Chronic Psychological and Functional Sequelae After Emergent Hand Surgery

SCIENTIFIC ARTICLE

Chronic Psychological and Functional Sequelae After

Emergent Hand Surgery

Todd Richards, MD, DonnW. Garvert, BA, Elizabeth McDade, PhD, Eve Carlson, PhD,Catherine Curtin, MD

Purpose Several studies have shown that upper extremity trauma has serious, acutepsychological effects after injury. This study’s goal was to assess the psychologicaloutcomes, including symptoms of major depression, posttraumatic stress disorder(PTSD), and other psychosocial variables, as well as the Quick Disabilities of the Arm,Shoulder, and Hand (QuickDASH) results, after severe hand trauma. We hypothesizedthat hand trauma would have persistent psychological sequelae long after the physicalinjury.

Methods We performed a cross-sectional survey of 34 patients who had emergency handsurgery at a Level 1 trauma center an average of 16 months (range, 7–32 mo) earlier. Thehand disability measure was the QuickDASH, and the psychological measures included theCenter for Epidemiologic Studies Depression Scale, the Screen for Posttraumatic StressSymptoms, the Medical Outcomes Study Social Support Survey Form, the Social ConstraintsSurvey (to assess interpersonal stressors), and the Perceived Stress Scale.

Results The overall QuickDASH score was 27. The mean score for PTSD was 13 (above theclinical threshold for PTSD), and 29% of respondents had high levels of both depression andPTSD. High pain scores on the QuickDASH were strongly correlated with both depressionand PTSD symptoms.

Conclusions This study found high levels of psychological distress in patients after handtrauma. Hand disability was strongly related to pain, depression, and PTSD symptoms. Thisstudy shows that the psychological sequelae of hand trauma can persist long after thephysical injury. (J Hand Surg 2011;36A:1663–1668. Copyright © 2011 by the AmericanSociety for Surgery of the Hand. All rights reserved.)

Type of study/level of evidence Therapeutic IV.

Key words Chronic pain, depression, hand injury, posttraumatic stress disorders.

SEVERE HAND INJURIES are common and have alarge cost to the patient, their family, and soci-ety.1,2 In treating these injuries, hand surgeons’

goal is to return their patients to pre-injury life. The

From the Department of Surgery, Stanford University School of Medicine, Stanford, CA; National CenterforPTSD,VAPaloAltoHealthCareSystem,PaloAlto,CA;DepartmentofSurgery,VAPaloAltoHealthCareSystem, Palo Alto, CA.

Received for publication June 1, 2010; accepted in revised form June 27, 2011.

The views expressed in this article are those of the authors and do not necessarily represent the viewsof the Department of Veterans Affairs.

No benefits in any form have been received or will be received related directly or indirectly to the

©

main strategy to improve outcomes has been to refinesurgical techniques. However, an increasing body ofliterature advocates a more holistic treatment approach,and full recovery requires addressing more than the

Supported in part by a VHA Career Development Award (C.C.).

Corresponding author: Catherine Curtin, MD, 770 Welch Rd., Palo Alto, CA 94304; e-mail:curtincatherine@yahoo.com.

0363-5023/11/36A10-0015$36.00/0doi:10.1016/j.jhsa.2011.06.028

ASSH � Published by Elsevier, Inc. All rights reserved. � 1663

1664 CHRONIC SEQUELAE AFTER EMERGENT HAND SURGERY

damaged anatomy.3 For a truly successful result, thepatient must be returned to a functional state of bodyand mind.

Previous work suggests that psychosocial factorscorrelate more with pain and disability than with thephysical injury.4–6 Previous studies have assessed pa-tients shortly after hand injury.5,6 Little is known, how-ever, about how people adapt to their injuries over time.Humans are adaptable, and time is an important tool forany surgeon, but time alone might not heal all psycho-logical problems caused by hand injuries. It is importantto understand the characteristics of long-term sequelaeof hand trauma to help direct management in the acuteperiod.

