Please rate topic.
Average 3.0 of 61 Ratings
A 29-year-old healthy Caucasian female presents to the emergency department with her boyfriend with a left anterior shoulder dislocation and several facial abrasions after tripping in the shower approximately three hours prior to arrival. She is 5’7’’ and weights 120 lbs (BMI 18.8). The patient notes that she has not had a menstrual period in three months and that she is training for a long-distance triathlon. Physical examination reveals no other obvious injuries. Basic serum laboratory values are unremarkable. A urine pregnancy test is positive. In addition to treating her shoulder dislocation, the orthopaedic surgeon should
Perform a skeletal survey to evaluate for other fractures or dislocations
Question the patient in private about the specific details of this injury and her sense of safety in the home
Refer the patient to a nutritionist given the patient’s BMI of 18.8
Obtain additional laboratory studies and admit the patient to the hospital for treatment of anorexia nervosa
Obtain advanced imaging of the shoulder to evaluate for underlying pathologic lesions
Select Answer to see Preferred Response
While this patient may have a perfectly reasonable explanation for her current injury, it is imperative for health care providers to inquire into the safety of the home environment in potential cases of intimate partner violence (IPV).
Risk factors for female victims IPV include being in the 2nd or 3rd decade of life, current pregnancy, having 1 or more prior children, and low socioeconomic status. Reporting requirements for adult abuse are not standardized amongst most states and physicians must understand the importance of identification and documentation in cases of suspected IPV.
Bhandari et al. state that musculoskeletal injuries are the second most common form of IPV (28%) after head and neck injuries (40%). Musculoskeletal injuries can be variable, including sprains, fractures, dislocations, and foot injuries.
Della Rocca et al. conducted a survey and found orthopaedic surgeons have several misconceptions regarding victims of IPV and further, nearly half of their survey respondents reported identifying a victim of IPV while only 4% reported that they currently screen their injured female patients for IPV.
Zillmer presents a review of the issues surrounding IPV including proper identification, documentation, appropriate questioning and how to involve community services.
Illustration A shows some basic facts regarding IPV during pregnancy as reported by the CDC. Additional information can be found at the following link. http://www.cdc.gov/reproductivehealth/violence/IntimatePartnerViolence/index.htm
Answer 1. There is no indication for a skeletal survey and it would be inappropriate to subject this pregnant patient to additional radiation.
Answer 3. There is no need to refer a patient to a nutritionist for a normal BMI
Answer 4. There is no indication for admission or other laboratory studies in this otherwise healthy patient.
Answer 5. There is no need for advanced imaging in the emergency department in the case of an isolated traumatic shoulder dislocation
Bhandari M, Dosanjh S, Tornetta P 3rd, Matthews D; Violence Against Women Health Research Collaborative.
J Trauma. 2006 Dec;61(6):1473-9. PMID: 17159694 (Link to Abstract)
Bhandari, JTACS 2006
Della Rocca GJ, Sprague S, Dosanjh S, Schemitsch EH, Bhandari M.
Clin Orthop Relat Res. 2013 Apr;471(4):1074-80. Epub 2013 Jan 3. PMID: 23283672 (Link to Abstract)
Della, CORR 2013
J Am Acad Orthop Surg. 2000 Mar-Apr;8(2):91-6. PMID: 10799094 (Link to Abstract)
Zillmer, JAAOS 2000
Please rate question.
Average 1.0 of 42 Ratings
Risk factors for intimate partner violence after musculoskeletal injury includes all of the following EXCEPT?
Shorter length of relationship
History of prior divorce
History of marriage ending in divorce has not been identified in the literature as a risk factor for intimate partner violence (emotional, physical, and sexual abuse).
The approximate prevalence of intimate partner violence (emotional, physical, and sexual abuse) is 32% among females within the 1 year before they are seen by an orthopaedist for the treatment of musculoskeletal injuries.
Bhandari et al. performed a level 2 cohort study of 282 females presenting to their institution for orthopaedic injuries. The prevalence of intimate partner violence (emotional, physical, and sexual abuse) within the twelve months prior to presentation was 32%.
Bhandari et al. also performed a level 4 review of 263 females referred to the Minnesota Domestic Abuse Program. Identified risk factors for physical abuse included younger age, shorter length of relationship, emotional abuse, psychological abuse, sexual abuse, drug dependency, and alcohol dependency.
Illustration A shows a table that outlines the roles and responsibilities of orthopaedic surgeons according to the Canadian Orthopaedic Association 2012 position statement.
Shorter length of relationship, younger age, current pregnancy, and alcohol dependency have all been indentified as risk factors for intimate partner violence.
Bhandari M, Sprague S, Dosanjh S, Petrisor B, Resendes S, Madden K, Schemitsch EH; P.R.A.I.S.E. Investigators.
J Bone Joint Surg Am. 2011 Jan 19;93(2):132-41 PMID: 21148744 (Link to Abstract)
Bhandari, JBJS 2011
Average 1.0 of 56 Ratings
Which of the following is true regarding intimate partner violence (IPV)?
