Falls from great heights continue to represent a significant portion of the orthopedic/trauma surgery patient population and are associated with considerable mortality. To date, there is very limited knowledge regarding potential differences in the timing of the accident, injury patterns, and clinical outcomes between various types of falls. Consequently, no tailored recommendations for action can be derived during the early clinical phase.

In this study, we retrospectively analyzed data since 2014 on falls from great heights (> 3 m) and low heights (< 3 m). Additionally, falls from great heights were further categorized based on their circumstances into suicidal and accidental, with accidental falls subdivided into occupational and non-occupational. To our knowledge, we are the first to conduct this detailed categorization of high falls in such a large patient cohort, aiming to identify relevant differences that could prove valuable for clinical practice, particularly during the initial treatment phase.

As expected, the high falls group, with an average age of approximately 52 years, is significantly younger than the low falls group, which has an average age of nearly 70 years. Thus, the low falls group predominantly consists of a fall-prone geriatric patient population. Appropriately, the ISS following a fall in these older patients is lower at 18.7 compared to 23.0 in the high falls group. Interestingly, however, low falls in these geriatric patients still represent a serious event: Following a low fall, a significantly higher percentage of patients (22.6%) died compared to 13.6% after a high fall. Notably, over half of the low falls involved head injuries. Older patients often undergo long-term anticoagulation therapy, which significantly increases the risk of intracerebral hemorrhages even after mild head injuries [9, 10]. These findings emphasize that falls among geriatric patients should be taken seriously, as they are associated with high morbidity and mortality [11]. Often, a predisposition to falling exists long before a fall event necessitating hospitalization occurs. Therefore, a tendency to fall in older patients should prompt the consistent implementation of preventive measures [12, 13].

In early clinical management, it appears advisable to initiate comprehensive diagnostics, even when patients with impaired cognitive performance may not adequately report their symptoms. Particular attention should be given to detecting head injuries.

When comparing accidental falls and suicidal falls, it is noticeable that suicidal patients are, on average, about 46 years old—approximately 7 years younger. This age is about 10 years below the general peak age for suicides in Germany [14]. While accidents predominantly affect men, the gender ratio in suicides is roughly balanced. It is worth noting that patients who experienced a suicidal fall were significantly more severely injured and died more than twice as often in the hospital, which has also been reported in other non-European studies [15, 16]. Kang and colleagues attributed this, among other factors, to a greater fall height in suicides. Correspondingly, these patients required significantly more prehospital intubations, resuscitations, blood transfusions, and emergency surgeries.

In our data, roughly 18% of high falls are suicidal attempts. The proportion of suicide attempts among high falls is inconsistently reported in the literature, ranging between 13% and 50%, likely due to the often unclear cause at the initial assessment [7, 17].

The injury patterns of the two types of falls differ markedly: suicidal falls are significantly more likely to result in extremity and pelvic trauma, while accidental falls more often lead to head injuries. Suicidal falls therefore frequently appear to involve a “feet-first” mechanism, whereas accidental falls occur in a more uncontrolled manner [18]. Accordingly, suicidal falls show a predominantly caudal injury distribution, while accidental falls are characterized by a cranial injury predominance. Regarding the time of day and season, the data on general suicide rates remain inconclusive, without a clear trend [19,20,21]. However, we observed that suicidal falls, in comparison to accidental falls, occur slightly more often at night and more frequently during winter and spring. Notably, despite reports of higher overall suicide rates during winter in epidemiological studies, suicidal falls were least frequent in winter in our cohort compared to other seasons. This discrepancy may indicate that during winter months other suicide methods are preferentially used, while falls from height contribute less to overall suicide incidence.

For early clinical management, this suggests that it is worthwhile to attempt to determine the circumstances of a fall as soon as a high-fall trauma patient is announced. If a suicidal intent is suspected, the treating team should be instructed to prepare for potential emergency surgeries, intubations, and blood transfusions, and to streamline the corresponding workflows. Special attention should be paid to pelvic stabilization and thorough diagnostics of the distal lower extremities in suicidal falls.

Work-related falls primarily affect men, likely due to the fact that many high-risk occupations, such as construction work, continue to be predominantly male. Interestingly, work-related falls have a comparable ISS to non-work-related accidents, but significantly fewer patients die in the hospital (6.5% compared to 16.1% in leisure-related falls). One possible explanation is that workplace falls are more often witnessed and better medical infrastructure is available, enabling faster initiation of medical measures.

The injury patterns of leisure-related and work-related high falls are comparable. Only the arms are slightly more frequently affected in work-related high falls. One possible explanation for this is that falls occur more often during manual tasks, possibly leading to the involvement of the arms. Another possibility is that in some cases, arm injuries occurred first, which then led to a fall.

This study is not without limitations. First, it is a retrospective analysis with the well-known inherent limitations. Additionally, the TraumaRegister DGU® data only allow differentiation between high falls (> 3 m) and low falls (< 3 m). Further differentiation of fall heights is not possible but could be valuable for a more nuanced risk adjustment of the fall types. Furthermore, only data from patients who survived the prehospital phase after a fall are captured, meaning potential biases in the reported injury patterns cannot be ruled out. Moreover, these findings therefore provide limited recommendations for the prehospital phase. Finally, the registry does not provide detailed information on pre-existing comorbidities or acute intoxications, which may represent important confounders influencing both fall mechanism and injury patterns.

In conclusion, there are characteristic differences between various types of falls. Low falls frequently affect geriatric patients, who may still suffer severe injuries and have high mortality rates. High falls resulting from suicide attempts involve more severe injuries and higher mortality rates than accidents. Additionally, suicidal falls are more likely to involve extremity and pelvic injuries, whereas accidents are more commonly associated with head injuries. Work-related accidents are comparable to non-work-related accidents in principle but have lower mortality rates, possibly due to faster access to medical care or due to occupational safety measures.