Traumatic brain injuries in people falling from trees in Ziguinchor: a pathology in a rural area of a developing country

Abstract

Background

Traumatic brain injury (TBI) in people falling from trees is a condition rarely reported in the literature and is often observed in rural areas of developing countries such as Senegal. Ziguinchor, a heavily forested and agricultural region, experiences seasonal fruit harvesting activities that expose populations to the risk of falling from trees. The aim of our study was to highlight the epidemiological, diagnostic, therapeutic, evolutionary, and prognostic aspects of this pathology in Ziguinchor over a period of 3 years and 8 months, with the goal of identifying preventive measures.

Materials and methods

This was a cross-sectional retrospective, descriptive, and analytical study conducted from April 1, 2019, to December 31, 2022. The study included complete records of patients admitted for TBI due to falling from trees at the neurosurgery unit of Ziguinchor Regional Hospital. Morbidity refers to all the subsequent effects of trauma, often described as functional sequelae.

Results

Among 83 patients, 72 were male, with an average age of 17.7 ± 13.1 years. There was a statistically significant correlation between season (quarter) and the type of tree involved (P = 0.012). The average fall height was 4 ± 2.9 m. Most patients (77.6%) had a Glasgow Coma Scale (GCS) Score ≥ 13. There was a significant relationship between fall height and the presence of scalp wounds (P = 0.023). The average hospital stay was 7.5 ± 6.3 days (range: 1–30 days). The mortality rate was 8.4%, and the morbidity rate was 12%.

Conclusion

Climbing trees remains a hazardous activity, as it can lead to falls, causing injuries such as traumatic brain injuries. Educational programs should focus on safe practices for fruit and leaf harvesting to prevent injuries associated with these activities.

Background

Climbing trees is a common activity in rural areas of developing countries. Some of these trees are very tall, and falls from such heights can result in severe or even fatal injuries [4, 13, 17]. The brain is among the most frequently affected organs [6]. However, studies addressing traumatic brain injuries (TBIs) in people who fall from trees are rare [1, 11]. Such injuries are likely specific to forested areas where the climate favours the growth of fruit trees and where socioeconomic conditions compel people to climb in search of fruits [8]. Ziguinchor is a wooded region with extensive agricultural activity, where nearly every household has fruit trees. Seasonal fruit-picking activities are carried out annually, exposing the population to the risk of falling from trees. The objective of this study was to highlight the epidemiological, diagnostic, therapeutic, evolutionary, and prognostic aspects of TBIs caused by falling from trees at the neurosurgery unit of Ziguinchor Regional Hospital to propose preventive measures.

Materials and methods

This was a cross-sectional, retrospective, descriptive, and analytical study conducted from April 1, 2019, to December 31, 2022. All patients admitted for TBIs among people who fell from trees were included in the study. Patients with incomplete medical records or who were lost to follow-up were excluded. Data were collected via a preestablished form and entered into Microsoft Excel 2016. The data analysis was performed via SPSS (Statistical Package for Social Sciences).

The descriptive study involved calculating frequencies and proportions for qualitative variables, as well as means and standard deviations for quantitative variables.

The analytical study was based on cross-tabulations. To compare frequencies, Pearson’s chi-square test was used, while mean comparisons were performed via analysis of variance, with a significance threshold of p < 0.05. Consciousness levels were assessed via the GCS Score.

A patient was considered polytraumatized if they presented fractures in at least two long bones, an injury associated with at least one other trauma that could result in immediate death, or a severe TBI associated with at least one other lesion [16].

Transportation by family members (taxi) refers to car transportation where the fare is determined on the basis of the distance travelled.

Morbidity refers to all the subsequent effects of trauma, often described as functional sequelae. These effects are mainly harmful and long-lasting.

