Ladder-Related Injuries Treated in Emergency Departments in the United States, 1990–2005

  • Anjali L. D’Souza
    Affiliations
    Center for Injury Research and Policy, Columbus Children’s Research Institute, Columbus Children’s Hospital, The Ohio State University College of Medicine, Columbus, Ohio
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  • Gary A. Smith
    Affiliations
    Center for Injury Research and Policy, Columbus Children’s Research Institute, Columbus Children’s Hospital, The Ohio State University College of Medicine, Columbus, Ohio
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  • Lara B. Trifiletti
    Correspondence
    Address correspondence and reprint requests to: Lara B. Trifiletti, PhD, Columbus Children’s Research Institute, Center for Injury Research and Policy, Assistant Professor, Department of Pediatrics, The Ohio State University College of Medicine, 700 Children’s Drive, Columbus OH 43205.
    Affiliations
    Center for Injury Research and Policy, Columbus Children’s Research Institute, Columbus Children’s Hospital, The Ohio State University College of Medicine, Columbus, Ohio
    Search for articles by this author

      Background

      Ladder use is involved in many occupational and non-occupational activities. Falls from ladders can result in serious injury and affect people of all ages. The purpose of this study was to comprehensively examine nonfatal ladder-related injuries on a national level.

      Methods

      Using the National Electronic Injury Surveillance System (NEISS) database, cases of nonfatal ladder-related injuries treated in U.S. emergency departments (EDs) from 1990 through 2005 were selected using NEISS ladder product codes. Analysis was conducted from June 2006 to August 2006.

      Results

      An estimated 2,177,888 (95% confidence interval [CI]=1,885,311–2,470,466) individuals ranging in age from 1 month to 101 years were treated in U.S. EDs for ladder-related injuries during the 16-year study period, yielding an average of 136,118 cases annually, an average of 49.5 per 100,000 people. Males predominated in ladder-related injuries (76.5%, 95% CI=75.8–77.2). Fractures were the most common type of injury (31.5%, 95% CI=30.5–32.6). The body parts most frequently injured were the legs and feet (30.4%, 95% CI=29.5–31.2). Nearly 10% of injuries resulted in hospitalization (8.5%, 95% CI=7.4–9.6) or transfer to another hospital (1.4%, 95% CI=1.1–1.8), approximately twice that of consumer product–related injuries overall. The number of ladder-related injuries increased by more than 50% from 1990 to 2005. Ladder-related injuries per 100,000 people rose almost 27% during the 16-year study period. Of the cases for which locale of injury was recorded, 97.3% occurred in non-occupational settings, such as homes and farms.

      Conclusions

      Given the 50% increase in ladder-related injuries during the study period, the relatively high likelihood of hospital admission, and the predominance of injuries in non-occupational settings, increased efforts are needed to prevent ladder-related injuries.

