Rope Tangling Injuries—How Should a Climber Fall?

To the Editor: Rope tangling injuries are an established pathology in climbing accidents. Traumatic finger avulsion amputations (Figure 1) were first reported in 20031.Hochholzer T. Schöffl V. One Move Too Many. Lochner Verlag, Ebenhausen, Germany2003Google Scholar, followed by subsequent reports that had different causative mechanisms.2.Jakubietz R.G. Jakubietz M.G. Gruenert J.G. Digital amputation caused by climbing-rope entanglement.Wilderness Environ Med. 2006; 17: 178-179Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar There are 3 major mechanisms involved with rope entanglement or rope catching injuries:I.A sport climber takes a minor fall, just above the protection. While falling he may grab the ascending rope, mainly as a reflex (Figure 2). This grabbing action is unnecessary, as ‘catching a fall’ is the responsibility of the belayer at the other end of the rope. However, by instinctively grabbing the rope close to the protection point, the following injuries are possible: the climber may 1) catch the fall by himself and receive severe skin and soft tissue injuries in the palm; 2) get tangled with the belay point (Figure 3); 3) unwillingly unclip the belay device, which may create the potential for more serious injuries; or 4) tangle the rope around his hand or fingers (Figures 1 and 4). All these causative mechanisms have been reported.3.Deutscher Alpenverein [German Alpine Club] Bergunfallstatistik 2004–2005. München, Germany: Deutscher Alpenverein; 2006.Google ScholarFigure 3This climber tried to catch the quickdraw during a fall and suffered an impalement of the palm with the carabineer. The tape was attached after the injury for stabilization during transport to the hospital. Reprinted with permission of Deutscher Alpenverein (DAV).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4Danger of rope entanglement during a fall.View Large Image Figure ViewerDownload Hi-res image Download (PPT)II.A climber takes a long fall and, in accordance with recommendations, grabs the rope in front of his tying knot. This longer rope may tangle or loop around his hand or fingers, and once the rope tightens at the moment of the fall impact, the resulting tension causes avulsion amputations or severe contusions/bruises.1.Hochholzer T. Schöffl V. One Move Too Many. Lochner Verlag, Ebenhausen, Germany2003Google Scholar,2.Jakubietz R.G. Jakubietz M.G. Gruenert J.G. Digital amputation caused by climbing-rope entanglement.Wilderness Environ Med. 2006; 17: 178-179Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar,4.Schöffl V.R. Schoffl I. Finger pain in rock climbers: reaching the right differential diagnosis and therapy.J Sports Med Phys Fitness. 2007; 47: 70-78PubMed Google ScholarIII.A climber has had a fall on a steep or overhanging route. As he is dangling by the rope beneath the last point of protection the standard technique in sport climbing to get back onto the wall and up is to perform 1 or 2 pull-ups on the rope and then let go. With each pull-up, the belayer takes in the excess rope or runs backward to reestablish rope tension. Thus, the climber can slowly make his way up the rope. However, we have seen one case of a very experienced high-level climber who entangled his hand with the rope while performing this described technique, which caused severe bruises, soft tissue damage, and metacarpal fractures.Figure 1Avulsion amputation of the thumb as a result of rope entanglement. The digit was reattached successfully, and the climber is climbing again.View Large Image Figure ViewerDownload Hi-res image Download (PPT) While the urge to grab for the ascending rope in a short fall as outlined in point I above is mostly seen with beginners, all severe injuries through mechanisms described in points II and III have occurred in very experienced rock climbers. A few points should be considered when analyzing the possible origin of these injuries. In modern sports climbing (here, we are mainly speaking about bolted routes), falls and jumps are a normal consequence of climbing participation—one cannot make every move or handhold. A climber climbing an average of 3 to 4 times per week may have 5 falls per day—a quite moderate estimate if he works on a hard route. This amounts to almost 1000 falls per year for the semiprofessional. Accordingly, the incidence of injuries can be quite high. Locker and colleagues5.Locker T. Chan D. Cross S. Factors predicting serious injury in rock-climbing and non–rock-climbing falls.J Trauma. 