Fortunately, splenic injuries are not very common in sports medicine. However, when injury to the spleen occurs, it can have serious, if not fatal, consequences, due to the high vascularity of the organ. Despite these injuries being uncommon, the spleen is the most frequently injured organ with blunt abdominal trauma (5,7,24,26). Splenic injury can occur from a trivial mechanism of injury and does not always present in the classic fashion of abdominal pain and signs of peritoneal irritation on physical exam. Injury to the spleen has been documented after a collision with another player, blows to the abdomen from surfboards, boogie boards, snowboards, and lacrosse balls, during mountain biking, and after a seemingly benign fall onto a football, to name a few (2,4,10,21,22). Because of the wide variety of possible mechanisms of injury, it is crucial to consider splenic injury in the differential diagnosis of any injured athlete presenting with abdominal pain or discomfort. This article focuses on the diagnosis of traumatic splenic injuries, as well as current guidance for imaging, management, and return-to-play guidelines. Liver injury and splenic rupture secondary to infectious diseases, such as mononucleosis, will not be addressed.
The spleen lies behind ribs 9 through 11 on the left side of the adult abdomen. Normally, the adult spleen does not extend beyond the left costal margin unless it is enlarged. In young children, however, the rib cage does not completely cover the spleen. In addition, the thoracic cage in children is more compliant and transmits more energy from trauma. This results in organ injury from relatively less energy than it would take to cause trauma in adults (7). A spleen enlarged because of infection, pregnancy, or portal hypertension also can sustain injury from less force than an otherwise healthy spleen (18,20).
The spleen consists of the parenchyma and capsule. The capsule encases the organ and is made of tough fibroelastic connective tissue and smooth muscle (17). The spleen has a very rich vascular supply, receiving 5% to 6% of the cardiac output, while filtering 10% to 15% of total blood volume every minute (18,21). The splenic artery enters the spleen at the hilum and perfuses the five segments of the spleen, while the splenic vein drains the spleen and exits at the hilum. The spleen functions in humeral and cell-mediated immunity by housing B and T cell lymphocytes in the parenchyma, produces IgM antibodies, and is involved in hematopoiesis and phagocytosis (14,15,18,21).
The differences in anatomy between children and adults may lead to different treatment options. A major risk associated with nonoperative management of a splenic injury is delayed splenic rupture. The pediatric spleen tends to bleed less because of the thicker capsule, more elastic parenchyma, and a higher portion of smooth muscle allowing for contraction of splenic arterioles and thrombosis of pseudoaneurysms (6,13,18). The higher success rate of nonoperative management in children with splenic injury may be attributed to these anatomic differences.
Splenic injuries are graded on computed tomography (CT) scan by 1) the location of the hematoma or laceration (subcapsular, capsular tear, parenchymal), 2) the percentage of splenic involvement, and 3) the involvement of the hilar vasculature. See the Table for the American Association for the Surgery of Trauma Splenic Injury Scale (ASSI). This classification aids in staging the severity of the injury and directs treatment options.
EVALUATION OF THE ATHLETE
Signs of splenic injury can be subtle and easily overlooked early in the injury process. Therefore, a high index of suspicion is needed for correct diagnosis and the best possible outcome. A careful history and physical exam should be conducted in any athlete suspected of having sustained an abdominal injury (1). Important details in the history include the mechanism of injury, prior illnesses such as upper respiratory infections, fever, and hematologic disorders that may predispose the spleen to injury. The physical exam should focus on vital signs for indications of hemodynamic compromise, tenderness to palpation in the left upper quadrant, abdominal guarding or rebound tenderness, and change in mental status. Splenic injury classically presents with left upper quadrant pain and tenderness to palpation. Kehr's sign, referred pain to the left shoulder and proximal one third of the left arm because of free blood in the abdomen irritating the diaphragm and phrenic nerve, often is seen with splenic injury (21,22,26). The Cullen and Turner signs, ecchymosis in the periumbilical area and lateral abdominal wall respectively, are signs suggestive of hemoperitoneum (18,21,22). They are not evident immediately after injury and likely will not be seen early in the examination of the athlete. The lack of these classic signs reinforces the importance of frequent reassessment of the athlete, as signs of injury and hemodynamic compromise evolve over time.
