Pediatr Clin N Am 49 (2002) 581 – 591

Catastrophic pediatric sports injuries

Eugene F. Luckstead, MDa,*, Dilip R. Patel, MDb
a
Pediatric Medicine Department, Texas Tech Medical School-Amarillo,
1400 Coulter Drive, Amarillo, TX 79160, USA
b
Department of Pediatrics & Human Development, Michigan State University,
Kalamazoo Center for Medical Studies, 1000 Oakland Drive, Kalamazoo, MI 49008, USA

Catastrophic sports injuries

A concern of most parents, some coaches, and the occasional athlete is
possible catastrophic injury resulting either directly or indirectly from sports.
Most people, however, do not realize that Theodore Roosevelt almost banned
American football in the early nineteenth century because of the high football –
related death rate or that the National Collegiate Athletic Association (NCAA)
owes part of its early inception to sport-related deaths [1]. Dr. Fredrick Mueller
has been compiling a national high school and college database on sport related
catastrophic injuries.
The National Center for Catastrophic Sport Injury Research (NCCSI) has been
directed by Mueller at the University of North Carolina, Chapel Hill since 1980.
Financial support is provided by the NCAA, American Football Coaches
Association, and the National Federation of State High School Associations.
The purpose established originally by the American Football Coaches in 1931
was to monitor annual football fatalities. Today, the primary goal is to make
football a safer sport by developing needed rule changes and improving
equipment, coaching methods, and medical care available to high school and
college athletes [2]. Data are collected each year by personal contact with
officials and questionnaires when there is a reported or suspected fatality.
Due to the success of the football surveillance [2], the research data were
expanded in 1982 to most high school and college sports for both men and
women [2,3]. The paucity of data from other sports, the need for sport-related
safety, and the rapid growth of women’s sport at the high school and college
levels has served as an impetus for the expanded National Data Center Report
from 1982 to 2000 [3].

* Corresponding author.
E-mail address: gene@cortex.ama.ttuhsc.edu (E.F. Luckstead).

0031-3955/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.
PII: S 0 0 3 1 - 3 9 5 5 ( 0 2 ) 0 0 0 0 6 - 8
582 E.F. Luckstead, D.R. Patel / Pediatr Clin N Am 49 (2002) 581–591

It has been reported that approximately 7% of the 2500 new cases of

paraplegia and 7% of the 1050 new cases of quadriplegia in America each year
are related to sports injury [4]. About 410,000 people sustain brain injuries each
year with 17,600 left with permanent disabilities. Approximately 10% of these
brain injuries result from sport or recreational activities [2,4]. An estimated
142,600 people die of injuries each year. Injury is the leading cause of death in
children and young adults, and although the number of deaths related to sports is
actually low, the injuries caused are often catastrophic. Such injuries led to the
initiation in 1965 of studying football-related catastrophic injuries [2,5].
Catastrophic injuries are divided into three categories: (1) serious when the
injury is severe but not permanent, (2) nonfatal when severe with permanent
disability, or (3) fatal when death occurs [2 –4]. Catastrophic sports injuries are
considered either direct or indirect injuries. Direct injuries result directly from the
sport participation itself. Indirect injuries result either from sport-related exertion
or from a secondary nonfatal complication of sport participation. Data were
collected for fall, winter, and spring sports over the 18-year survey period of this
report. (Table 1) [3]

Catastrophic head and spine injuries

The brain and spinal cord make up the most complex and vital organ system in
the body. Although recovery from mild brain and spinal cord injury is possible,
both the brain and spinal cord currently are incapable of severe injury recovery
and cannot be replaced by transplantation or artificial parts [4,6,7].

