• Create awareness among vulnerable groups

Regulations must be enforced to ensure that those working at heights comply with the necessary safety standards, while compliance with the same may be enhanced by creating awareness among vulnerable groups.

These recommendations were made in an original article on “Fatalities following falls from heights presented to three medico-legal units in Sri Lanka” which was authored by A.N. Vadysinghe, E.M.K.B. Ekanayake, B.G. Premaratne, R.M.I.S.D. Rathnayake, and W.M.M.H.P. Wickramasinghe (all five attached to the Peradeniya University’s Medical Faculty’s Forensic Medicine Department), D.P.P. Senasinghe and M. Sivasubramanium (both attached to the Kandy National Hospital’s Judicial Medical Officer’s [JMO] Office), and P.B. Dassanayake (attached to the Colombo South Teaching Hospital’s JMO’s Office) and published in the Medico-Legal Journal of Sri Lanka’s 11th volume’s second issue in December 2023.

One of the most common modes of sustaining unintentional trauma, as mentioned in J.S. Sampalis, R. Nathanson, J. Vaillancourt, A. Nikolis, M. Liberman, J. Angelopoulos, N. Krassakopoulos, N. Longo, and E. Psaradellis’s “Assessment of mortality in older trauma patients sustaining injuries from falls or motor vehicle collisions treated in regional level one trauma centres”, is falls, which is only second to road traffic accidents. The term “falls”, per studies (R. Bahr and T. Krosshaug’s “Understanding injury mechanisms: A key component of preventing injuries in sport”, H. Granhed, E. Altgarde, L.M. Akyurek, and P. David’s “Injuries sustained by falls – A review”, T. Krosshaug, T.E. Andersen, O.O. Olsen, G. Myklebust, and R. Bahr’s “Research approaches to describe the mechanisms of injuries in sport: Limitations and possibilities”, E. Uluoz’s “Investigation of sport injury patterns in female futsal players”, and G.A. Maria, U. Eren, and D.Z. Filiz’s “Study on the usage status of exercise equipment and technologies by the individuals participating in physical exercise”) encompasses those occurring under many different circumstances including falls from stairs and steps, ladders, buildings, into holes, from one level to another (e.g. from playground equipment), from cliffs or furniture, and falls on level ground as a result of slipping, tripping, stumbling, or in sports. 

Deaths following a history of “falls” are routinely encountered by the forensic pathologist during death investigations including autopsy examinations. Cases of vertical falls from heights or vertical deceleration, as per T.C. Chao, G. Lau, and C.E. Teo’s “Falls from a height”, are among an entity which is not an unusual forensic presentation. 

The Health Ministry’s Epidemiology Unit (“Weekly epidemiological report: Ageing population [Report number 47], 2010”) states that falls comprise 3% of all unintentional injuries. 

The local study

In Vadysinghe et al.’s retrospective study, data were accessed from police reports, eyewitness accounts, bedhead tickets, and post-mortem reports from three medico-legal units at Kandy, Peradeniya, and Panadura during 2005-2016. Only vertical falls from a height of more than two metres were considered. The exclusion criteria were victims aged less than 14 years, a disease or physical condition or any factors influencing the fall, natural diseases directly or indirectly contributing to the cause of death, rolling over injuries, putrefied bodies, and cases where the manner of death was suspicious. 

Out of the 26,920 medico-legal post-mortems performed during the period, 877 cases had a history of a fall and 124 fatalities were selected. The youngest victim identified was 16 years old while the eldest individual was 83.

A total of 93% were males with 49% being between 41-60 years, 20% being between 21-40, and 19% being between 61-80. Falls were relatively rare in those less than 20 (6%) and more than 81 (5%). Of the deaths, 88% were accidental, 2% were suicidal, and 10% were undetermined in nature. The majority was employed as unskilled labourers (38%) at the time of the fatal accident.

Regarding the location from which they fell, 41% fell from tall trees, 16% from buildings, 10% from a hill, 6% down a staircase, and 3% from a tall parked vehicle (roof of a shipping container truck, tipper lorry, or boom truck). A significant proportion (24%) fell from ladders and lamp posts or tables.

The majority had fallen from a height of 6-20 feet followed by 21-40 feet.

The sites of primary impact were the head and neck (71%), chest (18%), abdomen (2%), and limbs (1%), with the site not being known in 8%.

The evaluation of the injuries to the head and neck region revealed that a majority sustained a combination of injuries. Of all those who sustained head and neck trauma, skull fractures were the commonest (60%), followed by 51% intra-cerebral haemorrhages, 46% cortical injuries (both lacerations and contusions), 11% brain stem injuries, and 6% cervical spine injuries.

