Pancreatic Trauma: An Unusual Soccer Injury.
SOCCER IS THE MOST popular sport worldwide and is gaining increasing prominence as a youth sport in the United States. Despite widespread belief to the contrary among casual observers of the game, some physical contact is allowed. This at times may be vigorous without violating the rules of the game. Serious injuries are uncommon, however, with most being musculoskeletal and involving the lower extremities. 
Pancreatitis is uncommon in childhood. Most cases are related to trauma due to motor vehicle crashes or handlebar trauma from bicycle accidents. [5-7] Contact sports are not usually associated with traumatic pancreatitis. We report a case of pancreatic trauma occurring as a result of a violent collision during a youth soccer match.
A 15-year-old adolescent boy was participating in a soccer game (Division III). As he was attempting to play the ball with his head into the goal, the goalkeeper jumped forward with his right hip and knee flexed. A violent collision between the goalkeeper's knee and the patient's abdomen ensued, flipping the patient to the ground. Immediately after the collision, he was stunned and breathless but otherwise apparently uninjured. He was examined in a local emergency room and thought to have a benign abdomen, though he was having mild mid-abdominal pain. Over the next 24 hours, he had increasingly severe mid-abdominal pain prompting a reevaluation. On physical examination, he was in no distress, and vital signs were normal. Head, neck, and chest examinations were unremarkable. Abdominal examination revealed normal bowel sounds. The abdomen was firm but not rigid, and there was only mild tenderness to deep palpation in the epigastrium. No masses were palpable.
Laboratory values were hemoglobin 15.9 g/dL; white blood count 17,500/[mm.sup.3] with 89% segmented neutrophils, 1% band neutrophils, 3% lymphocytes, and 7% monocytes; alkaline phosphatase 205 IU/L (normal, 30 to 115 IU/L); total bilirubin 1.7 mg/dL (normal, 0.2 to 1.0 mg/dL); aspartate transaminase 26 IU/L (normal, 0 to 40 IU/L); electrolytes normal; amylase 1,248 IU/L (normal, 0 to 88 IU/L). Computed tomography (CT) of the abdomen showed a large amount of free intraperitoneal fluid and a small amount of free retroperitoneal fluid, with a dilated second portion of the duodenum and a poorly enhanced portion of the pancreas near the dilated duodenum (Fig 1).
At emergency celiotomy, an extensive hematoma was encountered in the right retroperitoneum, as well as around the pancreatic head and the duodenum. There was also a contusion of the transverse mesocolon, but the duodenum was intact. Extensive saponification and inflammation were present around the anterior surface of the pancreas, but no obvious tear in the neck of the pancreas or devitalized tissue around the pancreatic head were apparent. Two 10-mm fiat Jackson-Pratt drains were placed in the pancreatic bed, and a jejunostomy was done.
Postoperatively, the patient initially did well. He tolerated tube feedings, and oral intake was resumed on the sixth postoperative day. Coincident with the resumption of oral intake, however, output from the pancreatic drains increased. Oral intake was stopped, and octreotide therapy was begun. High drain output continued, and CT was done on postoperative day 15. Some peripancreatic fluid remained, and there was a defect in the head and neck of the pancreas consistent with a laceration (Fig 2). Endoscopic retrograde cholangiopancreatography (ERCP) was then done. Injection at the major and minor papillac showed no filling of the pancreatic duct beyond the pancreatic head, but there was no obvious leakage. Clinically, the patient was doing well, though high-amylase-content fluid continued to issue from the pancreatic drains. Continued conservative management with octreotide, tube feeding, and observation was chosen. By the 25th hospital day, drainage had stabilized at 250 to 430 mL/day, and the patient was dis charged with the pancreatic drains in place. Tube feeding with no oral intake was continued.
One month after discharge, the patient continued to have drainage of 250 to 400 mL/day but was doing well clinically and had returned to most of his usual activities. Because of the persistent drainage, a second ERCP was done. Again, no filling of the pancreatic duct into the body and tail was seen. Over the next 2 months, the patient remained asymptomatic, and the pancreatic drainage slowly resolved. Drains were removed and oral intake resumed. He has continued to do well and rejoined his soccer team after 1 year's absence. At 2-year follow-up, he remains healthy and pain-free.
