Which of the following considerations is most important when caring for a geriatric trauma patient

Br J Radiol. 2018 Jul; 91(1087): 20170739.

Angela Atinga, MB BChir BA (MA Cantab), FRCR,

Abstract

Major Trauma Centres and Emergency Departments are treating an increasing number of elderly trauma patients in the UK. Elderly patients, defined as those over the age of 65 years, are more susceptible to injury from lesser mechanisms of trauma than younger adults. The number of elderly trauma cases is rising yearly, accounting for >25% of all major trauma nationally. The elderly have different physiological reserves and a different response to trauma due to premorbid frailty, co-existing conditions and prescribed medication. These factors need to be appreciated in trauma triaging, radiological assessment and clinical management. A lower threshold for trauma-call activation is recommended, including a lower threshold for advanced imaging. We will review general principles of trauma in the elderly, outline injury patterns in this age group and illustrate the radiological features per anatomical site, from head to pelvis and the extremities. We advocate using contrast-enhanced computed tomography as the primary diagnostic imaging modality as concern about intravenous contrast agent-induced nephropathy is relatively minor. Prompt investigation and diagnosis leads to timely appropriate treatment, therefore the radiologist can discerningly improve morbidity and mortality in this vulnerable group.

Introduction

Elderly patients differ significantly from the younger trauma patient in physiology, shock response, mechanisms and types of injury. An appreciation of these differences reduces the risk of under-triaging, so avoiding delay in investigation and diagnosis and decreasing morbidity and mortality.

We will review general principles of trauma in the elderly, outline injury patterns in this age group and illustrate the radiological features by anatomical region.

Trauma in Elderly Patients: Why is age a factor?

Across the Western world, the population is ageing. In the UK, 18% of the population is now aged 65 and over (up from 16% 10 years ago), while 2.4% are aged 85 and over.1 More than a quarter of trauma patients are over the age of 75, with obvious implications for national and local healthcare planning, particularly for Major Trauma Centres (MTCs) and Emergency Departments.2

The elderly are not only important demographically;advancing age is also associated with worse outcomes after trauma. Increasing age is an independent predictor of poor outcome following trauma, with a 2.4–5.6 greater risk of death.3–6 Age over 65 years is an independent risk factor for increased mortality in trauma, controlled for the same Injury Severity Score (ISS).7, 8 Hence, 65 years is commonly accepted as the definition of elderly for trauma purposes.7, 8

Physiological Reserves in the Elderly Trauma Patients and Response to Shock

Advancing age is associated with progressive physiological changes affecting multiple systems, summarised in Table 1.9

Table 1.

Physiological changes with ageing

Impaired physiological responses or system failure(s) may also mask injuries and their severity, making clinical assessment and treatment more difficult. For example, haemorrhage and/or hypoperfusion can be missed because basal vital signs do not reflect shock response. Medication such as beta-blockers, anticoagulants and steroids further hide the normal shock response.9

Co-morbid factors such as renal and hepatic impairment, chronic steroid use or previous malignancy, further increase the mortality risk in the elderly trauma patients, by up to five times.10

Clinical Evaluation and Triaging

Triage can be more challenging in elderly trauma if there are barriers to communication, such as deafness or dementia, which can result in the severity of injury being under-appreciated.

Lower threshold for trauma protocol activation is recommended, because if an elderly trauma patient is under-triaged at presentation, their discharge disability and mortality rate are significantly increased (up to four times greater than younger adult patients).11 Additionally, patients who are under-triaged away from higher dependency units (HDU) to a general ward have a fourfold increase in mortality rate and discharge disability compared to younger patients.5 As for other trauma patients, outcomes in elderly trauma are better for patients treated at MTCs.12

Elderly trauma patients in shock should be treated promptly and aggressively. Early admission of the appropriate patients to HDU and use of invasive monitoring reduces morbidity and mortality.13 Early involvement of geriatric physicians improves advanced care planning and multidisciplinary care makes discharge more speedy and, importantly, more successful.14 The radiologist can help clinicians with early, accurate diagnosis, enabling timely intervention.

