|Year : 2013 | Volume
| Issue : 1 | Page : 37-41
A retrospective study on fall-related injuries at a tertiary care level
TM Celine, Jimmy Antony, Abraham Johnson
Department of Community Medicine, M.O.S.C Medical College Kolenchery, Ernakulam, Kerala, India
|Date of Web Publication||29-May-2013|
T M Celine
Department of Community Medicine, M.O.S.C Medical College Kolenchery, Ernakulam, Kerala
Source of Support: None, Conflict of Interest: None
Background: Fall-related injuries will disable the injured person to earn money or lead to death or will lead the family to the poor economic condition. Aims: To find the case fatality rate, type of fall-related injuries, and the body parts affected by injuries among the hospitalized patients with fall-related injuries from 1 st April 2005 to 31 st March 2010. Patients and Methods: A retrospective study on hospitalized fall-related injured patients in MOSC Medical college Hospital, Kolenchery, Ernakulam, Kerala, India from 1 st April 2005 to 31 st March 2010. Data collected from the registers maintained in the medical records department. Z test was used for the comparison of proportions. Results: Of 4530 patients admitted with fall-related injuries during the study period, 2723 (60.1%) were males and 1807 (39.9%) were females. The major types of fall-related injuries were fall on and from stairs and steps (1.3%), fall involving bed (1.4%), fall from tree (3.2%), fall from one level to another (14.1%), unspecified falls (77.75%). While going to injuries, affected on body region were head (42.2%), elbow and forearm (13.1%), knee and lower leg (7.9%), hip and thigh (7.6%). Most of the fall-related injuries were happened in the age group of 15-64 years. Fall-related injuries were happened more in males than in females in the age group of 15-64 years. Fall-related injuries were more happened in females than in males in the age group of >64 years. The case fatality rate due to falls was 2.25%. Of 102 deaths, 74 (72.55%) were males and 28 (27.45%) were females. Proportion of male deaths 74 (2.7%) was more than of females 28 (1.5%) (P = 0.0079). Of 102 deaths, 46 (44.4%) were occurred in the age group of >64 years. Conclusion: Take care and give care is the only policy to prevent the fall-related injuries. Whoever be the injured, wherever it is affected, the injuries always make loss on human work power and national economy. Therefore, the only solution for this is the prevention by ensuring the human physical environment as healthy. In addition to this, much emphasis needs to be given to the older ones while handling them.
Keywords: Fall, injuries, male, female
|How to cite this article:|
Celine T M, Antony J, Johnson A. A retrospective study on fall-related injuries at a tertiary care level. Saudi J Health Sci 2013;2:37-41
| Introduction|| |
A fall is an event, which results in a person coming to rest inadvertently on the ground or floor or other lower level. Injury is an important contributor to global burden of disease,  and prevention and control of injuries are a public health priority in many countries. ,, Studies have established reliable estimates of the incidence of fall-related injury, events in population-based setting; ,,, however, detailed analysis of injury by type and body region is not readily available. Falls from rooftops, balconies, widows, and staircases are common. Factors specific to South-East Asian region (SEAR) countries are falls from trees of workers picking fruits or coconuts, tapping toddy, children falling from roof tops while flying kites, high incidence of falls among construction and forestry workers.  In the South-East Asia region, falls are responsible for the largest number of hospital visits for non-fatal injuries, especially for children and young adults. This is in stark contrast to western regions, where falls are most common among elderly. Fall from a height of two meters onto concrete can cause a serious head injury. As life expectancy increases in these countries, the incidence of hip and other fractures due to falls among the elderly are also assuming greater proportions. The most common fracture in elderly is that of the hip followed by those of vertebrae, forearm, leg, ankle, pelvis, upper arm, and hand. 
