Geriatric Patients And Missed Traumatic Injuries: What Do We Miss, And How Do We Improve?

Author: Anatoliy Goltser, MD (EM Attending Physician/APD, St. Joseph Medical Center) // Reviewed by: Jessica Pelletier, DO (EM Education Fellow, Washington University in St. Louis); Alex Koyfman, MD (@EMHighAK); Brit Long, MD (@long_brit)

Case

A 78-year-old female presents to the emergency department after a mechanical fall at home in her bathroom earlier tonight. She said she slipped on a wet tile and slid onto her bathtub. She is complaining of some pain in her right hip and right torso. When asked she says she did hit her head but denies headache or neck pain. She has known hypertension but is otherwise healthy and lives independently. Denies taking any anticoagulants. Vitals: T 36.8, HR 78, BP 145/70, RR 22, O2 sat 91% on room air. Her exam is significant for right chest wall tenderness and she appears to be splinting. There is subtle ecchymosis over the right lateral chest wall. Her lower extremities are without deformity but she has significant pain when you attempt to range her right hip. She is alert with a GCS of 15 and has no obvious focal neurologic deficits.

Special considerations for the elderly trauma patient

Elderly patients’ physiology, mechanisms, and patterns of injury are generally unlike those of young trauma patients. These age-related differences not only make the elderly more susceptible to injury, but they also increase mortality for the same given injury, or the same Injury Severity Score (ISS) (1). Most significantly, it is not uncommon for elderly patients with relatively minor mechanisms to sustain significant and even life-threatening injuries that may not be apparent on the initial clinical evaluation. 

For a more in-depth discussion on approaching the elderly injured patient, check out this emDocs post from 2016: Geriatric Trauma and Medical Illness: Pearls and Pitfalls.

Head injuries in the elderly

The overall prevalence of clinically significant head injuries in patients over 65 is approximately 5-9% (2, 3) and slightly higher (5-12%) for those on anticoagulation (4). Among the patients in the NEXUS II dataset, the elderly were almost twice as likely as their non-elderly counterparts to sustain significant injuries, and of those patients over 65 years old with significant head injuries, 15% had no other high risk clinical features other than age (3). Moreover, elderly patients presenting with a GCS of 15 or who are at their baseline mentation after minor mechanism trauma have a 3% chance of having traumatic intracranial hemorrhage (tICH) (5). 

There are multiple physiologic reasons for this, including a decrease in protective reflexes and increased reaction time, which result in more head strikes. Normal shrinkage in brain volume that occurs with age and decreased elasticity of the subdural bridging veins predispose elderly patients to higher rates of subdural hemorrhage.

Because of the higher incidence of tICH in the elderly, the NEXUS and New Orleans Head CT rules cannot be applied to patients over the age of 65 (6,7). As of this writing, there is no validated tool to clinically exclude tICH in this population, and most sources will recommend the liberal use of neuroimaging, particularly head CT owing to its relative speed and greater availability than MRI. 

For elderly patients who are anticoagulated and suffer head trauma, there is a small risk of delayed intracranial hemorrhage, wherein a patient develops intracranial hemorrhage (typically subdural hematoma) after an initial normal head CT. In the past there had been some controversy on whether or not to obtain repeat head CTs on these patients. A prospective observational study by Nishijima et al., 2012 (4) identified a 0.6 % rate of delayed tICH in patients on warfarin and 0% for patients on clopidogrel. A more recent study by Chenoweth et al., 2018 (8) found a similar rate of tICH: 1 patient on warfarin, and 2 who were not on any anticoagulation experienced a delayed tICH. A similar retrospective study by Broderick et al., 2024 (9) which investigated rates of tICH in head injury patients on direct anticoagulants (i.e. dabigatran, apixaban, and rivaroxaban) found no incidence of delayed tICH in 159 patients evaluated for falls and head trauma at a single institution from 2016 to 2018. While delayed tICH remains a possibility, the 2023 ACEP guidelines recommend against the routine use of repeat neuroimaging for elderly head injury patients who are anticoagulated presuming they are at their baseline neurologic status (10).