      Introduction

      In the United States, falls are the leading cause of unintentional nonfatal injury for all children and adults except for the 15- to 24-year-old cohort, for whom falls from heights are the third leading cause of unintentional nonfatal injury.
      Office of Statistics and Programming, National Center for Injury Prevention and Control
      Falls from ladders in occupational and non-occupational settings are a common cause of major, sometimes fatal, injuries.
      • Partridge R.A.
      • Virk A.S.
      • Antosia R.E.
      Causes and patterns of injury from ladder falls.
      Ladder-related injury data from occupational and non-occupational studies show that males aged 35 to 55 years are at highest risk for injury.
      • Partridge R.A.
      • Virk A.S.
      • Antosia R.E.
      Causes and patterns of injury from ladder falls.
      • Bjornstig U.
      • Johnsson J.
      Ladder injuries: mechanisms, injuries and consequences.
      • Driscoll T.R.
      • Mitchell R.J.
      • Hendrie A.L.
      • Healey S.H.
      • Mandryk J.A.
      • Hull B.P.
      Unintentional fatal injuries arising from unpaid work at home.
      • Faergemann C.
      • Larsen L.B.
      Non-occupational ladder and scaffold fall injuries.
      • Kent A.
      • Pearce A.
      Review of morbidity and mortality associated with falls from heights among patients presenting to a major trauma centre.
      • Tsipouras S.
      • Hendrie J.M.
      • Silvapulle M.J.
      Ladders: accidents waiting to happen.
      • Payne S.R.
      • Waller J.A.
      • Skelly J.M.
      • Gamelli R.L.
      Injuries during woodworking, home repairs, and construction.
      • O’Sullivan J.
      • Wakai A.
      • O’Sullivan R.
      • Luke C.
      • Cusack S.
      Ladder fall injuries: patterns and cost of morbidity.
      • Smith G.S.
      • Timmons R.A.
      • Lombardi D.A.
      • et al.
      Work-related ladder fall fractures: identification and diagnosis validation using narrative text.
      The general public is at risk for ladder injuries, yet receives little, if any, instruction on ladder use and safety.
      • Tsipouras S.
      • Hendrie J.M.
      • Silvapulle M.J.
      Ladders: accidents waiting to happen.
      • Cattledge G.H.
      • Schneiderman A.
      • Stanevich R.
      • Hendricks S.
      • Greenwood J.
      Nonfatal occupational fall injuries in the West Virginia construction industry.
      Non-occupational ladder-related injuries account for one half to two thirds of injuries from ladder-related falls, even though ladders may not always be necessary for the tasks being performed.
      • Partridge R.A.
      • Virk A.S.
      • Antosia R.E.
      Causes and patterns of injury from ladder falls.
      • Bjornstig U.
      • Johnsson J.
      Ladder injuries: mechanisms, injuries and consequences.
      • Diggs B.S.
      • Lenfesty B.
      • Arthur M.
      • Hedges J.R.
      • Newgard C.D.
      • Mullins R.J.
      The incidence and burden of ladder, structure, and scaffolding falls.
      Most studies show that the severity of injury increases with height of fall and age.
      • Bjornstig U.
      • Johnsson J.
      Ladder injuries: mechanisms, injuries and consequences.
      • Tsipouras S.
      • Hendrie J.M.
      • Silvapulle M.J.
      Ladders: accidents waiting to happen.
      • Diggs B.S.
      • Lenfesty B.
      • Arthur M.
      • Hedges J.R.
      • Newgard C.D.
      • Mullins R.J.
      The incidence and burden of ladder, structure, and scaffolding falls.
      • Agnew J.
      • Suruda A.J.
      Age and fatal work-related falls.
      Data from seven studies show that common types of ladder-related injuries were strains/sprains, bruises/contusions, and fractures to the upper and lower extremities.
      • Partridge R.A.
      • Virk A.S.
      • Antosia R.E.
      Causes and patterns of injury from ladder falls.
      • Bjornstig U.
      • Johnsson J.
      Ladder injuries: mechanisms, injuries and consequences.
