Dr. Stephen H. Boyce, A&E Dept., Crosshouse Hospital, Kilmarnock, Scotland. Email : steveboyce_scotland@yahoo.com
Dr.
Michael A. Quigley, A&E Dept., Dumfries Royal Infirmary, Scotland.
Abstract
Objective
- To assess the incidence of attendance, type of injury, sport involved and
management of sports injuries in children attending an Accident & Emergency
(A&E) department.
Method
- Children, aged between 5-16 years, presenting with an injury related to sport,
were studied over a period of three months.
Results
- 1858 children attended the A&E department during the three month period.
238 (12.8%) were classified as sports injuries. Boys (71%) were injured more
frequently than girls (29%). Injury rates in boys peaked at 14 years whereas in
girls a peak occurred earlier at 12 years. Football was the most common sport
implicated in injuries (39%). Rollerblading (14%), Rugby (8%), Basketball (7%)
and Physical Education at school (7%) were the next most frequently involved
sports. Soft tissue injuries dominated (61%). The upper limb was the most common
anatomical area injured (46%). Other injuries involved the lower limb (36%),
head and neck (15%) and the trunk (3%). Injuries to the wrist were the most
frequent presentation accounting for 30 fractures and 30 soft tissue injuries
(25%). The majority of children were discharged from the A&E department
after treatment (71%). 26% were reviewed at out-patient clinics and 3% required
hospital admission. No children were referred for physiotherapy.
Conclusion
- Children participate in sport and can be injured. The majority of sports
injuries presenting to an A&E department appear to be of a minor nature and
could be managed with simple first aid techniques by parents, teachers and
coaches at the scene or by attending primary care in the first instance.
Supervision of children, participation in organised sport and the use of
protection devices may help to prevent serious injury.
Key
Words - Sports injuries, Children, Accident & Emergency.
Introduction
The
concept of term “sports injuries” presents to the physician an image of an
adult patient involved in a physical activity and receiving a form of injury,
either through accident, physical contact or overuse. However, children also
participate in a variety of sporting activities. Children have unique skeletal
features in particular the presence of active growth plates. Injuries may result
in disruption of bone growth and lead to deformity and growth abnormalities.
Similarly, poorly managed soft tissue injuries can lead to prolonged periods of
inactivity and significant morbidity. Future sporting careers may also be
damaged in the physically gifted children by inadequate care.
Our
observational study aimed to assess the incidence of attendance, types of
injuries, nature of the sport involved and the arrangements for follow-up
management in children presenting, with an injury related to sport, to the
Accident & Emergency (A&E) department of Crosshouse hospital,
Kilmarnock, Scotland.
Method
The
study took place over a period of three months, February - April 1999. Children
were classified as being a minimum of 5 years old and under 16 years of age on
the day of attendance. Any child presenting with a sports injury, defined as an
injury occurring during participation in an organised sport or a recreational
physical activity, had their details and A&E number noted by the triage
nurse on duty. Only new attendances were included. Relevant A&E cards were
then removed from filing and analysed retrospectively by hand.
The
following demographic trends for each child was recorded : name, age, sex,
sport, type of injury and follow-up arrangements or outcome. The types of injury
sustained were classified into five categories: soft tissue injury, fracture,
dislocation, head injury and lacerations. The term soft tissue injury
encompassed a wide spectrum of pathology. This included ligament, muscular and
tendinous injuries. These results are presented below.
Incidence
Of Attendance
Throughout
the three month period the overall attendance at the A&E department was 12
030. Children accounted for 1858 attendances. Of these, 238 (12.8%) were
classified as sports injuries. Boys were injured more frequently than girls by a
ratio of approximately 2.5:1 with 168 (71%) of cases. Only 70 cases (29%) were
girls.
Age
There
was a steady increase in attendance with age in boys peaking at 14 years old. A
similar pattern was noted for girls but with the peak age group for attendance
being 12 years old.
Sport
Children
exhibited a wide diversity in their choices of sport with 24 different sports
represented. Table 1 displays
the wide range of sports involved.
Types
Of Injuries
Soft
tissue injuries (STI) dominated representing 61% of all attendances. Figure
1 represents the different types of injuries sustained. Injuries to the
upper limb accounted for 46% of all injuries. The lower limb, head and neck, and
trunk were responsible for 36%, 15% and 3% respectively. All the injuries to
these anatomical areas are highlighted in Tables
2-4.
Outcome
Following
assessment of their injury the majority of children were discharged from the
A&E department with no appointment for review (71%). 60% of these children
were asked to attend their GP if further problems occurred. 26% of children were
referred to out-patient clinics (Fracture clinic 16%, A&E soft tissue injury
clinic 9% and Hand/ENT 1%) at the hospital for review. 3% were admitted to the
hospital either for fracture manipulation or observation following a head
injury. No children were referred for physiotherapy. These results are presented
in Figure2.