2004; 57: 1321-1323Crossref PubMed Scopus (10) Google Scholar analyzed factors predicting serious injury in rock-climbing and non–rock-climbing falls. Surprisingly, the questions of whether and by what means the victims used protection devices (harness, helmet, and rope) were not further explored in this study. There is a vast amount of sport-specific science literature examining climbing injuries and overuse syndromes and their prevention.4.Schöffl V.R. Schoffl I. Finger pain in rock climbers: reaching the right differential diagnosis and therapy.J Sports Med Phys Fitness. 2007; 47: 70-78PubMed Google Scholar,6.Addiss D.G. Baker S.P. Mountaineering and rock-climbing injuries in US national parks.Ann Emerg Med. 1989; 18: 975-979Abstract Full Text PDF PubMed Scopus (55) Google Scholar, 7.Bannister P. Foster P. Upper limb injuries associated with rock climbing.Br J Sports Med. 1986; 20: 55Crossref PubMed Scopus (43) Google Scholar, 8.Bollen S.R. Upper limb injuries in elite rock climbers.J R Coll Surg Edinb. 1990; 35: S18-S20PubMed Google Scholar, 9.Bowie W.S. Hunt T.K. Allen Jr, H.A. Rock-climbing injuries in Yosemite National Park.West J Med. 1988; 149: 172-177PubMed Google Scholar, 10.Haas J.C. Meyers M.C. Rock climbing injuries.Sports Med. 1995; 20: 199-205Crossref PubMed Scopus (63) Google Scholar, 11.Logan A.J. Makwana N. Mason G. Dias J. Acute hand and wrist injuries in experienced rock climbers.Br J Sports Med. 2004; 38: 545-548Crossref PubMed Scopus (76) Google Scholar, 12.Schöffl V. Hochholzer T. Winkelmann H.P. Strecker W. Pulley injuries in rock climbers.Wilderness Environ Med. 2003; 14: 94-100Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar, 13.Schöffl V. Hochholzer T. Winkelmann H.P. Strecker W. Differential diagnosis of finger pain in sport climbers [in German].D Z Sportmed. 2003; 54: 38-43Google Scholar, 14.Morrison A.B. Schoffl V.R. Physiological responses to rock climbing in young climbers.Br J Sports Med. 2007; 41: 852-861Crossref PubMed Scopus (95) Google Scholar By contrast, studies on fall analysis and recommendations as to how to perform falls are few.15.Hohlrieder M. Lutz M. Schubert H. Eschertzhuber S. Mair P. Pattern of injury after rock-climbing falls is not determined by harness type.Wilderness Environ Med. 2007; 18: 30-35Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar,16.Mägdefrau H. Die Belastung des menschlichen Körpers beim Sturz ins Seil und deren Folgen.Anthrop Anz. 1991; 49: 85-95PubMed Google Scholar Historically, the recommendation for a climber in a fall was to place his hands onto the knot of the sit harness.2.Jakubietz R.G. Jakubietz M.G. Gruenert J.G. Digital amputation caused by climbing-rope entanglement.Wilderness Environ Med. 2006; 17: 178-179Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar,17.Sturztraining. Lehrplan Trainer C, ed. München, Germany: Deutscher Alpenverein; 2006:11Google Scholar, 18.Deweze S. LeMenestrel M. Escalade Libre. Laffont, Paris, France1987Google Scholar, 19.Güllich W. Kubin A. Sportklettern Heute. Bruckmann, München, Germany1986Google Scholar Before the advent of sit harnesses, most climbers used a full body harness, and only a few used a chest harness. By the mid-1980s, when sport climbing started to become popular and the emphasis changed to achieving more technically difficult climbs, the first sit harnesses came onto the market. At least in Europe, this development aroused a large discussion within the climbing community, comparable to those discussions that had occurred pro and contra bolts. The “older” fraction of the alpinists was absolutely against the sit harness, while the “young” fraction of the sport climbers completely supported its use. During this time, there were a lot of generational conflicts with regard to these issues. These discussions were often heated and were seldom based on technical or scientific proof. The main argument against the sit harness alone was the proclaimed danger of life-threatening thoraco-lumbar hyperextension trauma or “head down positions.”15.Hohlrieder M. Lutz M. Schubert H. Eschertzhuber S. Mair P. Pattern of injury after rock-climbing falls is not determined by harness type.Wilderness Environ Med. 2007; 18: 30-35Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar Although this injury was described in most alpine textbooks, it