An 81-year-old woman is brought to the emergency department by her nephew. The patient says that she fell on an outstretched arm while trying to get to the bathroom. The patient's medical history includes systemic lupus erythematosus, chronic kidney disease, and remitted breast cancer. The patient's medications include hydroxychloroquine and prednisone. She lives with her nephew, who is her primary caregiver. Physical examination reveals a thin and disheveled woman with bruising over her left bicep. Lung fields are clear and she has normal S1 and S2. The abdomen is soft and nontender. X-ray reveals a mid-shaft spiral fracture of her left humerus. Which of the following is the most likely cause of the patient's condition?

Question

An 81-year-old woman is brought to the emergency department by her nephew.  The patient says that she fell on an outstretched arm while trying to get to the bathroom.  The patient's medical history includes systemic lupus erythematosus, chronic kidney disease, and remitted breast cancer.  The patient's medications include hydroxychloroquine and prednisone.  She lives with her nephew, who is her primary caregiver.  Physical examination reveals a thin and disheveled woman with bruising over her left bicep.  Lung fields are clear and she has normal S1 and S2.  The abdomen is soft and nontender.  X-ray reveals a mid-shaft spiral fracture of her left humerus.  Which of the following is the most likely cause of the patient's condition?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c1e2_cf92_8f63_8bf68f9ae2be_MD0005_00 This patient's spiral fracture of a long bone and signs of possible neglect (eg, malnutrition, decreased self-care) are concerning for elder abuse. Elder abuse is generally defined as abuse (eg, physical, sexual, psychological, financial) or neglect (eg, abandonment) of individuals age >65. Risk factors include age >80, female sex, and psychological/physical impairment (eg, dementia, depression, dependence in activities of daily living). Signs of elder abuse include atypical injuries (eg, spiral fractures, abrasions in unusual locations), malnutrition, and pressure ulcers. Physicians should screen individuals age >65 for elder abuse, with special attention to those with known risk factors. Patients should be interviewed alone and asked direct questions about living arrangements and abuse/neglect. If elder abuse is suspected, agencies such as Adult Protective Services should be involved immediately. (Choices A, B, C, and E) Although bone metastasis, glucocorticoid-induced osteoporosis, chronic kidney disease, and nutritional deficiency may all increase the risk of fractures, this patient's risk factors for abuse, disheveled appearance, and atypical injury (ie, mid-shaft humeral spiral fracture) are more suggestive of elder abuse, which physicians should rule out prior to exploring alternate etiologies. Educational objective: Physicians should screen for elder abuse those patients with known risk factors (eg, age >80, female sex, psychological/physical impairment) and with specific warning signs (eg, atypical injuries, malnutrition, pressure ulcers). Patients should be interviewed alone and the appropriate agencies notified if elder abuse is suspected. References: Elder abuse: systematic review and implications for practice. (http://www.ncbi.nlm.nih.gov/pubmed/26096395) Understanding the medical markers of elder abuse and neglect: physical examination findings. (http://www.ncbi.nlm.nih.gov/pubmed/25439636)

An 81-Year-Old Woman Is Brought to the Emergency Department by Her