Immediate post-injury considerations in games

All mobile collision sports have a quota of injuries. Specific injuries are not confined to any particular sport, but regular injury patterns do occur among players in their chosen pastime.

The circumstances, diagnostic assay, treatment and management of injuries both on the field of play and immediately afterwards vary considerably, particularly in personnel and facilities available. Ideally, a team is covered by a doctor and physiotherapist, both skilled in medicine in sport, and an enlightened coach; the playing area is regularly inspected while first aid facilities at hand include a stretcher, inflatable splints and a treatment room, easily accessible from the field of play, which is equipped with good lighting, running water, couch, steriliser and ice, and so on. In practice, facilities at most matches seldom extend beyond the proverbial bucket and sponge and an elementary first aid box, possibly locked with the key unavailable! This happens despite encouragement and prompting from the concerned sporting organisation.

GENERAL CONSIDERATIONS

At all times medicine in sport should be advisory rather than authoritative, similar to its role in the community, and it is as well for the attendant to remember this. He should, ideally, have a working knowledge of the prevailing laws of the sport, be situated close to the field, undisturbed and able to watch the game closely, so allowing maximum opportunity to recognise cause and site of injury.

When summoned on to the field of play (solely by the referee) it is most important to remember what not to do and as far as possible no treatment should occur before a shrewd idea of the diagnosis has emerged. It should be appreciated that the attendant has arrived at a situation which every casualty officer envies – within a minute of the incident and before effects such as exudate, swelling, bruising, painful muscle spasm can cloud the diagnosis.

Well before the player is touched important aspects can be elicited such as; Who saw the incident? What happened? Where is the site of the injury? Observation and inspection are paramount necessities by which the presence of vital normal function such as consciousness, breathing, limb movements, source of haemorrhage is established without necessarily touching the injured player. Removal of a mouthguard, if worn, reassurance in approach to the casualty, and quiet authoritativeness to the other participants are fundamental.

Palpation and establishment of movement range must be with the player’s cooperation rather than despite him. Passive movements may rarely be employed as a primary diagnostic or therapeutic aid. Fortunately, the human anatomy, with one or two notable areas of exception, has been duplicated thus allowing comparative examination of the uninjured side. The attendant should be ever mindful of the possible pitfalls, such as the artificial eye, the slight long-standing squint, the ‘normally’ deformed nose of an earlier injury, long-standing calcification and hard swelling of an old quadriceps muscle injury, the permanent lump over an old costal cartilage injury or deformity of the acromio-clavicular joint from former damage.

The attendant is there to give advice and assistance and must have control of the situation. No one should attempt to drag the injured player to his feet without the agreement of the attendant, or medical or paramedical supervision.

Within one minute or thereabouts basic decisions of likely diagnosis and playability should be made or, if not possible in such a short time, decided off the pitch after unhurried removal of the player. Where the particular sport permits replacements or substitutes, the casualty should be taken directly to the main facilities.

Always before the match, the attendant must be acquainted with the location of a stretcher and the address, location and telephone number of the ground. In major injury an unnecessarily long delay can occur with the ambulance careering around the countryside vainly following inadequate instructions as to the whereabouts of, say, the Tolpuddle Martyrs fifth eleven pitch. The appropriate official should also be notified of the hospital to which the injured player has been taken.

Specific areas of injury may be considered from surface anatomical situations, being ever mindful that there are areas of increased vulnerability in particular sports.

REGIONAL INJURIES

Head, neck and face

Difficult diagnostic and management decisions arise with these areas. Applied forces causing injury to the head and neck are mechanically similar to those applied to a heavy ball on the end of a chain. The forces are sudden acceleration and deceleration, hyperextension, flexion, rotation and compression – the last mentioned commonly with the vertex of the skull fixed as in a rugby front row player when the scrum collapses, or in a badly executed tackle with the head anterior to the hip or thigh or an acute frontal approach to the tackle. These forces can result in the rare but terrible injury of fracture-dislocation of the cervical spine with consequent paralysis.