Radiological assessment

Prompt whole body computed tomography (CT) is the gold standard in elderly trauma imaging, as for younger patients. This decreases the duration of hospital stay, intensive therapy unit (ITU) admission rates, morbidity and mortality, even if the patient has a high ISS.15

Our institution applies a standard imaging protocol to all patients over the age of 18 years presenting with traumatic injury. In cases of blunt trauma, patients undergo a “Combiscan”, which involves biphasic contrast administration to allow simultaneous arterial and portal venous enhancement followed by a single volumetric multidetector CT acquisition.16 In penetrating trauma, separate arterial phase and portal venous phase scans are obtained to differentiate between arterial and venous bleeding;this better detect targets for interventional radiological or surgical response.16

Intravenous contrast is used as part of the standard protocol unless there is documented evidence of a contrast allergy (as set out in the Royal College of Radiologists Guidelines17) . There is a higher prevalence of background renal impairment in older patients, but there is no evidence that age is an independent risk factor for contrast-induced nephropathy.11 In our opinion, the diagnostic yield of a contrast-enhanced study outweighs the risk of contrast-induced nephropathy which can be managed medically; especially in view of the potential consequences of under-triage.

Causes of trauma

The elderly are susceptible to more serious injury from lesser/minor trauma when compared to younger adults. Unlike the young, only 25% of trauma in the elderly is due to road traffic collisions (—driver or pedestrian). Falls are the main cause of trauma in the elderly, accounting for 75% of cases, and are often low-level from standing or sitting height.10,11,15,18–20 These may be mechanical or due to a variety of medical causes.21 Injuries due to such low-level falls in the elderly should not be presumed to be insignificant and can carry serious consequences. Falls are the fifth leading cause of death in adults over 65 years old.22

Patterns of Injury by Anatomical Region

Head Trauma

Head trauma in the elderly carries a greater risk of intracranial injury irrespective of ISS, as well as increased mortality and morbidity (2x and 4x respectively), when compared to the younger trauma patient group.11, 23,24 This is due to the increased risk of haemorrhage in all the intracranial compartments, but particularly the subdural compartment. As the brain atrophies, the subdural compartment widens, stretching the bridging cortical veins which are then more susceptible to shearing injury.10, 11 In addition, increasing fragility of vessels, hypertension, amyloid angiopathy, haematological conditions, alcohol and anticoagulant use increase the risk of bleeding in all compartments of the brain.11, 20 Patients on anticoagulation have a 4–5 times increased risk of mortality from intracranial haemorrhage and are more likely to require intervention or experience complications (Figure 1).25

A 90-year-old female patient with loss of consciousness after a fall from a height of less than 2 m. Axial unenhanced CT image shows a large right concavity subdural haematoma and a small volume of subarachnoid blood, with moderate midline shift to the left and effacement of the lateral ventricles.

It is estimated that around 3% of elderly patients will have intracranial injury without clinical indicators such as history of loss of consciousness, focal neurology or change in GCS.26 This may be partly explained by the age-related increase in space between the brain and the skull which allows expansion of the intracranial contents with less symptoms.20 Although National Institute of Clinical Excellence criteria for performing CT Head examinations in the elderly are the same as for younger adults (GCS < 13 or GCS < 15 two hours after injury), it may be wise to perform these studies in all elderly trauma patients, other than in minimal to mild trauma. Early detection and treatment of traumatic abnormalities significantly improves overall clinical outcome and increases the chance of returning to normal independent living.24, 26

If a patient on anticoagulation has a positive scan for haemorrhage, this should be reversed. If the scan is negative, a protocol of twenty four hours of observation followed by repeat CT will identify most occurrences of delayed bleeding.27

Spinal trauma

The elderly are at greater risk of having a spinal injury, mainly due to poorer osseous mineralisation, osteoporosis, and increased spinal rigidity. Spinal injuries tend to occur with seemingly minor trauma and are not infrequently multilevel.11,28–30 Since these may be clinically unstable and at risk of neurological decline, prompt imaging is required.11