The purpose of the present study was to assess thefunctioning of patients roughly a year after hand inju-ries that required operative intervention. The primarygoal was to assess their function using the Quick Dis-abilities of the Arm, Shoulder, and Hand (QuickDASH)score and psychological outcomes, including symptomsof major depression, posttraumatic stress disorder(PTSD), and other psychosocial variables. We hypoth-esized that there would continue to be a high burden ofpsychological distress even a year after injury. Oursecondary goal was to better understand the interrela-tionship of hand function, pain, psychological symp-toms, and social support.

METHODS

Subjects

This is a retrospective cross-sectional study of all pa-tients who had emergent hand surgery by 5 facultymembers at our university between 2003 and 2007.None of these treatments were performed electively orsemi-electively, and all were managed in the operatingroom. The survey was administered in 2008 to 104patients who met our inclusion criteria. Thirty-four ofthe 104 patients completed the survey, for a responserate of 33%. The type of injuries these surgeons coveredincluded complex soft tissue injuries of the forearm andany trauma of the carpus and hand. Exclusion criteriaincluded age under 18 or simple trauma that did notrequire treatment in the operating room. Our institu-tional review board approved all procedures, surveyswere de-identified, and need for formal written consentwas waived.

There were 34 participants who had a mean age of42 (SD, 14) and were predominantly men (85%). Themajority of participants were Caucasian (65%), fol-lowed by Hispanic/Latino (18%), Asian (6%), AfricanAmerican (6%), and other/mixed (6%). The most com-

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lowed by fractures–dislocations (29%), complex lacer-ations (27%), and infections (3%). The remainingparticipants (9%) had multifaceted injuries. The aver-age time since injury was 15 months (SD, 6) withdurations ranging from 7 to 32 months. There were nostatistical differences between responders and nonre-sponders for age (P � .48) or gender (P � .48).

Procedures

The survey was implemented with 3 points of contactthat included a pre-survey letter of intent to engage theparticipant, a follow-up letter for nonresponders, and afinal attempt at telephone contact for nonresponders.7

The survey consisted of basic background information,questions related to trauma recovery, and symptomsand ability to perform certain activities after the sur-gery. Depression, PTSD, and active efforts to acknowl-edge, understand, and express emotions were assessedfor the past week. Social support, social constraints, andperceived stress were assessed for the past month.

Measures

The QuickDASH was used to measure upper extremityphysical function and disability. The QuickDASH con-sists of 11 items from the original 30-item DASHquestionnaire and has similar reliability and correlationwith psychological stress as the full DASH question-naire.8 The scores range from 0 (best function) to 100(worst function).9 We chose the QuickDASH to de-crease the burden on respondents. Sub-scores were cal-culated for functional impairment (8 items, with a totalscore ranging from 0 to 32) and pain (3 items, with atotal score ranging from 0 to 12).

The Center for Epidemiologic Studies DepressionScale was used to measure symptoms of depression. Itis a 20-item, self-reported depression symptom scalethat has been shown to have high internal consistency,concurrent validity by clinical and self-report, andstrong evidence of construct validity.10 A score of 16 orhigher is commonly used as the cutoff for the clinicalrange for depressive symptoms.11

The Screen for Posttraumatic Stress Symptoms(SPTSS) is a 17-item instrument used to measure symp-toms of PTSD. The SPTSS was designed to be a brief,easily understood, self-report screening instrument forPTSD symptoms. It does not link symptoms to a singleevent and can be used with persons who report single,multiple, or no traumatic events. The SPTSS has beenfound to have internal consistency, concurrent validity,and construct validity.12 A score of 12 or higher hasbeen used as the cutoff for the clinical range for PTSD

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CHRONIC SEQUELAE AFTER EMERGENT HAND SURGERY 1665

The Medical Outcomes Study Social Support Surveyis a 19-item instrument used to measure emotional/informational, tangible, affectionate, and positive socialinteraction. It has been found to have internal consis-tency and has supported construct validity in a largesample of patients with chronic conditions.13

The Social Constraints Survey is a 15-item instru-ment used to measure communications from friendsand family that inhibit expression of thoughts and feel-ings related to the hand injury. It has been found to haveinternal consistency and convergent, predictive, anddiscriminate validity.14

The Perceived Stress Survey, 10-item version, wasused to measure the degree to which current life situa-tions are perceived as stressful. It has been found tohave internal consistency, reliability, and construct va-lidity.15

Each of the 34 survey respondents completed 100%of the included instruments. It is estimated that eachinstrument took approximately 10 to 15 minutes tocomplete, for a total of 60 to 90 minutes to complete theentire survey.

