With Forearm Fracture in Women, Suspect Domestic Violence

Radiologists who interpret scans of non-displaced fractures to the ulna in female patients can play a role in identifying a victim of intimate partner violence, a new study says.

In research presented this week during the Radiological Society of North America (RSNA) annual meeting, investigators from Brigham & Women’s Hospital shared their findings that they say supports need to screen for intimate partner violence in women who have these types of injuries.

These non-displaced fractures typically occur when someone uses their forearm to shield their face from being struck, said senior study author and radiologist Bharti Khurana, M.D. They are mostly seen in men, so when a woman presents with a break like this, it should raise a red flag.

“I would see these types of injuries in men, but one in a while, I would see them in women,” she said, discussing her own practice experience. “I never correlated it with intimate partner violence until recently.”

Related Content: Radiology Spotlights Disturbing Uptick of Intimate Partner Violence During Pandemic

But, after sharing her suspicions with an orthopedic surgeon colleague, she decided to study this issue. After searching the electronic medical records from six hospitals, looking specifically for ulnar fractures in women ages 18 to 50, Khurana’s team identified 62 women who fit the description. Their average age was 31, and 12 had been confirmed as victims of intimate partner violence. Another eight were suspected.

Based on her analysis, she determined that intimate partner violence was strongly associated with X-ray that included a minimally displaced fracture.

“The radiological characteristics we were looking at were the location of the fracture, the pattern of the fracture in terms of how it broke, and the displacement of the fracture,” said lead study author David Sing, M.D., an orthopedic surgery resident at Boston Medical Center. “Out of all those things, what we usually saw was a minimally displaced fracture, meaning the bone is broken all the way through but has not shifted significantly.”

In many cases, Khurana explained, women who have ulnar fractures due to intimate partner violence typically blame a fall. However, falls are much more likely to result in a break in the arm’s other bone, the radius.

“It’s actually rare to break your ulna in a fall,” Khurana said. “If a radiology is seeing an ulnar fracture that is non-displaced, and the woman says she had a fall, it’s actually quite concerning for intimate partner violence.”

This finding was bolstered by the fact that four out of eight intimate partner violence victims reported their injuries as the outcome of a fall, but the ones who were not sustained the ulnar fractures from car accidents or an accidental strike, such as hitting a tree while skiing.

The frequency of this type of injury among victims of intimate partner violence underscores the need for greater screening, she said. In only 40 percent of confirmed or suspected cases did providers do a formal evaluation or screening. Consequently, in many cases, the radiologist who sees such a fracture on an image can help improve these efforts by alerting the emergency department physician or orthopedic surgeon that an ulnar fractur frequently accompanies intimate partner violence, giving the ordering physician the opportunity to dig deeper into the patient’s history. In fact, she said historical imaging analysis by itself raised the red flag with 75 percent of confirmed intimate partner violence patients.

“Careful analysis of previous imaging exams may also help radiologists confirm their suspicion of intimate partner violence,” said study co-author Rahul Gujrathi, M.D., a Brigham & Women’s radiology fellow.

The ability to recognize the signs of intimate partner violence is particularly critical now since the rate of abuse has increased significantly during the pandemic. A quick diagnosis can be substantially beneficial for the patient.

“The sooner we can address and change the behavior, the better,” she said. “Just like radiologists want to diagnose cancer as early as possible, it’s the same thing with this. If we diagnose early, we have a better chance to break the cycle of violence.”

For additional RSNA coverage, click here.