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.
