Pediatr Radiol (2009) 39:12641274 DOI 10.

1007/s00247-009-1359-6

MINISYMPOSIUM

Imaging of American football injuries in children

Daniel J. Podberesky & Bryan J. Unsell & Christopher G. Anton

Received: 15 May 2009 / Revised: 22 June 2009 / Accepted: 1 July 2009 / Published online: 23 September 2009 # Springer-Verlag 2009

Abstract It is estimated that 3.2 million children ages 6 to 14 years participated in organized youth football in the United States in 2007. Approximately 240,000 children play football in the nations largest youth football organization, with tackle divisions starting at age 5 years. The number of children playing unsupervised football is much higher, and the overall number of children participating in American football is increasing. Sports are the leading cause of injury-related emergency room visits for teenagers, and football is a leading precipitating athletic activity for these visits. Football is also the most hazardous organized sports in the United States. Though most pediatric footballrelated injuries are minor, such as abrasions, sprains, and strains of the extremities, football accounts for more major and catastrophic injuries than any other sport. Given footballs popularity with children in the United States, combined with the high rate of injury associated with participation in this activity, radiologists should be familiar with the imaging features and injury patterns seen in this patient population.
The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Departments of the Air Force or Defense. The results of this study were presented at the 45th ICAAC Meeting in December 2005. D. J. Podberesky (*) : C. G. Anton Department of Radiology, Cincinnati Childrens Hospital Medical Center, 3333 Burnet Ave., MLC 5031, Cincinnati, OH 45229, USA e-mail: daniel.podberesky@cchmc.org B. J. Unsell Department of Radiology, Wilford Hall Medical Center, Lackland Air Force Base, San Antonio, TX 78236, USA

Keywords Football . Sports injuries . Pediatric

Introduction American tackle football is one of the most popular youth sports in the United States, with more than 3.2 million participants between 6 and 14 years of age in 2007 [1]. It is also estimated that approximately 1.1 million youths participated in organized high school football in the United States in 20062007 [2]. Participation in high school football has increased steadily in the last decade [2]. Approximately 240,000 children participate in the countrys largest youth football organization, with the number increasing, and with full tackle divisions beginning at age 5 years and 35 lb [3]. Football is an easy game to play, requiring no equipment other than a ball and a field. It can be played in any weather, and on any type of field. Thus, the number of children participating in unsupervised pick-up football games is unknown but assumed to be much larger than the number participating in organized, supervised programs. Sports injuries account for approximately 23% of pediatric emergency department injury-related visits [4]. Of these sports injury-related visits, football is one of the leading precipitating activities, accounting for approximately 10% of visits [4]. In 2003, for example, there were approximately 350,000 reported football-related injuries in children [5]. In the 13- to 19-year age range, sports are the most common cause of injury and the second leading cause of emergency department visits and hospitalization [6]. Football is also the most hazardous organized sport in the United States. President Theodore Roosevelt nearly banned American football because of the high associated death and injury rates (19 players killed or paralyzed in 1904) [7]. When considering injury rate/1,000 athlete-

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exposures (defined as a participant in a coach-directed session that involves physical activity, whether in practice or game situations), football participation results in the most injuries, at 8.1 injuries per 1,000 athlete-exposures [8]. Although most football-related injuries in children are minor, such as strains and sprains, the incidence of major injuries is relatively high compared with other sports [911]. High school football participation is associated with more catastrophic injuries (defined as death or severe injury with or without permanent disability) than any other sport [12]. Many risk factors have been studied as they relate to football injuries in the pediatric population. Playing in an unsupervised environment places the participant at greater orthopedic injury risk than in an organized, supervised environment [13]. Injuries occur at a greater rate in games than in practices [5]. Players who have the ball, such as quarterbacks and running backs, are at greatest injury risk, followed by linebackers [14]. Increased level of experience also increases the risk of injury [10]. The third quarter of games and the first half of the season have also been found to have a propensity for injury occurrence [15]. Interestingly, less than 2% of high school football-related injuries are the result of illegal activity/foul play, which is less than soccer, basketball and wrestling [16]. This low illegal activity-related injury rate speaks to the inherent injury risk associated with football even when played according to the rules. Many parents are unaware of the potential risks associated with youth football participation. A study by Goldhaber [17] showed that less than 1% of parents were aware of the risk of severe brain damage, less than 10% were aware of the risk of severe neck and spine injuries, and 80% of parents believed that wearing a helmet completely eliminated the risk of severe brain damage from a football injury [17]. Along with coaches, athletic trainers, pediatricians, and emergency room physicians, radiologists are frequently on the front line in the evaluation of children presenting with football injuries. It is therefore important for radiologists to be familiar with both the common and the unusual imaging presentations of pediatric football injuries. An understanding of the basic mechanisms of these injuries is also helpful in correctly diagnosing injury patterns, especially in the musculoskeletal system.

