Fractures

Injuries resulting from interpersonal violence: blunt force trauma, penetrating trauma (stab or gunshot wounds), strangulation, or sexual assault. Management requires simultaneous attention to clinical injury, forensic documentation, and safeguarding or legal considerations.

Classified by mechanism: blunt (fists, weapons, kicks : contusions, fractures, organ injury without breach of skin), penetrating (direct tissue disruption along the trajectory), strangulation (manual or ligature: risk of delayed airway and vascular complications despite an initially reassuring presentation).

Follow the trauma primary survey (ABCDE) as for any traumatic injury ; mechanism dictates the injury pattern assessed.

• Stab wounds: assess entry and exit wound location relative to underlying structures (thoracic; cardiac/great vessel/lung; abdominal ; solid or hollow organ; neck ; zones I-III guide investigation). Do NOT remove an in-situ weapon or foreign object in the field or ED ; it may be tamponading bleeding; remove only in a controlled theatre setting

• Gunshot wounds: assess entry/exit wounds and trajectory; higher energy transfer causes more extensive tissue damage than the wound size suggests, with high suspicion for multiple organ involvement along the presumed path

• Strangulation: petechiae (face, conjunctivae), voice change, dysphagia/odynophagia, neck bruising or ligature marks, subcutaneous emphysema (tracheal injury); significant risk of DELAYED airway compromise from progressive laryngeal edema, and of carotid or vertebral artery dissection, even with an unremarkable initial examination

• Sexual assault: injuries may be absent or minimal even in confirmed assault; the presence or absence of injury neither confirms nor refutes an allegation

• Signs of high-risk domestic violence: injury pattern inconsistent with the account, injuries at different healing stages, defensive wounds on the forearms, reluctance to disclose mechanism, a controlling partner present during consultation

• Primary and secondary survey per trauma protocol

• CT (chest/abdomen/neck as indicated by wound location and trajectory) for penetrating trauma in hemodynamically stable patients; immediate theatre for unstable patients

• CT angiography neck: for strangulation with any neurological symptoms, or significant reported force or loss of consciousness: screens for arterial dissection

• FAST scan: rapid assessment for hemoperitoneum or hemopericardium

• Forensic documentation: body maps, photography with consent following local forensic protocol, preservation of clothing and evidence per chain-of-custody procedures: involve the forensic medical examiner per local pathway

• STI and pregnancy screening, and forensic sample collection for sexual assault, ideally by a trained examiner within the recommended timeframe

Resuscitate per trauma principles ; clinical care takes priority over forensic considerations, though both can generally proceed in parallel.

• Penetrating trauma: do not remove impaled objects; urgent surgical referral for exploration of wounds violating fascia, peritoneum or pleura; local wound exploration only for clearly superficial wounds

• Strangulation: even asymptomatic patients require careful evaluation; consider CT angiography, extended observation (laryngeal edema can progress over 24-48 hours), low threshold for admission

• Analgesia, tetanus prophylaxis, wound care as per soft tissue injury principles

Sexual assault:

• Emergency contraception: levonorgestrel 1.5mg single dose within 72h, ulipristal acetate within 120h, or copper IUD within 5 days (most effective)

• HIV post-exposure prophylaxis within 72h, ideally within hours ;combination ART for 28 days per local protocol

• STI screening and empirical treatment, hepatitis B vaccination/immunoglobulin per status

• Psychological support and counseling referral

Safeguarding: mandatory referral per local child or adult safeguarding protocols if a child is involved, a vulnerable adult, or the pattern suggests ongoing domestic violence. Document objectively; offer referral to domestic violence support services and police; patient autonomy is respected regarding police involvement unless a safeguarding duty overrides it.

Documentation: thorough and objective, as it may be required as evidence; factual language, avoiding conclusions about mechanism or perpetrator beyond the clinical findings.

Referral: trauma/general surgery for penetrating injury, ENT or vascular surgery for strangulation with airway or vascular concern, safeguarding team, sexual assault referral centre, psychiatry/psychology for acute severe distress.