Casey Tingle , 2025-05-13 15:46:00
Key takeaways:
- Traumatic injuries can impact an individual’s physical and psychological health.
- Orthopedic surgeons should be a bridge to connect patients with mental health experts.
According to the CDC, unintentional injuries are the leading cause of death for people aged 1 to 44 years, with approximately 21 million people treated and released from the ED with nonfatal injuries each year.
Not only has published literature shown that traumatic events and injuries lead to significant physical impairment, functional limitations, pain and long-term disability, but it can also impact an individual’s psychological health. Within 1 year of orthopedic injury, one in three patients meet criteria for PTSD or depression, and one in five patients will report poor mental health outcomes, according to Sacha McBain, PhD, clinical psychologist and associate professor at Rush University Medical Center.
Marty Carrick, Cleveland Clinic
“If you think about a fall, a car accident, an assault or an amputation, what is occurring at the time of the injury in and of itself constitutes as trauma. But then there are also these characteristics of what we call the peri-trauma phase — what is happening around the traumatic event itself that can compound those reactions,” McBain told Healio. “The acute response, getting to the hospital, stabilization and repeated surgeries, each of those characteristics has also been associated with depression, anxiety and posttraumatic stress disorder in something that we call medical traumatic stress.”
Sacha McBain
In the past, orthopedic surgeons may not have focused on a patient’s psychological well-being after orthopedic injury. However, it has gained more attention in the past several years due to orthopedic surgeons looking to treat the whole patient and not just the injury, according to Heather A. Vallier, MD, vice chair of orthopedic enterprise for safety, quality and patient experience at the Cleveland Clinic Lerner College of Medicine.
“This person that comes to us with a given injury which we are trained to diagnose and treat also is a person who has, perhaps, serious social challenges, economic challenges, mental health challenges or all of the above,” Vallier, professor of orthopedic surgery at Case Western Reserve University, said. “The mental health piece is particularly important because, in addition to something that we have not paid a lot of attention to as a profession, it has a profound impact on how that person is going to perceive their injury as well as their ability to participate in treatment.”
Risks for psychological distress
Although poor psychological well-being can impact any socioeconomic or demographic group, Anna N. Miller, MD, said patients with more severe or complex injuries and those with pre-existing mental health conditions may be at higher risk for developing psychological distress.
“It has been shown in patients undergoing elective orthopedic surgery that if they have pre-existing depression or anxiety, they may have worse outcomes,” Miller, professor and chair of the department of orthopedics at Dartmouth Hitchcock Medical Center and Geisel School of Medicine at Dartmouth, told Healio. “This most likely effects orthopedic trauma also.”
Anna N. Miller
Vallier said some people may “have genetic or historical tendencies toward substance use,” which may lead to other psychological illnesses and impact outcomes after traumatic injury.
“There are a lot of other risk factors, as well. People who have a fair amount of stress in their life with economic hardship or other types of social challenges are also at increased risk,” she said. “A lot of that relates to the burden they face on a daily basis, which is probably heavier than others may face.”
Patients who feel they experienced injustice related to their injury may also experience higher levels of pain, psychological distress and lower quality of life, according to McBain. She said pre-trauma risk factors include pre-existing experiences of discrimination and bias, which is common among those who have been socially marginalized due to one or more identities (eg, race, gender, sexuality, ability status), as well as limited education or low socioeconomic status.
A perceived life threat at the time of injury or in the acute recovery phase is another factor that can lead to poor psychological well-being, McBain said. This can include the belief that the injury was intentional, such as in cases of assault, or hospital-based factors post-injury, including interactions with medical staff, surgical experience, adjustment to injury, being in the ICU and pain severity.
Protective factors
Vallier said there are factors that may protect patients from developing poor psychological well-being. Patients in a stable relationship and those who have older children may present with better psychological well-being, she said.
“Employment that people enjoy and find fulfillment in, regardless of the type of job, tends to be a protective factor. And, for some people, spirituality and participation in an organized religion group seem to have some protection against mental illness,” Vallier said. “But there is no hard and fast rule. Mental illness affects everybody in all of these groups.”
Source: Data were derived from Nedder VJ, et al. J Trauma Inj. 2024;doi:10.20408/jti.2023.0068.
Miller said support from a patient’s physician may also help decrease psychological distress.
“Patients who have interventions early on and have a good supportive care team can be helped with their recovery and maybe that is protective of having more ongoing psychological concerns,” Miller said.
Another factor that may prevent or reduce the risk for poor psychological outcomes after orthopedic injury is a patient’s outlook, according to Hassan R. Mir, MD, MBA, professor of orthopedic surgery and director of orthopedic trauma research at the Florida Orthopaedic Institute and the University of South Florida.
Hassan R. Mir
“People who have a positive mindset and have strong self-efficacy who have, for lack of a better term, the ‘willpower’ and think that they are going to recover and improve, it can help them to recover and improve,” Mir told Healio.
Psychological assessment
When treating patients with orthopedic trauma, the American College of Surgeons recommends that all trauma centers implement a protocol for mental health screening to assess whether a patient is at risk for developing long-term distress.
