Traumatic Head Injury (THI) is one of the major causes of morbidity, mortality and disability in the United States (US) [1]. Especially in the older populations, patients with a THI have been shown to have a greater than 80% chance of long-term disability and/or mortality [2]. A subgroup of THI, traumatic brain injuries, or TBIs, are also associated with significant morbidity and mortality. As TBI often occurs amidst THI, these 2 injury classifications are often intertwined. A large number of survivors of TBI are currently living with significant disabilities, resulting in an outstanding socioeconomic burden [1,3]. In 2010, the financial impact of TBI was estimated to be 76.5 billion United States Dollars (USD); of these, US$11.5 billion were caused by direct medical costs and US$64.8 billion were caused by indirect costs [4]. Regarding THI more generally, according to the United States National Center for Injury Prevention and Control, the highest rates of THI were observed in older adults (≥75 years; 2232 per 100,000 population), versus very young (0 to 4 years; 1591 per 100,000), and young adults (15 to 24 years; 1081 per 100,000). The most common mechanisms of THI, adjusted for age, were falls (413 per 100,000), versus being struck by an object (142 per 100,000), and motor vehicle crashes (122 per 100,000) [3].

Elderly patients are at significant risk for subdural hematomas after THI due to many common risk factors such as previous THI, chronic alcohol use, and cerebral atrophy. In the presence of cerebral atrophy, the bridging leptomeningeal veins are stretched over a greater distance, which allows more shear force against the bridging veins immediately after impact of a fall [5]. Also, the use of vitamin K antagonists (Warfarin) and direct oral anticoagulants increases the risk of bleeding dramatically post THI in the elderly.

Many of these patients may also have chronic dementia and other cognitive deficits at baseline which makes it more challenging to accurately assess their mental status on presentation to the hospital [2]. Coupled with the presence of distracting injuries secondary to their orthopedic trauma, there is a high chance that THI goes unrecognized in these patient populations. Delays in presentation and the recognition of these THIs prior to treatment contribute to the high morbidity and mortality seen [2]. For many of these patients, transient loss of consciousness may be the only apparent symptom for THI secondary to orthopedic trauma. Therefore, it is paramount that middle-aged and geriatric patients receive a comprehensive mental status assessment and physical exam to pick up any signs of THI.

In this study, head injury severity was graded by the Abbreviated Injury Score – Head (AIS-H). The AIS is a severity scoring system that classifies each injury in every body region according to its relative importance on a six-point ordinal scale. Grade 1 is minor, 2 is moderate, 3 is serious, 4 is severe, 5 is critical, and 6 is maximum severity. The first scoring system was published in 1971 and has been utilized for decades by the trauma research community as a universal injury language and reliable injury assessment. The most recent version published in 2005 and revised in 2008, is the most up to date validated scale, and the one used in the current study [6].

As the population continues to age and the populations of middle-aged and geriatric individuals grow, we must continue to improve our ability to recognize THI in the setting of orthopedic trauma. It is our hope that this study emphasizes the impact THI coupled with orthopedic trauma can have on patients in these at-risk populations. This is this first epidemiological study, to our knowledge, with the purpose to characterize head injuries amongst the middle-aged and geriatric population and its effects on hospital quality measures, costs, and outcomes in an orthopedic trauma setting.