School rugby has become a high-impact sport. Emulating professionals, boys weight-train and wear padding to deliver greater force to their tackles and scrums.
Despite weight, height and age matching, this can result in unmatched scrums, which can lead to serious injuries.
Anxieties about an apparent increase in spinal injuries in teenagers playing rugby have prompted a Scottish government enquiry and caused the Queen Elizabeth National Spinal Injury Unit in Glasgow to analyse the problem.
Touch-line GPs know to 'move the match not the patient', and carry equipment to combat shock, maintain an airway, start CPR and call an ambulance.
But these are not the injuries we see in surgery. School children often go home after injury and are brought to surgery the next day because their symptoms have not improved.
From head to toe, here are some points to consider when a child with a rugby injury presents.
A history of head injury in a child requires a full CNS examination in the surgery.
Even if this is negative, a continuing history of headache or a history of transient symptoms such as amnesia, vomiting, double vision and unconsciousness would be a reason for immediate referral to exclude skull fracture or intracranial haemorrhage.
Always ask the child how the injury happened. The history is the key to diagnosis and correct treatment.
A black eye may just be bruising, but a knee in the eye may cause bleeding into the anterior chamber, a detached retina, or even undisplaced fracture of the maxillary arch.
Nose bleeds are common. Check the BP, even though the usual cause is venous fragility in Little's area, which improves with age. Cautery seems a dramatic measure in childhood, but may be necessary in some cases.
Protective equipment should always be worn. Mouth guards minimise tooth injury. Padded headgear protects against cauliflower ear and head knocks.
Laryngeal insult from a high tackle may cause hoarseness due to vocal cord swelling. Rest and observation is usually enough but exclude exercise-induced asthma first.
In the first and second row of a scrum, the cervical spine may be damaged by hyperextension injury following scrum collapse, although any tackle where the unprotected head hits the ground first can cause it.
It is this catastrophic injury that the Queen Elizabeth National Spinal Injury Unit in Glasgow is researching.
Head-on contact can cause compression fractures of lower cervical vertebrae without cord involvement and front-on tackles can cause neck and shoulder injuries to the tackler.
Residual pain in the cervical region, especially on movement, radiating pain with numbness in either arm, impaired skin sensation below the level of the injury or muscle weakness are all serious signs that require immediate referral to a specialist unit.
Type II Scheuermann's disease with kyphotic deformity of the thoracic and upper lumbar vertebrae is caused by repeti-tive stress, axial trauma and flexion. It affects 8 per cent of the population. Onset is associated with heavy athletic activity in adolescence and back pain is a frequent symptom.
It is useful to ask adolescent boys who play in the first or second row if they have back pain. If they have, I would consider an X-ray to exclude the condition.
Sudden death from cardiac causes during play is mercifully rare. A familial history of sudden death, Marfan's syndrome or mitral valve disease should prompt a formal check before a child enters a contact sport.
Splenic rupture from abdominal injury in athletes may be fatal. The spleen may be ruptured by a heavy tackle without rib fracture. If minor, there is no catastrophic bleeding but residual local pain and abdominal rigidity is present.
Do not be fooled by pain in the left shoulder and upper arm. This may be referred pain from the abdomen (Kehr's sign). Refer for emergency splenectomy and you may save the patient's life.
Kidneys are well protected by muscle but a hefty kick in the back can cause trauma and massive bleeding. Haematuria and residual flank pain may also lead to a rugby player presenting at the surgery.
Spontaneous haematuria following heavy exercise is possible but if it occurs with a history of flank pain and injury this is a reason to refer.
Testicular torsion, more common around puberty, may appear to have recovered spontaneously by the time the patient presents, but don't miss it. A history of transient pain and tenderness is worth referral to save testicular function and testicular examination should be included in any assessment of young men with abdominal pain.
With leg injuries, again, the history is useful. Look for calf muscle or thigh muscle tear following pushing in the scrum, or a cruciate ligament tear or ankle injury from a side tackle against a fixed foot.
Get it right and you have grateful parents and a happy patient.
- Dr Scott is a retired GP in Edinburgh.