Laboratory tests are not always helpful in identifying splenic injury, as an athlete may or may not be hemodynamically stable on initial presentation (21,24,26). Prolonged capillary refill, weak pulses, cool skin, or low blood pressure for age are signs of poor tissue perfusion. Because of the risk of hemodynamic instability, any athlete with a suspected splenic injury should be transported to the hospital for further evaluation and imaging.
For the hemodynamically unstable patient, immediate exploratory laparotomy usually is warranted, as it provides for definitive diagnosis and treatment. In a stable patient, a CT scan is the diagnostic study of choice for blunt abdominal trauma. Additional diagnostic modalities include abdominal ultrasound using the Focused Abdominal Sonography for Trauma (FAST) exam and diagnostic peritoneal lavage (DPL) for detection of hemoperitoneum.
The CT scan should be administered with intravenous contrast in order to detect splenic injury. The ASSI scale grades injuries based on location and extent of bleeding as seen on CT scan (Table). The term ``contrast blush'' on CT scan is used to describe pooling of contrast around or within the injured organ, which is suggestive of active bleeding and is associated with a higher grade of injury (9,12). This radiographic finding in adults is suggestive that the patient may fail nonoperative treatment and require angiographic embolization or splenectomy (6,12). Children with a blush sign found on CT still may be treated conservatively if hemodynamically stable (6,12,13).
Abdominal ultrasound scan may be used for the detection of hemoperitoneum. The test can be performed rapidly and may aid in deciding the course of management. However, the utility of the FAST exam is being called into question because of poor specificity, especially in children (7,18). The sensitivity of detecting hemoperitoneum is 83% to 91% in adults, and the false negative rate has been reported at 38% for children (9,18). Therefore, a negative scan cannot rule out hemoperitoneum and should prompt further imaging in suspicious cases.
DPL is an accurate and reliable test, but its use has fallen out of favor because of the wide availability of CT scans. It may be considered in hemodynamically unstable patients who are unable to undergo a CT scan. DPL has a very low false negative rate (2%-4%) but is limited in that it does not indicate which abdominal organ is bleeding (18).
Field side management of the athlete with a suspected splenic injury should be prompt with rapid transport to the hospital for imaging and hemodynamic monitoring. The patient should be admitted to the hospital for observation. The suggested duration of this observation is ``grade plus one'' days using the ASSI injury grade (7). Patients with signs of hemodynamic compromise, a blush sign on CT scan, higher grade injuries (IV and V), or who require blood transfusions should be admitted to the intensive care unit (7,8,12,25,28). A multidiscipline approach including surgeons and critical care specialists should be involved in the care of these patients.
Approximately 75% to 93% of children with splenic injuries from blunt trauma are managed successfully with observation, whereas 35% to 65% of adults are successfully managed with observation. Ideally, nonoperative treatment of splenic injury is preferred because of the risk of overwhelming postsplenectomy infection (OPSI). OPSI was first described in the 1950s when patients were experiencing rapidly progressing and often lethal systemic infections after splenectomy (9,15,21). The mortality rate of OPSI is approximately 50% and has pushed the treatment of splenic injuries towards spleen-saving procedures when possible.
The concern involving nonoperative medical management is the rare complication of delayed splenic rupture. The incidence ranges from 1% to 8% in adults and 0% to 7.5% in children (6,13). This is thought to result from the development of pseduoaneurysm, splenic abscess, secondary tearing of the parenchyma from adherent omentum, and delayed hemorrhage. Splenic pseudoaneurysms are thought to be intraparenchymal hematomas that gradually increase in size and rupture (5,6,18).
Angiography can be considered in adults who are thought to be at high risk for delayed bleeding from pseudoaneurysms (9). Frumiento et al. found that splenic pseudoaneurysms in children are more likely to resolve spontaneously and less likely to bleed, allowing for a more conservative, noninterventional approach.
Provided the athlete is hemodynamically stable, the majority of injuries are monitored closely in a hospital setting with nonoperative management. In the pediatric population, nonoperative treatment of hemodynamically stable cases is very successful, regardless of the grade of injury or presence of a blush sign on CT. This is thought to be because of the anatomy of the pediatric spleen. In adults, severe splenic injury correlates with higher grade injury and increased bleeding. CT findings alone do not dictate the need for surgery; however, laparotomy should be considered in adults with grade IV or V injuries (7,18).
