1. Psychological difficulties following open fracture are common and should receive attention alongside the physical effects of injury to help improve long-term functioning.
2. Patients require support from trauma teams to express strong emotions, manage their pain, adjust to their wounds, live with limited mobility, and reimagine their future lives.
3. Drawing on cognitive-behavioural therapy (CBT) and eliciting a patient’s thoughts, feelings, behavioural choices, and physiological reactions may help validate patient experience and provide information for mental health referral where indicated.
4. Common post-traumatic symptoms will often alleviate over time, but their elevation can be predictive of later post-traumatic stress disorder. Patients experiencing acute stress will benefit from regular orientation to their surroundings and help to focus on daily life.
5. A patient’s distress about change in appearance is linked to their subjective perception rather than objective clinical assessment. Patients may require: support to look at and touch scars and flaps; help with anxiety, which may be indicated by excessive checking or avoidance of their wound; and opportunities to discuss their concerns. Neutral descriptors should be used where possible (e.g. change in appearance rather than deformity).
6. Patients should be referred to a trained mental health clinician for evidence-based treatment where their psychological difficulties are negatively impacting their functioning and recovery.
In the immediate aftermath of an open fracture, patients are faced with the psychological effect of trauma, sudden hospitalisation, and ongoing physical impairment. Psychological distress in this context is common and can be lasting. Evidence suggests that approximately a third of severely injured adults screen positive for a likely psychological disorder up to 2 years post-injury (1, 2). This is a new diagnosis for many (1), indicating that the impact of injury has a sustained effect on their lives. Evidence from patient experience combined with existing psychological models may provide guidance for appropriate clinical input. This chapter outlines what we know about patient experience of open fracture of the lower limb, considers practical psychological support drawing on cognitive-behavioural principles, and explores two key patient challenges: changes to appearance and heightened psychological distress.
Patient-based evidence underpins clinical guideline development (3) and provides opportunities for developing shared understanding and decision making (4). Interviews with patients whilst in hospital (5) as part of the UK Wound Management of Open Lower Limb Fractures (WOLLF) trial (6) highlight the significant impact of trauma on patients’ lives and emotional well-being. The following provides a summary of their experience:
◆ Participants were shocked by the strength of their emotions, which they had not experienced before, or they compared to feelings they had when a family member died. It felt like an emotional rollercoaster. At the same time, they were controlling their emotions to help their family and friends cope with the impact of their injury.
◆ Participants talked extensively about their pain, the different types of pain, and approaches to pain control. Many identified a time when they were in extreme pain.
◆ Participants were horrified by their wounds, skin, and muscle flaps. They were grateful to staff who supported them and helped them to understand what was happening to their legs. However, they needed to feel ready to see their wound for the first time and time to adjust to their wounds, often before showing them to family members.
◆ Being physically constrained by their injuries was a real struggle for patients; they monitored their bodies and were grateful for a degree of control over their ability to move about but were frustrated by inactivity.
◆ Being able to imagine how their life might continue at home was a challenge for participants. They felt there was a point where they became ready to think about it and visually imagine it. However, they remained anxious about what it would be like and sad about the things they would not be able to do.
In summary, in the early phase of recovery patients with open fracture of the lower limb require support to enable them to: (i) express strong emotions, (ii) manage their pain, (iii) adjust to having wounds, (iv) live with limited mobility, and (v) reimagine their future life.
Later on in recovery, there is some evidence that patients have changed lives and struggle to return to normal or adapt to being disabled. For example, the impact of not being able to bear weight was noted by patients with fractures around the ankle in interviews (n = 36) up to 10 weeks post-injury, where they expressed frustration and felt depressed due to inactivity and being confined to a small geographical space (7). In addition, major trauma patients (n = 15) at 3–6 months, including those with lower limb injury, identified how they were determined to get better, frustrated by setbacks, wanted to do the right thing but ultimately felt they needed to redefine who they were in order to incorporate their injury into their life (8). Interviews with participants with open lower limb fractures (n = 9) up to 2.8 years post-injury suggested they were still struggling, with some not returning to normal (9). In this study, participants identified ongoing pain and stiffness, reduced mobility, fear of falling, concerns about their appearance, and changed finances as affecting their lives. The vulnerability expressed by patients with open fractures of the lower limb suggests that a continued focus on emotional well-being, pain, wound management, mobility, and hopes for the future are important to support patients’ recovery from traumatic injury.