using the top of the head or helmet (Fig. 1). Inexperienced players must be taught from a young age to avoid spear tackling. However, even with the elimination of spearing, head injuries continue to occur. These injuries result from direct contact (with or without use of a helmet) with another player or the ground, or rapid change in directional forces following a tackle in which there is no direct head contact. The vast majority of pediatric football-related head injuries are concussions [20]. Football accounts for the majority of pediatric sports-related concussions [21]. It is estimated that 20% of high school football players sustain a concussion sometime during their football career and that, on average, a high school football team can expect at least two concussions per season [21, 22]. Although simple concussions are inconspicuous on imaging examinations, radiologists must have a high index of suspicion for more severe injury because a spectrum of intracranial pathology can present on imaging examinations when a reported history of football-related concussion is provided. Football has the highest overall number of direct catastrophic head injuries of all sports, with an average 7.23 per year occurring in high school and collegiate football players between 1989 and 2002 [23]. A prior head injury places an athlete at increased risk of a subsequent severe head injury [23]. Intracranial hemorrhage, specifically subdural hematoma, is the leading cause of death related to football head injuries [23]. The imaging procedure of choice for the child presenting with a football-related head injury is a CT scan without contrast agent (Fig. 2). Hemorrhage may be intraparenchymal, within the subdural, epidural, or subarachnoid spaces,

Discussion Head and neck injuries There has been a significant decrease in the frequency and severity of catastrophic head injuries since the advent of the modern day football helmet in the 1970s and a rule change in 1976 banning spearing [18, 19]. Spearing, or spear tackling, is defined as a tackle in which the tackler initiates contact

Fig. 1 Schematic demonstrates spearing, or spear tackling. The white jersey player is initiating contact using the top of the helmet. This maneuver is illegal and should be discouraged as it raises the risk of head and neck injuries in the white jersey player

1266 Fig. 2 Traumatic brain injuries. a A 10-year-old wearing a helmet was hit in the head during a football game. Noncontrastenhanced CT image shows a hyperacute, mixed-attenuation left frontal subdural hematoma (arrows). There is mild associated mass effect. b A 10-yearold with headaches following football practice. Noncontrastenhanced CT image shows a subacute, isoattenuating left subdural hematoma (arrows) with associated mild midline shift. c A 15-year-old with loss of consciousness following a tackle. He was not wearing a helmet. Noncontrast-enhanced CT image shows an acute left epidural hematoma (arrow) with associated mass effect. d CT bone windows in the same patient as in c on a more inferior slice shows an associated temporal bone fracture (arrow)

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or intraventricular. Associated findings such as attenuation of the hemorrhage, associated mass effect, midline shift or ventriculomegaly, and the presence of fractures, should be noted. The anterior and lateral aspects of the neck are areas of the body relatively unprotected by the football protective gear. This places the superficially located vascular structures in the neck at risk from direct blows to the region (Fig. 3). Injuries to the carotid or vertebral arteries, or the jugular veins, can result in vascular compromise of the brain parenchyma. Dissections and pseudoaneurysms are readily apparent on CT or MR angiography. The intracranial effects of a neck great vessel injury, such as infarct or hemorrhage, are best evaluated with MRI. Diffusionweighted imaging is critical in the evaluation of early ischemic brain injury (Fig. 4). Spine injuries Severe cervical spine injuries are more common than thoracic or lumbar injuries in youth football participants

