Recognizing Isolated Ulnar Fractures as Potential Markers for Intimate Partner Violence

Musculoskeletal injuries from gender-based violence at a tertiary hospital orthopaedic centre, central South Africa

INTRODUCTION

Limited research describing the pattern of orthopaedic musculoskeletal injuries among gender-based violence (GBV) victims has been conducted in South Africa. With the high prevalence of GBV in our locality, there is a need for healthcare workers to identify this vulnerable population for early management, intervention, and prevention of subsequent assaults. This study aimed to describe the pattern of musculoskeletal injuries resulting from physical assaults due to GBV.

METHODS

This retrospective analysis was conducted in the orthopaedic department of a tertiary hospital in South Africa. Medical records of GBV victims between 01 January 2021 and 31 December 2021, including adult males and females with acute musculoskeletal injuries, were analysed.

RESULTS

Of the 138 GBV victims, 92.7 % were female, with a median age of 32 (range 19-80). Most (66.7 %) were unemployed, while 63.8 % of cases occurred within intimate partner relationships. The predominant mechanism of injury was blunt force trauma (35.5 %), stab injuries (22.4 %), and fall from standing height (19.5 %). Men predominantly sustained soft tissue injuries (60.0 %), while women sustained upper limb fractures (53.9 %). Soft tissue injuries were noted in 34.1 % of victims, of which 23.3 % were lacerations. Just over half (51.5 %) of victims had upper limb fractures, and 19.6 % had lower limb fractures. A significant difference was found between gender and upper limb fractures (p = 0.0328). Isolated ulnar fracture was the predominant upper limb fracture (18.8 %). Males (70.0 %) and females (60.9 %) were predominantly injured between 16:00 and 00:00; 50.7 % of assaults occurred over weekends. Overall, 47.1 % reported alcohol use, which was strongly associated with female gender as 48.4 % of females reported its use either by themselves or their assailant, compared to 30.0 % of male victims (p = 0.026).

CONCLUSION

The pattern of musculoskeletal injuries in our study may be due to defensive manoeuvres from assaults, especially among female victims. This is worsened by the association between alcohol use and GBV and, therefore, underlines the importance of interventions to identify and protect this vulnerable population.

Providing Comprehensive Care Beyond the Broken Bones: Identification and Interventions for Survivors of Intimate Partner Violence

Intimate partner violence is common among orthopedic patients and leads to significant morbidity and mortality. The orthopedic surgeon may be the first contact a survivor has with the health care system and is in an important place to identify victims. By improving screening and identifying victims in the clinic, interventions that improve housing and safety can be established to improve the overall well-being of victims.

[Blunt force trauma in forensic radiology]

OBJECTIVE

Description of the main forensic radiological examination modalities and findings in blunt force trauma in living and deceased adults.

METHODS

Elaboration of the essential points based on the authors' own experiences and relevant literature.

RESULTS AND CONCLUSION

Injury-related consequences of blunt force are frequently observed in forensic radiological diagnostics, especially in the context of accidents and suicides, and less frequently in homicides. The method of choice for radiological imaging of blunt force in deceased persons is native postmortem computed tomography (PMCT). In principle, the radiological effects of blunt force in PMCT do not differ significantly from those in living persons. Postmortem magnetic resonance imaging (PMMRI) is very suitable for imaging blunt soft tissue injuries in the shorter postmortem interval. In the case of living individuals with the consequences of blunt force trauma, imaging is primarily indicated for clinical diagnostic reasons. Common indications are domestic violence, violence against the elderly, and disputes in public spaces. The choice of radiological examination method depends on the clinical history and symptoms, and the radiological examinations can be subjected to a forensic assessment.

Orthopaedic Injury Patterns in Intimate Partner Violence: Defensive Wounds and Fracture Patterns: A Systematic Literature Review

BACKGROUND

Intimate partner violence (IPV) is a prevalent issue in the United States, despite universal screening measures for women of reproductive age. Orthopaedic surgeons have a unique opportunity to intervene in cases of IPV as musculoskeletal injuries, including fractures, are the second most common type of injury seen in IPV patients. This systematic literature review aims to identify patterns in musculoskeletal injuries caused by IPV to increase identification of patients afflicted by IPV.

