Trauma/Emergency RadiologyFree Access

Intimate Partner Violence: A Primer for Radiologists to Make the “Invisible” Visible

Published Online:https://doi.org/10.1148/rg.2020200010

Abstract

Intimate partner violence (IPV) is the physical, sexual, or emotional violence between current or former partners. It is a major public health issue that affects nearly one out of four women. Nonetheless, IPV is greatly underdiagnosed. Imaging has played a significant role in identifying cases of nonaccidental trauma in children, and similarly, it has the potential to enable the identification of injuries resulting from IPV. Radiologists have early access to the radiologic history of such victims and may be the first to diagnose IPV on the basis of the distribution and imaging appearance of the patient’s currrent and past injuries. Radiologists must be familiar with the imaging findings that are suggestive of injuries resulting from IPV. Special attention should be given to cases in which there are multiple visits for injury care; coexistent fractures at different stages of healing, which may help differentiate injuries related to IPV from those caused by a stranger; and injuries in defensive locations and target areas such as the face and upper extremities. The authors provide an overview of current methods for diagnosing IPV and define the role of the radiologist in cases of IPV. They also describe a successful diagnostic imaging–based approach for helping to identify IPV, with a specific focus on the associated imaging findings and mechanisms of injuries. In addition, current needs and future perspectives for improving the diagnosis of this hidden epidemic are identified. This information is intended to raise awareness among radiologists, with the ultimate goal of improving the diagnosis of IPV and thus reducing the devastating effects on victims’ lives.

©RSNA, 2020

SA-CME LEARNING OBJECTIVES

After completing this journal-based SA-CME activity, participants will be able to:

  • ■ Describe the current methods of diagnosing IPV and the challenges associated with diagnosing this major public health problem.

  • ■ Define the role of the radiologist in identifying victims of IPV.

  • ■ Identify the imaging findings and mechanisms of injuries associated with IPV.

Introduction

Intimate partner violence (IPV), defined as the physical, sexual, or emotional violence between current or former partners, is a major public health problem that affects millions of women in the United States and worldwide (1). IPV satisfies any definition of a public health emergency: It is widespread, chronic, progressive, and potentially fatal.

Data from the Centers for Disease Control and Prevention (CDC) (2) show that nearly one out of four women and one out of nine men have experienced IPV throughout their lifetime, with an estimated prevalence of 25%–30% in the United States. Data from outside of the United States (35) have shown that IPV is a global phenomenon encountered in all regions and countries. As a representative example, in a survey from 2014 (6), 32% of women in Denmark reported that they had been physically assaulted by their partner during their lifetime.

To further complicate this issue, worldwide data from the United Nations Global Study on Homicide (1) and the CDC National Intimate Partner and Sexual Violence Survey (7) have shown that IPV often starts in adolescence, as “teen dating violence,” and culminates in homicide perpetrated by an intimate partner with a long-standing pattern of abuse. Thus, victims of IPV, as compared with their age-matched counterparts, end up seeking medical care that more often involves greater use of imaging services (810).

Nonetheless, IPV remains widely underdiagnosed. Patients often present for care of their injuries without reporting IPV. Victims often underreport episodes of violence to health care providers for various reasons, including embarrassment, economic dependency, fear of retaliation, and lack of trust of their care providers (2,11). Although screening programs are effective in reducing violence and other abuse owing to increased referrals to support services, several barriers hinder the application of these programs (12).

Imaging has played a significant role in the identification of nonaccidental trauma in children, demonstrating that imaging is crucial in the detection of abuse (13). Similarly, imaging has the potential to enable the detection of injuries caused by IPV, which otherwise would go undetected with use of the current diagnostic approach, which is mainly based on the information gleaned from clinician-administered screening questionnaires or self-reporting of IPV (14). Thus, it is imperative that radiologists be familiar with the imaging findings of injuries caused by IPV and the associated mechanisms, to raise the possibility of underlying IPV when such an injury is detected.

This review article is intended to provide an overview of IPV diagnosis, define the role of the radiologist in these cases, and describe a successful diagnostic imaging–based approach to IPV. We describe the common imaging findings of IPV, review the presumed mechanisms of IPV-related injuries, and identify current needs and future perspectives for improving the diagnosis of IPV. Our ultimate goal is to raise the awareness of this hidden epidemic.

Diagnosis of IPV

Because of the high prevalence of IPV in the general population and data showing that referring IPV victims to support services can reduce the risk of subsequent violence, mental harm, and other forms of abuse, the United States Preventive Services Task Force (15) recommends question-based screening for IPV in all women of childbearing age. Nonetheless, practices vary widely among different health care providers and screening is often underutilized. In a survey of 4821 women with access to regular health care, only 7% of them reported undergoing IPV screening (16,17). Even for high-risk categories, adherence to screening is inconsistent. In a study involving 253 women with a history of IPV (18), only 39% of the women reported undergoing appropriate screening.

IPV can manifest in association with a wide range of conditions, from physical injuries related to violent episodes to chronic gastrointestinal, endocrine, gynecologic, pulmonary, and psychiatric disorders. IPV has also been associated with negative short- and long-term health consequences, such as drug and alcohol abuse, smoking, and other stress-related symptoms, which persist even after the abuse has ended (Table) (1922).

Injuries and Conditions Associated with IPV

Often the symptoms of the victim at presentation are not directly related to violence, making the diagnosis of IPV extremely challenging in any setting, from the emergency department to the family medicine practice. In a study involving 185 victims of IPV (9), 47% of the victims presented to the emergency department with symptoms that were not directly related to violence, and in 18% of the cases, the symptoms at presentation were psychiatric. Furthermore, owing to time constraints and a lack of resources in some instances, it is challenging to fully delve into a patient’s clinical history and assimilate all of the information in his or her medical record, which can potentially hint to a history of IPV (8). This phenomenon has been termed tyranny of the urgent. The brief patient-physician visit allows time to address only acute situations rather than focus on long-term issues (23). As a result, much of the electronic health information is not properly interpreted or even accessed. This situation potentially leads to missed diagnoses of IPV (8).

Thus, a longitudinal approach to the diagnostic data available in electronic medical records has been proposed to predict the risk of underlying abuse (8). In fact, after a diagnosis of IPV is made, retrospective review of the medical record often reveals a pattern of diagnoses suggestive of a history of violence (8). In one study (8), a model in which this longitudinal approach was used seemed to be particularly effective in predicting the risk of underlying abuse, as the patterns of injuries differed between IPV victims and control subjects, with the potential to detect IPV years earlier. The results of the study (8), in which only historical data that were readily available in electronic health records were used, showed that the strongest predictor of a diagnosis of IPV is the frequency rather than severity of the injuries. The results further showed that the likelihood of an IPV diagnosis directly correlates with the number of emergency department visits per year (8). This model is based on both the recurring nature of IPV, as IPV manifests with a long-standing pattern of escalating abuse involving acute and recurring episodes of violence, and the increased use of health care services among IPV victims due to the long- and short-term health consequences associated with abuse (8,22).

Role of the Radiologist

Radiologists are in a crucial position to detect IPV. They have rapid access to imaging studies and have the skills necessary to assess the radiologic history of patients. Clinical care providers may miss potential victims of IPV for multiple reasons such as subconscious bias toward the victim’s physical appearance and educational and socioeconomic background, fear of offending the patient when inquiring about IPV, time constraints, and the need to focus mainly on the presenting symptom(s) (14). Conversely, radiologists can have an unbiased perspective of the radiologic history of the victim and later on correlate the identified imaging findings with the reported history.

It is known that certain patterns and distributions of injuries correlate with IPV.

Teaching Point In victims of IPV, injuries are commonly in defensive locations of the body such as the upper extremities and in targeted areas, including the midface, head, and posterior chest (24,25). Various studies have shown that injuries to multiple sites of the body are extremely common in victims of IPV and predictive of a history of IPV (26,27).
By recognizing common injury patterns and distributions on patients’ imaging studies, radiologists can help diagnose IPV in a manner similar to the approach used to diagnose nonaccidental trauma in children.

Radiologists can also easily identify the longitudinal pattern of IPV injuries on imaging studies as the coexistence of acute and chronic injuries in the same patient, a highly specific sign of IPV (Fig 1) (28). Furthermore, radiologists can detect inconsistencies between the type of injury observed at imaging and the history provided by the patient. In a study involving 123 victims of IPV (28), a mismatch between the history provided at triage and the history reported to the emergency department physician was highly specific for IPV. By knowing the common mechanisms of injuries, radiologists can detect these discrepancies and raise suspicion for IPV.

Acute and chronic fractures in different victims of IPV. (a) Axial CT                    image of the face in a 52-year-old woman who presented to the emergency                    department with left facial swelling shows periorbital swelling in the soft                    tissues. (b) Axial bone-algorithm reconstructed CT image in the same patient                    shows a minimally displaced nasal bone fracture (arrow) with well-corticated                    margins and no soft-tissue swelling, suggesting an old fracture. This patient                    reported multiple prior episodes of violence from her partner. (c) Frontal                    radiograph of the left wrist in a 58-year-old woman who presented to the                    emergency department 4 days after a fall over her dog’s leash (reportedly                    wrapped around her leg) and landing on her left wrist shows a comminuted,                    minimally displaced fracture (arrow) of the midshaft of the ulna. Of note, the                    patient was right-hand dominant. (d) Old Grashey view radiograph of the right                    shoulder of the same patient a year earlier (found in picture archiving system)                    shows a healed right humeral fracture (arrow). This fracture was reportedly                    related to a prior episode of a fall due to the same mechanism.

Figure 1a. Acute and chronic fractures in different victims of IPV. (a) Axial CT image of the face in a 52-year-old woman who presented to the emergency department with left facial swelling shows periorbital swelling in the soft tissues. (b) Axial bone-algorithm reconstructed CT image in the same patient shows a minimally displaced nasal bone fracture (arrow) with well-corticated margins and no soft-tissue swelling, suggesting an old fracture. This patient reported multiple prior episodes of violence from her partner. (c) Frontal radiograph of the left wrist in a 58-year-old woman who presented to the emergency department 4 days after a fall over her dog’s leash (reportedly wrapped around her leg) and landing on her left wrist shows a comminuted, minimally displaced fracture (arrow) of the midshaft of the ulna. Of note, the patient was right-hand dominant. (d) Old Grashey view radiograph of the right shoulder of the same patient a year earlier (found in picture archiving system) shows a healed right humeral fracture (arrow). This fracture was reportedly related to a prior episode of a fall due to the same mechanism.

Acute and chronic fractures in different victims of IPV. (a) Axial CT                    image of the face in a 52-year-old woman who presented to the emergency                    department with left facial swelling shows periorbital swelling in the soft                    tissues. (b) Axial bone-algorithm reconstructed CT image in the same patient                    shows a minimally displaced nasal bone fracture (arrow) with well-corticated                    margins and no soft-tissue swelling, suggesting an old fracture. This patient                    reported multiple prior episodes of violence from her partner. (c) Frontal                    radiograph of the left wrist in a 58-year-old woman who presented to the                    emergency department 4 days after a fall over her dog’s leash (reportedly                    wrapped around her leg) and landing on her left wrist shows a comminuted,                    minimally displaced fracture (arrow) of the midshaft of the ulna. Of note, the                    patient was right-hand dominant. (d) Old Grashey view radiograph of the right                    shoulder of the same patient a year earlier (found in picture archiving system)                    shows a healed right humeral fracture (arrow). This fracture was reportedly                    related to a prior episode of a fall due to the same mechanism.

Figure 1b. Acute and chronic fractures in different victims of IPV. (a) Axial CT image of the face in a 52-year-old woman who presented to the emergency department with left facial swelling shows periorbital swelling in the soft tissues. (b) Axial bone-algorithm reconstructed CT image in the same patient shows a minimally displaced nasal bone fracture (arrow) with well-corticated margins and no soft-tissue swelling, suggesting an old fracture. This patient reported multiple prior episodes of violence from her partner. (c) Frontal radiograph of the left wrist in a 58-year-old woman who presented to the emergency department 4 days after a fall over her dog’s leash (reportedly wrapped around her leg) and landing on her left wrist shows a comminuted, minimally displaced fracture (arrow) of the midshaft of the ulna. Of note, the patient was right-hand dominant. (d) Old Grashey view radiograph of the right shoulder of the same patient a year earlier (found in picture archiving system) shows a healed right humeral fracture (arrow). This fracture was reportedly related to a prior episode of a fall due to the same mechanism.

