Traumatic Subway-Related Injuries: A 16-Year Experience in New York City

Subway injuries represent a unique form of urban trauma in which the victim is subjected to massive direct mechanical forces. New York City is home to one of the world's largest subway systems with an annual ridership of 1.4 billion people. The most common sequelae of victims surviving these injuries are mangled limbs and resultant multiple amputations – the authors' hospital provides care for the large majority of these patients. This is presented as the largest case series investigating causes, outcomes, and reconstructive attempts for traumatic subway-related injuries. The study has implications for reconstructive and trauma surgeons attempting to manage various types of direct high-impact trauma.

A 16-year (1989–2005) retrospective review of the trauma registry at Bellevue Trauma Center, a Level 1 New York City trauma and regional limb-replantation center, was performed. Fifty patients with subway-related limb injuries were analyzed.

Most patients surviving subway injuries were brought to the emergency room with torn and mangled limbs. These patients were usually middle-aged males (average age: 37.1 years) with a significant number having drug abuse or psychiatric history. Most patients were under the influence of drugs and alcohol at the time of injury (55.6%), while suicide (22.2%) and foul play (13.3%) were also common precipitating events. Most patients required an amputation of the lower extremities (66.7% of patients), while exclusively upper limb amputations (28.9%) and mixed upper/lower limb amputations (4.4%) were less common. Salvage and/or replantation, while attempted infrequently (11.1% of patients), were always unsuccessful, most likely due to the complexity of the crush/avulsion type injuries. In addition, large but often nonapparent zones of injury, concomitant burns, venous thromboses, and high ischemia time prior to reconstruction were all reasons why limb salvage universally failed in these patients. Local wound-site infections were a common postoperative complication (24.4%). Almost all patients required multiple operations for washouts, debridements, revisions, and completion amputations. Patients required on average 2.95 total surgical procedures over the course of their hospital stay. Patients almost always required intensive care (9.24 days spent in the ICU on average) and long hospital stays (31.3 days spent in the hospital on average), but death was an uncommon sequela (6.25% of patients). In the authors' experience, individuals who survived the initial high-impact trauma caused by a moving subway train sustained severe limb injuries that were complex and uniformly unsalvageable.