      • Faergemann C.
      • Larsen L.B.
      Non-occupational ladder and scaffold fall injuries.
      • Tsipouras S.
      • Hendrie J.M.
      • Silvapulle M.J.
      Ladders: accidents waiting to happen.
      • O’Sullivan J.
      • Wakai A.
      • O’Sullivan R.
      • Luke C.
      • Cusack S.
      Ladder fall injuries: patterns and cost of morbidity.
      • Smith G.S.
      • Timmons R.A.
      • Lombardi D.A.
      • et al.
      Work-related ladder fall fractures: identification and diagnosis validation using narrative text.
      • Cattledge G.H.
      • Schneiderman A.
      • Stanevich R.
      • Hendricks S.
      • Greenwood J.
      Nonfatal occupational fall injuries in the West Virginia construction industry.
      The majority of published studies have assessed ladder-related injuries in small sample populations of fewer than 300. The results vary as to the most common location and type of injury.
      • Partridge R.A.
      • Virk A.S.
      • Antosia R.E.
      Causes and patterns of injury from ladder falls.
      • Bjornstig U.
      • Johnsson J.
      Ladder injuries: mechanisms, injuries and consequences.
      • Driscoll T.R.
      • Mitchell R.J.
      • Hendrie A.L.
      • Healey S.H.
      • Mandryk J.A.
      • Hull B.P.
      Unintentional fatal injuries arising from unpaid work at home.
      • Kent A.
      • Pearce A.
      Review of morbidity and mortality associated with falls from heights among patients presenting to a major trauma centre.
      • Tsipouras S.
      • Hendrie J.M.
      • Silvapulle M.J.
      Ladders: accidents waiting to happen.
      • O’Sullivan J.
      • Wakai A.
      • O’Sullivan R.
      • Luke C.
      • Cusack S.
      Ladder fall injuries: patterns and cost of morbidity.
      • Cattledge G.H.
      • Schneiderman A.
      • Stanevich R.
      • Hendricks S.
      • Greenwood J.
      Nonfatal occupational fall injuries in the West Virginia construction industry.
      • Muir L.
      • Kanwar S.
      Ladder injuries.
      • Husberg B.J.
      • Fosbroke D.E.
      • Conway G.A.
      • Mode N.A.
      Hospitalized nonfatal injuries in the Alaskan construction industry.
      • Salazar M.K.
      • Keifer M.
      • Negrete M.
      • Estrada F.
      • Synder K.
      Occupational risk among orchard workers: a descriptive study.
      Ladder-related injuries, especially fractures, lead to costly medical expenses and worker compensation claims.
      • Driscoll T.R.
      • Mitchell R.J.
      • Hendrie A.L.
      • Healey S.H.
      • Mandryk J.A.
      • Hull B.P.
      Unintentional fatal injuries arising from unpaid work at home.
      • Hofmann J.
      • Snyder K.
      • Keifer M.
      A descriptive study of workers’ compensation claims in Washington State orchards.
      • Hayward G.
      Risk of injury per hour of exposure to consumer products.
      Lost productivity from work and school is important as well, especially because the majority of those injured are men and women who represent a cross-section of the U.S. labor force, that is, individuals aged 16 and older.
      • Bjornstig U.
      • Johnsson J.
      Ladder injuries: mechanisms, injuries and consequences.
      • Driscoll T.R.
      • Mitchell R.J.
      • Hendrie A.L.
      • Healey S.H.
      • Mandryk J.A.
      • Hull B.P.
      Unintentional fatal injuries arising from unpaid work at home.
      • Faergemann C.
      • Larsen L.B.
      Non-occupational ladder and scaffold fall injuries.
      • Kent A.
      • Pearce A.
      Review of morbidity and mortality associated with falls from heights among patients presenting to a major trauma centre.
      • Tsipouras S.
      • Hendrie J.M.
      • Silvapulle M.J.
      Ladders: accidents waiting to happen.
      • Payne S.R.
      • Waller J.A.
      • Skelly J.M.
      • Gamelli R.L.
      Injuries during woodworking, home repairs, and construction.
      • Hayward G.
      Risk of injury per hour of exposure to consumer products.