METHODS

A comprehensive search of PubMed, PsycINFO, and Web of Science yielded 316 articles. Included were cohort studies and literature reviews of patients with an IPV-associated orthopaedic injury. Excluded were case studies, perspective articles, material predating 2003, and studies with pediatric or elderly populations. Sixteen articles met criteria.

RESULTS

Data supported historical findings that musculoskeletal injury is the second most common injury in patients with IPV, with upper extremity fractures prevailing. Minimally displaced phalanges fractures were most common (9.9%-64%), and isolated ulnar fractures had significant relative risk of IPV association (8.5-12.8). Patients with multiple fractures of varying chronicity were more likely to be victims of IPV (sensitivity 25.2%, specificity 99.2%, positive predictive value 96.2%), and these chronic fractures matched patterns of acute injury caused by IPV. New findings in male victims included a higher proportion of lower extremity and pelvic fractures seen in male cohorts.

CONCLUSION

This study synthesizes evidence of IPV-related orthopaedic injuries, offering objective criteria for identifying victims. Despite limitations in fracture descriptions, the findings aid various physicians in recognizing IPV victims. Considering ongoing IPV prevalence and screening challenges, further research on injury patterns is recommended.

LEVEL OF EVIDENCE

Level III. See Instructions for Authors for a complete description of levels of evidence.

Evidence and best practices for trauma-informed care in gynecologic oncology patients

Diagnosing, treating, and managing gynecologic cancer can lead to significant physical and emotional stress, which may have lasting effects on a patient's overall health and quality of life. The physical symptoms of gynecologic cancer, such as pain, discomfort, and loss of function, may also contribute to emotional distress and anxiety. Further, the diagnosis, treatment, and surveillance of gynecologic cancer may be traumatic due to the need for invasive exams and procedures, especially in women with a history of sexual assault or other traumatic experiences.Women with gynecologic cancer may experience various emotional and psychological symptoms, including anxiety, depression, post-traumatic stress disorder, and fear of recurrence. Trauma-informed care is an approach to healthcare that emphasizes the recognition and response to the impact of trauma on a patient's life. Further, trauma-informed care acknowledges that prior traumatic experiences may affect a patient's mental and physical health and that the healthcare system may unintentionally re-traumatize patients.Implementation of trauma-informed care can improve patient outcomes, increase patient satisfaction with care, and reduce the risk of re-traumatization during cancer treatment and follow-up care. Therefore, gynecologic oncology providers should become familiar with the principles and practices of trauma-informed care and implement trauma-informed screening tools to identify patients who may benefit from additional support or referrals to mental health services. This review will explore the importance of trauma-informed care in patients with gynecologic cancer and its impact on outcomes. Further, we discuss principles and evidence-based practices of trauma-informed care and strategies to implement trauma-informed screening tools to identify patients who may benefit from additional support or referrals to mental health services.

DORIS study: domestic violence in orthopaedics, a prospective cohort study at a Swedish hospital on the annual prevalence of domestic violence in orthopaedic emergency care

BACKGROUND

Domestic violence (DV) is a major problem which despite many efforts persists globally. Victims of DV can present with various injuries, whereof musculoskeletal presentation is common.

OBJECTIVES

The DORIS study (Domestic violence in ORthopaedIcS) aimed to establish the annual prevalence of DV at an orthopaedic emergency department (ED) in Sweden.

DESIGN

Female adult patients with orthopaedic injuries seeking treatment at a tertiary orthopaedic centre between September 2021 and 2022 were screened during their ED visit.

SETTING

This is a single-centre study at a tertiary hospital in Sweden.

PARTICIPANTS

Adult female patients seeking care for acute orthopaedic injuries were eligible for the study. During the study period, 4192 female patients were provided with study forms and 1366 responded (32.5%).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was to establish the annual prevalence of injuries due to DV and second, to establish the rate of current experience of any type of DV.

RESULTS

One in 14 had experience of current DV (n=100, 7.5%) and 1 in 65 (n=21, 1.5%) had an injury due to DV.

CONCLUSIONS

The prevalence of DV found in the current study is comparable to international findings and adds to the growing body of evidence that it needs to be considered in clinical practice. It is important to raise awareness of DV, and frame strategies, as healthcare staff have a unique position to identify and offer intervention to DV victims.