Table 1
National center sports data collection
Baseball
Basketball
Cheerleading
Cross country
Field hockey
Football
Gymnastics
Ice hockey
Lacrosse
Skiing
Soccer
Softball
Swimming
Tennis
Track
Volleyball
Water polo
Wrestling
From Mueller FO, Cantu RC. NCCSIR Eighteenth annual report of the National Center for
Catastrophic Sport Injury Research: Fall 1982 – Spring 2000, Chapel Hill, NC: National Center for
Catastrophic Sport Injury Research; 2000; with permission.
 E.F. Luckstead, D.R. Patel / Pediatr Clin N Am 49 (2002) 581–591 583

Brain injuries
Brain injuries result from coup or contrecoup injuries and fractures with
displacement. When the brain and spinal cord sustain injury from compression,
tensile and shearing types of stress forces occur; neural tissues tolerate such
shearing forces poorly [3,4,7]. Studies have shown that the scalp acts as a
protective ‘‘damper’’ to outside forces on the head, with ten times greater force
needed to cause a skull fracture when the scalp is intact; also when the neck
muscles are tensed on impact, the head tolerates greater force without sustaining
brain injury [4]. Sport related brain injuries include concussion, postconcussion
syndrome, intracranial hemorrhages, and second impact syndrome.
There continues to be several concussion diagnostic or semantic ‘‘turf’’
areas, but after more than 20 years’ experience as a team physician at both the
college and high school levels, one author (EFL) still favors the practical
grading scenario proposed by Cantu. In 1986, Cantu incorporated posttraumatic
amnesia with other presentation symptoms and signs of concussions and
classified them as mild, moderate, or severe [5]. (Landry describes concussion,
postconcussion syndrome, and second impact syndrome in more detail else-
where in this issue.)

Intracranial hemorrhage
Intracranial hemorrhage is the leading cause of death from sport-related head
injuries [1,4,5]. All four types of brain hemorrhage, epidural, subdural, intra-
cerebral, and subarachnoid can be rapidly fatal, and therefore, proper assessment
and anticipatory head injury follow-up is critical. Epidural intracranial hemor-
rhage is typically most rapidly progressive with death occurring within 30 to 60
minutes; changes virtually always present within a 1- to 2-hour period after injury
[4,5,7]. Associated brain injury with epidural injury is uncommon if clot removal
occurs early. Subdural hematomas are the most common fatal head injury with
clot-associated brain injury common and thus cause greater morbidity and high
mortality when surgery is required in the first 24 hours [4,7]. CT scan of the head
is the diagnostic procedure of choice. Subarchnoid bleeding is more like a brain
contusion or bruise. Headaches are common, and other secondary changes can
occur such as trauma-related seizures.
For those athletes with milder head injuries, prevention remains the key.
Players in all sports should understand the need to report mild head trauma
symptoms to coaches, trainers, parents, and physicians [5,24]. Second impact
syndrome results from sustaining a second head injury before symptoms of the
first head injury have resolved. An approximately 50% mortality rate and a
100% morbidity rate have been reported; however, these high mortality and
morbidity rates have been challenged in recent years as being too high. It
should be noted that the severity of the first impact could be mild or moderate
and that the risk period is at least 72 hours and possibly up to a week in some
cases [4,6].
584 E.F. Luckstead, D.R. Patel / Pediatr Clin N Am 49 (2002) 581–591

Cervical spine injuries

Cervical spine injuries can involve the seven cervical vertebrae, associated
multiple ligaments, and intervening cartilage units and neck muscles. The
cervical spine is more injury tolerant for flexion (forward) motion toward the
anterior chest or sternum than posterior (extension) cervical spine motion toward
the back, which results in more severe injury [4]. Flexion, extension, rotation,
and compression cervical spine injuries result from sport-related forces. Com-
pression or burst injuries occur to the cervical spine when the neck is flexed with
the spine straight vertically instead of the normal head up position with the spine
having a slightly lordotic curve. When such an injury causes additional vertebral
displacement into the spinal cord, then quadriplegia results [4,8,9]. Most cervical
spine injuries occur from head trauma in sports such as American football, ice
hockey, or diving. Other types of neck injuries can occur with direct or indirect
neck trauma. Occasionally vascular neck lacerations do occur with the attendant
risk of large vessel bleeding [4,8].
Cervical spine injuries rarely have subdural bleeding sites but instead
typically have intraspinal (within the cord) bleeding. Epidural bleeding is the
second most common type of cervical spine bleeding. Unstable cervical fractures
are a major concern in cervical spine injuries with resulting quadriplegia;
diagnostic confirmation is required by cervical radiographs. An athlete fully
conscious after cervical injury typically demonstrates muscle spasm and pain.
Those athletes unconscious after an injury should be presumed to have a neck
injury until radiographic clearance occurs. Transport must have mandated
immobilized protection of the head and neck. A neurologic examination is
followed by lateral neck radiographs while the athlete is still immobilized. If the
lateral cervical spine is normal by radiograph, obtain a complete cervical spine
series for cervical spine injuries, as 20% are missed by lateral examination alone
[10]. If injury is documented on the lateral cervical spine, CT, contrast CT, or
MR imaging is required to further define the degree of cervical injury [4,7,10].
Guidelines for appropriate care of the spine-injured athlete, developed by the
Inter-Association Task Force For Appropriate Care of the Spine-Injured Athlete,
are listed in Table 2 [11].

