April 2002 Bulletin

Orthopaedic sugeons play a key role in identifying family violence and injury prevention

We need to ask, "Has someone hurt you?"

By Carolyn Rogers

Orthopaedic surgeon Debra Zillmer, MD, grew suspicious when a patient’s "tennis elbow" persisted, even with standard treatment.

"It occurred to me that I needed to ask different questions," said Dr. Zillmer, who practices in Downers Grove, Illinois. She began to probe, and the patient admitted that her husband was abusive. Once the abuse was identified, Dr. Zillmer referred the patient to a community social worker and the woman received assistance. The elbow problem was resolved soon thereafter.

Scenarios like these will become more common in orthopaedic surgeons’ offices as they begin to work proactively to identify and deal with family violence, which includes domestic, child and elder abuse, Dr. Zillmer said at a media briefing held during the AAOS 2002 Annual Meeting in Dallas. According to the National Institute of Justice, total costs associated with adult domestic violence are estimated at $67 billion annually in the United States.

As medical specialists trained in the diagnosis and treatment of musculoskeletal disorders, orthopaedic surgeons can be the first medical providers to treat victims of family violence. That puts orthopaedic surgeons in an exceptional position to link victims with community family violence resources and to facilitate intervention, including hospitalization, for patients in immediate danger.

The Academy is working to educate its members about all forms of family violence, including offering educational courses to inform orthopaedic surgeons and orthopaedic nurses. An instructional course at the 2002 Annual Meeting entitled "Family Violence: Facts and Tools for the Orthopaedic Surgeon" addressed the orthopaedic impact of adult, child and elder abuse and the impact of family violence on the practice of orthopaedic surgery.

Dr Zillmer, who chairs the AAOS Task Force on Family Violence, coordinated the session and was joined by fellow instructors William J. Robb, III, MD, Mininder S. Kocher, MD and Donald K. Bynum Jr., MD. "We must look for the red flags of abuse, including inconsistencies between the injury and a patient’s description of what caused it, or, in the case of children and seniors, discrepancies between a patient’s and a caregiver’s or parent’s accounts," Dr. Zillmer stated.

All of the instructors strongly encouraged orthopaedic surgeons to routinely ask about the circumstances surrounding a condition or injury and to make the possibility of family violence a part of the patient’s diagnosis.

"The bottom line is, orthopaedic surgeons need to become more aware of the possibility of family violence as the etiology of not only obvious injuries, but also chronic conditions, " Dr. Bynum said "We need to ask the question ‘Has someone hurt you?’"

Data on family violence are "dizzying and compelling," Dr. Bynum says. According to a landmark U.S. Department of Justice survey published in 1998 called "The National Violence Against Women Survey," 75 percent of the time a woman is a victim of interpersonal violence, the perpetrator is an intimate. That compares to one in seven times for men.

While men are more likely to be victimized by a stranger (60 %) than by an intimate partner, Dr. Bynum pointed out, the lifetime incidence of intimate or family violence for men is eight percent, or about 1 in 12. "That is not a negligible number."

What does this mean for practicing orthopaedist? "This means if you’re seeing human beings with traumatic problems in your practice, you’re seeing victims of family violence," Dr. Bynum said.

During her lifetime, a woman is more likely to be a victim of abuse than she is of breast cancer, colon cancer, thyroid disease or hypertension, he adds.

"Now, do we screen for those conditions? Yes we do. Do we screen for violence? Not often enough … I mention these statistics only to make a point that there’s a lot of bad behavior out there."

Again, what does this mean to the practicing orthopaedist?

"It means that if you’re not seeing victims, it’s because you don’t recognize them—not because they’re not there."

According to Dr. Zillmer, overt signs of abuse include bruises and fractures. Subtle signs include chronic health conditions such as back pain, eating disorders, and chronic pain. Also, when abused victims are not identified they may develop a pattern of frequent emergency department visits or the use of outpatient care facilities.

Characteristics of injuries that may suggest abuse include injuries inconsistent with offered explanation, defensive injuries, multiple injuries, injuries in different stages of healing, and substantial delay between onset of injury and presentation for treatment.

Most domestic violence victims, whether they disclose their problem or not, are grateful for being asked and for being given information about community resources that can be used when needed, Dr. Zellmer says. As medical providers, simply by providing information about family violence resources, it may help someone break free from the cycle of domestic violence.