was only supported by a scientific paper published by Mägdefrau.16.Mägdefrau H. Die Belastung des menschlichen Körpers beim Sturz ins Seil und deren Folgen.Anthrop Anz. 1991; 49: 85-95PubMed Google Scholar Nevertheless, over the years these postulated injuries never occurred in the numbers that would be necessary to assert that they occurred as a consequence of the sit harness, and the sit harness alone became standard for sport and rock climbing (without a backpack!). Hohlrieder and colleagues15.Hohlrieder M. Lutz M. Schubert H. Eschertzhuber S. Mair P. Pattern of injury after rock-climbing falls is not determined by harness type.Wilderness Environ Med. 2007; 18: 30-35Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar finally disproved Mägdefrau's16.Mägdefrau H. Die Belastung des menschlichen Körpers beim Sturz ins Seil und deren Folgen.Anthrop Anz. 1991; 49: 85-95PubMed Google Scholar theory through a study in 2007, and they demonstrated the advantage of the sit harness alone. In early discussions and textbooks the recommendation for a climber in a fall entailed that he should grab the rope or the knot that secured him in the harness in order to maintain an erect position and avoid flipping over backwards or landing head down and in order to avoid suffering a lumbar hyperextension injury.2.Jakubietz R.G. Jakubietz M.G. Gruenert J.G. Digital amputation caused by climbing-rope entanglement.Wilderness Environ Med. 2006; 17: 178-179Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar,17.Sturztraining. Lehrplan Trainer C, ed. München, Germany: Deutscher Alpenverein; 2006:11Google Scholar, 18.Deweze S. LeMenestrel M. Escalade Libre. Laffont, Paris, France1987Google Scholar, 19.Güllich W. Kubin A. Sportklettern Heute. Bruckmann, München, Germany1986Google Scholar Mägdefrau16.Mägdefrau H. Die Belastung des menschlichen Körpers beim Sturz ins Seil und deren Folgen.Anthrop Anz. 1991; 49: 85-95PubMed Google Scholar also recommended grabbing for the rope to avoid flipping over backwards. The official teaching concept for sport climbing trainers of the German Alpine Club (DAV—Deutscher Alpenverein) suggests bringing the legs up and forward and, if necessary, grabbing the rope. Deweze and LeMenestrel18.Deweze S. LeMenestrel M. Escalade Libre. Laffont, Paris, France1987Google Scholar and Jakubietz and colleagues2.Jakubietz R.G. Jakubietz M.G. Gruenert J.G. Digital amputation caused by climbing-rope entanglement.Wilderness Environ Med. 2006; 17: 178-179Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar also proclaim that the climber should grab the rope during a fall, as they feel this is an essential skill for a climber in long falls in order to stabilize his body. We consider this a historically based error and proclaim the opposite. The best action for a climber in a fall is the same movement used by a ski jumper—extending the arms forward to get into a stable position. At the end of the fall, when the body is pulled toward the wall through the drag of the rope, the climber should try to use his feet to minimize the impact and his hands to avoid crashing full on into the wall. If anything is to be protected as a reflex reaction of the hands, it should be the face and head, especially if no helmet is worn. With the technique of “hands to the rope” during a fall, tangling is likely and dangerous, and it must be avoided. The climber should not grab the rope until after the fall is stopped. Considering the rising numbers of climbers and the high numbers of falls occurring in modern sport climbing, correct behavior and positioning during the fall should be taught to avoid entanglement injuries. The historical advice to grab the rope above the knot during a fall is based on insufficient scientific evidence and may result in more serious injuries and possibly even death. We recommend the following positioning in a fall. During the fall, the climber should extend his arms forward at shoulder level to stabilize his body position (Figure 5). In addition, once the full impact of the fall occurs and there is no slack in the rope (ie, just before contact with the rock), he should put his feet forward as he swings into the wall in order to lessen the impact. If necessary, he should bring his hands and arms forward to protect against any direct head or chest trauma. Immediately after the full impact of the fall, he should put his hands on the rope above the knot to avoid flipping over.