Globally, falls were the 2 nd leading cause of unintentional injury, after road traffic in juries, in 2004. A total of 424 deaths and loss of 17.2 million DALY's was reported due to falls in the same year. China has the greatest fall-related injury burden with almost twice as many DALY's lost to this type of injury than any other world region. Elderly over the age of 70 years contribute to over 40% of fall mortality; the rate being 21.7 (70-79 yrs) and 107.8 (>80 yrs) per 1,00,000 population, respectively.  During the year 2002, there were 1, 21, 000 estimated deaths due to falls in the SEAR countries.  The number of deaths due to falls in India during the years 1998-2000 was 6201, 6613, and 7087.  The number of deaths due to falls in India during the years 2001-2003 was 7446, 7826, and 8800.  A study report in United States in the year 2005 mentioned that 15,802 persons aged >65 years died as a result of injuries from falls. 
This study aimed to find case fatality, type of injures of patients admitted with fall-related injuries during the period from 1 st April 2005 to 31 st March 2010 and also to find out the body parts, which were affected by fall-related injuries during the same period of time.
| Patients and Methods|| |
The study was a retrospective study conducted on patients admitted with fall-related injuries in M.O.S.C Medical College, Kolenchery, Ernakulam, Kerala India from 1 st April 2005 to 31 st March 2010.
Selection of description of patients
The study population consists of all patients admitted in the hospital due to fall-related injuries during the period from 1 st April 2005 to 31 st March 2010. Data was collected from the medical records department. The data was collected with the permission of institutional ethical committee. Medical record department follows the guidelines of International Classification of Diseases (ICD)-10 coding. 
Z test is applied for the comparison between proportions. Z test is used for comparing the sex-wise difference between proportions of age, type of injuries, and body region. (Critical ratio (Z) = sex-wise difference between proportions age/standard error of difference between sex-wise proportions. Standard error of difference between sex-wise proportions = √(p 1 q 1/ n 1 ) + (p 2 q 2/ n 2 )
P value is taken from the table with the corresponding value of z (critical ratio). P value less than or equal to 0.05 indicates that there is significance difference between the proportions of two groups. P value greater than 0.05 mentions that there is no significant difference occurred between two groups.) Microsoft excel was used for analyzing the data. The diagnosis is recorded in the medical records department as ICD 10 codes.
| Results|| |
Total of 4530 patients were admitted with fall-related injuries in a tertiary care level during the period from 1 st April 2005 to 31 st March 2010. Out these patients, 2733 (60.2%) were males and 1807 (39.8%) were females.
In [Table 1], 2nd and 3rd column represent the number of cases and percentage of cases among the gender group. Among the hospitalized fall-related cases, males were more than females in the age group 5-54, but in the age group of under five and above 64 years, females were more than males. Most of the fall-related cases occurred in the age group of 15-64 years [2336 (51.6%)]. Of the fall-related cases in the age group of 15-64 years, 1544 (66.1%) were males and 792 (33.9%) were females. Fall-related cases among the males 1544 (56.5%) occurred in the age group of 15-64 years and among females, 792 (43.83%) were occurred in the age group of 15-64 years. Fall-related cases were more among males than females in the age group of 15-64 years. (P = 0.0001) Of the fall-related admissions, 2194 (48.4%) were occurred in the age group of less than 15 years and ≥ 65 years. This group is come in the dependent age group; therefore, more attention is given to this age group. Proportion of fall-related cases in the age group >64 years was 861 (19%). Of this age group (>64 years), proportion of fall-related cases among females 512 (28.33%) was more than males 349 (12.77%). (P = 0.0001) Proportion of fall-related admissions among males and females in the age group of 65-74 years were 6.4% and 11.9%, respectively. And, in the age group of ≥75 years males and females, it was 6.4% and 16.4%, respectively. It indicates that fall-related admissions among females were more than males in the age group of >64 years [Table 1].