      Clark SL, Weismantle M. Employment status: 2000. Washington DC: U.S. Census Bureau, 2003:1-12. Available at: www.census.gov/prod/2003pubs/c2kbr-18.pdf.

      Due to the prevalence, cost, and severity of ladder-related injuries, the objective of this research was to determine national patterns of ladder-related injuries for people of all ages treated in emergency departments (EDs) between January 1, 1990 and December 31, 2005. To our knowledge, this is the first U.S. study to use national data to comprehensively examine nonfatal ladder-related injuries by demographics, type of injury, body part affected, and disposition from the ED.

      Methods

      Data were obtained through the National Electronic Injury Surveillance System (NEISS), which is operated by the U.S. Consumer Product Safety Commission (CPSC). The CPSC provides data on consumer product–related and sports activity-related injuries treated in U.S. EDs. The NEISS receives data from a network of 98 hospitals, representing a stratified probability sample of 6100 hospitals in the U.S. and its territories with at least six or more beds and a 24-hour ED.
      U.S. Consumer Product Safety Commission
      The network includes urban, suburban, rural, and children’s hospitals.
      • Schroeder T.
      • Ault K.
      Data incorporated into NEISS are weighted to produce national estimates for consumer product–related injuries to specific products treated in individual hospitals.
      • Schroeder T.
      • Ault K.
      Established in 1972, the NEISS sampling frame was revised in 1978, 1990, and 1997. At all 98 hospitals, ED medical records are viewed by professional NEISS coders, and data regarding patient age, gender, race, injury diagnosis, body part injured, product(s) involved, treatment received, and a brief narrative describing the incident are recorded. Analysis was conducted from June 2006 to August 2006.
      After reviewing all NEISS data narratives identified by ladder codes for straight or extension, step, and other/not specified ladders (product codes 4077, 0618, and 4078, respectively), cases describing patients treated for “carrying,” “hitting,” “bumping,” “tripping over,” or “being hit by” ladders were excluded. The estimates for this study were based on weighted data for 55,077 patients treated for injuries in EDs between January 1, 1990 and December 31, 2005 from “climbing on,” “slipping on,” “jumping off,” “stepping off,” or “falling off” ladders.
      Data were analyzed using SPSS, version 14.0 (SPSS Inc., Chicago IL, 2003). The sample weight assigned to each case was based on the inverse probability of selection. Computation of relative risks (RRs) with 95% confidence intervals (CIs) was performed. All data reported in this article are national estimates unless otherwise specified.