The commonest type of skull fracture was linear and placed on the vault (67%). Depressed, basal, comminuted, and hinge fractures represented 28%, 33%, 19%, and 9%, respectively. The temporal (36%) and occipital (36%) were the most frequently involved bones of the skull. The parietal and frontal bones were involved in 24% and 14% of the cases, respectively, while the facial bones were involved only in 4% of the cases.

The most common thoracic injuries were rib fractures (84%), haemothorax (45%), lung contusions and lacerations (18%), clavicle fractures (9%), and sternal fractures (7%).

The most common injuries to the abdomen and pelvic region were liver lacerations (59%), lumbar and pelvic fractures (41%), splenic lacerations (24%), and lacerations and perforations of the gastro-intestinal system (12%).

A large contusion was seen on the knee joint with a femur fracture in one of the cases while 2% sustained fractures of the forearm bones, 4% showed extensive lacerations and 77% demonstrated abrasions, small contusions, and superficial lacerations.

With increasing height, there was a gradual increase in the proportionate involvement of the thorax, the abdomen and pelvis, and limbs.

The majority of the victims (68%) had died after being brought to the hospital, 19% died on the way to the hospital, and 13% were found dead at the scene. Of all the deaths that occurred after admission, 43% died in the first six hours, 14% died between 6-12 hours, 6% died between 12-24 hours, and 5% died after 24 hours.

There were a number of risk factors for falls from heights. The most significant finding was the failure of all the victims to use any sort of safety equipment which led to fatal outcomes following falls. None had used even primary methods of safety such as a rope, harness, or any safety devices, like protective headgear, specialised clothing, or footwear. A total of 10% had consumed alcohol.

International studies

The World Health Organisation’s “Manual of the international statistical classification of diseases, injuries, and causes of death: Based on the recommendations of the Ninth Revision conference, 1975, and adopted by the 29th World Health Assembly, 1977” states that “a fall from a height is an unexpected event where a person falls to the ground from an upper level”. P. Kannus, J. Parkkari, S. Koskinen, S. Niemi, M. Palvanen, M. Järvinen, and I. Vuori’s “Fall-induced injuries and deaths among older adults” defines it as “a descent from an upright, sitting, or horizontal position”, the descent height being less than or equal to one metre. 

M.G. Ory, K.B. Schechtman, J.P. Miller, E.C. Hadley, M.A. Fiatarone, M.A. Province, C.L. Arfken, D. Morgan, S. Weiss, M. Kaplan, and the Frailty and Injuries: Co-operative Studies of Intervention Techniques (FICSIT) group’s “Frailty and injuries in later life: The FICSIT trials” studies define a fall as “unintentionally coming to rest on the ground, floor, or other lower level”. 

Falls can be categorised, according to T. Masud and R.O. Morris’s “Epidemiology of falls” (published in Age and Ageing), based on the reason for the fall: intrinsic (internal factors contributing to the control of the posture of the body) or extrinsic (external environmental factors). Depending on the height of the fall, as mentioned in C.V. Murthy, S. Harish, and Y.G. Chandra’s “The study of the pattern of injuries in fatal cases of falls from heights”, they can be divided into low falls and high falls.

A Sierra Leone-based study revealed that “falls were the most common cause of non-fatal injuries, accounting for over 40% of injuries”. The principal factors which determine the nature of the injury in falls from a height are, per T.C. Atanasijevic, S.N. Savic, S.D. Nikolic, and V.M. Djokic’s “Frequency and severity of injuries in correlation with the height of the fall”, “the height of the fall, the body weight, the velocity, the nature of the surface impacted, the orientation of the body at the moment of impact, and the elasticity and viscosity of the tissues of the contact body region, out of which the height of the fall is the major determining factor”. 

SL setting in comparison

In Sri Lanka, men engage in occupations which involve heights, including tree climbing and building construction. The produce from trees such as coconut, jackfruit, durian, clove, avocado, mango, and rambutan are manually plucked by male labourers, after climbing trees of approximately 10-60 feet in height. However, there is a significant shortage of tree climbers due to lower salaries, higher literacy, the inability to climb trees in monsoonal periods, poor job recognition, fatal outcomes or permanent disability following falls, and the absence of insurance or compensation when injured. Regardless, many tree climbers engage in this occupation on a part-time basis.

