An 82 year old woman arrives in your emergency room with a shortened and externally rotated hip. She does not remember falling but was found down in the assisted care facility she lives in. The x-ray confirms a displaced sub-capital hip fracture. This is a slam dunk easy case, right? We see this everyday; admit to ortho for ORIF, write some holding orders, (maybe do a 3 in 1 block if you believe in pain control), and move on to the next patient. Right?

Trauma in the elderly is common and we see it everyday. We see hip fractures, wrist fractures and head lacerations usually as a consequence of falls. Those of us in community hospitals may become unaccustomed to dealing with major trauma, as well developed EHS systems tend to route these cases to trauma centres, but the flow of injured elderly continues uninterrupted. In general elderly patients cope poorly with trauma, and have much higher morbidity and mortality than our younger patients, and this is predictable based on burden of concurrent chronic disease and decreased physiological reserve. These patients often have an obvious injury and this is best viewed as a distraction during the first phase of the assessment.

When an elderly patient arrives with what seems to be an isolated traumatic injury resist the temptation to prematurely close the case, and resist the pressure to assess them in the low acuity area of your department. These patients frequently have a more complex story than initially meets the eye.

Our 82 year old patient with a hip fracture is best viewed as a trauma patient, and our assessment should proceed along those lines. The ABCDE approach of ATLS provides a good framework for initial assessment. Additionally there are some important questions you must ask yourself as your assessment proceeds:

1. Is this patient unstable? Remember elderly patients may not mount a tachycardia, and a ‘normal’ blood pressure may represent relative hypotension.
2. Does this patient have another injury? Just like in any trauma patient, palpate everything. In particular consider the possibility of c-spine injury, rib fractures, and inter cranial bleeding.
3. Does this patient have a concurrent disease that will impact or be impacted by their injury? Baseline physiology will impact a patients response to injury, and capacity for recovery.
4. Does this patient take a medication that will impact or be impacted by this injury? Consider medications that may impact the trauma (ie. anticoagulants), affect the physiological response (ie. beta-blockers, calcium channel blockers, digoxin) or those which may have precipitated the trauma (ie. opioids, benzodiazipines, tricyclic antidepressants).
5. Is this patients trauma the result of a destabilized/acute medical problem? The cause of trauma is often subtle and discriminating a trip and fall from a syncope is important.

Trauma is usually portrayed as a dashing specialty area of emergency medicine. Trauma doctors are handsome, poorly shaved and sleep deprived heroes who save the lives of the young and beautiful when they play too hard and drive too fast. As a community emergency doctor I can only assume that this image of big trauma centres, as portrayed on TV, is completely accurate and I wish these heroes all the best, but trauma in my emergency room is often a little bit different.

I am frequently confronted by seemingly simple cases of elderly patients with supposed isolated trauma. By refusing to accept premature closure on these cases, and insisting on running them all as traumas I have been surprised by the frequency with with significant concurrent injury or unstable medical condition is discovered. Inter-cranial haemorrhage and rib fractures are particularly common concurrent injuries, and electrocardiographic explanations for syncope not infrequent. So the next time an elderly injured person arrives in your ambulance bay don’t just close the case and admit to ortho, hunt for injuries, and you will be surprised by what you find.