Imaging of Intimate Partner Violence, From the AJR Special Series on Emergency Radiology

Intimate partner violence (IPV) is a highly prevalent public health issue with multiple adverse health effects. Radiologists are well suited to assessing a patient's likelihood of IPV. Recognition of common IPV injury mechanisms and resulting target and defensive injury patterns on imaging and understanding of differences between patients who have experienced IPV and those who have not with respect to use of imaging will aid radiologists in accurate IPV diagnosis. Target injuries often involve the face and neck as a result of blunt trauma or strangulation; defensive injuries often involve an extremity. Awareness of differences in injury patterns resulting from IPV-related and accidental trauma can aid radiologists in detecting a mismatch between the provided clinical history and imaging findings to support suspicion of IPV. Radiologists should consider all available current and prior imaging in assessing the likelihood of IPV; this process may be aided by machine learning methods. Even if correctly suspecting IPV on the basis of imaging, radiologists face challenges in acting on that suspicion, including appropriately documenting the findings, without compromising the patient's confidentiality and safety. However, through a multidisciplinary approach with appropriate support mechanisms, radiologists may serve as effective frontline physicians for raising suspicion of IPV.

Intimate Partner Violence in the Orthopaedic Patient Population: What Surgeons Need to Know

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Intimate partner violence (IPV) is under-reported and pervasive in the orthopaedic surgical setting.

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Screening programs that could increase reporting and assist in treatment and prevention are commonly underutilized.

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There is little formalized education during orthopaedic surgery training for IPV.

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The incidence of IPV continues to increase in the setting of recent stressors, such as COVID-19, and the orthopaedic surgeon should play a role in the screening and identification of patients presenting with IPV injuries and provide resources and referral.

Facial injury patterns in victims of intimate partner violence

Purpose

To evaluate the imaging findings of facial injuries in patients reporting intimate partner violence (IPV).

Methods

A retrospective review of radiology studies performed for 668 patients reporting IPV to our institution’s violence prevention support program identified 96 patients with 152 facial injuries. Demographics, imaging findings, and clinical data obtained from a review of the electronic medical records (EMR) were analyzed to categorize injury patterns.

Results

The study cohort consisted of 93 women and 3 men with a mean age of 35 years (range 19–76; median 32). At the time of presentation, 57 (59.3%) patients reported IPV as the mechanism of injury. The most frequent site of injury was the midface, seen in 65 (67.7%) patients. The most common fracture sites were the nasal bones (45/152, 29.6%), followed by the mandible (17/152, 11.1%), and orbits (16/152, 10.5%). Left-sided injuries were more common (90/152; 59.2%). A vast majority of fractures (94.5%) showed minimal or no displacement. Over one-third of injuries (60/152, 39.4%) demonstrated only soft tissue swelling or hematoma without fracture. Associated injuries were seen most frequently in the upper extremity, occurring synchronously in 11 (11.4%) patients, and preceding the index facial injury in 20 (21%) patients.

Conclusion

/advances in knowledge.

The midface was the most frequent location of injury in victims of intimate partner violence, and the nasal bone was the most commonly fractured facial bone. Recognizing these injury patterns can help radiologists suspect IPV and prompt them to discuss the possibility of IPV with the clinical providers.

Injury patterns and associated demographics of intimate partner violence in men presenting to U.S. emergency departments

Research suggests that there are differences between sexes in physical intimate partner violence (IPV) victimization that could lead to different injury patterns. In addition, research shows that men under-report their injuries yet may suffer grave consequences. It is, thus, vital to establish physical injury patterns in male IPV victims. A retrospective review of prospectively collected data was performed using the National Electronic Injury Surveillance System-All Injury Program data from 2005 to 2015 for all IPV-related injuries in both male and female patients. Sex differences by demographics, mechanism, anatomic location, and diagnoses of IPV injuries were analyzed using statistical methods accounting for the weighted stratified nature of the data. IPV accounted for 0.61% of all emergency department visits; 17.2% were in males and 82.8% in females. Male patients were older (36.1% vs. 16.8% over 60 years), more likely to be Black (40.5% vs. 28.8%), sustained more injuries due to cutting (28.1% vs. 3.5%), more lacerations (46.9% vs. 13.0%), more injuries to the upper extremity (25.8% vs. 14.1%), and fewer contusions/abrasions (30.1% vs. 49.0%), compared to female IPV patients (p < .0001). There were also more hospitalizations in men (7.9% vs. 3.7% p = .0002). Knowledge of specific IPV-related injury characteristics in men will enable healthcare providers to counteract underreporting of IPV.