Discussion
Over
the last 15 years in Britain studies have been published regarding the incidence
of sports injuries attending an A&E department1,2,3,4. None of these studies
exclusively dealt with the issue of children. Children were either included in
the overall results1, partially excluded (those under the age of 12 years)2 or
not mentioned3,4. Only one study specifically addresses this issue, however,
within the setting of a sports injury clinic5. Published studies concerning
children’s sports injuries from A&E departments originate from Denmark6,
Finland7, France8,9, United States10,11,12,13, New Zealand14, Trinidad &
Tobago15.
In
our study sports injuries represented 12.8% of all children’s attendances. The
incidence in other studies were lower ranging from 3-11.1% with only one study
in Finland having a higher incidence of 21%7. In other countries, with different
healthcare systems, presentation to an A&E department may not be the first
place that a an injured child may be taken for medical attention, therefore the
comparison of values between different countries regarding children’s sports
injuries may not provide a true representation. Data from family practices,
sports clinics and A&E departments would all require to be included to
define the true incidence of presentation. Boys appear to be injured more
frequently than girls, the ratio varying depending upon the country of origin.
One possible reason for this difference is that boys, anecdotally, have a higher
participation rate in sport. With reference to the age of children attending
with injuries there is a steady increase in attendance up to a peak at aged 14
years in boys. A similar pattern exists in girls, though this time the peak is
earlier at 12 years. This progression is perhaps more easily explained. As
children get older they begin to participate in organised sport, for example,
school teams or boys clubs, thus increasing the likelihood of injury occurring.
Football
is the most popular sport in the world and not surprisingly was the most common
sport implicated in injury with 92 cases (39 %). Rollerblading or in-line
skating was significantly the second most frequently involved with 34 injuries
(14%). Rugby and basketball were third and fourth with 19 (8%) and 17 (7%) cases
respectively. Notably, physical education (PE) at school was responsible for 16
cases (7%). The nature of the sport involved in injury in other studies varies
with national origins. Danish6 and French8 studies, in common with ours, had
football as the most common sport, whereas in Finland7, injuries due to ice
hockey were most frequent. The other studies made no mention of individual
sports. However, two interesting points emerged. Rollerblading or in-line
skating was the second most frequently involved activity in injury, raising
questions as to whether safety measures, e.g., wrist protection devices, should
be worn. However, the literature available is inconclusive regarding the degree
of protection afforded by wrist splints with authors having varied opinions on
their effectiveness17-22. Injuries during PE at school accounted for the fifth
most common presentation. One possible reason to explain the this is the
phenomenon of “teacher triage”, where a child has a minor injury at school
which can be treated with simple first aid procedures but fear of litigation and
parental complaint mandates that they call the parent and advise taking the
child to the A&E department.
Injuries
to the soft tissues are more common than any other form of injury in all
studies. Injuries to the lower limb and specifically the ankle are the most
common injuries seen in sport1,2,3,4. Significantly, we found that injuries to
the upper limbs were more common than any other anatomical area, accounting for
46% of all injuries. The lower limb, head and neck, and trunk were responsible
for 36%, 15% and 3% respectively. The wrist was the single most injured area of
the body with 60 cases (25%), 30 fractures and 30 soft tissue injuries.
Rollerblading alone accounted for 12 fractures and 9 soft tissue injuries of the
wrist. Ankle sprains, the most common adult sport injury, accounted for only 27
cases (11%). Soft tissue injuries to the fingers, minor head injuries and soft
tissue injuries to the knee were the next most common injuries. This is in sharp
contrast not only to adults, but also other children’s studies, who found that
the lower limb and ankle were most often injured5,10,16. Only one study had a
similar finding to our own9. No definite explanation can be given for this
difference, however, rollerblading is a relatively new activity and the high
amount of injuries sustained may have falsely elevated our figures.
The
majority of children (71%) received no hospital out-patient follow-up, either
being discharged directly from the department or referred to their GP for
assessment should any further problems arise following discharge. This would
suggest that a significant proportion of injuries were of a minor nature and
could possibly have been managed in the first instance by the primary care
service, parents, teachers or coaches using simple first aid techniques. Despite
the availability of direct referral to the physiotherapy department no children
were referred to the physiotherapy department.
This
study is limited in its conclusions by several factors. A three month study only
provides a snapshot of sports injuries and a one year study would provide a
greater sample size to base demographics upon. Relying on the triage nurse to
note patients presenting with a sports injury introduces human error. Patients
may have been overlooked if something else occurred at the time of triage in a
busy A&E department. The triage nurses perception of a sports injury may be
different from ours and have led to the inadvertent exclusion of valid cases.
A&E departments are often staffed by inexperienced senior house officers and
we are relying on their clinical decisions to base our conclusions upon. Future
research involving sports injuries and their relationship with A&E requires
a longer study period producing a larger sample size and include the time of
presentation after injury, the treatment performed, reviewing the injuries
referred to the GP and any complications following injury.
Conclusion
Children
participate in sport and can suffer injury. The majority of sports injuries
presenting to an A&E department appear to be of a minor nature and could be
managed with simple first aid techniques by parents, teachers and coaches at the
scene or by attending primary care in the first instance. Supervision of
children, participation in organised sport and the use of protection devices may
help to prevent serious injury.
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