Tangential blows can produce serious brain damage, apart from lacerations and facial bone fractures, by shock waves passing through the skull into the loosely suspended brain covered by three membranous layers or meninges. These are namely the tough outer fibrous tissue or dura mater (the inner lining of the skull), the middle layer or arachnoid and the inner membrane closely applied to the surface of the brain, the pia mater . The resultant spaces are traversed by blood vessels and the space between the inner two mem- branes contains the cerebrospinal fluid. Hence the importance of the awareness of the possibility of structural damage to the brain which can be fatal in a matter of hours. There were eight fatal accidents in rugby in England from October 1971 to November 1978, a fatality in soccer in 1978 and a fractured skull in hockey in the same year.

Momentary insensibility, confusion, unsteadiness, incoordination and retrograde amnesia, are all symptoms which make the removal of the injured player from the field of play mandatory.

An unconscious player represents an emergency and immediate attention should be given to fundamental principles – if he is not breathing, then resuscitation is vital whether or not there is a suggested broken neck. Remove the mouthguard if present, check deeply with a probing index finger that there are no loose avulsed teeth, dentures, chewing gum or anything else in the mouth and throat preventing maintenance of a good airway. Concurrently, start emergency resuscitation with the neck extended and chin well forward. After establishment of normal respiration and if there is no suspected neck injury, the injured player should be placed on his side with the knee of the uppermost leg bent at a right angle.

If mouth-to-mouth resuscitation is not causing movement of the chest, or lividity, foaming at the mouth and extreme restlessness are occurring, the player may be asphyxiating because of airway obstruction from a foreign body. Sit him up and at the same time apply sharp pressure with the heel of one hand from behind placed over the spine just below the ribs to attempt expulsion of the foreign body. This can be carried out very quickly; if unsuccessful, while inverting the player, give sharp blows between the shoulder blades; there are enough strong men around to make this a rapid manoeuvre which in practice has proved life-saving. In every case the player must be taken to hospital without delay.

The classical example of only transient alteration in brain function without any structural damage, is concussion. On the field, diagnosis and decision can be difficult and misleading in the two following phases of concussion and symptoms.

Firstly, the mildest degree of concussion occurs with doubtful loss of consciousness, very transient memory loss and the player appearing mentally alert at the time of examination. If he is able to rise promptly to his feet without assistance, to stand firmly with eyes closed, to perform heel-toe and ‘tandem’ walking, followed by a shuttle run to a mark then he may continue to compete but he should be watched carefully for the rest of the game for any further signs developing. His fellow players should also be told to watch him.

Secondly, difficulty arises with moderate degrees of concussion where the player may not necessarily go down but be ‘out on his feet’ – a situation analogous to the boxer stopped on a ‘technical knock-out’: he is dazed, amnesic, unsteady, possibly aggressive and unreasonable, and repeating the same phrases. For example, to the question ‘What is the score?’ he may reply ‘Has the game begun yet?’ In all sports, such casualties must be withdrawn from the game with firmness, and the captain and referee must assist if necessary. Remember, there is no sophisticated method on the field of play or, for that matter, in a neurosurgical unit to determine whether or not a player at the moment of injury has suffered a simple concussion or is going to develop secondary brain damage necessitating urgent surgical interference.

Neck injuries can vary from a simple muscle sprain with the neck held in flexion, or an acute wry neck caused by subluxation of one of the pars articularis facets with the chin rotated to the opposite side and pointing upwards, to fracture-dislocation and resultant paralysis. The utmost vigilance is required.

The player may, on questioning while down on the ground, be able to manage full limb movements, but, for example, if he complains of a sensation of numbness or tingling, heat running into the arms or hands, no matter how transient, he must be removed on a stretcher and referred to hospital. Persistent high interscapular pain requires similar firm management and the game suspended until ambulance facilities have been arranged. These signs indicate suspicion of cervi- cal nerve root damage or developing cord involvement at C7 level and require strict immobilisation before removal. At Twickenham Rugby Football Union ground a Ferney-Washington ‘scoop’ stretcher is always present for such an eventuality. In the period October 1973 to April 1978, there were ten reported cases of neck injuries involving paralysis (quadriplegia) in rugby in England, estimated by the writer from insurance claim reports.

Cuts and lacerations predominate in this area in rugby and to a much lesser extent in soccer and hockey. Seventy-five per cent of lacerations occur in the front five forwards in rugby with usually over half requiring suture. All lacerations should be adequately cleaned: a dilute solution of cetrimide and chlorhexidine is preferred for this purpose, though in the absence of anything else, soap and water is excellent for debridement. A protective dressing should be applied before returning to play. If there are facilities available to suture a wound this should be carried out forthwith; if not, the casualty should be referred for suturing within four hours. (The numbing effect of the injury makes local infiltrative anaesthesia unnecessary for immediate suture: there is no swelling of the tissues, there is more accurate alignment of the skin edges and as a result a more acceptable scar. In preparation, never shave any segment of the eyebrows before suture – re-growth is uncertain in timing and the resultant appearance might result in litigation.) Prevention of such injuries or at least reduction of their incidence would be assisted considerably by firmer application and review of existing laws, increased club and player cooperative responsibility and equipment modification.

A plastic/rubber composite stud is feasible for those sports. There is no room for complacency: the incidence of disfiguring lacerations is not falling and the elimination of the nylon stud and sharp-edged sole is not the answer. Sports authorities must maintain regular contact with the Shoe and Allied Trades Research Association. Finally, it is a foolhardy player who has not had a full course of tetanus immunisation plus regular booster injections.

In any collision sport eye injuries can be disastrous. In the middle of the furious scrambles of forwards and centres for the ball rebounding at eye level in basket–ball, the eyes are very vulnerable. Eye injuries may also arise from fingers, thumb, or collision of heads in any sport. Mistiness of more than a brief duration or partial loss of vision require examination off the pitch; where there is contusion the application of ice and prompt hospital referral is advised. Apart from the pain of a corneal abrasion which resolves fairly rapidly after 48 hours or so depending on dimension, discomfort may not always be a prominent symptom of eye injury despite obvious haemorrhage into the interior or posterior chamber of the eye. (Proxymetacaine hydrochloride (Ophthaine) drops plus an eye pad will relieve the abrasion pain: the possession of an ophthalmoscope is invaluable to eliminate more serious injury and avoid hospital referral.)

Dislocation and fracture of the teeth occur in the unguarded mouth. If this occurs, retrieve the tooth, wash it gently in normal saline or under the tap and apply sustained gentle pressure until the blood and tissue fluids are expelled. Gentle pressure will maintain position until specialist dental advice is sought. Latex mouthguards, dentally moulded and fitted, drastically reduce facial and dental injuries, and concussion. The type available ‘off the peg’ in sports shops should be avoided as it is loose, ill-fitting, and can and has caused asphyxia. Examination for a fracture of the lower jaw includes a full inspection and palpation via the mouth: a swab plus probing finger may reveal bleeding from a tooth at the gum margin; biting on a folded handkerchief can produce localised pain even as posteriorly as the tempero-mandibular joint. With such signs present, a fracture is likely. The player who is tackling is usually the victim, frequently through incorrect technique or the faulty coaching of smother tackling in rugby.

Injuries to the nose primarily require arrest of haemorrhage. This is best effected on the field of play by firm pressure on the distal one inch (2.5cm) of the nose using ice, adrenaline gauze or ribbon gauze packing. Any displacement of the nasal septum can often be corrected painlessly on the spot by pressure with the handle of a scalpel or straight forceps inserted into the nasal vestibule. No further investigation or treatment is rewarding for approximately four days due to oedema, and bruising.

The shoulder and arm

Any injury to the shoulder joint and girdle is not adequately examined until comparison with the surface anatomy of the normal side has been made. The angular ‘step down’ of the acromio-clavicular joint injury, the absence of the normal gentle rounded curve of the shoulder in gleno-humeral dislocation, especially when viewed from behind, the forward displacement of the humerus in dislocation of the elbow joint (no rarity in schoolboys) will all be readily established.

Fractures, particularly of the ulna or head of radius, may not be accompanied by a complaint of pain. Quite frequently only loss of power is apparent until later, when exudate and haematoma formation promote discomfort. Fractures of the metacarpal bones can result from a misguided punch providing a salutary lesson to the offender. Whether or not reduction of dislocation of the phalangeal joints is promptly attempted by skilled attendants, a subsequent x-ray is essential. A Bradford support or Kirschner malleable padded metal splint should be applied to injured fingers post-match.

Thorax and abdomen

Direct forces as in tackling, kicking and crushing, cause injuries to the thorax in team games, though surprisingly, rib fractures are not so common as those of other bones. A reasonable opinion should be possible ‘on site’ as to whether or not the ribs are broken . Naturally, the exertional dyspnoea caused by the game will increase the pain. Sudden but slight pressure with the heel of one hand over the lower end of the sternum and the heel of the other hand over the back bone will produce confirmatory pain at the site of the fracture. If the diagnosis is still uncertain and discomfort persists, further decision should be taken on the touch line; a hasty, ill-advised return to competition may produce the alarming sign of blood stained spit on the pitch thus showing there is lung involvement. An x-ray is essential.

At the costal margin, in the lower part of the front of the chest, the ribs join the costal cartilages and this is the area of maximum chest movement. Costal cartilage injuries are generally due to a crush injury: they are characterised by a sore area, possibly a palpable click on inspiration and the development within half an hour or so of a hard swelling which to some extent will be permanent. An x-ray frequently reveals no fracture. Strapping is inadvisable and the player is match fit when totally pain free. This usually takes five to six weeks.

Serious abdominal injuries are fortunately rare: this is surprising when one considers the blunt trauma to which the area is exposed, e.g. a high velocity boot over the ball, a football weighing approximately 450g and reaching speeds of up to 100km per hour, or a 200g hockey ball at approximately the same speed, from 10 to 15 metres in a penalty corner. A winded player left alone will recover completely after a minute or two. Intelligent awareness and suspicion on the part of the attendant on the field of play are important; if the winded player shows delayed recovery, vomits, looks pale or shocked, prompt hospital referral is required. Unfortunately, the three main internal organs – the spleen, liver and intestines – do not show early bleeding externally; internal bleeding can be rapid and catastrophic.

Be advised: get the player to the hospital in time. Similarly, blunt trauma in the loin may fracture one or more transverse processes or damage the kidney. If a player is injured in this way, even apparently slightly, a routine urine test for the presence of blood, using Haemostix, should be performed after the match; if the test is positive, hospital referral is necessary.

The pelvis and lower limbs

Success in team sports basically depends on running ability. In consequence, more ill-advised decisions to continue playing in the match are made for injuries to this vulnerable region than anywhere else. Objective examination is essential: try to decide whether it is a direct or indirect injury: question the possibility of previous injury at the site, e.g. wasting of the vastus medialis in a former knee injury and look for signs of deformity by comparison with the other limb.

Again, initial pain may be misleading; whereas a superficial type of soft tissue lesion or ligamentous stretch may produce intense transient discomfort which rapidly disappears with an equally rapid recovery, a condition such as an oblique fracture of the fibula just above the lateral malleolus may initially produce a complaint of loss of power and inability to support the body, even though there is a palpable click at the fracture site.