Acute and chronic fractures in different victims of IPV. (a) Axial CT                    image of the face in a 52-year-old woman who presented to the emergency                    department with left facial swelling shows periorbital swelling in the soft                    tissues. (b) Axial bone-algorithm reconstructed CT image in the same patient                    shows a minimally displaced nasal bone fracture (arrow) with well-corticated                    margins and no soft-tissue swelling, suggesting an old fracture. This patient                    reported multiple prior episodes of violence from her partner. (c) Frontal                    radiograph of the left wrist in a 58-year-old woman who presented to the                    emergency department 4 days after a fall over her dog’s leash (reportedly                    wrapped around her leg) and landing on her left wrist shows a comminuted,                    minimally displaced fracture (arrow) of the midshaft of the ulna. Of note, the                    patient was right-hand dominant. (d) Old Grashey view radiograph of the right                    shoulder of the same patient a year earlier (found in picture archiving system)                    shows a healed right humeral fracture (arrow). This fracture was reportedly                    related to a prior episode of a fall due to the same mechanism.

Figure 1c. Acute and chronic fractures in different victims of IPV. (a) Axial CT image of the face in a 52-year-old woman who presented to the emergency department with left facial swelling shows periorbital swelling in the soft tissues. (b) Axial bone-algorithm reconstructed CT image in the same patient shows a minimally displaced nasal bone fracture (arrow) with well-corticated margins and no soft-tissue swelling, suggesting an old fracture. This patient reported multiple prior episodes of violence from her partner. (c) Frontal radiograph of the left wrist in a 58-year-old woman who presented to the emergency department 4 days after a fall over her dog’s leash (reportedly wrapped around her leg) and landing on her left wrist shows a comminuted, minimally displaced fracture (arrow) of the midshaft of the ulna. Of note, the patient was right-hand dominant. (d) Old Grashey view radiograph of the right shoulder of the same patient a year earlier (found in picture archiving system) shows a healed right humeral fracture (arrow). This fracture was reportedly related to a prior episode of a fall due to the same mechanism.

Acute and chronic fractures in different victims of IPV. (a) Axial CT                    image of the face in a 52-year-old woman who presented to the emergency                    department with left facial swelling shows periorbital swelling in the soft                    tissues. (b) Axial bone-algorithm reconstructed CT image in the same patient                    shows a minimally displaced nasal bone fracture (arrow) with well-corticated                    margins and no soft-tissue swelling, suggesting an old fracture. This patient                    reported multiple prior episodes of violence from her partner. (c) Frontal                    radiograph of the left wrist in a 58-year-old woman who presented to the                    emergency department 4 days after a fall over her dog’s leash (reportedly                    wrapped around her leg) and landing on her left wrist shows a comminuted,                    minimally displaced fracture (arrow) of the midshaft of the ulna. Of note, the                    patient was right-hand dominant. (d) Old Grashey view radiograph of the right                    shoulder of the same patient a year earlier (found in picture archiving system)                    shows a healed right humeral fracture (arrow). This fracture was reportedly                    related to a prior episode of a fall due to the same mechanism.

Figure 1d. Acute and chronic fractures in different victims of IPV. (a) Axial CT image of the face in a 52-year-old woman who presented to the emergency department with left facial swelling shows periorbital swelling in the soft tissues. (b) Axial bone-algorithm reconstructed CT image in the same patient shows a minimally displaced nasal bone fracture (arrow) with well-corticated margins and no soft-tissue swelling, suggesting an old fracture. This patient reported multiple prior episodes of violence from her partner. (c) Frontal radiograph of the left wrist in a 58-year-old woman who presented to the emergency department 4 days after a fall over her dog’s leash (reportedly wrapped around her leg) and landing on her left wrist shows a comminuted, minimally displaced fracture (arrow) of the midshaft of the ulna. Of note, the patient was right-hand dominant. (d) Old Grashey view radiograph of the right shoulder of the same patient a year earlier (found in picture archiving system) shows a healed right humeral fracture (arrow). This fracture was reportedly related to a prior episode of a fall due to the same mechanism.

In addition, because radiologists have access to image archiving systems, they can easily assess the imaging utilization patterns among victims of IPV. In a study involving 185 IPV victims and 555 age- and sex-matched control subjects (9), a median of four times more imaging studies were performed in IPV victims in 5 years compared with the number of imaging studies performed in control subjects. When the history is not available, the victim has no available prior imaging studies, and only acute injuries are seen, the diagnosis of IPV can be challenging. In these cases, radiologists must rely on only the presence of injuries in defensive locations and target areas, such as the face and upper extremities, to suggest a diagnosis of IPV. In all cases, the imaging findings need to be corroborated with the clinical assessment findings of the referring provider.

Finally,

Teaching Point by providing an objective unbiased report, radiologists can help clinicians identify potential victims of IPV. First, the radiologist should carefully scrutinize the image archiving systems to review prior imaging studies of different parts of the body to identify any hint of IPV, which can then be correlated with the clinical findings and history taken at presentation (14). All findings, both acute and chronic, even if they are nonspecific, should be reported (Fig 2). The simultaneous presence of more than one imaging finding suggestive of injury, as well as the presence of fractures at different stages of healing, increases the likelihood that the patient’s injuries are the result of IPV (14,28).
Completeness of the report is key: In addition to exposing IPV, radiologic reports can be used in trials and submitted by the victim or the victim’s attorney as evidence for issuing a range of protective relief orders to the abuser, such as a restraining order (29).

Diagram illustrates the role of the radiologist in the detection of                    IPV.

Figure 2. Diagram illustrates the role of the radiologist in the detection of IPV.

Currently there is no widely accepted method of communication between the radiologist and referring provider regarding concerns related to IPV. As a rule, radiologists should document findings in the report without specifying IPV as a potential cause, for various reasons including the fact that the report constitutes a permanent record in the patient’s chart and ultimately it is the victim’s choice to disclose IPV. Furthermore, the report potentially can be read by the violent partner, leading to escalated violence.

Imaging Findings

Craniofacial Injuries

The head and face are the most commonly injured parts of the body in victims of IPV, as they are easily accessible target areas for abuse (30,31). More than 88% of victims of IPV-related assault present to the emergency department with facial injuries, and 56% of them have an associated facial fracture (25). In women who present to the emergency department, more than half of the cases of facial injury are secondary to IPV (28). The most common type of assault is punching, followed by assault with a blunt household object such as a bottle (30,32).

The most common location of facial injury is the left side of the middle third of the face. This is probably due to the prominence of the zygomatic region and nose, the greater proportion of right-handed assailants, and a reflex of victims to turn their face to the right, exposing the left side of the face (Fig 3) (25,31). In approximately one-third of cases, there is involvement of more than one facial region (33).

Teaching Point The most common type of craniofacial injury is contusion. In a study in which victims of IPV were compared with victims of stranger assault (34), the presence of soft-tissue thickening in the midface was highly specific for IPV, as IPV victims are less likely to be assaulted by weapons. Thus, a higher proportion of these victims present with facial contusions only (28,34). Contusions often manifest with soft-tissue swelling and/or variable degrees of subcutaneous hematoma (Fig 4).

Facial injuries in a 31-year-old woman who presented to the emergency                        department with left eye pain, and swelling and bruising on the left side of                        her face. This patient, whose boyfriend assaulted her and punched her in the                        face, experienced a prior episode of IPV the year before with the same                        partner. Coronal (a) and axial reconstructed (b) CT images show a small left                        periorbital hematoma (arrow), with normal-appearing orbital contents that                        include the globes, intraconal structures, and extraocular                        muscles.

Figure 3a. Facial injuries in a 31-year-old woman who presented to the emergency department with left eye pain, and swelling and bruising on the left side of her face. This patient, whose boyfriend assaulted her and punched her in the face, experienced a prior episode of IPV the year before with the same partner. Coronal (a) and axial reconstructed (b) CT images show a small left periorbital hematoma (arrow), with normal-appearing orbital contents that include the globes, intraconal structures, and extraocular muscles.

Facial injuries in a 31-year-old woman who presented to the emergency                        department with left eye pain, and swelling and bruising on the left side of                        her face. This patient, whose boyfriend assaulted her and punched her in the                        face, experienced a prior episode of IPV the year before with the same                        partner. Coronal (a) and axial reconstructed (b) CT images show a small left                        periorbital hematoma (arrow), with normal-appearing orbital contents that                        include the globes, intraconal structures, and extraocular                        muscles.

Figure 3b. Facial injuries in a 31-year-old woman who presented to the emergency department with left eye pain, and swelling and bruising on the left side of her face. This patient, whose boyfriend assaulted her and punched her in the face, experienced a prior episode of IPV the year before with the same partner. Coronal (a) and axial reconstructed (b) CT images show a small left periorbital hematoma (arrow), with normal-appearing orbital contents that include the globes, intraconal structures, and extraocular muscles.

Soft-tissue contusions in different victims of IPV. (a, b) Axial CT                        images show skin thickening, subcutaneous swelling, and stranding in the                        left zygomatic (arrow in a) and left anterior maxillary (arrow in b)                        regions. (c–e) Axial CT images show soft-tissue contusions (arrow) in                        the right maxillary (c), right zygomatic (d), and right frontal (e) regions.                        An associated subcutaneous hematoma (arrowhead in c) also is seen. (f) Axial                        CT image shows a subcutaneous hematoma (arrow) in the left supraorbital                        region. (g) Lateral radiograph of the left forearm shows soft-tissue                        swelling of the dorsal aspect of the forearm (arrow) caused by a direct                        injury that occurred while the victim was using her arm to protect her                        face.

Figure 4a. Soft-tissue contusions in different victims of IPV. (a, b) Axial CT images show skin thickening, subcutaneous swelling, and stranding in the left zygomatic (arrow in a) and left anterior maxillary (arrow in b) regions. (c–e) Axial CT images show soft-tissue contusions (arrow) in the right maxillary (c), right zygomatic (d), and right frontal (e) regions. An associated subcutaneous hematoma (arrowhead in c) also is seen. (f) Axial CT image shows a subcutaneous hematoma (arrow) in the left supraorbital region. (g) Lateral radiograph of the left forearm shows soft-tissue swelling of the dorsal aspect of the forearm (arrow) caused by a direct injury that occurred while the victim was using her arm to protect her face.

Soft-tissue contusions in different victims of IPV. (a, b) Axial CT                        images show skin thickening, subcutaneous swelling, and stranding in the                        left zygomatic (arrow in a) and left anterior maxillary (arrow in b)                        regions. (c–e) Axial CT images show soft-tissue contusions (arrow) in                        the right maxillary (c), right zygomatic (d), and right frontal (e) regions.                        An associated subcutaneous hematoma (arrowhead in c) also is seen. (f) Axial                        CT image shows a subcutaneous hematoma (arrow) in the left supraorbital                        region. (g) Lateral radiograph of the left forearm shows soft-tissue                        swelling of the dorsal aspect of the forearm (arrow) caused by a direct                        injury that occurred while the victim was using her arm to protect her                        face.

Figure 4b. Soft-tissue contusions in different victims of IPV. (a, b) Axial CT images show skin thickening, subcutaneous swelling, and stranding in the left zygomatic (arrow in a) and left anterior maxillary (arrow in b) regions. (c–e) Axial CT images show soft-tissue contusions (arrow) in the right maxillary (c), right zygomatic (d), and right frontal (e) regions. An associated subcutaneous hematoma (arrowhead in c) also is seen. (f) Axial CT image shows a subcutaneous hematoma (arrow) in the left supraorbital region. (g) Lateral radiograph of the left forearm shows soft-tissue swelling of the dorsal aspect of the forearm (arrow) caused by a direct injury that occurred while the victim was using her arm to protect her face.

Soft-tissue contusions in different victims of IPV. (a, b) Axial CT                        images show skin thickening, subcutaneous swelling, and stranding in the                        left zygomatic (arrow in a) and left anterior maxillary (arrow in b)                        regions. (c–e) Axial CT images show soft-tissue contusions (arrow) in                        the right maxillary (c), right zygomatic (d), and right frontal (e) regions.                        An associated subcutaneous hematoma (arrowhead in c) also is seen. (f) Axial                        CT image shows a subcutaneous hematoma (arrow) in the left supraorbital                        region. (g) Lateral radiograph of the left forearm shows soft-tissue                        swelling of the dorsal aspect of the forearm (arrow) caused by a direct                        injury that occurred while the victim was using her arm to protect her                        face.