[24]. Although most cervical spine injuries in pediatric football players are minor, such as stingers (acute traumatic temporary cervical radiculopathy), permanent catastrophic injury can occur. Sports injuries are the second leading cause of spinal cord injury in the first three decades of life [25]. At a large tertiary care level 1 pediatric trauma center in the Midwest, football was found to be the third leading cause of pediatric cervical spine injuries, after motor vehicle accidents and falls, accounting for about one-third of all injuries [26]. As with catastrophic head injuries, there has been a significant decrease in the frequency and severity of catastrophic spine injuries since a rule change in 1976 banning spearing [24]. The player who is spear tackling his opponent typically holds the cervical spine in a flexed position, tackling with the top of the helmet (Fig. 1). Despite the illegality of spearing, this method of tackling is still widely taught to and practiced by up to 83% of high school football players [27]. Pediatric vertebral bodies, as they are not fully ossified, are smaller and more elastic than those of adults. The stabilizing cervical spine ligaments are relatively lax, and in

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Fig. 3 Schematic demonstrates the vulnerability of the neck secondary to the relative lack of protective gear. The direct impact increases the risk of great vessel injury, and resultant potential brain injury, in the white jersey player. In addition, the blue jersey tackler is using an illegal spear tackle technique, increasing his own injury risk Fig. 4 A 13-year-old football player presented with right hemiparesis following a tackle to the neck region. a Noncontrast-enhanced CT image demonstrates loss of graywhite matter differentiation in the left middle cerebral artery (MCA) territory (arrow). b Diffusion-weighted image demonstrates restricted diffusion in the same territory (arrow), indicating acute infarct. c Single source image from a time-offlight MR angiogram demonstrates asymmetrically decreased flow signal in the left internal carotid artery (arrow) consistent with a dissection. d Maximumintensity projection frontal image of the circle of Willis demonstrates lack of signal in the left MCA distribution

combination with underdeveloped paraspinal musculature, there is relative hypermobility of the pediatric cervical spine. For these reasons, spinal cord injury without radiographic abnormality (SCIWORA) is much more frequent in children than in adults [28]. The original definition of SCIWORA (objective signs of myelopathy after trauma with no evidence of fracture or ligamentous instability on conventional radiographs) was offered in 1982 before the routine use of MRI in evaluation of spine injuries [29]. Today, with the widespread use of MRI, SCIWORA findings can span from normal to radiographically occult vertebral fractures to soft-tissue injuries (ligamentous or intervertebral disc) to spinal cord injury such as contusion, hematoma, or transection (Fig. 5). The imaging of a pediatric football player with an acute severe cervical spine injury typically begins with conventional radiographs and is followed by CT with sagittal and coronal reformations and may be followed by MRI to further evaluate suspected soft-tissue and cord injuries (Fig. 6). Spondylolysis is a fracture through the pars interarticularis that is typically caused by repetitive microtrauma from

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hyperextension (Fig. 7). Approximately 90% of cases occur at L5 [30]. Although the incidence in the general population is reported to be 56%, the incidence in adolescent football players is significantly higher (approximately 11%), particularly in linemen, and is a common cause of low back pain [30, 31]. Spondylolysis can be detected with conventional radiographs, CT, MRI, or bone scintigraphy (Fig. 8). Trunk injuries Football participation results in more intraabdominal injuries than any other major sport [32]. Football is a contact sport with high-energy collisions. Thoracic and abdominal injuries most often result from being tackled but can also result from a player being crushed at the bottom of a pile-up of players or from being stepped on (Fig. 9). Children are at increased risk of blunt traumatic intraabdominal injuries because of the incompletely ossified rib cage, underdeveloped chest and abdominal wall musculature, less intraabdominal fat to cushion blows, and proportionally larger visceral organs relative to total body size compared with an adult. Contrast-enhanced CT is the first-line imaging modality for the evaluation of suspected thoracoabdominal trauma from a football injury (Fig. 10). Evaluation of the CT scan in a football injury patient should follow the same pattern as in any other blunt trauma patient, with attention to the liver, spleen, pancreas, and kidney, as

Fig. 5 Sagittal T2-W MR image of the cervical spine in a 16-year-old football player with neck pain, decreased range of motion, paresthesia, and normal conventional radiographs (not shown), reveals increased signal involving the interspinous ligaments, without other abnormality identified. The appearance is consistent with a ligament sprain in this athlete with clinical spinal cord injury without radiographic abnormality (SCIWORA)

