Tree stand falls: a persistent cause of sports injury.

Objective: Tree stand falls are a well-known cause of hunting-related injury. Spine and brain injuries associated with these falls result in a significant incidence of permanent disability. Prior studies indicate that hunting tree stand injuries are largely preventable with the proper use of safety belts; however, compliance with safety belt use is variable. The purposes of this study were to determine 1) current compliance with safety belt use, 2) alterations in the spectrum of injury, and 3) causes of the falls.

Methods: From January 1996 to October 2001, 51 tree stand-related injuries referred to either of two regional trauma centers or their region's medical examiner's office were reviewed. Data had been recorded in each hospital's trauma registry, and the registries were searched for falls. Medical records were reviewed for additional data retrospectively, with an emphasis on determining the use of safety belts, and mechanisms contributing to the fall.

Results: Fifty-one cases of tree stand-associated injuries were identified. These injuries all occurred in men, with a mean age of 42.6 years (range, 22-69 years). Alcohol use was present in 10% of patients and in two of the three deaths. The mean Injury Severity Score was 18.1 (range, 2-75). The most common injuries were spinal fractures (51% of series) and extremity fractures (41% of series). Closed head injuries were identified in 24% and lung injuries were identified in 22% of patients. Abdominal visceral injuries were present in 8% and genitourinary injuries were present in 4%. Three patients died. In addition to injury from the fall, a significant number (six patients [12%]) had additional morbidity from exposure. Only two patients reported the use of a safety belt (4% of series). There were no cases of gunshot wounds in this review, either self-inflicted or hunter-related. The chief reasons reported for these falls were errors in placement that resulted in structural failure of the stand, or errors made while climbing into or out of the stand (50% of falls).

Conclusion: Devastating spine and brain injuries continue to occur after falls from tree stands during recreational hunting when safety belts are not used. Our results suggest a continuing need for the education of hunters concerning safe tree stand hunting practices, including proper methods of stand placement, assessment of tree branch strength, avoidance of fatigue and alcohol, anticipation of firearm recoil, and proper methods of stand entrance and exit. Trauma prevention programs directed toward heightened public awareness of these injuries during hunting season are still needed.

Key Words: deer tree stands, injury, public health

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The use of tree stands as a vantage point is a highly effective technique for large game hunting in deciduous forests and along field edges. Tree stands are routinely used for boar, deer, bear, and turkey hunting with a bow, rifle, or shotgun. Tree stands are usually placed approximately 15 feet above the forest floor; they provide the hunter with a wide field of view and decrease the hunter's scent at the ground level. There are many different commercial models of tree stands sold in the United States, and there are many homemade variants. The standard commercial tree stand generally consists of a seat that is fixed to a tree with a combination of straps, bolts, and toothed metal plates. Various options to enter the tree stand after installation are also sold. As a safety feature, many hunters choose to also wear a safety strap, or harness, which is intended to support the hunter should he or she fall. Beyond providing a more effective hunt, tree stands probably have contributed to a reduced incidence of hunting-associated bow and firearm accidents, as they allow better visualization of the hunting area, preventing a hunter from mistaking another hunter for a game animal.

In 1989, tree stand falls were identified as the leading cause of hunting-related injuries in the United States. (1) In addition, up to 50% of injuries treated at trauma centers resulted in neurologic damage severe enough to result in permanent paralysis or death. (2-10) Since then, small series have demonstrated that public education on safety belt use has reduced the incidence of devastating spinal cord injury. (11) Western New York and central Maryland are two regions of the United States that offer a wide variety of opportunities for trophy game hunting in deciduous forest. We retrospectively examined the tree stand-related trauma patients evaluated at two regional trauma centers serving these areas--one in western New York and the other in central Maryland. In addition, we examined those cases evaluated by the state medical examiner in each trauma center's referral area. Fifty-one cases were identified over a 5-year period. The goals of this study were to determine current safety belt use, factors contributing to falls, and any changes in the spectrum of injuries.

Methods

From January 1996 through October 2001, all tree standrelated injuries referred to the University of Rochester's Strong Memorial Hospital in western New York and the Washington County Hospital in central Maryland were examined. Prospectively collected trauma databases from each center were cross-referenced with the discharge diagnosis of "Other fall from one level to another," International Classification of Diseases, Ninth Revision code E884.9, to identify all cases. All falls not incurred while hunting from a tree stand were excluded. Twenty-seven tree stand injury cases were identified at Strong Memorial Hospital and 21 were identified at Washington County Hospital. The New York and Maryland State Medical Examiner's offices also examined their regional databases to identify all hunting stand-associated deaths occurring in the same region during this time. Overall, 51 cases were identified, which form the basis of this review. The study received exempt status from the associated institutional review boards at both institutions where the data were obtained, and all investigators completed training in protection of human subjects. A retrospective review of these cases was undertaken with attention to injuries encountered, precipitating causes, mechanism of injuries, and outcome.

