Advisory Statement

Domestic and Family Violence and Abuse: The Orthopaedic Surgeon’s Responsibilities

This Information Statement was developed as an educational tool based on the opinion of the authors. It is not a product of a systematic review. Readers are encouraged to consider the information presented and reach their own conclusions.

Violence and abuse are significant problems in the United States. Victims are of all ages and genders. The public health impact in terms of lives lost or lives harmed is immeasurable and likely underestimated by statistics. These problems present in a variety of settings and ways in the health care system. Sometimes they are obvious and sometimes they are not. It is important to be aware when someone is a victim and assist appropriately.

This Advisory Statement is intended to give the orthopaedic surgeon a current overview of the problem of Family and Domestic Violence and Abuse in our society and to assist in meeting the ethical and legal obligations that the orthopaedic surgeon has in recognizing and appropriately managing these problems as they may affect his or her patients and their families.

Definition of Domestic or Family Violence and Abuse

Domestic or family violence and abuse is often thought of in the context wife beating and child or elder abuse. Not all violence occurs in the context of the family and not all abuse is violent. For purposes of this discussion, we are talking about a spectrum of situations where one individual inflicts harm on another with whom they have an intimate or controlling relationship. There is a misuse of power and control of one person over another in inflicting the harm.

The circumstances or relationships may include:

• Spousal abuse or violence against both women and men;

• Child abuse and violence;

• Intimate partner abuse – both heterosexual and homosexual;

• Elder abuse and neglect;

• Controlling e.g., – coworker, supervisor, guardian, custodian, prison guard; and

• Unrelated individual who is the victim of gang or criminal violence.

The violence or abuse may include:

• Physical violence and abuse;

• Sexual abuse, rape, incest;

• Psychological/emotional abuse/intimidation;

• Economic abuse and deprivation;

• Property destruction; and

Neglect of a dependant individual.

Statistics

Violence and abuse are found in all cultures. It is generally thought that reporting of domestic and family violence and abuse significantly underestimates the magnitude of the problem. The U.S. Centers for Disease Control and Prevention estimate that domestic and family violence affects over 10% of the US population, or more than 32 million Americans. The indirect effects clearly touch on nearly everyone. All types of abuse appear to be on the increase partly because of improved recognition and reporting.

Spouse and Intimate Partner Violence

Intimate partner violence and spousal abuse is reported only 20-50% of the time. Women are victims 74% of the time, with men being the victims 26% of the time. In 2003, intimate partner violence resulted in over two million injuries and 1,300 deaths. An intimate partner committed 11% of all homicides and nearly half of the women victims had visited a hospital Emergency Department with an injury in the previous year. Repeated violence over time seems to carry more serious consequences. The importance of recognition and intervention is clear in preventing the progressive effects of such violence. Costs are currently estimated at $5.8 billion a year, with $4.1 billion being direct health care costs.

Elder Abuse

The growth of our aging population is well known and a source of concern as it relates to the need for orthopaedic care of fractures and joint replacement. We may expect an increasing burden of elder abuse since this growing geriatric population is vulnerable to these problems.

A 2004 Survey of State Adult Protective Services provides the most current insight into the problem of elder abuse and neglect. For the year 2003:

565,747		Reports of suspected abuse
192,243		Investigated reports of suspected abuse
46.7%		Investigated reports substantiated
89%		Abuse occurred in a domestic setting
11%		Abuse occurred in an institutional setting

The victims were:

66%		Women
40%		80 years of age or older
11%		Abused by spouse
33%		Abused by children
22%		Abused by other family members

The types of elder abuse included:

37%		Self neglect
20%		Caregiver neglect
15%		Financial exploitation
11%		Physical abuse
1%		Sexual abuse

Child Abuse

It is estimated that child abuse and neglect contributed to 1,400 fatalities in 2002. Most researchers feel that is an underestimate, caused by varying definitions and reporting practices among the states.

The youngest children are most vulnerable as a result of their small size and extreme dependency. They are defenseless, non-verbal and demanding. Seventy six percent of childhood fatalities from neglect and abuse were in children less than four years of age.

Child fatalities were the result of:

38%		Neglect
30%		Physical abuse
29%		Multiple types of abuse

Those responsible for fatal child abuse are:

79%		One or both parents
16%		Non-parent care takers
-		Most often young adults without a high school diploma
-		Likely to have been a victim of violence or abuse themselves

There was often a pattern of neglect or abuse leading up to the fatality of the child. Accordingly, recognition and prevention becomes an important matter for physicians who see these children with their injuries and other health problems resulting from abuse and neglect. The daily costs of child abuse and neglect have been estimated to be $258 million in direct and indirect costs. That amounts to an annual cost of $94 billion for the U.S. or $1461 per family.

The cumulative costs of the various forms of domestic and family violence and abuse are enormous and not well accounted for anywhere. This clearly constitutes a major public health problem that orthopaedic surgeons should be aware as they encounter patients who they see for care of the various consequences of abuse.

