Objective: To study the relationships between seatbelt use and injury patterns, hospital charges, morbidity, and mortality in elder motor vehicle crash victims. Methods: A retrospective review of individuals at least 65 years old presenting to an urban emergency department (ED) after a motor vehicle crash. Results: Over a two-year period, 339 patients had documentation of seatbelt use or non-use at the time of the crash. Of these, 241 (71%) patients had been wearing a seatbelt and 98 (29%) had not. Elders not using seatbelts were more likely to require hospitalization (29% unbelted vs. 17% belted) and had a higher mortality rate. Injury patterns were different in the two groups. Emergency department charges were significantly different between belted and unbelted elders ($351 vs. $451, p = 0.01) and head computed tomography (CT) utilization was higher in the unbelted group (25.6% vs 12.7%, p = 0.005). Conclusions: Improved seatbelt compliance in elders can reduce injuries, hospitalization rates, ED charges, and mortality resulting from motor vehicle crashes.