Cervical spine

Cervical spine trauma is an important source of morbidity and mortality in elderly patients who often sustain fractures after relatively low energy injuries. There are three recognised patterns of falls: fall from standing, fall from a height and falling down stairs. The latter results in a hyperextension injury, which may be associated with loss of consciousness and upper cervical injury.28, 29 Hyperextension injuries also occur in patients with direct anterior craniofacial (“faceplant”) injury.28

Conditions such as senescent spondylosis deformans, ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis and ossification of the posterior longitudinal ligament may result in increased rigidity of the mid and lower cervical spine, with relatively increased mobility of the superior cervical spine (C1 and C2) and craniocervical junction.28, 29 As a result, up to 60% of fractures in the elderly involve the C1 ring and C2 dens.29 If a fracture is detected, further assessment for possible contiguous and non-contiguous spinal fractures is required, as 30–40% of patients sustain multilevel cervical spinal injuries (Figure 2a–c).29

A 70-year-old male patient after fall from a height of less than 2 m. (a) Sagittal CT image on bone windows demonstrates widening at C6-C7 vertebral bodies (arrow) likely secondary to a hyperextension injury. (b) T2- weighted sagittal MRI performed the same day. There is constitutional narrowing of the mid-cervical canal. This sequence demonstrates a shallow prevertebral haematoma (arrow 1), cord contusion and haemorrhage from C4 to T2 (arrow 2), and ligamentum flavum interruption (arrows 3). Anterior and posterior longitudinal ligament interruption (arrow 4) and disc extrusion was also present (not shown). “Minor” trauma can have devastating consequences in the elderly. (c) A 90-year-old male patient with a fall from a height of less than 2m. Sagittal CT image on bone windows demonstrates diffuse moderate osteopenia. There is a mildly displaced fracture through the base of the odontoid peg (arrow 1), a fracture of the anterior inferior corner of C4 (arrow 2) and fractures of spinous processes of C3 and C4 (arrows 3 and 4). The pattern of fractures suggests a hyperextension injury. C2 fractures are common in the elderly, as are multiple associated fractures.

Spondylosis also results in an increased incidence of spinal canal stenosis. This increases the risk of spinal cord injury, with or without bony injury, especially if the paraspinal ligaments and the ligamentum flavum are disrupted.11 In hyperextension injuries, the bulging ligamentum flavum may compress the spinal cord resulting in a central cord syndrome (Figure 2a–c).

The diagnostic value of radiographic assessment is limited by reduced bone density and spondylotic changes, therefore injuries may be missed in up to 40% of adult and 80% of elderly trauma patients.28 Hyperextension injuries, for example, may be very subtle or occult on radiography with only slight widening of an intervertebral disc space or a soft tissue haematoma.28 There should be a low threshold for imaging with CT (±MRI), given the complications that may arise from a missed cervical spinal fracture and the risk of spinal cord injury without radiological evidence of trauma (SCIWORET) (Figure 3).

A 70-year-old male with right upper limb weakness following a fall from height of less than 2 m. No fracture or dislocation is demonstrated on the sagittal CT image on bone windows (a), but there is mild diffuse osteopenia. A sagittal T2 weighted MRI (b) obtained within 24 h demonstrates oedema in the spinal cord from C2 to C5 without ligamentous disruption, on a background of constitutional narrowing of the mid cervical vertebral canal and ligamentum flavum hypertrophy. This constitutes spinal cord injury without radiological (CT) evidence of trauma (SCIWORET).

Since patients with an apparently isolated head injury have a 5% risk of additional spinal injury, we suggest that cervical spine CT is added to all CT head studies in the elderly.30

Cervical trauma is also associated with blunt cerebrovascular injury.31 Factors associated with increased incidence of vascular injury include neurological deficits, GCS < 6, petrous bone fracture, foramen transverseria fracture, diffuse axonal injury and a Le Fort II or III fracture (41% risk of blunt cerebrovascular injury). In these patients, CT angiography is helpful in detecting any cerebrovascular injury (Figure 4).

