL-S at 2 and 4 month follow-up.
Lower limb trauma and PTSD require longer hospital stays, with more complex procedures required for reconstruction, and cause greater morbidity to the patient. This may account for the higher scores in the younger age groups. An interesting point noted from the study was that although all age groups scored lower at subsequent followup reviews, which may have been due to the fact that most patients at the 4-month stage were well on the road to recovery having completed the most difficult part of their rehabilitation, the scores decreased quicker and to a greater extent in the patients in the above-50-year-old age group. In part, this could relate to the cause of injury being of a lower velocity. Although positive correlation with higher PCL-S scores were seen in those patients with lack of social support and substance abuse, due to the unreliability of information given and that not all historic cases had this information available, accurate conclusions could not be drawn from this study, although this correlation seems an obvious contributor to patients having higher scores. A recent study of patients with severe lower limb injuries found a 42% prevalence of psychological disorder at the 24month follow-up and that only 22% of such patients reported receiving mental health services.9 No relationship was found between injury severity and psychological distress; however, the authors suggested that low variability in injury severity might have obscured this result. This differs from our study in which there was a strong positive correlation between the scores in all age groups and the injury severity. This correlation between psychological distress and physical complaints has been reported by several authors.10 Zatzick et al. also compared psychological distress and health-related quality of life in 101 hospitalised trauma patients. One year after injury, 30% of the patients (n Z 22) met the symptomatic criteria for PTSD. Starr et al. conducted a study of 588 patients and found that 51% of patients met the criteria for PTSD11; specifically, patients scored higher on questions pertaining to avoidance. Our study further identified that higher scores were significantly associated with phobic anxiety. Management of co-morbid psychological illness has had important positive effects on recovery from trauma following sexual abuse, spousal abuse, head injury and critical illness.12e15 It remains plausible that lower limb trauma patients presenting with co-morbid psychopathology may experience similar benefits. Previous work has reported that mental illness is an independent predictor of poor outcome following trauma. Our findings add to a growing body of literature that suggests psychological symptoms among patients treated for sever lower limb injuries by orthoplastic intervention may be an important target for intervention.16,17
Strengths and limitations Our study is strengthened by the high rate of response from a consecutive group of patients attending for management of lower limb trauma in one trauma centre. The limitations of the study are that we did not collect data on psychological morbidity prior to injury, and it is not
559 clear to what degree post-injury distress can be attributed to the injury. Although epidemiologic studies suggest that the prevalence of psychiatric disorders in the general community is about 20%,18 our study design did not allow for this fact. Thus, our findings cannot rule out the possibility of pre-existing psychiatric illness and it is not clear to what degree post-injury distress can be attributed to the injury. PTSD can last >1 year and follow-up should be for a longer period. A prospective cohort study including multiple follow-up assessments over time that incorporate insights from this study is needed to further resolve this issue.
Conclusion With this cohort of patients, early psychiatric and psychological support is required to prevent the progression to PTSD. The presented work seeks to increase the awareness of this condition among those treating severe lower limb casualties so that appropriate treatment choices could be made to address them. The ultimate goal of patient care should be the development of protocols that include psychosocial preinjury assessment and follow-up as a standard of care in the lower limb trauma setting.
Ethics approval The study was carried out at the Frenchay Hospital, Bristol, UK, with approval from the local institutional review board.
Conflict of interest We declare no conflict of interest (personal or financial) in the publication of this article.
References 1. Ponsford J, Hill B, Karamitsios M, Bahar-Fuchs A. Factors influencing outcome after orthopedic trauma. J Trauma 2008; 64:1001e9. 2. O’Donnell ML, Creamer M, Elliott P, Atkin C, Kossmann T. Determinants of quality of life and role-related disability after injury impact of acute psychological responses. J Trauma 2005; 59:1328e35. 3. Weathers F, Litz B, Herman D, Huska J, Keane T. The PTSD checklist (PCL): reliability, validity, and diagnostic utility. In: Paper presented at the Annual Convention of the International Society for Traumatic Stress Studies October 1993 [San Antonio, TX]. 4. Bliese PD, Wright KM, Adler AB, Cabrera O, Castro CA, Hoge CW. Validating the primary care posttraumatic stress disorder screen and the posttraumatic stress disorder checklist with soldiers returning from combat. J Consult Clin Psychol 2008;76:272e81. 5. Yao SN, Cottraux J, Note I, De Mey-Guillard C, Mollard E, Ventureyra V. Evaluation of post-traumatic stress disorder: validation of a measure, the PCLS. Encephale 2003;29:232e8. 6. Blanchard E, Jones-Alexander J,Buckley T, Forneris C. Psychometric properties of the PTSD checklist (PCL). Behav Res Ther 1996;34:669e73.