Fig. 6 Catastrophic spine injury in a 15-year-old football player who arrived to the emergency department with quadriplegia. a Lateral radiograph of the cervical spine demonstrates a C5 fracture (arrow) with posterior subluxation of C5 relative to C6. b Sagittal reformatted

CT image better demonstrates the fracture (arrow) and focal malalignment. c Sagittal T2-W MR image further demonstrates the fracture and malalignment, along with anterior longitudinal ligament disruption (arrowhead), as well as cord compression and contusion (arrow)

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inflamed secondary to mononucleosis, there is a greater propensity for injury from blunt trauma. The enlarged spleen is only palpable on physical examination in about 50% of patients, and therefore sonography of the spleen can be very helpful in determining spleen size [34, 35]. Current recommendations for when to return to football participation remain controversial. Avoidance of contact sports for 4 to 6 weeks after mononucleosis symptom onset, assuming the spleen is nonpalpable, with measurement of the spleen by sonography at the 4-week point, seems prudent [35]. Normal sonographic splenic measurements vary by age, though in an adolescent a splenic length of less than 12 13 cm is considered normal [36].
Fig. 7 Schematic demonstrates hyperextension of the spine in the blue jersey player. Repetitive hyperextension of the lumbar spine increases the risk of spondylolysis. This mechanism of injury is commonly seen in linemen

Injuries of the extremities The extremities are the most commonly injured sites in pediatric football participants, with the lower extremities involved in 3159% and the upper extremities in 2134% of injuries [37]. Most extremity injuries are minor, sprains, strains, bruises, and abrasions, and therefore are generally not imaged. With increased participation in sports and increased level of experience at younger ages, major injuries that in the past were less common in the pediatric age group, such as cruciate ligament injuries, meniscal tears, and labral tears, are becoming more commonplace in children. This increase in sports-related injuries at younger ages is becoming widely publicized by the mainstream news media [38]. The radiologist must be familiar with the common injury patterns in these children. Pediatric extremity injury patterns differ significantly from those in adults, as there are areas of increased injury susceptibility in the

these organs are injured more frequently in football than in any other sport [32]. The risk of injury to the spleen is increased when a child has infectious mononucleosis, creating a common dilemma for clinicians and radiologists related to youth football participation regarding when a child with infectious mononucleosis can return to play. Understanding the risks involved is critical. Approximately 6075% of sportsrelated splenic trauma is from football [32, 33]. Frelinger [33], in an analysis of splenic rupture in college athletes, found that approximately 40% of patients with a ruptured spleen had mononucleosis. When the spleen is enlarged and

Fig. 8 Spondylolysis. a A 16-year-old football player with low back pain. Lateral radiograph of the lumbar spine demonstrates L5 spondylolysis (arrow) with grade I anterolisthesis. b A 17-year-old football player with low back pain. Axial CT image demonstrates bilateral L5 pars interarticularis defects (arrows). c A 16-year-old

football player with low back pain. Coronal SPECT bone scintigraphy image demonstrates focal, relatively symmetric, increased uptake within the posterior elements of L5 (arrows), consistent with spondylolysis

1270 Fig. 9 Schematic demonstrates mechanisms of football-related abdominal trauma. a The white jersey player is using proper tackling technique. The blue jersey player is receiving a highenergy collision to his abdomen. b The white jersey player is being stepped on by the blue jersey player, placing the abdominal viscera at risk

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immature musculoskeletal system. These vulnerable locations include attachment points of ligaments and tendons, ossification centers and apophyses, and growth plates. The knee is the most frequently injured joint, followed by the ankle, shoulder, wrist, and hand [37]. Knee injuries

most commonly occur from legal tackles and rapid directional changes but also occur from illegal activities such as clipping (hitting an opponent from behind or the side, typically at leg level) and chop-blocking (blocking an opponent at or below the knees, when he is already