Statistical analysis

Descriptive analyses consisted of examining means andstandard deviations across measures. To analyze theassociation between disability and psychiatric and psy-chosocial variables, we used Pearson 2-tailed correla-tions.

RESULTSThe participants had an overall mean QuickDASHscore of 27, which is comparable to scores after minorsurgery such as carpal tunnel release8 and indicatesmild to moderate difficulty. However, the QuickDASHresults had a large standard deviation (SD, 25) withscores ranging from 0 to 89 (Table 1). The pain scoresof the QuickDASH had a mean pain level of 3 (SD, 3),which is congruent with a rating of mild on the painscale. The mean functional impairment score was 9(SD, 8), which falls between mild difficulty and mod-erate difficulty on the functional impairment scale.Functional impairment and pain scores did not differacross injury types (F � 0.2, nonsignificant [NS], andF � 0.1, NS).

The mean depression score was 13 (SD, 11), and thePTSD mean score was 13 (SD, 12). The PTSD meanscore was above the cutoff of 12 for clinically notewor-thy symptoms. Furthermore, 29% of participants met orexceeded the cutoff for clinically noteworthy symptomsfor both depression and PTSD. On average, par-

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support most of the time by their friends andfamily (mean, 75; SD, 19) and that they rarely feltsocially constrained (mean, 26; SD, 10). Partici-pants had elevated levels of perceived stress(mean, 16; SD, 8) when compared to a nonclinicalsample of adults aged 30 to 44 (mean, 13; SD, 6).16

Table 2 shows the correlations of functional impair-ment and pain scales with psychiatric and psychosocialvariables. Correlations were generally moderate to largein size and ranged from 0.31 to 0.74. Pain and func-tional impairment scales were also highly correlatedwith one another (r � 0.79). Symptoms of depressionand PTSD were highly correlated with functional im-pairment and pain scales, although the correlations with

TABLE 1. Responses to Functional andPsychological Measures

Measure n Mean SD Range

QuickDASH disability/symptom 34 27 25 0–89

QuickDASH work impairment 26 26 32 0–100

QuickDASH sports/performingarts impairment

23 41 40 0–100

Depression (CES-D)* 34 13 11 0–44

PTSD (SPTSS)† 34 13 12 0–58

CES-D, Center for Epidemiologic Studies Depression Scale.*The clinically significant cutoff for CES-D is 16.†The clinically significant cutoff for SPTSS is 12.

TABLE 2. Correlation of Psychiatric andPsychosocial Variables With FunctionalImpairment and Pain

FunctionalImpairment Pain

Psychiatric symptoms

Depression (CES-D) 0.69* 0.74*

PTSD (SPTSS) 0.60* 0.60*

Psychosocial variables

Social support (MOS) �0.31 �0.38†

Interpersonal stressors (SCS) 0.52* 0.46*

Perceived stress (PSS) 0.52* 0.61*

Pain 0.79* —

CES-D, Center for Epidemiologic Studies Depression Scale; MOS,Medical Outcomes Study; SCS, Social Constraints Survey; PSS,Perceived Stress Survey.

*P � .01.†P � .05.

depression were higher than with PTSD. There was no

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1666 CHRONIC SEQUELAE AFTER EMERGENT HAND SURGERY

association between the length of time since injury anddisability (r � 0.05, NS).