Figure 4c. Soft-tissue contusions in different victims of IPV. (a, b) Axial CT images show skin thickening, subcutaneous swelling, and stranding in the left zygomatic (arrow in a) and left anterior maxillary (arrow in b) regions. (c–e) Axial CT images show soft-tissue contusions (arrow) in the right maxillary (c), right zygomatic (d), and right frontal (e) regions. An associated subcutaneous hematoma (arrowhead in c) also is seen. (f) Axial CT image shows a subcutaneous hematoma (arrow) in the left supraorbital region. (g) Lateral radiograph of the left forearm shows soft-tissue swelling of the dorsal aspect of the forearm (arrow) caused by a direct injury that occurred while the victim was using her arm to protect her face.

Soft-tissue contusions in different victims of IPV. (a, b) Axial CT                        images show skin thickening, subcutaneous swelling, and stranding in the                        left zygomatic (arrow in a) and left anterior maxillary (arrow in b)                        regions. (c–e) Axial CT images show soft-tissue contusions (arrow) in                        the right maxillary (c), right zygomatic (d), and right frontal (e) regions.                        An associated subcutaneous hematoma (arrowhead in c) also is seen. (f) Axial                        CT image shows a subcutaneous hematoma (arrow) in the left supraorbital                        region. (g) Lateral radiograph of the left forearm shows soft-tissue                        swelling of the dorsal aspect of the forearm (arrow) caused by a direct                        injury that occurred while the victim was using her arm to protect her                        face.

Figure 4d. Soft-tissue contusions in different victims of IPV. (a, b) Axial CT images show skin thickening, subcutaneous swelling, and stranding in the left zygomatic (arrow in a) and left anterior maxillary (arrow in b) regions. (c–e) Axial CT images show soft-tissue contusions (arrow) in the right maxillary (c), right zygomatic (d), and right frontal (e) regions. An associated subcutaneous hematoma (arrowhead in c) also is seen. (f) Axial CT image shows a subcutaneous hematoma (arrow) in the left supraorbital region. (g) Lateral radiograph of the left forearm shows soft-tissue swelling of the dorsal aspect of the forearm (arrow) caused by a direct injury that occurred while the victim was using her arm to protect her face.

Soft-tissue contusions in different victims of IPV. (a, b) Axial CT                        images show skin thickening, subcutaneous swelling, and stranding in the                        left zygomatic (arrow in a) and left anterior maxillary (arrow in b)                        regions. (c–e) Axial CT images show soft-tissue contusions (arrow) in                        the right maxillary (c), right zygomatic (d), and right frontal (e) regions.                        An associated subcutaneous hematoma (arrowhead in c) also is seen. (f) Axial                        CT image shows a subcutaneous hematoma (arrow) in the left supraorbital                        region. (g) Lateral radiograph of the left forearm shows soft-tissue                        swelling of the dorsal aspect of the forearm (arrow) caused by a direct                        injury that occurred while the victim was using her arm to protect her                        face.

Figure 4e. Soft-tissue contusions in different victims of IPV. (a, b) Axial CT images show skin thickening, subcutaneous swelling, and stranding in the left zygomatic (arrow in a) and left anterior maxillary (arrow in b) regions. (c–e) Axial CT images show soft-tissue contusions (arrow) in the right maxillary (c), right zygomatic (d), and right frontal (e) regions. An associated subcutaneous hematoma (arrowhead in c) also is seen. (f) Axial CT image shows a subcutaneous hematoma (arrow) in the left supraorbital region. (g) Lateral radiograph of the left forearm shows soft-tissue swelling of the dorsal aspect of the forearm (arrow) caused by a direct injury that occurred while the victim was using her arm to protect her face.

Soft-tissue contusions in different victims of IPV. (a, b) Axial CT                        images show skin thickening, subcutaneous swelling, and stranding in the                        left zygomatic (arrow in a) and left anterior maxillary (arrow in b)                        regions. (c–e) Axial CT images show soft-tissue contusions (arrow) in                        the right maxillary (c), right zygomatic (d), and right frontal (e) regions.                        An associated subcutaneous hematoma (arrowhead in c) also is seen. (f) Axial                        CT image shows a subcutaneous hematoma (arrow) in the left supraorbital                        region. (g) Lateral radiograph of the left forearm shows soft-tissue                        swelling of the dorsal aspect of the forearm (arrow) caused by a direct                        injury that occurred while the victim was using her arm to protect her                        face.

Figure 4f. Soft-tissue contusions in different victims of IPV. (a, b) Axial CT images show skin thickening, subcutaneous swelling, and stranding in the left zygomatic (arrow in a) and left anterior maxillary (arrow in b) regions. (c–e) Axial CT images show soft-tissue contusions (arrow) in the right maxillary (c), right zygomatic (d), and right frontal (e) regions. An associated subcutaneous hematoma (arrowhead in c) also is seen. (f) Axial CT image shows a subcutaneous hematoma (arrow) in the left supraorbital region. (g) Lateral radiograph of the left forearm shows soft-tissue swelling of the dorsal aspect of the forearm (arrow) caused by a direct injury that occurred while the victim was using her arm to protect her face.

Soft-tissue contusions in different victims of IPV. (a, b) Axial CT                        images show skin thickening, subcutaneous swelling, and stranding in the                        left zygomatic (arrow in a) and left anterior maxillary (arrow in b)                        regions. (c–e) Axial CT images show soft-tissue contusions (arrow) in                        the right maxillary (c), right zygomatic (d), and right frontal (e) regions.                        An associated subcutaneous hematoma (arrowhead in c) also is seen. (f) Axial                        CT image shows a subcutaneous hematoma (arrow) in the left supraorbital                        region. (g) Lateral radiograph of the left forearm shows soft-tissue                        swelling of the dorsal aspect of the forearm (arrow) caused by a direct                        injury that occurred while the victim was using her arm to protect her                        face.

Figure 4g. Soft-tissue contusions in different victims of IPV. (a, b) Axial CT images show skin thickening, subcutaneous swelling, and stranding in the left zygomatic (arrow in a) and left anterior maxillary (arrow in b) regions. (c–e) Axial CT images show soft-tissue contusions (arrow) in the right maxillary (c), right zygomatic (d), and right frontal (e) regions. An associated subcutaneous hematoma (arrowhead in c) also is seen. (f) Axial CT image shows a subcutaneous hematoma (arrow) in the left supraorbital region. (g) Lateral radiograph of the left forearm shows soft-tissue swelling of the dorsal aspect of the forearm (arrow) caused by a direct injury that occurred while the victim was using her arm to protect her face.

Fractures most commonly involve the nasal bone, followed by the zygomatic complex and the mandible (25,28,30,35). Nasal bone fractures are relatively common, can be acute or chronic, and may be associated with significant facial deformity and soft-tissue swelling (Fig 5). In cases of soft-tissue swelling of the midface, sagittal and coronal CT images should be carefully inspected to avoid missing nasoseptal fractures that may lead to permanent deformity (36).

Nasal bone fractures in different victims of IPV. (a, b) Coronal (a)                        and axial (b) bone-window CT images show a minimally displaced left nasal                        bone fracture (arrow). (c) Coronal bone-window CT image shows a comminuted                        right nasal bone fracture (arrow). (d) Axial bone-window CT image shows a                        depressed left nasal bone fracture (arrow).

Figure 5a. Nasal bone fractures in different victims of IPV. (a, b) Coronal (a) and axial (b) bone-window CT images show a minimally displaced left nasal bone fracture (arrow). (c) Coronal bone-window CT image shows a comminuted right nasal bone fracture (arrow). (d) Axial bone-window CT image shows a depressed left nasal bone fracture (arrow).

Nasal bone fractures in different victims of IPV. (a, b) Coronal (a)                        and axial (b) bone-window CT images show a minimally displaced left nasal                        bone fracture (arrow). (c) Coronal bone-window CT image shows a comminuted                        right nasal bone fracture (arrow). (d) Axial bone-window CT image shows a                        depressed left nasal bone fracture (arrow).

Figure 5b. Nasal bone fractures in different victims of IPV. (a, b) Coronal (a) and axial (b) bone-window CT images show a minimally displaced left nasal bone fracture (arrow). (c) Coronal bone-window CT image shows a comminuted right nasal bone fracture (arrow). (d) Axial bone-window CT image shows a depressed left nasal bone fracture (arrow).

Nasal bone fractures in different victims of IPV. (a, b) Coronal (a)                        and axial (b) bone-window CT images show a minimally displaced left nasal                        bone fracture (arrow). (c) Coronal bone-window CT image shows a comminuted                        right nasal bone fracture (arrow). (d) Axial bone-window CT image shows a                        depressed left nasal bone fracture (arrow).

Figure 5c. Nasal bone fractures in different victims of IPV. (a, b) Coronal (a) and axial (b) bone-window CT images show a minimally displaced left nasal bone fracture (arrow). (c) Coronal bone-window CT image shows a comminuted right nasal bone fracture (arrow). (d) Axial bone-window CT image shows a depressed left nasal bone fracture (arrow).

Nasal bone fractures in different victims of IPV. (a, b) Coronal (a)                        and axial (b) bone-window CT images show a minimally displaced left nasal                        bone fracture (arrow). (c) Coronal bone-window CT image shows a comminuted                        right nasal bone fracture (arrow). (d) Axial bone-window CT image shows a                        depressed left nasal bone fracture (arrow).

Figure 5d. Nasal bone fractures in different victims of IPV. (a, b) Coronal (a) and axial (b) bone-window CT images show a minimally displaced left nasal bone fracture (arrow). (c) Coronal bone-window CT image shows a comminuted right nasal bone fracture (arrow). (d) Axial bone-window CT image shows a depressed left nasal bone fracture (arrow).

Mandible fractures are frequently observed in victims of IPV; however, they are more common among patients assaulted by strangers (25). IPV-related mandible fractures most commonly involve the condyle and then the angle, followed by the body of the mandible (30). Often, multiple mandibular fractures can be observed (30).

Orbital fractures are considered an identifiable manifestation of IPV, as IPV is more commonly detected in women who have orbital fractures at admission than in women admitted for any other reason (37). Orbital fractures also are significantly more common in victims of IPV than in victims of stranger assault, and they more often involve the right side (Figs 68) (28,38). In severe cases, patients can develop optic neuropathy or vision loss (Fig 7) (31).

Orbital fractures in a 25-year-old woman with a history of IPV who                        presented to the emergency department with swelling of the right face and                        blurry vision, which reportedly occurred after a fall. Axial (a, c, d) and                        coronal reconstructed (b) CT images show a mildly displaced fracture of the                        right nasal bone (arrowhead in a), comminuted displaced fractures involving                        the orbital floor and right maxillary sinus (arrows in a and b) with                        hemosinus, a comminuted depressed fracture of the right zygomatic arch                        (arrow in c), and a depressed fracture of the right lateral orbital wall                        (arrow in d). Soft-tissue swelling of the right orbital region also is                        noted.

Figure 6a. Orbital fractures in a 25-year-old woman with a history of IPV who presented to the emergency department with swelling of the right face and blurry vision, which reportedly occurred after a fall. Axial (a, c, d) and coronal reconstructed (b) CT images show a mildly displaced fracture of the right nasal bone (arrowhead in a), comminuted displaced fractures involving the orbital floor and right maxillary sinus (arrows in a and b) with hemosinus, a comminuted depressed fracture of the right zygomatic arch (arrow in c), and a depressed fracture of the right lateral orbital wall (arrow in d). Soft-tissue swelling of the right orbital region also is noted.

Orbital fractures in a 25-year-old woman with a history of IPV who                        presented to the emergency department with swelling of the right face and                        blurry vision, which reportedly occurred after a fall. Axial (a, c, d) and                        coronal reconstructed (b) CT images show a mildly displaced fracture of the                        right nasal bone (arrowhead in a), comminuted displaced fractures involving                        the orbital floor and right maxillary sinus (arrows in a and b) with                        hemosinus, a comminuted depressed fracture of the right zygomatic arch                        (arrow in c), and a depressed fracture of the right lateral orbital wall                        (arrow in d). Soft-tissue swelling of the right orbital region also is                        noted.