Fig. 10 Abdominal injuries. a A 16-year-old stepped on during a game presented with abdominal pain. Contrast-enhanced CT shows a linear area of decreased attenuation within the pancreatic neck consistent with transection (arrow). b A 14-year-old tackled in the right flank presented with right upper quadrant pain. Contrastenhanced CT image demonstrates a linear area of decreased attenuation within the right lobe of the liver (arrow) consistent with

a grade 3 laceration. c A 16-year-old tackled in the right flank presented with severe pain and hematuria. Delayed contrast-enhanced CT image demonstrates a grade 5 right renal injury with extravasation of excreted contrast. d A 15-year-old tackled during football practice presented with left upper quadrant pain. Contrast-enhanced CT image demonstrates a grade 4 splenic injury with active contrast extravasation (arrows) and a large hemoperitoneum

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Fig. 11 Schematic demonstrates mechanisms of football-related knee injury. a The white jersey player has sustained a direct blow to the knee resulting in abnormal hyperextension. b The white jersey player is the victim of an illegal chop-block. While actively engaged in

blocking one blue jersey player, the white jersey player s knee is extremely vulnerable, and a second blue jersey player blocks him at the knee level

engaging another opponent) (Fig. 11). As opposed to adults, children often present with cruciate and collateral ligament tears at their origin or insertion, rather than in their mid-substance. These ligament injuries frequently manifest as small avulsive fractures on radiographs but are best evaluated with MRI (Fig. 12). An unusual injury in the skeletally immature athlete that is often first suggested by a radiologist is the traumatic physeal injury. The growth plate is susceptible to injury, especially during periods of rapid growth, as it is less resistant to stress than the adjacent bone and surrounding soft tissues [39]. The physes of the distal femur and proximal tibia are especially susceptible to compressive forces experienced during football. Physeal injuries can result in growth disturbances leading to leg length discrep-

ancies, angular deformities, and decreased range of motion. Acute physeal fracture occurs in a variety of sports but is reported most often in football players, with an incidence of 39% of football-related injuries [39]. Chronic stressrelated physeal injuries are the result of repetitive microtrauma and result in growth plate widening and irregularity. This injury manifests on MRI as physeal widening and extension of physeal signal into the adjacent metaphysis and might be radiographically occult (Fig. 13) [40]. The shoulder girdle is injured commonly in adolescent football participants. Shoulder girdle injuries present with a variety of trauma patterns related to the mechanism of injury and the immature status of the musculoskeletal structures. Posterior sternoclavicular joint dislocation is a very uncommon injury, comprising only about 0.1% of all

Fig. 12 Knee injuries. a A 14-year-old clipped in the knee. Sagittal intermediate-weighted image demonstrates an anterior cruciate ligament tear at its insertion on the tibial spine (arrow). b A 15-year-old landed on hyperflexed knee after being tackled. Sagittal gradient recalled echo image demonstrates a patellar tendon tear proximally with avulsion of the inferior patellar pole (arrow). c An 11-year-old clipped in the knee. Coronal T2-W image demonstrates a medial

collateral ligament tear at its origin from the femoral condyle (arrow). d A 15-year-old clipped in the knee. Coronal intermediate-weighted image demonstrates a lateral meniscus tear, with a portion of the meniscus extruded into the epiphyseal component of a Salter-Harris 3 fracture (arrow). There is also a medial collateral ligament tear from its insertion on the proximal tibia, with the torn fragment flipped into the physeal component of the Salter-Harris 3 fracture (arrowhead)

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Fig. 13 Sagittal gradient-recalled echo image in an 11-year-old football player with chronic knee pain shows focal areas of physeal thickening with extension of physeal signal into the metaphysis of the distal femur (arrows). The appearance is consistent with chronic repetitive stress injury of the physis Fig. 15 Schematic demonstrates the large posteriorly directed force vector the white jersey player s shoulder experiences with a proper football tackle. Unfortunately, the blue jersey player can experience a flank injury (spleen, kidney, or liver) in this scenario, as well

joint dislocations, but it is an injury particularly seen in football secondary to a direct blow to the posterolateral shoulder with the arm adducted and flexed [41]. Although sternoclavicular dislocation is sometimes seen on conventional radiography (serendipity series), the findings can be subtle. CT with coronal and three-dimensional reformations can clearly depict the dislocation while also evaluating for associated complications such as vascular, airway, and pulmonary injury (Fig. 14). The shoulder itself is the most common point of impact when a tackler uses proper technique, resulting in a large posteriorly directed force

