**3.8. Abdominal trauma**

Abdominal examination can be less reliable and more difficult because of decreased pain sensation and increased laxity of abdominal wall musculature. Also, guarding and rigidity may be lacking in the elderly. Tachycardia response to hemorrhagic shock may not be seen even in the setting of significant blood loss. High index of suspicion and close observation must be continued to be avoided under-diagnosis. The Focused Assessment with Sonography for Trauma (FAST) can be used to detect intraperitoneal fluid in patients who sustain blunt abdominal trauma. CT remains the gold standard to diagnose intra-abdominal injuries. Retroperitoneum is an occult source of bleeding. Also, the risk of occult retroperitoneal bleeding is higher with chronic anticoagulant usage. Therefore, CT with contrast should be considered to evaluate hemorrhage, especially for the elderly patients who have pelvis or hip fracture.

### **3.9. Musculoskeletal trauma**

Fractures are frequent in the elderly and can cause severe pain, disability and loss of independence. The increased risk of fracture with age may attribute to increased risk of fall, osteoporosis, sarcopenia and frailty.

**Pelvis fractures:** In the elderly, low-energy traumas such as ground level falls may result in pelvic fractures [43]. Although patients with pelvic fractures due to minor trauma generally do not present complications, mortality and morbidity increase with accompanied hemorrhage and other associated injuries. The portable AP pelvic X-ray should be obtained as a part of the primary survey. However, posterior ring fractures can be missed. Patients who have pelvic tenderness following pelvic trauma must be assessed regarding pelvic fracture. CT of the pelvis can be obtained in stable patients. If an active bleeding is suspected, pelvic contrast CT is recommended considering the risk of contrast-induced nephropathy. If an active bleeding is identified, arteriography and embolization can be performed for the patients in danger of life. Consequently, expeditious hemorrhage control with simultaneous emergency skeletal stabilization and resuscitation is crucial for the management of pelvic fractures in the elderly.

**Proximal femur fractures:** In elderly patients, hip fractures should be considered as a serious injury. They may lead to immobility, permanent dependence and death. According to several epidemiological studies, the incidence of proximal femoral fractures increases with age, starting at 40 years, with a steep increase after 75 years of age. The average age of patients with hip fracture is over 80, and nearly 80% are women [44]. Although isolated hip fractures do not usually cause class III or class IV shock, long-term prognosis mostly depends on age, comorbidities, anticoagulant therapy and frailty [45]. Hip fractures are the most common cause of accident-related deaths in older people accounting for 18% deaths within 4 months of a hip fracture and 30% within a year [46]. The risk of fracture increases with the number of falls [47] and backward fall mechanism and low bone mineral density (BMD) [48]. Most hip fractures can be diagnosed by typical history and clinical presentations. The first choice for diagnose is plain radiographs. However, it is estimated that 2–9% of fractures may be radiographically occult [49], and further imaging such as CT and MRI is required to make a definitive diagnosis. MRI has higher sensitivity than CT for detecting occult hip fractures. Additionally, nuclear medicine scintigraphy may be another choice for diagnosis due to high sensitivity. However, access to the scintigraphy usually is difficult and, it has limited capability to delineate the full nature of the fracture.
