Although most orthopaedic surgeons are aware of and actively look for warning signs of child abuse and non-accidental injury in children, the same cannot be said about their encounters with victims of intimate partner violence (IPV). It is estimated that 30% to 55% of female homicides are due to IPV compared with 5% of male homicides and that the majority of these victims have had an encounter with public services, including health services, in the year preceding their death1. Recent epidemiological studies in this area have shown that musculoskeletal injuries are second only to head and neck injuries in victims of IPV2. This means that many of these victims may have had an encounter with an orthopaedic surgeon in either the emergency room or a fracture clinic. Unfortunately, these encounters are unlikely to have resulted in any preventive action through referral to an appropriate victim support social service. A survey of members of the Orthopaedic Trauma Association revealed some astonishing results when it comes to awareness of and attitudes toward IPV. These results included orthopaedic surgeons’ misconceptions that the victim is benefiting from the abusive relationship, the victim has an abuse-inducing personality, and the violence would stop if the abusive partner stopped drinking alcohol3. Only 4% of respondents screened for IPV in female patients. The actual percentage in the profession at large is likely to be much lower. Exemplifying the increased interest in this area, a number of epidemiological studies using large data sets and specialized clinical studies attempted to identify musculoskeletal injury types that are more common in IPV victims4.
In their article, Madden et al. examine the risk of IPV to women during the first year of recovery from a musculoskeletal injury. This multicenter study, conducted in 4 countries in North America and Europe, uncovers some alarming statistics. One-third of women presenting to one of these fracture clinics reported a history of IPV, and 12.4% of women who did not report IPV at the initial visit reported experiencing IPV during the study period. Women disclosing a history of IPV also had a lower likelihood of recovering to pre-injury functional levels, a lower health-related quality of life at 6 months, and lower EuroQol-5 Dimensions (EQ-5D) Function Index scores at 12 months, even though they did not have an increased rate of injury-related complications. The authors argue that the altered relationship dynamics during recovery from musculoskeletal injuries places these women at increased risk for IPV. Although the study was designed as an exploratory project, it has many strengths, including most prominently its adequately powered prospective design and the variety of geographical, cultural, and socioeconomic settings. This study’s use of validated tools and outcome measures underlies its robustness. The authors are to be commended for objectively highlighting some of the limitations. Another concern is the required voluntary nature of participation, which is a potential source of self-selection bias. Also, the direct questioning of the patients is very different from routine clinical practice. The exclusive focus on female participants is another limitation5. The study centers are all located in developed countries with relatively similar cultural and socioeconomic values, which limits the global applicability of the study’s conclusions.
Nevertheless, given the social and professional facts detailed earlier, the study’s findings have important implications for patients, orthopaedic practice, and health-care services. The study presents a previously unknown fact that even women with no previous IPV experience are at an increased risk for IPV during their recovery from a musculoskeletal injury. As most patients are unlikely to volunteer a history of IPV, fracture clinics need to be optimized to uncover this history when there is suspicion of IPV. Mitigation of the risk of further IPV through the establishment of appropriate and supportive measures is necessary. These patients are also likely to need more intensive rehabilitation with closer follow-up in view of their lower functional recovery. Orthopaedic educational programs need to be modernized by incorporating the association between IPV and musculoskeletal injuries to increase awareness and train clinicians to look for relevant warning symptoms and signs. Finally, as emphasized by the investigators, more qualitative and quantitative research in this area is needed.
1. Campbell JC. Helping women understand their risk in situations of intimate partner violence. J Interpers Violence. 2004 Dec;19(12):1464-1-2.
2. 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 Dec;61(6):1473-1-2.
3. Della Rocca GJ, Sprague S, Dosanjh S, Schemitsch EH, Bhandari M. Orthopaedic surgeons’ knowledge and misconceptions in the identification of intimate partner violence against women. Clin Orthop Relat Res. 2013 Apr;471(4):1074-1-2.
4. Loder RT, Momper L. Demographics and fracture patterns of patients presenting to US emergency departments for intimate partner violence. J Am Acad Orthop Surg Glob Res Rev. 2020 Feb 18;4(2):e20.00009.
5. Downie S, Kanya I, Madden K, Bhandari M, Jariwala AC. Intimate partner violence (IPV) in male and female orthopaedic trauma patients: a multicentre, cross-sectional prevalence study. BMJ Open. 2021 Aug 24;11(8):e046164.