Social support was negatively associated with painbut not with functional impairment, indicating thathigher levels of social support were associated withlower levels of pain. Social constraints and perceivedstress were positively associated with functional impair-ment and pain. In Figure 1, we plotted pain scores withdepression and PTSD scores for each person. As seen inthis figure, most participants were experiencing lowlevels of pain and psychiatric symptoms (lower lefthand corner). However, of those participants who wereexperiencing elevated pain or elevated psychiatricsymptoms, many were experiencing both.

DISCUSSIONThis study found that a sizable proportion of our cohorthad pain and psychological distress after their handinjuries had healed. Psychosocial variables, on average,indicated that patients received adequate social supportbut also were experiencing elevated levels of perceivedstress (as shown by the perceived stress survey). Cor-relation analyses found relatively strong associationsbetween psychological and functional variables. Wefound that function, pain, and psychological distresswere interconnected, and this relationship persistedmany months after injury.

It is well established that the upper limb is particu-larly susceptible to the development of disproportionate

3020100

12

10

8

6

4

2

0

Psychiatric Sy

Pai

n

Symptom Elevation

FIGURE 1: Plot of pain versus depression and PTSD symptomStudies Depression Scale (CES-D) and SPTSS. The cutoff foraxis. An elevated score on the SPTSS is 12 or higher.

pain and disability, and in this study, some of our

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subjects had pain long after injury.17 Chronic pain pres-ents an enormous hurdle to surgical success due to itsimpact on the patient. Pain contributes to patient dissat-isfaction and increases health care system costs.18–21

Chronic pain is entwined with psychological health andcan contribute to depression and disability.22 Ring et alshowed that even pain from common hand ailmentssuch as carpal tunnel syndrome and de Quervain tendi-nitis correlates with disability and depression.23

Despite pain’s negative impact on recovery, sur-geons are often ill-equipped to treat the demands of achronic pain patient and often underrecognize and un-dertreat pain.24 This prolongs the patient’s pain, andmany believe that early recognition and aggressivetreatment can prevent the transition of acute pain tochronic pain.25 The Institute of Medicine has recog-nized that there have been systemic failures in adequaterecognition and treatment of pain.26 Pain is now man-dated as the fifth vital sign.20 There are also new licen-sure and medical education requirements dedicated topain management. We believe that first steps for handsurgeons to improve pain care would be a heightenedawareness and early initiation of treatment. Treatmentdoes not necessarily translate into increased opioids butis more an expansive approach using medications, ther-apy, and psychological support. At the most basic level,this would decrease the burden on our patients andmight decrease the progression to chronic pain.27

The psychological burden in the hand trauma popu-

6050ms

"Mild" Pain Level

DepressionPTSD

e x axis shows scores from both the Center for Epidemiologicficant depression16 on the CES-D is marked vertically on the x

40mpto

s. Thsigni

lation is also not appreciated by doctors.28 However,

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CHRONIC SEQUELAE AFTER EMERGENT HAND SURGERY 1667

psychological distress with hand injuries is not partic-ularly surprising, given the pivotal role of the handfunction. We found that disability correlated with psy-chological distress. This correlation between psycho-logical distress and poor DASH scores has been dem-onstrated for other common disorders such as carpaltunnel syndrome.23 Depression decreases health andwell-being and has been found to be the strongestpredictor of health status across diseases and cultures.29

A particularly concerning finding of this and otherstudies is the high rate of psychological distress wellbeyond the immediate postoperative and rehabilitationperiods.30 We found that 35% of our participantsshowed measures of depression compared to about 6%in the general U.S. population.32 Thirty-eight percent ofour subjects showed clinically significant levels ofPTSD symptoms, whereas only 13% of veterans return-ing from Afghanistan report high levels of PTSD symp-toms.31 These high rates of psychological distress indi-cate a need for action, as early psychologicalintervention might improve patient coping after handinjury.2

There are several limitations to this study. First, wehad a response rate of 33%, which means that we do nothave insight into the psychological and functional statesof the 67% who were nonresponders. There might besystematic differences among the nonresponders (theyare better or worse functioning) that we are missing. Across-sectional study such as this cannot determine thedirection of causality (whether the pain is causingPTSD or vice versa). We also did not stratify by injurytypes. Although all patients required emergent opera-tions, the cohort includes a spectrum of injuries fromflexor tenosynovitis to multiple digital amputations.Thus, we cannot state whether more severe injurieswere predictive of worse psychological outcomes. De-spite these limitations, if surgeons recognize and treatboth functional and psychological problems, more pa-tients might reach maximal comfort and ability.