Results

During this period, 83 patients were recorded, out of a total of 728 TBIs, representing a frequency of 11.40%. The average age was 17.7 ± 13.1 years (range: 6–59 years), with the ≤ 10 years age group being the most represented (43.4%). Pupils were the most affected group (59%), and the male-to-female ratio was 7 (72 males to 11 females). One patient was known to have epilepsy, and another had previously fallen from a tree. Only two patients wore safety belts during the incident. The average time to hospital admission was 17.7 ± 37.3 h (range: 1 h to 8 days). There was a statistically significant correlation between the season (quarter) and the type of tree involved (P = 0.012). The mango trees (Fig. 1) were the most common, accounting for 60.2% of the cases, especially during the second quarter (April to June), which represented 71.7% of the incidents (Fig. 2). The average fall height was 4 ± 2.9 m, and the type of tree was significantly associated with the fall height (P < 0.05). Most falls occurred at home (53%), with fruit picking being the primary reason for climbing (73.5%). Broken branches were the main cause of falls (31.3%). The majority of patients (68.7%) were transported by nonmedical ambulances (Table 1).

Fig. 1.

A mango tree

Fig. 2.

Annual distribution of traumatic brain injuries caused by falling from trees

Table 1.

Outlines the epidemiological and demographic aspects of TBIs caused by tree falls

Age (years)	Average Age												17.7 ± 13.1 years
	Age group				≤ 10 years								43.4%
					11 to 20 years								27.7%
					21 to 30 years								12.0%
					31 to 40 years								8.4%
					41 to 50 years								4.8%
					> 50 years								3.6%
Gender	Male = 72(86.7%)										Female = 11(13.3%)
Education level/occupation			Type								Number (%)
			Pupil								49(59)
			Student								2(2.4)
			Farmer								14(16.9)
			Breeder								4(4.8)
			Unenrolled child								12(14.5)
			Mason								1(1.2)
			Unemployed								1(1.2)
Average admission delay											17.7 ± 37.3 h (1 h to 8 days)
Type of tree	Periode of fall from a tree													Total		P
	1st quarter			2nd quarter			3rd quarter			4th quarter
	n	%		n		%	n	%		n		%		n	%
Baobab	3	16.7		1		2.2	0	0.0		2		20.0		6	7.2	0.012
Mango tree	10	55.6		33		71.7	5	55.6		2		20.0		50	60.2
Not specified	1	5.6		8		17.4	0	0.0		1		10.0		10	12.0
Palm tree	3	16.7		1		2.2	3	33.3		3		30.0		10	12.0
Ron palm	1	5.6		3		6.5	1	11.1		2		20.0		7	8.4
Total	18	100		46		100.0	9	100.0		10		100.0		83	100.0
Average fall height (meters) = 4 ± 2.9 (1–15 m)
Type of tree	Height of fall						Total			P
	≤ 4 m			> 4 m
	n	%		n		%	n		%
Baobab	0	0.0		4		16.7	4		5.3	P < 0.05
Mango tree	39	75.0		8		33.3	47		61.8
Not specified	9	17.3		1		4.2	10		13.2
Palm tree	2	3.8		6		25.0	8		10.5
Ron palm	2	3.8		5		20.8	7		9.2
Total	52	100.0		24		100.0	76		100.0
Reasons for climbing	Type								Number (%)
	Fruit picking Leaf picking Cutting wood Not specified								61(73.5) 3(3.6) 6(7.2) 13(15.7)
Cause of fall	Slippage Branch breackage Belt rupture Not specified								18(21.7) 26(31.3) 2(2.4) 43(51.8)
Fall location	Home School Forest Not specified								44(53) 7(8.4) 27(32.5) 5(6)
Mode of transportation	Family members/Taxi 26(31.3%) Nonmedicalized ambulance 57(68.7%)

Initial loss of consciousness was the most common clinical manifestation (83.1%), followed by posttraumatic headaches (53%). Most patients (80.7%) had cephalic extremity injuries, and there was a statistically significant association between fall height and scalp wounds (P = 0.023). The majority (77.6%) had a GCS score ≥ 13. However, there was no correlation between fall height and GCS score (P = 0.930). Neurological deficits were observed in 21 (25.3%) patients. On CT scans, simple, nondisplaced skull fractures were the most common injuries (36.1%). Half of the patients (42 patients; 50.6%) experienced multiple traumatic events. Prehospital care was provided to 58 patients (69.9%), while 30 patients (36.1%) underwent surgery. The average hospital stay was 7.5 ± 6.3 days (range: 1–30 days). Mortality was recorded in 7 patients (8.4%), and morbidity affected 12% of the patients (Table 2).

