Golf & Brain Special - day 3. Brain damage on the fairway - when frustration swings back.

Golf is usually associated with gentlemanly behaviour, quiet greens, and lush fairways. In neurosurgery, however, golf sometimes appears in a completely different context.

While most golf-related brain injuries happen in children who accidentally wander into the swing path of a club, adult injuries are far less common and rarely intentional. A recent case series from South Africa examines a disturbing exception: assaults in which golf clubs are used as weapons.

The study offers a rare look at how these nasty injuries occur and why golf clubs create a very distinctive pattern of damage.

How a golf club becomes a high-speed physics lesson
Anyone who has played a long, slow round with an irritating partner has probably fantasized about creative uses of a golf club. Neurosurgeons would like to remind you: please keep that thought firmly in the fantasy category.

A golf club is not like a hammer, a fist, or a baseball bat. The club head is weighted, aerodynamic, and built to move through the air with minimal resistance. Its leading edge concentrates force and delivers maximum energy efficiently on a small area.

Modern golf clubs are designed to send a ball flying with precision and power, and unfortunately, the same engineering features make them dangerous. In the hands of even an amateur, a club head can reach a speed of over one hundred and forty kilometers per hour. Great for golf balls. Terrible for human heads.

Energy transfer from the club to the brain
From a neuroscience perspective, this focused transfer of energy means the brain is exposed to a sudden, localized force rather than a diffuse one.

Instead of widespread brain swelling often seen in car accidents or falls, golf-club injuries tend to create sharply defined regions of damage and compound skull fractures.

This distinction helps explain why patients assaulted with a golf club often showed localized neurological symptoms rather than generalized confusion or diffuse swelling of the brain.

A blow that compresses tissue in a single area is more likely to damage specific brain networks - motor, sensory, or speech-related, depending on where they took the hit - while leaving overall consciousness relatively preserved.

That also explains why most patients in this case series, despite the violent head trauma, were awake but had focal neurological deficits upon arrival at the neurosurgical department. All of them were understandably quite unhappy.

A compound skull fracture means that the skull is broken in a way that exposes the brain or surrounding tissues to the outside world. The golf club trauma is often strong enough to push pieces of skull inward, compressing brain tissue, tearing the dura, and creating small pockets of air inside the skull. This pattern reflects the underlying physics: a fast-moving, rigid object striking the head with concentrated force.

The angle of the swing also matters. A downward blow can act like a chisel, producing deep depressed fractures, whereas a glancing upward blow might lift fragments outward.

The study found far more depressed fractures than elevated ones, consistent with blows delivered from above—much like the motion of a club swung in a dispute that escalates into violence.

What the club-struck patients revealed
The researchers reviewed twenty-one adult cases of assault using golf clubs, creating the largest known clinical series of this injury type.

Twenty were men, and the average age of the victims was thirty-two. 17 of the 21 had been struck in the forehead, 3 at the temple, and only 1 in the back of the head, probably trying to escape a mad golfer.

Most presented with noticeable skull depression on the brain scan. Many also showed air inside the skull, which is a sign that the protective layers around the brain were breached.

Some had injuries to major venous sinuses that run on the inside of the skull. The sinuses are the major vessels that drain blood from the brain. When these are damaged, massive bleeding or clotting can occur, sometimes leading to neurological deficits.

It makes sense that 10 of them had clots in the brain under the fracture. And that a handful of patients arrived with weakness on one side of the body or language difficulties, reflecting the location of underlying hemorrhages.

Most patients required surgery. The usual procedure involves cleaning the wound, removing clots and contaminated bone fragments, fixing bleeding vessels, and repairing the dura. In some cases, the depressed bone fragment can be gently elevated again. In others, the skull around the blow was too damaged and requires reconstruction.

The infection problem and why it matters for the brain
Golf clubs are dirty. They are covered in a mixture of turf, dirt, microbes from the course, and whatever else is stuck to your wedge.

From a neuroscientific standpoint, a concerning aspect of these injuries is not just the mechanical damage but the biological environment created by the fracture + the soil from the club.

Once the dura is torn, the brain is no longer sealed off from external bacteria. Soil contamination from the club head enters the skull, and bacteria can spread in ways that cause inflammation, pus formation, pressure buildup, and widespread disruption of brain function.

In this series, one out of three patients developed serious complications such as meningitis or brain abscesses. These infections can be life-threatening and often require prolonged hospitalization, repeated surgeries, and long courses of intravenous antibiotics.

The timing of surgery appeared to influence outcomes. Delays of several days were common and increased the risk of infection. Those who developed infections stayed in the hospital much longer than those who healed without complications.

Why does South Africa see this type of injury?
Golf-club assaults remain rare globally, which is nice. But the study’s setting provides important context.

This case series stands out because it is collected over only 4 years at a single trauma center. It reflects the social environment of Cape Town, where head trauma from assaults is a major contributor to emergency neurosurgical workload.

South Africa has a unique combination of widespread golf infrastructure, ranking among the top 10 countries in the world in terms of the highest number of golf courses. This means golf clubs are common objects in many households.

On the other hand, South Africa has significant income inequality compared with other nations where golf is popular, and high rates of interpersonal violence.

In a UN report, South Africa has the second-highest overall serious assault rate. Surprisingly and oddly enough, France has the highest rate of assaults - and plenty of golfers too, so if you play in France, "Attention!"

The take home message is simple:
Golf clubs make excellent sports tools and truly terrible anger-management devices. They are too fast, too focused, and too dirty to be anywhere near someone’s head.

About the paper that inspired:

First author: R Grobler, South Africa
Published in: SAMJ, November 2024
Link to paper: https://samajournals.co.za/index.php/samj/article/view/2268/1155