Fall from Height

1
Fall from Height
2
Falls from height

• 30-40 associated with suicidal intent
• Remainder accidental
• Seasonal variation in accidental falls
• Suicidal attempts show no such seasonal variation
• Also associated with drugs, alcohol and
  psychiatric disease

3
Can the Distance Fallen Predict Serious Injury
after a Fall from a Height?

• J Trauma, Volume 46(6). June 1999.1055-1058
• Impact (v) is related to the Height fallen (h)
  and acceleration due to Gravity (g, 9.8msec-2)
  
• ATLS Fall gt20 feet(6.1M) a clinically important
  risk, above which major trauma is considered
• total of 166 cases 141 males and 25
  females.Height of fall 1 to 20 meters Mean
  height fallen was 3.2 meters

4
Can the Distance Fallen Predict Serious Injury
after a Fall from a Height?

• As a sole criterion, height of fall is a poor
  predictor of major injury
• Sensitivity is inadequate to rule out major
  injury
• Positive predictive value of the test is poor
• The relative risk of serious injury increases
  with age
• Those who landed on heads had an increased
  relative risk
• Conclusions
• Any trauma victim who has fallen more than 2
  meters (6.6 feet) is at significant risk of
  serious injury.
• The height of fall should not be used as a sole
  criterion for trauma triage decision-making.

5
Prognostic factors in victims of falls from height

• Crit Care Med 2005 331239-1242
• Patient age, height of fall, circumstances of
  fall, and the body part first touching the ground
  are independent prognostic factors in victims of
  falls from height
• Out-ofhospital mortality comprised 70 of the
  total mortality, including 56 of the patients
  who died immediately on site
• A strong correlation between height of fall and
  mortality.
• The median height of fall in patients who died
  15 m, 5 floors

6
Prognostic factors in victims of falls from height

• The nature of the impact surface
• Survival after fall from 96 m, with a 28 msec-1
  velocity at contact, and deceleration estimated
  at 191 G on a beach
• WWII, pilot jumped from plane at 7320 m and
  landed in pine forest and snow the survivor of
  the most extraordinary free fall ever reported
• Falls from height into water
• Impact of feet on the water, deceleration force
  is around 6 G.
• In cases of lateral impact, this force reaches 40
  G

7
Prognostic factors in victims of falls from height

• On a solid impact surface, body orientation at
  the time of the impact was a theoretical
  prognostic factor
• Impact on the feet results in lower extremity
  trauma which is not life threatening in most
  cases.
• In contrast, injuries after impact on the head
  are clearly life threatening.
• Mortality rate 57 in ventral impact 23 after
  dorsal impact
• Because of the head weight, children are
  particularly predisposed to cranial trauma.

8
Postmortem Analysis of Fatal Falls

• The head is the most frequently injured body
  region (70), followed by the chest, abdomen,
  extremities, and neck
• Primary cause of death was craniocerebral trauma
  and that the vast majority of skull injuries
  associated with falls down stairs were found
  above the hat brim line.
• Aortic lacerations and vertebral compression
  fractures were also frequent.

9
The Physics of Falling

• Falls are examples of vertical deceleration
  injuries (VDI)
• Patterns of injury differ from horizontal
  deceleration injuries (HDI) associated with motor
  vehicle accidents
• Fractures and retro-peritoneal injuries are more
  common in VDIs
• Intra-abdominal injuries are more common in HDIs

10
The Physics of Falling

• Factors influencing magnitude of injury
• Impact velocity
• Rate of deceleration
• Impact surface
• Body habitus
• Age of patient
• Orientation of body on impact
• Objects encountered during fall (associated with
  upper limb fractures)

11
Patterns of Injury in Victims of Urban Free-Falls

• Major damage to parenchymal organs of the
  abdominal and thoracic cavity is the predominant
  cause of death after falls from extreme heights.
• Scalea et al.
• J. Trauma 26706, 1981
• Mechanisms sufficient to cause serious damage to
  intra-abdominal organs are severe enough to cause
  other injuries resulting in immediate death.
• Retroperitoneum is the most likely source of
  hemodynamic instability, and they therefore
  recommended transportation to the angiography
  suite rather than the operating room for fall
  victims with evidence of continuous blood loss.

12
Patterns of Injury in Victims of Urban Free-Falls

• ARDS may occur owing to direct transmission of
  shear forces to the alveoli after acute vertical
  deceleration.
• Peripheral vascular injuries are rare but should
  not be overlooked.
• Usually consist of intimal tears or
  pseudoaneurysms
• Always associated with falls of more than 30 feet
  and fractures of the corresponding extremity.
• The popliteal artery is most commonly involved.

13
Patterns of Injury in Victims of Urban Free-Falls

• Survival is rare after urban free-falls from
  heights gt 40 feet
• Spinal injuries may occur after falls from any
  height and a low threshold for aggressive
  evaluation of the whole spine should be adopted,
  especially in the presence of associated lower
  extremity fractures.
• Intraabdominal organ injuries are not uncommon
  and should be prioritized before retroperitoneal
  trauma in the differential diagnosis of the
  hemodynamically unstable fall victim.
• Major vascular injuries are rare in survivors
  from urban falls but should be suspected and
  treated promptly for optimal results.
• The height of the fall is a good predictor of
  injury severity and ultimate outcome.