Fig. 3.

a left fronto-temporo-parietal extradural hematoma in a 12-year-old boy. b fracture of right parietal ligament (blue arrow) with contusion opposite (yellow arrow) in 10-year-old boy. c right fronto-orbital fracture (yellow arrow) in a 09-year-old boy

Table 2.

Summarizes the clinical, paraclinical, therapeutic, and evolutionary aspects

	Clinical signs							Nombre (%)
Post-traumatic events	Initial loss of consciousness							69(83.1)
	Post-traumatic headaches							44(53)
	Vomiting							33(39.8)
	Seizure							6(7.2)
Laceration of the head and face	Height of fall				Total		P
	≤ 4 m		> 4 m
	n	%	n	%	n	%
Scalp wound	7	70.0	7	12.3	14	20.9	0.023
Dermabrasion	1	10.0	12	21.1	13	19.4	0.692
Subcutaneous hematoma of the scalp	2	20.0	15	26.3	17	25.4	0.920
Nosebleed	0	0.0	8	14.0	8	11.9	0.071
Ear bleeding	0	0.0	2	3.5	2	3.0	0.542
Eyelid edema	0	0.0	3	5.3	3	4.5	0.787
Periorbital bruise	0	0.0	9	15.8	9	13.4	0.449
Skull depression	0	0.0	1	1.8	1	1.5	0.763
Total	10	100.0	57	100.0	67	100.0
Glasgow Coma Scale/Height of fall from a tree
Glasgow Coma Scale	Height of fall from a tree				Total		P
	≤ 4 m		> 4 m
	n	%	n	%	n	%
≤ 8	3	5.8	1	4.2	4	5.3	0.930
9–12	8	15.4	5	20.8	13	17.1
≥ 13	41	78.8	18	75.0	59	77.6
Total	52	100.0	24	100.0	76	100.0
Neurological deficit (n = 21)	Type				Number (%)
	Facial paralysis Hemiparesis Paraplegia Tetraplegia Brachial monoparesis				1(1.2) 2(2.4) 12(16.9) 3(3.6) 3(3.6)
Cerebral CT scan results	Type of lesion				Number (%)
	A simple nondisplaced skull fracture (Fig. 3a) Depressed skull fracture Maxillary and mandibular bone fracture Hemosinus Pneumocephalus Cerebral contusion Petechiae Epidural hematoma (Fig. 3b) acute minimal subdural hematoma Post-traumatic meningeal hemorrhage Cranio-cerebral injury (Fig. 3c)				30(36.1) 7(8.4) 4(4.8) 4(4.8) 2(2.4) 24(28.9) 4(4.8) 14(16.9) 9(10.8) 2(2.4) 1(1.2)
Associated injuries	Limb injuries (n = 20)		Forearm = 5		20(24.1)
			Shoulder = 5
			Femur = 4
			Leg = 6
	Pelvic injury				1(1.2)
	Spinal injury				15(18.1)
	Thoracic injuries				9(10.8)
	Abdominal injuries				3(3.6)
	Polytrauma				32(38.5)
Management	Type				Number (%)
	Medical				83(100)
	Surgical (n = 30)		Lifting of skull depression Evacuation of epidural hematoma Spinal osteosynthesis Femur and leg osteosynthesis Hemothorax drainage		3(3.6) 5(6) 13(15.6) 6(7.2) 3(3.6)
	Orthopedic				17(20.5)
	Physiotherapy				30(36.1)
	Favorable				66(79.51)
	Complications (n = 14)		Pneumonia Pressure sore Meningitis Pulmonary embolism		2(2.4) 10(12) 1(1.2) 1(1.2)
Outcome	Neurological sequelae				10(12)
Average length of hospital stay (days)					7.5 ± 6.3 (1–33)
Mortality					7(8.4)