Stingers
Stingers or ‘‘burners’’ occur frequently in high school and college age athletes.
Some estimate that at least half of all football players will have at least one
‘‘stinger’’ in a career [6,7]. The athlete experiences a shock type of pain sensation
with numbness and burning typically from the C5 and C6 dermatomes of the arm
and hand; some will have significant weakness. Symptoms are usually transient,
unilateral, and subside in minutes with full return to normal usually within 30 to
60 minutes. If symptoms are bilateral or involve the legs, then ‘‘burning hands
syndrome’’ should be considered [7]. (See the article by Landry in the next issue,
49/4 for further discussion of this area.)
 E.F. Luckstead, D.R. Patel / Pediatr Clin N Am 49 (2002) 581–591 585

Table 2
Interassociation task force guidelines for appropriate care of the spine-injured athlete
General guidelines
. Any athlete suspected of having a spinal injury should not be moved and should be managed as
though a spinal injury exists.
. The athlete’s airway, breathing, circulation, neurologic status, and level of consciousness should
be assessed.
. The athlete should not be moved unless absolutely essential to maintain airway, breathing,
and circulation.
. If the athlete must be moved to maintain airway, breathing, and circulation, the athlete should be
placed in a supine position while maintaining spinal immobilization.
. When moving a suspected spine-injured athlete, the head and trunk should be moved as a unit.
One accepted technique is to manually splint the head to the trunk.
. The Emergency Medical Services system should be activated.
Face mask removal
. The face mask should be removed prior to transportation, regardless of current respiratory status.
. Those involved in the prehospital care of injured football players should have the tools for face
mask removal readily available.
Football helmet removal
The athletic helmet and chin strap should only be removed:
. If the helmet and chin strap do not hold the head securely, such that immobilization of the
helmet does not also immobilize the head
. If the design of the helmet and chin strap is such that, even after removal of the face mask, the
airway cannot be controlled nor ventilation provided
. If the face mask cannot be removed after a reasonable period of time;
. If the helmet prevents immobilization for transportation in an appropriate position.
Spinal immobilization must be maintained while removing the helmet.
. Helmet removal should be practiced frequently under proper supervision.
. Specific guidelines for helmet removal must be developed.
. In most circumstances, it may be helpful to remove check padding and/or deflate air padding
prior to helmet removal.
Equipment
Appropriate spinal alignment must be maintained.
. There needs to be a realization that the helmet and shoulder pads elevate an athlete’s trunk
when in the supine position.
. Should either the helmet or shoulder pads be removed — or if only one of these is present —
appropriate spinal alignment must be maintained.
. The front of the shoulder pad can be opened to allow access for CPR and defibrillation.
Additional guidelines
. This task force encourages the development of a local emergency care plan regarding the
prehospital care of an athlete with a suspected spinal injury. This plan should include
communication with the institution’s administration and those directly involved with the
assessment and transportation of the injured athlete.
. All providers of prehospital care should practice and be competent in all of the skills identified in
these guidelines before they are needed in an emergency situation.