|Table 1: Age-sex distribution of hospitalized patients due to fall - related injuries from 1st April 2005 to 31st March 2010|
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Total deaths due to falls were 102. The case fatality rate due to falls was 2.25%. Of these total deaths, 74 (72.55%) were males and 28 (27.45%) were females. The proportion of male deaths among males was 74 (2.7%), which was more than the proportion of female deaths 28 (1.5%) among females. (P = 0.0079). Numbers of fall-related deaths in the periods 2005-2006, 2006-2007, 2007-2008, 2008-2009, 2009-2010 were 13, 23, 13, 28, and 25, respectively. Most of the fall-related deaths were occurred in the age group of 15-64 years 48 (47.06%). Of the fall-related deaths in the age group of 15-64 years, 42 (87.5%) were males and 6 (12.5%) were females. Fall-related deaths among the males 42 (56.76%) were occurred in the age group of 15-64 years and among females, 6 (21.43%) were occurred in the age group of 15-64 years. Fall-related deaths were more among males than females in the age group of 15-64 years. (P = 0.001) Of the fall-related deaths, 45 (44.12%) were occurred in the age group of >64 years. Of this age group (>64 years), proportion of fall-related deaths among females was 20 (71.43%), which was more than males 25 (33.78%). (P = 0.001) It indicates that fall-related deaths among females were more than males in the age group of >64 years.
Most of the injuries due to falls affected the head. An injury that affected in multiple body regions was very few in number. Injuries that affected the hip and thigh region were more in females than in males, and the head injuries more occurred in males than in females as shown in [Table 2].
|Table 2: The distribution of body region affected by fall - related injuries according to sex during the period from 1st April 2005 to 31st March 2010|
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Most of the falls happened from one level to another 637 (14.1%). This type of falls was more in males than in females. The next leading type of fall was from trees 145 (3%) as shown in [Table 3].
[Figure 1] showed that out of 4530 cases, most of the cases were reported in the year 1 st April 2006 to 31 st March 2007. It indicates that proportions of fall-related injuries are increasing. This chart mentioned that falls were more in males than in females.
|Figure 1: Trend according to sex of fall related injuries of patients admitted in a tertiary care hospital|
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Among the patients admitted with fall-related injuries, fractures were occurred more than superficial injuries and dislocation. And also mentioned that there was no sex-wise difference occurred in the proportion of superficial injuries, fractures, and dislocation [Table 4].
|Table 4: Type of fall - related injuries during the period from 1st April 2005 to 31st March 2010|
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| Discussion|| |
Fall-related injuries were more in males than in females. Most of the fall-related cases were occurred in the age group of 15-64 years. Among this age group, males were more than females. Fall-related admissions among females were more than males in the age group of ≥65 years. Proportion of deaths among males was more than females. Proportion of males deaths were more than the proportion of female deaths in the age group of ≥65 years. Most of the fall-related injuries affected body region was head. Head injuries were more occurred in males than in females. Hip and thigh injuries were 7.6% of total fall-related admissions, and also showed that it was more in females than in males (P < 0.00001). Fall on the same level from slipping, tripping, and stumbling was 0.2%.
According to WHO, the morbidity pattern of injuries due to falls was 38%.  Pramod Kumar Verma's study report mentioned that the rate of fall-related injuries among males in the age group 65-74 was 2.59 per 1000 male population and among females, it was 5.06 per 1000 female population, and in the age group ≥75 years, rate of fall-related injuries in males was 31.81 per 1000 male population and in females, it was 58.38 per 1000 female population.  Among people 65 years and older, falls are the leading cause of injury deaths and are the most common cause of non-fatal injuries and hospital admissions for trauma. Each year in the United States, nearly one third of older adults experience a fall. In 2003, more than 13,700 people, 65 years or older, died of fall-related injuries. Another 1.8 million were treated in emergency departments for non-fatal injuries related to falls.  In the present study, fall-related injuries were occurred more in males than in females. Among the fall-related cases, most of them were occurred in the age group of 15-64 years, of them, males were more than females. And also mentioned that among the fall-related admissions, females were more than males in the age group of >64 years. Pramod Kumar Verma's study result and the present study mentioned the same result, as fall-related injuries were more in females than in males in the age group of >64 years. This may be happened because both the studies are conducted in India and also it may be the cause of osteoarthritis.
The global estimates of injuries-related deaths by falls among males were 4.56% and females were 3.01% in the year 2002.  In the present study, the proportion of deaths due to fall-related injuries among males was 2.7% and among females, it was 1.5% during 1 st April 2005 to 31 st March 2010. The global estimate and the present study mentioned the same result that fall-related deaths were more occurred in males than in females. This may be happened because males are working more in the construction fields, climbing trees etc.
A study conducted by WHO mentioned that fall-related death rates for men and women 65 years and older increased significantly from 1993 to 2003. In 2003, more than 13,700 older adults died from falls, making them the leading cause of injury deaths among people 65 and older. From 1993 to 2003, fatal falls increased by more than 55%. This increase is with more men (46.2%) dying from falls than women (31.1%).  Among people 65 years and older, falls are the leading cause of injury deaths and the most common cause of non-fatal injuries and hospital admissions for trauma. Each year in the United States, nearly one third of older adults experience a fall.  In the present study of 102 fall-related deaths, 46 (44.4%) were occurred in the age group ≥65 years. Of these deaths, proportion of male deaths was significantly more than female deaths in the age group ≥65 years (P = 0.009).
Pramod Kumar Verma's study showed that head injuries affected by fall-related injuries were 30.8%  and in another study of old age people, it were 13%.  In the present study, head injuries were 42.2% of fall-related admissions. A study mentioned that head injuries were occurred more in males than in females (P < 0.01).  The same result was occurred in the present study also (P < 0.00001). As specified earlier, males are working more in the construction fields, climbing trees etc. than females. This mentions that chances of falling down from the high place were more in males than in females.
Fractures of the hip are common fall-related injuries documented in a number of epidemiological reviews. , The decline in women's hip fracture injury rates varies from 2001 to 2004. It may be a result of prevention efforts such as osteoporosis screening, and it is combined with widespread education about treatments to rebuild bone mass.  A study report showed that an injury to the hip and thigh was 48.4%.  But, in the present study, hip and thigh injuries were 7.6% of total fall-related admissions. This study result is different from the present study result.
The annual incidence of non-fatal fall-related injury is increasing with age. For the most recent non-fatal fall-related injury, home was the most common place of injury for women, and the farm for men, with former more likely to fall while climbing up/down (20.9%) compared with the latter (10.3%). Most falls were at the same level (71.7%), and slipping was the most common cause of falls (40%). Limbs (legs, 55%; hand/arm, 33.3%) were the most commonly injured body part. Fifty-six percent reported seeking treatment outside home for injury, of whom 74.6% were women; and 8.4% reported being admitted to a hospital.  In the present study, it is mentioned that fall on the same level from slipping, tripping, and stumbling was 0.2%, and fall on the same level was 0.8%. Fall from tree was 3.2%, and fall on and from ladder was 0.3%. Hip and thigh injuries due to fall were 7.6%. Most commonly injured body part was head (42.2%), and the second most injured body part was elbow and forearm (13.1%).
Limitations of the study: This study was a retrospective, hospital-based study.
| Conclusion|| |
To reduce the fall-related injuries, awareness needs to be given. Health awareness is the main tool for reducing this sort of accidents, and it is also important to make the environment safe and protective. "Fall death rates have increased faster than fall injury rates. In large part, this is because people are living longer, and many of our seniors now are older and frailer. They need our help to prevent potentially fatal fall injuries," said Dr. Judy Stevens, an epidemiologist in CDC's Injury Center and author of the report.  "Injuries from falls and the fear of falling lead older adults to limit their activities, which can interfere with independent living. But, we know that falls are not inevitable. Therefore, the preventive strategies have much importance to avoid the fall-related injuries.
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[Table 1], [Table 2], [Table 3], [Table 4]