560 7. Horowitz LM, Rosenberg S, Baer B, et al. Inventory and interpersonal problems: psychometric properties and clinical applications. J Consult Clin Psychol 1988;56:885e92. 8. Mason S, Wardrope J, Turpin G, et al. The psychological burden of injury: an 18 month prospective cohort study. Emerg Med J 2002;19:400e4. 9. Zatzick DF, Jurkovich GJ, Gentilello L, et al. Posttraumatic stress, problem drinking, and functional outcomes after injury. Arch Surg 2002;137:200e5. 10. Badcock LJ, Lewis M, Hay EM, et al. Chronic shoulder pain in the community: a syndrome of disability or distress? Ann Rheum Dis 2002;61:128e31. 11. Starr AJ, Smith W, Frawley W, et al. Symptoms of posttraumatic stress disorder after orthopaedic trauma. J Bone Joint Surg Am 2004;86:1115e21. 12. Zun LS, Downey LV, Rosen J. Violence prevention in the ED: linkage of the ED to a social service agency. Am J Emerg Med 2003;21:454e7. 13. Degeneffe CE. Family care giving and traumatic brain injury. Health Soc Work 2001;26:257e68.
W. Bhat et al. 14. Albert SM, Im A, Brenner L, et al. Effect of a social work liaison program on family caregivers to people with brain injury. J Head Trauma Rehabil 2002;17:175e89. 15. Delva D, Vanoost S, Bijttebier P, et al. Needs and feelings of anxiety of relatives of patients hospitalized in intensive care units: implications for social work. Soc Work Health Care 2002; 35:21e40. 16. Dyrehag LE, Widerstrom-Noga EG, Carlsson SG, et al. Relations between selfrated musculoskeletal symptoms and signs and psychological distress in chronic neck and shoulder pain. Scand J Rehabil Med 1998;30:235e42. 17. Holmes J, House A. Psychiatric illness predicts poor outcome after surgery for hip fracture: a prospective cohort study. Psychol Med 2000;30:921e9. 18. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62:593e602.
Lower limb trauma and posttraumatic stress disorder: A single UK trauma unit’s experience* Waseem Bhat*, Sergio Marlino, Victoria Teoh, Salman Khan, Umraz Khan Department of Reconstructive Plastic Surgery, Frenchay Hospital, Bristol BS16 1LE, UK Received 20 October 2013; accepted 21 December 2013
KEYWORDS Lower limb trauma; PTSD; Outcomes in trauma
*
Summary Introduction: The incidence and factors influencing posttraumatic stress disorder (PTSD) in victims of severe lower extremity injuries are largely unknown. We studied a cohort of patients treated in a specialist centre to try and elucidate these unknowns. Materials and methods: The Posttraumatic Stress Disorder Checklist Scale (PCL-S) was used as a reliable and reproducible patient-reported outcome measure (PROM) assessing all patients for PTSD. Sixty patients were included in the study. This was a prospective analysis of the progression of the PCL-S scores. The data were analysed using a non-parametric Wilcoxon test. Results: Sixty patients were recruited into the study cohort. We found that the incidence in this cohort of PTSD was 30%. We found that age had an influence on outcome. Those who were 50 years old or over had a significantly lower incidence of PTSD according to the PCL-S scores and appeared to recover from it significantly more effectively. Conclusions: Up to a third of patients suffering from a severe lower extremity injury will develop PTSD. Patients of the younger age group are more severely affected and will need psychological support to overcome their distress. ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Presented at the Summer Scientific Meeting for the British Association of Plastic, Reconstructive and Aesthetic Surgeons, Newcastle, UK on Friday 13th July, 2012. * Corresponding author. E-mail address: [email protected] (W. Bhat).