Results

51 cases of tree stand-associated injuries occuring from January 1996 through October 2001 were identified. Three deaths occurred in this group. Two tree stand-related deaths were encountered within the nine-county referral area of Strong Memorial Hospital. One tree stand-related death was encountered in the corresponding five-county referral area of Washington County Hospital. Mortality in the series was 6%. The cause of death was severe closed head injury in all three patients, with a concurrent high spinal cord transection in one of the deaths.

All tree stand-associated falls occurred in men. The mean age was 42.6 years (range, 22-69 years). The mean Injury Severity Score was 18.1 (range, 2-75). Injuries were primarily due to the direct blunt impact of the fall; however, a significant number of fall victims (six patients [12%]) also had concurrent secondary injury from prolonged exposure resulting in hypothermia. No instances of hunters injuring themselves or others due to the inadvertent discharge of a firearm while falling or causing the fall were encountered.

On the basis of patient reports, the mechanisms contributing to the fall were identified in 29 patients (58% of the series) (Table 1). The falls were attributed most frequently to structural failure of the tree stand (25%). Seven patients fell as a result of structural failure, either of the tree stand (bolts breaking, step collapse) or of the tree itself (broken branches). Six patients lost their balance and fell while either entering or exiting their tree stands (20%). Alcohol was directly attributable as the cause of the fall in five patients (17%). Falls were also attributed to fatigue: falling asleep in three patients (10%) and recoil from discharging the weapon in two patients (7%). Additional causes of falls included sneezing, "lightheadedness," and one man who reportedly lost consciousness before his fall (Table 1).

The precipitating cause of the fall was not specified for the remainder of patients. Use of safety straps or harnesses was reported in only two (4%) of the patients. One patient reported harness failure and falling despite use of the safety feature.

The most common injuries were spinal fractures (52%) of the thoracic and lumbar vertebral bodies, followed by extremity fractures (40%) of the forearm and calf. Closed head injuries were identified in 24%, and rib fractures were present in 22% of patients. Abdominal solid organ injuries were seen in 12%. No cases of penetrating injury due to gunshot wounds or impalement were identified in this series (Table 2).

Further characterization of the spinal column injuries includes 13 burst fractures, 12 vertebral body/compression fractures, 1 isolated transverse process fracture, and 3 isolated laminar fractures (Table 3). Eight (16%) patients required surgical stabilization of spinal fractures. Spinal cord injury was seen in four patients (8%). In one case, death occurred secondary to presumed respiratory failure after a high spinal cord transection. Another patient sustained a conus medullaris injury with incomplete paraplegia as a result of a T12 burst fracture.

Extremity fractures were present in 40% of the patients. Common injuries included fractures of the tibia/fibula (10%), radius/ulna (8%), foot and ankle (8%), pelvis (4%), and humerus (2%). Five patients went to the operating room for repair of extremity fractures. In addition, three patients had multiple extremity fractures and two patients had isolated calcaneal fractures.

Chest injury was the third most commonly encountered injury. Pulmonary contusion was observed in four patients (8%) and was treated with supportive care and pulmonary toilet. Another patient required thoracoscopic decortication of an empyema during his third week of admission. He had required prolonged ventilatory assistance due to pulmonary contusion. Chest tube placement was required in three patients (6%): for pneumothorax in two cases and for hemothorax in one case.

The falls resulted in closed head injuries, including nine concussions without changes on computed tomographic scan and three massive intracranial hemorrhages, two of which had associated basilar skull fractures. All three patients with intracranial hemorrhages died.

Intra-abdominal injuries included two Grade II splenic lacerations, one Grade IV splenic laceration, and a Grade II to III laceration of liver segments VI and VII. All of these abdominal solid organ injuries were successfully managed nonoperatively.

Three retroperitoneal injuries occurred. One patient presented 24 hours after his fall with dark urine and flank pain and was found to have a subcapsular hematoma of the left kidney. A second patient was found to have a perinephric hematoma, with a concomitant L3 compression fracture. The third patient presented with an open pelvic fracture, with a marked retroperitoneal hematoma. This patient was treated successfully with external pelvic fixation.