Cervical spine injuries in the elderly

Cervical spine injuries (CSI) have a prevalence of approximately 4% in the geriatric population, with over 50% of these resulting from falls of less than 3 feet in height (11). Traditional clinical tools used to evaluate for CSI, like the NEXUS criteria, typically exclude those over age 65 (12). This is partly because elderly patients are more likely to sustain significant CSI from relatively low energy mechanisms versus their younger cohorts. Factors such as osteoporosis and osteopenia play a role, as well as underlying cervical spine degenerative changes. 

Clinically, it is often challenging to exclude CSI in the elderly. When NEXUS was applied to the elderly population, the sensitivity was only 60-80% (13,14). In 2015, a case series of 173 patients over age 65 with CSI, included 36 patients (21%) who were asymptomatic, 7 of whom required surgical intervention (15). One group of researchers (16) attempted to retrospectively derive a clinical decision rule for cervical spine injuries specifically for elderly trauma patients and found that midline tenderness, focal neurologic deficits, and signs of trauma to the head or face were the most predictive; however, this is yet to be validated prospectively.

The generally accepted gold standard for diagnosing CSI is CT imaging. While plain films may be sufficient to exclude CSI for low-risk adult trauma, they are not sensitive enough for the elderly (17). The bigger debate when it comes to imaging elderly trauma patients is whether or not to perform an MRI (18,19). In general, MRI without contrast should be considered in patients with negative CT imaging but with persistent neurological deficits (eg central cord syndrome). The controversy arises for fear of patients who may have ligamentous injuries potentially leading to instability; however, these are unlikely to be present in the absence of neurological deficits (18).

Rib fractures in the elderly

Rib fractures are a significant cause of morbidity and mortality in elderly trauma patients. Falls from standing are the primary cause of this injury in the elderly population. Moreover, physiologic and anatomic changes due to aging – such as osteoporosis, kyphosis, and resultant decreases in thoracic volume/chest wall compliance – predispose the elderly to worse outcomes. These include increased hospital and ICU length of stay, increased rates of pneumonia, and increased days on the ventilator for the same injuries and the same ISS as their non-elderly counterparts (20, 21). Importantly, the chance of developing these complications and the mortality risk increase with the number of rib fractures sustained (20, 22). To avoid missing rib fractures, one must have a relatively high index of suspicion for more serious injury from more minor mechanisms. 

The imaging modality of choice for the diagnosis of rib fractures in the elderly population has been the subject of some debate. There is good evidence to suggest that in the general trauma population, including young patients with high-energy mechanism blunt trauma, plain film radiographs are insufficient to accurately diagnose non-displaced rib fractures (23, 24). This finding remains true in elderly patients with blunt chest wall trauma (25). 

There is perhaps more nuance in terms of imaging the elderly patient with isolated blunt thoracic trauma. There are minimal data on dedicated rib films versus CT in this population. One small retrospective study of 56 patients (26) with a mean age of 62 years found dedicated rib series to be about 82% sensitive for diagnosing rib fractures. The data from Bulger et al. suggests that it is important to determine the exact number of rib fractures, but the population in the Bulger study is from a level I trauma center and may not be applicable to all patient care settings; thus, an argument may be made that for low-risk elderly patients, a rib series may be adequate. A single-center retrospective review of 330 elderly patients with radiographically occult rib fractures and relatively minor mechanisms of injury found plain films to have a sensitivity of 50%, but despite a higher admission rate for patients with radiographically occult rib fractures, there was no difference in mortality or hospital/ICU length of stay in the two cohorts (27).

The other consideration when it comes to imaging is the association of solid organ injury with rib fractures. In the general trauma population, an increased number of rib fractures seems to correlate with an increased likelihood of solid organ injury (28). However, the mechanism of injury is a potential confounder here, and since the elderly typically have lower energy mechanisms this may or may not hold true.