Severe lower limb injuries, even when expertly treated, are known to induce a considerable drain on the patient’s physiology. There are now well-established ‘major trauma responses’ that have been studied.1 The physical stresses that the human body goes through during the various timelines after major trauma can be studied with various surrogate markers of improvement.2 The restoration of physical well-being is the ultimate aim of treatment protocols. There are many areas in major trauma that are well
1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.12.039
556 studied, in particular, head trauma, spinal cord injury, burns and gunshot injures. What is not entirely known is if there is also a resultant deep psychological cost. The mental stresses are often overlooked in the acute major trauma setting. Posttraumatic stress disorder (PTSD) is a disabling, long-term consequence of severe trauma. An analysis of factors important in leading to PTSD among this group has not been done. Certain demographics of the victims of high-energy lower extremity trauma are becoming clearer. It often, for example, results from motor-vehicle accidents and it tends to affect young males. The assessment of mental well-being can be done using various techniques including an interview-based assessment of questionnaire scale bases such as the Hamilton rating scale and Patient Health Questionnaire (PHQ-9) for depression. The questionnaire-based assessments are the least intrusive and most easy to administer. They can also be either doctor or patient administered, making their use attractive in major trauma. The Posttraumatic Stress Disorder Checklist Scale (PCL-S) has been reliably used in one major study assessing the factors influencing outcomes after orthopaedics surgery.1 PTSD has been a recognised distinct entity for anxiety that can develop after exposure to any event that results in psychological trauma. Although it was recognised that stresses of combat could cause long-lasting psychological effects, it was not until 1980 that PTSD was defined and first appeared in the Diagnostic and Statistical Manual of Mental Disorders (DSM III). The salient symptoms are: Reliving trauma, avoidance behaviour, numbing of emotion and/or physiological hyperarousal symptoms such as anger or hypervigilence. We used a reliable and reproducible method to assess the incidence of PTSD in patients with limb-threatening injuries who had undergone limb salvage. Associations between patient demographics, injury severity and duration of hospital stay were reviewed to see if there was a correlation between these factors and the incidence of PTSD.
Materials and methods Data were collected prospectively with strict inclusion criteria. After ethics approval, all patients attending a specialist clinic in a single trauma centre were considered in the study. We used the PCL-S questionnaire as an indication of the extent of mental distress. The PCL-S was described by Weather in 1993 to look at diagnosing, screening and monitoring PTSD.3 It has been shown that the PCL-S is reliable in many study settings and can be reproducible when studying the gravity of PTSD.4,5 The PCL-S thus provided us with an ideal tool. The study period was between April 2010 and December 2011 and patients were screened for study eligibility. Eligible patients were English speaking, had definitive orthoplastic reconstruction within 1 week of injury, were under active review in a specialist clinic and cognitively able to complete the questionnaire. All consenting patients completed a baseline assessment which included a limb function outcome and a PCL-S. At least two recordings at 2 and again at 4 months after discharge of PCL-S were necessary for inclusion into the study.
W. Bhat et al.
Study design We conducted a prospective study of all patients treated at one tertiary lower limb trauma centre attending the combined orthoplastics follow-up clinic from April 2010 to December 2011. Eligible patients were those who received treatment for lower limb injuries, all receiving definitive orthoplastic treatment within a week from the time of injury. They were all under active follow-up in a specialist clinic and of adequate cognition to complete the questionnaire and provide informed consent.
Patient assessment During each visit to the clinic, patients were screened for eligibility. Those included in the study all completed a baseline assessment PCL-S form, a 17-item brief and selfreport questionnaire (Figure 1), in which the patient gives a rating of 1e5 for each of the 17 items on the questionnaire. The score ranges from 17 to 85. A score of 30 or above is considered to be PTSD positive for the general population as well as military populations.4 The initial assessment included the following demographic information: age, sex, occupation, social habits (i.e., smoking and alcohol use), additional injuries, orthoplastic reconstruction, co-morbidities, complications and outcomes. The PCL-S scores were recorded at 2- and again at 4-month follow-up. The PCL-S is useful because the symptoms endorsed are usually linked to a specified event. It has been internationally recognised as a means of evaluating the severity of the three main sub-types of PTSD, screening individuals for PTSD and monitoring symptom change during and after treatment. The PCL-S has been evaluated in psychiatric patients and in patients with the most major medical surgical conditions.6,7 Our decision to use the PCL-S was based on its ease of application and on the considerable data supporting its reliability and validity. When looking at any effect of age, we subdivided the patients according to age as is suggested: 0e25, 25e50 and 50e75.