Six patients were hunting alone and had significant delays from the time of injury to transport to the emergency department for evaluation. None of these delays exceeded 24 hours, but all were greater than 6 hours. The average length of stay was 5.8 days for the 51-patient series (Table 2).

Discussion

Hunting remains a popular American sport and a time-honored tradition among many families. Over the years, several techniques have been developed to increase the success of game acquisition. In particular, tree stands or other elevated platforms are useful tools for pursuing large game, and are often invaluable in enabling a hunter to attain a trophy. We and others (1,6,7,10-12) have identified a large number of injuries associated with falls during the use of these elevated platforms. To provide better care to this group of patients after a fall, and to allow for safer tree stand hunting in the future, we set out to examine the precipitating causes and spectrum of injuries encountered.

We identified 51 cases of tree stand-related injuries over a 5-year period at two regional trauma centers. The combined regional population for these areas is approximately 2 million people. Notably, however, neither trauma center was the exclusive provider in its region, so the total number of injuries in these regions is likely to have been greater than the number of cases reported. Also, both regions may have had additional fatalities that may have been handled by other regional medical examiner's offices. Nonetheless, definite patterns of injury were observed. During the study period, no significant change in the incidence of annual falls was observed, indicating that this mechanism of injury continues to put recreational outdoorsmen at risk for permanent disability.

On the basis of patient histories, falls appeared to occur most commonly as a result of tree stand structural failure, slips while entering or exiting stands, and alcohol use while hunting. This is in agreement with other authors who report these contributing mechanisms. Given the large number of patients that are injured on exiting or entering the tree stands, education to prevent these injuries is required. Instruction on climbing or descending from the stand without the burden of backpacks and firearms, followed by hoisting or lowering the aforementioned items in a safe manner may decrease the incidence of injury. Education could be provided as part of the Hunter's Safety Course provided by state or county governments or as part of a prevention program at regional trauma centers. Further education is needed with the purchase of a tree stand (many tree stand instruction manuals include tips on how to enter and exit a tree stand safely). Furthermore, hunters should be encouraged to alert fellow sportsmen and/or family members as to their prospective whereabouts, to hunt in groups of at least two if possible, and to carry a cellular phone or portable two-way radio for use in emergency situations.

Once they were in the tree stands, a number of hunters fell while they were asleep or secondary to recoil from firearms. Increased use of safety strap harnesses may decrease the incidence of these types of falls. Of note, however, was one case in which a larger hunter exceeded the ability of his safety strap to support his weight and fell. In addition, use of some safety straps appeared to be associated with the development of rib fractures and pulmonary contusions. This recurring pattern of injury suggests that there may be a benefit from independent safety evaluation of these straps over a wide range of body types. One mechanism of injury involved a patient who fell from his tree stand while wearing a "belt-type" safety harness and died as a result of asphyxiation when the harness slid up around his neck.

Finally, minimizing the use of alcohol in the field would also likely contribute to a decrease in the number of tree stand-related falls, although the number of injuries associated with alcohol consumption in this review was low. On the basis of our study, the combination of a well-secured tree stand with the appropriate use of a well-designed safety strap would dramatically decrease the number of falls occurring while in the stands. Moreover, attention to the safe entry and exit of tree stands will further decrease the likelihood of falls.

Conclusion

Hunting from a tree stand remains a highly effective method of game acquisition; however, care must be taken to reduce the significant morbidity and mortality associated with the recreational use of tree stands. Proper placement of a stand in a tree that can support the stand and hunter combined, use of a safety harness of appropriate size, and avoidance of fatigue and alcohol are all recommended prevention procedures that have reduced falls and injuries. In addition, hunters should inform an individual of their location and an expected communication time-frame so that, if an injury were to occur, it would not result in significant delay and exposure, which would contribute to increased morbidity. Regional and community-wide injury prevention programs are needed in central Maryland and western New York State to educate hunters on the risks of tree stand use, the avoidance of common errors, and ways to maximize their safety and enjoyment.

It's better to keep one's mouth shut and be thought a fool than to open
it and resolve all doubt.
--Abraham Lincoln

Table 1. Reasons reported as cause of fall from tree stands

Reported reason      No. of falls   %

Structural failure        7         25
Entering or exiting       6         20
Alcohol                   5         17
Fell asleep               3         10
Rifle recoil              2          7
Error in placement        2          7
Other                     4         14
Totals                   29        100

Table 2. Demographics and categorization of injuries from tree stand
falls (n = 51) (a)

Characteristic                      Value

Age (yr)
  Average                            42.9
  Range                              22-69
Male gender (%)                     100
Average LOS (days)                    5.79
Injuries (%)
  Spine                              52
  Extremities                        40
  Abdominal viscera                   8
  Closed head injury                 24
  Pulmonary contusion/rib fracture   22
  Genitourinary tract                 4
  Exposure                           12
Fatalities                           10
EtOH use (%)                         10

(a) LOS, Length of stay: EtOH. alcohol.

