How can we better spot and manage Orthopaedic injuries as a result of abuse?

This essay was submitted to the University of Birmingham Trauma and Orthopaedics Society National Undergraduate Essay Competition on 30/3/21

Orthopaedic injuries can often arise from abuse, whether from intimate partner violence (IPV), child or elderly abuse. This is a serious public health problem that needs to be better managed and prevented. Though there are similarities in the identification and management of orthopaedic injuries across the types of domestic abuse, they can still result in differing presentations and consequently, management strategies differ.


Orthopaedic injuries as a result of abuse can be recognized with a careful history, physical examination, and radiographic examination. Recognition of abuse is the most critical component in ensuring its effective management and treatment. Patients with orthopaedic abuse injuries will normally present at the clinic or emergency room, giving doctors the opportunity to identify signs of abuse and intervene, preventing their escalation.1


Taking a good patient history and providing clear documentation of it in this situation is critical. A history that is vague with contradictory statements provided by a parent/ partner/ caregiver, a mechanism of injury with an unexplained fracture type, an inconsistent/ lack of injury history, an unwitnessed mechanism and/or a delay of more than 24 hours in seeking care, should raise suspicions towards abuse.2,3 Careful documentation is essential to provide the best overall and long-term care possible for the patient and in aiding any potential legal action.4


When abuse is suspected, a physical examination of the entire body should follow. The skin should be examined closely, as bruising can be a tell-tale sign of abuse (present in 50-75% of victims).5 To promptly identify abuse, healthcare professionals should be aware of the orthopaedic injury patterns in the different groups. In children, skeletal fractures are a common presenting sign and radiographic finding. In particular, children younger than 3 who present with skeletal fractures should be evaluated, as this does not correspond to their developmental stage.1 In a meta-analysis of IPV, head, neck or facial injuries were the most common, with women likely to have multiple injuries.6 Among the elderly, bruising in atypical locations, patterned injuries, wrist or ankle lesions could suggest abuse.4 Importantly, bruising or fractures which are at different stages of healing, indicate continuous abuse rather than a single accident. As an example, multiple fractures at different stages of healing are present in 70% of abused infants.7 Although there are suspicious fractures and locations which may indicate abuse, there is no fracture type or location specific to physical abuse. A careful history and physical examination are more effective as compared to searching for high-specificity indicators of abuse such as corner fractures.8 It’s vital that healthcare professionals keep up to date with the tell-tale signs of abuse, so that appropriate action can be swiftly taken.


A radiographic skeletal survey is the primary imaging tool for detecting and evaluating fractures. They should be performed on all children under 2 years with clinical suspicion of abuse and preferably on siblings and household contacts as well. During screening, it’s important to provide the radiologist with a detailed description of the clinical scenario, to improve the identification of a potential mismatch between the injury and its reported mechanism. Collaboration within the medical team is thus cardinal.


In order for such red flags to be readily recognised, universal screening using a standardised tool at all trauma centres and hospitals would be ideal, as abuse regularly goes unnoticed.4 Alternatively, non-voluntary presentation of patients to trauma centres represents an opportunity to screen patients and initiate intervention strategies. Among female victims of IPV identified in police databases, 64% received emergency care in the year before the reported assault, and the majority of victims had multiple prior visits for non-injury related complaints.4 Instances like these would have given healthcare professionals opportunities to screen for IPV. Additionally, since a third of abuse victims sustain musculoskeletal injuries, fracture clinics can also screen for signs of abuse.9 Elderly abuse amongst nursing home residents is also common. Regular screening can help identify this and prevent its associated poor medical outcomes such as higher mortality rates.10 Healthcare professionals involved in these areas should always be on the alert to identify victims, breaking cycles of abuse and decreasing associated orthopaedic injuries.


To enable effective identification of abuse, more training programs are needed to better educate healthcare professionals on what to look out for. Paediatric training programs provide more training in child abuse than emergency medicine, family medicine and, very likely, orthopaedic programs11, even though trauma and orthopaedic doctors may encounter just as many instances of abuse. In order for orthopaedic doctors to effectively manage abuse, it’s important for them and all relevant healthcare professionals (front-line providers, physicians, nurses) to receive adequate training in this respect. Training programs should be structured, with a focus on hospital-specific screening protocols and interview techniques. This is indispensable for interprofessional providers across the continuum of care to understand why and how to perform screening, reducing false positives and improving detection.


