Orthogeriatric trauma care is the interdisciplinary management of older patients with accident-related injuries. It combines three elements:
- Trauma surgery expertise: Operative care with implants and techniques tailored to osteoporotic bone and multimorbidity.
- Geriatric co-management: Joint medical care from admission onward — delirium prevention, pain therapy, nutrition, fluid management, medication review, mobilization planning.
- Structured rehabilitation and secondary prevention: Early rehabilitation from the first postoperative day, followed by post-acute rehabilitation and a fall/osteoporosis prevention program.
The model has been greatly expanded in Germany over the last ten years. Certified Geriatric Trauma Centers (ATZ DGU) have defined structural standards — firmly established geriatric co-management, standardized treatment pathways, quality indicators, regular review.
The injury patterns in old age differ markedly from those of younger patients. Typical are:
- Hip-region fractures: The femoral neck fracture and the pertrochanteric fracture — together around 150,000 cases per year in Germany.
- Distal radius fracture: The fall onto the outstretched hand. Often the “first warning call” for osteoporosis in old age.
- Proximal humerus fracture: Fracture of the upper arm at the shoulder joint — frequent in women after the menopause.
- Vertebral body fractures: Often spontaneous or after minimal trauma. Many remain clinically silent and only become noticeable through loss of body height or a hunched back.
- Pelvic ring fractures: Particularly in very old women with severe osteoporosis.
- Femoral shaft and peri-implant fractures: More frequent in patients with existing endoprostheses.
- Fall-related head injuries: High risk, particularly in patients on anticoagulation — here every traumatic brain injury must be taken seriously.
In my own hospital, the Main-Kinzig-Kliniken Schlüchtern, the femoral neck fracture remains the most frequent reason for an orthogeriatric trauma admission. Case numbers almost doubled between 2019 and 2025 — from 109 to 217 cases per year. This development corresponds to the nationwide trend and makes structured orthogeriatric care the rule, not the exception.
→ On the most frequent and most consequential fracture in old age: Femoral Neck Fracture in Old Age.
→ On the most frequent cause of these fractures: Falls in Old Age.
→ On the role of osteoporosis as the foundation of fracture risk: Osteoporosis in Old Age.
1. Different target variables
Classic trauma-surgery quality criteria focus on fracture healing, implant positioning and the function of the affected joint. In orthogeriatric trauma care, other target variables are added — partly of equal rank, partly taking priority:
- Preservation or recovery of the pre-existing mobility
- Prevention and treatment of delirium
- Return to one’s own home
- Secondary prevention of further fractures
- Quality of life, not just prolongation of life
2. Different time logic
In younger patients an operation can also be postponed by days if this is organisationally necessary. In older patients, the time until the operation is an independent predictor of mortality and complications. The S3 guideline therefore requires that hip-region fractures be treated within 24 to 48 hours. More on this under Surgical Risk in Old Age.
3. Different complication perspective
The classic complications of trauma surgery — wound infection, implant loosening, secondary bleeding — are also relevant in old age, but they recede behind other complications that are rarer at a younger age:
- Postoperative delirium — 30 to 50 percent after a hip-region fracture
- Pneumonia due to being bedridden
- Pressure ulcers
- Urinary tract infection and urosepsis
- Acute kidney dysfunction due to fluid and medication problems
- Functional decline despite a technically successful operation — a sign of frailty
4. Different team composition
Orthogeriatric trauma care is not a two-person model (surgeon plus anesthesiologist). It is a team comprising trauma surgery, geriatrics, anesthesia, physiotherapy, occupational therapy, nursing, social work, speech therapy and in part nutritional therapy. The effectiveness arises from the collaboration, not from the addition.
Day 0: Admission and preparation
- Emergency care by trauma surgery
- Immediate geriatric co-assessment — assessment, medication, delirium risk
- Pain therapy with as little opioid as possible
- Fluid management, exclusion of accompanying causes of the fall
- Anaesthesiological clearance for surgery (regional vs. general anesthesia)
Day 1: Operation and first mobilization
- Operation within 24 hours (at the latest 48 hours)
- Mobilization to the edge of the bed on the day of surgery or at the latest on Day 1
- Delirium screening
- Thrombosis prophylaxis, respiratory therapy, secretion management
Days 2 to 7: Early rehabilitation in the acute hospital
- Gait training with a walking aid
- Occupational therapy for activities of daily living
- Daily orthogeriatric round with both teams
- Medication adjustment through deprescribing, secondary prevention, osteoporosis evaluation
Days 8 to 21: Further rehabilitation and discharge planning
- Post-acute rehabilitation, geriatric early rehabilitation or discharge home
- Social-law counseling, provision of assistive devices, adaptation of the home environment
- Handover letter to the family doctor with detailed recommendations
→ On the course of geriatric early rehabilitation: Geriatric Early Rehabilitation.
→ On the preoperative assessment of risk in old age: Surgical Risk in Old Age.
Postoperative delirium is the most frequent and most consequential complication of orthogeriatric trauma care. It is not a side phenomenon — it is an independent predictor of mortality, longer length of stay and loss of independence. The most effective strategy is prevention:
- Early mobilization
- Multimodal pain therapy with opioid sparing
- Glasses, hearing aid and dentures at the bedside
- Encourage familiar caregivers
- Sufficient fluids and nutrition — particularly relevant in malnutrition in old age
- Protect the day-night rhythm
- Systematic screening with CAM or 4AT
→ For a detailed account of delirium and delirium prevention: Delirium in Older People and Delirium Prevention.
- Ask about the certified Geriatric Trauma Center: The structure of the hospital makes a measurable difference.
- Bring the current list of medications: Also name over-the-counter and herbal preparations. Keyword polypharmacy in old age.
- Provide glasses, hearing aid, dentures and familiar objects: This reduces delirium and promotes mobilization.
- Visit regularly: Familiar faces demonstrably reduce the risk of delirium.
- Participate actively in discharge planning: The earlier you are involved, the better the return home succeeds.
- Ask about osteoporosis diagnostics and secondary prevention: These steps are not optional. More on this: Osteoporosis in Old Age.
???? The central question that relatives are allowed to ask: “Is there a structured orthogeriatric co-management in this hospital?” The answer determines the quality of care more than many other factors.
In certified Geriatric Trauma Centers, geriatric co-management is standard. In other hospitals — and after discharge — a geriatric perspective is part of good care in the following constellations:
- After a hip-region fracture, when no structured co-management has taken place
- In the case of polypharmacy with five or more long-term medications
- After several falls in old age over the course of a year
- In the case of pre-existing cognitive impairment or suspected dementia in old age
- Three to six months after the fracture, to evaluate secondary prevention
- In the case of persistent insecurity, weakness or suspicion of a frailty syndrome after discharge
→ How the structured geriatric assessment accompanies further care: Geriatric Assessment.
→ On systematic fall evaluation after the first fracture: Fall Prevention — What Really Works.