If an athlete has transient quadriplegia or bilateral neurologic symptoms after a

contact sport injury, spinal cord injury may have occurred and cervical spinal
stenosis may be associated. There is some controversy regarding use of either
plain cervical radiographs or the Torg-Pavlov radiograph vertebral ratio method
586 E.F. Luckstead, D.R. Patel / Pediatr Clin N Am 49 (2002) 581–591

to diagnose cervical spine stenosis and predict future cervical spine injuries from
abnormal sagittal cervical canal diameter [2,4,8,12]. Torg strongly believes that
his patient data supports that any spinal canal to vertebral body ratio below 0.80
indicates significant cervical spinal canal stenosis [13,14].
According to Cantu [5,6], cervical spinal stenosis as measured by the ratio
method is less useful in detecting athletes at risk for further spinal injury. He
recommends using functional spinal stenosis, defined as loss of the cerebrospi-
nal fluid around the cord or deformation of the cord documented by MR
imaging, contrast enhanced CT, or myelography [5]. Cantu contends that ath-
letes with functional spinal stenosis and neuropraxia are at risk for permanent
cord injury and should be restricted from further contact or collision sport
participation [5].
Neuropraxia from cervical spine injuries raises the question of further sport
participation. A study of 117 young athletes who sustained permanent quadriplegia
recalled never having had prior transient quadriplegia, and conversely, those with
transient quadriplegia have not had been predisposed to permanent neurologic
injury. However, if demonstrably cervical spine instability or acute/chronic
degenerative conditions exist participation in contact sports should not be allowed
[8]. Cervical spinal stenosis is currently individualized regarding further contact
sport involvement. Spear tacklers spine, when identified, is an absolute contra-
indication for contact sports [9]. American football, diving, gymnastics, tram-
poline, ice hockey, and rugby are some of the higher risk sports for cervical spine
injuries (see Table 1).
Several authors have reviewed criteria for return to play for athletes with
cervical spine injury based on specific conditions and injuries and risk stratifica-
tion; a detailed discussion of these conditions and criteria is out of scope of this
review [5,14,15]. Schnebel notes that certain findings may restrict contact and
collision sport participation [16]. The following findings restrict contact and
collision sports: (1) intersegmental instability on flexion-extension radiographs,
(2) anterior/posterior glide in the upper cervical spine, (3) cervical stenosis
associated with transient quadriplegia, (4) cord impingement with myelopathy,
(5) significant neurologic impairment or risk of neurologic impairment with
herniated disk or obstructing lesion, (6) limiting pain, and (7) a previous spinal
fusion [16].

Football
There were three reported deaths in high school football for the 2000 season
and none in college [2]. Football had the greatest number of catastrophic injuries
during 1999 season with 21 direct catastrophic injuries in high school; these
numbers compares to 28 in 1998 and 34 for the 1993 high school season [2– 4].
College football had three direct catastrophic injuries but no fatalities during
2000. Because there were 1,800,000 high school participants in 2000, this notes a
direct fatality rate of 0.17/100,000 participants when junior high and high school
football player numbers were both included [2,3].
 E.F. Luckstead, D.R. Patel / Pediatr Clin N Am 49 (2002) 581–591 587

Two of the three deaths were from commotio cordis and the other from brain
injury. There were 12 indirect fatalities in 2000 with 10 associated with high
school football (8 heart related; 2 heat related); both college fatalities were heat
related. Similar numbers were noted in 1999 with 11 fatalities at the high school
level. (Seven were heart related, 2 heat related and 1 sickle cell disease and 1of
natural causes) [2,3].
Head and neck injuries have decreased markedly since the 1976 rule change
on spearing and a change in coaching of tackling techniques with the attention
to ‘‘keeping the head up when initial contact occurs and never leading with the
top of the head, helmet, or face mask.’’ Helmet or ‘‘face to the numbers’’
tackling or blocking techniques are by current rule changes illegal and are
recognized as dangerous from past NCCSI data [2– 4]. Failure to enforce this
illegal technique by either coaches or game officials places players at significant
risk for permanent paralysis or death [2 –4]. Close observation of football
players for head and neck injuries, heat intolerance symptoms, and any other
signs of medical problems should be a high priority and measures taken to
identify and safely protect such athletes [17]. One must ensure the use of
properly fitting and updated protective football equipment despite increasing
helmet and other equipment costs and ensure that worn or ill-fitting equipment is
discarded for safer team football participation.
Heat stroke and heat intolerance in young athletes is discussed further by
Martin earlier in this issue. Unfortunately, despite a widespread effort, the highly
preventable problem of sport related heat stroke persists with a significant
number of deaths each year. Our education efforts must improve and continue
at the highest priority levels.