vector (Fig. 15). When blocking, there is also a large posteriorly directed force vector. It is therefore not surprising that posterior labral tears have been found to be approximately 15 times more prevalent in football players than in players of other sports [42]. One particular type of labral tear that has been identified with increased frequency in football players is the posterior labrocapsular periosteal sleeve avulsion (POLPSA), in which the posterior labrum is torn and remains attached to the osteocartilagenous glenoid by a thin piece of periosteum (Fig. 16) [42, 43].

Fig. 14 Sternoclavicular joint disclocation. a A 16-year-old with pain following a tackle. Frontal radiograph demonstrates asymmetry in the appearance of the sternoclavicular joints, with the right side projecting more cephalad than the left. b Bone CT 3-D reformation in the same boy demonstrates the posteriorly dislocated right clavicle relative to the sternum

Fig. 16 Axial proton density image of the left shoulder in a 17-yearold football player with shoulder pain reveals a posterior labrocapsular periosteal sleeve avulsion (POLPSA) (arrow)

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Fig. 17 Stiff arm and ulnar artery injury. a Schematic demonstrates the blue jersey player carrying the football and stiff arming the oncoming white jersey tackler. b Representative axial T1 image through a normal wrist at the level of the hook of the hamate

(arrowhead) demonstrates the position of the ulnar artery (solid arrow) in Guyons canal, and its vulnerability to injury in this scenario given that only the palmaris brevis muscle (dotted arrow), a small amount of fat, and skin cover the vessel

Finally, injuries of the wrist and hand are not uncommon in football players. Stiff-arming is a common technique used by players carrying the ball (quarterbacks, running backs, wide receivers, and kick returners) in which the arm is outstretched, and the wrist extended to fend off an oncoming tackler (Fig. 17). When the hand impacts the oncoming defender, the mechanism of impact is similar to a fall on an outstretched hand (FOOSH), and can result in a similar array of expected injuries (distal radius and ulna fractures, scaphoid fractures, and distal humerus fractures). An unusual injury that has been encountered following blunt trauma to the hand or wrist while in the stiff-arm position is ulnar artery thrombosis. Although sports-related ulnar artery thrombosis is most commonly related to repetitive trauma from sports such as baseball, volleyball, and martial arts, the injury has also been reported from a single severe direct blow such as those in hockey and football [44]. The ulnar artery, as it travels through Guyons canal, is covered only by skin, subcutaneous fat, and the very thin palmaris brevis muscle (Fig. 17). With a direct blow, the ulnar artery impacts the hook of the hamate with the potential for intimal damage and resultant vessel thrombosis. This injury can present with symptoms of vascular compromise to the ring and little fingers, which are supplied primarily by the ulnar artery (Fig. 18).

football participation, though the vast majority of injuries are considered minor. Although they are relatively infrequent, severe, debilitating, and potentially fatal footballrelated injuries do occur in youths. The mechanisms and imaging features of a variety of distinctive injuries have been reviewed. The radiologist is instrumental in accurately reporting injuries in these athletes so that the ordering clinician, therapists, and athletic trainers can initiate appropriate treatment and return the player safely and rapidly to practice and competition. Although the spectrum of catastrophic injuries presented is enlightening and potentially disturbing, it is important to bear in mind the many benefits of youth sports participation such as improved teamwork skills, enhanced self-esteem, and increased self-reported mental and physical health.

Conclusion American tackle football is one of the most popular youth sports in the United States, and its popularity is increasing. There is a high incidence of injury associated with pediatric

Fig. 18 Digital subtraction angiogram following a selective ulnar artery injection in a 17-year-old running back who stiff-armed an oncoming tackler and presented with vascular compromise of the ring and little fingers. The image shows complete occlusion of flow to the ulnar aspect of the hand and digits at the level of the hamate, consistent with ulnar artery thrombosis

1274 Acknowledgements We thank MSGT William C. Vance, military graphic artist, at Lackland AFB, TX, for his invaluable depictions of pediatric football injury mechanisms.

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