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• Regression analysis found a higher AIS-H score was independently associated with greater mortality risk. • The most significant initial increase in poor outcomes occurred between the AIS-H score 2 and 3 cohorts. • The AIS-H 3 cohort experienced significantly worse outcomes despite similar baseline characteristics to other AIS-H cohorts. The purpose of this study is to characterize the effects of head injuries amongst the middle-aged and geriatric populations on hospital quality measures, costs, and outcomes in an orthopedic trauma setting. Patients with head and orthopedic injuries aged >55 treated at an academic medical center from October 2014-April 2021 were reviewed for their Abbreviated Injury Score for Head and Neck (AIS-H), baseline demographics, injury characteristics, hospital quality measures and outcomes. Univariate comparative analyses were conducted across AIS-H groups with additional regression analyses controlling for confounding variables. All statistical analyses were conducted with a Bonferroni adjusted alpha. A total of 1,051 patients were included. The mean age was 74 years, and median AIS-H score was 2 (range 1–6). While outcomes worsened and costs increased as AIS-H scores increased, the most drastic (and clinically relevant) rise occurs between scores 2–3. Patients who sustained a head injury warranting an AIS-H score of 3 experienced a significantly higher rate of major complications, need for ICU admission, inpatient and 1-year mortality with longer lengths of stay and higher total costs despite no differences in demographics or injury characteristics. Regression analysis found a higher AIS-H score was independently associated with greater mortality risk. AIS-H scores >2 correlate with significantly worse outcomes and higher hospital costs. Concomitant head injuries impact both outcomes and direct variable costs for middle-aged and geriatric orthopedic trauma patients. Clinicians, hospitals, and payers should consider the significant effect of head injuries on the hospitalization of these patients. [ABSTRACT FROM AUTHOR]