Figure 6b. Orbital fractures in a 25-year-old woman with a history of IPV who presented to the emergency department with swelling of the right face and blurry vision, which reportedly occurred after a fall. Axial (a, c, d) and coronal reconstructed (b) CT images show a mildly displaced fracture of the right nasal bone (arrowhead in a), comminuted displaced fractures involving the orbital floor and right maxillary sinus (arrows in a and b) with hemosinus, a comminuted depressed fracture of the right zygomatic arch (arrow in c), and a depressed fracture of the right lateral orbital wall (arrow in d). Soft-tissue swelling of the right orbital region also is noted.

Orbital fractures in a 25-year-old woman with a history of IPV who                        presented to the emergency department with swelling of the right face and                        blurry vision, which reportedly occurred after a fall. Axial (a, c, d) and                        coronal reconstructed (b) CT images show a mildly displaced fracture of the                        right nasal bone (arrowhead in a), comminuted displaced fractures involving                        the orbital floor and right maxillary sinus (arrows in a and b) with                        hemosinus, a comminuted depressed fracture of the right zygomatic arch                        (arrow in c), and a depressed fracture of the right lateral orbital wall                        (arrow in d). Soft-tissue swelling of the right orbital region also is                        noted.

Figure 6c. Orbital fractures in a 25-year-old woman with a history of IPV who presented to the emergency department with swelling of the right face and blurry vision, which reportedly occurred after a fall. Axial (a, c, d) and coronal reconstructed (b) CT images show a mildly displaced fracture of the right nasal bone (arrowhead in a), comminuted displaced fractures involving the orbital floor and right maxillary sinus (arrows in a and b) with hemosinus, a comminuted depressed fracture of the right zygomatic arch (arrow in c), and a depressed fracture of the right lateral orbital wall (arrow in d). Soft-tissue swelling of the right orbital region also is noted.

Orbital fractures in a 25-year-old woman with a history of IPV who                        presented to the emergency department with swelling of the right face and                        blurry vision, which reportedly occurred after a fall. Axial (a, c, d) and                        coronal reconstructed (b) CT images show a mildly displaced fracture of the                        right nasal bone (arrowhead in a), comminuted displaced fractures involving                        the orbital floor and right maxillary sinus (arrows in a and b) with                        hemosinus, a comminuted depressed fracture of the right zygomatic arch                        (arrow in c), and a depressed fracture of the right lateral orbital wall                        (arrow in d). Soft-tissue swelling of the right orbital region also is                        noted.

Figure 6d. Orbital fractures in a 25-year-old woman with a history of IPV who presented to the emergency department with swelling of the right face and blurry vision, which reportedly occurred after a fall. Axial (a, c, d) and coronal reconstructed (b) CT images show a mildly displaced fracture of the right nasal bone (arrowhead in a), comminuted displaced fractures involving the orbital floor and right maxillary sinus (arrows in a and b) with hemosinus, a comminuted depressed fracture of the right zygomatic arch (arrow in c), and a depressed fracture of the right lateral orbital wall (arrow in d). Soft-tissue swelling of the right orbital region also is noted.

Orbital fractures in a 76-year-old woman who presented to the                        emergency department with right-sided vision loss after being punched by her                        husband. Coronal (a) and axial (b) bone-window and axial soft-tissue (c) CT                        images show a blow-out orbital floor fracture (arrow in a), a fracture of                        the posterior wall of the maxillary sinus (arrowhead in b), maxillary sinus                        hemorrhage (arrow in b), soft-tissue swelling (arrow in c), and vitreous                        hemorrhage (arrowhead in c).

Figure 7a. Orbital fractures in a 76-year-old woman who presented to the emergency department with right-sided vision loss after being punched by her husband. Coronal (a) and axial (b) bone-window and axial soft-tissue (c) CT images show a blow-out orbital floor fracture (arrow in a), a fracture of the posterior wall of the maxillary sinus (arrowhead in b), maxillary sinus hemorrhage (arrow in b), soft-tissue swelling (arrow in c), and vitreous hemorrhage (arrowhead in c).

Orbital fractures in a 76-year-old woman who presented to the                        emergency department with right-sided vision loss after being punched by her                        husband. Coronal (a) and axial (b) bone-window and axial soft-tissue (c) CT                        images show a blow-out orbital floor fracture (arrow in a), a fracture of                        the posterior wall of the maxillary sinus (arrowhead in b), maxillary sinus                        hemorrhage (arrow in b), soft-tissue swelling (arrow in c), and vitreous                        hemorrhage (arrowhead in c).

Figure 7b. Orbital fractures in a 76-year-old woman who presented to the emergency department with right-sided vision loss after being punched by her husband. Coronal (a) and axial (b) bone-window and axial soft-tissue (c) CT images show a blow-out orbital floor fracture (arrow in a), a fracture of the posterior wall of the maxillary sinus (arrowhead in b), maxillary sinus hemorrhage (arrow in b), soft-tissue swelling (arrow in c), and vitreous hemorrhage (arrowhead in c).

Orbital fractures in a 76-year-old woman who presented to the                        emergency department with right-sided vision loss after being punched by her                        husband. Coronal (a) and axial (b) bone-window and axial soft-tissue (c) CT                        images show a blow-out orbital floor fracture (arrow in a), a fracture of                        the posterior wall of the maxillary sinus (arrowhead in b), maxillary sinus                        hemorrhage (arrow in b), soft-tissue swelling (arrow in c), and vitreous                        hemorrhage (arrowhead in c).

Figure 7c. Orbital fractures in a 76-year-old woman who presented to the emergency department with right-sided vision loss after being punched by her husband. Coronal (a) and axial (b) bone-window and axial soft-tissue (c) CT images show a blow-out orbital floor fracture (arrow in a), a fracture of the posterior wall of the maxillary sinus (arrowhead in b), maxillary sinus hemorrhage (arrow in b), soft-tissue swelling (arrow in c), and vitreous hemorrhage (arrowhead in c).

Orbital fractures in a 30-year-old woman assaulted by her                        ex-boyfriend. (a, b) Axial (a) and coronal (b) bone-window CT images show a                        blow-out right orbital fracture, with a fracture of the medial orbital plate                        (arrow in a), a mildly displaced fracture of the inferior orbital wall                        (arrow in b), and gas in the postseptal compartment (arrowhead in b). (c)                        Axial soft-tissue CT image shows gas (arrows) in the preseptal and                        postseptal compartments and an intact globus ocularis.

Figure 8a. Orbital fractures in a 30-year-old woman assaulted by her ex-boyfriend. (a, b) Axial (a) and coronal (b) bone-window CT images show a blow-out right orbital fracture, with a fracture of the medial orbital plate (arrow in a), a mildly displaced fracture of the inferior orbital wall (arrow in b), and gas in the postseptal compartment (arrowhead in b). (c) Axial soft-tissue CT image shows gas (arrows) in the preseptal and postseptal compartments and an intact globus ocularis.

Orbital fractures in a 30-year-old woman assaulted by her                        ex-boyfriend. (a, b) Axial (a) and coronal (b) bone-window CT images show a                        blow-out right orbital fracture, with a fracture of the medial orbital plate                        (arrow in a), a mildly displaced fracture of the inferior orbital wall                        (arrow in b), and gas in the postseptal compartment (arrowhead in b). (c)                        Axial soft-tissue CT image shows gas (arrows) in the preseptal and                        postseptal compartments and an intact globus ocularis.

Figure 8b. Orbital fractures in a 30-year-old woman assaulted by her ex-boyfriend. (a, b) Axial (a) and coronal (b) bone-window CT images show a blow-out right orbital fracture, with a fracture of the medial orbital plate (arrow in a), a mildly displaced fracture of the inferior orbital wall (arrow in b), and gas in the postseptal compartment (arrowhead in b). (c) Axial soft-tissue CT image shows gas (arrows) in the preseptal and postseptal compartments and an intact globus ocularis.

Orbital fractures in a 30-year-old woman assaulted by her                        ex-boyfriend. (a, b) Axial (a) and coronal (b) bone-window CT images show a                        blow-out right orbital fracture, with a fracture of the medial orbital plate                        (arrow in a), a mildly displaced fracture of the inferior orbital wall                        (arrow in b), and gas in the postseptal compartment (arrowhead in b). (c)                        Axial soft-tissue CT image shows gas (arrows) in the preseptal and                        postseptal compartments and an intact globus ocularis.

Figure 8c. Orbital fractures in a 30-year-old woman assaulted by her ex-boyfriend. (a, b) Axial (a) and coronal (b) bone-window CT images show a blow-out right orbital fracture, with a fracture of the medial orbital plate (arrow in a), a mildly displaced fracture of the inferior orbital wall (arrow in b), and gas in the postseptal compartment (arrowhead in b). (c) Axial soft-tissue CT image shows gas (arrows) in the preseptal and postseptal compartments and an intact globus ocularis.

Cranial fractures require significant force and are therefore observed in victims of IPV when the perpetrator uses a weapon or household object to hit the victim. Multiplanar and volume-rendered reconstructions can be helpful in recognizing depressed or comminuted skull fractures (Fig 9).

Depressed fractures in a 61-year-old woman who was unconscious when                        brought to the emergency department after being hit multiple times with a                        hammer by her husband. (a, b) Axial (a) and volume-rendered (b) CT images of                        the skull show multiple depressed cranial fractures (arrows). (c) Coronal                        reconstructed CT image shows a depressed right parietal bone fracture with                        adjacent intracranial lobules of gas (arrow), raising concern for an open                        fracture.

Figure 9a. Depressed fractures in a 61-year-old woman who was unconscious when brought to the emergency department after being hit multiple times with a hammer by her husband. (a, b) Axial (a) and volume-rendered (b) CT images of the skull show multiple depressed cranial fractures (arrows). (c) Coronal reconstructed CT image shows a depressed right parietal bone fracture with adjacent intracranial lobules of gas (arrow), raising concern for an open fracture.

Depressed fractures in a 61-year-old woman who was unconscious when                        brought to the emergency department after being hit multiple times with a                        hammer by her husband. (a, b) Axial (a) and volume-rendered (b) CT images of                        the skull show multiple depressed cranial fractures (arrows). (c) Coronal                        reconstructed CT image shows a depressed right parietal bone fracture with                        adjacent intracranial lobules of gas (arrow), raising concern for an open                        fracture.

Figure 9b. Depressed fractures in a 61-year-old woman who was unconscious when brought to the emergency department after being hit multiple times with a hammer by her husband. (a, b) Axial (a) and volume-rendered (b) CT images of the skull show multiple depressed cranial fractures (arrows). (c) Coronal reconstructed CT image shows a depressed right parietal bone fracture with adjacent intracranial lobules of gas (arrow), raising concern for an open fracture.

Depressed fractures in a 61-year-old woman who was unconscious when                        brought to the emergency department after being hit multiple times with a                        hammer by her husband. (a, b) Axial (a) and volume-rendered (b) CT images of                        the skull show multiple depressed cranial fractures (arrows). (c) Coronal                        reconstructed CT image shows a depressed right parietal bone fracture with                        adjacent intracranial lobules of gas (arrow), raising concern for an open                        fracture.

Figure 9c. Depressed fractures in a 61-year-old woman who was unconscious when brought to the emergency department after being hit multiple times with a hammer by her husband. (a, b) Axial (a) and volume-rendered (b) CT images of the skull show multiple depressed cranial fractures (arrows). (c) Coronal reconstructed CT image shows a depressed right parietal bone fracture with adjacent intracranial lobules of gas (arrow), raising concern for an open fracture.

Teaching Point The simultaneous presence of chronic and acute fractures is common and highly specific for IPV, and it provides insight regarding the recurring nature of the violent episodes experienced by the victim (28,39). Occasionally, chronic fractures can be the sole finding, as victims of IPV often visit the emergency department days after the violent episode.

Dental injuries represent 0.6%–27.0% of craniofacial injuries in IPV victims (31,37). The most frequently injured teeth are the incisors and maxillary canines. The most frequent types of injury are dental fractures, followed by luxations and avulsions (40). Tooth fractures can be seen as a linear area of low attenuation traversing the various layers of the tooth. Careful inspection of the fracture line is crucial, as fractures affecting the pulp are associated with a worse prognosis because they interrupt vascularization of the tooth (Fig 10) (41).