Practical psychological support
Emotional support offered to patients who experience closeness to death or loss of limb is embedded in daily hospital activities (10) and is a central part of interventions to reduce distress. Timely assessment of how patients are feeling, their social support, and current coping strategies provides a basis for identifying the specific interventions required. An evidence-based model for carrying out such an assessment can be drawn from cognitive-behavioural therapy (CBT) (11). As a treatment, CBT is one of a number of appropriate models that may be used and it can aid a trauma team’s understanding of a patient’s response to their injury. The model highlights the interplay between how an individual thinks, feels, and behaves in relation to their physical experience. It is underpinned by recognition that a person’s experience of an event, in this case an open fracture, is influenced by their thoughts about it, and these in turn are affected by pre-existing beliefs, which have been shaped by lived experience (12). It is important for the whole trauma team to understand this interplay between the physical injury and the emotional response. By eliciting what a patient is thinking, the team can develop understanding of their emotional responses, behavioural choices, and physiological reactions. Figure 17.1 highlights how each of these areas influences the others in a reciprocal fashion and has the potential to form a vicious cycle.
A simple way of gathering information within this framework is to ask the patient:
◆ ‘What’s going through your mind at the moment (thoughts)?’
Followed by questions such as:
◆ ‘And when you think this, what feelings come up for you (feelings)?’
◆ ‘And what does that lead you to do (behaviours)?’
◆ ‘And what sensations do you notice in your body (physical)?’
It is possible to start at any point (thoughts, feelings, behaviours, physical sensations) in this mini-formulation depending on the prominent experience for the patient. For example, ‘You’re looking worried, can you tell me what thoughts are going through your mind when we talk about your next operation?’ The thoughts and feelings shared may echo those identified in patient experience research, and valuable emotional support for the patient at this stage can be to reflect and summarise what they say; for example:
My understanding from what you have said is that when you hear that another operation may be necessary [trigger], you feel scared [feelings], your body tenses up [physical sensations], you worry that you are going to remain in hospital for a long time and that you may never fully recover [thoughts], and you feel frustrated [feelings] that you aren’t making the progress you had anticipated [thoughts]. All this makes it harder for you to try the exercises the physiotherapist has given you and you often decline their sessions [behaviours].
Acknowledging patient experience in this way is a form of psychological support accessible to all clinical staff, and for those patients where significant psychological distress is identified it provides referral information for assessment and intervention by an appropriately trained mental health practitioner.
This way of interacting with patients may be used to explore some of the key challenges faced by those with an open fracture, such as changes to appearance and heightened psychological distress.
Changes to appearance
Open fractures are often associated with large wounds and flaps. An ongoing task for the patient is therefore adjustment to the loss of their previous appearance, development of the confidence to manage any potential social stigma, and engagement in valued living. Injury severity and objective clinical assessment of visible change are not associated with patient-reported levels of appearance distress (13). Instead, the patient’s perception of disfigurement noticeability serves as a more accurate predictor (14). Crucially, such perceptions are amenable to psychological input (15). Supporting a patient to look at and (when appropriate) touch their scars and flaps is a valuable step towards encouraging reintegration of their altered body image into their sense of self. It is helpful to talk with patients about their thoughts and images prior to looking at their wounds and to be observant for avoidance or excessive checking, which may maintain anxiety. Sensitive use of ongoing photographs can be a valuable way of shared monitoring of the healing process (16). Patient concerns about how the injury looks should be openly discussed and medical vocabulary carefully chosen to avoid inadvertently alienating them (e.g. correction, deformity). Later in the recovery process, questions about how noticeable the patient believes the injury to be and whether this is a worry to them or leads to avoidance will help to legitimise potential concerns (13).
Heightened psychological distress
There are a number of relevant points to consider in relation to psychological distress in this group of patients. These are:
◆ The association between psychological distress and ongoing disability is strong (17), and indeed the psychological well-being of trauma patients has a greater influence than pain or injury severity on their longer-term functioning post-trauma (18, 19), even after controlling for baseline mental health (20).
◆ It is acknowledged that pain control post-surgery can be difficult to manage (21) and is often underestimated (22). There is evidence that psychological factors (including depression, anxiety, and pain catastrophising) play an important role in patient experience of acute pain and increase risk for the transition from acute to chronic pain (23).
◆ Anxiety and depression may be more common in open than closed fractures (17, 24). Such conditions tend to reduce a person’s capacity to actively manage their fracture and this predicts lowered functioning over time (25). Staff can support such concerns through realistic hopefulness, where they focus on what is possible in the short term and help the patient to develop achievable goals (26).
