Orthopedic trauma can induce PTSD symptoms in children

One-third of pediatric orthopedic trauma patients had high levels of post-traumatic stress symptoms.

Issue: November 2004

OTA 2004 [icon] HOLLYWOOD, Fla. — A survey of children suffering orthopedic trauma found that a significant number suffer from a high level of post-traumatic stress symptoms. Whether or not a child was admitted to the hospital was a significant predictor of elevated levels of symptoms.

“The idea that soldiers may have a psychological reaction to war is easily accepted by most people,” said Michael B. Sanders, MD, of the University of Texas Southwestern Medical Center in Dallas, in his presentation at the Orthopaedic Trauma Association 20th Annual Meeting. “We can see that people exposed to [battle] and civilian trauma might suffer mentally in addition to their physical wounds. But what about children?”

Sanders said that although studies have been done on post-traumatic stress disorder (PTSD) in children, they have frequently focused on crime or natural disasters rather than orthopedic trauma. “Historically, children’s psychological response to trauma has been minimized,” he said. “Some people believe that children are too developmentally immature to experience PTSD, or perhaps they are too young to remember the traumatic events. … Since physical wounds heal well, it seems unlikely that any psychological problem might exist.”

Symptom questionnaire

Researchers asked 415 pediatric orthopedic trauma patients to complete a PTSD symptom questionnaire designed specifically for children aged eight to 18 years. The survey directly assesses the 17 PTSD symptoms of the DSM-11; responses are based on a four-point Likert scale ranging from zero to three. Scores are added in order to determine severity of symptoms, and a total score of 11 or higher indicates a high level of PTSD symptoms.

“Symptoms of PTSD are typically broken down into three subcategories,” Sanders said. “The first, intrusion, includes items such as nightmares and flashbacks. Avoidance includes items such as loss of interest and emotional distancing. And finally, arousal includes concentration, irritability and jumpiness.”

The average age of the study population was 11; 258 were boys and 142 were girls. The average Injury Severity Score was 4, and the average time since injury was 36 days. Fifty-four patients were admitted to the hospital with an average hospital stay of four days. The most common diagnosis was fracture of the distal radius.

Sanders found that 130 patients, or 33%, met criteria for high levels of PTSD symptoms. Admission to the hospital was strongly associated with development of these symptoms, with 42% of those admitted meeting the high symptom criteria. Other variables such as age, gender, ethnicity, ISS and ICD-9 code were not significantly associated with PTSD symptoms.

“The take-home message is, if a pediatric orthopedic patient is in your office after an injury, there is a one-in-three chance that they are suffering from high levels of PTSD symptoms,” Sanders said. “These children may have few outward signs of their psychological stress, but if you ask them, they will talk about their problem. Our role is quite clear. Many times, we are the only doctor they see after they leave the hospital. If we can learn to ask about this problem, we can help these patients start to get better.”

For more information:

Sanders MB, Starr AJ, Frawley WH, et al. Post-traumatic stress symptoms in pediatric orthopaedic trauma patients. #47. Presented at the Orthopaedic Trauma Association 20th Annual Meeting, Oct. 8-10, 2004. Hollywood, Fla.