Falls from height due to accident and suicide attempt in Greece. A comparison of the injury patterns

Highlights

• Patients following a suicidal high falls attempts suffer from multiple trauma, mostly lower limb fractures, pelvis, spinal fractures and head injuries.

• Patients following an accidental high fall mostly had upper limb fractures.

• Spinal fractures are common either when the fall is accidental or following a suicidal attempt.

Abstract

Background

Falls from height are a common cause of death and disability. Falls from height can be divided between accidental and suicide attempts. The aim of this study is to ascertain the demographic characteristics of these patients, and to identify the fracture patterns.

Methods

In this retrospective cross sectional comparative study we present 244 patients who sustained injuries as a result of a fall from height. They were divided into those with accidental falls (n = 180, group I) and those with suicide attempts (n = 64, group II). Data collected included age, gender, associated trauma, injury severity score (ISS), Glasgow Coma Scale (GCS), haemodynamic status, length of intensive care unit (ICU) and hospital stay. The diagnosis of mental disorder was ascertained by psychiatric specialists using the criteria of the International Classification of Disease Ninth Version Clinical Modification (ICD - 9CM). Postoperative follow-up ranged from 12 months to 10 years.

Results

The injuries sustained were as follows: Abdominal trauma in 9 cases (5 in group I, 4 in II), thoracic trauma in 81 cases (49 in group I, 32 in II), head injury in 23 cases (7 in group I, 16 in II), 383 extremities fractures (184 in group I, 199 in II) and 133 spinal fractures (101 in group I, 32 in II). Twenty-one patients died in hospital while 223 patients survived to hospital discharge. The mean height from which the fall occurred was 5.4 m (range, 3 - 25 m). The mean Injury Severity Score was 19 (range, 6 to 58) for all fall victims.

Conclusions

Patients following an accidental high fall mostly had upper limb fractures. Patients following a suicidal high fall mostly had lower limb fractures, pelvis, spinal fractures and head injuries. Spinal fractures are common either when the fall is accidental or following suicide attempt.

Introduction

Falls from height cause significant death and disability worldwide, due to the severe traumatic load inflicted on their victims [1], [2], [3]. Falls from height can be divided between accidental falls and suicide attempts. Accidental falls are more common in rural places [4, 5] and suicidal attempts from height usually are held in cities [6]. According to the WHO, accidental falls of height or same level, are the second cause of accidental death worldwide, with a yearly mortality approximately 646.000 people. Every year 37.7 million falls are severe enough to require hospitalization [7]. Also according to the WHO, the yearly mortality due to suicide worldwide is approximately 8oo.ooo people [8].

Causes for this mechanism of injury include both accidental falls and suicide attempts [9]. The latter constitutes a major social problem, with implications for the entire society, but particularly for the affected family. The psychological profile of people committing suicide is complex and unique for each case [3]. The type of injuries incurred after a fall constitute a unique pattern of blunt trauma, with a characteristic distribution of damage (multiple lesions in a variety of body areas) [10, 11]. The most common form of trauma are fractures followed by other areas, such as the head, the thorax, the abdomen as well as the retroperitoneum, being injured by a varied degree [12]. The quantity and quality of traumatic load absorbed depends on factors like the height from which the fall occurred, the part of the patient's body that had the first impact, the surface where the impact occurred and the victim's age, taking into account the associated comorbidity and reduced physiologic reserve that advanced age implies [13], [14], [15]. Anticipation and prediction of the exact areas being injured is not possible because of the multitude of factors involved, and the exact unpredictability of the fall's kinematic [16, 17].

From the aforementioned one can infer that the differential diagnosis of falls from height from other types of blunt trauma (for example a road-traffic-collision with expulsion of the occupants from the vehicle), is difficult. Thus, a high index of suspicion must be maintained concerning the initial cause in cases of polytrauma in victims with an unknown history [18]. An array of papers has dealt with injury-related deaths in general, while other have differentiated between unintentional and intentional injury related deaths [19], [20], [21], [22]. There are few studies, though, that have looked into patients with intentional or unintentional injuries due to a fall from height, at a single center [11, 23]. The aim of this study is to ascertain the demographic characteristics of these patients, and to identify the fracture patterns.

In this retrospective cross sectional comparative study, 244 patients (113 males and 131 females) who were treated as a result of falls from height were reviewed from January 1990 to October 2012. The inclusion criteria were: age above 18 years of old; accidental and suicide attempts; and minimal height of fall above 3 m. Exclusion criteria were injured patients died at the scene; and falls due to criminal acts. These 244 cases comprised our series and for comparison, were divided into those with accidental falls (n = 180, group I) and those with suicidal attempts (n = 64, group II).

The principles of Advanced Trauma Life Support were followed in the management of all patients. Basic laboratory screening included haemoglobin level, prothrombin time, type and cross-match, and arterial blood gas analysis. Data collected included age, gender, associated trauma, injury severity score (ISS), Glasgow Coma Scale (GCS), haemodynamic status (systolic blood pressure less than 90 mm Hg on arrival in the emergency department), length of intensive care unit (ICU) and hospital stay.

Also, for the purpose of this study we analysed the following trauma variables: specific intracranial injuries (epidural, subdural, and subarachnoid hemorrhage and brain contusion), spinal injuries (cervical, thoracic, and lumbar spine), thoracic injuries, specific intra-abdominal injuries (liver, spleen, kidney, and hollow viscus) and specific fractures (pelvis, femur, and tibia). The diagnosis of mental disorder was ascertained by psychiatric specialists using the criteria of the International Classification of Disease Ninth Version Clinical Modification (ICD - 9CM).

Data were expressed as mean (range) for continuous variables and as frequencies, percentages for categorical variables. Comparison of categorical variables between groups was performed using Fisher's exact test. All tests were two - sided, statistical significance was set at p < 0,05. All analyses were carried out using the statistical package SPSS vr 21.00 (IBM Corporation, Somers, NY, USA).