      Results

      From 1990 to 2005, an estimated 2,177,888 people (95% CI=1,885,311–2,470,466) were treated in EDs for unintentional ladder-related injuries, 76.5% of which were men (1,666,311 cases, 95% CI=1,443,303–1,889,317) (Table 1). Age range was 1 month to 101 years with a mean age of 45.6 years and a median age of 44.0 years. Injury rates were highest for the 36- to 45-year-old group (493,358 cases, 95% CI=425,021–561,693) (Figure 1). The estimated number of patients treated for ladder-related injuries showed an overall increase from 107,477 (95% CI=80,425–134,530) in 1990 to 161,940 (95% CI=123,028–200,852) in 2005, representing a 50.7% increase during the 16-year study period. Of the 1,457,723 cases (66.9% of the total) for which location was recorded, 97.3% of ladder-related injuries occurred at home (1,418,250 cases, 95% CI=1,188,103–1,648,397).
      Table 1Nonfatal unintentional ladder-related injuries treated in U.S. emergency departments, 1990–2005
      CharacteristicCases (n)Weighted estimate (%)95% confidence interval
      Age (years)
      Numbers do not total to 100.0% due to rounding.
       <182,835107,484 (4.9)92,864–122,104
       18–253,728159,329 (7.3)136,017–182,642
       26–358,913386,183 (17.7)332,399–439,967
       36–4511,502493,357 (22.7)425,021–561,693
       46–559,200393,258 (18.1)336,270–450,246
       56–656,684296,152 (13.6)255,008–337,296
       66–754,937232,116 (10.7)195,379–268,852
       ≥762,278110,010 (5.1)90,447–129,573
      Gender
       Male38,6381,666,311 (76.5)1,443,303–1,889,318
       Female11,429511,269 (23.5)439,324–583,214
       Not recorded
      Estimates may be unstable because they are based on <20 cases or the coefficient of variation >30%.
      10309 (<1)45–574
      Race/ethnicity
       White15,742679,990 (31.2)489,908–870,071
       Black1,94564,346 (3.0)35,084–93,607
       Other1,50754,418 (2.5)32,178–76,657
       Not stated/missing30,8831,379,135 (63.3)1,198,966–1,559,306
      Diagnosis
       Contusions/abrasions11,369501,385 (23.0)434,261–568,509
       Fractures15,805686,594 (31.5)593,923–779,265
       Strains/sprains11,470506,924 (23.3)430,598–583,249
       Lacerations/avulsions4,810219,222 (10.1)190,758–247,686
       Dislocations1,07346,095 (2.1)38,443–53,748
       Concussions63725,781 (1.2)19,742–31,821
       Other
      Includes hematoma, puncture, hemorrhage, crushing, not stated, and other unspecified.
      4,913191,888 (8.8)152,229–231,547
      Body part affected
       Upper trunk
      Including shoulders and neck.
      9,758433,654 (19.9)371,991–495,318
       Arm
      Upper and lower arm including elbow, wrist, hand, and finger.
      10,571473,344 (21.7)409,572–537,115
       Leg
      Upper and lower leg including knee, ankle, foot, and toe.
      14,869661,346 (30.4)570,683–752,009
       Head/face6,060241,890 (11.1)207,892–275,887
       Lower trunk7,881331,179 (15.2)279,451–382,908
       Other
      Includes pubic region, 25% to 50% of body, all parts of body, and not stated.
      93836,476 (1.7)28,734–44,217
      Disposition
      Numbers do not total to 100.0% due to rounding.
       Treated/released44,2511,946,861 (89.4)1,678,704–2,215,018
       Treated/transferred51231,203 (1.4)24,913–37,493
       Hospitalized4,996185,885 (8.5)152,620–219,151
       Other
      Includes held for observation, left without being seen/against advice, fatality, and not recorded.
      /unknown
      31813,940 (0.6)10,661–17,219
      Location of event
       Home/farm31,1201,418,250 (65.1)1,188,103–1,648,397
       Other
      Includes street/highway, other public property, industrial, school, and recreational facility.
      92539,473 (1.8)32,936–46,009
       Not recorded18,032720,166 (33.1)573,452–866,880
      a Numbers do not total to 100.0% due to rounding.
      b Estimates may be unstable because they are based on <20 cases or the coefficient of variation >30%.
      c Includes hematoma, puncture, hemorrhage, crushing, not stated, and other unspecified.
      d Including shoulders and neck.
      e Upper and lower arm including elbow, wrist, hand, and finger.
      f Upper and lower leg including knee, ankle, foot, and toe.
      g Includes pubic region, 25% to 50% of body, all parts of body, and not stated.
      h Includes held for observation, left without being seen/against advice, fatality, and not recorded.
      i Includes street/highway, other public property, industrial, school, and recreational facility.
      Figure thumbnail gr1
      Figure 1Age and gender distributions of individuals treated for ladder-related injuries in U.S. emergency departments, 1990–2005.
      Fractures were the most common injury type for all age groups except the 18-to-25 and 26-to-35 age groups (686,595 cases [31.5%], 95% CI=593,923–779,265), among which sprains and strains were the most common. Fractures were the most common injury to the arms/hands (52.9%, 250,380 of 473,343 cases) and the arms/hands were the most commonly fractured body parts (36.5%, 250,380 of 686,594 cases). Of all leg injuries, strains and sprains were the most common (37.6%, 248,561 of 661,346 cases). Of all strains and sprains, injuries to the legs/feet were the most common (49.0%, 248,561 of 506,923 cases). The legs/feet sustained the highest percentage of total injuries (661,346 cases [30.4%], 95% CI=570,683–752,009). Strains and sprains were the most common injury to the lower trunk (35.5%, 117,646 of 331,180 cases). Contusions/abrasions were the most common injury to the upper trunk (including shoulders and neck) (36.2%, 156,876 of 433,654 cases, RR=1.83, 95% CI=1.74–1.92). Lacerations/avulsions were 6.48 times more likely to occur (95% CI=5.95–7.05) if an injury was to the head/face.
      Most injured patients (1,946,861 cases [89.4%], 95% CI=1,678,704–2,215,018) were treated and released from the ED. Patients who were hospitalized or transferred to another hospital comprised 9.9% of cases (217,088 cases, 95% CI=177,532–256,643). Hospitalization rates showed an overall increase with increasing age. Patients in the ≥76 age group were 2.69 times more likely (95% CI=2.40–3.01) to be admitted for hospitalization than patients in all other age groups. The highest percentages of hospitalization were for the legs/feet (28.2%, 52,469 of 185,885 cases) and lower trunk (23.4%, 43,495 of 185,885 cases). Admission rates were highest for fractures (RR=5.73, 95% CI=5.01–6.56), concussions (RR=2.24, 95% CI=1.80–2.77), and lower-trunk injuries (RR=1.70, 95% CI=1.51–1.93).
      When NEISS data narratives included information about the height of fall or the height of the ladder, that height was recorded and used to calculate an association between hospital admission and fall height. Although much of the data concerning the height of fall was missing (76.8%), the available data show that hospital admission rates increase with increasing fall height. Admission rates are 2.3 times higher (95% CI=1.92–2.82) when patients fall from heights ≥6.10 m compared with patients who fall from heights less than 6.10 m above the ground. Similarly, admission rates increase for patients who fall from heights ≥7.62 m and higher compared with those who fall from heights <7.62 m (RR=2.97, 95% CI=2.15–4.09). Fractures are the leading type of injury resulting from a fall, slip, or jump from any height from a ladder. However, there is higher risk associated with increased height. There is no increased risk associated with patients who fall from heights ≥1.52 m as compared with patients who fall from heights <1.52 m.

