The Hidden Injury: Behavioral Health's Role in Pediatric Orthopaedic Outcomes-A Systematic Review

The psychological toll of injuries in youth athletes is often overlooked, even while these injuries continue to increase in incidence. Research exploring the role that psychology plays in recovery from these injuries demonstrates that not addressing them can be detrimental to return-to-sport and postoperative outcomes. There are limited studies investigating these questions and the role that integrated care pathways can play in optimizing these outcomes in pediatric athletes undergoing orthopaedic surgeries.

A systematic review of PubMed, Cochrane, and Ovid MEDLINE was done using the following search string: (pediatric OR child OR adolescent) AND (orthopedic OR orthopaedic OR musculoskeletal OR fracture OR injury OR surgery) AND (psychological OR "mental health" OR anxiety OR depression OR coping OR resilience) AND (recovery OR rehabilitation OR "treatment outcome" OR "return to sport" OR healing). Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were utilized to structure our search. Inclusion criteria included: articles published in English, articles of studies or reviews assessing the role of psychiatric and psychological factors in orthopaedic conditions. Exclusion criteria included: articles not published in English, concussion-related and traumatic brain injury-related articles, and other articles unrelated to the search criteria. Outcomes assessed included study type, condition studied, outcomes collected and relevant findings.

A total of 197 articles were included in the final analysis. Across clinical and experimental studies, commonly studied conditions were anterior cruciate ligament injuries, general athletic/sport injuries, and adolescent idiopathic scoliosis. Multiple articles addressed the emotional distress that occurs with injury and the potential negative implications that can occur if the psychological aspect of injury is not managed properly. Studied groups varied between pediatric, adolescent, adult and mixed populations, with variation in definitions of these terms.

Behavioral health clinicians, including sports psychologists and sports psychiatrists, may be beneficial for high-risk athletes to improve outcomes. It is important to be able to discuss psychological aspects of sports injury with patients and their families, identify at-risk athletes, and offer timely interventions to optimize their care. Future directions to integrate psychological care into pediatric orthopaedic surgical care include the development of multidisciplinary clinics that have both orthopaedic and behavioral health care services available to patients, standardized behavioral health screenings, and increased awareness of the implications of untreated psychological distress in these patients.

Level III.