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Domestic violence related fractures: Orthopedists may be the first to see the signs
Study suggests that surgeons, health care personnel in fracture clinics should consider intimate partner violence when interacting with injured women
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Introduction
For much of my career, I never included domestic violence in my differential as the cause of the musculoskeletal injuries I was treating. I always accepted what the patient said if it seemed plausible. Through public education, I have come to realize the frequency of domestic and intimate partner violence was more common then I had suspected.
As orthopedic surgeons, we are in a position to offer assistance. If we make our female patients comfortable and give them the chance to confide in us, we can screen for injuries resulting from domestic violence. To give us more insight into the correlation between some domestic violence and abuse and traumatic injuries treated by orthopedists, I have asked Mohit Bhandari, MD, FRCSC,4 Questions based upon some recent work his group has performed and published in the Journal of Bone and Joint Surgery. Hopefully, this month’s interview will stimulate you to be more observant of your patients’ injuries and even to get involved in the programs at your hospital in your communities.
Douglas W. Jackson, MD
Chief Medical Editor
Douglas W. Jackson, MD: What was the background information that prompted you and your co-investigators to look at domestic violence and fractures being evaluated and treated?
Mohit Bhandari, MD, FRCSC: The idea for moving in this area of inquiry came in 2004 from Sonia Dosanjh, a social worker working at the Minneapolis-based Domestic Abuse Project. This initial collaboration led to the development of the Violence Against Women Health Research Collaborative and our initial study published in the Journal of Trauma suggested that sprains, dislocations, fractures, and foot injuries accounted for 28% of all clinical manifestations of abuse among women who were identified over a 2-year period by the Minneapolis Domestic Abuse Program. Further, advocacy within the Canadian Orthopaedic Association (COA) led to the formulation of the COA’s official recommendations on intimate partner violence. The COA in its position statement recognized that intimate partner violence is a significant social determinant of morbidity and mortality, and that orthopedic surgeons are well positioned to identify patients living with this type of violence and can initiate an intervention.
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The COA encouraged its members to educate themselves further about intimate partner violence and considers it good medical practice to take steps to identify and offer assistance to its victims. As a direct result of the recommendations, we conducted a prospective pilot in two Canadian fracture clinics to confirm — or refute — previous estimates of domestic violence among injured women presenting to such clinics.
Jackson: What was your study group population and what were reasons for ineligibility to be included in the investigation?
Bhandari: Six-hundred and ninety patients were screened for participation in this study and 295 patients were deemed ineligible. Of the 395 patients who met our eligibility criteria, 113 did not provide informed consent. Two-hundred and eighty-two patients met the inclusion criteria and completed all or part of the questionnaire and were included in our analyses.
Jackson: What were your results and conclusions?
Bhandari: The overall prevalence of intimate partner violence, including emotional, physical, and sexual abuse, within the last 12 months was 32% (95% CI 26.4% to 37.2%). One in 12 injured women disclosed a history of physical abuse (24/282, 8.5%) in the past year. Seven women (2.5%) indicated the cause for their current visit was directly related to physical abuse. Ethnicity, socioeconomic status, or injury patterns were associated with abuse. Of 24 women with physical injuries, only four had been asked about intimate partner violence by a physician, none of whom were their treating orthopedic surgeons.
Our study suggests a high prevalence of intimate partner violence among female patients with injuries attending two orthopedic surgical clinics in Ontario. Surgeons and health care personnel in fracture clinics should consider intimate partner violence when interacting with injured women.
Jackson: What programs have been instituted and what advice can you offer to orthopedic surgeons treating female fracture patients?
Bhandari: Our work has led to the Prevalence of Abuse and Intimate Partner Violence Surgical Evaluation (PRAISE) multinational cohort study, which is currently recruiting, to ensure validity of our Ontario pilot findings. Locally, we are working with experts to continue to improve awareness of domestic violence issues among orthopedic surgeons managing injured women. We continue to reinforce the message that surgeons, above emergency physicians, have real opportunity to screen for domestic violence because they often develop trusting relationships with women through their follow-up visits. Simply understanding that a surgeon is open to receive information about domestic violence may be the critical first step towards a victim’s decision to disclose.
Reference:
- Bhandari M, et al. The prevalence of intimate partner violence across orthopaedic fracture clinics in Ontario. J Bone Joint Surg (Am). 2011;93(2):132-141.
- Mohit Bhandari, MD, FRCSC, can be reached at Department of Surgery, McMaster University, 293 Wellington Street North, Suite 110, Hamilton, ON L8L 8E7, Canada: e-mail: bhandam@mcmaster.ca.