14
Patterns of Injury in Victims of Urban Free-Falls

• The battleship fracturesimultaneous fracture
  of the lumbar spine and a tarsal or metatarsal
  bone.
• Two-thirds of patients with a fracture in the
  foot also had a lumbar spine fracture.
• All patients with spine fractures in whom the GCS
  was 14 or 15 had positive physical findings of
  their spinal fracture pain, palpation
  tenderness, or neurologic deficits.
• Bypass extensive spinal radiographs in patients
  who clearly are awake and alert and have a
  negative physical examination.

15
Head-First Falls

• Hyperextension of the head.
• Compression of the cervical spine.
• Chest, lower spine and pelvic injuries are also
  common.

16
Feet-First Falls

• Compression travels up the spinal column.
• Falls greater than 20ft. possible affect on
  internal organs.
• Foreword falls look for Colles or silver fork
  fractures of the wrist.
• Thrown backwards look for injuries to head, back,
  and pelvis.

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Calcaneal fractures

• Diagnosis
• Bohlers salient angle lt 20 degrees suggests
  fracture
• 7 common fracture patterns
• Treatment
• Need CT to assess involvement of sub-talar joint
• Can be surgically reconstructed or managed
  conservatively

18
Pelvic Fractures

• Common in buttock and feet first landings
• Occur in 20-30 of all falls from height
• As with other fractures, has been shown to
  increased in frequency with increasing height of
  fall
• All types of pelvic fractures described

19
Thoraco-lumbar fractures

• Commonest skeletal fracture associated with falls
  with an incidence of 80
• Thoracolumbar junction is area most often
  involved
• L1 gt L2 gt T12
• Stability depends upon column theory
• CT useful in determining stability

20
Cervical Spine Fractures

• Rare in falls
• Can be seen with feet first landings with flexion
  of the neck at impact
• Flexion type cervical spine fractures
• Anterior subluxation
• Bilateral facet joint dislocation
• Wedge / compression fracture
• Clay-shoveler fracture

21

• Pediatric Falls from Height

22
Pediatric Falls from Height

• How common are falls ?
• Roughly half lt 1yr fall from height
• Frequent source of ED Visits (1/100/yr)
• Frequent source of hospitalization ( 1/1000/yr)
• Infrequent cause of death ( 4/1,000,000/yr)

23
Body Orientation on Impact

• Determines the pattern of injuries sustained
• Determines mortality rate
• Head first
• 50 mortality from 1 floor
• Feet first
• 50 mortality from 5 floors
• Horizontal landing
• Associated with chest and abdominal injuries

24
Feet First Landing

• Commonest orientation on landing
• Associated with typical fracture distribution
• Calcaneus and subtalar joint
• Tibial plateau and fibula
• Femur
• Pelvis
• Lumbar spine
• Thoracic and cervical spine

25
Free Falls Fatality

• Deaths from falls in children how far is fatal?
  J Trauma. 1991 311353-1355.
• Fatalities 10-45ft 1/118 5-9ft 0/65 1-4ft
  7/100
• When children incur fatal injuries in falls of lt
  4ft, the history is incorrect.
• The mortality of childhood falls. J Trauma. 1989
  291273-1275.
• Fatalities 50ft 8 4-40ft 18 3ft 18
• Minor falls can be lethal, especially in a
  toddler.
• Additionally, we have found (as others) that it
  is extremely rare to have visceral, thoracic, or
  non-skull fractures in children who fall from lt 3
  floors. --if these injuries are found,one should
  suspect abuse.

26
Free Falls Fatality

• The nature of injuries associated with free falls
  in children is considerably different from that
  in adults.
• Children lt3 yrs are much less likely to have
  serious injuries than older children who fall the
  same distance.
• It is thought that because younger children have
  more fat and cartilage and less muscle mass than
  older children, they dissipate the energy
  transferred by the fall.
• Young children who fell from lt3 m sustained only
  minor injuries, such as contusions, abrasions,
  and lacerations.

27
Free Falls Fatality

• Fractures were the most common of their serious
  injuries, and the radius, ulna and femur were the
  most frequent sites.
• Mortality rate increased in falls from 6 m.
• Children with low-level falls had a similar risk
  for intracranial and abdominal injury as those
  who fell from greater heights.
• 58,000 fall-related hospitalizations and the 130
  deaths below the age of 15 are most often
  associated with falls gt10 m.

28
Free Falls Fatality

• Nearly 3/4 of falls from heights in children are
  unintentional, and the circumstances of injury
  should always be investigated for inflicted
  trauma, especially in children lt5 yrs).
• Children Cant Fly program
• Legally requiring window guards in all family
  houses with children lt10 yrs old.
• Accidental falls decreased by 96 in 4 yrs.
• 98 children were injured during a 3-yr period
  from 1997 to 1999 in Dallas, because of an
  injury-prone situation permitted by older
  building codes