Improve care of children with soccer injuries
Prevent long-term side effects
Increasing numbers of children are coming to EDs with injuries from soccer, says a just-published study. From 1990 through 2003, there were an estimated 1.6 million soccer-related injuries that resulted in ED visits, ranging from 96,179 in 1990, to 118,963 injuries in 2003.1
For children or adolescents, it is important to remember the implications that the growth plates place on injury, says Lisa Kluchurosky, manager of the sports medicine program at Columbus (OH) Children's Hospital. "The growth plate is weaker than the ligaments that surround a joint, and therefore much more susceptible to injury or fracture," she says. "Proper diagnosis and prompt treatment of growth plate injuries are critical to preventing long-term side effects."
Long-term problems could include gait disturbances, unequal limb lengths, loss of full range of motion of the affected joint, says Joyce Ordun, MS, CRNP, nurse practitioner for the pediatric ED at Johns Hopkins Hospital in Baltimore.
Kluchurosky gives these warning signs that a more significant injury might be involved: Obvious deformity, significant swelling, discoloration or bruising, tenderness over any bone, specifically toward the ends of the bone, numbness, tingling and weakness, extreme difference in temperature (hot or cold) compared to uninjured side, and an inability or reluctance to move the body part or bear weight.
In a young child, a fracture may not be apparent initially and may be identified only when follow-up films are taken a week later and callous formation is seen at the fracture site, adds Ordun. This means that although an X-ray may be negative, you should discharge a child with a lower extremity injury on crutches, she says. "He or she should be instructed to use them until pain-free," says Ordun. "The important thing to remember is to rest the affected part."
5 steps to take
To improve care of children with soccer injuries, do the following:
• Don't assume that an injury is isolated.
Always consider the potential for multiple injuries, says Ordun. "When evaluating an extremity, always evaluate the joint above and below the injury," she says. For example, a young child who is not able to localize pain in a lower extremity but who refuses to bear weight could have an injury to the foot, ankle, knee, or hip, says Ordun.
• Ask whether the head-injured child has sustained a prior closed head injury.
If so, determine when it occurred, says Ordun. Be aware of the second impact syndrome, which occurs when the child sustains a seemingly minor head injury, with some associated concussive symptoms, she explains. Following a second minor head injury, the child may exhibit profound neurologic deterioration or death, says Ordun.
"The nurse must notify the physician that the child has sustained a prior closed head injury," she says. "This child would merit closer observation while in the ED."
• Remember that children who have Down syndrome have extreme joint laxity.
These children are at higher risk for cervical spine subluxation, so you must immobilize the c-spine until it has been cleared radiographically, says Ordun. "If this involves C1 and C2, there is the potential for more serious outcome," she says. "Remember that all head injuries are potential c-spine injuries, until proven otherwise."
• Don't give anything by mouth until the child is evaluated by the provider.
Fractures may require operative intervention or procedural sedation, notes Ordun. Most physicians require at least a six-hour period to allow the stomach to empty, so that the child does not aspirate, she explains.
"Many EDs have vending machines in the lobby," says Ordun. "Not only should the nurse not feed the child, but he or she must advise the parent not to do so either."
• Ask at what age the child received his or her last immunizations.
Don't simply ask whether immunizations are up to date, because many parents will reflexively say yes to this question, says Ordun. The 2007 guidelines from the Centers for Disease Control and Prevention recommend administration of the tetanus and diphtheria toxoids and acellular pertussis (Tdap) vaccine, for adolescents aged 13-18 who missed the 11-12 year booster shots but who have completed the recommended childhood diphtheria and tetanus toxoids and acellular pertussis vaccine (DTap) vaccination series, notes Ordun.
If the child has missed these immunizations, or has not yet received them, the Tdap should be given, says Ordun. "This is important for any child with a laceration," she says. "Keep in mind that this is a different vaccine than the dT [diphtheria and tetanus toxoids] pediatric formulation that we were formerly using."
Reference
- Leininger RE, Knox CL, Comstock RD. Epidemiology of 1.6 million pediatric soccer-related injuries presenting to U.S. emergency departments from 1990 to 2003. Am J Sports Med 2007; 35:288-293.
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