A Fracture from a Fall: What's Going on Here? | Case Study

"I fell, hit my head, and can't stop bleeding": What's happening to this woman?

A new case study in which a 77 yo white female arrives to the emergency room by taxi with a suspected skull fracture. This topic was suggested by a reader – thank you so much for your ideas – keep them coming!

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Specializes in Education, FP, LNC, Forensics, ED, OB.

We've had several members come to the Admin Help Desk to register their answers and amend a couple, too.

Get your answer(s) and rationale(s) in soon. ?

SafetyNurse1968, ADN, BSN, MSN, PhD

81 Articles; 523 Posts

Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience.


After further questioning, the patient breaks down in tears and admits that her daughter pushed her into a wall, causing the fracture. The patient says, “please don’t do anything to her – she didn’t mean to. She does the best she can. I’m such a burden to her.” Eventually she admits that the bruise on her arm is from her daughter as well. She tells you that her daughter restricts what she can eat and that she isn't allowed to see a physician. A report is made to adult protective services and they begin the process of ensuring the safety of the patient.

According to the National Council on Aging, up to five million Americans are abused every year. “Elder abuse includes physical abuse, emotional abuse, sexual abuse, exploitation, neglect, and abandonment. Perpetrators include children, other family members, and spouses—as well as staff at nursing homes, assisted living, and other facilities.” Approximately 1/10 Americans over the age of 60 have experienced some form of elder abuse. It is estimated that only 1/24 cases are reported. In almost 60% of incidents the perpetrator is a family member and 2/3rds are adult children or spouses. Elders who have been abused have a 300% higher risk of death when compared to those who have not been mistreated.

Risk factors include mental impairment and social isolation. Interpersonal violence occurs at a higher rate among adults with disabilities.

  • Physical signs include
  • Dehydration or unusual weight loss
  • Missing daily living aids
  • Unexplained injuries, bruises, cuts or sores
  • Unsanitary living conditions and poor hygiene
  • Unattended medical needs
  • Emotional/Behavioral Signs of Elder Abuse include:
  • Increased fear or anxiety
  • Isolation from friends or family
  • Unusual changes in behavior or sleep
  • Withdrawal from normal activities

In a study of characteristics and comorbid diagnoses in older adults with fractures, the following characteristics were associated with elder abuse (Gironda, 2016):

  • Age 65-79
  • Female
  • White
  • No dementia diagnosis
  • ED
  • Only 1 visit to medical facility in past 3 years
  • Fracture at home
  • Fracture from fall
  • Head as location of fracture

The most common forensic markers from the Gironda study were laceration, abrasion, bruise, depression, anxiety or mood disorder, malnutrition, pressure ulcer and dehydration.

It is important that medical practitioners be aware of the signs and symptoms of elder abuse. It is crucial that we report suspected abuse to DSS so that elders can live out their lives with dignity and health.

The Council on Aging link has many resources where you can learn more.


Has 50 years experience.

The following are the guesses/diagnoses/rationales from members who came to the Help Desk during the "A Fracture from a Fall: What’s Going on Here?" Case Study.

Thank you, @SafetyNurse1968, for this excellent and very informative Case Study.



I think this poor lady is suffering from elder abuse, in addition to malnutrition. Adult Protective Services needs to investigate. 




There are 2 or 3 diagnoses that I'll arrange in priority order:

  1. Ineffective coping as evidenced by agitated replies to basic questions related to suspected domestic violence
  2. Fluid volume deficit as evidenced by high levels of BUN & Creatinine as well as high levels of Na,Cl and K
  3. Imbalanced nutrition as evidenced by low BMI, protein, prealbumin, glucose and albumin





Failure to thrive due to neglect and abuse.



I think the woman in the case study is the victim of elder abuse and possibly neglect. She is vague on what caused her injuries, avoids eye contact, blames her own clumsiness, refuses to give contact information for her daughter, and verbalized that she wants to get home before her daughter gets home.  I'm suspicious that her daughter has hit her in the face (lost glasses?), but I don't have enough evidence. It could be a boyfriend of either the daughter or the victim, or even someone else. This isn't for the RN to investigate, but we are required to put in a report with adult protective services. I would also get a SANE nurse in to make sure this woman wasn't also sexually assaulted, but they may be able to help in building rapport to aid investigation even if there is no sexual assault. 
Neglect is also a major concern given her frayed, stained clothing and mismatched socks. Possibly financial abuse may be involved.

?Good job everyone! ?

Be on the lookout for the next Case Study by @SafetyNurse1968.