Ideally, these complex facets of patient care could beaddressed by early use of a multidisciplinary team.However, the reality is that pain doctors and/or psychol-ogists might not be readily accessible. For the time inwhich a patient is awaiting specialist intervention, wehave a few recommendations for the surgeon. First, theVeterans Affairs system has a congressionally man-dated interest in the care of PTSD, which has resulted inresources being available for physicians and patients.For physicians, there is an information sheet for pro-viders caring for patients with PTSD at http://www.ptsd.va.gov/professional/pages/screening-and-

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http://www.ptsd.va.gov/public/index.asp, provides in-formation on PTSD, self-help, and, if necessary, re-sources for finding an appropriate psychological pro-vider. For pain, consideration of early use ofneuropathic pain medication in the postoperative pro-tocol should be added. Vitamin C after surgery hassome promise for decreasing the incidence of complexregional pain syndrome.32 Finally, if the patient is de-pressed, contacting the psychological provider to seewhether treatment could include a tricyclic antidepres-sant might have a secondary benefit of improvingpain.20 Ultimately, it would be optimal if methods weredeveloped to identify those with persisting pain and/orpsychological symptoms. Methods to accomplish thiswould be routinely assessing pain and psychologicalsymptoms at follow-up visits and developing methodsto identify those at high risk for pain and psychologicalsymptoms.

Hand surgeons should not be satisfied with repairingdamaged anatomy. It is clear that these patients can beaffected psychologically after their injuries. Surgeonsshould advocate for their patients to ensure that thenecessary pain and psychological treatments are avail-able in their own practices and nationally.

REFERENCES1. Dias JJ, Garcia-Elias M. Hand injury costs. Injury 2006;37:1071–

1077.2. Hoxie SC, Capo JA, Dennison DG, Shin AY. The economic impact

of electric saw injuries to the hand. J Hand Surg 2009;34A:886–889.3. Vranceanu AM, Barsky A, Ring D. Psychosocial aspects of disabling

musculoskeletal pain. J Bone Joint Surg 2009;91A:2014–2018.4. Grunert BK, Matloub HS, Sanger JR, Yousif NJ. Treatment of

posttraumatic stress disorder after work-related hand trauma. J HandSurg 1990;15A:511–515.

5. Grunert BK, Smith CJ, Devine CA, Fehring BA, Matloub HS,Sanger JR, et al. Early psychological aspects of severe hand injury.J Hand Surg 1988;13B:177–180.

6. Williams AE, Newman JT, Ozer K, Juarros A, Morgan SJ, Smith WR.Posttraumatic stress disorder and depression negatively impact generalhealth status after hand injury. J Hand Surg 2009;34A:515–522.

7. Dillman DA. Mail and telephone surveys: the total design method.New York: Wiley, 1978:375

8. Niekel MC, Lindenhovius AL, Watson JB, Vranceanu AM, Ring D.Correlation of DASH and QuickDASH with measures of psycho-logical distress. J Hand Surg 2009;34A:1499–1505.

9. Matsuzaki H, Narisawa H, Miwa H, Toishi S. Predicting functionalrecovery and return to work after mutilating hand injuries: usefulnessof Campbell’s Hand Injury Severity Score. J Hand Surg 2009;34A:880–885.

10. Radloff LS. The CES-D Scale: A self-report depression scale forresearch in the general population Appl Psychol Meas 1977;1:385–401.

11. Boyd JH, Weissman MM, Thompson WD, Myers JK. Screening fordepression in a community sample. Understanding the discrepanciesbetween depression symptom and diagnostic scales. Arch Gen Psy-chiatry 1982;39:1195–1200.