“There are a few different standardized surveys that you can use to measure these types of things,” Vallier told Healio. “Level 1 and level 2 trauma centers that care for people who have symptoms of adverse mental health are required to initiate mental health treatment during the acute trauma episode vs. level 3 centers, where it is required that some arrangements be made after the hospitalization if they are not able to provide the care during the hospitalization.”
Some validated screening tools to assess adults for PTSD and depression include the PCL-5 PTSD Screen, Injured Trauma Survivor Screen, Patient Health Questionnaire, Peritraumatic Distress Inventory, Posttraumatic Adjustment Screen and Generalized Anxiety Disorder Screen. McBain said the care team can also utilize either the collaborative stepped care model or the multi-tier approach to psychological intervention (MAP-IT).
“Within the MAP-IT model, when people are admitted, they answer yes or no questions about pre-, peri- and post-trauma risk factors. Those who are determined to be at increased risk for post-injury mental health concerns receive brief intervention at the bed side that is focused on education, ensuring coping and other specific interventions as needed for each particular patient and their family; and then referral to outpatient services and support, which can also include integration into surgical follow-up clinics,” McBain said.
Although many hospitals and practices may routinely have patients fill out these assessments to measure levels of hopelessness and insecurity, David C. Ring, MD, PhD, said many patients may not answer honestly.
David C. Ring
“If it is a measure based on item response theory, there is a timing that is taken into account, and each question is a little test. What happens is you can see when they are filling it out quickly — so hasty completion — and then you get this floor effect, which indicates they may be downplaying symptoms of depression and anxiety,” Ring, who is an associate dean for comprehensive care, professor and associate chair for faculty academic affairs in the department of surgery and perioperative care, and courtesy professor of psychiatry and behavioral sciences at Dell Medical School at the University of Texas at Austin, told Healio. “The tendency for a person seeking musculoskeletal specialty care to complete a mental health measure hastily and not be forthright is probably a reflection of mental health stigma. They want their physical problem to be taken seriously and worry about overemphasis on mental health.”
Additional tools
In addition to the screening tools, Mir said physicians can ask patients how they are doing, if they are sleeping OK and about their life and work situation. He said it is important for physicians to tell patients that their feelings are normal and that a lot of people go through these experiences after a traumatic event.
“Try to provide them whatever resources your community has, whether as far as formal health care or referring them to their primary doctor to help get involved or referring them to well-being apps,” Mir said. “Then on the social side, taking the time to help them with their paperwork for work and disability forms, etc. Those things can go a long way to help them with their physical recovery.”
Ring said cognitive behavioral therapy may also help patients train their “mind to tell the healthiest possible story about their body and its sensations.” In a preliminary randomized controlled trial, Ana-Maria Vranceanu, PhD, and colleagues found cognitive behavioral and relaxation response strategies were feasible, acceptable and potentially efficacious in reducing pain intensity and magnitude of disability in patients with acute musculoskeletal trauma.
“It is interesting that prior studies have had difficulty demonstrating benefit to mindset training,” Ring said. “It may depend on the specific training. One area that holds promise is psychologically informed physical therapy. That is where the mindset training is combined with the exercises to regain motion, strength and agility. We need to work more of this out, but I do believe that there are strategies for helping people recover more easily and more fully from injury.”
Multidisciplinary approach
When treating patients with orthopedic trauma, Miller said a multidisciplinary approach is key.
“We all tend to be in our silos a little bit. With these patients, there should be a team of people involved, including the physicians who are taking care of the injuries, but also the larger trauma team that might include psychiatrists, psychologists [and] mental health counselors,” Miller said.
Many hospitals also have community outreach programs for follow-up after the hospital, as well as case managers or social workers, according to Miller. She said pharmacists can also be involved with managing a patient’s pain and coordinating the multimodal pain approach.
“Having everybody on the same page to understand how important these mental health aspects are but also how we can all work together to intervene for the patients, have good patient education [and] minimize the use of opioids — all of those things together are important and that is where that multidisciplinary approach comes into play,” Miller said.
But Mir said not every hospital or health system is set up to have social workers or psychologists readily available.
“It is a different thing to try to guide a patient through a system where everything is all one and you are highly resourced vs. guiding patients through a system where it is more of a hodgepodge of different groups and providers,” Mir said. “There is a bit of a dichotomy, depending on your practice setting, on how you can guide patients. It is not uniform at all across the country. It is not uniform at all even in the same city, depending on what hospital the patient ends up in.”
Short- and long-term care
Regardless of the level of expertise physicians may have in the psychological health of trauma patients, McBain said modifiable risk factors for poor psychological outcomes should be addressed, such as providing patient-centered care, managing pain, and reducing the risk for adverse events or unscheduled ICU admissions. Physicians also can provide patients with “information about natural recovery, how to cope [and] utilize integrated care models to make sure people are getting the access to care that they need early,” according to McBain.
“The final thing is emphasizing the idea of wellness,” she said. “How do we orient our patients as best as possible to the environment that they are in? How do we provide education, care management [and] peer navigation to help people to navigate these obstacles and losses that occur after recovery? For some people, if we can level some of those obstacles they then know how to recover naturally.”