Unfortunately, false identifications can sometimes occur and its vital to be aware of the differential diagnoses for abuse-like fractures. For example, Osteogenesis imperfecta (OI) is a metabolic disorder that results in bones fracturing easily, regularly referred to in legal proceedings. Appropriate documents and history taking can be used to understand if a patient is experiencing a metabolic disorder like OI instead of abuse.1


For effective management of an abuse patient with orthopaedic injuries, clear communication and teamwork, with a multispecialty team approach is essential for the best patient outcomes. For instance, abused children may be admitted to an orthopaedic service for fracture management with help from social services. Femur fractures in children younger than 6 months can be managed with either a spica cast or Pavlik harness, which then requires clinical follow-up to observe any need for remodelling or future malunion treatment.1 Factual documentation and communication of the injuries and a clear treatment plan with a well-documented follow-up is crucial, especially as social services may have to handle return clinical visits.


With IPV, after the stabilization of injuries and addressing immediate safety concerns, the patient still has the right to make their own decisions. The goal of healthcare intervention in this scenario is to ensure the patient has access to the resources to maintain their safety after discharge. If patients decide to remain in their IPV relationship, healthcare professionals need to remain supportive.4,6


Abuse arises from a complex set of social, community and relationship factors, which may be further compounded in this difficult time of Covid-19, where many families are socially isolated and financially unstable.12 It’s easy for abuse and associated orthopaedic injuries to go unnoticed and it’s more important than ever to ensure screening and education programs with regards to identifying and managing abuse are continuously improved.


References

All documents accessed on 28/3/21

1) Child abuse: The role of the orthopaedic surgeon in nonaccidental trauma. (2011, March) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3032840/

2) Rib fractures in 31 abused infants: post-mortem radiologic-histopathologic study. (1996, September) < https://pubs.rsna.org/doi/10.1148/radiology.200.3.8756936>

3) Fractures in young children: are physicians in the emergency department and orthopaedic clinics adequately screening for possible abuse? (2003, June) <https://pubmed.ncbi.nlm.nih.gov/12813297/>

4) Best Practice Guidelines for Trauma Centre Recognition of Child Abuse, Elder Abuse and Intimate Partner Violence (pdf) <https://www.facs.org/-/media/files/quality-programs/trauma/tqip/abuse_guidelines.ashx>

5) Long bone fractures in children under 3 years of age: is abuse being missed in Emergency Department presentations (2004, April) <https://pubmed.ncbi.nlm.nih.gov/15009543/>

6) Intimate Partner Violence In Orthopaedic Trauma Patients: A chance to intervene? (2019, May) <https://online.boneandjoint.org.uk/doi/abs/10.1302/1358-992X.2019.7.009>

7) Soft-tissue injury as an indication of child abuse (1995, Aug) <https://pubmed.ncbi.nlm.nih.gov/7642662/>

8) Patterns of osseous injuries and psychosocial factors affecting victims of child abuse. (1990, June) < https://pubmed.ncbi.nlm.nih.gov/2346440/>

9) Pattern of physical injury associated with intimate partner violence in women presenting to the emergency department: A systematic review and meta-analysis. Trauma Violence Abuse. (2010, April) <https://pubmed.ncbi.nlm.nih.gov/20430799/>

10) Physical abuse of older adults in nursing homes: A random sample survey of adults with an elderly family member in a nursing home. (2012, January) <https://www.researchgate.net/publication/51977795 >

11) Child abuse training and knowledge: a national survey of emergency medicine, family medicine, and pediatric residents and program directors (2009, March) <https://pubmed.ncbi.nlm.nih.gov/19273504/>

12) Non-accidental injury in children n the time of Covid-19 Pandemic (2020, April) <https://www.boa.ac.uk/resources/knowledge-hub/non-accidental-injury-in-children-in-the-time-of-covid-19-pandemic.html>

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