Clinical Geriatrics

This article is the third in a continuing series on trauma care and the older adult. The series discusses the growing problem of trauma in the elderly, including its causes and possible ways to prevent it, care in the acute stages, and manifestations and treatment strategies when trauma involves the torso, spine, brain, and hip. Authors include skilled experts in the trauma field representing various specialties at the R Adams Cowley Shock Trauma Center at the University of Maryland Medical Center and the University of Maryland School of Medicine.

Introduction
Elderly persons, defined as persons age 65 years or older, constitute one of the fastest growing segments of the U.S. population. By the year 2030, the number of persons over age 65 will double relative to 2000, representing almost 20% of the nation’s total population.¹ Today’s elderly population has an improved quality of life, enabling them to remain physically active and mobile longer.² Ironically, this active lifestyle has become a risk factor for injury.

Some consider trauma to be exclusively a disease of the young; however, as the population in the United States ages over the next several decades, injuries in older patients will become more apparent. One must realize that trauma is sometimes a different disease in the elderly than in young people, with the elderly responding differently to their injuries.³ Advanced age has been shown to be a risk factor for poor outcomes in trauma patients; however, older patients may benefit from intensive monitoring and aggressive management following injury.⁴

Falls and motor vehicle collisions (MVCs) are the two most common mechanisms of injury (MOI) in the elderly. Falls tend to be ground-level falls, occurring in 30-40% of those over 65 years of age annually.⁵ In 2006, more than 177,000 elderly people suffered nonfatal injuries as a result of a MVC.⁶ Torso trauma represents the second leading cause of mortality in the elderly after brain injury.⁷ Older persons are at risk for the same thoracic injuries as are younger people. Some injuries, including pneumothorax and hemothorax, require essentially identical treatment, and do not require specific age-associated considerations. Others, including rib fractures, flail chest, and blunt aortic injuries, require specific considerations and will be the focus of this article. Additionally, nonoperative management (NOM) of solid organ injuries and rhabdomyolysis, often exacerbating post-injury course, will be discussed.

Rib Fractures in Older Persons
Rib fractures are the most common injury found in elderly patients with blunt trauma. The two predominant MOI for rib fractures in the elderly are MVCs followed by falls. Rib fractures are a significant cause of increased morbidity and mortality in older patients. This increase can be attributed to several factors including anatomical differences between young and elderly people (osteoporosis, decreased muscle mass, and thinned vertebral bodies), as well as decreased physiological reserve (low cardiopulmonary status and lower immunity). Additionally, the presence of pre-existing comorbidites is a known risk factor for increased morbidity and mortality in this patient population.⁸

Bulger et al⁹ demonstrated that in patients older than 65 years of age who had rib fractures, mortality increased 19%, and risk for pneumonia increased 27% for each rib fracture. In addition, elderly patients with rib fractures had significantly worse outcomes than those younger than age 65 with similar injury severity. Rib fractures in older persons have also been associated with intra-abdominal injury. Shweiki et al¹⁰ showed that the incidence of liver injuries was 10.7% in their population of patients with rib fractures, and 11.3% had splenic injuries.