Most patients do not have a fear of domestic retaliation upon reporting
Victims of IPV rarely have a history of injury during the previous 12 months
Interdisciplinary collaboration yields positive outcomes
Emotional abuse is easily identifiable in patients suffering from IPV
Victims of IPV feel comfortable discussing their issues to male physcians
Identification of IPV is essential in the orthopedic ambulatory setting. Discerning physical abuse is more straightforward as patients can have frequent visits with multiple, unexplained fractures. Emotional abuse is more difficult to discern. Communication and awareness is advocated. Most barriers to reporting include a lack of awareness of IPV, downplaying of the situation, fear of partner retaliation, concern for custody conflicts, shame, embarrassment and a reluctance to talk to male physicians.
Interdisciplinary collaboration among healthcare workers was a predictor of positive treatment outcomes. Included were more accurate assessments of past history, more descriptive emotional symptoms as displayed by victims and written documentation of recommendations concerning intervention and linkage to community resources.
Bhandari et al performed a cross-sectional study of 282 women who presented to fracture clinic at two Level-I trauma centers in Canada. The prevalence of abuse was found to be 32% while 8.5% were found to have a history of previous abuse in the past 12 months. Ethnicity, socioeconomic status, and injury patterns were not associated with abuse.
Shields et al reviewed 153 cases of domestic violence victims who presented to two Emergency departments. They determined that positive treatment outcomes were correlated to the degree of interdisciplinary collaboration among treating health care providers.
Shields G, Baer J, Leininger K, Marlow J, DeKeyser P.
Soc Work Health Care. 1998;27(2):27-48. PMID: 9606817 (Link to Abstract)
Wis Med J. 1992 Jun;91(6):284-6. PMID: 1471368 (Link to Abstract)
Average 1.0 of 37 Ratings
Regarding the role of the orthopaedic surgeon in addressing domestic and family violence, all of the following statements are true EXCEPT:
Report all cases of child abuse, as this is required by all states
Report all cases of adult spousal or intimate partner abuse, as this is required by all states
Hospitalize elderly victims who are in immediate danger and help develop a plan to ensure their safety
Advocate for appropriate legislation and public policy on violence and abuse related to health care
Orthopedic surgeons are responsible for knowing the reporting laws and procedures for suspected abuse
Reporting requirements for adult spousal or intimate partner abuse is not standardized among states and it is the responsibility of the orthopaedic surgeon to understand the laws of his or her state. The AAOS Advisory statement gives information to assist in meeting the ethical and legal obligations on Domestic and Family Violence and Abuse.
Domestic and family violence affects over 10% of the US population (approximately 32 million Americans). Child abuse and neglect contributed to 1,400 fatalities in 2002 and there was 565,747 reports of suspected elder abuse.
Reporting of suspected child abuse is required in all states. The orthopaedic surgeon should hospitalize elderly victims who are in immediate danger and help develop a plan to insure their safety.
Average 1.0 of 134 Ratings
An 78-year-old woman who lives in a nursing home sustains an injury to her left forearm. Radiograph is shown in Figure A. It is determined that the injury occurred as the result of elder abuse. All of the following are considered risk factors for elder abuse EXCEPT?
Disruptive behavior by the victim
Poor physical health of the victim
Physicians have an ethical and legal duty to protect patients from suspected abuse, and most states mandate reporting by health-care personnel so it is imperative physicians know the statutes in their state. Gender has not been identified as an independent risk factor.
Risk factors include substance abuse or mental illness on the part of the abuser, dependence of the abuser on the victim, shared living arrangements, external factors causing stress, social isolation, a history of violence, increased age of victim, race, poverty, functional disability and cognitive impairment. A strong association between reported child abuse and reported elder abuses within a regional population has been reported.
The review by Chen et al states the prevalence of elder abuse is 32 cases per 1,000 persons and is increasing with the growing elderly population.
The review by Lachs states that risk factors for abuse include dementia, poor physical and emotional health, disruptive or aggressive behavior, social dysfunction and prior violence or abusive acts by the victim toward the abuser.
Chen AL, Koval KJ.
J Am Acad Orthop Surg. 2002 Jan-Feb;10(1):25-31. PMID: 11809048 (Link to Abstract)
Chen, JAAOS 2002
Lachs MS, Pillemer K.
N Engl J Med. 1995 Feb 16;332(7):437-43. PMID: 7632211 (Link to Abstract)
Lachs, NEJM 1995
Each of the following are guidelines for management of a domestic violence victim EXCEPT:
Socioeconomic status should not preclude evaluation for domestic violence
Interview the patient outside the presence of other non-medical personnel
Federal law mandates photographs be taken of injuries
Document your opinion if the patient’s injuries are not consistent with the offered explanation
Physicians should check requirements to see if there is mandatory reporting statute in their state
It is important to fully document the abuse as it has been described to you, however there is no federal law mandating photographic documentation of domestic violence injuries. Photographs may be taken but only with the patient's permission. Disclosure of a diagnosis of abuse to any third party and reporting it to the authorities should be done only with the abused patient’s knowledge and consent, unless there is a mandatory reporting statue in the particular state of practice. Being a female, age 19-29, pregnant, or of a low socioeconomic status (<$10,000 per/yr) increase one's risk for domestic abuse. Pregnancy is the highest risk factor for abuse with 40% to 60% of battered women reporting that they were abused during pregnancy. Interviewing should be done outside the presence of others to minimize potential interference by the abusive spouse/partner.
The review article by Zillmer outlines that as many as 35% of women presenting to ERs for trauma care have injuries that are a result of domestic violence.
Average 2.0 of 36 Ratings