Geriatric Trauma Pearls

Falls in older adults are usually a geriatric syndrome, not just a simple trip and fall. Geriatric trauma disproportionately means falls, occult hip fracture, clinically important rib injury, and intracranial hemorrhage that cannot be ruled out by exam alone.

Falls and injury patterns in older adults

• Non-syncopal fall framing: Retire the term mechanical fall; non-syncopal fall keeps the differential broad for medication effects, infection, dehydration, vision loss, and other contributors that cluster in geriatric syndrome.
• Dominant trauma mechanism: Falls account for about 80% of geriatric trauma admissions, and unlike younger trauma populations roughly 70% occurs in women.
• Three major injury patterns: Geriatric falls classically produce lower-extremity fractures, neck or trunk fractures, and intracranial bleeding, a pattern that sharpens the initial trauma survey.
• Disposition beyond the fracture: A splinted injury is not the whole problem; mobility at home, medication access, follow-up, and comprehension of instructions often determine whether discharge is actually safe. We get into the practical discharge lens in the episode.

High-yield imaging and pain pearls

• Occult hip fracture clue: A normal hip x-ray does not end the workup; inability to stand or tolerate axial loading should trigger advanced imaging for occult fracture, with MRI the gold standard.
• Miss rate on x-ray: Plain films miss up to 10% of hip fractures, which is why persistent functional pain after a negative study deserves another look rather than reassurance.
• CT for rib concern: Chest x-ray is insensitive for rib fractures, and in older adults each additional rib fracture raises pneumonia and mortality risk, so chest CT is the imaging test to favor when suspicion remains.
• Head bleed threshold: No validated decision rule reliably excludes intracranial hemorrhage after head trauma in older adults, and the baseline risk is higher regardless of anticoagulant use. We walk through the imaging threshold in the episode.
• Analgesia with restraint: Start pain control low and go slow; acetaminophen is a reasonable opener, fentanyl or morphine are preferred IV opioids, and regional blocks such as fascia iliaca are worth considering in selected patients.

References:

1. ADET tool: https://poctools.acep.org/POCTool/Confusion%2FAgitationintheElderly(ADEPT)/6db3c051-8851-4822-852a-9c48a214c2fe/
2. Haentjens P, Magaziner J, Colón-Emeric CS, et al. Meta-analysis: excess mortality after hip fracture among older women and men. Ann Intern Med. 2010;152(6):380-390. PMID: 20231569
3. Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma. 2000;48(6):1040-1047.PMID: 10866248.
4. Bergeron E, Lavoie A, Clas D, et al. Elderly trauma patients with rib fractures are at greater risk of death and pneumonia. J Trauma. 2003;54(3):478-485. PMID: 12634526.
5. de Wit K, Merali Z, Kagoma YK, Mercier É. Incidence of intracranial bleeding in seniors presenting to the emergency department after a fall: A systematic review. Injury. 2020;51(2):157-163. PMID: 31901331
6. Probst MA, Gupta M, Hendey GW, et al. Prevalence of Intracranial Injury in Adult Patients With Blunt Head Trauma With and Without Anticoagulant or Antiplatelet Use. Ann Emerg Med. 2020;75(3):354-364. PMID: 31959538