American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Injuries Due to Falls from Heights

Carol R. Schermer MD, FACS

Falls remain a significant cause of morbidity and mortality. At most trauma centers, falls are the primary mechanism of injury resulting in admission for children. Factors determining the probability of serious injury in a fall are the distance of the fall, the landing surface, orientation on falling, and whether the fall was broken. Factors contributing to falls from heights include faulty equipment, such as ladders and scaffold structures, and human factors, such as intoxication and inattention. In occupational settings, the most common type of accident is a fall from a height.1 The brain, spinal cord, and extremities are the most commonly injured systems. Falls from more than 20 feet have historically been triaged to trauma centers, but even low-level falls can cause serious head injuries.2,3

Demographics of Falls in Children

  • Falls among children and adolescents account for more than 3 million emergency department visits each year, and more than 40 percent occur among infants, toddlers, and preschoolers.
  • In contrast to ground-level falls in the elderly, males and children are more susceptible to falls from heights.4 Black males under age 5 are at particularly high risk.5
  • Accounting for 5.9 percent of childhood deaths due to trauma, falls represent the third leading cause of death in children.6 Death due to falls is generally from a head injury.7
  • Falls in children tend to be from balconies, windows, and trees, and most frequently tend to occur in homes, followed by schoolyards and playgrounds.8
  • Nearly three-quarters of falls from a height in children are unintentional.
  • In children under age 5, falls of less than 2 meters rarely result in death, and the proposed mechanism of injury should be investigated for inflicted trauma.9

Demographics of Falls in Adults

  • Nonoccupational falls from ladders and scaffolds have increasing incidence with increasing age. One-fifth result in hospitalization.10
  • In occupational injuries, greater heights and impact on concrete predict injury severity in nonfatal construction falls.
    • Nonunion status and poor safety climate scores predict increased risk.11
  • More than one-half of nonoccupational falls in adults and 17 percent of occupational falls are associated with alcohol use.12,13

Demographics of Falls in the Elderly

  • Falls in the elderly tend to occur with activities of daily living.14
  • Falls account for 29 percent of injury deaths among adults aged 65 and older.6
  • Older adults are five times more likely to be hospitalized due to falls than to injuries from other causes.15
  • Host factors such as poor muscle tone, vision problems, medication use, and sedentary lifestyle are the biggest contributors to ground-level and stair falls, but environmental components such as poor lighting and no handrails may increase the frequency.6

Fall Prevention and Safety

  • The "Children Can't Fly" program in New York City required window guards to be installed in all multiple-family dwellings with children under age 10 and decreased accidental falls by 50 percent at two years and by 96 percent at four years.5,16
  • Height and surfacing requirements on playground equipment effectively prevent injuries. On playgrounds, the most important risk factor for injury is the height of the tallest piece of climbing equipment.17 Injuries are 2.56 times more likely to occur if a child falls from playground equipment higher than 2 meters.18,19 The acceptable surface absorption level for a playground should be set at less than 150-200 g.18
    • Compliance with safety standards for soft surfaces on playgrounds has improved, whereas there has been less compliance with maximum height of equipment.19
    • In children and older adults, supervision is generally considered the strongest (yet least understood) of the protective factors against falls.
  • Most ladder injuries are due to safety precautions and regulations not being observed, and in the majority of preventable cases, precautions were ignored, resulting in patient fall.20,21

Recommendations

  1. Bars should be placed on windows in locations where children are at risk for falling.
  2. Alcohol and drug use should not occur prior to working in high places or on ladders.
  3. Stair gates effectively prevent falls in infants and toddlers except those in baby walkers.
  4. The maximum height of playground equipment should be 1.5-2 meters.
  5. The acceptable surface absorption level for a playground should be set at less than 150-200 g (such as sand or shredded rubber).
  6. In older adults, handrails in bathrooms and on stairs decrease fall frequency.

References

1. Jeong BY. Occupational deaths and injuries in the construction industry. Appl Ergon. 1998;39(5):355-360.

2. Murray JA, Chen D, Velmahos GC, et al. Pediatric falls: Is height a predictor of injury and outcome? Am Surg. 2000;66(9):863-865.

3. Kennedy RL, Grant PT, Blackwell D. Low-impact falls: Demands on a system of trauma management, prediction of outcome, and influence of comorbidities. J Trauma. 2001;51(4):717-724.

4. Hoyert DL, Kochanek KD, Murphy SL. Deaths: Final Data for 1997. National Vital Statistics Reports. Vol 47 No 19. Hyattsville, MD: National Center for Health Statistics, 1999.

5. Barlow B, Niemirska M, Gandhi RP, et al. Ten years of experience with falls from a height in children. J Pediatr Surg. 1983;18(4):509-511.

6. Centers for Disease Control and Prevention. Injury Research Agenda: Preventing Injuries at Home and in the Community. National Center for Injury Prevention and Control. 2002.   [www.cdc.gov/ncipc/pub_res/research_agenda/04]

7. Hall JR, Reyes HM, Horvat M, et al. The mortality of childhood falls. J Trauma. 1989;29(9):1273-1275.

8. Lallier M, Bouchard S, St-Vil D, et al. Falls from heights among children: A retrospective review. J Pediatr. 1999;Surg 34(7):1060-1063.

9. Reiber GD. Fatal falls in childhood: How far must children fall to sustain fatal head injury? Report of cases and review of the literature. Am J Forensic. 1993;14(3):201-207.

10. Faergemann C, Larsen LB. Non-occupational ladder and scaffold fall injuries. Accid Anal Prev. 2000;32(6):745-750.

11. Gillen M, Faucett JA, Beaumont JJ, et al. Injury severity associated with nonfatal construction falls. Am J Ind Med. 1997;32(6):647-655.

12. Mosenthal AC, Livingston DH, Elcavage J, et al. Epidemiology and strategies for prevention. J Trauma. 1995;38(5):753-756.

13. Alleyne B, Stuart P, Copes R. Occupational and other drug use in occupational fatalities. J Occup Med. 1991;33:496.

14. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988;319:1701.

15. Alexander BH, Rivara FP, Wolf ME. The cost and frequency of hospitalization for fall-related injuries in older adults. Am J Public Health. 1992;82(7):1020-1023.

16. Spiegel CN, Lindaman FC. Children can't fly: A program to prevent childhood morbidity and mortality from window falls. Am J Public Health. 1977;67(12):1143-1147.

17. Briss PA, Sacks JJ, Addiss DG, et al. Injuries from falls on playgrounds: Effects of day care center regulation and enforcement. Arch Pediatr Adolesc Med. 1995;149(8):906-911.

18. Laforest S, Robitaille Y, Lesage D, et al. Surface characteristics, equipment height, and the occurrence and severity of playground injuries. Inj Prev. 2001;7(1):35-40.

19. Chalmers DJ, Parry ML, Crawford AI, et al. Compliance of Dunedin school playground equipment with the New Zealand playground standard. Aust NZ J Public Health. 2001;25(3):253-255.

20. Muir L, Kanwar S. Ladder injuries. Injury. 1993;24(7):485-487.

21. Eriksson A, Bjornstig U, Kullenberg K. Snowy roofs-A potential hazard. Scand J Soc Med. 1988;16:179.