Missed opportunities in orthopaedics for intimate partner violence identification: A retrospective review over 24 years

BACKGROUND: Intimate partner violence (IPV) commonly manifests as a musculoskeletal injury, yet the majority of orthopaedic surgeons estimate IPV to be rare in "their" orthopaedic patients. This work aimed to (1) provide education on the prevalence and manifestations of IPV, (2) investigate departmental referral patterns to Domestic Abuse Intervention Programs (DAIP) at 2 high-volume quaternary-academic centers, and (3) characterize IPV cases identified by orthopaedic surgery providers. 

METHODS: The DAIP registry from 2000 to 2024 was queried for patients reporting IPV. Referrals were categorized by department and provider type. The electronic health record of patients referred by orthopaedics was further investigated for case characteristics. Findings were summarized as count/percentages and referral rates compared via the 2-proportion z-test with alpha set at 0.05. 

RESULTS: A total of 11,227 patients were referred to DAIPs. The most common referrals were from the emergency department (ED) (29.3%; n = 2,393), behavioral health (18.2%; n = 2039), and obstetrics/gynecology (8.4%; n = 939), while only 0.3% (n = 30) patients were referred by orthopaedic surgery providers (p < 0.001). Patients referred by orthopaedics were commonly female (83.3%; n = 25) and identified during an inpatient encounter (76.7%; n = 23). Half (53.3%; n = 16) presented with an injury sustained from abuse, while the remaining patients presented for scheduled care. Injuries included high-energy injuries such as subtrochanteric, open tibia, bicondylar tibial plateau, and nongeriatric elbow fractures. Orthopaedic referrals to DAIPs relied on social workers (93.3%; n = 28). In the inpatient/ED setting, patients initially disclosed to bedside nurses (56.0%; n = 14), residents (20.0%; n = 5), and advanced practice providers (16.0%; n = 4), while patients disclosed to attendings (60%; n = 3) and fellows (40%; n = 2) in the outpatient setting. The majority (76.7%; n = 23) of patients reporting IPV-only interacted with orthopaedic providers in the 6 months preceding IPV disclosure. IPV identification led to patient safety coordination (16.7%; n = 5), alternative care plans (23.3%; n = 7), and resource assistance applications (23.3%; n = 7). Patients referred to DAIPs remained engaged in services a median 6.8 years after referral. 

CONCLUSIONS: Orthopaedic surgery referrals to DAIPs are significantly lower than other specialties, highlighting missed opportunities for intervention in both inpatient and outpatient contexts. Enhancing IPV awareness and screening in orthopaedics could improve patient safety and long-term support. Integration of artificial intelligence has the potential to facilitate efficient targeted screening within existing practice models. 

LEVEL OF EVIDENCE: Level III (retrospective cohort).