An 80-year-old male patient who fell from a height greater than 2 m. Unenhanced axial CT (a) shows moderate osteopenia with an acute unstable C6 vertebral body fracture involving both transverse foramina (thick arrows) and the spinous process. The coronally reformatted CT angiogram (b) demonstrates short segment occlusions of the vertebral arteries bilaterally at the level of the fracture (thin arrows).

Thoracolumbar spine

Osteoporosis is a major risk factor for vertebral compression fractures particularly in the thoracolumbar spine. As well as being common in post-menopausal women, osteoporosis also affects a third of men over the age of 75 years.11

Thoracolumbar spinal injuries, like cervical spinal injuries, can be difficult to detect radiographically.32 CT offers better diagnostic value and assessment of vertebral body height reduction and spinal canal diameter in cases of burst fractures with retropulsion. It also permits assessment of underlying lesions in suspected pathological fractures. A CT examination of the whole spine is advised in patients with significant spinal trauma, as 40% of injuries involve multiple, non-contiguous segments.11 MRI is useful in cases of equivocal CT findings, suspected ligamentous injury, spinal cord injury or occult fractures.33

The most common site of injury is at the thoracolumbar junction (T12-L2), followed by the mid-thoracic spine. Mortality is related to the number of fractured vertebrae and has been shown to be as high as 20% for fractures in rigid spines; often as a result of pneumonia and respiratory failure.11,33–35

While the evidence for vertebroplasty and kyphoplasty in decreasing pain and encouraging mobilisation is equivocal, the radiologist can help to triage vertebral fracture patients into those who might be suitable for these procedures and those where it is contraindicated, such as for a burst fracture.36

Blunt Thoracic Trauma

Rib fractures are the most common manifestation of blunt thoracic trauma in the elderly. Age-related osseous demineralisation leads to increased risk of rib fractures even with low energy mechanisms. These need to be treated seriously as they have a higher mortality rate, which may be partially explained by diminished physiological reserve, respiratory compromise and increased susceptibility to infections. Higher ISS (>30) and multiple fractures are particularly concerning.37

Rib fractures are also often a sentinel injury associated with a higher ISS and more severe trauma, such as cardiac and great vessel injuries, pneumothoraces, pulmonary contusions, as well as liver and splenic trauma. Similarly, clavicular fractures are sentinel injuries for severe thoracic and brain injuries and are associated with a higher mortality rate in the elderly (Figure 5).5, 11,37,38

A 70-year-old driver who was ejected from the car in a road traffic accident. Axial contrast-enhanced CT of the thorax demonstrates displaced right rib fractures on the bone window image (a). The soft tissue window (b) shows an underlying right pneumothorax (arrow 1), haemorrhagic pulmonary contusions in the right lower lobe (arrow 2), right haemothorax (arrow 3), right soft tissue injury and subcutaneous emphysema (arrow 4). There is also a fracture of the right transverse process of the thoracic vertebra at this level (arrow 5). There is a partially imaged right pleural drain anteriorly (thin arrow).

Mortality is directly proportional to the number of ribs fractured: if more than 6 ribs are fractured, the mortality rate is 33%. If there are more than 3 rib fractures, outcomes are better if the patient is treated aggressively with HDU admission and adequate analgesia to reduce the infection rate and need for mechanical ventilation. Adequate analgesia may be achieved with nerve blocks and epidural anaesthesia.11, 37,38

Flail segments are increasingly treated with open reduction and internal fixation at many MTCs. This has been shown to reduce the need for ventilatory support, shorten the intensive care and overall hospital stay, reduce the incidence of pneumonia and septicaemia, reduce the risk of chest deformity and reduce the mortality rate (Figure 6).38–41

An 80-year-old female patient who had an unwitnessed fall down multiple stairs. There are multiple displaced fractures of the first 5 right ribs demonstrated on the volumetric 3D CT reconstructions (arrows in a). The subsequent radiograph (b) shows open reduction and internal fixation of the right rib and right clavicle fractures. The patient has developed right lower lobe collapse and consolidation and a right pleural effusion in the interim. There is an endotracheal tube in situ, a right pleural drain and previous bilateral breast augmentations.

