Archives of Emergency Medicine, 1991, 8, 245-252
Injuries sustained by falls
G.S. ROZYCKI & K.
Department of Surgery, University of Tennessee Medical Center, Knoxville, Tennessee,
During a recent 4-year period, 381 patients were admitted with injuries sustained
from falls. Equal numbers of patients were less than and greater than 50 years of
age and included 53 children (- 16 years) and 214 elderly (>55 years). Falls from
heights occurred predominately in young males (mean age 34.2 years), were most
commonly job or recreation related and resulted in higher injury severity scores
(ISS). Falls in the elderly occurred more commonly in women, typically on a flat
surface, and were less severe. Despite lower mean ISS, fall victims over 55 years of
age had longer hospitalizations (11-4 vs. 4-5 days) and incurred higher hospital
charges compared to younger patients. There were 35 deaths (9-2%). In patients
under 55 years, deaths resulted from fall-related central nervous system (CNS)
injury and/or multisystem trauma. In patients over 55 years, fatalities were most
commonly related to pre-existent medical conditions.
Based on a review of this experience, we conclude that:
(1) unlike other causes of blunt and penetrating trauma, both sexes are equally
at risk from fall-related injuries but sex incidence is age related;
(2) falls from heights are more common in men;
(3) advanced age and pre-existing medical conditions account for the increased
morbidity and mortality following falls and;
(4) cost containment measures for fall-related trauma must consider not only
injury severity, but the age and pre-existent medical conditions of the patient.
Falls are the second leading cause of both spinal cord and brain injury (accounting
for 20% of CNS trauma in the United States) and constitute a major cause of trauma
deaths in all ages (Maull et al., 1981; Barancik et al., 1983). In addition, falls are the
most common cause of non fatal injury. Each year one person in 20 is injured
Correspondence: Kimball I. Maull, M.D., Department of Surgery, University of Tennessee Medical Center,
1924 Alcoa Highway, Knoxville, Tennessee 37920, U.S.A.
G. S. Rozycki & K. I. Maull
seriously enough from a fall to require emergency department evaluation and
treatment. If hospitalization is required, the patient may have multisystem trauma
or severe isolated musculoskeletal or CNS injuries, all of which may be life-
threatening or lead to physical impairment and lasting disability. An increasing
awareness of this problem in our own trauma patient population promoted
The University of Tennessee Medical Center, a verified Level 1 trauma centre
received 381 patients injured by falls during the 4-year period ending December
1987. Thirty-five patients were dead on arrival or expired shortly thereafter in
the emergency department and were classified as 'early deaths' (Group 1). Each
patient in Group 1 was a medical examiner's case and information was obtained
from the medical examiner's records and/or post-mortem examination. Group 2
consisted of 346 patients injured seriously enough to require hospitalization.
Medical records were reviewed and age, sex, circumstances of fall, site of incident,
injuries sustained, and outcome were determined for each patient. Length of
hospital stay (LOS) was defined and pre-existent medical conditions were care-
fully sought. Falls were classified as accidental or intentional and the incident
site identified as 'workplace', 'recreational', 'home', or 'other'. A significant number
of patients in the latter category involved moving vehicles.
There were 35 patients in Group 1, 30 men and 5 women, ranging in age from
11-75 years with a mean age of 35-4 years. Ninety-four per cent of the deaths
(33 patients) were classified as accidental while the remaining patients (6%) suc-
cessfully committed suicide. Recreational injuries and falls from moving vehicles
were the most common causes of fatal falls (Table 1). Head injury was the leading
cause of death (15 patients) followed by multisystem trauma.
Group 1-DOAs (n = 35)
Site of injury occurrence.
Injuries sustained by falls
There were 346 patients in Group 2, 165 males and 181 females. Age ranged from
1 month-96 years with a mean age of 44-2 years. The subgroup aged over 55 was
composed of 214 patients of which 165 were women. Mean age was 75 years. In
the elderly subgroup, there were 400 risk factors identified. Pre-existing medical
conditions were absent in 48 patients aged over 55 (Table 2). Among the 132
patients under 55, there were only 28 women. Mean age in the younger subgroup
was 24-5 years. Concurrent disease was absent in 97 of the 132 patients. There
were 53 children (< 6 years).