Injury to the quadriceps muscle mass whether due to strain, boot, ball, stick or knee drastically reduces in-match mobility. The ‘charley-horse’ of a central trauma, or the ‘dead-leg’ of the laterally placed lesion need to be treated properly; such injury should be treated early and off the field of play, rather than rubbing with liniment and attempting to ‘run it off with reckless endeavour. The injury site should be first covered with olive oil or Vaseline petroleum jelly to reduce ice burn risk, then crushed ice applied for at least twenty minutes with compression and elevation. A hot bath should not be taken, only a quick shower, followed by replacement of the compression dressing and elevation; ice application should be repeated three times daily for the 48 hour ‘treatment vacuum period’ until review. A player who cannot flex his knee to a right angle 48 hours after the quadriceps injury is most likely suffering from an intramuscular haematoma. This will necessitate careful management, patience, rest, ice contrast treatments, ultrasound, and static quadriceps contractions, otherwise calcification at the site or myositis ossificans may appear insidiously within six weeks.

The sudden jumping when in full stride, or the slide tackling manoeuvre of soccer, may produce avulsion injuries of muscular attachments to the pelvic rami and chronic adductor muscle strain in the thigh, with instability of the symphysis pubis. These injuries also occur in other sports but are much less common. Hamstring injuries, including partial tears, will also drastically reduce coordination and mobility. Avulsion of the biceps femoris tendon of origin has been known to occur. Examination should be full and include the prone position to accurately define the lesion. Frequently it is a recurrence of an injury due to inadequate preparation after the previous one. It should be emphasised that recurrent thigh and adductor lesions require orthopaedic and radiological investigation rather than expectantly persisting with physiotherapy.

The knee, probably the most publicised joint with reference to injuries in sport, is examined initially with the player sitting, not standing. Gently locate the site of pain or tenderness; encourage the player to carry out a few static quadriceps contractions for promoting confidence thus facilitating assessment of the range of active movements; locate the joint line – at the inferior end of the patella with the knee extended. The degree of any injury to the collateral ligaments can be assessed roughly by the range of abduction or adduction, and the presence of ability to draw the tibia forwards in relation to the femur indicates damage to the anterior cruciate ligament. Any suspicion of the presence of these abnormal signs in a previously normal knee joint demands that weight-bearing be avoided and the player carried off for an early orthopaedic opinion: ice should be applied. An effusion into the knee joint may only appear by the time the player has reached hospital. If in doubt, any player with a full movement range who cannot hop on the afflicted leg should come off. (Note: in the case of a minor collateral ligament tear, ice followed by four-hourly treatments with ice and ultrasound preferably for 48 hours often rapidly assist recovery.) With such precautions much recurrent knee joint pathology could be considerably reduced.

Ankle injuries may well beby the type of sports footwear which gives no support to the ankle joint and increases forefoot running instability. A stirrup of extension plaster or the Louisiana Wrap technique are useful measures to augment support.

The traction force of extreme plantar flexion from the prolonged kicking of a soccer ball with the strain of the blow borne by the dorsal capsule of the ankle joint, has long been suspected of exacting a toll on the kicker’s foot with periosteal roughening and bony outgrowths developing laterally. Basketball perhaps shares the running with abrupt changes of direction as in soccer with resultant chronic troublesome stresses. On the field, the decision simply demands absence of full painless movement for the player to be advised to leave the field of play. Likewise, competitors with acute inversion sprains, or injury to the inferior tibiofibular joint should leave the field. The ice technique already mentioned should be used routinely. To some, it would seem reasonable that, after injury, immobilisation of the ankle joint with plaster of Paris, for up to a week as an initial measure, would reduce the incidence of recurrence.

Although the team attendant’s main preoccupation is with primary treatment, he should envisage other responsibilities. He should feel that he has a moral duty to bring to the notice of club officials and the referee after the match any injuries caused in his opinion by dangerous or violent play or improper playing equipment. Furthermore, he should be prepared to discuss with them any player who is predisposed to repetitive injuries particularly concussional incidents. Where injuries are concerned on the field of play, there is no place for heroes!

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