Upper extremity fractures due to intimate partner violence versus accidental causes

PURPOSE

The purpose of this study is to evaluate the prevalence of intimate partner violence (IPV)-related upper extremity fractures (UEF) in women presenting to US emergency departments (ED) and compare their anatomic location to those due to accidental falls or strikes.

METHODS

An Institutional Review Board exempt, retrospective review of prospectively collected data was performed using the National Electronic Injury Surveillance System's All Injury Program data from 2005 through 2015 for all UEF sustained in women 15 to 54 years old. Injuries based on reported IPV versus accidental falls or strikes were analyzed accounting for the weighted, stratified nature of the data.

RESULTS

IPV-related UEF represented 1.7% of all UEF and 27.2% of all IPV fractures. The finger was the most common fracture site in IPV (34.3%) and accidental striking (53.3%) but accounted for only 10% of fall-related UEF. There was a higher proportion of shoulder fractures in IPV (9.2%) compared to accidental falls (7.4%) or strikes (2.9%). The odds of a finger fracture were 4.32 times greater in IPV than falling and of a shoulder fracture were 3.65 greater in IPV than accidental striking (p < 0.0001).

CONCLUSIONS

While the finger is the most common site for IPV UEF, it is also the most common location for accidental striking. A lower proportion of finger fractures in fall and of shoulder/forearm fractures in accidental striking should prompt the radiologist to discuss the possibility of IPV with the ED physician in any woman presenting with a finger fracture due to fall and a shoulder/forearm fracture with a vague history of accidental striking.

Intimate Partner Violence and Trauma-Informed Care in Pregnancy

Intimate partner violence is defined as any behavior within an intimate relationship that causes physical, psychological, or sexual harm to those in the relationship. Globally, women are disproportionately victims of intimate partner violence. The risk increases during pregnancy, with rates estimated as high as 20% among pregnant persons. Intimate partner violence is associated with adverse perinatal outcomes, including perinatal and maternal death. As pregnancy is a period of frequent interaction with the healthcare system, it is an opportune time to screen and intervene for intimate partner violence. Universal screening at the first prenatal visit and subsequently every trimester is recommended, with either written or verbal validated tools. Pregnant persons experiencing intimate partner violence need nonjudgmental, compassionate, confidential and trauma-informed care. The goal of this review is to outline pregnancy-specific care considerations.

Longitudinal imaging history in early identification of intimate partner violence

OBJECTIVES

To describe the imaging findings of intimate partner violence (IPV)-related injury and to evaluate the role of longitudinal imaging review in detecting IPV.

METHODS

Radiology studies were reviewed in chronological order and IPV-related injuries were recorded among 400 victims of any type of abuse (group 1) and 288 of physical abuse (group 2) from January 2013 to June 2018. The likelihood of IPV was assessed as low/moderate/high based on the review of (1) current and prior anatomically related studies only and (2) longitudinal imaging history consisting of all prior studies. The first radiological study date with moderate/high suspicion was compared to the self-reported date by the victim.

RESULTS

A total of 135 victims (33.8%) in group 1 and 144 victims (50%) in group 2 demonstrated IPV-related injuries. Musculoskeletal injury was most common (58.2% and 44.5% in groups 1 and 2, respectively; most commonly lower/upper extremity fractures), followed by neurologic injury (20.9% and 32.9% in groups 1 and 2, respectively; most commonly facial injury). With longitudinal imaging history, radiologists were able to identify IPV in 31% of group 1 and 46.5% of group 2 patients. Amongst these patients, earlier identification by radiologists was provided compared to the self-reported date in 62.3% of group 1 (median, 64 months) and in 52.6% of group 2 (median, 69.3 months).

CONCLUSIONS

Musculoskeletal and neurological injuries were the most common IPV-related injuries. Knowledge of common injuries and longitudinal imaging history may help IPV identification when victims are not forthcoming.

KEY POINTS

• Musculoskeletal injuries were the most common type of IPV-related injury, followed by neurological injuries. • With longitudinal imaging history, radiologists were able to better raise the suspicion of IPV compared to the selective review of anatomically related studies only. • With longitudinal imaging history, radiologists were able to identify IPV earlier than the self-reported date by a median of 64 months in any type of abuse, and a median of 69.3 months in physical abuse.