Splenic Contusion and Rupture

By admin Last updated Nov 16, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Eugene Hong

Basics

Description

Splenic injury spectrum includes contusion, hematoma, laceration, and rupture.
Not uncommon in contact and collision sports or with falls during activities, including football, hockey, lacrosse, biking, skiing, horseback riding, and motorsports.

Epidemiology

Most common abdominal organ injury in sports (1)
May represent up to 50% of all sports-related abdominal organ injuries
1.5 million adults are admitted to hospitals each year in the U.S. following an injury; ∼2.6% will have a blunt splenic injury (2).

Risk Factors

Recent or distant history of trauma that may have caused a prior splenic injury that did not completely resolve (see “Delayed splenic rupture” in “Complications” section below)
Overlying rib fracture
Recent infectious mononucleosis infection resulting in splenomegaly

Etiology

Trauma mechanism resulting in direct or indirect force on the spleen

Commonly Associated Conditions

Liver injury
Rib injury
Kidney injury

Diagnosis

History

Symptoms of hypovolemia: Dizziness, light-headedness, syncope, palpitations, shortness of breath
Abdominal pain: May be localized to left upper quadrant
Left shoulder pain: Referred via the left phrenic nerve from intraabdominal diaphragmatic irritation (Kerr sign)
Pain elsewhere also should raise suspicion for concurrent injuries elsewhere, eg, liver, rib, kidney.

Physical Exam

Vital signs including orthostatics: Serial measurements; assess for stability; relative tachycardia may be an early sign.
Abdominal tenderness
Abdominal rebound or guarding, consistent with peritoneal irritation from bleeding
Decreased or absent bowel sounds
Avoid palpating spleen aggressively or deeply.
Decreased breath sounds
Rib tenderness, crepitus, or deformity
Costovertebral angle tenderness
Skin discoloration in the periumbilical area (Cullen sign) or flank (Turner sign) may take 24 hr to appear; both signs are consistent with intra-abdominal bleeding.

Diagnostic Tests & Interpretation

Lab

CBC
Type and screen or type and crossmatch in the event that a transfusion is needed.
Serum electrolytes
Consider serial hemoglobin/hematocrits as indicated clinically.

Imaging

Consider abdominal CT scan if splenic injury suspected.
US may not be as sensitive as CT scan in determining severity in splenic injury.
Imaging results will help to assess for the presence and severity of splenic injury.
Severity grading will help to guide management by the American Pediatric Surgical Association (APSA) Guidelines 2000.
American Association for the Surgery of Trauma Splenic Injury Scale (revised 1994):
- Grade I:
  - Hematoma, subcapsular: <10% surface area
  - Laceration, capsular tear: <1 cm parenchymal depth
- Grade II:
  - Hematoma, subcapsular: 10–50% surface area, intraparenchymal, <5 cm diameter
  - Laceration, capsular tear: 1–3 cm parenchymal depth; does not involve trabecular vessel
- Grade III:
  - Hematoma, subcapsular: >50% surface area or expanding; ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma >5 cm or expanding
  - Laceration: >3 cm parenchymal depth or involving trabecular vessels
- Grade IV: Laceration: Involving segmental or hilar vessels producing major devascularization (>25% of spleen)
- Grade V:
  - Laceration: Completely shattered spleen
  - Vascular: Hilar vascular injury that devascularizes spleen
Advance 1 grade for multiple injuries up to grade III.

Treatment

Pre-Hospital

Transport all patients with suspected splenic injuries to hospital for further evaluation.
Assess vital signs, and perform complete physical examination.
Assess for other injuries, especially in a trauma setting.
Obtain medical history, if possible.
If the patient is unstable, place 2 large-bore IVs, and begin fluid resuscitation.
Call ahead to advise ED/trauma team of clinical situation.

ED Treatment

Assess hemodynamic stability of patient.
Thorough trauma assessment and workup
Begin resuscitation as indicated clinically.
Type and screen or type and crossmatch in case transfusion is required.
Trauma surgery consultation

Medication

Consider not giving pain medications until after ED/trauma team initial evaluation.

Additional Treatment

General Measures

Emergent surgical consult and evaluation for all unstable patients with known or suspected splenic injury for consideration of emergency exploratory surgery and possible splenectomy
Admission for observation and management for all known splenic injuries
ICU admission for more severe splenic injuries or as indicated clinically
American Pediatric Surgical Association (APSA) Guidelines in Children with Isolated Spleen Injury Guidelines 2000 [B]: Guidelines for 5 parameters in management (excludes grade V injuries and unstable patients) (3).
- CT grade I:
  - ICU stay: None
  - Hospital stay: 2 days
  - Predischarge imaging: None
  - Postdischarge imaging: None
  - Activity restriction: 3 wks*
- CT grade II:
  - ICU stay: None
  - Hospital stay: 3 days
  - Predischarge imaging: None
  - Postdischarge imaging: None
  - Activity restriction: 4 wks*
- CT grade III:
  - ICU stay: None
  - Hospital stay: 4 days
  - Predischarge imaging: None
  - Postdischarge imaging: None
  - Activity restriction: 5 wks*
- CT grade IV:
  - ICU stay: 1 day
  - Hospital stay: 5 days
  - Predischarge imaging: None
  - Postdischarge imaging: None
  - Activity restriction: 6 wks*

*Return to full-contact, competitive sports should be at the discretion of the individual pediatric trauma surgeon. The proposed guidelines for return to unrestricted activity include “normal” age-appropriate activities (Stylianos, APSA Trauma Committee, 2000).