Results Sixty patients were included in the study. The age ranged from 9 to 88 years. The mean ages of male and female patients were 46 and 48 years, respectively. Two-thirds of the patients were male, representing the trend that more males are involved in major road traffic accidents (RTAs). The most common cause of lower limb injuries amongst our cohort of patients was RTAs, followed by falls from height and sports (Figure 2). The type of reconstruction was primarily governed by the nature of the injury. The most common flap used was the parascapular and scapular flaps (Table 1). Sixty percent of patients had complex reconstructions (free flap). In 30% of patients, the reconstruction was of moderate difficulty (local flap reconstruction). Fourteen patients experienced complications. Six patients had minor wound infections which all resolved
Lower limb trauma and PTSD
557
Figure 1
PTSD checklist given to patients at follow-up clinic.
following courses of antibiotics. Two patients had deep vein thromboses; amputation was performed in only one patient. This was done as a primary procedure as a result of the extent of the injury.
Three patients developed infected non union, two patients had free-flap failures from their initial surgery but later had successful flap coverage on subsequent surgery. Both these patients were young (<35 years old), heavy
Table 1
Figure 2
Chart showing causes of lower limb trauma.
Type of reconstructions utilised.
Reconstruction
Number of patients (n Z 60)
Free scapular/parascapular ALT free flap Local fasciocutaneus flap Radial forearm free flap Free gracilis flap Gastocnemius (local) Free groin flap Free medial plantar flap Primary amputation (acute)
20 15 8 6 5 3 1 1 1
558
W. Bhat et al.
smokers, alcoholics and ex-intravenous drug abusers, who refused to comply with early postoperative instructions (Table 2). Patients (aged >50) had statistically lower PCL-S scores than younger patients. The difference observed on the chisquared test at 2 months was 0.054. With respect to age variance, Fisher’s exact test showed a P value of 0.013. A Wilcoxon test demonstrated that subsequent scores at the 4-month follow-up were lower than the scores at 2 months in all age groups and this was statistically significant (P value of 0.021).
PCL-S score with age Of the 60 patients included in the study, 33 were >50 years old and 27 were <50 years old. When assessed at 2 months in the outpatient clinic, >26 patients in the 50-year-old age group had PCL-S scores <30 and only seven patients scored >30 on the checklist. In the under-50-year-old age group, 15 patients scored <30 and 12 patients >30 (Table 3). The difference observed on the chi-squared test at 2 months was 0.054.
Trends in PCL-S Trends across the four age groups were analysed (Table 4). In all age groups, higher scores were noted at the 2-month follow-up and this was significantly less at the 4-month follow-up. The Wilcoxon test demonstrated that scores at the 4month follow-up were lower as compared to scores at the 2-month follow-up regardless of age; this was statistically significant (P Z 0.021). The under-25-year-old age group scored significantly higher than those in the older age groups. This may in part be due to the fact that younger patients are more likely to be involved in significant high-energy injuries, and this was reflected in higher scores. Fisher’s exact test showed P Z 0.013 for age variance at 2 months. This was used as it is similar to the chi-squared test but more accurate for small sample sizes. Correlations were drawn between the PCL-S scores and length of hospital stay, complications and age of patients. With regard to hospital stay, there was a strong positive correlation between high PCL-S scores and length of hospital stay (correlation þ0.419). This positive correlation was also observed with respect to correlation with associated complications. The age of the patient was negatively correlated with the PCL-S score correlation 0.277. The older the patient, the less likely they were to have scored >30 on the PCL-S. Table 2 Complications in patients that underwent reconstructive surgery. Complication
Number of patients (n Z 60)
Wound infection Non union (osteomylitis) Flap loss Deep vein thrombosis Amputation
6 3 2 2 1
Table 3
PCL-S scores relating to age.
<50 years old >50 years old Total
Score <30
Score >30
15 26 41
12 7 19
PCL-S scores were subsequently lower at 4 months (correlation 0.956). Nineteen patients rated their PCL-S scores >30; of these patients, 30% lacked social support networks and were unemployed, supporting the fact that lack of support and substance dependence may correlate with an increased likelihood of PTSD following trauma.
