How High of a Fall Can You Survive

Scand J Trauma Resusc Emerg Med. 2011; 19: 63.

Survival following a vertical free fall from 300 feet: The crucial office of trunk position to bear on surface

Sebastian Weckbach

¹Section of Orthopaedic Surgery, Denver Wellness Medical Center, Academy of Colorado Denver, School of Medicine, 777 Bannock Street, Denver, CO 80204, USA

Michael A Flierl

¹Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado Denver, School of Medicine, 777 Bannock Street, Denver, CO 80204, U.s.a.

Michael Blei

^aneDepartment of Orthopaedic Surgery, Denver Wellness Medical Center, University of Colorado Denver, School of Medicine, 777 Bannock Street, Denver, CO 80204, U.s.a.

Clay Cothren Burlew

²Department of Surgery, Denver Health Medical Centre, University of Colorado Denver, School of Medicine, 777 Bannock Street, Denver, CO 80204, USA

Ernest East Moore

²Department of Surgery, Denver Wellness Medical Center, University of Colorado Denver, School of Medicine, 777 Bannock Street, Denver, CO 80204, USA

Philip F Stahel

¹Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado Denver, School of Medicine, 777 Bannock Street, Denver, CO 80204, USA

Received 2022 Sep 22; Accepted 2022 Oct 25.

Abstract

We study the case of a 28-year old rock climber who survived an "unsurvivable" injury consisting of a vertical free fall from 300 feet onto a solid rock surface. The trauma mechanism and injury kinetics are analyzed, with a item focus on the relevance of torso positioning to ground surface at the fourth dimension of bear upon. The role of early patient transfer to a level ane trauma center, and "damage command" direction protocols for avoiding delayed morbidity and bloodshed in this critically injured patient are discussed.

Introduction

Vertical deceleration injuries correspond a significant cause of preventable deaths and long-term morbidity in survivors [one]. The corporeality of energy absorbed by the falling trunk is dependent on the fall height and the characteristics of the contact surface. For example, a autumn onto concrete results in an instantaneous loss of speed, whereas falling onto a soft surface will allow for a more than gradual deceleration over fourth dimension [2]. In addition, the position of the body relative to the impact surface represents an important determinant of injury severity. The American College of Surgeons' Commission on Trauma (ACS-COT) defines a critical threshold for a fall height in adults as > xx anxiety (6 meters), as role of the field triage decision scheme for transport to a designated trauma center [three]. A retrospective analysis of 101 patients who survived vertical deceleration injuries revealed an average autumn height of 23 feet and vii inches (7.2 meters), confirming the notion that survivable injuries occur beneath the critical threshold of a falling summit effectually 20-25 feet [1]. A more than recent written report on 287 vertical fall victims revealed that falls from peak of eight stories (i.e. around 90-100 anxiety) and higher, are associated with a 100% mortality [4]. Thus, a vertical falling peak of more 100 feet is more often than not considered to constitute a "non-survivable" injury.

The present case report describes the rare survival of a 28-year old rock climber who survived a complimentary autumn from 300 feet onto a solid stone surface. This report emphasizes the crucial relevance of body positioning at the time of impact, and the importance of standardized institutional "damage control" management protocols for survival.

Example report

A 28-year sometime woman was free climbing with her boyfriend most Gunnison, Colorado. Both were wearing a helmet and a harness for prophylactic. The daughter had 20 years of experience of rock climbing, being taught early tricks by her father at the age of 8 years. The ascent consisted of three pitches of ninety-100 feet (ca. 30 yard) each. The climbing distance was defined by the climbing rope which had been stock-still at a defined length. The girl took the lead on the third pitch, to a total height of 300 feet (ca. ninety m). After securing the anchor at that tiptop, the rope - which was lacking a security knot - slid through her harness. She then roughshod a total of 300 feet, with a offset impact at 200 feet onto a flat rock surface, and a further fall for near 100 anxiety. Based on this falling meridian, the velocity at the time of bear upon is estimated around 75-80 mph. Her young man witnessed the unabridged fall, climbed dorsum down and provided beginning aid at the scene. The patient was awake and moaning, but not responsive to exact or painful stimuli. She was intubated at the scene and transported to a local level Iv trauma center, where she was resuscitated and transfused with 4 units of packed ruddy blood cells (PRBC). Due to ongoing hypotension and transfusion requirements, a decision was made for transfer to our regional level 1 trauma centre. On arrival, the patient was intubated and sedated. She was hypotensive, with systolic pressures in the 80s. She was successfully resuscitated with crystalloids and blood products, using a standardized institutional massive transfusion protocol with indicate-of-intendance thrombelastography-guided resuscitation [5,6]. The patient was managed according to the ATLS guidelines for initial assessment and management, and by our institutional "damage control" protocols, including the initial spanning external fixation of femur shaft fractures [7,8] and a proactive "spine damage control" arroyo [9].