J. Agnew and A.J. Suruda’s “Age and fatal work-related falls: Short note” revealed that the number of fatalities increased from the age group of 45-54 years, while low-energy impacts had a higher chance of fatality in older people compared to younger age groups. 

The instant study revealed that those between 41-60 represented almost half of all fatalities. Furthermore, a significant proportion (20%) was of the 21-40 age group. In the present study, the majority (38%) were unskilled labourers who worked as part-time tree climbers. The vast majority of the falls (93%) had occurred from heights of less than 60 feet, with a significantly high percentage (57%) having sustained falls from heights less than 20 feet. The most common type of falls was falls from trees, whose heights are usually within that range.

The head and neck were the commonest primary site of impact (71%) and the region involved (75%) followed by the chest and the abdomen. One reason for the high numbers of head injuries may be the lack of usage of safety measures like helmets, safety lines, harnesses, etc. especially among tree climbers. However, Chao et al. revealed that thoracic injuries were seen in 98% followed by injuries to the head and face (82%), the internal organs of the abdomen and the pelvis (79%), and the pelvic girdle (55%). 

The primary site of impact is where the area of the body first impacts the ground and it is important to reconstruct the event. However, the primary site of the impact is difficult to determine and may only be an opinion after evaluating all the injuries, per G. Lau, C.E. Teo, and T. Chao’s “The pathology of trauma and death associated with falls from heights”. 

However, if there are overwhelmingly predominant head injuries, it is, as noted in U.A. Goonetilleke’s "Injuries caused by falls from heights", indicative of a primary head impact. In the instant study, the possible site of primary impact as the head and neck was determined after evaluating the injuries of the deceased, the findings at the scene of the fall, and eyewitness accounts. 

J.V. Kumar and A.K. Srivastava’s “Pattern of injuries in falls from heights” revealed that the head and face were the commonest areas of primary impact (47%) followed by a side of the body (37%), the feet and the lower limbs. Commonest injuries seen in the head and neck area, according to descending frequency, were, per Lau et al., fractures of the skull and cervical spine, intra-cerebral haemorrhages, and cortical injuries.

Specific injuries

When considering the types of skull fractures, the linear type was the commonest followed by depressed, basal, and comminuted fractures, respectively. According to Murthy et al., the linear fracture was the commonest skull fracture recorded in 26% of the cases, with comminuted fractures recorded in 23% of the cases. The instant study identified the temporal and occipital bones as the most commonly involved bones associated with skull fractures, almost equally representing 72% of all subjects with skull fractures. 

Fractures of the sternum and ribs, lung contusions, and liver lacerations suggest an anterior impact, frontal falls, or by impact or primary contact with the horizontal branches of the trees whilst falling before landing on the ground. Furthermore, fractures of the lumbar vertebrae or pelvis were significantly higher than limb injuries, which indicate that most victims landed either on the buttocks or lower back and had been unable to break the fall by using the limbs. In this sample, 88% died due to an accidental manner.

Furthermore, it is possible that most victims of the instant study fell from 6-20 feet and sustained fatal injuries to the head region. B.H. Cummins and J.M. Potter’s “Head injury due to falls from heights” concluded that the velocity of the impact was not significantly associated with skull fractures accounting for 42% of all head injuries.

Injuries to the cervical spine were predominantly seen in the instant study. However, studies (M.P. Hahn, D. Richter, P.A. Ostermann, and G. Muhr’s “Injury pattern after falls from a great height: An analysis of 101 cases”, Y. Chen, Y. Tang, V. Allen, and M.J.D. Vivo’s “Fall-induced spinal cord injury: External causes and implications for prevention”, and a United States study) revealed that spinal injuries were seen more in the thoracic region.

The definition of “jumpers” and “fallers” have been explained in relation to those individuals sustaining intentional and accidental free falls, respectively. In the instant study, almost all the victims died in an accidental manner, which may be a reason for less injuries on the lower limbs, per S.R. Lowenstein, M. Yaron, R. Carrero, D. Devereux, and L.M. Jacobs’s “Vertical trauma: Injuries to patients who fall and land on their feet”; J. Teh, M. Firth, A. Sharma, A. Wilson, R. Reznek, and O. Chan’s “Jumpers and fallers: A comparison of the distribution of skeletal injury”; and G.C. Velmahos, D. Demetriades, D. Theodorou, E.E. Cornwell III, H. Belzberg, J. Asensio, J. Murray, and T.V. Berne’s “Patterns of injury in victims of urban free falls”.