The radiologist can proactively identify patients with significant rib injuries and flail segments that may benefit from the above interventions. This will enable patients to mobilise and commence physiotherapy earlier, decreasing the risk of secondary chest infections and their consequences.40, 41

Traumatic vascular injuries are uncommon in the elderly population, occurring in approximately 1% of cases. They are associated with a fourfold increase in adjusted mortality and early intervention should be considered.42, 43 Injury is usually secondary to blunt trauma, most commonly in motor vehicle crashes, due to deceleration injury.43 Atherosclerosis may contribute to increased risk of injury.44 Patients with vascular injuries tend to have a higher ISS and the thoracic aorta is the most frequently involved vessel (Figure 7).43

An 80-year-old male patient who made an emergency stop. The patient had chest pain and marked bruising on examination of his chest. Sagittal and axial images from a contrast-enhanced CT of the thorax demonstrate an acute Type B aortic dissection, associated with aneurysmal dilatation of the proximal descending aorta (arrows in a and b). Right lung consolidation and haemothorax noted. The bony windows confirm the presence of a sternal facture (arrows in c and d). It was presumed that this dissection was traumatic, although the converse is also possible and the emergency stop was due to the dissection.

Blunt Abdominal Trauma

Blunt abdominal injury occurs following high-energy trauma and is no more common in elderly patients than in younger patients. However when abdominal trauma does occur, there is up to a fivefold increase in the mortality rate when compared to younger patients.11 Clinical assessment is more challenging in geriatric patients, yet failure to intervene promptly results in a higher morbidity and mortality.18 Therefore, there should be a lower threshold for early imaging with contrast-enhanced CT to enable surgical and radiological intervention (Figure 8).

A 70-year-old male driver who was involved in a head on crash and ejected from the car. Coronal image from an arterially enhanced CT of the abdomen demonstrates a grade 4 left renal laceration with a large subcapsular haematoma (arrow 1), a small subcapsular haematoma surrounding the right kidney (arrow 2) and retroperitoneal haematoma (thin arrows). In addition, there is a perisplenic haematoma (arrow 3) from a low grade laceration (not shown).

Pelvic Trauma

Pelvic trauma in the elderly may be caused by low- or high-energy trauma: including motor vehicle accidents and falls.11, 45,46 Lateral compression fractures are five times more common than antero-posterior compression fractures in the elderly population, a reversal of the normal pattern observed in younger patients. Osteoporosis may also account for the susceptibility of older patients to fractures from low energy mechanisms that would not normally produce fractures in younger patients.11, 46

Elderly patients who sustain pelvic trauma have a fourfold increase in mortality rate (up to 20%) when compared to younger patients. They also suffer greater morbidity and have a longer length of hospital stay despite aggressive treatment. Mortality is most often a result of multiorgan failure; however, haemorrhage remains a major concern. Age over 60 years has been shown to be a significant risk factor for active bleeding, with the elderly having an eightfold risk of significant pelvic bleeding compared with younger adults, which may require early intervention.11, 20,46,47

Haemorrhage in lateral compression fractures does not often respond to external fixation or fracture stabilisation. Occult cardiovascular dysfunction is common; as many as two thirds of patients over the age of 60 years with a bleeding complication on CT were asymptomatic. Early invasive monitoring and intervention with angiography has been shown to improve outcomes and although there are no universally agreed guidelines, many centres recommend a low threshold for repeat CT imaging or angiography with embolisation (Figure 9).11, 45,47

A 70-year-old male patient who fell down two steps. (a) Plain radiograph demonstrates undisplaced fractures of the left superior and inferior pubic rami. (b) Coronal CT images confirm extraluminal blush of contrast (fat arrow) from the right pelvic side wall with bilateral retroperitoneal haematoma, larger on the right (thin arrows). This area of active haemorrhage was subsequently successfully embolised. Apparently “minor” pelvic fractures may be associated with significant active bleeding.

