In our study, the sleep disorder is both common (51.4% PSQI > 5) and serious (15.4% PSQI > 10) in patients who suffered from acute traumatic orthopaedic injury. Muscatelli revealed the incidence of depression and PTSD in patients with acute orthopedic trauma through a systematic review which included 7109 subjects in the analysis. They confirmed that in patients with acute orthopedic trauma, the weighted combined prevalence of depression and PTSD was 16.8%. By comparing the results of our study with the data of this study, it can be shown that the proportion of patients with severe sleep disorders is similar to the incidence of PTSD and depression. Some literature showed that sleep disorders are closely related to PTSD and depression[1, 2], So we have reason to believe that severe sleep disorders are associated with PTSD and depression. At the same time, the PSQI score > 10 could be regarded as an important indicator for predicting PTSD in patients of acute orthopeadic trauma.
One interesting thing we found is that the VAS score of physical pain is not correlated with sleep quality in our research results. Besides, the average VAS score was 2.3 ± 1. 0. It’s a low level score. This is inconsistent with our previous experience, and the literatures also pointed out that pain is closely associated with poor sleep quality[21, 22]. To solve this problem, we checked relevant medical records of the inpatient department and emergency department. we found that the treatment of preemptive and multimodal analgesia is often arranged in patients of orthopedic trauma before the patient is hospitalized. Meanwhile, Preemptive and multimodal analgesia therapy had been proven to improve the patient's own feelings of patients in hospital and accelerate recovery. When the patient’s pain was been controlled,the incidence of sleep disorder in this study was still highly prevalent. Therefore, orthopedic physicians should realize that merely controlling physical pain cannot significantly improve the quality of sleep of patients. They also need to pay attention to the psychological problems of patients after trauma.
We recognize that poor sleep quality is independently related to physical disability[6, 7]. At the same time, sleep disorders may also be a core feature of PTSD. Therefore, comprehensive physical-psychological management is essential for patients with acute orthopedic trauma. We need to identify patients with sleep disorders early and treat them as soon as possible, which is of great significance for the accelerated recovery of patients.
Among the demographic indicators, we selected age, gender, marital status and education to perform univariate linear regression analysis with PQSI scores. A multi-center cross-sectional cohort study of 4399 outpatients including showed that the incidence of sleep disorder is different between men and women in China. In this study, women had a higher incidence of sleep disorders than men. At the same time, for women, sleep disorders are highly correlated with marital status, and women who are divorced or widowed are more likely to suffer from sleep disorder. For men, sleep disorders are associated with lower education levels. Similar results were obtained in our research. In univariate regression, females and low education level are associated with poor sleep quality, but marital status is not related to sleep quality. After eliminating the confounding factors among multiple factors, only gender is independently related to sleep disorder. This suggests that sleep disorder in patients with acute orthopedic trauma are still unique compared to the overall population. The company of relatives and a high level of education may help stabilize the patient’s mood and sleep quality, but our results showed that these help patients are limited. Necessary psychotherapy is still critical for patients who suffered from sleep loss especially female patients.
Besides,we found that the activities of daily living and the severity of trauma have a significant impact on the patient’s sleep quality in our study. Most orthopeadic truama patients (71.2%) were severe dependence even if they have suffered mild injury(81.8% patients were mild injury). Most orthopedic patients have a certain degree of loss of limb function. Even if the injury is minor, they still cannot complete some normal daily activities, such as getting out of bed, combing hair, washing face, etc. There was no related literature has been found to prove that ADL in orthopedic trauma patients is directly related to sleep quality,However, there is literature to explain and illustrate the activities of daily living decline may lead to patients with depression and sleep disorder. We still need stronger evidence to prove the relationship between ADL and sleep disorders. At the same time, we observed that the severity of trauma is independently related to sleep quality. In the orthopedic ward of our trauma center, in addition to the patients in this city, we also accepted critically ill patients from other cities in Southwest China. Therefore, there was a sufficient number of patients with multiple injuries to be included in the study who suffered severe injury. These patients have higher ISS scores and worse sleep quality. In the results of a study, ISS score of orthopeadic trauma patients was positively correlated with somatic anxiety. A higher degree of anxiety seriously affects the patient’s sleep quality, leading to sleep disorder. There is also literature that shows that the severity of trauma is not related to sleep quality. This result may be related to the low proportion of patients with multiple injuries included in this study. This requires prospective cohort studies to further confirm the relationship between trauma severity and sleep quality.
The biggest limitation of our study is the retrospective cross-sectional case analysis. All data came from the nurse's assessment of the patient's admission. The sleep quality assessment also comes from clinical nurses rather than professional investigators. This cannot guarantee the consistency of the assessment. At the same time, the ISS score lacks precise numerical values, only grade evaluation, so the statistical validity is not enough.Finally, we only collected data from a single level 1 trauma center. We still need prospective comparative studies to further clarify the impact of relevant risk factors on patients' sleep quality, so as to establish clinical prevention methods.