Home mishaps predominated in Group 2 patients but recreational injuries were
also common (Table 3). Only 12% occurred at work, and 22 patients in this group
(6%) fell from moving vehicles,
Risk factors in patients* injured by falls
Age > 55
Age < 55
*More than one risk factor per patient
Group II-patients, (n = 346)
Site of injury occurence.
Golf Cart (2)
G. S. Rozycki & K.
The mechanism of injury in Group 2 patients was most frequently a fall from
height (Table 4). It usually occurred in young males (mean age 37-8 years) and
most commonly was job or recreation related. Most falls in the elderly occurred
in or about the home and on a flat surface. Falling down stairs was the second
leading cause of injury in patients older than 55 years.
Table 5 demonstrates the specific injuries encountered in the Group 2 patients
and their relative frequency (the total number of injuries exceeds 346 since many
patients had more than one injury). As expected, musculoskeletal injuries pre-
dominated, especially those involving the lower extremity, which occurred in 77%
of patients. Distressingly, head injuries (skull fractures or cerebral contusions)
were also common and isolated CNS trauma occurred in 33 of these 79 patients,
almost half in children.
Table 6 contains data on ISS, LOS, and hospital charges. Despite a slightly
occurrence, Group II Patients, (n = 346)
Mechanism of injury
Fell from height
Fell on surface
Group II patients (n =346)
Injuries sustained by falls,
Upper extremity (86)
Lower extremity (130)
Injuries sustained by falls 249
ISS and patient age
Hospitalization and hospital charges versus
Age > 55 Age < 55
Hospital charges (Av)
higher severity of injury in the younger subgroup, when compared to patients
over 55 years, the mean LOS was significantly greater in the elderly (11-4 days vs.
4.5 days). Longer hospital stays were reflected in greater hospital charges in the
older patients. In addition, regardless of the severity of injury, the morbidity and
mortality encountered were closely related to pre-existent medical conditions as
well as age. Of the 16 deaths in Group 2, 14 occurred in the elderly group, (mean
age of 78-6 years), and pre-existent cardiorespiratory disease was the most common
cause of death. Two patients died as a direct result of a fall-related CNS injury.
Falls account for more than 16000 deaths each year in the United States and rep-
resent the leading cause of unintentional injury reported by hospital emergency
departments. (Maull et al., 1981; Barancik et al., 1983) Baker et al. (1984) suggest
that this figure underestimates the true incidence of significant falls since an even
greater number of patients die under circumstances where a fall only initiates or
contributes to the cause of death yet is not reported. Among unintentional injury
deaths for all ages falls rank second, behind motor vehicle crashes, which lead all
other causes of trauma related fatalities (Nahum & Melvin, 1985). In children falls
rank fourth in traumatic causes of death, behind motor vehicle crashes, fires and
drowning (National Safety Council, 1983). A 1978 study of 345 fatalities due to falls
or jumps from noncrash motor vehicle incidents showed that 44% of the patients
were under 5 years old (Williams & Goins, 1981). Although the relative lethality
of falls, i.e. death per incident, is significantly less than for vehicular trauma, the
magnitude of the problem of all-related trauma remains a major health concern.
The kinematics of motor vehicle crashes and falls are not dissimilar - both are
deceleration-type injuries. Whenever an external force is applied to the human
body, the severity of injury is the result of the interaction between the physical
factors of the force and the body. If the body is in motion, i.e. falling, and impacts
a fixed surface, the extent of the injury is related to the ability of the stationary
object to arrest the forward motion of the body. At impact, differential motion of
tissues within the organism cause tissue disruption. Decreasing the rate of the
deceleration and enlarging the surface area to which the energy is dissipated in-
creases the tolerance to deceleration by promoting a more uniform motion of the
250G. S. Rozycki & K. I. Maull
tissues. The fall arresting contact surface is also important since concrete, asphalt,
or hard firm surfaces increase the rate of deceleration (AV), and are associated
with more severe injuies (Cummins & Potter, 1970; Reichelderfer et al., 1979;
Garrettson & Gallagher, 1985). Cummins & Potter emphasized the importance of
contact surface and suggested that this is more important than the height of the fall.