Discussion

Falling from trees accounts for 0.5% to 14% of injuries [3, 14, 19]. TBIs in people falling from trees are increasingly common in rural areas of certain developing countries, such as Senegal, where we recorded a frequency of 11.40%, which falls within the frequency range reported by other authors (0.5–14%). Several studies focusing on trauma in people who fall from trees have reported findings on TBIs that align with our results. Gupta and Reeves [9] reported a frequency of 10% (4 cases out of 39) in Australia, Djientcheu [8] reported a frequency of 8.77% (5 cases out of 57) in Yaoundé, and Nabi et al. [13] reported a frequency of 9%. The majority of our patients (98%) were from rural areas, a phenomenon explained by the prevalence of tree climbing in rural populations and the lack of neurosurgical services in these regions. These injuries often occur in young individuals climbing trees for recreational purposes, such as hide-and-seek, swing games, or fruit gathering [4, 6, 8, 12, 19]. In our study, the average age was 17.7 ± 13.1 years (range: 6–59 years), with the age group ≤ 10 years being the most represented (43.4%). This aligns with the findings of Gupta and Reeves [9], where the average age was 16.4 years. This could be explained by the fact that in rural areas, adults often send children to climb trees for fruit or leaf collection, and children also climb trees for play. Over half of our patients (59%) were students, which is consistent with Djientcheu’s findings [8], where 47.37% of the patients were students. This predominance among students could be attributed to high school enrollment rates in countries such as Senegal. According to several authors, falls from trees occur year-round, with an increase during fruit ripening seasons [5, 7, 8, 19]. In our study, there was a statistically significant correlation between the season (quarter) and the type of tree involved (P = 0.012). The majority of falls (n = 46) occurred during the second quarter (April to June) (71.7%), which coincided with the mango harvest season in Ziguinchor. This period aligns with the April to June harvest reported by Okonkwo [15], the December to May season in Diallo’s study [7], and the June to November period reported by Gupta and Reeves [9]. The mango tree was the most involved in falls, as reported by Djientcheu [8], Bedaya [5], and Dakouré [6], with rates of 42.1%, 42%, and 50.9%, respectively. Gupta and Reeves [9] recorded 39 cases of falls from mango trees. The predominance of mango tree-related falls in our study (60.2%) can be attributed to the abundance of mango trees in Ziguinchor, where they line streets, schools, and homes, providing shade and recreation areas for children. Additionally, mango trees often have brittle branches that easily break. The high number of falls occurring at home (53%) can be explained by the fact that most homes in Ziguinchor have fruit trees, making it unnecessary for individuals to venture into forests for fruit gathering. During a fall from 25 m high trees, the victim acquired a speed of 80 kms per hour upon hitting the ground. [4]. The average height of falls in our study was 4 ± 2.9 m, with a significant correlation between the type of tree and the fall height (P < 0.05). Our findings are consistent with the literature: Djientcheu [8] reported an average height of 4 m, and Dakouré [6] reported an average height of 5.23 m. Our low fall height could be explained, on the one hand, by the frequency with which mango trees fell in our series. In Ziguinchor, the mango trees in home gardens are often small in size because of grafting. On the other hand, this could also be attributed to the fact that children are often afraid to climb to great heights. Our average admission delay (17.7 ± 37.3 h) was too long, indicating a delay in medical care, mainly due to the remoteness of healthcare facilities and the financial constraints of some parents in covering medical expenses. In our study, transport was provided by a taxi (family) in 43.24% of the cases. This is due primarily to financial limitations but also to traditional beliefs, as families often prefer to take the patient to a marabout before going to the hospital themselves. Additionally, most falls occurred in locations far from the hospital, further delaying patient transportation. TBIs in people falling from trees have rarely been described in the literature, and the symptomatology may depend on the fall height, impact location, landing surface (whether the patient falls on a sharp or hard surface rather than a soft surface that can absorb the impact), and the patient’s age. Some studies associate the presence of an initial loss of consciousness lasting 5, 30 s, or 5 min with a greater risk of intracranial injuries, whereas others suggest that an isolated initial loss of consciousness is not necessarily linked to such risks [10]. Loss of balance and protective reflexes upon landing may explain the occurrence of TBIs [6]. The majority of our patients (77.6%) had a GCS score of ≥ 13. According to Zargar [19], only one patient had a GCS score of 14. There was no significant correlation between fall height and the GCS score (P = 0.930). The head should always be systematically examined in cases of TBI caused by a fall from a tree. Scalp palpation is essential to determine the impact point and to check for a depressed skull fracture [18]. In our series, there was a statistically significant correlation between fall height and the occurrence of scalp wounds (P = 0.023). Head injuries caused by falls from trees are polymorphic and can range from skin and bone injuries to brain damage. These injuries were observed in 67 (80.7%) patients in our study. According to Aristide [2], facial wounds account for 44.44% of cases. These injuries could be due to direct impact on the ground, which may be hard or contain debris (stones or wood pieces), as well as to possible entanglement or collision with tree branches during the fall. Prehospital care can improve the prognosis of patients suffering from TBIs. The common practice is to perform emergency surgery for symptomatic extradural hematomas, subdural hematomas causing intracranial hypertension above 30 mmHg, and open depressed skull fractures. Managing injuries in people who fall from trees poses a significant economic burden [4, 7], especially when patients require prolonged intensive care. Our average hospitalization duration was 7.5 ± 6.3 days (range: 1–30 days), which aligns with the literature data [6, 7, 9]. In our series, mortality (8.4%) was associated with polytrauma and pulmonary embolism, whereas morbidity (12%) was linked to spinal injuries. Similar findings have been reported in the literature: According to Barss [4], fatal cases were due to polytrauma, severe TBI, thoracic trauma, and delayed medical care. Djientcheu [8] reported that mortality was primarily related to craniocerebral injuries (80% mortality: 4 out of 5 cases), whereas morbidity was linked to spinal injuries (9 cases of paraplegia with poor prognosis). Our study revealed that the outcome for patients suffering from TBIs in people who fell from trees was favourable in most cases (79.51%).

