Gunshot Trauma Patients Have Higher Risk of PTSD Compared With Blunt Trauma and Elective Populations: A Retrospective Comparative Study of Outpatient Orthopaedic Care
Authors: Wolf Jennifer Moriatis , Bouftas Fatima , Landy David C. , Strelzow Jason A. 
Published: June 2024

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.