Contemporary trauma to the elderly, its severity and associated mortality and morbidity in 111 United States and Canadian trauma centers are described. Three-thousand eight-hundred thirty-three (3,833) trauma patients age 65 years or older are compared to 42,944 injured patients under age 65. Although both groups had equivalent measures of injury severity, the older group had higher case fatality and complication rates and longer hospital stays. The results raise important questions regarding the triage, acute care, accurate prediction of outcome, and hospital reimbursement for the elderly injured patient, with implications for care evaluation, quality assurance, and the long-term viability of trauma centers and systems of care.