The patient sustained the following combination of injuries:

• Blunt chest trauma with sternal fracture, bilateral hemo-/pneumothoraces, bilateral pulmonary contusions, right 1 and two rib fractures, left 9-11 rib fractures.

• Blunt abdominal trauma with course 3 liver laceration, grade 2 splenic laceration, and a devascularized right kidney.

• Mild traumatic brain injury.

• Rotationally unstable flexion/lark injury at T6 (AO/OTA blazon 52-C2.1) with traumatic spinal cord transsection and complete paraplegia ASIA class A below T6.

• Unstable L1 flare-up/split fracture (AO/OTA type 53-A3.2).

• Unstable pelvic band injury with bilateral SI-joint disruption, bilateral L5 transverse process fractures, bilateral pubic rami fractures, and left-side transalar/transforaminal Denis type ii sacral fracture (Young-Burgess type LC-3, AO/OTA type 61-B3.iii).

• Right femur shaft fracture (AO/OTA type 42-A3.two).

• Right blazon IIIA open talar torso fracture (AO/OTA type 81-C3) and associated posterior facet calcaneus fracture (AO/OTA blazon 82-C2)

• Left comminuted articulation-low type calcaneus fracture (AO/OTA type 82-C3).

The injury pattern of bilateral lower extremity fractures and of the pelvic band injury are shown in Figure ​ 1.

Injury pattern of bilateral lower extremities and pelvic fracture on initial multislice CT scan. The patient sustained a right-side open, comminuted talar body fracture, and a contralateral comminuted "joint-depression"-blazon calcaneus fracture, and a highly unstable pelvic ring injury with bilateral sacro-iliac articulation disruptions (arrows).

The chest trauma was managed by placement of bilateral breast tubes. The patient responded well to initial resuscitation and remained normotensive and well oxygenated, with a claret pressure of 115/80 mmHg, heart rate of 82/min, and 100% Then₂ on 0.half-dozen FiO₂. She was taken to the operating room for "harm control orthopaedics" (DCO) procedure with unilateral spanning external fixation of the right femur fracture, surgical debridement of the open talar fracture with primary wound closure, and spanning external fixation of the correct talocrural joint in a delta-frame. The contralateral comminuted calcaneus fracture was placed in a well padded beefy Jones splint. The patient was then transferred to the surgical intensive care unit (SICU) for farther resuscitation. The physiological response to resuscitation during the kickoff 72 hours is depicted in Figure ​ 2.

Physiological response to resuscitation during the offset 72 hours after trauma. MAP, hateful arterial force per unit area; HR, heart rate; BPM, crush per minute.

An MRI of her C-/T-/ and L-spine was obtained the adjacent morning which documented a traumatic spinal string transsection at the level of the rotationally unstable T6 flexion/lark injury (Figure ​ 3). She was taken the same day for preliminary spinal fixation equally a "spine harm control" procedure [9]. This included a posterior spinal fusion from T4-T8 with laminectomy and spinal canal decompression at T6, also equally posterior spinal fusion T12-L2. The patient tolerated the procedure well and was brought back to the SICU in stable weather. She was mobilized with physical and occupational therapy on day ane, and placed on low molecular weight heparin for DVT prophylaxis. The intraabdominal injuries were managed non-operatively.

Unstable spine injuries at T6 and L1 on initial multislice CT scan (left panel). The MRI of the T-spine (right console) revealed a spinal cord transsection at the T6 injury level (arrow).

On day two, she was taken dorsum to the operating room for stabilization of the pelvic band injury using bilateral "triangular osteosynthesis" with lumbo-pelvic fixation from L4 to the ilium, and placement of bilateral 7.3 mm cannulated sacro-iliac screws through a rubber surgical corridor [10]. On day 3, an IVC filter was placed due to the loftier gamble constellation for a thromboembolic complication.

The patient recovered well from her injuries and from the "impairment control" procedures. She was extubated on hospital twenty-four hours four, and was successfully weaned to room air (Figure ​ 4). She remained fully awake and alert, with a GCS of 15. She had a normal neurological function to bilateral upper extremities, but lack of sensory function below T6, and consummate paraplegia to bilateral lower extremities. On day 5, she was taken back to the operating room for locked intramedullary boom fixation of the right femur shaft fracture (Figure ​ 5), removal of the spanning external fixator, and cannulated lag screw fixation of her right talar body fracture.