Dental fractures in a 28-year-old woman who presented to the emergency                        department 2 weeks after being punched in the face. Axial (a), coronal (b),                        and sagittal (c) bone-window CT images of the face show a mildly displaced                        fracture of the body of the mandible (arrow in a), a fracture of the right                        lateral mandibular incisor (arrow in b), and a minimally displaced right                        parasymphyseal fracture with involvement of the alveolar ridge (arrow in                        c).

Figure 10a. Dental fractures in a 28-year-old woman who presented to the emergency department 2 weeks after being punched in the face. Axial (a), coronal (b), and sagittal (c) bone-window CT images of the face show a mildly displaced fracture of the body of the mandible (arrow in a), a fracture of the right lateral mandibular incisor (arrow in b), and a minimally displaced right parasymphyseal fracture with involvement of the alveolar ridge (arrow in c).

Dental fractures in a 28-year-old woman who presented to the emergency                        department 2 weeks after being punched in the face. Axial (a), coronal (b),                        and sagittal (c) bone-window CT images of the face show a mildly displaced                        fracture of the body of the mandible (arrow in a), a fracture of the right                        lateral mandibular incisor (arrow in b), and a minimally displaced right                        parasymphyseal fracture with involvement of the alveolar ridge (arrow in                        c).

Figure 10b. Dental fractures in a 28-year-old woman who presented to the emergency department 2 weeks after being punched in the face. Axial (a), coronal (b), and sagittal (c) bone-window CT images of the face show a mildly displaced fracture of the body of the mandible (arrow in a), a fracture of the right lateral mandibular incisor (arrow in b), and a minimally displaced right parasymphyseal fracture with involvement of the alveolar ridge (arrow in c).

Dental fractures in a 28-year-old woman who presented to the emergency                        department 2 weeks after being punched in the face. Axial (a), coronal (b),                        and sagittal (c) bone-window CT images of the face show a mildly displaced                        fracture of the body of the mandible (arrow in a), a fracture of the right                        lateral mandibular incisor (arrow in b), and a minimally displaced right                        parasymphyseal fracture with involvement of the alveolar ridge (arrow in                        c).

Figure 10c. Dental fractures in a 28-year-old woman who presented to the emergency department 2 weeks after being punched in the face. Axial (a), coronal (b), and sagittal (c) bone-window CT images of the face show a mildly displaced fracture of the body of the mandible (arrow in a), a fracture of the right lateral mandibular incisor (arrow in b), and a minimally displaced right parasymphyseal fracture with involvement of the alveolar ridge (arrow in c).

Dental luxations include different injuries that affect the tooth support structures, including the periodontal ligament. These injuries can be observed on CT images as widening or narrowing of the periodontal ligament space in extrusive or intrusive luxation, respectively (42).

Musculoskeletal Injuries

Musculoskeletal injuries are the second most common type of IPV-related injury after craniofacial injuries (31). It is estimated that one out of six women with a musculoskeletal injury who present to an orthopedic clinic have a history of IPV that occurred within the prior 12 months, and one in three have a history of IPV that occurred sometime during their lifetime (43). The most common types of musculoskeletal injuries are fractures, followed by ligament sprains, muscle tears, and dislocations (31,43). Similar to craniofacial injuries, coexistent old and acute musculoskeletal fractures are highly specific for IPV, compared with injuries from stranger assault, and approximately half of these cases manifest as multiple injuries (28).

Teaching Point A significant number of IPV-related injuries occur in the upper extremities, in “defensive” locations such as the hands, wrists, and forearms, as these areas are hit when the victim tries to protect his or her body from the abuser (24).
The most common sites of fracture in the upper extremities are the phalanges, followed by the ulna and radius (24,44).

Victims of IPV most commonly report falling as the mechanism of injury, followed by sports-related injury and motor vehicle accident, rather than disclose the episode of violence (43). Regardless of the reported mechanism, the possibility of IPV should be considered when discrepancies between the reported mechanism of injury and the imaging findings are observed, specifically when the fracture observed is more likely to be related to a direct blow (14).

Fractures from direct blows to the upper extremities commonly involve the proximal or middle phalanges or the metacarpal bones in the hand. These bones manifest radiographically as linear lucencies in various locations and orientations (45). In general, fractures tend to be nondisplaced or only minimally displaced; however, careful inspection of images for intra-articular fractures and fragment displacements must be performed, as these may require surgical management (Fig 11). Isolated ulnar fractures, also termed “nightstick” fractures, are associated with a direct blow to the arm (4648). A fall is unlikely to cause an isolated ulnar fracture. The majority of the force at impact would be transmitted to the distal radius, which would consequently become fractured. In contrast, ulnar fractures are often sustained when a forearm is raised in a defensive manner to protect the face or head (Fig 12) (14). Radial fractures may occur when the victim falls as a consequence of being pushed by the assailant partner.

Radiographs of the hands of four IPV victims show dislocation of the                        second proximal interphalangeal joint (arrow in a), a comminuted fracture of                        the middle phalanx of the middle finger (arrow in b), a displaced fracture                        of the right fifth metacarpal diaphysis (arrow in c), and a minimally                        displaced comminuted fracture of the tuft of the distal phalanx of the fifth                        finger (arrow in d). In all cases, the victims were protecting their bodies                        from the assaults of the perpetrators. The victim in d presented to the                        emergency room 1 day after the injury. She reported that the injury occurred                        while she was cutting food with a knife, which slipped and cut her finger.                        The emergency medical service initially was called to her house but was sent                        away by her partner. The victim then presented to her primary care                        physician, who referred her to the emergency department.

Figure 11a. Radiographs of the hands of four IPV victims show dislocation of the second proximal interphalangeal joint (arrow in a), a comminuted fracture of the middle phalanx of the middle finger (arrow in b), a displaced fracture of the right fifth metacarpal diaphysis (arrow in c), and a minimally displaced comminuted fracture of the tuft of the distal phalanx of the fifth finger (arrow in d). In all cases, the victims were protecting their bodies from the assaults of the perpetrators. The victim in d presented to the emergency room 1 day after the injury. She reported that the injury occurred while she was cutting food with a knife, which slipped and cut her finger. The emergency medical service initially was called to her house but was sent away by her partner. The victim then presented to her primary care physician, who referred her to the emergency department.

Radiographs of the hands of four IPV victims show dislocation of the                        second proximal interphalangeal joint (arrow in a), a comminuted fracture of                        the middle phalanx of the middle finger (arrow in b), a displaced fracture                        of the right fifth metacarpal diaphysis (arrow in c), and a minimally                        displaced comminuted fracture of the tuft of the distal phalanx of the fifth                        finger (arrow in d). In all cases, the victims were protecting their bodies                        from the assaults of the perpetrators. The victim in d presented to the                        emergency room 1 day after the injury. She reported that the injury occurred                        while she was cutting food with a knife, which slipped and cut her finger.                        The emergency medical service initially was called to her house but was sent                        away by her partner. The victim then presented to her primary care                        physician, who referred her to the emergency department.

Figure 11b. Radiographs of the hands of four IPV victims show dislocation of the second proximal interphalangeal joint (arrow in a), a comminuted fracture of the middle phalanx of the middle finger (arrow in b), a displaced fracture of the right fifth metacarpal diaphysis (arrow in c), and a minimally displaced comminuted fracture of the tuft of the distal phalanx of the fifth finger (arrow in d). In all cases, the victims were protecting their bodies from the assaults of the perpetrators. The victim in d presented to the emergency room 1 day after the injury. She reported that the injury occurred while she was cutting food with a knife, which slipped and cut her finger. The emergency medical service initially was called to her house but was sent away by her partner. The victim then presented to her primary care physician, who referred her to the emergency department.

Radiographs of the hands of four IPV victims show dislocation of the                        second proximal interphalangeal joint (arrow in a), a comminuted fracture of                        the middle phalanx of the middle finger (arrow in b), a displaced fracture                        of the right fifth metacarpal diaphysis (arrow in c), and a minimally                        displaced comminuted fracture of the tuft of the distal phalanx of the fifth                        finger (arrow in d). In all cases, the victims were protecting their bodies                        from the assaults of the perpetrators. The victim in d presented to the                        emergency room 1 day after the injury. She reported that the injury occurred                        while she was cutting food with a knife, which slipped and cut her finger.                        The emergency medical service initially was called to her house but was sent                        away by her partner. The victim then presented to her primary care                        physician, who referred her to the emergency department.

Figure 11c. Radiographs of the hands of four IPV victims show dislocation of the second proximal interphalangeal joint (arrow in a), a comminuted fracture of the middle phalanx of the middle finger (arrow in b), a displaced fracture of the right fifth metacarpal diaphysis (arrow in c), and a minimally displaced comminuted fracture of the tuft of the distal phalanx of the fifth finger (arrow in d). In all cases, the victims were protecting their bodies from the assaults of the perpetrators. The victim in d presented to the emergency room 1 day after the injury. She reported that the injury occurred while she was cutting food with a knife, which slipped and cut her finger. The emergency medical service initially was called to her house but was sent away by her partner. The victim then presented to her primary care physician, who referred her to the emergency department.

Radiographs of the hands of four IPV victims show dislocation of the                        second proximal interphalangeal joint (arrow in a), a comminuted fracture of                        the middle phalanx of the middle finger (arrow in b), a displaced fracture                        of the right fifth metacarpal diaphysis (arrow in c), and a minimally                        displaced comminuted fracture of the tuft of the distal phalanx of the fifth                        finger (arrow in d). In all cases, the victims were protecting their bodies                        from the assaults of the perpetrators. The victim in d presented to the                        emergency room 1 day after the injury. She reported that the injury occurred                        while she was cutting food with a knife, which slipped and cut her finger.                        The emergency medical service initially was called to her house but was sent                        away by her partner. The victim then presented to her primary care                        physician, who referred her to the emergency department.

Figure 11d. Radiographs of the hands of four IPV victims show dislocation of the second proximal interphalangeal joint (arrow in a), a comminuted fracture of the middle phalanx of the middle finger (arrow in b), a displaced fracture of the right fifth metacarpal diaphysis (arrow in c), and a minimally displaced comminuted fracture of the tuft of the distal phalanx of the fifth finger (arrow in d). In all cases, the victims were protecting their bodies from the assaults of the perpetrators. The victim in d presented to the emergency room 1 day after the injury. She reported that the injury occurred while she was cutting food with a knife, which slipped and cut her finger. The emergency medical service initially was called to her house but was sent away by her partner. The victim then presented to her primary care physician, who referred her to the emergency department.

Frontal radiograph of the hand (a), frontal radiograph of the wrist                        (b), lateral radiograph of the forearm (c), frontal radiograph of the                        forearm (d), and oblique radiograph of the forearm (e) in different IPV                        victims show a nondisplaced fracture of the ulnar styloid (arrow in a and                        b), nondisplaced ulnar fractures (arrow in c and d), and a minimally                        displaced ulnar fracture (arrow in e).

Figure 12a. Frontal radiograph of the hand (a), frontal radiograph of the wrist (b), lateral radiograph of the forearm (c), frontal radiograph of the forearm (d), and oblique radiograph of the forearm (e) in different IPV victims show a nondisplaced fracture of the ulnar styloid (arrow in a and b), nondisplaced ulnar fractures (arrow in c and d), and a minimally displaced ulnar fracture (arrow in e).

Frontal radiograph of the hand (a), frontal radiograph of the wrist                        (b), lateral radiograph of the forearm (c), frontal radiograph of the                        forearm (d), and oblique radiograph of the forearm (e) in different IPV                        victims show a nondisplaced fracture of the ulnar styloid (arrow in a and                        b), nondisplaced ulnar fractures (arrow in c and d), and a minimally                        displaced ulnar fracture (arrow in e).

Figure 12b. Frontal radiograph of the hand (a), frontal radiograph of the wrist (b), lateral radiograph of the forearm (c), frontal radiograph of the forearm (d), and oblique radiograph of the forearm (e) in different IPV victims show a nondisplaced fracture of the ulnar styloid (arrow in a and b), nondisplaced ulnar fractures (arrow in c and d), and a minimally displaced ulnar fracture (arrow in e).

Frontal radiograph of the hand (a), frontal radiograph of the wrist                        (b), lateral radiograph of the forearm (c), frontal radiograph of the                        forearm (d), and oblique radiograph of the forearm (e) in different IPV                        victims show a nondisplaced fracture of the ulnar styloid (arrow in a and                        b), nondisplaced ulnar fractures (arrow in c and d), and a minimally                        displaced ulnar fracture (arrow in e).

