Factors predicting serious injury in rock-climbing and non-rock-climbing falls


Locker, T.; Chan, D.; Cross, S.

Journal of Trauma 57(6): 1321-1323

2004


TheJournal
of
TRAUMA®
Injury,
Infection,
and
Critical
Care
Factors
Predicting
Serious
Injury
in
Rock-Climbing
and
Non—
Rock-Climbing
Falls
Thomas
Locker, MBChB,
MRCSEd,
David
Chan,
MBChB,
MRCSEd,
and
Sue
Cross
key
Words:
Serious
injury,
Rock
climbing,
Falls.
J
Trauma.
2004;57:1321-1323.
R
ock
climbing
is
an
increasingly
popular
sport
in
the
United
Kingdom.
The
British
Mountaineering
Council
estimates
that
there
are
approximately
150,000
active
climbers
in
the
United
Kingdom.
Rock
climbers
often
use
ropes,
harnesses,
and
helmets
to
protect
themselves
in
the
event
of
a
fall.
Injuries
may
result
from
falls
while
rock
climbing
for
a
number
of
reasons.
Climbers
may
have
de-
cided
not
to
use
a
rope/harness,
or
the
nature
of
the
climb
may
prevent
the
placement
of
protective
equipment,
thus
resulting
in
a
fall
to
the
ground.
Equipment
may
fail
when
loaded
during
a
fall,
or
the
climber
may
strike
the
rock
as
they
fall
but
be
prevented
from
hitting
the
ground
by
their
protective
equipment.
This
study
was
undertaken
to
determine
whether
people
injured
in
falls
while
rock
climbing
have
a
similar
likelihood
of
sustaining
serious
injury
as
those
injured
in
non—rock-climbing
falls.
MATERIALS
AND
METHODS
Sheffield
is
a
large
city
situated
on
the
edge
of
the
Peak
District
National
Park.
The
Peak
District
National
Park
lies
in
the
north
of
England
and
covers
an
area
of
1,438
km
2
com-
prising
moorland,
woodland,
and
farmland
with
hills
reaching
heights
of
approximately
600
m.
Rock
climbing
takes
place
on
both
gritstone
and
limestone
cliffs
of
heights
up
to
ap-
proximately
70
m.
The
emergency
department
(ED)
in
Shef-
field
serves
an
area
that
includes
a
large
part
of
the
National
Park
where
rock
climbing
takes
place.
Data
on
injuries
caused
by
falls
from
a
height
were
collected
prospectively
as
part
of
the
U.K.
Major
Trauma
Outcome
Study.
Patients
were
included
in
this
database
if
Submitted
for
publication
June
23,
2003.
Accepted
for
publication
April
3,
2004.
Copyright
©
2004
by
Lippincott
Williams
&
Wilkins,
Inc.
From
the
Department
of
Accident
and
Emergency
Medicine
(T'.L.),
Department
of
Orthopaedics
and
Trauma
(D.C.),
and
Department
of
Clinical
Effectiveness
and
Audit
(S.C.),
Northern
General
Hospital,
Sheffield,
United
Kingdom.
Address
for
reprints:
Thomas
Locker,
MBChB,
MRCSEd,
27
Holyrood
Avenue,
Lodge
Moor,
Sheffield
S10
4ND,
England;
email:
tom@
locker.worldoline.co.uk
.
DOI:
10.1097/01.TA.0000130609.23499.2F
they
were
admitted
to
any
participating
hospital
for
3
or
more
days,
transferred
or
admitted
into
an
intensive
care
bed,
or
died
as
a
result
of
their
injuries.
For
the
purpose
of
this
study,
only
those
patients
who
initially
presented
to
the
ED
in
Sheffield
were
included.
The
data
collected
included
mech-
anism
of
injury, length
of
stay,
Injury
Severity
Score
(ISS),
1
New
Injury
Severity
Score
(NISS),
2
and
outcome.
Patients
presenting
from
January
1,
1995,
to
December
31,
2000,
having
fallen
from
a
height
greater
than
2
m
were
eligible
for
inclusion
in
this
study.
Patients
were
excluded
if
they
were
younger
than
14
years
of
age
at
the
time
of
injury,
if
the
estimated
length
of
fall
was
not
recorded,
or
if
the
fall
occurred
as
part
of
a
suicide
attempt.