◆ Alongside mood changes, it is important to remember that immediately after a traumatic injury such as an open fracture, patients will often report some post-traumatic symptoms (5). For a minority, these symptoms may elevate over time and this is predictive of subsequent post-traumatic stress disorder (PTSD) and depression (27).
◆ It should also be acknowledged that those experiencing acute stress will believe themselves to be in continued danger. Orientation to current surroundings will therefore frequently be necessary.
◆ Within an acute trauma setting, appropriate psychometric screening tools should be readily available, e.g. the Posttraumatic Adjustment Scale (28) and a referral route to psychology and psychiatry established. At subsequent outpatient appointments, a variety of self-report psychometric measures can be used to highlight ongoing psychological difficulty. A high incidence of post-traumatic stress symptoms among patients with severe lower limb trauma has been noted in this context (29).
◆ Ongoing research continues to highlight different possible early interventions for PTSD (30, 31) and National Institute for Health and Care Excellence (NICE) [NG116] now recommends trauma-focused CBT for adults with acute stress disorder or clinically important PTSD symptoms within the first month post-trauma. In addition, the depression and anxiety so often associated with limb fractures may be alleviated using evidence-based therapeutic techniques provided by trained clinicians (32, 33).
To conclude, patient experience research highlights the vulnerability expressed by patients with open fractures of the lower limb and suggests that a continued focus on emotional well-being, pain and wound management, mobility, and hopes for the future may aid a patient’s recovery. Trauma teams can support patients by being aware of patient concerns, proactive in creating an environment in which patients can express their emotions, enquiring about their well-being, normalising their experience and being alert to their need for additional support or treatment. Future research on patient experience needs to explore recovery trajectories and investigate which patient-focused interventions that incorporate emotional well-being are most effective, for whom, and under what circumstances.
1. Bryant RA, O’Donnell ML, Creamer M, McFarlane AC, Clark CR, Silove D. The psychiatric sequelae of traumatic injury. Am J Psychiatry. 2010;167(3):312–20.Find this resource:
2. McCarthy ML, MacKenzie EJ, Edwin D, Bosse MJ, Castillo RC, Starr A, et al. Psychological distress associated with severe lower-limb injury. J Bone Joint Surg Am. 2003;85-A(9):1689–97.Find this resource:
3. Staniszewska S, Boardman F, Gunn L, Roberts J, Clay D, Seers K, et al. The Warwick Patient Experiences Framework: patient-based evidence in clinical guidelines. Int J Qual Health Care. 2014;26(2):151–7.Find this resource:
4. CG138 NCG. Patient Experience in Adult NHS Services: Improving the Experience of Care for People Using Adult NHS Services. London: National Clinical Guideline Centre, 2012.Find this resource:
5. Tutton EA, J. Lamb, SE. Willett, K. Costa, M. on behalf of the UK WOLLF research collaborators. A qualitative study of the experience of an open fracture of the lower limb in acute care. Bone Joint J. 2018;100-B:522–6.Find this resource:
6. Costa ML, Achten J, Bruce J, et al. Effect of negative pressure wound therapy vs standard wound management on 12-month disability among adults with severe open fracture of the lower limb: the WOLLF Randomized Clinical Trial. JAMA. 2018;319(22):2280–8.Find this resource:
7. Keene DJ, Mistry D, Nam J, Tutton E, Handley R, Morgan L, et al. The Ankle Injury Management (AIM) trial: a pragmatic, multicentre, equivalence randomised controlled trial and economic evaluation comparing close contact casting with open surgical reduction and internal fixation in the treatment of unstable ankle fractures in patients aged over 60 years. Health Technol Assess. 2016;20(75):1–158.Find this resource:
8. Claydon JH, Robinson L, Aldridge SE. Patients’ perceptions of repair, rehabilitation and recovery after major orthopaedic trauma: a qualitative study. Physiotherapy. 2017;103(3):322–9.Find this resource:
