The Case of the Corpulent Commander Who Sustained a Fatal Fall

Albert B. Lowenfels, MD; Jennifer Dore, MD

Disclosures

February 19, 2008

How Would the Patient Be Treated Today?

Even today blunt trauma poses a therapeutic challenge, but we benefit from several imaging methods to assess the extent and location of intraabdominal injury and to ascertain blood loss.[9] Both diagnostic peritoneal lavage (DPL) and focused abdominal sonogram for trauma (FAST) have been shown to be highly accurate. DPL surpasses a physical examination, with an accuracy of between 92% and 98% for diagnosing intraperitoneal hemorrhage. FAST is a noninvasive procedure that it can be performed during resuscitation of the patient and can be repeated, although is has the disadvantage of requiring about 200 mL of blood for detection of hemoperitoneum.

The use of computed tomography (CT) scans was initially viewed with skepticism in evaluating blunt abdominal trauma because CT scanning required a cooperative, hemodynamically stable patient and transportation out of the trauma area. However, CT scans are now frequently being used as a routine screening measure in patients with blunt abdominal trauma. An initial DPL, followed by a CT scan if indicated, has been suggested as a way to limit the use of CT procedures following blunt trauma.[10]

If injured today, William's injury would have been diagnosed accurately and his abdominal injuries cared for promptly, leading to an excellent chance of survival. At age 59, although markedly obese, he was still a vigorous, healthy, physically fit man and might have lived for several more years.

William was reported to have become obese in his fifth decade and was markedly obese when he engaged in the battle at Mantes. His contemporaries compared his girth to that of a pregnant woman. This weight gain has been attributed mostly to his diet of beef, boar, venison, and mutton -- with no vegetables -- for all meals, accompanied by ample draughts of alcoholic beverages. One historian reports that his obesity was genuine fat, because there was no mention of tapping waterlogged tissues. However, we can not rule out a secondary cause of weight gain, such as ascites, hypothyroidism, or Cushing's disease.

Remembering that force equals mass times acceleration (F = M x A), we know that William's excess body mass would have directly increased the deceleration force pressing against his abdomen when his horse abruptly stopped. Warriors entering battle during the Middle Ages customarily wore heavy armor, which might have offered William protection against a blunt injury but would have added to his weight.

It has been shown that excess adipose tissue is associated with a proinflammatory state, putting obese patients at an increased risk for insulin resistance, endothelial damage, and importantly, postinjury organ dysfunction.[11] A prospective observational study of 716 trauma patients with severe injury demonstrated that multiple organ failure was more likely to occur in obese patients compared with nonobese patients.[12] There is, however, still some controversy concerning the relationship between body mass index and mortality after trauma.[13,14,15]

How Dangerous Is Horseback Riding?
Horseback riding is a popular sport, with an estimated 30 million persons engaging in this activity each year. A study from England found that injury rates per hour were higher for horseback riders than for motorcyclists.[15]

In the United States the estimated rate for nonfatal horseback injuries during the period 2001 through 2003 was 36 per 100,000 per year. The most common injuries were simple contusions and abrasions (31%) and fractures (25%). An estimated 11,500 head injuries related to horseback riding occur each year.[16,17]

Other famous persons who have sustained horseback injuries include Genghis Khan who died in 1227 after falling off his horse; William III, another English king who died in 1702 when he fell after his horse tripped on a molehill; and Christopher Reeve, the popular actor who became quadriplegic in 1995 following a fall from his horse. His death in 2004 was directly related to the antecedent horseback injury.

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