A
lower
age
limit
of
14
was
used,
as
patients
below
this
age
are
seen
in
a
separate
pediatric
ED
within
the
city.
Serious
injury
was
said
to
have
occurred
if
any
of
the
following
features
were
present:
an
ISS
>
15,
admission
to
the
ICU,
or
death
caused
by
the
injury.
An
ISS
>
15
has
been
widely
used
elsewhere
to
indicate
serious
injury.
3.4
Data
analysis
was
performed
using
SPSS
for
Windows
version
10
(SPSS,
Inc.,
Chicago,
IL).
The
data
were
analyzed
to
determine
whether
there
were
differences
between
climb-
ers
and
nonclimbers
in
age,
length
of
fall,
or
duration
of
hospital
stay.
Logistic
regression
analysis
was
performed
to
determine
whether
being
a
climber
was
independently
pre-
dictive
of
serious
injury
having
correcting
for
differences
in
age,
length
of
fall,
and
sex.
RESULTS
Two
hundred
thirty
patients
were
identified
from
the
database.
Of
these,
1
climber
and
70
nonclimbers
were
ex-
cluded,
as
the
length
of
fall
had
not
been
recorded.
A
total
of
27
climbers
and
132
nonclimbers
were
therefore
included
in
the
study.
Of
the
total
number
of
climbers,
5
(8.8%)
were
female
climbers,
compared
with
15
(11.4%)
nonclimbers.
The
distributions
of
age,
distance
fallen,
ISS,
MSS,
and
length
of
stay
for
climbers
and
nonclimbers
are
summarized
in
Table
1.
The
difference
in
mean
age
was
significant
(t
157
=
3.175,
p
=
0.002),
as
was
the
difference
in
ISS
(Mann-
Whitney
U
test,
p
=
0.001)
and
MSS
(Mann-Whitney
U
test,
Volume
57
Number
6
1321
TheJournal
of
TRAUMA®
Injury,
Infection,
and
Critical
Care
Table
1
Distribution
of
Age,
Distance
Fallen,
ISS,
NISS,
and
Length
of
Stay
Climbers
Nonclimbers
Mean
Median
Range
Mean
Median
Range
Age
(yr)
27.2
24
17-46
35.3
33.5
15-59
Distance
fallen
(m)
6.89
6.00
2-21
6.19
5.03
2-24
ISS
7.96
5.00
4-22
13.18
10.00
4-59
NISS
12.9
12.00
4-29
18.7
14.00
4-66
Length
of
stay
(days)
11.67
5.00
2-54
20.95
10.00
4-188
p
=
0.018).
There
was
no
significant
difference
in
distance
fallen
or
length
of
stay.
No
deaths
occurred
in
either
group.
The
proportion
of
subjects
seriously
injured
was
11.1%
(n
=
3)
of
climbers
and
29.5%
(n
=
39)
of
nonclimbers.
Correcting
for
differences
in
age,
sex,
and
length
of
fall,
being
a
rock
climber
is
a
significant
independent
predictor
of
serious
injury
(odds
ratio,
0.18;
95%
confidence
interval,
0.05-0.7;
p
=
0.013).
The
distribution
of
injuries
by
body
region
is
shown
in
Table
2.
This
table
clearly
demonstrates
considerable
differ-
ences
in
the
pattern
of
injuries
between
the
two
groups,
most
notably
regarding
injuries
to
the
head.
DISCUSSION
Rock
climbers
who
fall
are
approximately
one
fifth
as
likely
to
sustain
serious
injury
as
nonclimbers.
How
can
this
be
explained?
The
fact
that
climbers
are
less
likely
to
be
seriously
injured
might
be
expected
because
of
the
protective
equipment
used
in
climbing.
It
is
not
known
whether
the
climbers
or
other
subjects
included
in
this
study
were
using
any
such
equipment
when
they
fell,
as
this
was
not
recorded
in
their
hospital
notes.
However,
this
explanation
alone
is
probably
an
oversimplification.
The
energy
gained
(E)
by
a
person
falling
from
a
height
is
determined
by
the
height
fallen
(h),
their
mass
(m),
and
the
acceleration
caused
by
gravity
(g).
Energy
gain
is
directly
proportional
to
height
and
is
determined
by
the
equation
E
=
mgh.
For
a
given
mass
and
length
of
fall,
the
energy
gained
by
rock
climbers
and
non-rock
climbers
during
the
fall
would
be
the
same.