They showed that victims striking hard ground or concrete suffered greater injury
than those who hit grass, even though the distances were similar.
Certain features of living tissue must also be considered, especially the combined
cohesive properties of elasticity and viscosity of tissues. The tendency for a tissue
following impact to resume its prestressed condition is related to its elasticity. Viscosity
implies a resistance to change of shape with changes in motion. The tolerance of the
organism to deceleration forces is a function of these combined cohesive properties
and the point beyond which additional force overcomes this tissue cohesion deter-
mines the magnitude of the injury (Maull et al., 1981).
There appears to be little doubt that the severity of injury is closely related to
the kinematics of vertical deceleration, the combined cohesiveness of the body's
properties, and the consistency of the impact surface. Yet the resultant morbidity
and mortality do not necessarily coincide. Historically age is the most consistent
variable defining differences in fall morbidity and mortality rates, with the high-
est incidence occurring in early childhood and the elderly (Galasko & Edwards,
1974-75; Gallagher et al., 1984; Garrettson & Gallagher, 1985). This experience
with fall-related trauma confirms that there are certain epidemiologic factors specifi-
cally related to the age of the patient that contribute to morbidity and mortality.
These observations are particularly pertinent in today's climate of cost containment.
Our experience demonstrates that, unlike other causes of blunt and penetrating
trauma, both sexes are at relatively equal risk from fall-related injuries. However,
greater sex variation is noted when the age and circumstances of the fall are carefully
considered. Falls during recreational activities, in job-related circumstances, and in
the young are much more common in males. This is counterbalanced in later years by
a higher population of female patients who fall, particularly on level surfaces. Baker
et al. (1984) attribute the high death rate in the elderly to be secondary to their greater
likelihood of pre-existent medical conditions such as impaired vision, gait distur-
bance, lack of balance, bone weakness from osteoporosis, and a greater suscepti-
bility to complications. Our findings support their observation since 14 of the 16
deaths in Group 2 were in elderly patients and related to pre-existent cardio-
Most falls in the elderly and the very young occur in or near the home. Prevention
programmes are unlikely to have a meaningful impact on this segment of fall-
related injuries. Yet both groups have potentially preventable injuries. The cost of
observing building codes which make safer stairways, windows, and handrailings
would almost certainly be recaptured by savings in trauma care costs. Falls in
nursing homes alone account for over 1800 deaths annually (Baker et al., 1984). In
this report, 34 patients sustained injury after falling from moving vehicles, and 13
patients died (38% mortality). Closer supervision and use of seat belts and child
restraint devices may greatly impact this segment of the problem.
Determinants of outcome following injury include both controllable factors,
Injuries sustained by falls
such as quality of care rendered and time from injury to definitive care, and certain
uncontrollable factors, among which injury severity is considered both the most
important and most preventable. However, the age of the patient and pre-existent
medical conditions (risk factors) are also determinants of trauma outcome over
which there is little or no control. In 1974, Baker et al. confirmed that survival
following injuries of equal severity was lower for patients aged over 55 compared
to those under 55 (Baker et al., 1974). Our data supports the validity of patient age
as a trauma outcome determinant, and further correlates advanced age and risk
factors with length of hospitalization and health care costs.
In summary, deaths from accidental falls are far more common than from inten-
tional falls and both sexes are equally at risk. Falls during recreational and job-
related circumstances, from heights and in the very young are more common in
males. Falls occurring at home are more common in women. Unquestionably,
advanced age and pre-existent medical conditions contribute significantly to the
increased morbidity and mortality following falls. This is an important fact that
society must address, to provide adequate hospital reimbursement for LOS fol-
lowing such injuries in the elderly. Potentially preventable fall-related injuries
were noted in nursing home residents and children. As is true for most causes
of trauma, prevention of fall injuries has considerable potential for cost savings
and the lessening of morbidity and mortality.
The assistance of A. R. Clapp and K. R. Stidham is gratefully acknowledged.
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