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Intimate Partner Violence and the Orthopaedic Surgeon
A Call for Action
Mohit Bhandari, M.D.,FRCSC
Brad Petrisor, M.D., FRCSC
Jaydeep K. Moro, M.D., FRCSC
Krishan Rajaratnam, M.D., FRCSC
Emil H. Schemitsch, M.D., FRCSC*
Division of Orthopaedic Surgery,
McMaster University and *University of Toronto
What is Intimate Partner Violence?
Intimate partner violence, or domestic violence, is a pattern of assaultive and coercive behaviors, including physical, sexual, and psychological attacks as well as economic coercion that men or women typically use against partners.
The Impact
Injuries are the leading cause of death for females one to 34 years old, and a major source of preventable morbidity and mortality in middle-aged and elderly women1,2. In the United States, 43,000 women die from injuries and approximately one million women are hospitalized for injuries annually1,2. The lifetime cost of injuries to females is approximately 50 billion dollars annually1,2. Domestic violence is the most common cause of nonfatal injury to women in the United States1,2. Over four of ten women in the U.S. are likely to have experienced one or more forms of violence, including child abuse (17.8%), physical assault (19.1%), rape (20.4%), and intimate partner violence (34.6%)3.
What are the Common Injuries?
In a review of women presenting to a Minneapolis-based therapy and advocacy programme for victims of intimate partner violence, investigators identified 144 injuries in 218 physically abused women4. Head and neck injuries were the most prevalent following intimate partner violence (40%). Musculoskeletal injuries were the second most common manifestation of intimate partner violence (28%). The spectrum of injuries included sprains (N=21 injuries), fracture/dislocations (N=17 injuries) and foot injuries (N=2 injuries) - all of which would have necessitated referral to an orthopaedic surgeon4.
The Health Care Setting
Health care providers of all specialties are in a unique position to identify and assist victims of intimate partner violence during routine or annual office visits. The prevalence of intimate partner violence in women presenting to emergency departments has been reported to range from 14 to 41%5; however, only 12-17% of abused women have their experiences documented in a medical chart5. Women who have experienced intimate partner violence are seldom identified by emergency department physicians5. To our knowledge, there have been no reports of the incidence of intimate partner violence among women attending orthopaedic fracture and injury clinics. The attitudes of orthopaedic surgeons about intimate partner violence remains largely unknown.
Orthopaedic Surgeons (Mis)perceptions about Intimate Partner Violence
A recent survey of 186 Canadian orthopaedic surgeons (91% male) revealed several important misperceptions about intimate partner violence6. Almost all orthopaedic surgeons estimated that victims of intimate partner violence comprised less than 10% of their patients, the majority of whom (80% surgeons) believed it was exceedingly rare (<1% prevalence). The concept of mandatory screening for intimate partner violence was met with uncertainty by 64% of surgeons. Misconceptions were perpetuated by surgeons who believed that inquiring about intimate partner violence was an invasion of the victim's privacy, investigating intimate partner violence was not part of their duty, victims choose to be a victim, and that victims play a proactive role in causing their abuse. The majority of surgeons (91%) realized that that knowledge about intimate partner violence was relevant to their surgical practice.
 A Vital Opportunity
Given the infrequency of intimate partner violence identification by emergency or primary care physicians, orthopaedic surgeons, and orthopaedic clinic personnel have a second opportunity to identify and provide necessary referral to a local agency or hospital service. Several specialty associations including the American Medical Association, the American College of Obstetrics and Gynecology, the American Academy of Pediatrics, the American College of Emergency Physicians and the US Centers for Disease Control and Prevention have advocated screening for intimate partner violence (Table 1). The American Academy of Orthopaedic Surgeons recommends that "Orthopaedic surgeons should be aware of how harm from domestic violence and abuse may present to them".
The Canadian Task Force on Preventive Health Care, in a systematic review of published interventions for intimate partner violence, concluded insufficient evidence to recommend routine screening for violence against women; however, they recommended that physicians should be aware of the signs and symptoms of abuse and may wish to ask about exposure and women's experiences with it during their examination.
Table 1: Current Positions of Various Organizations
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Institution
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American Academy of Orthopaedic Surgeons
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"Orthopaedic surgeons should be aware of how harm from domestic violence and abuse may present to them."
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American Academy of Pediatrics
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"Pediatricians should attempt to recognize evidence of family or intimate partner violence in the office setting;... intervene in a sensitive and skillful manner that maximizes the safety of women and children victims; and... support local and national multidisciplinary efforts to recognize, treat and prevent family and intimate partner violence."
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American College of Emergency Physicians
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"[T]raining in the evaluation and management of victims of domestic violence should be incorporated into the initial and continuing education of EMS personnel. This training should include the recognition of victims and their injuries, an understanding of the patterns of abuse and how this affects care, scene safety, preservation of evidence, and documentation requirements."
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American College of Surgeons
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"Surgeons are encouraged to take a leadership role in their communities, hospitals, and medical schools in preventing and treating domestic violence."
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American Medical Association
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"The American Medical Association believes that all forms of family and intimate partner violence are major public health issues and urges the profession, both individually and collectively, to work with other interested parties to prevent such violence and to address the needs of victims."
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A Call for Action: The Canadian Orthopaedic Association and Intimate Partner Violence
Currently, the Canadian Orthopaedic Association provides no position statement on the role of Canadian orthopaedic surgeons in the identification or management of victims of intimate partner violence. Consistent with Canada's history of leadership in orthopaedic surgery, and the COA's guiding role in our vision and education, we recommend increased focus on intimate partner violence. Most importantly, it is the responsibility of every orthopaedic surgeon to empower themselves with knowledge and understanding of existing literature and guides to identification and appropriate management of victims of intimate partner violence. Let Canadian orthopaedic surgeons lead the way to advancing the safety and care of abused women in their practices.
A symposium on intimate partner violence, moderated by Dr. Bhandari, will be held during the COA Annual Meeting in Whistler, BC on Saturday, July 4. See www.coaannualmeeting.org for scheduling.
References
- Kyriacou D.N., Anglin D., Taliaferro E., Stone S., Tubb T., Linden J.A., Muelleman R., Barton E., Kraus J.F. Risk factors for injury to women from domestic violence against women. N Engl J Med. 1999;341:1892-8.
- Dannenberg A.L., Baker S.P., Li G. Intentional and unintentional injuries in women. An overview. Ann Epidemiol. 1994;4:133-9
- Plichta S.B., Falik M. Prevalence of violence and its implications for women's health. Womens Health Issues. 2001;11:244-58.
- Bhandari M., Dosanjh S., Tornetta P. 3rd, Matthews D.; Violence Against Women Health Research Collaborative. Musculoskeletal manifestations of physical abuse after intimate partner violence. J Trauma. 2006;61:1473-9.
- Dearwater S.R., Coben J.H., Campbell J.C., Nah G., Glass N., McLoughlin E., Bekemeier B. Prevalence of intimate partner abuse in women treated at community hospital emergency departments. JAMA. 1998;280:433-8.
- Bhandari M., Sprague S., Tornetta P. 3rd, D'Aurora V., Schemitsch E., Shearer H., Brink O., Mathews D., Dosanjh S.; Violence Against Women Health Research Collaborative. (Mis)perceptions about intimate partner violence in women presenting for orthopaedic care: a survey of Canadian orthopaedic surgeons. J Bone Joint Surg Am. 2008;90:1590-7
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