The patient after successful extubation on hospital day 4, with her fellow who witnessed the free fall from 300 anxiety.

Right femur shaft fracture managed past "harm control orthopaedics" with initial spanning external fixation (left panel) and delayed conversion to intramedullary nail fixation (right panel).

The patient had an excellent recovery and was mobilized into a wheelchair with physical and occupational therapy. On twenty-four hours thirteen, she was taken back to the operating room for completion 360° fusion T5-T7 and T12-L2, with anterior corpectomy of T6 and L1 vertebral bodies, inductive spinal culvert completion decompression, and placement of two titanium expandable cages and bone grafting (Figure ​ six). This procedure was performed through less-invasive left-side posterolateral approaches, including a transthoracic approach to T6 and a retroperitoneal approach to L1 (Figure ​ 7). This less invasive technique was shown to exist well tolerated by patients and allow early functional rehabilitation without restrictions [11-thirteen].

Postoperative X-rays after stabilization of the pelvic ring injury with bilateral lumbo-pelvic/triangular osteosynthesis, and 360° fusion of the unstable T6 and L1 injuries.

Less-invasive ii-crenel approach for inductive corpectomy, spinal canal decompression, and anterior spinal fusion of the unstable thoracic and lumbar spine fractures. The T6 injury was managed through a pocket-sized posterolateral thoracotomy (1), while the L1 fracture was addressed through a retroperitoneal arroyo along the eleven^thursday rib (2). The less-invasive procedure was tolerated well by the patient, and allowed for early mobilization without restrictions.

The patient had an uneventful farther recovery. All surgical wounds healed well, and there were no postoperative complications. At that fourth dimension, Ten-rays of her multiple orthopaedic injuries were obtained, which showed early on signs of uneventful fracture healing (Figure ​ 8). She was transferred to our neurorehabilitation unit of measurement on hospital 24-hour interval xviii. The patient remained flaccid beneath the level of lesion related to the T6 ASIA course A consummate spinal cord injury. She remained in spinal stupor until approximately half-dozen weeks after trauma. She also showed some general processing and dumb brusque term memory deficits related to her mild traumatic brain injury. Nerve conduction studies confirmed the notion from MRI imaging, in that there was no secondary neurologic conus injury due to the L1 flare-up fracture which may have farther complicated her bowel and bladder direction. The applied spinal and pelvic fixation techniques facilitated her mobilization without adjunctive truncal bracing. The initial efforts for cocky-care and mobilization, even so, were complicated past orthostatic hypotension, nausea and anxiety felt to exist multi-factorial in etiology. The weight bearing precautions to the lower extremities were discontinued around 9 weeks mail injury, based on progressive callus germination seen on follow-up X-rays (Figure ​ 8). The patient chop-chop progressed to contained transfers. Her cognitive processing improved to essentially normal. The IVC filter was removed prior to discharge. She was transferred to her local community regional spinal string rehabilitation center out-of-land at 2½ months after injury in excellent weather, for completion of her neurorehabilitation plan.

Early fracture healing documented by X-rays obtained at 6 weeks post injury.

Give-and-take

This is the showtime case report, to our knowledge, which documents survival from a gratuitous vertical fall of 300 anxiety onto a hard surface. The anecdotal threshold for sustaining critical injuries from a vertical fall has been defined by the American College of Surgeons' Committee on Trauma (ACS-COT) at >xx feet (6 meters) [three]. This threshold is corroborated by the published literature on survivors from accidental and suicidal free falls [1]. In general, a falling superlative of >100 feet is considered a "not-survivable" injury [iv]. The meridian of 300 feet is ascertained by the fact that in "lead climbing", the climbing rope is stock-still at a defined length, respective to 150 feet in the present case. The patient's boyfriend took the lead on the first pitch of 150 anxiety, where after she took over the lead on the next 150 feet. After securing the anchor at 300 anxiety height, the rope slid through her harness and she sustained an undamped vertical gratis autumn onto a flat rock surface.

