Have you noticed that your neighbor or his or her children are frequently bruised and injured? Do they have an explanation for these injuries whenever you question them? Have you or someone in your house been physically or verbally abused by another member of the household? Have you physically or verbally abused people in your house?

Family violence is a problem can affect all families, all age groups, and all household situations.

The term family violence refers to 3 types of abuse:

• Child abuse. Child abuse includes physical, sexual, psychological abuse, neglect, and maltreatment.
• Adult domestic violence (or intimate partner violence-IPV. Adult domestic violence includes physical, sexual, psychological abuse, and maltreatment.
• Elder abuse.. Elder abuse includes neglect, physical, psychological, financial or sexual abuse, abandonment, or self-neglect.

Children from all backgrounds and economic levels can be abused and maltreated. Data on the confirmed number of U.S. child maltreatment cases are available from state child protective service agencies. These data are generally considered underestimates. In 2002, 906,000 children in the United States were confirmed by child protective service agencies as being maltreated.

There are several risk factors that can contribute to child abuse:

• Young age (of child or parent)
• Low socioeconomic status
• Unplanned births
• Firstborn children
• Premature infants
• Stepchildren
• Handicapped children

In the National Study of Violence Against Women Survey in the year 2000, The U.S. Department of Justice estimated that there were 5.3 million incidents of adult domestic violence against women 18 years of age or older. The study found 3.2 million incidents of adult domestic violence against men 18 years of age or older.

The risk factors for being a victim or a perpetuator of adult domestic violence are complex combination of personal, relationship, and societal factors.

Elder abuse includes acts that cause harm or threaten harm to the health and welfare of adults 65 years of age and older. These acts may happen in the home. They may happen in an institution where the patient is a resident. In a Centers for Disease Control and Prevention (CDC) analysis of data from the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP), in 2001, an estimated 33,026 persons 60 years of age or more were treated in hospital emergency rooms for nonfatal assault-related injuries.

There are several risk factors that can contribute to elder abuse:

• Continuation of past abusive relationships with a spouse or a domestic partner.
• Personal problems of the abusers, such as financial strains or substance abuse.
• Isolation from the broader community.

Signs of abuse include a history of multiple emergency room visits for injuries, poor eye contact, evasive answers, and inconsistent explanations of injuries and bruises at varying stages of recovery.

Child Abuse:

• Skin lesions (bruises, cuts, burns, etc.)
• Fractures. Frequently abused children may have several fractures in various stages of healing

Domestic Adult Violence:

• Neck pain
• Back pain
• Chronically painful conditions that don't improve over time
• Pattern of frequent hospitalizations or emergency room visits

Elder Abuse:

• Changes in personality with no reasonable explanation
• Unexplained or poorly explained injuries
• Delays in getting care for an injury
• Frequent visits to medical offices or emergency rooms

Family violence can take many forms. The diagnosis can be complicated. The shape and position of a fracture on X-ray may help your doctor decide if an injury is from abuse or from an accident. For child abuse, doctors use a special series of x-rays called the skeletal survey. These x-rays can show fractures in young children who are not able to talk about how their injuries happened. Doctors can also use bone scans with radioactive tracers to find injured bone if this kind of detail is needed.

Diagnosing adult domestic and elder violence as the cause of a person's injury or condition is difficult. Some signs of physical violence, such as bruises and fractures, are easy to see. The subtle signs of physical violence are more difficult to make out.

The American Academy of Orthopaedic Surgeons recommends that doctors check all patients with trauma or chronic pain for domestic violence. If doctors see evidence that makes them suspicious, they will ask direct questions. These questions should be asked in a respectful way, away from family members, domestic partners, or caretakers.

If your doctor suspects the injuries are a result of abuse and not an accident, how he or she proceeds will depend on who the victim is. All 50 states and the District of Columbia require health care workers to report suspected child abuse to the police.

Doctors will report cases of adult domestic violence in capable adults only with the victim's prior knowledge. This is because the report could put the patient in greater danger from their abuser. Reporting requirements vary in each state. Doctors must make decisions on whether to make a report or not on a case-by-case basis. In the case of suspected elder abuse, all 50 states have passed legislation that provides protective services for the elderly. Many states insist that health care workers make mandatory reports of elder abuse.

If a person or their children are being abused, help is available. Most hospital emergency departments have assistance available to those in need. In addition, many communities have family shelter services that provide assistance in finding safe housing, legal assistance, and other help for victims of any of the categories of family violence. Phone books, the Internet, or county social service organizations can be used to identify ways to obtain needed services.

• Family Violence ResourcesFamily Violence Resources (http://www.aaos.org/about/abuse/abuse.asp)
• AAOS Advisory Statement: Domestic and Family Violence and Abuse: The Orthopaedic Surgeon's ResponsibilitiesAAOS Advisory Statement: Domestic and Family Violence and Abuse: The Orthopaedic Surgeon's Responsibilities (http://www.aaos.org/about/papers/advistmt/1030.asp)

AAOS Opinions on Ethics and Professionalism

• AAOS: Reporting of Suspected Abuse or Neglect of Children, Disabled Adults or the ElderlyAAOS: Reporting of Suspected Abuse or Neglect of Children, Disabled Adults or the Elderly (http://www.aaos.org/about/papers/ethics/1207eth.asp)