If the injury is severe enough to necessitate splenectomy, the patient should receive vaccinations against Pneumococcus, Haemphilus influenza type B, and Neisseria meningitides. Revaccination with the pneumococcal vaccination should be considered 5 yr after the initial vaccination in adults (21). Splenectomy also leads to an increased risk of blood-borne protozoal infections, such as malaria and babesiosis, and an increased risk of infection after dog bites because of Capnocytophaga canimorsus (18). Therefore, in addition to the proper vaccinations, patients also should receive prophylaxis antibiotics and antimalaria medications when needed (15,21).
RETURN TO PLAY
Guidelines for resuming full activity after a splenic injury are controversial. Recommendations on return to play vary from 3 wk to 3 months (7,8,11,19,26). The lack of consensus is due to our inability to predict when full recovery from an injured spleen occurs and the ability to predict delayed rupture. There are case reports in the literature of high-level athletes choosing splenectomy over nonoperative management in order to achieve a rapid return to play with full participation in collision sports 3 wk after surgery (26).
The majority of studies in both pediatric and adult populations find little value in reimaging the spleen in order to clear athletes for participation, as radiographic healing may lag behind physiologic healing (26). Brown et al. found radiographic healing on CT scan for a grade 1 injury to be 3.1 wk, grade 2 healing at 8.2 wk, grade III healing at 12.1 wk, and grade 4 healing at 20.1 wk (3). Savage et al. demonstrated that 84% of patients studied had a healed spleen at 2 to 2.5 months on CT scan regardless of severity of initial injury (23). The primary argument in favor of follow-up imaging is based on concern for missing a delayed splenic rupture. However, in a 2-yr study in 32 centers, fewer than 50% of patients had follow-up imaging after splenic injury, and there were no negative sequelae (25). In addition to an unclear correlation between radiographic and physiologic healing of the spleen, the radiation exposure from multiple CT scans should be considered, especially in the pediatric population.
Light activity may be advised to all patients with a splenic injury, regardless of the grade of injury during the first 3 months, with a gradual return to full activity after that time. The return-to-play decision can be a challenge after nonoperative management due to lack of evidence-based guidelines; however, the majority of injured spleens heal within 2 to 2.5 months (23). The return-to-play decision after splenectomy often is not as challenging because athletes can return to collision sports after postoperative healing, and a few case studies have reported return to play as early as 3 wk after surgery (19,26). Rib protection may be considered in athletes participating in contact sports after splenic injury; however, there are no evidence-based guidelines supporting their use. Follow-up imaging with a CT scan typically is not recommended. However, imaging may be considered if the patient has a high grade injury or is still experiencing symptoms such as abdominal pain, left shoulder pain, or early satiety on follow-up examinations. Athletes who sustain a splenic injury should be monitored very closely during the convalesce and return-to-play phases of recovery.
Although splenic injury is a relatively uncommon sports-related injury, medical providers should have a high index of suspicion for splenic injury with any history of abdominal trauma. An athlete presenting with abdominal pain requires frequent assessment and possible transport to the hospital for imaging, regardless of how trivial the initial injury may appear. CT scan is the diagnostic imaging study of choice after blunt abdominal trauma if the patient is hemodynamically stable. In general, management for pediatric and adult athletes is largely nonoperative. There is no consensus on return to play after sustaining a splenic injury because of the uncertainty of delayed splenic rupture. However, it is acceptable for an athlete to engage in light activity for the first 3 months after injury and then gradually return to full activity. Routine imaging is not recommended, as physiologic healing frequently lags behind signs of radiographic healing and does not aid in return-to-play decisions. However, follow-up CT scan may be considered in patients with higher-grade injuries or those who are still symptomatic. Athletes must be monitored closely immediately after sustaining blunt abdominal injury and well into the return-to-play phase to ensure proper diagnosis and a safe return to previous activities.
1. Barkun AN, Camus M, Green L, et al. The bedside assessment of splenic enlargement. Am. J. Med
. 1991; 91:512-8.
2. Bergqvist D, Hedelin H, Karlsson G, et al. Abdominal injury from sporting activities. Br. J. Sports Med
. 1982; 16:76-9.
3. Brown RL, Irish MS, McCabe AJ, et al. Observation of splenic trauma: when is a little too much? J. Pediatr. Surg
. 1999; 34;1124-6.