As part of our research, we recommend the following preventive measures aimed at reducing the frequency of this pathology:

• Constantly monitoring children in both school and family environments.

• Adults are advised to stop assigning children the task of climbing trees and should instead handle the harvesting themselves via appropriate tools.

• Climbers should therefore be encouraged to wear appropriate safety belts while practicing

• It is essential that the relevant authorities take the necessary measures to ensure safety during the mango harvesting season in Ziguinchor.

We also recommend these general guidelines on the basis of the literature from various authors:

• Dakouré [6]: Keeping children away from tall trees; promoting security in climbing activities (good weather, safety belts); and supporting safe fruit picking (picking bits, regular cutting of fruit trees to keep them short)

• Diallo [6]: Making educational programs, information, and awareness campaigns about the risks associated with these practices. Improving living conditions by ensuring access to appropriate harvesting tools is also essential

• Nabi [13]: Aggressive safety education is required to help prevent these casualties.

• Djientcheu [8]: The use of modern or rubber hoops for climbing oil palm trees and harvesting mangoes with a modern tool

• Barss [4]: Only healthy and experienced young adults should climb the tallest tree varieties. People with epilepsy should not climb tall trees.

Conclusion

Climbing a tree remains dangerous, as it can lead to falls and injuries, such as TBI. Preventive measures and management strategies are therefore necessary to reduce the burden of TBIs caused by tree falls in developing rural regions.

Study limitations

In Ziguinchor, patients have a small consultation booklet that they keep as their personal medical record. This is where the doctor can record details of any clinical consultation, and these records are not kept by the healthcare service. This means that there is currently no way to retrospectively obtain detailed data on injuries from falls from trees that do not result in hospital admission. A future prospective cohort study could be designed to document this information.

Abbreviations

TBI

Traumatic brain injury

TBIs

Traumatic brain injuries

GCS

Glasgow coma scale

Authors contributions

All authors participated in the design, drafting and revision of the manuscript: YC, DD, AD, RIM,RNM, DW, MF have redirected image placement ECNS, MM, MT, ABT, SBB and MCB approved final draft.

Funding

The manuscript has not been financed.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Human ethics and consent to participate declarations missing

Not applicable.

Consent for publication

The patients provided written and informed consent for the publication of this case series and the accompanying images. For children, we obtained the consent of their guardians.

Competing interests

The authors declare no competing interests.