From the Guidelines
Imaging after a fall should be guided by clinical assessment and risk factors, with a focus on detecting injuries that would change management and improve patient outcomes in terms of morbidity, mortality, and quality of life. For head injuries, CT scans are recommended for patients with loss of consciousness, amnesia, severe headache, vomiting, seizures, focal neurological deficits, Glasgow Coma Scale <15, anticoagulant use, or age >65 with concerning symptoms 1. Cervical spine imaging is indicated for neck pain, neurological deficits, altered mental status, high-energy trauma, or distracting injuries. For extremities, X-rays are appropriate when there is localized pain, swelling, deformity, or limited range of motion. Chest and abdominal imaging may be necessary with significant trauma, respiratory distress, or abdominal tenderness.
- Key considerations include:
- Patient age and comorbidities, such as osteoporosis or anticoagulant use
- Mechanism of injury and energy level of the trauma
- Clinical presentation, including symptoms and physical examination findings
- Risk of bleeding or other complications
- The decision to image should balance radiation exposure risks against the benefits of detecting clinically significant injuries that would change management, with a focus on minimizing harm and optimizing patient outcomes 1.
- Patients on anticoagulants require special consideration as they have higher bleeding risk, particularly for intracranial hemorrhage, even after seemingly minor falls, and may benefit from closer monitoring and repeat imaging 1.
- Recent studies suggest that delayed intracranial hemorrhage after blunt head trauma in neurologically intact patients on anticoagulant or antiplatelet therapy is rare, and that patients with a normal initial head CT can be safely discharged with clear instructions for return precautions 1.
From the Research
Criteria for Imaging After a Fall
The criteria for imaging after a fall can be complex and depend on various factors, including the patient's age, medical history, and the severity of the fall. The following are some key points to consider:
- For children who have fallen from a height, the injury pattern is different from that of adults, and a different imaging protocol is needed 2.
- Radiography of the cervical spine and chest alone is recommended in the initial evaluation of the injured child, with computed tomographic (CT) scans of the head obtained on a case-by-case basis 2.
- For adults, the decision to image after a fall should be based on clinical judgment and the presence of risk factors for serious injury, such as evidence of trauma and ambulatory status 3.
- The most common injuries after a fall are extremity fractures, head injuries, and pneumothoraces 2, 4.
- The cost of imaging after a fall can be significant, with head CT scans being the most expensive 4.
Risk Factors for Falls
Certain risk factors can increase the likelihood of a fall, including:
- A history of previous falls 5
- Clinically detected abnormalities of gait or balance 5
- Visual impairment 5, 6
- Medication use 5, 6
- Limitations in basic or instrumental activities of daily living 5, 6
- Cognitive impairment 5, 6
Imaging Studies
The following imaging studies may be ordered after a fall, depending on the patient's symptoms and risk factors: