Psychological Morbidity Associated with Orthopedic Trauma

Abstract

Little is known about the clinical consequences of psychological morbidity associated with orthopedic trauma. Previous work has reported that mental illness is an independent predictor of poor outcome following orthopedic trauma, and future studies should explore whether management of psychological symptoms independently predicts recovery from orthopedic trauma. Anxiety disorders, depression, bipolar disorder, schizophrenia, and personality disorders may all flare up during the post-operative period, leading to psychiatric consultation. Other common general post-operative issues include complications related to alcohol abuse, dependence, and withdrawal; pain management in opioid-dependent patients; the presence of personality disorders and other causes of lack of cooperation; and post-operative delirium. Posttraumatic stress disorder (PTSD) is also common after surgery, particularly after traumatic injuries, but is underrecognized and undertreated. Previous research has evaluated these and other issues in surgical patients. Although psychiatric problems are seen less frequently than previously, the orthopaedic surgeon must remain aware of their possible effect. The prevalence of psychological illness following traumatic injuries varies according to the diagnostic criteria used in studies, the timing of the assessment and definitions of trauma. Estimates of psychological symptoms following musculoskeletal trauma have ranged from 6.5% to 51.0%. Mason assessed the psychological state of 210 male accident and emergency department patients and followed them for 18 months, at which time 30% satisfied criteria for a psychiatric disorder. A recent study of patients with severe lower limb injuries found a 42% prevalence of psychological disorder at 24-month follow-up and that only 22% of such patients reported receiving mental health services. No relation was found between injury severity and psychological distress; however, the authors suggested that low variability in injury severity might have obscured this result. McCarthy further identified a high correlation between the Brief Symptom Inventory (a measure of psychological distress) and the Sickness Impact Profile (a measure of patient function). A high index of suspicion for the presence of psychiatric disorders is important in treating the orthopaedic patient with multiple trauma, chronic disease, factitious disorder, or suspected malingering or who fails to improve with recognized treatment. Recognition of a psychiatric problem should be part of preoperative planning in orthopaedic practice, and a formal psychiatric referral for diagnosis and treatment should be made for the patient with significant psychiatric involvement. When associated psychiatric disease is diagnosed and controlled before orthopaedic treatment commences, the patient is more likely to comply with the treatment regimen, which may lead to better results. It is important for providers who care for patients with minor injury to include a psychiatric history and/or rapid screening for psychiatric disorders as part of the health assessment. Psychosocial factors, specifically, ongoing litigation and psychological symptoms are related with reduced health-related quality of life. Further, the goal of care is to help patients attain maximal functional recovery. Therefore, the presence of a positive psychiatric history or a current psychiatric disorder should stimulate a referral of these patients for appropriate emotional support and therapeutic follow-up. By doing so, providers will give patients important interventions to maximize full recovery.