Table 3. Spectrum of injuries encountered after tree stand falls
(n = 51) (a)

Types of Injuries         No.  %

Spinal column
  Compression/body Fx     12   24
  Lamina                   3    6
  Spinal process           1    2
  Burst                   13   25
  Transverse process       1    2
  Cord                     4    8
  To OR                    8   16
Thorax
  Pulmonary contusion      4    8
  PTX                      2    4
  HTX                      1    2
  Chest tube placed        3    6
  Rib Fx                   8   16
  Pneumonia                1    2
  Clav Fx                  3    6
  Sternal Fx               1    2
Head injuries
  Concussion               9   18
  ICH                      3    6
  Skull Fx                 2    4
  Facial Fx                1    2
Intra-abdominal injuries
  Spleen                   3    6
  Liver                    1    2
  Kidney                   2    4
  Retroper                 1    2
Extremity injuries
  Humerus                  1    2
  Radius/ulna              4    8
  Femur                    2    4
  Tibia/fibula             5   10
  Knee                     1    2
  Foot/ankle               4    8
  Pelvis                   2    4
  Other                    3    6
  To OR                    7   14

(a) Fx, Fracture; Sp, spinous; PTX, pneumothorax; HTX, hemothorax; Clav,
clavicular; ICH, intracranial hemorrhage; Retroper, retroperitoneal; OR,
operating room.

Accepted October 23, 2003.

References

1. Centers for Disease Control and Prevention. Tree stand-related injuries among deer hunters: Georgia, 1979-1989. MMWR Morb Mortal Wkly Rep 1989;38:697-700.

2. Kennedy RL, Grant PT, Blackwell D. Low-impact falls: Demands on a system of trauma management, prediction of outcome, and influence of comorbidities. J Trauma 2001;51:717-724.

3. Wilson S, Bin J, Sesperez J, et al. Clinical pathways: Can they be used in trauma care? An analysis of their ability to fit the patient. Injury 2001;32:525-532.

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6. Crites BM, Moorman CT III, Hardaker WT Jr. Spine injuries associated with falls from hunting tree stands. J South Orthop Assoc 1998;7:241-245.

7. Price C, Mallonee S. Hunting-related spinal cord injuries among Oklahoma residents. J Okla State Med Assoc 1994;87:270-273.

8. Brandes SB, McAninch JW. Urban free falls and patterns of renal injury: A 20-year experience with 396 cases. J Trauma 1999;47:643-650.

9. Goodacre S, Than M, Goyder EC, et al. Can the distance fallen predict serious injury after a fall from a height? J Trauma 1999;46:1055-1058.

10. Urquhart CK, Hawkins ML, Howdieshell TR, et al. Deer stands: A significant cause of injury and mortality. South Med J 1991;84:686-688.

11. Lawrence DW, Gibbs LI, Kohn MA. Spinal cord injuries in Louisiana due to falls from deer stands, 1985-1994. J La State Med Soc 1996;148:77-79.

12. Gates RL, Helmkamp JC, Wilson SL, et al. Deer stand-related trauma in West Virginia: 1994 through 1999. J Trauma 2002;53:705-708.

RELATED ARTICLE: Key Points

* Falls from hunting stands are common.

* Neurologic injury is a frequent complication of such falls.

* Alcohol use may increase the risk of such falls.

* Education is required to reduce the number of falls.

Matthew Metz, MD, Marc Kross, MD, PHD, Peter Abt, MD, Paul Bankey, MD, PHD, and Leonidas G. Koniaris, MD

From the Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY; the Department of Surgery, Washington County Hospital, Hagerstown, MD; and the DeWitt Daughtry Department of Surgery, University of Miami School of Medicine, Miami, FL.

None of the authors has any financial or proprietary interest in any aspect of this study or the conclusions made. This study received exempt status from the associated institutional review boards where the data were obtained, and all investigators completed training in protection of human subjects.

Reprint requests to Leonidas G. Koniaris, MD, DeWitt Daughtry Department of Surgery (310T), University of Miami School of Medicine, 1475 N.W. 12th Street, Miami, FL 33156. Email: [e-mail]