      Discussion

      This study is the first to examine ladder-related injuries treated in U.S. EDs on a national level. Consistent with other studies, injuries due to falls from ladders most often occur to men. The low proportion of injuries among women (23.5%, CI=22.7–24.2) was unexpected, because do-it-yourself home renovations are popular among women.
      • Kent A.
      • Pearce A.
      Review of morbidity and mortality associated with falls from heights among patients presenting to a major trauma centre.
      Two possible explanations follow: (1) men are involved in more ladder-related activities than women, and (2) men may be more susceptible to ladder-related injuries given similar exposure to ladder use as women.
      • Driscoll T.R.
      • Mitchell R.J.
      • Hendrie A.L.
      • Healey S.H.
      • Mandryk J.A.
      • Hull B.P.
      Unintentional fatal injuries arising from unpaid work at home.
      Individuals using ladders are often not mindful of the severe risks associated with use, whether in occupational or non-occupational settings.
      • Hammer W.
      • Schmalz U.
      Human behaviour when climbing ladders with varying inclinations.
      Most ladder injuries result from improper ladder positioning or support, overextension by the user causing imbalance, or slipping of the base of the ladder on the ground.
      • Partridge R.A.
      • Virk A.S.
      • Antosia R.E.
      Causes and patterns of injury from ladder falls.
      • Tsipouras S.
      • Hendrie J.M.
      • Silvapulle M.J.
      Ladders: accidents waiting to happen.
      • Cattledge G.H.
      • Schneiderman A.
      • Stanevich R.
      • Hendricks S.
      • Greenwood J.
      Nonfatal occupational fall injuries in the West Virginia construction industry.
      • Salazar M.K.
      • Keifer M.
      • Negrete M.
      • Estrada F.
      • Synder K.
      Occupational risk among orchard workers: a descriptive study.
      • Hofmann J.
      • Snyder K.
      • Keifer M.
      A descriptive study of workers’ compensation claims in Washington State orchards.
      Ladder injuries also result from defective equipment, such as broken rungs or when a person slips or loses balance.
      • Partridge R.A.
      • Virk A.S.
      • Antosia R.E.
      Causes and patterns of injury from ladder falls.
      • Cattledge G.H.
      • Schneiderman A.
      • Stanevich R.
      • Hendricks S.
      • Greenwood J.
      Nonfatal occupational fall injuries in the West Virginia construction industry.
      Many patients (65.1%, 95% CI=59.8–70.4) in this study were injured in non-occupational settings. Workers may have the benefit of protection and training from organizations like the Occupational Safety and Health Administration (OSHA),
      • Partridge R.A.
      • Virk A.S.
      • Antosia R.E.
      Causes and patterns of injury from ladder falls.
      although the extent to which safety training is followed or enforced is unknown.
      Men and women aged 36 to 45 sustained the greatest numbers of ladder injuries in this study with a mean age of 45.6 years. Previous studies that assessed both non-occupational and occupational ladder-related injuries showed that the mean age range was significantly higher for non-occupational injuries (46.5 to 59.0 years)
      • Faergemann C.
      • Larsen L.B.
      Non-occupational ladder and scaffold fall injuries.
      • Kent A.
      • Pearce A.
      Review of morbidity and mortality associated with falls from heights among patients presenting to a major trauma centre.
      • Tsipouras S.
      • Hendrie J.M.
      • Silvapulle M.J.
      Ladders: accidents waiting to happen.
      • Payne S.R.
      • Waller J.A.
      • Skelly J.M.
      • Gamelli R.L.
      Injuries during woodworking, home repairs, and construction.
      • O’Sullivan J.
      • Wakai A.
      • O’Sullivan R.
      • Luke C.
      • Cusack S.
      Ladder fall injuries: patterns and cost of morbidity.
      • Muir L.
      • Kanwar S.
      Ladder injuries.
      versus a range of 36 to 43 years for occupational injuries.
      • Bjornstig U.
      • Johnsson J.
      Ladder injuries: mechanisms, injuries and consequences.
      • Kent A.
      • Pearce A.
      Review of morbidity and mortality associated with falls from heights among patients presenting to a major trauma centre.
      • Tsipouras S.
      • Hendrie J.M.
      • Silvapulle M.J.
      Ladders: accidents waiting to happen.
      • O’Sullivan J.
      • Wakai A.
      • O’Sullivan R.
      • Luke C.
      • Cusack S.
      Ladder fall injuries: patterns and cost of morbidity.
      • Cattledge G.H.
      • Schneiderman A.
      • Stanevich R.
      • Hendricks S.
      • Greenwood J.
      Nonfatal occupational fall injuries in the West Virginia construction industry.
      • Muir L.
      • Kanwar S.
      Ladder injuries.
      • Salazar M.K.
      • Keifer M.
      • Negrete M.
      • Estrada F.
      • Synder K.
      Occupational risk among orchard workers: a descriptive study.
      Ladder-related injuries are associated with long periods of hospitalization (mean 18.4 days),
      • Hayward G.
      Risk of injury per hour of exposure to consumer products.
      with longer hospital stays when injuries occur at home.
      • Kent A.
      • Pearce A.
      Review of morbidity and mortality associated with falls from heights among patients presenting to a major trauma centre.
      In this study, almost 10% of ladder injuries resulted in hospitalization (8.5%) and transfer to another hospital (1.4%). The admission rate is approximately twice that of consumer product–related injuries overall, indicating the relatively high severity of these injuries. Ladder-related injury severity has been shown to increase with age.