Fall sports
Overall, in 1999, fall sports had 23 direct catastrophic injuries, with 21
associated with football, one with cross-country, and one with soccer [3]. There
were 5 fatalities; 10 injuries with permanent disabilities, and 8 serious injuries
with recovery [3].
During the 18-year period studied, high school fall sports had 478 direct
catastrophic injuries with football having 460 (96.2%) [2,3]. There were 147
indirect fall catastrophic injuries in the 18 years (1982 – 1999) with 146 fatalities;
112 were related to football. Four of the deaths were of girls, with 3 in soccer and
1 in cross-country.
There were 108 college direct sports catastrophic injuries with 105 associated
with football during the 18-year study. Of the 31 indirect college catastrophic
injuries, 25 were with football. Football, soccer and cross-country have similar
indirect fatality rates. Rates for direct sport catastrophic injury (0.30 fatalities;
0.71 nonfatal; 0.76 serious injuries) for football, however, was higher than for
soccer and cross-country [3].
588 E.F. Luckstead, D.R. Patel / Pediatr Clin N Am 49 (2002) 581–591

Winter sports
There were five direct catastrophic injuries during 1999 in winter sports; one
in basketball, two in ice hockey, and two in wrestling. Five indirect catastrophic
injuries were also noted; all were fatalities were heart related and if male athletes,
with four in basketball, and one in ice hockey. College sports had no indirect
injuries but had two direct catastrophic injuries in basketball and one in ice
hockey. During the 18-year study, there were 92 high school direct catastrophic
injuries (7 fatalities; 48 nonfatal, and 37 serious) and 102 indirect catastrophic
injuries [3].
Wrestling had 42 (45.6%) and gymnastics had 12 (13%) of the direct
catastrophic injuries during this 18-year study [3]. Basketball was associated
with 12 (14.1%) of the direct catastrophic injuries and also had the largest number
of indirect fatalities with 78 (76.5%). Ice hockey had 15 (16.3%), swimming
9 (9.8%), and volleyball 1 (1.1%) of the remaining winter sport direct injuries.
College athletes had 22 direct and 25 indirect catastrophic injuries. Ice hockey
had 8 (36.4%), gymnastics 6 (27.3%), basketball 5 (22.7%,) and swimming,
skiing, and wrestling 1 (4.5%) each [3].
Of the 25 college indirect catastrophic injuries, 14 (56%) were in basketball, 4
in swimming, 3 in wrestling, 2 in ice hockey and 1 each in skiing and volleyball
[3]. High school wrestling had the greatest number of indirect injuries but along
with basketball and swimming had low direct injury rates. Ice hockey and
gymnastics had the highest direct injury rates for winter sports. Indirect rates were
all below 1 per 100,000 participants. Both direct and indirect college catastrophic
injury rates were higher than for the high school athlete in wrestling, ice hockey,
gymnastics, basketball, and swimming [3]. (Note: Three heat-related deaths were
noted in college wrestlers.)

Spring sports
High school spring sports had seven direct and seven (all fatal) indirect
catastrophic injuries in 2000; none occurred in college spring sports [3]. Direct
injuries occurred as follows: 2 in baseball and lacrosse and 1 each in track and
softball. During the 18-year period, high school spring sports had 91 direct
catastrophic injuries with 29 fatalities, 29 nonfatal, and 33 serious [3]. Baseball
accounted for 38, track for 46, lacrosse 4, and softball 3. Female athletes
accounted for 4 of the 46 in track and all 3 of the softball injuries.
There were 37 fatalities during the 18 years from 1982 to 1999 with 23 in
track, 9 in baseball, 3 in lacrosse, and 2 in tennis [3]. Four of the track fatalities
were female. College spring sports had 18 direct and 6 indirect fatalities (2 tennis,
1 track, 2 baseball, and 1 lacrosse) during the study period. The were 5 fatal, 7
nonfatal, and 6 serious college direct catastrophic injuries, with 8 in track and 5
each in baseball and lacrosse. Both high school and college had low direct and
indirect catastrophic injury rates in general [3].
 E.F. Luckstead, D.R. Patel / Pediatr Clin N Am 49 (2002) 581–591 589