Most falls from stone climbing result in simple sprains which touch on ankle, elbow, and shoulder joints [14]. A retrospective analysis revealed that fractures of the spine and lower limbs represent the nigh frequent injury pattern in survivors from vertical falls from a height [one]. These findings hold with the notion presented in this case report, that a autumn on both feet represents the "ideal" body to bear upon surface position with regard to survival from vertical falls. In contrast, encephalon injuries and cervical spine injuries resulting from a fall on the caput represent the main cause for lethal outcomes later falls [xv]. The patient's specific injury blueprint is suggestive of a trauma mechanism past which the patient landed on both feet kickoff, followed by a deceleration/twisting mechanism to her right femur and the thoracic and lumbar spine, catastrophe in a fall on the back which induced the final deceleration forces leading to the intra-abdominal and thoracic injuries. As outlined by the presumed trauma mechanism depicted in the diagram in Figure ​ 9, the patient landed feet start, leading to an free energy transfer over a longer deceleration area from feet (panel A) to femur and pelvis (panel B) to a rotational flexion/distraction machinery of the thoracic spine (panel C), followed by a fall on the back (console D), which is associated with a distribution of the deceleration force over a larger surface surface area. Since the soft tissues and viscera decelerate slower than the skeleton, the final impact likely led to the chest trauma and intra-abdominal injuries to the parenchymal organs (console D). This patient would likely not accept survived the aforementioned injury mechanism, if she had landed head and neck first.

Presumed trauma mechanism resulting from a 300 anxiety vertical autumn in the present case. Landing feet first is the likely root crusade for survival in this 28-year old patient who sustained an injury mechanism generally classified as "not-survivable". Please refer to text for details.

Furthermore, the rapid intubation, early resuscitation, and timely transfer to a qualified level 1 trauma center likely contributed to this patient'south survival. It is striking to note that, despite the critical overall injury design, the patient did not sustain meaning complications which may have been expected every bit the sequelae of the traumatic impact, including posttraumatic/postoperative infections, and the development of remote organ insults, including astute respiratory distress syndrome (ARDS) and multiple organ failure, which stand for the main cause of late deaths in patients who survive the initial injury [16-18].

Likely, the application of standardized resuscitation strategies, in conjunction with thrombelastography-guided administration of blood products, and the limited exposure to the interventional burden by "harm command" strategies applied in the first few days afterward trauma, contributed to the survival of this patient [5-vii,nine,eleven,19,20].

The impact of falling height, quality of affect surface, and the position of the body to the impact surface on injury severity and consequence require farther investigation in ex-vivo experimental and biomechanical studies.

Competing interests

The author declares no competing interests with regard to this manuscript.

Authors' contributions

PFS, EEM, and CCB designed this instance report. PFS and SW drafted the first version of the manuscript. MAF contributed the graphic artwork in Effigy 8. EEM and CCB managed the initial rescuscitation and performed all full general surgery procedures. PFS performed all orthopaedic surgical procedures. MB was in charge of the neurorehabilitation of this patient. All authors contributed to the revised drafts of this manuscript and approved the final version of this newspaper.

Written informed consent

Written informed consent for publication of this instance report and of all radiological images and pictures was obtained from the patient by the senior author. She agreed to publish the case study including all figures shown in this paper. Written consent by the patient is available to the journal's Editor-in-Chief upon asking.

