School Health policies are introduced in schools to ensure children remain healthy whilst in school and also provide a conducive and accident-free environment for learning.

There is this schoolboy who got injured during games in what may be described as a single, isolated case but potentially serious with devastating consequence if not recognised early and managed appropriately.

History
A young boy of eleven years reported at a hospital with lower abdominal pain which he sustained whilst playing football at school. He had apparently been booted in the groin by a peer during a struggle for the ball sending him immediately to the ground. He could not get up immediately on his own and had to be helped by his friends to a corner of the field where after some time he was able to get up and take some few steps, albeit with difficulty.

He was then rushed to a nearby hospital with severe lower abdominal pains and difficulty in passing urine.

Physical Examination & Treatment
At the hospital it was found that the lower part of the abdomen in the region of the bladder was painful to touch and there was a small abrasion on the left side of the groin. Based on this information bladder injury was suspected.

The patient was admitted and managed. By the fourth day the patient was able to pass urine with ease and the wound in the groin had also healed. He was discharged when his condition was found to be satisfactory.

Follow-up and Subsequent Management
The child was reviewed on outpatient basis and each time he complained of pains in the lower part of his abdomen. On his second review he was referred to see a specialist but, like most people in the rural areas, he did not go or rather he was not taken there by his parents.

He turned up three months later with a history of intermittent abdominal pains and not being able to attend school ever since he sustained the injury. His father admitted having noticed and removed the tip of a pencil about 2 cm long from the apparently healed wound when the child strained during defecation two weeks earlier.

On further examination at the groin there was no wound but a slightly raised scar was found.  A small lump could be felt around the scar.

Based on this information the patient was immediately booked for operation (explorative laparotomy), the indication being suspected foreign body in the abdomen and penetrating injury.

After cutting through the skin into the muscle layer, a small round mass was found. It was the tip of a pencil. With little traction, the tip was pulled out gradually and, lo and behold, it was an 11.5 cm long pencil, apparently pushed and stuck into the abdomen from the child’s pocket when he was kicked in the groin during the football match. (The total length of the pencil then was about 13.5cm)

Discussion
A lot of injuries associated with sports are often blunt (non-penetrating) trauma to the abdomen and, if severe, may result in organ damage. In children, rupture of the spleen is a common complication with fatal consequences. Penetrating injuries normally result from stab and bullets wounds and are less commonly encountered in sports.

The fact that this type of injury was not suspected at first is significant. Normally penetrating injuries cause minimal damage to the skin at the point of entry and diagnosis could easily be missed if the presenting complaint is silent on it.

The child did not give any history of having a pencil in his pocket which had disappeared and, as said earlier, initial examination did not reveal any lump which may have necessitated immediate exploration.

It is possible that there was no significant injury to the bladder as urine obtained from bladder catheterisation was clear of blood. The difficulty in passing urine initially could just be attributed to the severe pain felt in the lower abdomen around the bladder.

Conclusion
Whilst congratulating staff of the hospital especially the theatre team which finally operated on the patient, the essence of this presentation is not to debate whether or not the case was well managed.
Lessons which can be drawn here among others are:

1)    Young children need a thorough examination when they present with injuries of the abdomen as they may fail to bring out  vital clues  that will aid diagnosis

2)     Schoolchildren must be advised to remove sharp objects such as pens and pencils from their pockets during games.

3)     A second chance and re-evaluation should be given to patients who are referred but for one reason or the other could not make it as the situation might have changed.

Cases are known where health facilities refuse to re-evaluate or wash off their hands on patients who had earlier been referred but did not go when they make subsequent appearance with the same complaints.