Figure 12c. Frontal radiograph of the hand (a), frontal radiograph of the wrist (b), lateral radiograph of the forearm (c), frontal radiograph of the forearm (d), and oblique radiograph of the forearm (e) in different IPV victims show a nondisplaced fracture of the ulnar styloid (arrow in a and b), nondisplaced ulnar fractures (arrow in c and d), and a minimally displaced ulnar fracture (arrow in e).

Frontal radiograph of the hand (a), frontal radiograph of the wrist                        (b), lateral radiograph of the forearm (c), frontal radiograph of the                        forearm (d), and oblique radiograph of the forearm (e) in different IPV                        victims show a nondisplaced fracture of the ulnar styloid (arrow in a and                        b), nondisplaced ulnar fractures (arrow in c and d), and a minimally                        displaced ulnar fracture (arrow in e).

Figure 12d. Frontal radiograph of the hand (a), frontal radiograph of the wrist (b), lateral radiograph of the forearm (c), frontal radiograph of the forearm (d), and oblique radiograph of the forearm (e) in different IPV victims show a nondisplaced fracture of the ulnar styloid (arrow in a and b), nondisplaced ulnar fractures (arrow in c and d), and a minimally displaced ulnar fracture (arrow in e).

Frontal radiograph of the hand (a), frontal radiograph of the wrist                        (b), lateral radiograph of the forearm (c), frontal radiograph of the                        forearm (d), and oblique radiograph of the forearm (e) in different IPV                        victims show a nondisplaced fracture of the ulnar styloid (arrow in a and                        b), nondisplaced ulnar fractures (arrow in c and d), and a minimally                        displaced ulnar fracture (arrow in e).

Figure 12e. Frontal radiograph of the hand (a), frontal radiograph of the wrist (b), lateral radiograph of the forearm (c), frontal radiograph of the forearm (d), and oblique radiograph of the forearm (e) in different IPV victims show a nondisplaced fracture of the ulnar styloid (arrow in a and b), nondisplaced ulnar fractures (arrow in c and d), and a minimally displaced ulnar fracture (arrow in e).

Obstetric-Gynecologic Injuries

Approximately 25% of IPV victims present to the emergency department with injury-related obstetric-gynecologic anomalies, which include failed pregnancy, subchorionic hematoma, retained products of conception, intrauterine growth restriction, low birth weight, preterm birth, and perinatal death of the newborn (Fig 13) (10,49). Obstetric-gynecologic anomalies are five times more common in victims of IPV than in nonvictims, and the presence of any obstetric-gynecologic injury is associated with a two- to fourfold increase in the odds of IPV (10).

IPV involving a 21-year-old pregnant woman who presented to the                        emergency department with vaginal spotting. (a) Sagittal transvaginal US                        image obtained 10 days earlier shows a normal intrauterine pregnancy                        (arrow). (b) Sagittal transvaginal US image obtained after the spotting                        episode shows a uterus with no fetal components or products of conception,                        indicating complete miscarriage.

Figure 13a. IPV involving a 21-year-old pregnant woman who presented to the emergency department with vaginal spotting. (a) Sagittal transvaginal US image obtained 10 days earlier shows a normal intrauterine pregnancy (arrow). (b) Sagittal transvaginal US image obtained after the spotting episode shows a uterus with no fetal components or products of conception, indicating complete miscarriage.

IPV involving a 21-year-old pregnant woman who presented to the                        emergency department with vaginal spotting. (a) Sagittal transvaginal US                        image obtained 10 days earlier shows a normal intrauterine pregnancy                        (arrow). (b) Sagittal transvaginal US image obtained after the spotting                        episode shows a uterus with no fetal components or products of conception,                        indicating complete miscarriage.

Figure 13b. IPV involving a 21-year-old pregnant woman who presented to the emergency department with vaginal spotting. (a) Sagittal transvaginal US image obtained 10 days earlier shows a normal intrauterine pregnancy (arrow). (b) Sagittal transvaginal US image obtained after the spotting episode shows a uterus with no fetal components or products of conception, indicating complete miscarriage.

It is estimated that approximately 4%–12% of victims of IPV are pregnant, although the prevalence varies widely among different countries (50,51). However, although the prevalence of IPV during pregnancy is unknown, it has been postulated that it may be higher than that among nonpregnant women owing to the reluctance of the victim to disclose IPV during the pregnancy. The proposed higher prevalence of IPV among pregnant women might also be due to inconsistent screening for IPV during pregnancy by medical providers, possibly because of fear of shocking the patient and uncertainty regarding the management of IPV in this population (31,52). Unplanned or unwanted pregnancies are a recognized risk factor in cases of IPV during pregnancy (50). Pregnant IPV victims are more likely to have multiple injuries, compared with nonpregnant victims, and can present with both obstetric injuries and non–pregnancy-related injuries (53).

In a study involving a cohort of 185 IPV victims and 555 age-matched control subjects (10), subchorionic hematoma, retained products of conception, and fetal growth restriction were significantly more common in IPV victims than in control subjects.

Subchorionic hematoma most commonly occurs within the first two trimesters of pregnancy, can manifest with vaginal bleeding, appears as a crescent-shaped heterogeneous collection below the chorion on US images, and is avascular at color Doppler US (54). The size of the hematoma correlates with the risk of miscarriage (55).

Retained products of conception refers to the persistence of fetal tissue after delivery or pregnancy termination (54). At US, these products may manifest as an endometrial mass, an endometrium greater than 10–13 mm in thickness, and/or internal flow on color Doppler images (5658). The diagnosis of fetal growth restriction is described in the dedicated literature (59,60).

Head and Neck Injuries

Head and neck injuries are frequently associated with episodes of severe violence. They include traumatic brain injuries and strangulation-related injuries (vascular, soft-tissue, and airway injuries to the neck).

Traumatic brain injury is common in victims of IPV (6163). In a study involving 53 adult female victims of IPV, 92% of the women reported sustaining hits to the head or face, and in 40% of these cases, the victim reported a loss of consciousness after an assault (64). Traumatic brain injury in survivors of IPV often manifests with a postconcussive syndrome, a cluster of symptoms that include disturbed sleep, anxiety or depression, dizziness or vertigo, headache, and posttraumatic stress disorder (6163).

Traumatic brain injury in cases of IPV is often related to repetitive injuries and may lead to long-term brain modifications. An MRI-based brain volume study (65) showed that survivors of IPV have a smaller supratentorial cranial vault and smaller frontal and occipital gray matter volumes compared with control subjects. Prior studies with football players and individuals who suffered traumatic brain injuries (6668) have shown that long fiber tracts of the white matter, which are highly susceptible to axonal injuries, often show alterations of MRI-based diffusion-tensor imaging parameters, such as fractional anisotropy. Correlations between MRI-based diffusion-tensor imaging white matter changes and mild traumatic brain injuries in victims of IPV, which typically go unreported, are under investigation (68).

Different injury types may lead to traumatic brain injury, including skull fractures, intracranial hemorrhages, brain contusions, and axonal injuries, and each type has different imaging findings. A detailed description of these findings is beyond the scope of this article (69). In the earlier described study involving 185 IPV victims and 555 control subjects (10), intracranial hemorrhages were observed in three (1.6%) of the 185 IPV victims. However, such hemorrhages are considered a nonspecific sign of IPV, as they are commonly observed in nonvictims (10). The coexistence of acute and chronic hemorrhages indicates recurrent trauma, which could be secondary to IPV in otherwise healthy young women with no history of reported concussions or falls (Figs 14, 15) (70).

Axial (a) and coronal reconstructed (b) head CT images in a                        42-year-old woman who presented to the emergency department after a reported                        fall from stairs show a large right subdural collection with                        high-attenuation components (arrowheads in a) and a high-attenuation                        parafalcine collection (straight arrow in a) consistent with                        acute-on-subacute subdural hemorrhage. The patient had a history of right                        middle cerebral artery remote stroke with changes from encephalomalacia                        (curved arrow) in the right parietal region.

Figure 14a. Axial (a) and coronal reconstructed (b) head CT images in a 42-year-old woman who presented to the emergency department after a reported fall from stairs show a large right subdural collection with high-attenuation components (arrowheads in a) and a high-attenuation parafalcine collection (straight arrow in a) consistent with acute-on-subacute subdural hemorrhage. The patient had a history of right middle cerebral artery remote stroke with changes from encephalomalacia (curved arrow) in the right parietal region.

Axial (a) and coronal reconstructed (b) head CT images in a                        42-year-old woman who presented to the emergency department after a reported                        fall from stairs show a large right subdural collection with                        high-attenuation components (arrowheads in a) and a high-attenuation                        parafalcine collection (straight arrow in a) consistent with                        acute-on-subacute subdural hemorrhage. The patient had a history of right                        middle cerebral artery remote stroke with changes from encephalomalacia                        (curved arrow) in the right parietal region.

Figure 14b. Axial (a) and coronal reconstructed (b) head CT images in a 42-year-old woman who presented to the emergency department after a reported fall from stairs show a large right subdural collection with high-attenuation components (arrowheads in a) and a high-attenuation parafalcine collection (straight arrow in a) consistent with acute-on-subacute subdural hemorrhage. The patient had a history of right middle cerebral artery remote stroke with changes from encephalomalacia (curved arrow) in the right parietal region.

(a–c) Axial (a) and coronal reconstructed (b) head CT images                        and axial bone-window head CT image (c) in a 52-year-old woman with a                        history of multiple-substance abuse and multiple episodes of                        partner-inflicted violence, who was brought to the emergency department by                        the emergency medical service after a seizure episode. These images,                        obtained at presentation to the emergency department, show a small                        subarachnoid hemorrhage within the left postcentral sulcus (arrow in a), a                        moderate-sized right parietal subgaleal hematoma with soft-tissue laceration                        (arrow in b), and a comminuted and displaced fracture of the left zygomatic                        arch (arrow in c). A right parietal burr hole also is present. (d–g)                        Axial head CT images acquired 4 years (d–f) and 2 years (g) before                        the current presentation to the emergency department (stored in picture                        archiving system) show a chronic comminuted left nasal bone fracture (arrow                        in d), frontal (e) and parietal (f) subgaleal hematomas (arrow in e and f),                        and a small left hematoma of the left temporalis muscle (arrow in g). All                        injuries were related to assaults by the same partner.

Figure 15a. (a–c) Axial (a) and coronal reconstructed (b) head CT images and axial bone-window head CT image (c) in a 52-year-old woman with a history of multiple-substance abuse and multiple episodes of partner-inflicted violence, who was brought to the emergency department by the emergency medical service after a seizure episode. These images, obtained at presentation to the emergency department, show a small subarachnoid hemorrhage within the left postcentral sulcus (arrow in a), a moderate-sized right parietal subgaleal hematoma with soft-tissue laceration (arrow in b), and a comminuted and displaced fracture of the left zygomatic arch (arrow in c). A right parietal burr hole also is present. (d–g) Axial head CT images acquired 4 years (d–f) and 2 years (g) before the current presentation to the emergency department (stored in picture archiving system) show a chronic comminuted left nasal bone fracture (arrow in d), frontal (e) and parietal (f) subgaleal hematomas (arrow in e and f), and a small left hematoma of the left temporalis muscle (arrow in g). All injuries were related to assaults by the same partner.

(a–c) Axial (a) and coronal reconstructed (b) head CT images                        and axial bone-window head CT image (c) in a 52-year-old woman with a                        history of multiple-substance abuse and multiple episodes of                        partner-inflicted violence, who was brought to the emergency department by                        the emergency medical service after a seizure episode. These images,                        obtained at presentation to the emergency department, show a small                        subarachnoid hemorrhage within the left postcentral sulcus (arrow in a), a                        moderate-sized right parietal subgaleal hematoma with soft-tissue laceration                        (arrow in b), and a comminuted and displaced fracture of the left zygomatic                        arch (arrow in c). A right parietal burr hole also is present. (d–g)                        Axial head CT images acquired 4 years (d–f) and 2 years (g) before                        the current presentation to the emergency department (stored in picture                        archiving system) show a chronic comminuted left nasal bone fracture (arrow                        in d), frontal (e) and parietal (f) subgaleal hematomas (arrow in e and f),                        and a small left hematoma of the left temporalis muscle (arrow in g). All                        injuries were related to assaults by the same partner.