Another important injury associated with rib fracture is pulmonary contusion. There is limited data on pulmonary contusions in the elderly population; however, one single-center retrospective review (29) in a level I trauma population over the age of 65 showed 18% of patients sustained pulmonary contusions with >50% due to falls. In this population, a significant number of patients had other associated serious orthopedic, head and axial injuries, not isolated rib fractures. Similar to rib fractures, CT is also superior to chest radiography in diagnosing pulmonary contusions (30). Thus, CT is the imaging modality of choice for elderly patients with chest trauma. 

Hip and pelvis fractures

Hip and pelvic injuries, particularly hip fractures, are a well-described source of mortality (14-35% at one year for hip fractures), and are often due to low-energy mechanisms such as falls (31). Because of degenerative changes and osteopenia/osteoporosis, non-displaced fractures may not be immediately evident on initial radiographs. Overall, initial x rays will miss 2-10% of hip fractures (32). Thus, clinicians must have a high index of suspicion to avoid diagnostic delays, particularly in patients who are unable to weight-bear after sustaining their injuries. In these patients, CT is often the preferred imaging modality owing to its relative availability and speed. For pelvic fractures, one retrospective review of the elderly population found that radiographs missed about 50% of pelvic fractures that were found on CT (31). For hip fractures, a meta-analysis from 2020 found that CT had a sensitivity of 79% for diagnosing radiographically occult fractures, compared with MRI as the gold standard with 100% sensitivity (34).

Tibial plateau fractures are another significant source of morbidity in the elderly and may be easy to miss on plain radiographs, thus requiring a high index of suspicion. In the younger population, these are often associated with high-energy mechanisms like high-speed motor vehicle accidents. In the elderly, however, tibial plateau fractures are primarily due to falls onto the proximal tibia, or direct trauma such as cars attempting to brake and striking pedestrians over the proximal tibia, typically at low speeds (35). Tibial plateau fractures may be subtle and easy to miss on plain films in all age cohorts, particularly in the elderly due to underlying bone demineralization and degenerative changes associated with age. The data on the prevalence of radiographically occult tibial plateau fractures is sparse, and limited to case series and case reports. Whether a CT or an MRI is the study of choice remains unclear (36, 37). Generally, CT imaging is beneficial in the identification of tibial plateau fractures since it allows better visualization of the articular surface and will often change management – though not necessarily on an emergent basis (36). For elderly patients with persistent knee pain after an injury who are unable to bear weight, it is reasonable to obtain CT imaging of the knee to rule out a tibial plateau fracture.

Back to the case

Although the patient sustained a relatively minor mechanism of injury, her exam is concerning for significant injuries, including intracranial hemorrhage, cervical spine and rib fractures, and associated pulmonary and intra-abdominal solid organ injuries, as well as hip/pelvic injuries. The initial diagnostic and resuscitative approach should focus on stabilization, ensuring that the airway patency and evaluating for signs of shock, as well as potential precipitants of the fall, such as syncope, underlying infections, or electrolyte disturbances. Given the limitations of plain films, patients at high risk for significant injuries should undergo emergent CT imaging, in this case, the head, c-spine, and chest/abdomen/pelvis. Laboratory studies should be considered to evaluate for underlying medical illness leading to the patient’s fall.

Take-home points

• In the elderly, falls are a significant mechanism with a high risk for serious injury.
• Clinical decision rules must be used with extreme caution in the elderly population.
• Elderly patients on anticoagulation may have delayed intracranial bleeding and should be given strict return precautions
• CT is often the initial imaging of choice for cervical spine injuries in the elderly.
• MRI without contrast of the cervical spine should be strongly considered in the setting of a new neurologic deficit with otherwise unremarkable CTs.
• Rib fractures are associated with pulmonary and solid organ injuries.
• An increasing number of rib fractures is associated with increased morbidity and mortality.
• In low-risk isolated blunt chest wall trauma, a dedicated rib series may be considered depending on study availability and clinical gestalt. However, CT is the preferred imaging modality in these patients.
• Hip fractures may not be visible on initial x-rays or CT, so if clinical suspicion remains, an MRI without contrast is warranted.
• In previously ambulatory patients who sustained an extremity or hip injury and are subsequently unable to bear weight due to their injury, advanced imaging should be strongly considered to exclude an occult hip or tibial plateau fracture.

References

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