Discussion Our review of the 60 patients in our study found the following: One in three patients met the criteria for PTSD. Patients’ PCL-S component summary scores were significantly associated with younger age groups and recovery is longer. Patients with high PCL-S scores were significantly associated with ongoing treatment, complex surgery and complications. Higher scores were associated with long hospital stay. PCL-S scores were significantly lower at subsequent follow-up. The scores of older patients improved quicker. Our finding that 33% of the patients with lower limb injuries met the criteria for psychological illness is consistent with previous reports.8 The most remarkable finding was that the younger age groups scored higher at both the 2- and 4-month follow-ups. This may have been related to the fact that injuries among the younger age groups tended to be of a higher velocity such as RTAs compared to the higher proportion of older patients sustaining injures by trivial slips/falls. As a result, it can be seen that those injuries were more likely to
Table 4
Trends in PCL-S at 2 and 4 month follow-up.
Lower limb trauma and PTSD require longer hospital stays, with more complex procedures required for reconstruction, and cause greater morbidity to the patient. This may account for the higher scores in the younger age groups. An interesting point noted from the study was that although all age groups scored lower at subsequent followup reviews, which may have been due to the fact that most patients at the 4-month stage were well on the road to recovery having completed the most difficult part of their rehabilitation, the scores decreased quicker and to a greater extent in the patients in the above-50-year-old age group. In part, this could relate to the cause of injury being of a lower velocity. Although positive correlation with higher PCL-S scores were seen in those patients with lack of social support and substance abuse, due to the unreliability of information given and that not all historic cases had this information available, accurate conclusions could not be drawn from this study, although this correlation seems an obvious contributor to patients having higher scores. A recent study of patients with severe lower limb injuries found a 42% prevalence of psychological disorder at the 24month follow-up and that only 22% of such patients reported receiving mental health services.9 No relationship was found between injury severity and psychological distress; however, the authors suggested that low variability in injury severity might have obscured this result. This differs from our study in which there was a strong positive correlation between the scores in all age groups and the injury severity. This correlation between psychological distress and physical complaints has been reported by several authors.10 Zatzick et al. also compared psychological distress and health-related quality of life in 101 hospitalised trauma patients. One year after injury, 30% of the patients (n Z 22) met the symptomatic criteria for PTSD. Starr et al. conducted a study of 588 patients and found that 51% of patients met the criteria for PTSD11; specifically, patients scored higher on questions pertaining to avoidance. Our study further identified that higher scores were significantly associated with phobic anxiety. Management of co-morbid psychological illness has had important positive effects on recovery from trauma following sexual abuse, spousal abuse, head injury and critical illness.12e15 It remains plausible that lower limb trauma patients presenting with co-morbid psychopathology may experience similar benefits. Previous work has reported that mental illness is an independent predictor of poor outcome following trauma. Our findings add to a growing body of literature that suggests psychological symptoms among patients treated for sever lower limb injuries by orthoplastic intervention may be an important target for intervention.16,17
Strengths and limitations Our study is strengthened by the high rate of response from a consecutive group of patients attending for management of lower limb trauma in one trauma centre. The limitations of the study are that we did not collect data on psychological morbidity prior to injury, and it is not
559 clear to what degree post-injury distress can be attributed to the injury. Although epidemiologic studies suggest that the prevalence of psychiatric disorders in the general community is about 20%,18 our study design did not allow for this fact. Thus, our findings cannot rule out the possibility of pre-existing psychiatric illness and it is not clear to what degree post-injury distress can be attributed to the injury. PTSD can last >1 year and follow-up should be for a longer period. A prospective cohort study including multiple follow-up assessments over time that incorporate insights from this study is needed to further resolve this issue.
Conclusion With this cohort of patients, early psychiatric and psychological support is required to prevent the progression to PTSD. The presented work seeks to increase the awareness of this condition among those treating severe lower limb casualties so that appropriate treatment choices could be made to address them. The ultimate goal of patient care should be the development of protocols that include psychosocial preinjury assessment and follow-up as a standard of care in the lower limb trauma setting.
Ethics approval The study was carried out at the Frenchay Hospital, Bristol, UK, with approval from the local institutional review board.
Conflict of interest We declare no conflict of interest (personal or financial) in the publication of this article.
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