The
difference
in
severity
of
injury
may
arise
either
Table
2
Distribution
of
Injuries
by
Body
Region
for
Abbreviated
Injury
Scale
Score
>2
AIS
Region
Climbers
(%)
Nonclimbers
(%)
Head
1
(4.5)
55
(26.8)
Face
0
4
(2.0)
Neck
0
0
Thorax
3
(13.6)
25
(12.2)
Abdomen
and
pelvic
contents
0
1
(0.5)
Spine
6
(27.3)
35
(17.1)
Upper
extremity
3
(13.6)
43
(21.0)
Lower
extremity
8
(36.4)
42
(20.5)
Total
22
205
AIS,
Abbreviated
Injury
Scale.
1322
because
the
pattern
of
injury
is
different
between
the
two
groups
or
the
way
in
which
the
fall
energy
is
dissipated
differs.
It
is
likely
that
both
these
factors
play
a
part.
Energy
dissipation
occurs
by
several
routes
in
falls
dur-
ing
rock
climbing.
This
is
discussed
in
depth
by
Schad
5
and
includes
friction
between
the
rope
and
other
equipment
or
between
the
rope
and
rock,
and
elongation
of
the
rope.
If
protective
equipment
fails
under
loading,
it
will
have
dissi-
pated
some
energy
before
failure.
These
mechanisms
will
not
operate
in
climbers
who
are
using
no
protective
equipment
or
in
nonclimbing
falls
where
protective
equipment
is
not
being
used.
If
the
fall
ultimately
results
in
contact
with
the
ground,
as
is
probably
the
case
in
most
non-rock-climbing
falls,
this
is
the
final
mechanism
by
which
energy
is
dissipated.
In
this
case,
the
angle
of
incidence
with
the
ground
and
the
nature
of
the
surface
struck
may
influence
the
severity
of
injury.
The
surface
on
which
a
subject
lands
has
been
shown
to
have
a
significant
association
with
injury
severity
in
falls
from
a
height
occurring
in
construction
workers.
6
The
data
presented
here
have
shown
considerable
differ-
ences
in
the
frequency
with
which
different
body
regions
are
injured
between
climbers
and
nonclimbers.
Schussman
et
al.,'
in
a
study
of
mountaineering
and
rock
climbing
accidents,
found
that
injuries
predominately
occurred
to
the
lower
limbs.
This
would
imply
that
in
rock
climbers,
the
force
of
impact
is
being
taken
mainly
by
the
lower
limbs.
This
has
two
possible
explanations.
First,
in
climbers,
the
combination
of
rope
and
harness
are
attached
at
waist
height.
As
the
climber
falls,
one
would
expect
this
point
of
attachment
to
maintain
them
in,
or
rotate
them
to,
a
vertical
position.
If
the
protective
equipment
ultimately
fails,
the
climbers
will
drop
to
the
ground
in
this
vertical
position
and
the
force
of
impact
will
be
taken
by
the
legs.
In
most
non-rock-climbing
falls,
this
mech-
anism
will
not
operate
and
there
will
be
nothing
to
counteract
any
rotational
momentum
that
develops
during
the
fall.
Sec-
ond,
in
some
circumstances,
climbers
may
be
aware
they
are
about
to
fall,
for
example,
when
attempting
a
particularly
difficult
move
on
a
climb
that
is
at
the
limit
of
their
ability.
This
awareness
may
allow
them
to
control
to
some
extent
how
the
fall
occurs
and
possibly
identify
the
safest
point
to
land
if
no
protection
is
being
used
and
a
fall
to
the
ground
is
anticipated.
Isbister
and
Roberts
8
demonstrated
that
the
length
of
fall
associated
with
a
50%
chance
of
survival
was
one
floor
for
head-first
falls,
three
or
four
floors
for
side-first
December
2004
Factors
Predicting
Serious
Injury
in
Falls
falls,
and
four
or
five
floors
for
feet-first
falls.
It
may
be
that
a
similar
pattern
exists
for
severity
of
injury.
In
a
study
of
28
patients,
Steedman
3
demonstrated
a
positive
correlation
between
length
of
fall
and
Injury
Severity
Score.
Other
studies
have
failed
to
confirm
this
finding.
s
9
Goodacre
et
al
.
4
showed
that
length
of
fall
is
a
poor
predictor
of
serious
injury.
These
findings
support
the
hypothesis
that
although
length
of
fall
is
in
part
responsible
for
determining
the
severity
of
injury,
other
factors
must
be
involved.
