Spinal fractures resulting from the 1995 Great Hanshin Earthquake of the Kobe - Osaka area of Japan

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1 Spinal Crd (1996) 34, Internatinal Medical Sciety f Paraplegia All rights reserved /96 $12. Spinal fractures resulting frm the 1995 Great Hanshin Earthquake f the Kbe - Osaka area f Japan Suji Maru and Manabu Matumt Hyg Cllege f Medicine, Department f Orthpedic Surgery, Nishinmiya, Japan One f the wrst earthquakes hit the Hanshin area between Kbe and Osaka, in the early mrning at 5:46 AM n January 17th The destructive frce with MG 7.2 severely damaged buildings, huses, rads and railways, leaving 65 dead, and 34 9 injured. Hyg Cllege f Medicine lcated in this area was als severely damaged, thus there was a majr challenge t prvide pst-quake medical supprt. A pst-quake investigatin in this area was dne by 5 affiliated hspitals. Mre than 15 victim-patients were treated at these hspitals during the first 3 days after the quake. Majr injuries were spinal fractures, and ther trunk fractures, induding rib r pelvis fractures, but fractures f lng bnes were uncmmn, because the quake hit this area in the early mrning when mst peple were asleep. In this study, the mechanisms f these majr injuries were analysed by direct interview sn after the quake, with 23 victim-patients wh had 14 spinal fractures, and 1 with rib r pelvis fractures. Mst f thse wh had a spinal fracture had either sat up r std up n their 'Futn' mattresses withut bed frames and were struck n their backs by falling furniture r ceilings. On the ther hand, patients wh had fractures f the ribs r the pelvis had been lying in the supine r lateral psitin and were hit n their chest r pelvis. This characteristic lifestyle pattern f the Japanese peple t lie dwn n the flr directly beside furniture, resulted in these injuries. Frm these results, we will emphasize the fllwing precautins:- If an earthquake ccurs during sleeping hurs at hme, d nt stand up r sit up. The best psitin is t cruch n the 'Futn' mattress. Keywrds: spinal fracture; earthquake; disaster; rib fracture; pelvis fracture; Kbe-Japan Intrductin It was just like a nightmare. The Hanshin area f Japan, lcated between the cities f Kbe and Osaka, was hit by ne f the wrst earthquakes in histry, named the Great Hanshin Earthquake, in the early mrning f January I (SM) als had a terrible experience as ne f the victims f Kbe city where I live and as a victim-dctr wh treated the victimpatients in ur damaged hspital, lcated in Nishinmiya city near Osaka (Figure 1). We dctrs at the Hyg Cllege f Medicine hspital and its affiliated hspitals were greatly challenged t prvide afterquake medical supprt despite the severe damage suffered by ur hspital facilities. During these medical activities, investigatins were made with reference t hw many victim-patients were treated, what kind f majr injuries were fund and Crrespndence: S Maru what were the characteristic bne injuries caused by this special urban earthquake which ccurred in the early mrning, especially affecting thse peple wh live in traditinal Japanese style. This Great Hanshin Earthquake ccurred in the early mrning, 5:46 AM n January The destructive frce f the quake was measured at 7.2 magnitude n the Richter scale. It caused many buildings and huses t cllapse and destryed the railways. The Western part f Kbe was mstly damaged by pst-quake fire, but the Eastern part where ur hspital is lcated was mainly damaged by the quake cllapsing huses and buildings. Many victims were rescued frm cllapsed wden huses r buildings (Figure 2). Resulting frm this terrible earthquake disaster, the final death tll was 65 and 34 9 were injured. Amng the damaged huses r buildings, cmpletely cllapsed, and were partially destryed, and were cmpletely burned dwn.