RECOGNIZING AND DOCUMENTING ABUSE AND VIOLENCE

Orthopaedic surgeons should be aware of how harm from domestic violence and abuse may present to them. Musculoskeletal injuries that cause concern are:

• Multiple injuries/fractures
• Bilateral injuries/fractures
• Unusual Patterns of injury/fracture
• Injuries/fractures of varying ages
• Injuries/fractures inconsistent with or disproportional to the history

Non-musculoskeletal aspects of trauma that should alert one to abuse are:

• A central pattern of injury
• Defensive pattern of injury
• Substantial delay between injury and treatment
• Injuries during pregnancy
• Repeated injuries
• Inappropriate/strained relationship with patient’s partner

Violence and abuse have significant associated psychosocial consequences for victims. Depression, anxiety, suicide, fear of intimacy and distrust of the opposite sex are among them. They are also more likely to engage in high-risk behavior with sex, drugs, alcohol, smoking, and eating. They have problems with chronic pain. All of this leads to a much higher utilization of health care services.

The incidence of fractures and musculoskeletal injuries in elder abuse is not known but is likely significant especially related to neglect. Suffering for elders is often silent. One must be alert to the problem with changes in a patient’s behavior or circumstances and with any apparently strained relationships with caregivers.

One should be aware that when women leave an abusive partner, they are at great risk for being murdered by the abuser.

Good medical records can be of help to victims of domestic violence and abuse. The records can be submitted to help obtain legal protection and relief or to obtain other social services such as public housing and welfare benefits. Orthopaedic surgeons can do the following to make the record as useful as possible to victims:

• Take photographs to document injuries.
• Use body maps or drawings to document injuries.
• Write legibly or use electronic medical records.
• Quote the patient’s words to make the source of the information clear. Avoid terms such as alleges or claims which may imply doubt.
• Indicate who harmed the patient and when.
• Describe the patient’s demeanor (agitated, angry, sad, happy etc.).

THE ROLE OF THE ORTHOPAEDIC SURGEON

The American Academy of Orthopaedic Surgeons (AAOS) believes that orthopaedic surgeons should as appropriate to their situation:

• Be knowledgeable about various forms of domestic and family violence and how it may present to them in their practices.
• Appropriately screen for problems of domestic violence and document them in the medical record.
• Assess and assure the safety of the victim.
• Appropriately treat victims.
• Take steps to prevent further harm.
• Be familiar with the applicable laws and resources for reporting and referring suspected cases of violence and abuse.
• Comply with all mandatory reporting laws.
• Report all cases of child abuse, as this is required by all states.
• Report adult victims with discretion and the knowledge of the victim as a report may put the victim at greater risk for further abuse.
• Hospitalize elderly victims who are in immediate danger and help develop a plan to insure their safety.
• Help educate the public and other health care professionals about the problems of domestic violence and abuse.
• Encourage and participate in research on domestic violence and abuse.
• Advocate for appropriate legislation and public policy on violence and abuse related to health care.

The AAOS also believes that in addition to their primary responsibility to care for the patient, orthopaedic surgeons have the legal obligation to report violence and abuse to appropriate authorities. Reporting of suspected child abuse is required in all states. Reporting requirements for adult abuse is not uniform among states. The orthopaedic surgeon is obligated to understand the laws of his or her particular practice situation.

Resources

The following resources are current as of this update and are cited with the impression that they will be maintained and updated over time. Since laws and phone numbers change with time, orthopaedic surgeons should check the current status of the information.

Child Abuse Laws and Reporting

Child Abuse Prevention & Treatment Act as amended by the Keeping Children Safe Act of 2003. URL links to the full text of the federal law.

Child Welfare Information Gateway. URL links to an information reporting hotline (800-422-4453) and to state specific numbers for reporting child abuse.

http://www.childwelfare.gov/responding/reporting.cfm

Child Welfare Information Gateway. URL links to state specific laws related to child abuse.

http://www.childwelfare.gov/systemwide/laws_policies/index.cfm

Adult Violence and Abuse

National Coalition Against Domestic Violence Hotline. 800-799- SAFE (7233)

URL links to the NCADV and also to each state’s coalition against domestic violence.

http://www.ncadv.org/protectyourself/GettingHelp_128.html

American Prosecutors Research Institute.

This is a good source of information and issues about reporting domestic violence related to competent adult victims. It summarizes the relevant state statutes for medical professionals.

National Resource Center on Domestic Violence. 800-537-2238

This is a good resource for information on and help with domestic violence in adults.

Elder Abuse

National Center on Elder Abuse. This is funded by the U.S. Administration on Aging and is the most comprehensive resource on elder abuse. It includes links to state hotlines and resources.

© February 2007 American Academy of Orthopaedic Surgeons

This material may not be modified without the express written permission of the American Academy of Orthopaedic Surgeons^®.

Information Statement 1030

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