The
findings
of
this
study
reflect
a
cohort
of
patients
falling
from
a
limited
range
of
heights.
It
is
not
possible
to
determine
therefore
whether
the
importance
of
length
of
fall
in
predict-
ing
serious
injury
would
become
more
significant
with
greater
length
of
fall.
A
further
problem
in
determining
the
influence
of
length
of
fall
both
in
this
and
in
other
studies
is
that
the
length
recorded
will
be
an
estimate
in
the
majority
of
cases.
Attempting
to
reduce
injury
caused
by
rock
climbing
falls
is
problematic.
Part
of
the
attraction
of
the
sport
for
many
of
its
participants
is
the
inherent
risk.
As
modern
climbing
equipment
has
developed,
there
has
been
a
sharp
rise
in
climbing
standards
to
parallel
the
increase
in
safety.
It
is
likely
that
any
further
increase
in
safety
would
result
in
a
proportionate
increase
in
standards
to
maintain
the
per-
ceived
level
of
risk.
It
is
likely
that
the
mechanism
of
"risk
homeostasis"
operates
in
rock
climbing
in
a
way
similar
to
that
proposed
for
motor
vehicle
safety.
For
example,
as
motor
vehicles
have
become
safer
through
the
use
of
seat
belts,
airbags,
and
so
forth,
the
risks
taken
by
the
driver
have
increased
such
that
the
level
of
risk
the
driver
perceives
remains
constant.
11
Improvements
in
training
and
instruction
may
prevent
some
accidents,
particularly
those
that
occur
because
of
basic
errors
in
the
use
of
safety
equipment.
How-
ever,
in
a
sport
that
has
no
formal
requirement
for
its
partic-
ipants
to
undergo
any
type
of
instruction,
it
is
difficult
to
know
how
much
impact
this
would
have.
Making
training
compulsory
would
in
part
address
this,
but
it
would
be
dif-
ficult
to
enforce
such
a
policy
in
a
sport
that
is
conducted
in
remote
areas.
From
the
evidence
presented
here,
it
is
clear
that
the
history
taken
regarding
all
patients
who
have
fallen
from
a
height
needs
to
include
much
more
than
the
length
of
fall.
Where
possible,
the
exact
mechanism
of
the
fall
should
be
determined.
Important
factors
may
include
the
surface
on
which
the
subject
landed,
the
part
of
the
subject's
body
sustaining
the
initial
impact,
and
impact
with
any
objects
during
the
fall.
For
rock
climbers
and
any
industrial
falls
where
safety
equipment
may
have
been
in
use,
further
spe-
cific
inquiries
should
be
made
to
determine
what
safety
equipment
was
being
used
(such
as
ropes,
harnesses,
and
helmets)
and
whether
any
of
this
equipment
failed.
This
more
detailed
history
will
allow
a
more
focused
and
effective
assessment
of
the
patient.
CONCLUSION
Subjects
injured
because
of
falls
while
rock
climbing
are
considerably
less
likely
to
sustain
serious
injury
than
subjects
injured
in
other
types
of
falls.
REFERENCES
1.
Baker
SP,
O'Neill
B,
Haddon
W
Jr,
Long
WB.
The
injury severity
score:
a
method
for
describing
patients
with
multiple
injuries
and
evaluating
emergency
care.
J
Trauma.
1974;14:187-196.
2.
Osler
T,
Baker
S,
Long
W.
A
modification
of
the
Injury
Severity
Score
that
both
improves
accuracy
and
simplifies
scoring.
J
Trauma.
1997;41:922-926.
3.
Steedman
DJ.
Severity
of
free
fall
injury.
Injury.
1989;20:259-261.
4.
Goodacre
S,
Than
M,
Goyder
EC,
Joseph
AP.
Can
the
distance
fallen
predict
serious
injury
after
a
fall
from
a
height?
J
Trauma.
1999;46:1055-1058.
5.
Schad
R.
Analysis
of
climbing
accidents.
Accid
Anal
Prey.
2000;
32:391-396.
6.
Gillen
M,
Faucett
JA,
Beaumont
JJ,
McLoughlin
E.
Injury
severity
associated
with
nonfatal
construction
falls.
Am
J
Ind
Med.
1997;
32:647-655.
7.
Schussman
LC,
Lutz
LJ,
Shaw
RR,
Bohnn
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