References

• Richter D, Hahn MP, Ostermann PA, Ekkernkamp A, Muhr G. Vertical deceleration injuries: a comparative study of the injury patterns of 101 patients after accidental and intentional loftier falls. Injury. 1996;27(9):655–659. doi: 10.1016/S0020-1383(96)00083-half-dozen. [PubMed] [CrossRef] [Google Scholar]
• Bragg Due south. Vertical deceleration: falls from summit. J Emerg Nurs. 2007;33(4):377–378. doi: 10.1016/j.jen.2007.04.017. [PubMed] [CrossRef] [Google Scholar]
• American College of Surgeons Committee on Trauma. Resources for optimal intendance of the injured patient. Chicago, IL: American College of Surgeons; 2006. [Google Scholar]
• Lapostolle F, Gere C, Borron SW, Petrovic T, Dallemagne F, Beruben A, Lapandry C, Adnet F. Prognostic factors in victims of falls from height. Crit Care Med. 2005;33(six):1239–1242. doi: 10.1097/01.CCM.0000164564.11989.C3. [PubMed] [CrossRef] [Google Scholar]
• Stahel PF, Moore EE, Schreier SL, Flierl MA, Kashuk JL. Transfusion strategies in postinjury coagulopathy. Curr Opin Anaesthesiol. 2009;22(two):289–298. doi: 10.1097/ACO.0b013e32832678ed. [PubMed] [CrossRef] [Google Scholar]
• Kashuk JL, Moore EE, Sawyer Thousand, Le T, Johnson J, Biffl WL, Barnett C, Stahel PF, Silliman CC, Sauaia A, Banerjee A. Postinjury coagulopathy management: goal directed resuscitation via POC thrombelastography. Ann Surg. 2010;251(iv):604–614. doi: 10.1097/SLA.0b013e3181d3599c. [PubMed] [CrossRef] [Google Scholar]
• Stahel PF, Smith WR, Moore EE. Current trends in resuscitation strategy for the multiply injured patient. Injury. 2009;40(Suppl four):S27–35. [PubMed] [Google Scholar]
• Flierl MA, Stoneback JW, Beauchamp KM, Hak DJ, Morgan SJ, Smith WR, Stahel PF. Femur shaft fracture fixation in caput-injured patients - when is the right fourth dimension? J Orthop Trauma. 2010;24:107–114. doi: 10.1097/BOT.0b013e3181b6bdfc. [PubMed] [CrossRef] [Google Scholar]
• Stahel PF, Flierl MA, Moore EE, Smith WR, Beauchamp KM, Dwyer A. Advocating "spine damage control" as a safe and effective treatment modality for unstable thoracolumbar fractures in polytrauma patients: a hypothesis. J Trauma Manag Outcomes. 2009;iii:6. doi: 10.1186/1752-2897-3-half-dozen. [PMC gratis article] [PubMed] [CrossRef] [Google Scholar]
• Hasenboehler EA, Stahel PF, Williams A, Smith WR, Newman JT, Symonds DL, Morgan SJ. Prevalence of sacral dysmorphia in a prospective trauma population: Implications for a "rubber" surgical corridor for sacro-iliac screw placement. Patient Saf Surg. 2011;5:8. doi: ten.1186/1754-9493-5-eight. [PMC complimentary commodity] [PubMed] [CrossRef] [Google Scholar]
• Haschtmann D, Stahel PF, Heyde CE. Direction of a multiple trauma patient with all-encompassing instability of the lumbar spine as a result of a bilateral facet dislocation and multiple complete vertebral flare-up fractures. J Trauma. 2009;66(3):922–930. doi: 10.1097/01.ta.0000215415.87801.fc. [PubMed] [CrossRef] [Google Scholar]
• Kossmann T, Payne B, Stahel PF, Trentz O. Traumatic paraplegia: surgical measures [High german] Swiss Med Wkly. 2000;130:816–828. [PubMed] [Google Scholar]
• Kossmann T, Jacobi D, Trentz O. The employ of a retractor system for open, minimal invasive reconstruction of the anterior column of the thoracic and lumbar spine. Eur Spine J. 2001;ten(5):396–402. doi: 10.1007/s005860100330. [PMC free commodity] [PubMed] [CrossRef] [Google Scholar]
• Gerdes EM, Hafner JW, Aldag JC. Injury patterns and safety practices of rock climbers. J Trauma. 2006;61(half-dozen):1517–1525. doi: 10.1097/01.ta.0000209402.40864.b2. [PubMed] [CrossRef] [Google Scholar]
• Stahel PF, Heyde CE, Flierl MA, Wilkerson JA. In: Medicine for Mountaneering. Volume 6. Wilkerson JA, Moore EE, Zafren K, editor. Seattle, WA: The Mountaneers Books; 2010. Head and cervix injuries; pp. 86–95. [Google Scholar]
• Sauaia A, Moore EE, Johnson JL, Ciesla DJ, Biffl WL, Banerjee A. Validation of postinjury multiple organ failure scores. Shock. 2009;31(5):438–447. doi: 10.1097/SHK.0b013e31818ba4c6. [PMC costless article] [PubMed] [CrossRef] [Google Scholar]
• Keel M, Trentz O. Pathophysiology of polytrauma. Injury. 2005;36(six):691–709. doi: 10.1016/j.injury.2004.12.037. [PubMed] [CrossRef] [Google Scholar]
• Stahel PF, Smith WR, Moore EE. Role of biological modifiers regulating the allowed response afterwards trauma. Injury. 2007;38(12):1409–1422. doi: ten.1016/j.injury.2007.09.023. [PubMed] [CrossRef] [Google Scholar]
• Burlew Cothren C, Moore EE, Smith WR, Johnson JL, Biffl WL, Barnett CC, Stahel PF. Preperitoneal pelvic packing/external fixation with secondary angioembolization: optimal care for life-threatening hemorrhage from unstable pelvic fractures. J Am Coll Surg. 2011;212:628–637. doi: 10.1016/j.jamcollsurg.2010.12.020. [PubMed] [CrossRef] [Google Scholar]
• Osborn PM, Smith WR, Moore EE, Cothren CC, Morgan SJ, Williams AE, Stahel PF. Direct retroperitoneal pelvic packing vs. pelvic angiography: a comparison of two management protocols for hemodynamically unstable pelvic fractures. Injury. 2009;forty:54–threescore. doi: 10.1016/j.injury.2008.08.038. [PubMed] [CrossRef] [Google Scholar]

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3212924/

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