12. Carlson EB. Psychometric study of a brief screen for PTSD: assess-ing the impact of multiple traumatic events. Assessment 2001;8:

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1668 CHRONIC SEQUELAE AFTER EMERGENT HAND SURGERY

13. Sherbourne CD, Stewart AL. The MOS social support survey. SocSci Med 1991;32:705–714.

14. Lepore SJ, Silver RC, Wortman CB, Wayment HA. Social con-straints, intrusive thoughts, and depressive symptoms among be-reaved mothers. J Pers Soc Psychol 1996;70:271–282.

15. Cohen S, Kamarck T, Mermelstein R. A global measure of perceivedstress. J Health Soc Behav 1983;24:385–396.

16. Cohen S, Williamson GM. Perceived stress in a probability sampleof the United States. The Social Psychology of Health, NewburyPark, CA: Sage, 1988:31–67.

17. Puchalski P, Zyluk A. Complex regional pain syndrome type 1 afterfractures of the distal radius: a prospective study of the role ofpsychological factors. J Hand Surg 2005;30B:574–580.

18. Jensen MP, Chodroff MJ, Dworkin RH. The impact of neuropathicpain on health-related quality of life: review and implications. Neu-rology 2007;68:1178–1182.

19. O’Connor AB. Neuropathic pain: quality-of-life impact, costs andcost effectiveness of therapy. Pharmacoeconomics 2009;27:95–112.

20. Phillips DM. JCAHO pain management standards are unveiled. JointCommission on Accreditation of Healthcare Organizations. JAMA2000;284:428–429.

21. Sofaer-Bennett B, Walker J, Moore A, Lamberty J, Thorp T,O’Dwyer J. The social consequences for older people of neuropathicpain: a qualitative study. Pain Med 2007;8:263–270.

22. Jenewein J, Wittmann L, Moergeli H, Creutzig J, Schnyder U.Mutual influence of posttraumatic stress disorder symptoms andchronic pain among injured accident survivors: a longitudinal study.J Trauma Stress 2009;22:540–548.

23. Ring D, Kadzielski J, Fabian L, Zurakowski D, Malhotra LR, Jupiter

JHS �Vol A, O

JB. Self-reported upper extremity health status correlates withdepression. J Bone Joint Surg 2006;88A:1983–1988.

24. Deandrea S, Montanari M, Moja L, Apolone G. Prevalence ofundertreatment in cancer pain. A review of published literature. AnnOncol 2008;19:1985–1991.

25. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: riskfactors and prevention. Lancet 2006;367:1618–1625.

26. Institutes of Medicine NAP. Priority areas for national action: trans-forming healthcare quality. http://www.nap.edu/openbook.php?record_id�10593&page�42. February 10, 2010.

27. Perkins FM, Kehlet H. Chronic pain as an outcome of surgery. Areview of predictive factors. Anesthesiology 2000;93:1123–1133.

28. Magruder KM, Frueh BC, Knapp RG, Davis L, Hamner MB,Martin RH, et al. Prevalence of posttraumatic stress disorder inVeterans Affairs primary care clinics. Gen Hosp Psychiatry 2005;27:169 –179.

29. Moussavi S, Chatterji S, Verdes E, Tandon A, Patel V, Ustun B.Depression, chronic diseases, and decrements in health: results fromthe World Health Surveys. Lancet 2007;370:851–858.

30. Grunert BK, Devine CA, Matloub HS, Sanger JR, Yousif NJ,Anderson RC, et al. Psychological adjustment following work-related hand injury: 18-month follow-up. Ann Plast Surg 1992;29:537–542.

31. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, KoffmanRL. Combat duty in Iraq and Afghanistan, mental health problems,and barriers to care. N Engl J Med 2004;351:13–22.

32. Zollinger PE, Ellis ML, Unal H, Tuinebreijer WE. Clinical outcomeof cementless semi-constrained trapeziometacarpal arthroplasty, andpossible effect of vitamin C on the occurrence of complex regional

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