In most Sri Lankan localities, the trees are less than 60 feet tall. Stout branches and the undergrowth of many smaller trees around large trees limit the visibility of the ground. This may prevent the victim from reacting in a protective way by breaking the fall.

Out of the thoracic injuries, the commonest were rib fractures, haemothorax, and lung contusions. 

The liver is the most commonly injured organ in fatalities due to abdominal injuries in free falls. In the instant study, the commonest injury of the abdomen and pelvis was liver lacerations, constituting 59% of all the injuries of that area. Splenic injury also represented a significant component in the instant study sample. Furthermore, it was evident that liver and splenic injuries were common even in falls from less than 40 feet because the majority of the sample of the instant study fell from trees and probably impacted on intervening objects such as tree branches before landing on the ground. 

Another possibility is resuscitation which is known to cause injuries to the liver, spleen, sternum, etc., as noted in H. Beydilli, Y. Balci, M. Erbas, E. Acar, S. Isik, and B. Savran’s “Liver laceration related to cardiopulmonary resuscitation” and A. Kaplon-Cieslicka, D.A. Kosior, M. Grabowski, A. Rdzanek, Z. Huczek, and G. Opolski’s “Coronary artery dissection, traumatic liver and spleen injury after cardiopulmonary resuscitation – A case report and review of the literature”. However this was excluded at autopsy examination by the absence of overlying skin injuries, the pattern of injuries, and hospital notes.

Multiple factors

The injury pattern depends on many factors such as body weight, the height of fall, body dynamics while falling, age, the landing surface, etc., per G.S. Rozycki and K.I. Maull’s “Injuries sustained by falls”; G.E. Bertocci, M.C. Pierce, E. Deemer, F. Aguel, J.E. Janosky, and E. Vogeley’s “Influence of fall height and impact surface on the biomechanics of feet-first free falls in children”; D.H. Glaister’s “Head injury and protection”; B.F. Gomberg, G.S. Gruen, W.R. Smith, and M. Spott’s “Outcomes in acute orthopaedic trauma: A review of 130,506 patients by age”; P. Saukko and B. Knight’s Knight’s Forensic Pathology; and L. Vogt, H. Mertens, and H.E. Krause’s “Model of the supine human body and its reactions to external forces”. 

The instant study revealed that with the increasing height of a fall, there was an upward tendency of causing injuries to the thorax, the abdomen and pelvis, and the limbs, respectively. There is also a predominance of multiple injuries with the increase in the height of the fall.

The majority of the victims (68%) died after being admitted to the hospital. This was probably due to the fact that the falls in the instant study occurred from lesser heights. Evidence of alcohol consumption was noticed in a significant proportion of the victims (10%) at the first encounter with medical personnel and during the autopsy by the forensic pathologist. 

Alcohol consumption is a known risk factor in falls from heights, as emphasised in O. Savola, O. Niemelä and M. Hillbom’s “Alcohol intake and the pattern of trauma in young adults and working-aged people admitted after trauma” and V. Jain, S. Jain, and B.K. Dhaon’s “A multi-factorial analysis of the epidemiology of injuries from falls from heights”. Since most of the victims died after hospital admission, most had undergone extensive resuscitation procedures (e.g. massive crystalloid and colloid infusions), thereby rendering the testing of post-resuscitation blood alcohol levels, futile.

Out of the 124 cases which were considered in the instant study, none had been using any safety gear at the time of the fall, regardless of their occupation and the site of the fall. Additionally, none had complied with any safety standards despite being required to wear safety gear at all times whilst working at heights. Protective equipment – including head gear, harnesses, boots, and safety lines – are likely to protect the vital areas and lessen the severity and frequency of the falls. Disregarding the use of safety measures may have been a key factor for fatalities in these individuals.

On the other hand, tree climbers or personnel working at heights in Sri Lanka do not undergo training nor are they assessed for fitness. The term “qualified tree climber” is defined as a worker who, through related training and with experience, shows familiarity with techniques and hazards involved in tree maintenance and removal, and uses special equipment. 

Therefore, Vadysinghe et al. noted that it is time to think of re-formulating and implementing guidelines for this vulnerable group. Public education and awareness among the general population, on safety methods to be used when working at heights, have to be ensured in order to reduce injuries sustained due to falls.

A majority of the victims were middle-aged men who fell from trees accidentally. The most vulnerable regions were the head and the neck, with the primary site of impact presumed to be the same in such fatal falls. None had been using any safety equipment at the time of the fall. There was evidence of a significant proportion of victims having consumed alcohol prior to the event.