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J Indian Acad Forensic Med. Jan-March 2013, Vol. 35, No.

1 ISSN 0971-0973

Case Report

Unusual fall from Height in an Elevator: A Case Report


*Amit M Patil, *Satin K Meshram, *Rajesh B Sukhadeve

Abstract
Deaths due to fall from height are more commonly seen in urban area especially where high rise
buildings are constructed. Invariably such falls from great height results in tragic death of the innocent
victims mainly construction workers who are working without any safety measures. A fatal fall from height
can result from accident, suicide or homicide. This paper reports an unusual incident where four
construction worker suffered accidental fall due to snapping of the cable of a temporary elevator erected
at the construction site. Out of the four victims, one died on the spot while the remaining three victims
were hospitalized who subsequently died within few hours of admission due to the fatal injuries sustained
during the fall. The medico-legal autopsy on each of the victims showed characteristic pattern of skeletal
and internal injuries sustained on account of blunt trauma due to fall from height . The following case is
reported due to its rarity and unusual form of accidental death due to fall from height.

Key Words: Fall from height, Elevator, Accident, Blunt trauma, Skeletal & Internal Injuries

Introduction: Fall from height is defined in many


The higher you climb, the harder ways, the international classification of diseases
you fall.- Chinese idiom [1] (ICD9) states that a fall from height is an event
The incidence of deaths due to fall from where a person falls to a ground from upper
height is increasing day by day as many work level. Whereas the Frailty and Injuries Co-
activities require working at a considerable operative Studies of Intervention (FICSIT) define
height. This is more found to be true in workers fall from height as unintentionally coming to rest
who are engaged in employment activities like on the ground, floor or other lower level. A more
maintenance, construction, painting, decoration recent definition of fall from height is to descent
and window cleaning. Moreover such odd jobs from upright, sitting or horizontal position, the
are performed without proper training, planning descent height being less than or equal to 1
and safety measures. Fall from height refers to meter. [7]
fall from one higher level to another level Case History:
involving ladder, stairs, roof, etc. [2] The incident occurred in March 2005,
The frequency, type and extensiveness where 4 dead bodies were brought for medico-
of injuries in falls from height are determined by legal autopsy to the mortuary of Department of
body weight and velocity, nature of the surface Forensic Medicine, TNMC and BYL Nair
impacted, duration and intensity of the impact Hospital, Mumbai. All the deceased victims were
force, body orientation in the moment of impact, working at the construction site of the OPD
as well as the elasticity and viscosity of the building of the hospital. The construction
tissue of the contact body region. [3-5] fall are a company had erected a temporary elevator (lift)
leading cause of injury in the United States, at the construction site for the inspection of
second only to motor vehicle crashes. [6] construction work.
A group of 4 workers (compromised of 1
Corresponding Author: civil engineer, 1 supervisor and 2 construction
*Associate Professor, worker) were coming down by this temporary lift
Department of Forensic Medicine & Toxicology, from the eighth floor, when the cable of the lift
Padmashree Dr. D.Y. Patil Medical College, snapped and the lift came crashing down on to
Hospital & Research Centre, Sector 5, Nerul (East), the ground. It was a free fall from a height of
Navi Mumbai 400706. Maharashtra, India about 60 feet. The incident happened around
E mail: dramp1976@gmail.com. 21.00 hours. Out of the 4 worker, one worker
*Assoc. Prof., Dept. of Forensic Medicine,
Indira Gandhi Medical College, Nagpur,
died on the spot while the other three workers
*Assoc. Prof, Dept. of Forensic Medicine, sustained injuries for which they were admitted
Seth GS Medical College and KEM Hospital, Mumbai in the surgical unit of the hospital. They
DOR: 22.6.12 DOA: 4.2.13