2 Spinal fractures in the 1995 Kbe earthquake 383 Table 1 Majr bne injuries treated at 5 affiliated hspitals ".../ X Awa' J Centre f Earthquake Osaka Bay iairprt I Spinal fractures Rib fractures 17 3 Pelvis fractures 4 Crush syndrme 37 5 Burns 28 6 Finger fractures 27 7 Others 199 Ttal Figure 1 Hanshin area and majr cities damaged by this earthquake Table 2 The majr fractures ccurring in 23 patients wh had agreed t a direct interview Spinal fractures 14 spinal crd injuries 6 (Frankel A:3, :3) Other trunk bne fractures 1 Fractures f ribs 45 Fractures f clavicle 6 Fractures f pubis 34 Fracture f ischium 15 Ttal 24 Figure 2 Many wden huses cllapsed in the quake and victims were rescued at the eastern part f Kbe city (Pht by Kbe Shinbun) Materials and methds A pst-quake investigatin in the area was dne by the staff f 5 affiliated hspitals. The number f quake victims at these hspitals was abut IS 773 during the first 3 days fllwing the quake. But it might have been mre, because f the large number f victims wh came t these hspitals just after the disaster fr medical care befre there was time t make medical recrds. Out f 757 majr bne injuries, spinal fracture (n = 222) were the mst cmmn, fllwed by ribs (n = 17) and pelvic fractures (n = 74), with few lng bne fractures, as shwn in Table I. In this study, the mechanisms f these majr injuries were analysed thrugh direct interview f 23 victim-patients wh suffered 14 spinal fractures, 1 ther trunk fractures including 45 rib and 34 pubic fractures and thers, 1 bth fractures, a ttal f 24 fractures. One f the reasns why the three majr llljuries were spinal fractures and ther trunk fractures, with fewer lng bne fractures ccurring, was the timing f the quake, which ccurred while mst f the victims were still sleeping, and als because f the traditinal custm in Japan f sleeping n grass-mat flrs 'Tatami', n cttn mattresses 'Futn', withut bed frames. The number f victims was greater than might have been had the earthquake happened during waking hurs, except fr thse hurs when cmmuting is heavy We can easily understand why the victims sleeping n cttn mattresses, 'Tatami', in the supine r lateral psitin, were hit n their chest r pelvis by falling bjects, at the time f disaster. But why were spinal fractures s cmmn? The victims must have been sitting in an upright psitin, r be in the standing psitin with their back facing the falling bjects which struck them. Psture at the time f the disaster and the severity f the damaged huses are imprtant factrs. Thus direct interviews were dne. Results The number l victim-patients (by direct interview) The number f victim-patients wh agreed t the direct interview were 23 ut f 466. The classificatin f 24 fractures n these 23 victim-patients is shwn in Table 2. Frtunately, there were nly six patients (.5%) with a spinal crd injury ut f the 14 with a spinal fracture, and the severity in these six patients was classified as either Frankel A:3 r D:3.

3 384 Spinal fractures in the 1995 Kbe earthquake The sex and age distributin The sex and age distributin f 23 victim-patients suffering frm spinal r ther trunk fractures are shwn in Figure 3. The average age was 62.9 years ld. As t the sex distributin, females 162, males 68, 7% f them were aged females. The site f spinal fracture The site f 169 affected vertebrae n 13 victim-patients, including duble lesins, are shwn in Figure 4. The 'victims' hme and the extent f damage at the time f the disaster (Figure 5A - E) Cmparisn between the spinal fracture grups (Grup S) and the ther trunk fracture grups (Grup-T) was dne t analyse the factrs resulting in these different types f fractures. We used nly the data frm the replies f the victim-patients, because sme did nt remember exactly the situatin at the time f the quake. Wden huses were the mst cmmn denminatr in bth grups. Grup-S: 83 (7S%) ut f Ill, and Grup-T: 61 (6S%) ut t 94. Apartment huses r deluxe apartments fllwed (Figure SA). The severity f damage f these huses r buildings is shwn in Figure SB. Ttally cllapsed huses were 32 (34%), and partially cllapsed were 41 (43%) ut f 9S in grup-s, and 36 (47%) ttal and IS (2%) partial, ut f 76 in grup-t. There were n significant differences between these tw grups. Types f falling bjects, and the way f escape (Figure 5C and D) Regarding the way t escape, n significant differences were fund (Figure SD) (]) 6 69 D> '" 5 59 ' 4 49 g;, 3 39 ;C i'i'"""-i j _ Figure 3 Site C7 T3 T7 T8 T12 Ll L2 L number f patients Sex and age distributin f--'",j,.- male(n-68) female(n= 162) The psture f the patients The psture f victims at the time f the quake revealed significant differences. (Figure SE). In Grup-S, the victims were in the psture f either sitting up 31 (29%), r standing up 28 (26%), r in the prne psitin 22 (2%), with a ttal f 81 (7S%) ut f 18, lying n their mattresses (Futn) during the quake. This implies that many peple std upright, r were in a prne r a cruched psitin surprised by the strng tremr, and tried t escape with their backs facing the falling bjects and were then struck n their back. In grup-t, the victims wh were supine psitin 26 (3%), lateral psitin 28 (33%), with a ttal S4 (62%) ut f 861ying n their mattress 'Futn' during the quake. Falling bjects hit the chest r the upper part f the bdy resulting in rib fractures and the lwer part f the bdy resulting in pelvis fractures, especially pubic fractures, with a ttal f 14 trunk fractures. Discussin The cnditins f this earthquake were very similar t that f the Tangshan earthquake in China, which als Figure The site f affected vertebrae number f vertebrae ccurred in the early mrning, at 3:43 AM n January 28th The destructive frce measured 7.8 magnitude n the Richter Scale, and resulted in very severe damage t the city resulting in a death tll f , with 164 8S 1 injured. l Accrding t the pstquake investigatin, the three majr injuries in the quake were the crush syndrme, fracture f the pelvis and f the spine. Mst f the patients wh suffered frm spinal fractures, were arused by the strng tremrs and as sn as they sat up in their beds, they were hit n their backs by falling ceilings. 7% sustained injuries f the thrac-iumbar spine, and unfrtunately mre than 34% became paraplegic. This may be due t the difference between the stne huses in China, and wden huses in Japan. Cnversely, are the cnditins f Armenian earthquake in the frmer Sviet Unin which ccurred later