Figure 15b. (a–c) Axial (a) and coronal reconstructed (b) head CT images and axial bone-window head CT image (c) in a 52-year-old woman with a history of multiple-substance abuse and multiple episodes of partner-inflicted violence, who was brought to the emergency department by the emergency medical service after a seizure episode. These images, obtained at presentation to the emergency department, show a small subarachnoid hemorrhage within the left postcentral sulcus (arrow in a), a moderate-sized right parietal subgaleal hematoma with soft-tissue laceration (arrow in b), and a comminuted and displaced fracture of the left zygomatic arch (arrow in c). A right parietal burr hole also is present. (d–g) Axial head CT images acquired 4 years (d–f) and 2 years (g) before the current presentation to the emergency department (stored in picture archiving system) show a chronic comminuted left nasal bone fracture (arrow in d), frontal (e) and parietal (f) subgaleal hematomas (arrow in e and f), and a small left hematoma of the left temporalis muscle (arrow in g). All injuries were related to assaults by the same partner.

(a–c) Axial (a) and coronal reconstructed (b) head CT images                        and axial bone-window head CT image (c) in a 52-year-old woman with a                        history of multiple-substance abuse and multiple episodes of                        partner-inflicted violence, who was brought to the emergency department by                        the emergency medical service after a seizure episode. These images,                        obtained at presentation to the emergency department, show a small                        subarachnoid hemorrhage within the left postcentral sulcus (arrow in a), a                        moderate-sized right parietal subgaleal hematoma with soft-tissue laceration                        (arrow in b), and a comminuted and displaced fracture of the left zygomatic                        arch (arrow in c). A right parietal burr hole also is present. (d–g)                        Axial head CT images acquired 4 years (d–f) and 2 years (g) before                        the current presentation to the emergency department (stored in picture                        archiving system) show a chronic comminuted left nasal bone fracture (arrow                        in d), frontal (e) and parietal (f) subgaleal hematomas (arrow in e and f),                        and a small left hematoma of the left temporalis muscle (arrow in g). All                        injuries were related to assaults by the same partner.

Figure 15c. (a–c) Axial (a) and coronal reconstructed (b) head CT images and axial bone-window head CT image (c) in a 52-year-old woman with a history of multiple-substance abuse and multiple episodes of partner-inflicted violence, who was brought to the emergency department by the emergency medical service after a seizure episode. These images, obtained at presentation to the emergency department, show a small subarachnoid hemorrhage within the left postcentral sulcus (arrow in a), a moderate-sized right parietal subgaleal hematoma with soft-tissue laceration (arrow in b), and a comminuted and displaced fracture of the left zygomatic arch (arrow in c). A right parietal burr hole also is present. (d–g) Axial head CT images acquired 4 years (d–f) and 2 years (g) before the current presentation to the emergency department (stored in picture archiving system) show a chronic comminuted left nasal bone fracture (arrow in d), frontal (e) and parietal (f) subgaleal hematomas (arrow in e and f), and a small left hematoma of the left temporalis muscle (arrow in g). All injuries were related to assaults by the same partner.

(a–c) Axial (a) and coronal reconstructed (b) head CT images                        and axial bone-window head CT image (c) in a 52-year-old woman with a                        history of multiple-substance abuse and multiple episodes of                        partner-inflicted violence, who was brought to the emergency department by                        the emergency medical service after a seizure episode. These images,                        obtained at presentation to the emergency department, show a small                        subarachnoid hemorrhage within the left postcentral sulcus (arrow in a), a                        moderate-sized right parietal subgaleal hematoma with soft-tissue laceration                        (arrow in b), and a comminuted and displaced fracture of the left zygomatic                        arch (arrow in c). A right parietal burr hole also is present. (d–g)                        Axial head CT images acquired 4 years (d–f) and 2 years (g) before                        the current presentation to the emergency department (stored in picture                        archiving system) show a chronic comminuted left nasal bone fracture (arrow                        in d), frontal (e) and parietal (f) subgaleal hematomas (arrow in e and f),                        and a small left hematoma of the left temporalis muscle (arrow in g). All                        injuries were related to assaults by the same partner.

Figure 15d. (a–c) Axial (a) and coronal reconstructed (b) head CT images and axial bone-window head CT image (c) in a 52-year-old woman with a history of multiple-substance abuse and multiple episodes of partner-inflicted violence, who was brought to the emergency department by the emergency medical service after a seizure episode. These images, obtained at presentation to the emergency department, show a small subarachnoid hemorrhage within the left postcentral sulcus (arrow in a), a moderate-sized right parietal subgaleal hematoma with soft-tissue laceration (arrow in b), and a comminuted and displaced fracture of the left zygomatic arch (arrow in c). A right parietal burr hole also is present. (d–g) Axial head CT images acquired 4 years (d–f) and 2 years (g) before the current presentation to the emergency department (stored in picture archiving system) show a chronic comminuted left nasal bone fracture (arrow in d), frontal (e) and parietal (f) subgaleal hematomas (arrow in e and f), and a small left hematoma of the left temporalis muscle (arrow in g). All injuries were related to assaults by the same partner.

(a–c) Axial (a) and coronal reconstructed (b) head CT images                        and axial bone-window head CT image (c) in a 52-year-old woman with a                        history of multiple-substance abuse and multiple episodes of                        partner-inflicted violence, who was brought to the emergency department by                        the emergency medical service after a seizure episode. These images,                        obtained at presentation to the emergency department, show a small                        subarachnoid hemorrhage within the left postcentral sulcus (arrow in a), a                        moderate-sized right parietal subgaleal hematoma with soft-tissue laceration                        (arrow in b), and a comminuted and displaced fracture of the left zygomatic                        arch (arrow in c). A right parietal burr hole also is present. (d–g)                        Axial head CT images acquired 4 years (d–f) and 2 years (g) before                        the current presentation to the emergency department (stored in picture                        archiving system) show a chronic comminuted left nasal bone fracture (arrow                        in d), frontal (e) and parietal (f) subgaleal hematomas (arrow in e and f),                        and a small left hematoma of the left temporalis muscle (arrow in g). All                        injuries were related to assaults by the same partner.

Figure 15e. (a–c) Axial (a) and coronal reconstructed (b) head CT images and axial bone-window head CT image (c) in a 52-year-old woman with a history of multiple-substance abuse and multiple episodes of partner-inflicted violence, who was brought to the emergency department by the emergency medical service after a seizure episode. These images, obtained at presentation to the emergency department, show a small subarachnoid hemorrhage within the left postcentral sulcus (arrow in a), a moderate-sized right parietal subgaleal hematoma with soft-tissue laceration (arrow in b), and a comminuted and displaced fracture of the left zygomatic arch (arrow in c). A right parietal burr hole also is present. (d–g) Axial head CT images acquired 4 years (d–f) and 2 years (g) before the current presentation to the emergency department (stored in picture archiving system) show a chronic comminuted left nasal bone fracture (arrow in d), frontal (e) and parietal (f) subgaleal hematomas (arrow in e and f), and a small left hematoma of the left temporalis muscle (arrow in g). All injuries were related to assaults by the same partner.

(a–c) Axial (a) and coronal reconstructed (b) head CT images                        and axial bone-window head CT image (c) in a 52-year-old woman with a                        history of multiple-substance abuse and multiple episodes of                        partner-inflicted violence, who was brought to the emergency department by                        the emergency medical service after a seizure episode. These images,                        obtained at presentation to the emergency department, show a small                        subarachnoid hemorrhage within the left postcentral sulcus (arrow in a), a                        moderate-sized right parietal subgaleal hematoma with soft-tissue laceration                        (arrow in b), and a comminuted and displaced fracture of the left zygomatic                        arch (arrow in c). A right parietal burr hole also is present. (d–g)                        Axial head CT images acquired 4 years (d–f) and 2 years (g) before                        the current presentation to the emergency department (stored in picture                        archiving system) show a chronic comminuted left nasal bone fracture (arrow                        in d), frontal (e) and parietal (f) subgaleal hematomas (arrow in e and f),                        and a small left hematoma of the left temporalis muscle (arrow in g). All                        injuries were related to assaults by the same partner.

Figure 15f. (a–c) Axial (a) and coronal reconstructed (b) head CT images and axial bone-window head CT image (c) in a 52-year-old woman with a history of multiple-substance abuse and multiple episodes of partner-inflicted violence, who was brought to the emergency department by the emergency medical service after a seizure episode. These images, obtained at presentation to the emergency department, show a small subarachnoid hemorrhage within the left postcentral sulcus (arrow in a), a moderate-sized right parietal subgaleal hematoma with soft-tissue laceration (arrow in b), and a comminuted and displaced fracture of the left zygomatic arch (arrow in c). A right parietal burr hole also is present. (d–g) Axial head CT images acquired 4 years (d–f) and 2 years (g) before the current presentation to the emergency department (stored in picture archiving system) show a chronic comminuted left nasal bone fracture (arrow in d), frontal (e) and parietal (f) subgaleal hematomas (arrow in e and f), and a small left hematoma of the left temporalis muscle (arrow in g). All injuries were related to assaults by the same partner.

(a–c) Axial (a) and coronal reconstructed (b) head CT images                        and axial bone-window head CT image (c) in a 52-year-old woman with a                        history of multiple-substance abuse and multiple episodes of                        partner-inflicted violence, who was brought to the emergency department by                        the emergency medical service after a seizure episode. These images,                        obtained at presentation to the emergency department, show a small                        subarachnoid hemorrhage within the left postcentral sulcus (arrow in a), a                        moderate-sized right parietal subgaleal hematoma with soft-tissue laceration                        (arrow in b), and a comminuted and displaced fracture of the left zygomatic                        arch (arrow in c). A right parietal burr hole also is present. (d–g)                        Axial head CT images acquired 4 years (d–f) and 2 years (g) before                        the current presentation to the emergency department (stored in picture                        archiving system) show a chronic comminuted left nasal bone fracture (arrow                        in d), frontal (e) and parietal (f) subgaleal hematomas (arrow in e and f),                        and a small left hematoma of the left temporalis muscle (arrow in g). All                        injuries were related to assaults by the same partner.

Figure 15g. (a–c) Axial (a) and coronal reconstructed (b) head CT images and axial bone-window head CT image (c) in a 52-year-old woman with a history of multiple-substance abuse and multiple episodes of partner-inflicted violence, who was brought to the emergency department by the emergency medical service after a seizure episode. These images, obtained at presentation to the emergency department, show a small subarachnoid hemorrhage within the left postcentral sulcus (arrow in a), a moderate-sized right parietal subgaleal hematoma with soft-tissue laceration (arrow in b), and a comminuted and displaced fracture of the left zygomatic arch (arrow in c). A right parietal burr hole also is present. (d–g) Axial head CT images acquired 4 years (d–f) and 2 years (g) before the current presentation to the emergency department (stored in picture archiving system) show a chronic comminuted left nasal bone fracture (arrow in d), frontal (e) and parietal (f) subgaleal hematomas (arrow in e and f), and a small left hematoma of the left temporalis muscle (arrow in g). All injuries were related to assaults by the same partner.

In victims of IPV, a history of strangulation is common. It is estimated to occur in more than 25% of victims of IPV and tends to occur later in the cycle of violence, when the abuse has escalated to more aggressive violent episodes (31). Strangulation is associated with a more than sevenfold increase in the odds of future homicide (71). Nonetheless, imaging evaluation of the strangulated victim is rarely sought. In a study involving 112 victims of strangulation (72), only 11 (10%) of these victims underwent MRI in the emergency department, even though the majority of them presented with signs or symptoms related to strangulation, including petechiae, voice disorders, and neck pain. At neck CT or MRI, the most common imaging findings include unilateral or bilateral subcutaneous edema, intramuscular hemorrhage involving the platysma and sternocleidomastoid muscles, lymph node or submandibular gland hemorrhage, edema or hemorrhage of the vocal cords, and neck abscesses (7275). In addition, vascular imaging, preferably CT angiography or MR angiography of the neck, should be performed to assess for carotid artery dissection, which can lead to delayed stroke (7678). Since strangulation is most commonly carried out with two hands, bilateral and symmetric dissections of the carotid arteries can be observed (76). The examination of strangulation victims with use of chest radiography also has been advocated, to recognize pulmonary edema, aspiration pneumonia, and adult respiratory distress, all of which are associated with strangulation (31,79).

Skull base and cervical fractures are uncommon in victims of IPV and occur most frequently in cases of violent assaults. In either case, CT angiography should be performed to assess for vertebral artery dissection.

In a recent population-based study (80) involving females aged 5–49 years who presented to the emergency department with a concussion, and thus were at high risk for IPV, the odds of sustaining a comorbid neck injury were significantly greater than those in their male counterparts. Therefore, screening for neck injuries may be considered for women who present to the emergency room with head injury (80).

Thoracoabdominal Injuries

Victims of IPV can present with injuries to the trunk, although these are relatively uncommon and nonspecific (81). Nonetheless, certain regions of the trunk—namely, the shoulder girdle, posterior chest wall, and anterior abdomen—are considered target areas and should be considered at risk for injury (31).

Posterior chest and shoulder injuries often occur when victims are pushed against the wall or down the stairs, sustaining trauma to the posterior chest wall or shoulders (Fig 16). Posterior rib fractures also can occur in victims who are pushed to the wall or onto the floor and can be associated with lung contusion, splenic injury, and/or pneumothorax (Fig 17) (82). In a series of 191 patients with traumatic pneumothorax requiring emergency thoracostomy, 11 (6%) cases were related to domestic accidents, including IPV (83).

Sagittal (a) and axial (b) bone- window CT images of the shoulder of                        two IPV victims show a comminuted displaced scapular fracture (arrows in a)                        and a mildly displaced acromion process fracture (arrow in b).

Figure 16a. Sagittal (a) and axial (b) bone- window CT images of the shoulder of two IPV victims show a comminuted displaced scapular fracture (arrows in a) and a mildly displaced acromion process fracture (arrow in b).

Sagittal (a) and axial (b) bone- window CT images of the shoulder of                        two IPV victims show a comminuted displaced scapular fracture (arrows in a)                        and a mildly displaced acromion process fracture (arrow in b).

Figure 16b. Sagittal (a) and axial (b) bone- window CT images of the shoulder of two IPV victims show a comminuted displaced scapular fracture (arrows in a) and a mildly displaced acromion process fracture (arrow in b).

(a) Coronal reconstructed contrast material–enhanced CT image                        acquired during the portal venous phase in a 30-year-old woman who presented                        to the emergency department after a reported fall from standing shows a                        splenic laceration (arrow) and hemoperitoneum (arrowheads). (b, c) Axial                        bone-window CT images of the lower chest in the same patient show minimally                        displaced fractures of the 11th (b) and 12th (c) posterior left ribs                        (arrow). At admission to the emergency department, the patient was found to                        have bipolar disorder and to be the subject of violence from her                        partner.

Figure 17a. (a) Coronal reconstructed contrast material–enhanced CT image acquired during the portal venous phase in a 30-year-old woman who presented to the emergency department after a reported fall from standing shows a splenic laceration (arrow) and hemoperitoneum (arrowheads). (b, c) Axial bone-window CT images of the lower chest in the same patient show minimally displaced fractures of the 11th (b) and 12th (c) posterior left ribs (arrow). At admission to the emergency department, the patient was found to have bipolar disorder and to be the subject of violence from her partner.

(a) Coronal reconstructed contrast material–enhanced CT image                        acquired during the portal venous phase in a 30-year-old woman who presented                        to the emergency department after a reported fall from standing shows a                        splenic laceration (arrow) and hemoperitoneum (arrowheads). (b, c) Axial                        bone-window CT images of the lower chest in the same patient show minimally                        displaced fractures of the 11th (b) and 12th (c) posterior left ribs                        (arrow). At admission to the emergency department, the patient was found to                        have bipolar disorder and to be the subject of violence from her                        partner.

Figure 17b. (a) Coronal reconstructed contrast material–enhanced CT image acquired during the portal venous phase in a 30-year-old woman who presented to the emergency department after a reported fall from standing shows a splenic laceration (arrow) and hemoperitoneum (arrowheads). (b, c) Axial bone-window CT images of the lower chest in the same patient show minimally displaced fractures of the 11th (b) and 12th (c) posterior left ribs (arrow). At admission to the emergency department, the patient was found to have bipolar disorder and to be the subject of violence from her partner.

(a) Coronal reconstructed contrast material–enhanced CT image                        acquired during the portal venous phase in a 30-year-old woman who presented                        to the emergency department after a reported fall from standing shows a                        splenic laceration (arrow) and hemoperitoneum (arrowheads). (b, c) Axial                        bone-window CT images of the lower chest in the same patient show minimally                        displaced fractures of the 11th (b) and 12th (c) posterior left ribs                        (arrow). At admission to the emergency department, the patient was found to                        have bipolar disorder and to be the subject of violence from her                        partner.

Figure 17c. (a) Coronal reconstructed contrast material–enhanced CT image acquired during the portal venous phase in a 30-year-old woman who presented to the emergency department after a reported fall from standing shows a splenic laceration (arrow) and hemoperitoneum (arrowheads). (b, c) Axial bone-window CT images of the lower chest in the same patient show minimally displaced fractures of the 11th (b) and 12th (c) posterior left ribs (arrow). At admission to the emergency department, the patient was found to have bipolar disorder and to be the subject of violence from her partner.

Gun and knife injuries are uncommon in victims of IPV. They are reported in fewer than 1% of patients who experience IPV (Fig 18) (84). Compared with the everyday household objects used as weapons, guns and knives are less common instruments of IPV injuries.

Axial contrast-enhanced CT image acquired during the portal venous                        phase with intrarectal contrast material administration in a 40-year-old man                        who presented to the emergency department after being stabbed by his wife                        with a butter knife shows a left lower quadrant subcutaneous hematoma                        (straight arrow); subcutaneous air from the stab wound (arrowhead);                        extravasated rectal contrast material (curved arrow) adjacent to the                        descending colon, indicating perforation; and an adjacent retroperitoneal                        hematoma anterior to the left psoas muscle. Pneumoperitoneum (not shown)                        also was observed.

Figure 18. Axial contrast-enhanced CT image acquired during the portal venous phase with intrarectal contrast material administration in a 40-year-old man who presented to the emergency department after being stabbed by his wife with a butter knife shows a left lower quadrant subcutaneous hematoma (straight arrow); subcutaneous air from the stab wound (arrowhead); extravasated rectal contrast material (curved arrow) adjacent to the descending colon, indicating perforation; and an adjacent retroperitoneal hematoma anterior to the left psoas muscle. Pneumoperitoneum (not shown) also was observed.

Duodenal and pancreatic injuries are uncommonly associated with assault and occur with blunt or penetrating trauma to the abdomen (31). Duodenal injuries include duodenal contusion, hematoma, and perforation (85). Differentiating duodenal contusion and hematoma from perforation is crucial. While duodenal contusion or hematoma may be subtle, manifesting as only bowel wall thickening greater than 4 mm or hematoma of the bowel wall, duodenal perforation can be suspected in the presence of extraluminal air or discontinuity of the duodenal wall (8588).

Pancreatic injuries include pancreatic fracture, laceration, contusion, and hematoma. Contusion and hematoma manifest with hypoattenuating areas in the parenchyma or mixed-attenuation collections in or contiguous to the pancreas (85). On CT images, pancreatic fracture or laceration appears as a hypoattenuating line crossing the pancreatic parenchyma. Coronal reformatted and curved planar reformatted CT images are helpful for identifying the fracture line and the continuity of the main pancreatic duct (89,90). In the absence of a disclosed history of high-energy trauma, duodenal or pancreatic injuries should always raise suspicion for IPV.

Injuries to the other abdominal organs, including bowel injuries, occur more commonly in cases of stab and gunshot wounds. Bowel injuries can manifest with a multitude of imaging signs, including pneumoperitoneum, hemoperitoneum, oral or rectal contrast material leakage, a wound tract extending to the bowel, mesenteric stranding or fluid, and thickening or discontinuity of the bowel wall (Fig 18) (91). Nonetheless, these imaging findings can often be subtle.

Current Needs and Future Perspectives

Medical providers are vital to limiting IPV: Only by improving and increasing the frequency of early diagnosis and providing early intervention can the vicious cycle of violence be stopped. Early diagnosis can be improved by increasing adherence to screening by medical providers and establishing predictive models that enable the identification of IPV victims. A recent study (92) showed that screening and referral systems for IPV can be successfully implemented in radiology departments, thereby facilitating screening of a larger portion of the population for IPV.

Regarding the implementation of predictive models, the first necessary step is to establish imaging patterns of IPV, which ultimately can be used to build automated artificial intelligence–driven predictive systems for IPV (14). One of the challenges of establishing these imaging patterns is the lack of a reference standard owing to significant underreporting of IPV. However, increased awareness and reporting of IPV can lead to more accurate imaging pattern models. The rationale behind the need for an automated system for predicting IPV is based on evidence that current diagnostic strategies often over-rely on the manifestation of symptoms, and in acute settings it is extremely challenging to retrieve prior data from the electronic medical record. Furthermore, an artificial intelligence–driven system based on radiologic and clinical data would not be biased by the interaction between the medical provider and the victim (14).

Eliminating IPV is part of the United Nations’ sustainable development goals for 2030 and represents a challenge for upcoming years (93). One target of the United Nations’ sustainable development goals is to eliminate all forms of abuse against women and girls in the public and private spheres, including trafficking and other forms of exploitation.

Conclusion

IPV is a highly prevalent public health problem that affects millions of women, yet it is significantly underdiagnosed by health care providers. Radiologists need to be aware of their vital role in identifying IPV, which is due to their ability to recognize imaging patterns on current and prior imaging studies of different parts of the body, so that they can provide an objective unbiased report. Injuries in defensive locations and target areas such as the face and upper extremities, a combination of injury patterns, fractures at different stages of healing, and discrepancies between the injury mechanism reported by the victim and the imaging findings can be observed in cases of IPV.

Further research is needed to explore the sensitivity and specificity of the imaging findings linked to IPV and integrate artificial intelligence–enabled tools to provide a clinical decision support rule and predict the risk probability of IPV for each patient. However, by developing expertise in pattern recognition and communicating their suspicion for IPV to ordering providers, radiologists can facilitate early identification of IPV victims and timely intervention, and, in turn, save lives.

Disclosures of Conflicts of Interest.— F.A. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: travel scholarship for trainees for 2018 SAR meeting from the Society of Abdominal Radiology, student travel stipend for 2018 RSNA Annual Meeting from the Radiological Society of North America. Other activities: disclosed no relevant relationships. A.K. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: employee of Harvard Medical School. Other activities: disclosed no relevant relationships. G.S.M.D. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: education grant support as the director of orthopedic residency from Depuy Synthes and Stryker. Other activities: disclosed no relevant relationships. P.T. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: receives royalty IP payments from and has pending and issued intellectual property with Smith & Nephew, owns stock or stock options in 4 Web. Other activities: disclosed no relevant relationships. S.E.S. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: receives reimbursement for travel to GE Healthcare-AUR research fellowship program board meetings from the Association of University Radiologists and for travel to Academy of Radiology Research board meetings from the Academy of Radiology Research. Other activities: disclosed no relevant relationships. B.K. Activities related to the present article: received Stepping Strong Injury Prevention Innovator award, Massachusetts General Brigham Innovation Discovery award, and Brigham Care Redesign Incubator and Start up program award from BCRISP. Activities not related to the present article: research grant from GE Healthcare, book royalties from Cambridge University Press, royalties as Section Editor, Emergency Radiology, from UptoDate Wolters Kluwer Health. Other activities: disclosed no relevant relationships.

B.K. supported by the Stepping Strong Injury Prevention Innovator Award, Mass General Brigham Innovation Discovery Award, and Brigham Care Redesign Incubator and Startup Program Award.

Presented as an education exhibit at the 2019 RSNA Annual Meeting.

For this journal-based SA-CME activity, the authors F.A., A.K., G.S.M.D., P.T., S.E.S., and B.K. have disclosed relationships; all other authors, the editor, and the reviewers have disclosed no relevant relationships.

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Article History

Received: Feb 12 2020
Revision requested: Apr 28 2020
Revision received: May 10 2020
Accepted: May 28 2020
Published online: Oct 02 2020
Published in print: Nov 2020