Cheerleading
There has been an 18-year collection of data on cheerleading injuries at the
high school and college levels [3]. Dramatic increases (over threefold) in the
number of injuries have occurred largely due to change from previous cheer-
leading styles to more gymnastic-type cheerleader skills and expectations. Each
group had one fatality but high school cheerleaders had higher serious and
nonfatal catastrophic injury rates than college-level cheerleaders. Cheerleaders
in college and high school account for more than half of the catastrophic in-
juries that occur in female athletes [3]. If cheerleading is going to continue to
have gymnastic-type conditioning and training demands, this should be viewed
from a similar gymnastic-like injury perspective, as a sport with higher injury
risks and expectations.

Eye trauma
Injuries to eyes can be potentially catastrophic resulting in permanent loss of
vision. Injuries can result from direct impact to eyes from a ball, bat, or foreign
body or collision with another player and can lead to penetrating or blunt injury
[18 – 21].
Certain symptoms indicate the severity of the injury: loss of vision, pho-
tophobia, diplopia, proptosis, irregular pupils, foreign body sensation, sclero-
conjunctival injection, hyphema, and halos around lights [19]. The eye should be
meticulously examined.
Sports with high risk for severe eye injuries include indoor cricket, full-contact
martial arts, racquet sports, lacrosse, wrestling, softball, baseball, and hockey
[18,19]. The American Academy of Pediatrics (AAP) strongly recommends poly-
carbonate protective eyewear for all athletes in high-risk sports to prevent severe
eye injuries. Such protection has been shown to reduce the risk of significant eye
injury by almost 90%. The AAP and NCAA [18,20] have made appropriate
protective eyewear recommendations.

Indirect causes of death in athletes

Sudden death in young athletes
Indirect or nontraumatic deaths in high school and college athletes have been
identified to be predominately caused by the following cardiac anomalies:
hypertrophic cardiomyopathy, coronary artery anomalies, myocarditis, aortic
stenosis, aortic rupture, and right ventricular cardiomyopathy (particularly in
Europe/Italy) [17]. Dysrhythmias from Ebstein’s anomaly with pre-excitation,
long QT syndromes, Brugada syndrome, and other pre-excitation syndromes also
have been identified but less commonly. Certain dysrhythmias are potentially
vulnerable to exercise or sports such as swimming or high levels of exertion [17].
590 E.F. Luckstead, D.R. Patel / Pediatr Clin N Am 49 (2002) 581–591

(See the article by Luckstead earlier in this issue.) Exertional rhabdomyolysis can
occur in athletes with sickle cell trait, particularly in those individuals who
‘‘excessively’’ push themselves in conditioning and heat intolerance situations or
who may be dehydrated or poorly conditioned [22,23].
Direct causes of sudden death are cardiac concussion or commotio cordis
syndrome. Such young athletes usually have thinner chest walls and are struck in
the chest by a hard object that causes sudden cardiac death from ventricular
fibrillation [17]. (See the article by Luckstead in the next issue, 49/4.)

Summary
The high school sports of wrestling, gymnastics, ice hockey, baseball, track,
and cheerleading should receive closer attention to prevent injury. Safer equip-
ment and sport-specific conditioning should be provided and injuries strictly
monitored. Greater attention must also be paid to swimming and diving techni-
ques, and continued observation is needed for heat stroke and heat intolerance in
sports such as football, wrestling, basketball, track and field, and cross-country.
An increased awareness of commotio cordis in sports other than baseball should
include ice hockey, football, track field events, and lacrosse. American football
because of the sheer numbers and associated catastrophic injury potential must
continue to be monitored at the highest medical levels!

References

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