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J Indian Acad Forensic Med. Jan-March 2013, Vol. 35, No. 1 ISSN 0971-0973

subsequently succumbed to their injuries within e. Tearing of the pleura at sites subjacent to
3 hours of admission. the displaced fractures of ribs.
A complete and thorough medico-legal f. Avulsion of posterior attachments of the
autopsy was conducted on the body of each domes of the diaphragm on both sides.
victim on the next day. All the victims were male g. Contusion of both lungs at their hilae.
between the age group of 30 years to 40 years. h. Two irregular tears over the posterior aspect
On external examination it was found that all the of the right lobe of the liver.
victims were of moderate to average built. Rigor i. Contusion of the right psoas muscle along
mortis was well developed. The post mortem its entire length.
lividity was faintly developed over back and j. Compression fracture of the lower half of the
th
dependant parts except over the areas of body of 5 lumbar vertebra.
contact flattening. k. Fracture of the body and alae of the sacrum
The post-mortem lividity was fixed. with dislocations of the lumbosacral and
There was oozing of blood from the nostril of both sacroiliac joints.
one of the deceased victim. The victims had l. Fracture dislocation of pubic symphysis.
suffered external injuries in the form of multiple m. Fracture dislocation of atlanto occipital joint.
irregular impact abrasions with subjacent n. 2600 ml of fluid blood was drained and 440
contusions, irregular grazed abrasions and gm of clots was evacuated from the sub
irregular stretch lacerations. Out of the three diaphragmatic space of both sides.
admitted victim, one deceased victim showed Case 2: Male, 37 years
presence of sutured surgically incised wounds of On External Examination:
exploratory laparotomy and thoracotomy with a. Swelling, visible deformity and compound
intercostal drainage. The details of injuries of fractures and dislocation of lower ends of
each victim is described as below both Tibia and Fibula of both legs, Talus and
Case 1: Male, age 34 years Calcaneum of both the foot.
On External Examination: On Internal Examination:
a. Swelling, visible deformity and compound a. Fracture of the sternum at the junction of the
fracture and dislocation of lower ends of Manubrium with the body.
both bones of the right leg, fracture of Talus b. Contusion of anterior pericardium.
nd th
and Cuboid bones of the right foot. c. Displaced fracture of ribs from 2 to 7 rib
rd th
b. Swelling and visible deformity of the left of right side and 3 and 4 ribs of left side of
ankle joint and foot, with palpable fractures the chest anteriorly in midclavicular line with
of lower ends of both bones of the left leg contusion of subjacent intercostal muscle.
st nd rd
and fracture of Talus and Calcaneum bones d. Displaced fractures of 1 , 2 and 3 ribs of
of the left foot. right side at its posterior end with subjacent
On Internal Examination: contusion.
a. Subarachnoid haemorrhage about 20 ml at e. Bilateral haemothorax of about 1500 ml of
the base of the brain. fluid blood. Tearing of pleura at sites
b. Contusions of the intercostal muscles of the subjacent to the displaced fractures of ribs.
right side of the chest over the front from the f. Roughly triangular penetrating laceration
th
clavicle down to the level of the 6 rib and 1cm X 1cm X 1cm deep on posterior aspect
th th
over the outer aspect, along the 7 , 8 and of upper lobe of right lung.
th
9 intercostal spaces of size maximum 18 g. Multiple contusions of size ranging from 3
cm X 16 cm and minimum 11.5 cm X 13.5 cm X 2 cm to 1 cm X 1cm on both upper and
cm. lower lobes of both lungs.
c. Contusions of the intercostal muscle of the h. Haemo peritoneum of about 800 ml of blood.
left side of the chest over the front extending i. Contusion of anterior surface of right lobe of
st th
downwards from 1 rib to the 6 rib size liver.
19.5 cm X 16.5 cm and over the front and j. Multiple contusions of size ranging from 3.2
th th
outer aspect of the 9 and 10 intercostal cm X 2 cm to 1.8 cm X 1 cm on the coils of
spaces, size 6 cm X 10 cm associated with intestine and mesentery.
th th
undisplaced fracture of the 9 and 10 rib in k. Bilateral perirenal haematoma.
anterior axillary line. l. Fracture dislocation of the lumbar spine at
th rd th
d. Displaced fracture of the 7 rib on right side the level of 3 and 4 lumbar vertebra.
nd rd th
and 2 , 3 and 4 ribs on the left side at m. Fracture dislocation of the cervical spine of
nd rd
their costovertebral junction. 2 and 3 cervical vertebra with contusion
of underlying cervical spinal cord.

