Geriatric winter falls: When a simple bump on the ice can be serious

Winter falls on the ice and snow are serious business for elderly Minnesotans. A fall from which a child or young adult might bounce right back up may lead to broken bones, spinal cord injuries or even death from associated injuries in an older adult.

Winter fall risks and the elderly

Older adults are more likely to fall in the winter or at any time of the year than are younger people, and are also at greater risk if they do experience a fall.

"This is a direct result of aging," says Jeremy L. Fogelson, M.D., a neurosurgeon at Mayo Clinic's campus in Rochester, Minnesota. "They are more likely to have an unsteady gait, and the bones are less strong and flexible. Also, depending on an elderly person's physical state, sidewalks may not be tended to as much and icy conditions will build up."

Despite the appearance that falling is a simple mechanism, older adults are more likely to incur serious injuries with a slip on the ice. For example, it's plausible for an older adult who has recently suffered a fall and then notes new back or neck pain to have suffered a fracture or a serious injury, while in a younger person it's likely a sprain, says Dr. Fogelson.

The likelihood of more serious injury due to a fall for older adults stems from several factors. Their brain blood vessels become more fragile, making them much easier to bleed with the force of a fall, says Dr. Fogelson. Also, bones are more brittle, so hip and arm fractures are common in falls with older adults.

Spines also are less flexible in older people, sometimes related to conditions such as diffuse idiopathic skeletal hyperostosis (DISH) or ankylosing spondylitis. Hence, they are more likely to fracture even with a low-mechanism fall. Not only are elderly patients more likely to break their spines during a fall, but when their spines do break, spinal cord injury is more common, related to the narrowing present in arthritic spines.

Brain injuries resulting from falls can threaten older adults especially, due to diminished capacity to recover.

"Falls in the elderly can be life-threatening, as their brains are not as responsive to healing, and they can develop other complications once hospitalized for a brain injury," says Dr. Fogelson.

Recognizing and managing spinal cord injury from winter falls

If an older adult patient arrives at the hospital having suffered a fall in the cold outdoors, it's important to identify whether a spinal cord injury is present, but start by attending to the trauma ABCs: airway, breathing and circulation. In the setting of spinal cord injury, the blood pressure can get quite low related to the loss of autoregulation. Low blood pressure leads to further spinal cord ischemia and secondary injury.

It's also prudent to conduct a basic neurologic exam with an older adult who has fallen on ice or snow, along with an evaluation for spinal pain that could signal injury. Hypersensitivity in the hands and arms, especially burning pain despite good strength, is a telltale sign of possible spinal cord injury, as is new limb paralysis, weakness or numbness.

Some injuries are easy to miss in an older adult examined at the hospital after a winter fall. Abdominal and head injuries are easy to overlook and should be checked, says Dr. Fogelson, explaining that it's important to remember that patients who have suffered head injuries may be confused. Spinal cord injuries can be missed if minor or if present with polytrauma.

"Performing a thorough exam is critical," says Dr. Fogelson, "as you can get distracted by one injury and miss others, such as a spine fracture. Later on, the spine can slip out of alignment and cause cord injury."

If the patient has a suspected spinal cord injury, conduct basic imaging — CT scans, not MRI scans — of the neck, thoracic or lumbar regions to look for fracture. In addition, arrange for transfer to a level of care that has neurosurgery or orthopedic spine surgery coverage, such as a Level I, II or some Level III Trauma Centers in the region. If completing a CT scan is a barrier or will cause a significant delay in transfer, stabilize and send the patient on without imaging. Use spinal precautions such as a cervical collar and a spinal board.

Presently, administering steroids to patients with a spinal cord injury is controversial, as noted in World Neurosurgery, November 2014, and may depend on physician preference. Consequently, Dr. Fogelson recommends speaking to the receiving providers about whether this therapy might be appropriate in any particular patient's case.

For more information

Bydon M, et al. The current role of steroids in acute spinal cord injury. World Neurosurgery. 2014; 82:848.