Splenic Injuries

Splenic Injuries

Injuries to the spleen are often caused by direct trauma to the left lower chest wall or left upper abdominal quadrant. Initial presentation may include fainting, dizziness, and weakness from blood loss, but is often limited to left upper quadrant pain with or without left shoulder pain (Kehr's sign). A mass in the left upper quadrant, abdominal distension, and abdominal stiffness were also common on physical examination. Ballone's sign (fixed dullness on the left flank and dullness changing position on the right flank) has been described as a rare finding. The spleen capsule may contain bleeding, and physical examination results are sometimes delayed in presentation. Late spleen rupture is a rare complication of splenic injury20 but a major treatment concern.

Standard radiographs may show an enlarged spleen if there is a subcapsular hematoma with an intact capsule. An enlarged spleen can also move the stomach anteriorly and the left kidney, left transverse colon, and splenic flexure downward. On radiography, turbidity of the abdomen,

The bulging flanks and loops of the small intestine are associated with signs of free peritoneal fluid, such as blood. The use of ultrasound to diagnose splenic injuries is common, and the sensitivity to diagnose splenic injuries is greater than for other abdominal organs. However, the appearance of the spleen on ultrasound scans can vary greatly. Siniluoto et al. has shown that repeated ultrasound evaluation will eventually detect splenic lesions if the exam is performed for 1-3 days. Many trauma centers use ultrasound as a screening test because it can be done quickly and

Targeted examination can be performed as a low-cost method of classifying patients with blunt abdominal trauma. Some authors use ultrasound to monitor patients due to their low cost and lack of ionizing radiation. The "gold standard" test for evaluating a spleen injury is computed tomography (CT). CT scan results include capsular abnormalities,

subcapsular and intrasplenic hematomas, single and multiple fractures and shattered and fragmented spleens. The sensitivity and specificity of computed tomography in the diagnosis of splenic injury are generally in the 96% range.

Buntain’s Classification of Splenic Injury

■ Grade I: Localized capsular disruption or subcapsular hematoma without significant parenchymal injury

■ Grade II: Single or multiple capsular and parenchymal disruptions that do not extend into hilum or involve major vessels

■ Grade III: Deep fractures, single or multiple, extending into the hilum and involving major blood vessels

■ Grade IV: Completely shattered or fragmented spleen or separated from its normal blood supply at the pedicle required for radiologic healing and return to activity. The American Association for the Surgery of Trauma (AAST) classification has been shown to correlate with an increased

risk for operative management. The majority of injuries to the spleen can be treated nonoperatively, with more than half of the higher-grade injuries managed nonoperatively. However, patients who do not stabilize with minimal resuscitation, those with recurrent hemodynamic instability, and

those with the presence of pooling or “blush” in the spleen on the initial CT scan with intravenous contrast all predict the failure of nonoperative management. On the field, the athletic trainer should obtain baseline vital signs, perform an abdominal examination, reassess vital signs for evidence of vascular instability, and decide if triage to the emergency room is required. If vital signs appear stable and abdominal pain does not increase with cough, sneeze, or rapid movements (all seen with peritoneal irritation), observation is a reasonable option. If there is any evidence of vascular

instability, transport should be considered. Placement of an IV for fluid challenge if a question of vascular instability is present should be considered only when transportation to a hospital cannot be easily accomplished.

Injuries to the spleen are most often caused by direct trauma to the left lower chest wall or left upper abdominal quadrant. The initial presentation may include fainting, dizziness, and weakness from blood loss but often is confined to left upper quadrant tenderness with or without left shoulder pain (Kehr’s sign). A left upper quadrant mass, abdominal distension, and abdominal rigidity are also frequent physical examination findings. Ballone sign—fixed dullness in the left flank and shifting position dullness in the right flank—has been described as an infrequent finding. The capsule of the spleen can contain bleeding, and physical examination findings are occasionally delayed in their presentation. Delayed rupture of the spleen is an uncommon complication of splenic injury20 but an important concern in management.

Plain x-rays may demonstrate an enlarged spleen if a subcapsular hematoma with an intact capsule is present. An enlarged spleen may also displace the stomach anteromedially and the left kidney, left transverse colon, and splenic flexure inferiorly. On x-ray, haziness of the abdomen,

bulging flanks, and displacement of small bowel loops are associated with signs of free peritoneal fluid, such as blood. Use of ultrasound to diagnose splenic injuries is common, and sensitivity in diagnosing splenic injuries is greater than for other abdominal organs. However, the appearance of the spleen on sonograms can vary widely. Siniluoto et al. demonstrated that repeat ultrasound evaluation will ultimately pick up splenic injuries if the examination is followed for 1 to 3 days. Many trauma centers use ultrasound as a screening test because it can be performed rapidly, and a

focused examination can be performed as a low-cost method for triaging patients with blunt abdominal trauma. Some authors use ultrasound to follow patients because of its low cost and lack of ionizing radiation. The “gold standard” test to evaluate an injury to the spleen is computed tomography (CT) scanning. Findings on CT scan include capsular disruptions,

subcapsular and intrasplenic hematomas, single and multiple fractures, and shattered and fragmented spleens. Sensitivity and specificity of CT scan in the diagnosis of splenic injury are generally in the range of 96%.

Buntain’s Classification of Splenic Injury

■ Grade I: Localized capsular disruption or subcapsular hematoma without significant parenchymal injury

■ Grade II: Single or multiple capsular and parenchymal disruptions that do not extend into hilum or involve major vessels

■ Grade III: Deep fractures, single or multiple, extending into the hilum and involving major blood vessels

■ Grade IV: Completely shattered or fragmented spleen or separated from its normal blood supply at the pedicle required for radiologic healing and return to activity. The American Association for the Surgery of Trauma (AAST) classification has been shown to correlate with an increased

risk for operative management. The majority of injuries to the spleen can be treated nonoperatively, with more than half of the higher-grade injuries managed nonoperatively. However, patients who do not stabilize with minimal resuscitation, those with recurrent hemodynamic instability, and

those with the presence of pooling or “blush” in the spleen on the initial CT scan with intravenous contrast all predict the failure of nonoperative management. On the field, the athletic trainer should obtain baseline vital signs, perform an abdominal examination, reassess vital signs for evidence of vascular instability, and decide if triage to the emergency room is required. If vital signs appear stable and abdominal pain does not increase with cough, sneeze, or rapid movements (all seen with peritoneal irritation), observation is a reasonable option. If there is any evidence of vascular

instability, transport should be considered. Placement of an IV for fluid challenge if a question of vascular instability is present should be considered only when transportation to a hospital cannot be easily accomplished.