Although short-term psychological care performed in the hospital can be helpful for recovery after traumatic injury, Miller said long-term outpatient treatment is just as important.
“A lot of times patients may develop more problems or symptoms later on,” Miller said. “For example, posttraumatic stress disorder cannot be diagnosed on day 1 after an injury. Some of these patients will need follow-up long term, and having that intervention right away can help the patient understand what the options are — how they can get help. Then, long term, there are lots of different ways to continue treatment.”
According to Miller, orthopedic surgeons may not address psychological health with their patients due to lack of treatment options or not having the resources to help them. However, she said orthopedic surgeons should make the effort to identify resources in the community and have a list ready for patients in need.
“We would not expect an orthopedic surgeon to be the mental health professional expert that these patients need, but having you be a bridge to connect and get those patients the help that they need is important,” Miller said. “Just like we should take responsibility for our patients’ bone health and make sure they get follow-up if they have a concerning X-ray, this should be a part of that evaluation, and we should not be ignoring it.”
References:
- American College of Surgeons launched guidelines to help trauma centers screen patients for mental health disorders and substance misuse. https://www.facs.org/media-center/press-releases/2023/tqp-best-practices-guideline-mental-health-substance-use. Published Jan. 11, 2023. Accessed April 10, 2025.
- Ayers DC, et al. J Bone Joint Surg Am. 2013;doi:10.2106/JBJS.L.00799.
- Best practices guidelines: Screening and intervention for mental health disorders and substance use and misuse in the acute trauma patient. https://www.facs.org/media/nrcj31ku/mental-health-guidelines.pdf. Published December 2022. Accessed April 2, 2025.
- Bhandari M, et al. Can J Surg. 2008;51:15-22.
- Economics of injury and violence prevention. https://www.cdc.gov/injury-violence-prevention/economics/index.html. Published Dec. 5, 2024. Accessed April 2, 2025.
- Erwin ER, et al. J Clin Orthop Trauma. 2023;doi:10.1016/j.jcot.2023.102313.
- Fracasso JL, et al. Trauma Surg Acute Care Open. 2024;doi:10.1136/tsaco-2024-001436.
- Injuries and violence. https://www.who.int/news-room/fact-sheets/detail/injuries-and-violence. Published June 19, 2024. Accessed April 2, 2025.
- Jarman MP, et al. J Surg Res. 2020;doi:10.1016/j.jss.2019.12.023.
- J Orthop Trauma. 2022;36(Suppl 5).
- Kirven JC, et al. HSS J. 2019;doi:10.1007/s11420-019-09731-w.
- Leading causes of nonfatal injury. https://wisqars.cdc.gov/lcnf/?y1=2023&y2=2023&ct=10&cc=0&s=0&g=00&a=lcd1age&a1=0&a2=199&d=0. Accessed April 2, 2025.
- Nedder VJ, et al. J Trauma Inj. 2024;doi:10.20408/jti.2023.0068.
- Piuzzi NS, et al. J Am Acad Orthop Surg. 2021;doi:10.5435/JAAOS-D-20-00810.
- Ring D. J Bone Joint Surg Am. 2020;doi:10.2106/JBJS.19.01520.
- Scott S, et al. J Orthop Surg Res. 2024;doi:10.1186/s13018-024-04932-4.
- Serious illness conversation guide. https://www.ariadnelabs.org/wp-content/uploads/2023/05/Serious-Illness-Conversation-Guide.2023-05-18.pdf. Published May 2023. Accessed April 2, 2025.
- Sharma AK, et al. JBJS Rev. 2021;doi:10.2106/JBJS.RVW.20.00169.
- Trauma facts. https://www.aast.org/resources/trauma-facts. Accessed April 2, 2025.
- Web-based Injury Statistics Query and Reporting System. https://wisqars.cdc.gov/infographics. Accessed April 2, 2025.
- Versluijs Y, et al. Clin Orthop Relat Res. 2021;doi:10.1097/CORR.0000000000001727.
- Vincent HK, et al. PM R. 2015;doi:10.1016/j.pmrj.2015.03.007.
- Vranceanu AM, et al. Injury. 2015;doi:10.1016/j.injury.2014.11.001.
For more information:
Sacha McBain, PhD, of Rush University Medical Center, can be reached at sacha_mcbain@rush.edu.
Anna N. Miller, MD, of Dartmouth Hitchcock Medical Center, can be reached at anmiller@gmail.com.
Hassan R. Mir, MD, MBA, of the University of South Florida, can be reached at hmir@floridaortho.com.
David C. Ring, MD, PhD, of The University of Texas at Austin, can be reached at david.ring@austin.utexas.edu.
Heather A. Vallier, MD, of the Cleveland Clinic, wishes to be contacted through Grant Passel at passelg@ccf.org.
Sources/Disclosures
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Source:
Healio Interviews
Disclosures:
Ring reports being a board or committee member for the American Society for Surgery of the Hand, Chair Quality, Access and Metrics Committee Orthopedic Trauma Association – Mental Health Task Force and receiving support from the NIH. Vallier reports being a co-founder of the Evellere Group. McBain, Miller and Mir report no relevant financial disclosures.