9. Trickett RW, Mudge E, Price P, Pallister I. A qualitative approach to recovery after open tibial fracture: the road to a novel, patient-derived recovery scale. Injury. 2012;43(7):1071–8.Find this resource:
10. Tutton E, Seers K, Langstaff D. Professional nursing culture on a trauma unit: experiences of patients and staff. J Adv Nurs. 2008;61(2):145–53.Find this resource:
11. Greenberger DP, CA. Mind Over Mood: Change How You Feel By Changing the Way You Think. Second edn. New York, NY: Guildford Press; 2015.Find this resource:
12. Beck A. Cognitive Therapy for Depression. New York, NY: Guildford Press; 1979.Find this resource:
13. Rumsey N, Clarke A, Musa M. Altered body image: the psychosocial needs of patients. Br J Community Nurs. 2002;7(11):563–6.Find this resource:
14. Lansdown RR, N. Bradbury, E. Carr, T. Partridge, J. Visibly Different: Coping with Disfigurement. Boca Raton, FL: CRC Press; 1997.Find this resource:
15. Rumsey N, Harcourt D. Body image and disfigurement: issues and interventions. Body Image. 2004;1(1):83–97.Find this resource:
16. NG37 NCG. Fractures (Complex): Assessment and Management. London: NICE; 2016.Find this resource:
17. Crichlow RJ, Andres PL, Morrison SM, Haley SM, Vrahas MS. Depression in orthopaedic trauma patients. Prevalence and severity. J Bone Joint Surg Am. 2006;88(9):1927–33.Find this resource:
18. O’Donnell ML, Varker T, Holmes AC, Ellen S, Wade D, Creamer M, et al. Disability after injury: the cumulative burden of physical and mental health. J Clin Psychiatry. 2013;74(2):e137–43.Find this resource:
19. Starr AJ. Fracture repair: successful advances, persistent problems, and the psychological burden of trauma. J Bone Joint Surg Am. 2008;90(Suppl 1):132–7.Find this resource:
20. Michaels AJ, Michaels CE, Smith JS, Moon CH, Peterson C, Long WB. Outcome from injury: general health, work status, and satisfaction 12 months after trauma. J Trauma. 2000;48(5):841–8; discussion 8–50.Find this resource:
21. Eriksson K, Wikstrom L, Fridlund B, Arestedt K, Brostrom A. Patients’ experiences and actions when describing pain after surgery—a critical incident technique analysis. Int J Nurs Stud. 2016;56:27–36.Find this resource:
22. Seers T, Derry S, Seers K, Moore RA. Professionals underestimate patients’ pain: a comprehensive review. Pain. 2018;159(5):811–18. DOI: 10.1097/j.pain.0000000000001165Find this resource:
23. Mcgreevy K, Bottros MM, Raja SN. preventing chronic pain following acute pain: risk factors, preventive strategies, and their efficacy. Eur J Pain Suppl. 2011;5(2):365–72.Find this resource:
24. Giannoudis PV, Harwood PJ, Kontakis G, Allami M, MacDonald D, Kay SP, et al. Long-term quality of life in trauma patients following the full spectrum of tibial injury (fasciotomy, closed fracture, grade IIIB/IIIC open fracture and amputation). Injury. 2009;40(2):213–19.Find this resource:
25. Wegener ST, Castillo RC, Haythornthwaite J, Mackenzie EJ, Bosse MJ, Group LS. Psychological distress mediates the effect of pain on function. Pain. 2011;152(6):1349–57.Find this resource:
26. Tutton E, Seers K, Langstaff D. Hope in orthopaedic trauma: a qualitative study. Int J Nurs Stud. 2012;49(7):872–9.Find this resource:
27. Mellman TA, David D, Bustamante V, Fins AI, Esposito K. Predictors of post-traumatic stress disorder following severe injury. Depress Anxiety. 2001;14(4):226–31.Find this resource:
28. O’Donnell ML, Creamer MC, Parslow R, Elliott P, Holmes AC, Ellen S, et al. A predictive screening index for posttraumatic stress disorder and depression following traumatic injury. J Consult Clin Psychol. 2008;76(6):923–32.Find this resource:
29. Bhat W, Marlino S, Teoh V, Khan S, Khan U. Lower limb trauma and posttraumatic stress disorder: a single UK trauma unit’s experience. JPRAS. 2013; 67(4): 555–60Find this resource:
30. Kearns MC, Ressler KJ, Zatzick D, Rothbaum BO. Early interventions for PTSD: a review. Depress Anxiety. 2012;29(10):833–42.Find this resource:
31. O’Donnell ML, Lau W, Tipping S, Holmes AC, Ellen S, Judson R, et al. Stepped early psychological intervention for posttraumatic stress disorder, other anxiety disorders, and depression following serious injury. J Trauma Stress. 2012;25(2):125–33.Find this resource:
32. CG90 NCG. Depression in Adults: Recognition and Management. London: NICE; 2009.Find this resource: