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Pancreatic Trauma: An Unusual Soccer Injury.



ABSTRACT: We report a case of pancreatic duct pancreatic duct
n.
The excretory duct of the pancreas, extending through the gland from tail to head, where it empties into the duodenum. Also called Wirsung's canal.
 laceration laceration /lac·er·a·tion/ (las?er-a´shun)
1. the act of tearing.

2. a torn, ragged, mangled wound.


lac·er·a·tion
n.
1. A jagged wound or cut.

2.
 and acute pancreatitis acute pancreatitis Inflammation of the pancreas of abrupt onset, often with gallstones and alcohol ingestion Epidemiology 109,000 hospitalizations, 2251 deaths–US; 10-fold ↑ from 1960s to 1980s–reason unclear;  resulting from blunt abdominal trauma sustained in a youth soccer match. Since this sports injury sports injury A injury sustained practicing or competing in a sport Sites Thigh, foot, knee, lower leg, ankle, hip, finger Types Contusion, strain, sprain, heat exhaustion, lacerations, etc Sports with most Martial arts–judo, tae kwon do, wrestling,  is unusual, a brief discussion of soccer injuries and of the management of pancreatic trauma in childhood is provided.

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 musculoskeletal /mus·cu·lo·skel·e·tal/ (-skel´e-t'l) pertaining to or comprising the skeleton and muscles.

mus·cu·lo·skel·e·tal
adj.
Relating to or involving the muscles and the skeleton.
 and involving the lower extremities. [14]

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.

CASE REPORT

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 abdominal examination Clinical medicine A hands-on evaluation of the abdominal cavity to identify abnormalities, if any, based on any change in size, shape, consistency, or sound on percussion of the organs found therein. See Abdomen.  revealed normal bowel sounds bowel sounds
pl.n.
Abdominal sounds caused by the products of digestion as they move through the lower gastrointestinal tract, usually heard on auscultation.
. The abdomen was firm but not rigid, and there was only mild tenderness to deep palpation palpation /pal·pa·tion/ (pal-pa´shun) the act of feeling with the hand; the application of the fingers with light pressure to the surface of the body for the purpose of determining the condition of the parts beneath in physical diagnosis.  in the epigastrium epigastrium /epi·gas·tri·um/ (ep?i-gas´tre-um) the upper and middle region of the abdomen, located within the sternal angle.epigas´tric

ep·i·gas·tri·um
n. pl.
. No masses were palpable.

Laboratory values were hemoglobin 15.9 g/dL; white blood count 17,500/[mm.sup.3] with 89% segmented neutrophils neutrophils (ner·ō·trōˑ·filz),
n.pl white blood cells with cytoplasmic granules that consume harmful bacteria, fungi, and other foreign materials.
, 1% band neutrophils, 3% lymphocytes, and 7% monocytes monocytes,
n.pl the largest of the white blood cells. They have one nucleus and a large amount of grayish-blue cytoplasm. Develop into macrophages and both consume foreign material and alert T cells to its presence.
; alkaline phosphatase 205 IU/L (normal, 30 to 115 IU/L); total bilirubin Bilirubin

The predominant orange pigment of bile. It is the major metabolic breakdown product of heme, the prosthetic group of hemoglobin in red blood cells, and other chromoproteins such as myoglobin, cytochrome, and catalase.
 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 amylase (ăm`əlās'), enzyme having physiological, commercial, and historical significance, also called diastase. It is found in both plants and animals. Amylase was purified (1835) from malt by Anselme Payen and Jean Persoz.  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 retroperitoneal /ret·ro·peri·to·ne·al/ (-per?i-to-ne´al) posterior to the peritoneum.

ret·ro·per·i·to·ne·al
adj.
Situated behind the peritoneum.
 fluid, with a dilated dilated

a state of dilatation.


dilated cardiomyopathy
see congestive cardiomyopathy.

dilated pupil syndrome
see feline dysautonomia (Key-Gaskell syndrome).
 second portion of the duodenum duodenum: see intestine; pancreas.
duodenum

First and shortest (9–11 in., or 23–28 cm) segment of the small intestine. It curves down and then up from the pylorus of the stomach, where chyme enters it.
 and a poorly enhanced portion of the pancreas near the dilated duodenum (Fig 1).

At emergency celiotomy, an extensive hematoma hematoma /he·ma·to·ma/ (he?mah-to´mah) a localized collection of extravasated blood, usually clotted, in an organ, space, or tissue.  was encountered in the right retroperitoneum, as well as around the pancreatic head and the duodenum. There was also a contusion CONTUSION, med. jurisp. An injury or lesion, arising from the shock of a body with a large surface, which presents no loss of substance, and no apparent wound. If the skin be divided, the injury takes the name of a contused wound. Vide 1 Ch. Pr, 38; 4 Carr. & P. 381, 487, 558, 565; 6 Carr.  of the transverse mesocolon, but the duodenum was intact. Extensive saponification saponification /sa·pon·i·fi·ca·tion/ (sah-pon?i-fi-ka´shun) conversion of an oil or fat into a soap by combination with an alkali.  and inflammation were present around the anterior surface of the pancreas, but no obvious tear in the neck of the pancreas or devitalized de·vi·tal·ized
adj.
Devoid of vitality or life, as a tooth with destroyed pulp.
 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 Endoscopic Retrograde Cholangiopancreatography Definition

Endoscopic retrograde cholangiopancreatography (ERCP) is a technique in which a hollow tube called an endoscope is passed through the mouth and stomach to the duodenum (the first part of the
 (ERCP ERCP
abbr.
endoscopic retrograde cholangiopancreatography


Endoscopic retrograde cholangiopancreatography (ERCP)
Diagnostic technique used to obtain a biopsy.
) 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.

DISCUSSION

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. [8] The etiology of soccer injuries is complex and relates to factors involving the nature of the sport, the player, and the environment. [9] 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. [10] No similar data are available for youth soccer, but tackling is a frequent cause of lower extremity, especially ankle, injuries in youth games. [11] 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. [12] The risk of injury varies directly with the age of the player [3,4] and the level of competition. [13] 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. [16]

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. [16] 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. [7] 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 Pancreatectomy Definition

Pancreatectomy is the surgical removal of the pancreas. Pancreatectomy may be total, in which case the whole organ is removed, or partial, referring to the removal of part of the pancreas.
 [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. [5] On the other hand, ERCP allows reliable diagnosis of pancreatic ductal rupture, an injury which usually requires surgical intervention. [25]

Advances in magnetic resonance imaging magnetic resonance imaging (MRI), noninvasive diagnostic technique that uses nuclear magnetic resonance to produce cross-sectional images of organs and other internal body structures.  now allow imaging of the pancreatic duct without administration of contrast medium. The technique of magnetic resonance cholangiopancreatog raphy (MRCP MRCP Member of Royal College of Physicians.

MRCP
abbr.
Member of the Royal College of Physicians
) will show the normal pancreatic ductal anatomy in most cases. [26] 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 en·do·scope  
n.
An instrument for examining visually the interior of a bodily canal or a hollow organ such as the colon, bladder, or stomach.



en
 pancreatography. A recent preliminary report [27] suggests that MRCP can detect or exclude pancreatic injury caused by blunt abdominal trauma. The actual clinical utility of this imaging modality is evolving.

References

(1.) Fried T, Lloyd GJ: An overview of common soccer injuries. management and prevention. Sports Med 1992; 14:269-275

(2.) Inklaar H: Soccer injuries: I. Incidence and severity. Sports Med 1994; 18:55-73

(3.) Schmidt-Olsen S, Jorgensen U, Kaalund S, et al: Injuries among young soccer players. Am J Sports Med 1991; 19:273-275

(4.) Tucker AM: common soccer injuries, diagnosis, treatment and rehabilitation. Sports Med 1997; 23:21-32

(5.) Arkovitz MS, Johnson N, Garcia VF: Pancreatic trauma in children: mechanisms of injury. J Trauma 1997; 42:49-53

(6.) Smith SD, Nakayama DK, Gantt N, et al: Pancreatic injuries in childhood due to blunt trauma. J Pediatr Surg 1988; 23:610-614

(7.) Takishima T, Sugimoto K, Asari Y, et al: Characteristics of pancreatic injury in children: a comparison with such injury in adults. J Pediatr Surg 1996; 31:896-900

(8.) Nielson AB, Yde J: Epidemiology and traumatology traumatology /trau·ma·tol·o·gy/ (-tol´o-je) the branch of surgery dealing with wounds and disability from injuries.

trau·ma·tol·o·gy
n.
 of injuries in soccer. Am J Sports Med 1989; 17:803-807

(9.) Inklaar H: Soccer injuries: II. Aetiology aetiology

see etiology.
 and prevention. Sports Med 1994; 18:81-93

(10.) Hawkins RD, Fuller CW: Risk assessment in professional football: an examination of accidents and incidents in the 1994 World cup finals. Br J Sports Med 1996; 30:165-170

(11.) Yde J, Nielsen AB: Sports injuries in adolescents' ball games: soccer, handball handball

Any of a variety games in which a small rubber ball is struck against a wall with the hand or fist. It can be played in a three- or four-walled court or against a single wall by two or four players (in singles or doubles games, respectively).
, and basketball. Br J Sports Med 1990; 24:51-54

(12.) Poulsen TD, Freund KG, Madsen F, et al: Injuries in high. skilled and low-skilled soccer: a prospective study. Br J Sports Med 1991; 25:151-153

(13.) Ficarra BJ: Diseases and injuries in athletes: a review. J Med 1996; 27:241-275

(14.) Warner RL Jr, Othersen HB Jr, Smith CD: Traumatic pancreatitis and pseudocyst pseudocyst /pseu·do·cyst/ (soo´do-sist)
1. an abnormal or dilated space resembling a cyst but not lined with epithelium.

2.
 in children: current management. J Trauma 1989; 29:597-601

(15.) Ziegler DW, Long JA, Philippart AI, et al: Pancreatitis in childhood. experience with 49 patients. Ann Surg 1988; 207:257-261

(16.) Craig MH, Talton DS, Hauser CJ, et al: Pancreatic injuries from blunt trauma. Am Surg 1995; 61:125-128

(17.) Jurkovich GJ, Carrico CJ: Pancreatic trauma. Surg Clin North Am 1990; 70:575-593

(18.) Sivit CJ, Eichelberger MR, Taylor GA, et al: Blunt pancreatic trauma in children: CT diagnosis. AJR AJR American Journal of Roentgenology
AJR American Journalism Review
AJR Academy for Jewish Religion
AJR Association of Jewish Refugees (UK organization)
AJR Accelerated Junctional Rhythm
 Am J Roentgenol 1992; 158:1097-1100

(19.) Keller MS. Stafford PW, vane Vane , John Robert 1927-2004.

British pharmacologist. He shared a 1982 Nobel Prize for research on prostaglandins.



vane

the membranous or main part of the contour feather in birds as distinct from the shaft.
 DW: Conservative management of pancreatic trauma in children. J Trauma 1997; 42:1097-1100

(20.) Patton JH Jr, Lyden SP, Croce MA, et al: Pancreatic trauma: a simplified management guideline. J Trauma 1997; 43:234-239

(21.) McGahren ED, Magnuson D, Schaller RT, et al: Management of transected pancreas in children. Aust NZ J Surg 1995; 65:242-246

(22.) Patton JH Jr, Fabian TC: Complex pancreatic injuries. Surg Clin North Am 1996; 76:783-795

(23.) Farrell RJ, Krige JE, Bornman PC, et al: Operative strategies in pancreatic trauma. Br J Surg 1996; 83:934-937

(24.) Sparnon AL, Ford WD: Bicycle handlebar injuries in children. J Pediatr Surg 1986; 21:118-119

(25.) Barkin JS, Ferstenberg RM, Panullo W, et al: Endoscopic retrograde cholangiopancreatography in pancreatic trauma. Castrointest Endosc 1988; 34:102-105

(26.) Bret PM, Reinhold C, Trourel P, et al: Pancreas divisum: evaluation with MR cholangiopancreatography. Radiology 1996; 199:99-103

(27.) Fulcher AS, Turner MA, Yelon JA, et al: Magnetic resonance cholangiopancreatography Magnetic resonance cholangiopancreatography (MRCP) is a medical imaging technique which uses magnetic resonance imaging to visualise the biliary and pancreatic ducts in a non-invasive manner.  (MRCP) in the assessment of pancreatic duct trauma and its sequence: preliminary findings. J Trauma 2000; 48:1001-1007

KEY POINTS

* 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.
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Author:CUSTER, MONFORD D.
Publication:Southern Medical Journal
Geographic Code:1USA
Date:Jul 1, 2001
Words:2269
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