4. Choo KL, Hansen JB, Bailey DM. Beware the boogie board: blunt abdominal trauma from bodyboarding. Med. J. Aust
. 2002; 176:326-7.
5. El-Osta H. Delayed splenic rupture: myth or reality? Ann. Inter. Med
. 2009; 150:224-5.
6. Frumiento C, Sartorelli K, Vane D. Complications of splenic injuries: expansion of the nonoperative theorem. J. Pediatr. Surg
. 2000; 35:788-91.
7. Gaines BA. Intra-abdominal solid organ injury in children: diagnosis and treatment. J. Trauma
. 2009; 67:135-8.
8. Gandhi RR, Keller MS, Schwab CW, et al. Pediatric splenic injury: pathway to play? J. Pediatr. Surg
. 1999; 34:55-9.
9. Harbrecht BG. Is anything new in adult blunt splenic trauma? Am. J. Surg
. 2005; 190:273-8.
10. Hayes JR, Groner JI. The increasing incidence of snowboard-related trauma. J. Pediatr. Surg
. 2008; 43:928-30.
11. Huebner S, Reed MH. Analysis of the value of imaging as part of the follow-up of splenic injury in children. Pediatr. Radiol
. 2001; 31:852-5.
12. Lutz N, Mahboubi S, Nance ML, et al. The significance of contrast blush on computed tomography in children with splenic injuries. J. Pediatr. Surg
. 2004; 39:491-4.
13. Maurer SV, Denys A, Lutz N. Successful embolization of a delayed splenic rupture following trauma in a child. J. Pediatr. Surg
. 2009; 44:E1-4.
14. McClusky DA, Lee BA, Skandalkis LJ, et al. Tribute to a triad: history of splenic anatomy, physiology and surgery - part 1. World J. Surg
. 1999; 23:311-25.
15. McClusky DA, Lee BA, Skandalkis LJ, et al. Tribute to a triad: history of splenic anatomy, physiology and surgery - part 2. World J. Surg
. 1999; 23:514-26.
16. Moore EE, Shackford SR, Pachter HL, et al. Organ injury scaling: spleen, liver, and kidney. J. Trauma
. 1989; 29:1664-6.
17. Moore KL, Dalley AF. Clinically Oriented Anatomy
, 4th ed., Baltimore: Lippincott Williams & Wilkins; 1999, p. 256-7.
18. Peitzman AB, Ford HR, Harbrecht BG, et al. Injury to the spleen. Curr. Prob. Surg
. 2001; 38:921-1008.
19. Pucci E, Brody F, Zemon H, et al. Laparoscopic splenectomy for delayed splenic rupture after embolization. J. Trauma
. 2007; 63:687-90.
20. Putukian M, O'Connor FG, Stricker PR, et al. Mononucleosis and athletic participation: an evidence-based subjective review. Clin. J. Sport Med
. 2008; 18:309-15.
21. Ralston DJ, Scherm MJ. Splenic artery avulsion in a high school football player: a case report. J. Athl. Train
. 2004; 39:201-5.
22. Rifat SF, Gilvydis RP. Blunt abdominal trauma in sports. Curr. Sports Med. Rep
. 2003; 2:93-7.
23. Savage SA, Zarzaur BL, Magnotti LJ, et al. The evolution of blunt splenic injury: resolution and progression. J. Trauma
. 2008; 64:1085-92.
24. Shamim SM, Razzak JA, Umer SM, et al. Splenic injury after blunt abdominal trauma: an unusual presentation. J. Emerg. Med
. 2008 [Epub].
25. Stylianos S. Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury. J Pediatr. Surg
. 2000; 35:164-9.
26. Terrell TR, Lundquist B. Management of splenic rupture and return-to-play decisions in a college football player. Clin. J. Sports Med
. 2002; 12:400-2.
27. Yang JC, Sharp SW, Ostlie DJ, et al. Natural history of nonoperative management for grade 4 and 5 liver and spleen injuries in children. J. Pediatr. Surg
. 2008; 43:2264-7.
28. Zabolotny B, Hancock BJ, Postuma R, et al. Blunt splenic injuries in a Canadian pediatric population: the need for a management guideline. Can. J. Surg
. 2002; 45:358-62.