      • Smith G.S.
      • Timmons R.A.
      • Lombardi D.A.
      • et al.
      Work-related ladder fall fractures: identification and diagnosis validation using narrative text.
      • Diggs B.S.
      • Lenfesty B.
      • Arthur M.
      • Hedges J.R.
      • Newgard C.D.
      • Mullins R.J.
      The incidence and burden of ladder, structure, and scaffolding falls.
      In this study, the 36-to-45 age group received the greatest number of injuries, but hospital admission rates were highest for adults aged 56 and older (RR=2.57, 95% CI=2.37–2.79). These results agree with those of Diggs et al.,
      • Diggs B.S.
      • Lenfesty B.
      • Arthur M.
      • Hedges J.R.
      • Newgard C.D.
      • Mullins R.J.
      The incidence and burden of ladder, structure, and scaffolding falls.
      who found marked increases in hospitalization rates among patients aged 56 and older, who fell off ladders.
      Consistent with other published studies, fractures, strains/sprains, and contusions/abrasions were the three most common types of ladder-related injury.
      • Partridge R.A.
      • Virk A.S.
      • Antosia R.E.
      Causes and patterns of injury from ladder falls.
      • Bjornstig U.
      • Johnsson J.
      Ladder injuries: mechanisms, injuries and consequences.
      • Faergemann C.
      • Larsen L.B.
      Non-occupational ladder and scaffold fall injuries.
      • Tsipouras S.
      • Hendrie J.M.
      • Silvapulle M.J.
      Ladders: accidents waiting to happen.
      • O’Sullivan J.
      • Wakai A.
      • O’Sullivan R.
      • Luke C.
      • Cusack S.
      Ladder fall injuries: patterns and cost of morbidity.
      • Smith G.S.
      • Timmons R.A.
      • Lombardi D.A.
      • et al.
      Work-related ladder fall fractures: identification and diagnosis validation using narrative text.
      • Cattledge G.H.
      • Schneiderman A.
      • Stanevich R.
      • Hendricks S.
      • Greenwood J.
      Nonfatal occupational fall injuries in the West Virginia construction industry.
      In the current study, men and women sustained different types of injuries at roughly the same rates.
      • Smith G.S.
      • Timmons R.A.
      • Lombardi D.A.
      • et al.
      Work-related ladder fall fractures: identification and diagnosis validation using narrative text.
      Not only were fractures the most common injury in this study, but they were 5.7 times more likely to result in hospital admission (95% CI=5.01–6.56). Hospital admission and fracture injuries increase with increasing age. Fracture cases generally result in higher medical costs and more disability days than other ladder-related injury cases.
      • Driscoll T.R.
      • Mitchell R.J.
      • Hendrie A.L.
      • Healey S.H.
      • Mandryk J.A.
      • Hull B.P.
      Unintentional fatal injuries arising from unpaid work at home.
      • Smith G.S.
      • Timmons R.A.
      • Lombardi D.A.
      • et al.
      Work-related ladder fall fractures: identification and diagnosis validation using narrative text.
      • Hofmann J.
      • Snyder K.
      • Keifer M.
      A descriptive study of workers’ compensation claims in Washington State orchards.
      When compared with 76 other consumer products, ladders were among the top five with the highest total annual medical cost per adult due to injuries.
      • Hayward G.
      Risk of injury per hour of exposure to consumer products.
      The high proportion of injuries to the legs/feet and arms/hands in this study are similar to findings of other ladder-related injury studies.
      • Partridge R.A.
      • Virk A.S.
      • Antosia R.E.
      Causes and patterns of injury from ladder falls.
      • Bjornstig U.
      • Johnsson J.
      Ladder injuries: mechanisms, injuries and consequences.
      • Faergemann C.
      • Larsen L.B.
      Non-occupational ladder and scaffold fall injuries.
      • Tsipouras S.
      • Hendrie J.M.
      • Silvapulle M.J.
      Ladders: accidents waiting to happen.
      • O’Sullivan J.
      • Wakai A.
      • O’Sullivan R.
      • Luke C.
      • Cusack S.
      Ladder fall injuries: patterns and cost of morbidity.
      • Smith G.S.
      • Timmons R.A.
      • Lombardi D.A.
      • et al.
      Work-related ladder fall fractures: identification and diagnosis validation using narrative text.
      Strains/sprains were twice as likely to be injuries to the legs/feet (95% CI=2.05–2.38), while fractures were twice as likely to be injuries to the arms/hands (95% CI=1.98–2.16). Many of the ladder-related injuries to the legs/feet were most likely caused by jumping from ladders or by stepping off incorrectly or slipping off rungs. Attempts to break a fall with outstretched arms probably account for fractures to the arms/hands.
      Although more than three fourths of data concerning the height of fall was missing, the available data show that hospital admission rates increase with increasing height. These results disagree with those from another U.S. study that found no association between height of fall and outcome of fracture injury or hospital admission, but concur with findings of studies from Australia and Sweden.
      • Partridge R.A.
      • Virk A.S.
      • Antosia R.E.
      Causes and patterns of injury from ladder falls.
      • Bjornstig U.
      • Johnsson J.
      Ladder injuries: mechanisms, injuries and consequences.
      • Tsipouras S.
      • Hendrie J.M.
      • Silvapulle M.J.
      Ladders: accidents waiting to happen.
      This study did not find any seasonal injury patterns. However, ladder injuries increased by more than 50% during the 16-year study period. According to U.S. Census Bureau statistics, the U.S. population increased by almost 20% from 1990 to 2005.