4 Spinal fractures in the 1995 Kbe earthquake 385 in the day, n December 7th, 1988, with 6.9 magnitude n the Richter scale, with a death tll f 25 with 3 injured. 2 The types f majr bne injuries were head, face, upper and lwer extremities, with few spinal r ther trunk fractures. In the Hanshin area quake the number f bne injuries were 1675 (14%) ut f the ttal (11 975) f all f the injured victim-patients. Fracture f the spine r ther trunk bnes was 995 (59%) ut f But frtunately nly 21 (2.1 %) had a spinal crd injury. Pst-mrtem examinatin by legal medical examiners after the quake shwed that 2761 (76%) ut f the 3651 cadavers' deaths were mainly caused by traumatic asphyxia frm chest r abdminal cmpres SIOn. A Wden huses! ---' Apartment huses --m",= Frm these results, the timing f the quake and the victim's psture at the time f the quake are seen t be imprtant factrs determining the lcatin f fracture. Anther imprtant factr is the traditinal custm in Japan f sleeping n grass-mat flrs 'Tatami', n cttn mattresses 'Futn', withut bed frames alng with the nearby furniture such as drawers, cnsle. cases r bk cases which hit the victims directly. Frm this analysis, we bserve the mechanisms f these injuries as fllws: (Figure 6). The earthquake ccurred during sleeping hurs in the early mrning in Japan. Regarding fractures, were thse wh were either sitting up r standing up n their Futn mattresses during the quake, and thus suffered frm spinal fractures. On the ther hand, the victims lying in the supine r lateral psitin suffered rib r pelvic fractures. We emphasize the fllwing precautins: If the earthquake ccurs during sleeping hurs at hme, 'Dn't stand up! Dn't sit up! Dn't walk!' The Cruch psitin n cttn mattresses 'Futn' might be the safest ptin. Deluxe apartment Grup-S (n=122) B a..!!! Ttal ' Half!!! Partial C U Others 1 Drawers Ceiling III E Rf : a; LL Bkcase TV set !TIl Grup-T (n=83) Grup-S (n=95) CJ Grup-T (n 76) Grup-S (n=69) D Grup-T (n=55) E ca :::l CT..c t::: ca '...c Sitting Standing P rne - Supine a; :::l iii... Lateral Grup-S (n=13) Grup-T (n=72) Grup-S (n=18) Grup-T (n=86) Figure 5 The situatin f damage at the time f disaster. (A) Type f huses r buildings. (B) Degree f damage t huses r buildings. (C) The srt f falling bjects. CD) The way t escape. (E) Psture at the time f injury 4

5 386 Spinal fractures in the 1995 Kbe earthquake. '. Z "' ". ';, <'C- Sitting, Standing Q IC \K spinal fracture W"," :" r :"PI"'" Lat2 :;II," -' -- - f( ' - V- ' ) (. WJ) \(j UID d rib fracture?:'pelvic fracture \3 death Figure 6 Mechanisms f each fracture. The victims sitting r standing suffered frm spinal fractures and the victims lying in the supine r the lateral psitin suffered frm rib r pelvic fractures Cnclusin One f the wrst earthquakes hit the Hanshin area, resulting in 65 deaths and 34 9 injuries. The earthquake ccurred in the early mrning, resulting in mre trunk injuries like spinal, rib and pelvic fractures, than lng bne fractures. Psture at the time f earthquake was imprtant als. Upright psitin resulted in mre spinal fracture. Prbably, the cruch psitn wuld have been the safest. References I Zhi-Y ng S. Medical supprt in the Tangshan earthquake: A review f the management f mass casualties and certain majr injuries. J Trauma 1987; 27: Nji EK el al. The 1988 earthquake in Sviet Armenia: A case study. Ann Emerg Med 199; 19: