The orthopaedic surgeon and post-traumatic psychopathology.

An orthopaedic surgeon working in fracture clinics will be aware of the differences in the demeanor of some patients and of the apparent difference between the speed of recovery of those who face their injuries objectively compared with others who remain introspective and unhappy. The boundary between a normal psychological response to trauma and the pathological reaction is often difficult to recognise. It has been increasingly appreciated that posttraumatic psychological morbidity, including post-traumatic stress disorder (PTSD), is not confined to combat veterans and those affected by major civil accidents, but can also affect victims of road-traffic accidents (RTAs), assaults, and accidents in the workplace. The diagnosis of PTSD was first defined in the Diagnostic and statistical manual of psychiatric disorders in the aftermath of the Vietnam War. Although its definition was an important milestone, the term is often loosely used to cover a range of post-traumatic psychopathological conditions. It is recognisable in the soldiers with ‘shell shock’ in the Great War, in the diaries of Samuel Pepys after the Great Fire of London, and in the psychological morbidity found in survivors of the Nazi holocaust. It is easy to see how such severe stressors can lead to psychological disturbance, but it is also important to recognise that 10% to 20% of victims of RTAs will have a major PTSD, with an estimated lifetime prevalence of 1% to 9%. Despite the high level of occurrence of such psychopathology a recent study of medical and nursing staff in hospital trauma units revealed a poor understanding of acute and chronic psychiatric reactions to trauma and their management. Aetiology and pathogenesis