Given the widespread participation in sporting activities at both the amateur and elite levels, it is surprising that serious abdominal trauma does not occur more frequently.  The etiology of soccer injuries is complex and relates to factors involving the nature of the sport, the player, and the environment.  Soccer is played primarily with the legs and feet. As expected, most injuries involve the lower extremities. Yet, bodily contact occurs regularly and may be considerable. Most injuries would be expected to occur under these circumstances; however, in the 1994 World Cup games, only 29% of injuries occurred when the referee judged foul play to have occurred.  No similar data are available for youth soccer, but tackling is a frequent cause of lower extremity, especially ankle, injuries in youth games.  Additionally, less skilled players lack body control, making them potentially more susceptible to injuries from careless play.
While low-skilled players tend to have more injuries than high-skilled players, this relates more to an increased number of competitions in which they compete than to skill level.  The risk of injury varies directly with the age of the player [3,4] and the level of competition.  It may also vary with the amount of playing time, position, conditioning, and fatigue of the player. Our patient's case of accidental, pancreatic trauma resulted from the use of excessive force during the course of play. To our knowledge, blunt abdominal trauma in soccer is rare, and no previous case of pancreatic trauma has been reported.
The intensity of play in front of the goal frequently puts goalkeepers in a vulnerable position. To protect themselves from injury, some goalkeepers believe they must keep one knee in front of the body. This technique puts opposing players in danger of injury, as illustrated by our case, and represents dangerous play or, when contact is made, a penal foul.
In childhood and adolescence, pancreatic trauma, which is the most common cause of acute pancreatitis, [14,15] usually results from motor vehicle accidents or handle bar trauma in bicycle accidents. [5-7] While there was no clear indication of a pancreatic laceration in our patient at the time of surgery, follow-up CT showed a laceration at the junction between the neck and body of the pancreas. An ERCP also suggested a ductal injury in this area. Laceration of the pancreas is most likely to occur at the junction of the head and neck where the pancreas overlies the spine. The classic mechanism of this injury is compression of the pancreas between the spine and a force applied external to the abdomen. This is consistent with our patient's case, in which the pancreas was crushed between the goalkeeper's knee and the player's spine. Pancreatic trauma may occur at other sites, however, suggesting that considerable force can be applied tangentially. 
Pancreatic injury is reported in 3% to 12% of all cases of abdominal trauma in adults but in less than 2% in children. [17,18] Other large series suggest pancreatitis is uncommon after blunt trauma.  Treatment in adults has traditionally involved surgical drainage and/or resection; however, the course and treatment of pancreatic trauma in childhood and adolescence may differ from that in adults.  Conservative management with drainage alone seems appropriate in many cases. [7,19,20] Major duct disruption, on the other hand, may best be treated with early distal pancreatectomy [10,19,21,22] Our patient responded to drainage alone despite ERCP evidence of a ductal injury. Although his future course is unknown and complications may yet occur, after 2 years he is healthy, active, and pain-free, suggesting that conservative management alone was effective.
Our case underscores the need to consider serious abdominal injury even in sports not commonly thought to be contact sports. Pancreatic trauma is sometimes difficult to diagnose, since pain is often initially mild and the serum amylase level is not always elevated. [5,22] An elevated level of serum amylase may accompany other serious abdominal injuries and, therefore, does not always reflect pancreatic injury. [7,23] Pancreatic trauma is usually associated with injury to other abdominal organs; however, isolated pancreatic injuries are more likely to occur in children than in adults. [7,24] Although CT may potentially identify a pancreatic laceration, it does not give information about the pancreatic duct.  On the other hand, ERCP allows reliable diagnosis of pancreatic ductal rupture, an injury which usually requires surgical intervention. 
Advances in magnetic resonance imaging now allow imaging of the pancreatic duct without administration of contrast medium. The technique of magnetic resonance cholangiopancreatog raphy (MRCP) will show the normal pancreatic ductal anatomy in most cases.  Because it makes visualization of the pancreatic duct possible, MRCP may be a reliable method of diagnosing suspected ductal trauma, thus eliminating the potential complications of endoscopic pancreatography. A recent preliminary report  suggests that MRCP can detect or exclude pancreatic injury caused by blunt abdominal trauma. The actual clinical utility of this imaging modality is evolving.
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* Pancreatic injury is reported in 3% to 12% of all cases of abdominal trauma in adults, but less than 2% in children.
* The course and treatment of pancreatic trauma in childhood and adolescence may differ from that in adults.
* Conservative management with drainage alone seems appropriate in many cases.
* Major duct disruption may best be treated with early distal pancreatectomy.
* Isolated pancreatic injuries are more likely to occur in children than in adults.
* Magnetic resonance cholangiopancreatography may be a reliable method of diagnosing suspected ductal trauma, eliminating the potential complications of endoscopic pancreatography.