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Fall from Height

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Fall from Height a line from the anterior articular process of the calcaneus (1) through the posterior articular surface (2) to intersect with a second line touching ... – PowerPoint PPT presentation

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Title: 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.

17
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
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