falls

When a person falls onto a hard surface such as a road surface, the prominent parts of the head and face, for example are injured.

The tissues covering the bony orbital rims are often torn, along with the skin covering the cheekbones and the lower jaw.

A fall from a standing position can result in extensive lacerations of these prominences. This pattern is to be compared with that seen in a fistfight, where recessed parts of the face are injured, for example by direct impacts to the orbit resulting in subconjunctival haemorrhage and a ‘black eye’.

Falls onto the back of the head result in an abraded scalp surface (worse in those with closely shawn hairstyles), which can be detached from the underlying supporting connective tissue. The undermined areas of scalp can be infiltrated with large collections or pockets of blood and liquefied fat (‘boggy swellings’) (Spitz 1993)

Undermining assists in identifying the direction of impact. Shearing forces may also avulse superficial tissues from deeper supporting connective tissue to produce such pockets of blood and fat, for example where a pedestrian is hit by the hood or bonnet of a car lifting them up, there may be undermining of the soft tissues at the back of their thighs.

Falls in the home are a significant cause of incapacitation and mortality, particularly those related to falls in the elderly leading to fractured neck of femur.

Approximately 50% of home injuries in children in an Australian study (Cordner and Ozanne-Smith 2000) resulted from falls. 31% were from a height of 1 m or less (of which 28% were on the same level). 80% were playing at the time, and many involved falls from beds, chairs or nursery furniture etc.

Lacerations to the face or scalp accounted for 31% of injuries, fractures (especially to the forearm) accounted for 20%, and 16% were bruises (mainly face and scalp).

Illustration of the pattern of facial injuries more in keeping with a fall than an assault (unilateral blunt trauma, predominantly restricted to bony prominences)

falls from a height

Suicide - Andy Warhol (1963)

Source: www.usc.edu

Falls from a height occur in several settings including accidental, occupational and suicidal.

Chao et al (2000) studied deaths from falls from a height (typically from tall appartment blocks), where primary impact on concrete surfaces resulted in severe deceleration injuries.

In combination, injuries to the head, thorax and abdomen were noted in 49% of cases.

Atanasijevic et al (2005) noted that the frequency and extent of injury was associated with height of fall, and that head injuries were characteristic of falls up to 7m and above 30m. In addition, brain injuries in falls from heights above 30m showed an abscence of contre coup contusions and macroscopically evident intra-cranial bleeding.

Liver injuries were the most common abdominal visceral injury, occurring at a critical height of fall of 15m. Injuries of liver and spleen were concomittant in high falls from heights beyond 24m, irrespective of the manner of impact, and a height of fall over 15m appeared to be a reasonable boundary height beyond which the injuries of two or three body regions are generally associated.

During incident reconstruction, Chao et al (2000) note that determining the region of the body impacting the ground first ('primary impact') was not always straightforward, due to the multiplicity of injuries, and the difficulty in excluding impacts against other structures during the fall, and injuries sustained if the body 'bounced' after 'primary impact' (so-called 'secondary impact injuries').

Frequency of injury to body regions caused by falls from height (Chao et al 2000)

In broad terms, however, vertical deceleration resulting from 'primary impact' of the feet could result in open or closed comminuted fractures and dislocations of the bones of the feet and ankle, and the tibia/ femur.

In addition, the transmitted energy could pass into the vertebral column and to the skull base, resulting in displaced vertebral fractures, spinal cord laceration or transection, ring fractures of the skull base and brainstem contusions or lacerations.

Where head injuries predominate, and are extensive/ severe - often with extrusion of the brain - whilst injuries to the rest of the body are relatively minor, a 'primary head impact' is likely.

Compound fracture dislocation of ankle following fall from a height (Source: Ed, Royal North Shore Hospital)

Estimated frequency of site of 'primary imapct' (Chao et al 2000)

falls down stairs

Falls down stairs occur relatively commonly, and are particularly associated with the elderly and the intoxicated.

Preuß et al (2004) analysed a series of 166 cases over a 11 year period, and found an almost 2:1 male to female ratio.

Injuries sustained affected many different parts of the body, due to impacts against different structural parts of the stairs and other objects during the fall, and from attempts to 'break the fall' etc.

The skull was injured in 90.5% of cases, the torso in 66.4% and the limbs in 60%. The face was injured in just under 60%.

Lacerations, bruises and abrasions of the back of the head were seen almost as frequently as on the forehead, whilst a smaller proportion exhibited these injuries in both locations.

65% had a skull fracture, and the majority of these were basal fractures. Facial fractures were seen in 57%.

Just under 8% suffered vertebral fractures (although no details are provided regarding the types of fractures identified), and 60% suffered extremity injury, particularly extensor surfaces.

They concluded that an external examination of the body alone could not discriminate from a vital fall or agonal fall (after suffering a cardiac arrythmia or infarction at the top of a flight of stairs, for example).

Of particular importance, in cases where bodies are found at the foot of a flight of stairs, is the ability to distinguish between a simple fall, and an assault, particularly given that falls down stairs result in a high frequency of severe head injuries. They note that many head injuries seen in falls down stairs occur above the so-called 'hat brim line'.

When considering falls on the level, injuries occurring above the 'hat brim line' are sometimes thought to be more in keeping with assault, rather than a fall, but in falls down stairs, this does not seem to apply.

Preuß et al (2004) also indicate that an examination of the brain with respect to coup and contra-coup contusions may be of assistance in identifying 'blows' to the head, but this evaluation may be complicated by the multiplicity of impacts received during a 'tumble' down stairs, unlike a collapse onto a hard surface involving only a single impact.

Factors to consider when investigating an apparent fall down stairs;

• The deceased's medical history;
• The staircase environment (slip/ trip hazards);
• Witness evidence;
• Complete autopsy;
• Neuropathological examination of the brain and cervical spinal cord; and
• Toxicology

chest trauma radiology

CT image of a 40 year-old man who fell from a ladder.

Palpation of the chest produced the typical “crackling sensation” of subcutaneous emphysema.

A large right pneumothorax with right lung collapse can easily be seen, as well as a right rib fracture and extensive subcutaneous emphysema.

Source: Radiology Picture of the Day (McMillan J)

Traumatic haemo-pneumothorax

Note the flat air-fluid level seen on this lateral chest x-ray, indicating the presence of a pneumothorax (and haemothorax). Pneumothorax and rib fractures were seen on the AP film.

Source:  Radiology Picture of the Day  (Dr Laughlin Dawes)