Do we perform screening imaging on patients who have fallen but have no complaints?

From the Guidelines

Screening imaging is not recommended for patients who have fallen but have no complaints or symptoms, unless they belong to high-risk populations such as the elderly, those with osteoporosis, or patients with altered mental status. The decision to perform imaging should be based on a thorough clinical assessment, including the mechanism of fall, physical examination findings, and risk factors for injury, as suggested by the American College of Radiology Appropriateness Criteria 1. For patients who are asymptomatic after a fall, with no pain, neurological deficits, or abnormal physical examination findings, watchful waiting is typically appropriate. However, certain high-risk populations may warrant consideration for imaging despite lack of symptoms, including elderly patients (especially those on anticoagulants), patients with osteoporosis, those with altered mental status who cannot reliably report symptoms, or patients with a history of significant trauma, as highlighted in the geriatric emergency department guidelines 1. If imaging is deemed necessary, the modality should be selected based on the suspected injury: X-rays for potential fractures, CT scans for suspected intracranial injuries, or MRI for soft tissue concerns. This conservative approach to imaging helps avoid unnecessary radiation exposure, healthcare costs, and potential false positive findings while ensuring that patients with clinically significant injuries are appropriately identified and treated. Some key points to consider when evaluating a patient who has fallen include:

• Mechanism of fall
• Physical examination findings
• Risk factors for injury
• Patient's age and medical history
• Presence of symptoms such as pain or neurological deficits. The American College of Radiology Appropriateness Criteria 1 provides evidence-based guidelines for specific clinical conditions, including acute hip pain-suspected fracture, and recommends imaging modalities based on the suspected injury. In contrast, the geriatric emergency department guidelines 1 focus on the evaluation and management of geriatric patients who present to the ED after a fall, and emphasize the importance of a thorough assessment for traumatic injuries and estimation of future fall risk. Overall, a thorough clinical assessment and consideration of individual patient factors are essential in determining the need for screening imaging in patients who have fallen but have no complaints or symptoms.

From the Research

Screening Imaging for Patients with No Complaints After a Fall

• The decision to perform screening imaging on patients who have fallen but have no complaints is a complex one, and the evidence suggests that it should be based on individual risk factors and clinical judgment 2.
• A study published in 2024 found that the use of torso imaging, such as CT scans, was not significantly associated with age, but was strongly associated with positive physical exam findings 2.
• The same study found that only two patients over the age of 65 had injuries identified on torso CT scans in the context of a negative physical exam and negative screening imaging, suggesting that more conservative use of CT imaging could decrease healthcare utilization costs without compromising patient care 2.
• Another study published in 2015 found that falls are a major cause of mortality and morbidity in older adults, and that several organizations have recommended screening older patients to identify those with a high risk of falling and fractures 3.
• A multifactorial screening tool, such as the Fall Risk Assessment & Screening Tool, can be used to identify older adults with high fall risk and provide targeted recommendations for intervention 4.
• The tool includes previously validated measures to assess balance, depression, falls efficacy, and home safety, and can be administered by minimally trained office staff with interpretation and follow-up provided by a primary care practitioner 4.

Risk Factors for Falls

• Impaired balance and gait, polypharmacy, and history of previous falls are major risk factors for falls in older adults 3.
• Other risk factors include advancing age, female gender, visual impairments, cognitive decline, and environmental factors 3.
• A study published in 2016 found that the Timed Up and Go test was the most important indicator of a recent fall, and that a cutoff score of 12 or more seconds was optimal for identifying individuals who had a recent fall 5.

Clinical Judgment and Decision-Making

• Clinical judgment and decision-making play a crucial role in determining whether to perform screening imaging on patients who have fallen but have no complaints 2.
• A positive physical exam finding is the only variable associated with significantly increased odds of having an abnormal torso CT scan 2.
• The use of screening imaging should be based on individual risk factors and clinical judgment, rather than solely on age or other demographic factors 2.