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J Indian Acad Forensic Med. Jan-March 2013, Vol. 35, No. 1 ISSN 0971-0973

n. Contusion of right psoas muscle. Fracture of d. Roughly triangular penetrating laceration


the left pubic bone. 1cm X 1cm X 1cm deep on posterior aspect
o. Comminuted fracture of the body of the of upper lobe of right lung.
sacrum with fracture dislocation of the right e. Multiple contusions of size ranging from 3
sacroiliac joint. cm X 2 cm to 1 cm X 1cm on both upper and
Case 3: Male, 30 years lower lobes of both lungs.
On External Examination: f. Multiple contusions of size ranging from 3.2
a. Swelling, visible deformity and compound cm X 2 cm to 1.8 cm X 1 cm on the coils of
fractures and dislocation of both ankle joints, intestine and mesentery.
Talus and Calcaneum of both sides. g. Bilateral perirenal haematoma.
On Internal Examination: h. Complete fracture dislocation of the lumbar
rd th
a. Diffuse subdural and subarachnoid spine at the level of 3 and 4 lumbar
haemorrhages over both cerebral vertebra.
hemispheres with blood clots at the base of i. Fracture dislocation of the cervical spine of
nd rd
the brain. 2 and 3 cervical vertebra with contusion
b. Contusions of diaphragm of varying sizes on of underlying cervical spinal cord.
both pleural and peritoneal surfaces. j. Comminuted fracture of the body of the
th th th sacrum with fracture dislocation of the right
c. Displaced fracture of 7 , 8 and 9 rib in
midaxillary line of left side of the chest with sacroiliac joint.
subjacent contusions. The cause of death was common in all
rd
d. Displaced fracture of 3 rib at costochondral the victims and was given as Death due to
junction of right side of the chest. haemorrhage and shock as a result of
e. Evidence of thoracotomy on left side. multiple injuries to internal organs and
f. Both lungs collapsed and show contusions multiple skeletal fractures due to blunt direct
at the hila with penetrating laceration seen and transmitted trauma (Unnatural).
on lower lobe of left lung of size 2cm X 1 cm Discussion:
parenchyma deep. Falls from a height present a great
g. Hemoperitoneum with 1000 ml of blood challenge to trauma services. In children, they
drained and 200 gm of clot removed. are most commonly due to accidents, while in
h. Multiple contusions seen on the coils of adults; they are attributed to suicide, accident or
intestine and mesentery. crime. The nature and magnitude of the injuries
i. Multiple lacerations on anterior and posterior occurring due to falls depend on the height of
aspect of the right and left lobe of the liver the fall, the nature of the contact surface, and
ranging between 3.4 cm X 2.5 cm body orientation on impact, body mass, the
parenchyma deep to 2.5 cm X 1.2 cm victims ability to distribute the impact forces
parenchyma deep. efficiently, and the victims age. [8, 9]
j. Both kidneys showed presence of perirenal The highest incidence of fall from height
haematoma and right Kidney laceration. occurs at construction site followed by fall from
k. Complete fracture dislocation of cervical public buildings. Fall from height is the most
nd rd
spine at 2 and 3 cervical vertebra level. common cause of fatal injuries and single
l. Fracture dislocation of lumbar vertebrae at biggest cause of work place deaths. On an
th th
4 and 5 level. average majority of fall related deaths happens
Case 4: in construction industry with remaining spread
On External Examination: across other industries. [10]
a. Swelling, visible deformity and compound In majority of falls, vertical landing with
fractures and dislocation of lower ends of feet first is common and next common being
both Tibia and Fibula of both legs, Talus and with the head first. [11]
Calcaneum of both the foot. In this case report, 4 victims died in a
On Internal Examination: single incidence of a fall from height in a
nd th temporary made elevator at a construction site
a. Displaced fracture of ribs from 2 to 7 rib
rd th of a Hospital. All the victims were male between
of right side and 3 and 4 ribs of left side of
the chest anteriorly in midclavicular line with the age group of 30 to 40 years. The manner of
contusion of subjacent intercostal muscle. death was accidental in nature.
b. Bilateral haemothorax of about 1500 ml of The medico-legal autopsy findings
fluid blood. revealed a common pattern of injuries in all the
c. Tearing of pleura at sites subjacent to the victims. All the victims showed open fractures of
displaced fractures of ribs. bones of lower extremities and feets. This can

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be attributed due to the fact that the feet must Conclusion:


have made the first contact with the hard The present case report revealed typical
ground. Since the fall occurred in an enclosed pattern of skeletal and internal injuries sustained
space of the elevator it restricted free fall and due to fall from height in an enclosed elevator.
change in the position of the body which is The nature of injuries suggests that the victims
usually seen in fall from height where the victim must have landed on their feets first.
is air born. More or less similar pathognomic The blunt force sustained due to landing
findings were noted on external examination in on the hard ground surface may have been
studies conducted by other researchers. [12-14] transmitted axially through the long bones of the
The postmortem findings of the victims lower extremity to the spine. Later on the force
revealed multiple skeletal fractures which is must have been distributed to the ribs and the
common in falls from greater heights. The internal organs consequently causing fractures
internal examination revealed abdominal and of the ribs and injuries to the internal organs.
chest injuries along with fracture of the spine, Unfortunately detailed scientific study
ribs and pelvis. (Table 2 & 3) Chest and about the capacity of the lift to carry persons,
abdominal injuries were seen most commonly dimensions of the lift, tensile strength of the
while cranio-cerebral injuries in the form of cable, presence of shock absorber and analysis
intracranial haemorrhages were noticed in only of the pulley could not be done.
two cases out of four. References:
Yagmur et al [8] have mentioned that 1. Manson J.K. The pathology of trauma 3 rd editions Arnold
abdominal and chest injuries were relatively publication, New York:
uncommon in falls from less than 4 m and the 2. 2000; 313-326
3. Murthy O.P. Pattern of injuries in fatal falls from height-a
head was the most frequently injured region. retrospective review Journal of Forensic Medicine and Toxicology
Chest, abdominal, extremity and neck injuries 1999; 16(2): 38-46.
occurred in decreasing order of frequency. As 4. Kroonenberg AJ, Hayes WC, McMahon TA. Hip impact velocities
the height increases, the incidence of chest, and body configurations for voluntary falls from standing height. J
Biomech 1996; 29(6): 80711.
abdominal and extremity injuries rises along with 5. Maull K, Whitley R, Cardea J. Vertical deceleration injuries. Surg
head injuries. Similar findings have been Gynecol Obstet 1981; 153: 2336.
reported by Gupta et al, [14] who described 63 6. Warner KG, Demling RH. The pathophysiology of free-fall injury.
persons who fell from heights. It was Ann Emerg Med 1986; 15: 108893.
7. Pipas L, Schaefer N, Brown LH. Falls from rooftops after heavy
demonstrated that lethal injuries involving snowfalls: the risks of snow clearing activities. Am J Emerg Med
multiple organs rose in number as the height 2002; 20: 635-7
increased. [15] 8. Tahir Masud and Robert O Morris. Epidemiology of falls Age
Fissure fracture of the skull and fracture and Aging 2001; 30(4): 3-7.
9. Yagmur Y, Gloglu C, Aldemir M, Orak M. Falls from Flat Roofed
of cervical spine was noticed when the fall Houses: A Surgical experience of 1643 patients. Injury 2004; 35:
occurred on to concrete from minimum height of 425-8.
3 feet and on to hard soil from the height of 10 10. Beale JP, Wyatt JP, Beard D, Busuttil A, Graham CA. A five year
feet. Multiple rib fractures, fracture of clavicle study of high falls in Edinburgh. Injury 2000; 31: 503-8.
11. Vasudeva Murthy CR, S Harish and Y P Girish Chandra. The
and laceration of liver was noticed when the fall Study of Pattern of Injuries in Fatal Cases of Fall from Height. Al
height was 7 feet on to concrete. Spleen and Ameen J Med Sci; Volume 5, No.1, 2012 4552.
kidneys were damaged when height of fall was 12. KS Narayan Reddy. The Essentials of Forensic Medicine and
more than 20 feet on to hard surface. Toxicology. 29th edition. K Suguna Devi; 2010: 213-253.
13. Gill JR. Fatal descent from height in New York City. J Forensic Sci.
Fracture of upper limbs were seen in 2001; 46: 11321137.
falls occurred on to concrete from height of 6 14. Li L, Smialek JE. The investigation of fatal falls and jumps from
feet where as the fracture of lower limb was height in Maryland. Am J Forensic Med Pathol. 1994; 15: 295299.
found when the fall height was more than 15 feet 15. Gupta SM, Chandra J, Dogra TD. Blunt force lesions related to the
heights of a fall. Am J Forensic Med Pathol. 1982; 3: 3543.
on to hard surface. [10] 16. Hall JR, Reyes HM, Horvat M, Meller JL, Stein R. The mortality of
In the current case report, since the fall childhood falls. J Trauma 1989; 29: 1273-5.
was from a greater height of about 60 feet the 17. Behet AL, Cuma YILDIRIM, Sacid OBAN. Falls from heights in
injuries were most commonly seen in the and around the city of Batman. Turkish Journal of Trauma &
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abdominal, thoracic and spinal regions involving
Table 1: External Skeletal Injuries
multiple organs. There were extremity injuries in External Skeletal Case 1 Case 2 Case 3 Case 4
100% cases, thoracic injuries 100%, abdominal injuries
injuries 75% and cranio-cerebral injuries in 50% Compound Fracture Present Present Present Present
of cases. A similar research on fall from height of Bones of Lower
Extremity
has revealed head injuries in 100%, extremity
Fracture Dislocation Present Present Present Present
injuries in 16.6%, abdominal injuries in 16.6%, of Bones of Feet
and thorax injuries in 16.6% of deaths. [16]

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Table 2: Internal Organ Injuries Table 4: Distribution of Injuries


Organ Case 1 Case 2 Case 3 Case 4 Injuries Cases (%)
Lungs Contusion Lacerations Lacerations Contusions 1. Head
and a. Fractures 0
Lacerations b. Intracranial haemorrhages 2 (50)
Heart Nil Contusion Nil Nil c. Cerebral Injury 0
anterior 2. Thorax
pericardium a. Haemothorax 1 (25)
Liver Nil Contusion Lacerations Nil b. Rib Fracture 4 (100)
Spleen Nil Nil Nil Nil c. Sternum Fracture 1 (25)
Kidney Nil Perirenal Perirenal Perirenal d. Diaphragm Injury 2 (50)
Hematoma Hematoma Hematoma 3. Abdomen
and a. Liver laceration 1 (25)
Laceration b. Spleenic laceration 0
Intestines Nil Contusions Contusions Contusions c. Renal laceration 3 (75)
and d. Intestine and Mesentery contusion 3 (75)
Mesentery e. Haemo peritoneum 3 (75)
Brain Sub Nil Diffuse Nil 4. Upper Extremity 0
arachnoid subdural 5. Lower Extremity
Haemorrh and sub a. Femur Fracture 0
age arachnoid b. Tibia Fracture 4 (100)
Haemorrha c. Fibula Fracture 4 (100)
ge d. Tarsal bone fracture 4 (100)
Spinal Nil Contusion of Nil Contusion e. Metatarsal Fracture 0
Cord cervical of cervical 6. Pelvis Fracture 3 (75)
spinal cord spinal cord 7. Spinal
Table 3: Internal Fractures a. Spinal cord contusion 2 (50)
Fractures Case 1 Casez 2 Case 3 Case 4 b. Cervical spine 3 (75)
Ribs Present Present Present Present c. Thoracic Spine 0
Spine Present Present Present Present d. Lumbar spine 4 (100)
Pelvis Present Present Nil Present

Your vision of a better tomorrow,


Steers us even today,
Your soul nurtures our hearts,
Your unseen presence still leads our way

Dr. G R Bhaskar
(06-Oct-1926 to 17-Nov-2012)

A towering influence in the field of Forensic Medicine, an intellectual of international


stature who chose to maintain a modest profile, Dr. G.R. Bhaskar was that glowing
beacon of inspiration, which lights up many paths towards the goal of the highest
achievements.

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