To the best of our knowledge, this study is the first to analyze pediatric rugby-related injuries from an Italian emergency department. This report gives a useful insight for pediatricians and sports and exercise medicine health care professionals, that are involved in the care of youth rugby injuries in Italy.

Although the number of studies on injury epidemiology in rugby has increased in the last few years, evidence remains scarce, mainly due to the heterogeneity of data collection methodology and research settings. Nonetheless, the results of our data analysis align closely with those reported in the literature[[14].

One of the main findings of our study, is that the upper limb is the most frequent injured body region, consistent with findings from several other studies[[9, 15,16,17]. The second most common site of injury varies across these studies; however, the head seems to be more frequently injured than lower limbs, in line with our findings[[15, 16]. It must be noted that several studies analyzing injuries in different settings, and sometimes using different injury classifications, found different results[[17, 18]. However, when focusing on studies conducted in the ED setting and including pediatric age groups, results are consistent across the USA, Ireland, Australia and Scotland[[8, 17, 19, 20].

An important aspect is the mechanism by which injuries occur. The literature consistently identifies contact with another player as the most frequent mechanism[[8, 17]. This is also confirmed by our data; specifically, contact with a teammate appears to be more frequently the cause of injury than contact with an opponent player. Other studies have also analyzed which component of the play is the most frequently associated with injuries, and it has been found that the tackle is definitely the most dangerous[[8, 15, 19, 20].

According to the Orchard Sports Injury and Illness Classification System (OSIICS) classification, we found that the most frequents type of injuries were contusions (34,7%), followed by joint sprains (22.9%), fractures (20.9%) and concussions (12.6%). One of the main reasons for the different percentages of injury sites reported in the literature, could be that rugby is a sport where rules, gameplay, and the utilization of personal protective gear differ depending on age groups[[10, 18]. For instance, rules of the scrum vary across different age categories and are introduced at different ages in various countries[[20]. However, contusions, fractures, sprains and concussions consistently rank as the top four injuries in every study[[12, 14,15,16].

As for the severity of injury, our study aligns with the literature, with 97% of injuries managed acutely in the ED and only 3% requiring hospitalization[[17].

Special attention should be given to concussions, which have a prevalence of 12.6% in our study, similar to what reported by McIntosh et al.[[21]. However, incidence rates vary dramatically across studies due to the difference in injury definition, lack of objective diagnosis criteria, different levels of competition and gender-related aspects[[22]. Kirkwood et al. conducted a metanalysis in 2015 and found out that the incidence of concussion in youth rugby union ranged from 0.2 to 6.9 concussions per 1000 player-hours, equivalent to a probability for a player of sustaining a concussion over a season between 0.3% and 11.4%[[23].

Our study spans across a period that includes the three years prior the rule “recognize and remove” implemented in 2012, was introduced[[24, 25]. This strategy involves identifying signs of concussion or head injury and immediately removing the affected player from the game for further assessment with the aim of prioritizing player safety. This, coupled with limited awareness of the issue, may have led to a lower recognition of concussion and thus its underdiagnosis.

However, the incidence of concussion remains high, needing careful attention, especially for the potential serious long-term consequences. For this reason, several studies have been conducted to investigate possible strategies to reduce the burden of this type of injury. One of the most discussed proposals for reducing the incidence of concussions in rugby is lowering the height of the tackle. This measure is based on the assumption that reducing the point of contact during a tackle may decrease the risk of head impact and, consequently, the likelihood of concussions. However, both van Tonder and Stokes did not find any statistically significant reduction of concussion’s incidence by reducing the tackle height from the line of the shoulder to the armpit of the ball carrier, whether in amateur or professional settings[[26, 27]. In detail, Van Tonder’s results showed a reduction in the incidence of concussion, which was not statistically significant but may be clinically relevant; while Stokes et al. found a lack of reduction in the incidence of this injury, due to the change of tackling technique that apparently makes the tackler more vulnerable. Understanding impacts in rugby is crucial for injury prevention strategies. A comprehensive approach to injury prevention may require combining tackle height adjustments with educational programs focusing on safe tackling techniques, improved referee enforcement, and continued monitoring of injury patterns[[26, 27]. Moreover, a recent systematic review suggests that the most effective primary prevention strategy for sport-related injuries (such as concussions and hamstrings lesions) appears to be neuromuscular training, followed by education, changes in law and use of specific equipment[[7]. Further research is needed to understand the effectiveness of these measures, which could play a crucial role in reducing the incidence of this type of injuries. Additionally, it is essential to emphasize the importance of raising awareness among players, coaches, and medical personnel regarding the recognition, assessment, and management of concussions to minimize consequences as much as possible. As expected, data from adolescent rugby players, suggest that coaches were less able to recognize symptoms of concussion compared with health care professionals, probably because of lack of concussion education, and that this could lead to an underestimation of the incidence of concussion in lower levels of play, emphasizing the need of training the team personnel[[22, 28]. Also, the knowledge that the tackle is responsible for more concussions, than any other contact event, suggests that interventions that focus on tackle technique training, law change (e.g., changes to the legal tackle height if proven effective) and player preparation, may be more effective at reducing injury risk than other interventions in this setting[[18].

Poisson regressions analysis were performed to examine trends over time. The trend of total visits shows a peak in 2013, followed by a rapid decline and stabilization in the subsequent years, with the lowest value reached in 2019. Given that the data pertains only to the pediatric emergency department of Padua, it is difficult to determine whether any specific cause or event is responsible for this trend. There are not much data in the literature, especially in Italy. However, England, Scotland and Australia professional rugby injury surveillance programs found that the incidence of injuries is stable in the same time period[[25]. Conversely, evidence from US emergency departments from 2004 to 2013 found an increased incidence of injuries, in the same period[[17].

Trend for head and neck injuries shows a seemingly slight upward progression, which, however, appears to be too modest to be attributed to an increased awareness of concussions after 2012, year of introduction of recognize and remove protocol. Published data confirm an increase in the diagnosis of concussions, their severity and burden. The Scotland injury program confirmed a growth of concussion diagnosis between 2009-2016 and a deflection after that[[25, 29].

Finally, the trend for PED admissions due to upper limb injuries appears to be decreasing over time. While it is challenging to pinpoint a specific underlying cause, one possibility might be that the management of some of these injuries has improved or has been encouraged to take place in the field, outside the hospital, after a world rugby medical education program was implemented[[30].

Our study has several limitations. First, it is a retrospective study. Therefore, ED histories could have some missing information (i.e. mechanism of injury or game phase). Indeed, the database records only a brief case narrative for each injury, and mechanisms of injury could not be determined in 22% of cases.

Another limit in this study is the lack of female athletes, probably due to the low representation in the local rugby union. Nevertheless, the number of female participants has been steadily increasing over the past few years, hence providing us with a potentially more significant sample to include in future analysis[[31].

It is important to underline that not all rugby injuries are equally reported to the ED. Many injuries are managed at alternative healthcare facilities, outpatient sport medicine practices or by team doctors/physiotherapists. Consequently, this could lead to a bias in the data towards more severe injuries and might result in an underrepresentation of certain types of milder injuries.

Furthermore, our study includes data from the years 2020-2021, during which the data might be skewed or altered by COVID-related restrictions.