Extremity Fractures

Extremity fractures in the elderly may be sustained following high-energy trauma in relatively normal bone or minor trauma or insufficiency fractures in osteopenic bone (including in patients on bisphosphonate therapy). Additionally, fractures may be pathological or peri-prosthetic.11

All extremity fractures in the elderly are associated with increased mortality with increasing age. A typical femoral neck fracture for example, is associated with increased mortality (up to 20% 1-year mortality risk) and morbidity (one third of patients do not return to independent living).11

Proximal femoral fractures are the most commonly sustained extremity osteoporotic injury, followed by fractures of the pelvis, femoral shaft, proximal humerus, distal femur and distal radius respectively.48 Fracture severity is increased in patients with osteoporosis, mimicking injuries seen in younger patients after high-energy trauma, and there is greater need for surgical fixation.49

All patients with suspected extremity fractures should initially be assessed by radiography. There should be a low threshold for continuing to CT or MRI if the initial radiograph is normal; retrospectively reviewed radiographs only detect as little as 15% of MRI-apparent insufficiency fractures of the proximal femur or pelvis.50 There is particularly poor sensitivity for sacral and acetabular fractures.50 CT identifies 69% of insufficiency fractures whereas MRI identifies 99% of insufficiency fractures of the pelvis and proximal femur. MRI will often reveal additional, unsuspected concomitant fractures at other sites in the pelvis (Figure 10).50–52

An 80-year-old male patient with a fall from a height of less than 2 m. Oblique coronal image (bone window) from a contrast-enhanced CT of the abdomen and pelvis demonstrates an acute fracture of the L2 vertebral body on the right (arrow 1) and a comminuted, moderately displaced left intertrochanteric fracture (arrow 2).

Periprosthetic fractures are more common in patients over the age of 70 years, female patients and in those who have had previous revisions.53 These fractures are best imaged with CT which allows simultaneous evaluation of bone stock.54

Fracture complications are commoner in the elderly, especially in cases of poor mobility or prolonged bed rest. These include skin sores (related to casts, skin traction or pressure/“bed-sores”), infection and delayed bone healing, wound healing or haematoma resolution. The incidence of venous thromboembolism is also greater in older patients, with age over 40 years an independent risk factor.55, 56

Elderly Abuse or Neglect

Physical abuse is an important consideration in elderly patients presenting with trauma. The true prevalence of elder abuse is difficult to determine but is estimated at up to 10%.57 It often overlaps with the presentation of accidental trauma and only a small fraction of cases are correctly identified in the Emergency Department. Therefore, a high level of vigilance for elder abuse is required, just as for non-accidental injury in children.

The most common injuries in physical abuse are: upper extremities (44%), maxillofacial, dental and neck (23%), skull and brain (12%), lower extremity (11%) and torso (10%). This distribution of injuries cannot be confidently distinguished from accidental trauma but some patterns are extremely suggestive, for example injuries to the axilla, posterior torso and lower extremity, inner thigh and the dorsal or plantar aspects of the foot.58, 59

Victims of abuse resulting in trauma have more severe injuries are more likely to be admitted to an intensive care unit and have a higher risk of death when compared to accidental trauma patients.60, 61 Prompt diagnosis of elder abuse is important but remains complex. Radiologists play an important role in highlighting unusual patterns of injury.

Conclusion

The elderly are a unique patient group and need to be treated as such. They are more susceptible to injury from lesser trauma than younger adult patients. Additionally, they may be frail, have decreased physiological reserves, co-morbid conditions, and be on medication with significant effects in trauma. Although clinical and radiological diagnosis in the elderly is more challenging, prompt investigation, diagnosis and treatment will improve morbidity and mortality. Radiologists can have a positive impact on the care and wellbeing of these more vulnerable patients.

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