Nondisplaced Ulna Fracture Could Mean Intimate-Partner Violence

Ingrid Hein

December 02, 2020

About one-third of women who presented to an emergency department (ED) with a fractured ulna were victims of intimate-partner violence, according to a study of records from six medical centers presented at the Radiological Society of North America (RSNA) 2020 Annual Meeting .

Bharti Khurana

Women who present to the ED with a fracture on the pinkie finger side of their forearm often report that they fell, but this type of injury, which is often referred to as a "nightstick fracture" to describe a person who's been hit by a police club, usually occurs when a person is blocking an object hitting them. It's not seen as often in women as in men, study author Bharti Khurana, MD, Brigham and Women's Hospital, Boston, said in a statement to the press. "I never correlated it with intimate-partner violence until recently," she reported. "I shared my thoughts with our orthopedic surgeons and, with their interest and support, decided to pursue a study."

David Sing

Khurana collaborated with orthopedic surgeon David Sing, MD, Boston Medical Center, to study cases of ulnar fracture. In records from six medical centers spanning the years 2005 to 2019, they identified 62 female patients between the ages of 18 and 50 who presented to the ED with an ulnar fracture.

Intimate-partner violence was reported in 12 of the 62 cases. Six of those patients initially reported falling, play-fighting, or having been struck by an "unknown" assailant, then later admitted their partner had struck them. The other six reported intimate partner violence upon presentation.

When researchers looked more closely at medical records, they pinpointed eight additional patient fractures suspected to have resulted from intimate-partner violence.

Eight others were not suspected to be related to intimate-partner violence, and 34 were confirmed to be unrelated to intimate-partner violence.

When further evaluating follow-up of intimate-partner violence, the researchers reported that formal documentation or screening was completed in only 40% (n = 8) of the 20 confirmed or suspected intimate-partner-violence cases.

Nondisplaced fracture of the ulna (Image courtesy of David Sing) Click here to enlarge

Researchers also reported that none of the ulna fractures in confirmed or suspected intimate-partner-violence cases were displaced fractures. "When the fracture is not significantly shifted, it's more indicative of a low energy, and comes from a defensive stance, like blocking something," Sing told Medscape Medical News.

He explained that when a person hits a tree in a ski accident, or has a car accident or a fall, "you tend to see more displacement."

Other factors that increase the likelihood of intimate-partner violence are homelessness and a higher number of documented ED visits.

"It's easy for this to slip through the cracks," Sing reported. A flag needs to be raised when a woman with a nondisplaced fractured ulna presents in the ED, he said.

Follow-up needs to be more persistent, Sing said. In this study, only 40% of the 62 women in the study were interviewed about their injury and asked if it was the result of partner violence. And the under-reporting surprised him. "It's difficult to put myself in their shoes and understand why they would not be honest with their healthcare provider," he commented. "We don't often stop to think if a patient is telling the truth."

Sing pointed out that a high ratio of orthopedic physicians are male, and this "lends itself to the values of men. That's a shortcoming for us to work on, providing care for the entire patient, not just their injuries," he said, adding "that's my personal opinion."

In her presentation, Khurana noted that the most difficult aspect of treating intimate-partner violence is recognizing it. "There aren't guidelines or standardized references, and there is little to no education during medical school about it," she noted.

"This is a fascinating study and draws out something we need to think about more," Randall Loder, MD, Indiana University School of Medicine, Indianapolis, told Medscape Medical News. "Orthopedic surgeons are trained to fix the problem and get the fracture to heal. It's not that we ignore the social issues, but it's not top of mind," he said.

Loder, who was not involved in the Khurana –Sing study, observed that there's been a recent increase in the literature on the topic. "In the last 3 years or so...a fairly new wave of studies are being done, looking into violence and injuries."

Earlier this year, Loder himself was involved in a study in the Journal of the American Academy of Orthopedic Surgeons on the demographics and fracture patterns of patients presenting to emergency departments in the United States after intimate-partner violence. That review revealed that the most common fractures in this population involved the face, fingers, the upper trunk, and the hand. "This RSNA study gives us all new information," he said. "This tells us that a woman with an ulna fracture that wasn't in a car crash should raise suspicion."

Sing and Khurana coauthored the study with George Dyer, MD, Mitchel B. Harris, MD, Camden Bay, PhD, Irene Chen, Steven E. Seltzer, MD, Giles W. Boland, MD, and Paul Tornetta III, MD.

Khurana, Sing, and Loder have disclosed no relevant financial relationships.

Radiological Society of North America (RSNA) 2020 Annual Meeting.

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