      U.S. Census Bureau. National intercensal estimates, 1990–2000. Available at: www.census.gov/popest/archives/EST90INTERCENSAL/US-EST90INT-04.html.

      U.S. Census Bureau. National and state population estimates. Annual population estimates 2000 to 2005. annual estimates of the population for the United States and States, and for Puerto Rico: April 1, 2000 to July 1, 2005 (NST-EST2005-01). Available at: www.census.gov/popest/states/NST-ann-est.html.

      Ladder-related injuries per 100,000 people rose almost 27% during the 16-year study period. With one exception, previous studies have not examined secular trends in ladder-related injuries because sample sizes were small or the study was limited to a short period of time (i.e., 1 year). An Australian study showed that ladder-related injuries, especially ladder-associated falls at home, increased from 2000 to 2003.
      • Kent A.
      • Pearce A.
      Review of morbidity and mortality associated with falls from heights among patients presenting to a major trauma centre.
      The reason for the increasing annual number of injuries is unknown. It may be due to increased ladder use reflected by growing interest in home improvement and do-it-yourself television shows, changes in ladder characteristics, changes in how and where ladders are used, or changes in the characteristics of those who use ladders.
      This study has several limitations. It is likely that the number of injuries was underestimated; the actual number of ladder-related injuries may be greater than the number reported in this study, because only injuries treated in EDs are included.
      • Quinlan K.P.
      • Thompson M.P.
      • Annest J.L.
      • et al.
      Expanding the National Electronic Injury Surveillance System to monitor all nonfatal injuries treated in U.S. hospital emergency departments.
      The findings of this study may not be representative of those for ladder-related injuries treated in other healthcare facilities, or those that did not receive medical treatment. Data reported to the NEISS are limited by the detail provided in the ED medical record. Missing data and inconsistent documentation in the medical record may also occur. The narrative portion of the NEISS database frequently lacks detail about the height of the fall, the surface on which the patient landed, the type of work/activity being performed, the type of ladder being used, other factors that may have contributed to the injury event, and injury severity. This level of detail, if included, might be useful for prevention efforts. Despite these limitations, the strength of this study is its large, nationally representative sample size over a 16-year study period.
      Increased public health initiatives that target men and women, especially of working age, could help reduce the number of ladder-related injuries. Currently, the U.S. CPSC and the National Ag Safety Database website, sponsored by the National Institute of Occupational Safety and Health and OSHA, publish tips for safe ladder use. In an educational pamphlet that specifies ladder safety techniques, OSHA recommendations include that ladders be used only on level surfaces, that objects under and around ladders be removed, that ladders should not be moved while in use, and that heavy loads should not be carried while on ladders.
      U.S. Occupational Safety and Health Administration
      People using ladders should pitch them at a 75-degree angle.
      U.S. Occupational Safety and Health Administration
      Having another person secure the ladder by holding it may also prevent injuries. The September 2006 issue of Consumer Reports magazine rated ladders based on strength, ease of use, tipping/swaying, and walking with the ladder.

      Consumer Reports. Ladders: some can extend your risk. Consumer Reports 2006:42–4.

      Consumer Reports recommends that users test ladders before buying, and that they consider the material of the ladder (e.g., do not use a metal ladder near sources of electricity) before use.

      Consumer Reports. Ladders: some can extend your risk. Consumer Reports 2006:42–4.

      Ladders should not be used if broken, defective, or susceptible to damage due to age of the product. (Table 2).
      Table 2Ladder-related injuries per 100,000 people treated in U.S. emergency departments, 1990–2005
      YearEstimated cases (n)U.S. populationCases per 100,000 people
      1990107,477249,622,81443.06
      1991115,594252,980,94145.69
      1992119,309256,514,22446.51
      1993119,090259,918,58845.82
      1994119,232263,125,82145.31
      1995116,868266,278,39343.89
      1996126,041269,394,28446.79
      1997129,020272,646,92547.32
      1998141,682275,854,10451.36
      1999145,441279,040,16852.12
      2000145,446282,193,47751.54
      2001158,634285,107,92355.64
      2002146,179287,984,79950.76
      2003158,496290,850,00554.49
      2004167,441293,656,84257.02
      2005161,940296,410,40454.63
      Source: U.S. Census data, 1990–2005.
      The authors wish to thank The Samuel J. Roessler Memorial Medical Scholarship Fund for financial stipend support for ALD while conducting this study. The authors appreciate the helpful comments and suggestions from Brenda Shields, MS, Center for Injury Research and Policy, and Sarah K. Fields, JD, PhD, School of Physical Activity and Educational Services, The Ohio State University.
      No financial conflict of interest was reported by the authors of this paper.

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