Fall Injuries

 Original Article

By Joseph Alton MD

A few years ago, we certified as Advanced Wilderness Expedition Providers, and many of the training scenarios involved dealing with victims who were injured in falls. Whether you’re on a backcountry trail or in your own bathroom, a fall can seriously damage you, causing orthopedic injuries, bleeding, traumatic brain injuries, and more. The Centers for Disease Control and Prevention (CDC) reports that one in five falls results in a major injury. All told, falls account for millions of emergency room visits and over 800,000 hospitalizations a year in the U.S.

Many risk factors exist that predispose people to fall. On the trail, loss of balance on uneven terrain and poorly supported backpacks could be to blame. Badly-fitting footwear leading to blisters and pain may also play a part. Essentially, anything that affects walking and balance may cause you to stumble over an obstacle and sustain an injury. At home, clutter, uneven steps, wet bathroom floors, and poor lighting put you at risk.

Whether you’re in the wilderness or at home, the use of medications (especially sedatives, anti-depressants, or other psychotropics) can affect your alertness and balance, leading to a fall.

TRAUMATIC BRAIN INJURIES

Falls are the most common cause of traumatic brain injuries. Most injuries are superficial and not life-threatening. Indeed, most head injuries amount to only a laceration of the scalp, a black eye, or a painful bump. These wounds, however, can hide damage inside the cranium, the part of the skull that contains the brain.

Injuries that affect the brain are called traumatic brain injuries (TBIs). It’s important to recognize when trauma to the skull has caused damage that is more than superficial.

Concussions are the most common type of TBI. A concussion is associated with a variety of symptoms that are often immediately apparent. The presentation differs from person to person. Although you might expect that loss of consciousness is the most common symptom, it’s actually headache; the victim may remain completely alert. Other symptoms include:

• Dizziness
• Confusion
• Nausea
• Loss of motor coordination
• Blurred or double vision
• Slurred speech
• Ringing in the ear (also called “tinnitus”)
• Difficulty focusing on tasks at hand

A person with trauma to the head may be knocked unconsciousness for a period of time. In most cases, they will “wake up” in less than 2 minutes. You can expect them to be “foggy” and behave inappropriately (put me in, coach!). They may not remember the events immediately prior to the injury.

Loss of consciousness, even for a short time, is a serious concern that requires close observation for the next 48 hours. You should examine for evidence of superficial injuries and determine that the patient can move all their extremities equally on each side with normal range and strength.

Rest is prescribed for the remainder of the day. When your patient goes to bed, it will be appropriate to awaken them every two or three hours, to make sure that they are easily aroused. In most cases, a concussion causes no permanent damage unless there are multiple episodes of head trauma over time, as in the case of boxers or other athletes in contact sports.

There are a number of signs and symptoms which might identify those patients that have a serious TBI. They include:

• Prolonged loss of consciousness
• Convulsions (Seizures)
• Worsening headache over time
• Nausea and vomiting
• Bruising (around eyes and ears)
• Bleeding from ears and nose
• Worsening confusion/Apathy/Drowsiness
• One pupil more dilated than the other
• Indentation of the skull

If the period of unconsciousness is over 10 minutes in length, you must suspect the possibility of significant injury, often from bleeding inside the skull. Call 911 if possible. In the meantime, vital signs such as pulse, respiration rate, and blood pressure should be monitored closely. The patient’s head should be immobilized, and attention should be given to the neck and spine, in case they are also damaged. Verify that the airway is clear and breathing is regular.

Raccoon Sign

Some signs tip you off that the fall has caused a significant head injury. Bruising behind the ears (“Battle’s sign”) or around the eyes (“Raccoon sign”) indicates internal bleeding in the skull. Bleeding from the ear itself or nose without direct trauma to those areas is another indication. The fluid that drains out may be clear; this may represent leakage of spinal fluid.  In addition, intracranial bleeding may cause pressure that compresses nerves that lead to the pupils. In this case, you will notice that your unconscious patient has one pupil more dilated than the other. Individuals with any of these signs should be taken to a modern health facility, if possible, immediately.

FRACTURES AND OTHER ORTHOPEDIC INJURIES

Besides head injuries, falls commonly cause fractures, especially in areas like the wrist, arm, ankle, and hip.

Fractures may affect the upper arm, called the “humerus” or the two bones in the forearm, the radius (mentioned earlier) and the “ulna”. Trauma from a fall could also cause a “dislocation” of the shoulder, elbow, or other joint. In either case, the limb often appears deformed and must be re-aligned and immobilized if it is to regain function. This is called a “reduction” and may or may not require surgical intervention.

Sprain or fracture?

Sprains and fractures are sometimes difficult to tell apart, as both appear swollen, bruised, and painful. Fractures tend to be more painful, however. One way to tell is if the victim can walk at all on the injury. The Ottawa Rules say that if the victim can’t take 4 steps, it’s probably a fracture. Pain when touching the malleolus (what we call the “ankle bone”) is more likely a fracture, while pain below it is more likely a sprain. This injury must be immobilized with a splint as soon as possible to prevent further damage.

A hip fracture is a break in the upper part of the thighbone where it connects to the pelvis to form the hip joint. It is most often seen in elderly people after a fall. Ordinarily a very strong bone, loss of calcium with age causes the area to become brittle and prone to injury. This occurs more often in women.

A person with a hip fracture will experience:

• An inability to move or put weight on the injured side
• Severe pain
• Bruising and swelling

Examination of the patient will reveal the leg has shortened on the side of the injury, with the extremity facing outward.

For an older person, this is a life-threatening condition; women who suffer a hip fracture are twice as likely to die within a year of the fall. Surgery is necessary to repair the damage.

FALL PREVENTION

There are some strategies that might decrease the risk of falls in the Great Outdoors:

• On the trail, use walking sticks or poles on uneven terrain.
• Keep backpack weight centered on your hips, not your back.
• Slow down and watch where you’re stepping.
• Be careful of slippery rocks when crossing streams.
• Be aware of loose gravel on steep inclines.
• Take care of your feet; you may get off-balance from favoring a blistered area.

Here’s some advice for the home:

• Get rid of clutter on the floor.
• Clean up spills immediately.
• Add grab bars and railings where appropriate.
• Consider a medical alert system for the elderly.

In general:

• Consider decreasing the use of alcohol or medications (prescription or over-the-counter) that cause drowsiness or make you dizzy. (for prescription meds, consult your healthcare provider)
• Maintain leg strength and balance with exercise. Tai Chi has been recommended as a good option, even for the elderly.
• Consider Vitamin D supplements to strengthen bone.
• Make sure your vision is clear (and watch where you’re going)
• Avoid walking in the dark if at all possible.

In life, there are always bumps in the road, but that doesn’t mean you have to trip over them. Don’t let a fall be the end of the road for you or your loved ones.