Introduction

Violence has generally been regarded as an aspect of human aggression. ¹ Economic, cultural, and psychological factors were the most prevalent causes of violence. ² Interpersonal violence is a growing problem in the developing world and also in Turkey. ^{1 2} Violence-related injuries are usually admitted to the emergency services (EDs), and vary from minor abrasions and bruises to multi-system trauma that can result in death. ^{3 4 5} Each year millions of people die worldwide, as the result of injuries due to violence. ⁶

Interpersonal violence is particularly difficult to assess, because of stigma related to its reporting and lack of accuracy of non-healthcare epidemiological sources. ⁷

Although this phenomenon recently aroused mainstream interest in worldwide, there are very few studies in Turkey. The primary objective of this study was to underscore the importance of those injuries in our country by describing characteristics such as injury severity, types of injury, mechanism, and site as well as age, gender, fatality, and hospitalization rates.

Materials and methods

The present retrospective study was performed in the Emergency Department of XXXX University Hospital which is located in Central Anatolia Region of Turkey and recognized as the reference hospital of the region for trauma patients while serving approximately 4 million people.

All the cases admitted with violence-related injuries between January 2008 and December 2008, were included in the study. Gun-shot injuries and stubbing injuries were excluded from the study. The Ethics Committee of Medical School approved the study. A pre-designed form for the patients admitted due to violence-related injuries was filled out. Information concerning the demographic characteristics of the patients such as age and gender was collected.

Injury sites, injury types, and clinical characteristics of all the cases were recorded; injury severity scores (ISS) were calculated.

Descriptive statistics about the number of patients, percentage of the total, mean, standard deviation (SD), and range were used to evaluate the data. Statistical analysis was performed using Statistical Package for Social Sciences, version 11.0.1 (SPSS Inc., Chicago, IL, USA).

Results

A total of 73 adult patients were admitted due to violence-related injuries during the study period. The mean age of the patients was 31±12 years (17-66). 61 of the patients (83.6%) were male and 12 (16.4%) female. The peak incidence occurred in the age group of 21 to 30 years, which constituted 42.5% of all cases (Figure 1). 47 (64.4%) of the injured patients were brought to our Emergency Department via an ambulance service.

Figure 1

Figure 1. Age distribution of violence related injury

The most common objects causing injury was thump in 41 cases (56.2%). Violence-related injuries caused objects are shown in Table 1.

Figure 2

Table 1. Distribution of objects that lead to injury

Most common assailants were unascertained person in 30 (41.1%) cases, close-friends in 19 (26%), relatives in 9 (12.3%), neighbors in 9 (12.3%), and family members in 6 (8.2%) cases.

Most commonly encountered injury sites were head-neck region in 49 (67.1%) cases and abdomen in 5 (6.8%) cases (Figure 2). 14 (19.2%) cases demonstrated multiple injury sites.

Figure 3

Figure 2. Affected body regions.

As 38.4% of the injuries had tenderness, 26% had haematoma/bruise, 24.7% had laceration/cut, and 11% had epistaxis (Table 2). A life threatening injury was present in 8.2% of the patients.

Figure 4

Table 2. Types of injuries associated with violence related injuries.

Mean ISS score of the cases was 7.7±7.1. 11 (15.1%) of the cases had a severe injury (ISS ≥15), and 62 (84.9%) had slight injuries (15

Figure 5

Table 3. Age and hospital admittance distribution of injury severity.

While 80.8% of cases were discharged following their treatment in the ED, 20.5% were hospitalized. The mean ISS score of injured patients admitted to hospital was 8±7.4. None of the injured was seen in mortality.

Discussion

This analysis reveals some important points about violence related injured patients presenting to an emergency department of university hospital in Central Anatolia, Turkey.

First of all, male patients admit to the ED as a result of violence-related injuries more frequently. This appears to be contradictory to the literature. ⁷ Main reason for this result may be patriarchal structure of Turkish society and heavy social pressure on women. This social structure impedes women from presenting to the hospitals following such injuries. Social stigma, fear, shaming, and embarrassment are known to be effective factors that avert presentation of female cases to healthcare providers. ⁸

The second most important result of our study was revealing the perpetrators in more than half of the injuries as a relative, friend, neighbor, or family member. In light of this result, preventive measures can be taken more efficiently as a result of focusing on the right target population.

Determining the injury mechanisms proves to be considerably difficult because of limited histories obtained from witnesses and the victim. ⁶ However, assault by bodily force was found to be the most common traumatic cause of injuries followed by blunt objects.

Most common injury site was the head-neck-face region. The incidence of injuries in that region is reported to be 50-80% in the literature. ⁶ This result is in accordance with the findings of our study. ^{7 9 10 11}

Majority of the cases comprised soft tissue injuries. Most of those had been discharged after their treatment in the ED. Moreover, although not many, we observed some extremity fractures requiring serious force to occur. Only in a few cases alcohol use was detected which shows that alcohol does not have a direct effect on this injuries. ^{7 12}

One of the interesting results of our study was the absence of significant difference between ISS of cases admitted to the hospital and discharged from the ED. We believe that the underlying reason might be willing behavior of emergency physicians towards admitting patients due to social and legal concerns. Although ISS shows the severity of injuries in such cases, it may not be effective in deciding whether admit a patient or not.

Our study had a limited number of cases because, due to social structure of our country there is an unwillingness of cases presenting to the ED in explaining the true cause of their injuries as violence. However, the current study bears importance by being the first investigation which outlines the data about the cases admitted to the ED with violence-related injuries.

This descriptive study contains important data about the status of an aggravating issue throughout the world, violence-related injuries, in Turkey, and helps raising awareness on the subject. Most of the violence-related injuries in our region are seen among ages 21-30 as a result of bodily force causing soft tissue injuries in the head-face-neck area. While majority of cases with violence-related injuries are considered to be not presenting to the hospitals and going unreported, the data outlined in this study may contribute to the implementation of preventive measures. Emergency physicians frequently treat victims subjected to violence in their daily practice. Generally, injuries are observed to be mild in those cases. However, ED staffs also encounter cases with a wide range of injuries.