Referral

Surgical consultation is indicated for all suspected splenic injuries.
Consider referral to trauma center or pediatric trauma center for evaluation and management of suspected or known splenic injuries.

Surgery/Other Procedures

Consider emergency exploratory surgery for possible splenectomy for all hemodynamically unstable patients with known or suspected splenic injury.
Consider surgery for patients with known splenic injury whose clinical course is worsening.
Splenic artery embolization is being used in some trauma centers in some select patients (4).
Laparoscopic surgery, if surgery is to be performed, in the nonemergent patient may be considered.

Ongoing Care

If splenectomy is performed, patient will need pneumococcal [A], meningococcal [B], and Haemophilus influenzae (Hib) [B] vaccines; give at or after 14 days for emergency splenectomy, and consider boosters every 5 yrs (5). Also, CDC recommends annual influenza vaccination in the asplenic population.
Need for follow-up imaging is controversial in the clinically improving patient with a nonoperatively managed isolated splenic injury. In pediatric patients engaged in normal age-appropriate activities, follow-up imaging may not be needed after isolated splenic injury (6)[C]. Further research studies may be required to determine if serial imaging is needed, and when, before acceptable return to contact and collision sports.
If indicated clinically, consider follow-up or serial imaging with abdominal CT scan in any age group.
Nonoperative management of stable isolated splenic injuries is appropriate in the majority of patients.
95–99% of pediatric patients with stable isolated splenic injury grades I–IV can be managed nonoperatively (7).
70–90% of adult patients with stable isolated splenic injuries can be managed nonoperatively.
Prior recommendation for return to play was 3 mos, in part based on studies looking at radiographic healing in splenic injuries.
For return to play in pediatric patients, see APSA Guidelines 2000 in “Treatment” section above.
There are no return-to-play guidelines similar to the APSA Guidelines for the adult population; it may be reasonable to use APSA Guidelines in this population as well.
As noted in the APSA Guidelines, return to play for full-contact and collision sports should be based on the individual clinical case and in discussion with the treating physician.

Complications

Possible reinjury or worsening of injury if return to activity too soon or if further trauma is sustained prior to full recovery
Unknown whether radiologic healing actually equals or translates to full physiologic healing
Delayed splenic rupture is main complication after nonoperative management of splenic injury. Occurrence rates vary from <1% to 2% in children and adults.
Delayed splenic rupture, if it occurs, has a 5–15% mortality rate (compared with the 1% mortality rate with primary splenic rupture) (8).

References

1. Rifat SF, Gilvydis RP. Blunt abdominal trauma in sports. Curr Sports Med Rep. 2003;2:93–97.

2. Zarzaur BL, Vashi S, Magnotti LJ, et al. The real risk of splenectomy after discharge home following nonoperative management of blunt splenic injury. J Trauma. 2009;66:1531–1536; discussion 1536–1538.

3. Stylianos S, et al. Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury. J Pediatric Surg. 2000;35:164–169.

4. Rajani RR, Claridge JA, Yowler CJ, et al. Improved outcome of adult blunt splenic injury: a cohort analysis. Surgery. 2006;140:625–631; discussion 631–632.

5. Webb CW, Crowell K, Cravens D. Which vaccinations are indicated after splenectomy? J Fam Pract. 2006;55:711–712.

6. Stylianos S. Compliance with evidence-based guidelines in children with isolated spleen or liver injury: a prospective study. J Pediatr Surg. 2002;37:453–456.

7. Davies DA, Pearl RH, Ein SH, et al. Management of blunt splenic injury in children: evolution of the nonoperative approach. J Pediatr Surg. 2009;44:1005–1008.

8. Brown, Rebeccah, et al. Observation of splenic trauma: when is a little too much? J Pediatric Surg. 1999;34:1124–1126.

Additional Reading

Harbrecht BG, Zenati MS, Ochoa JB, et al. Evaluation of a 15-year experience with splenic injuries in a state trauma system. Surgery. 2007;141:229–238.

Putukian M, O'Connor FG, Stricker P, et al. Mononucleosis and athletic participation: an evidence-based subject review. Clin J Sport Med. 2008;18:309–315.

Savage SA, Zarzaur BL, Magnotti LJ, et al. The evolution of blunt splenic injury: resolution and progression. J Trauma. 2008;64:1085–1091; discussion 1091–1092.

Stylianos S, Egorova N, Guice KS, et al. Variation in treatment of pediatric spleen injury at trauma centers versus nontrauma centers: a call for dissemination of American Pediatric Surgical Association benchmarks and guidelines. J Am Coll Surg. 2006;202:247–251.

Codes

ICD9

865.00 Unspecified injury to spleen without mention of open wound into cavity
865.01 Hematoma of spleen, without rupture of capsule, without mention of open wound into cavity
865.02 Capsular tears to spleen, without major disruption of parenchyma, without mention of open wound into cavity