Traditionally trauma training and triage have been based upon the mechanism and injury patterns, with outcomes of operative intervention, massive transfusion and mortality. Older people benefit from holistic care with recognition of the ageing physiological processes and medical complexity including frailty, dementia and multiple chronic conditions.

Hip fracture pathways in the UK are an excellent example of how joined up, high quality care for older people has resulted in sustained improvements in care processes and outcomes. However, this approach needs to extend beyond patients with fractures of the proximal femur to all types of major trauma, including head injury.

The most recent TARN report on older persons’ trauma demonstrated under triage both pre- and in-hospital, fewer trauma team activations and less senior reviews of older trauma patients. Using clinical cases we will discuss the difficulties in early identification of older patients with major trauma. This may be caused by the lower energy transfer mechanism of injury, with the most common mechanism in older people being a fall of less than 2 metres; medical co-morbidities which makes the presentation less obvious; or signs of significant injury that take longer to manifest. These patients are the fastest growing major trauma group, which explains the urgent need to focus upon silver trauma rather than the traditional perspective of trauma being due to high-energy transfer such as road traffic collisions.