Working Diagnosis:
Grade 5 Splenic Rupture

Treatment:
The patient was treated non-operatively and remained hemodynamically stable in the pediatric intensive care unit. After one day, he was transferred to a transitional unit. His three-day hospital course was unremarkable aside from a febrile episode. The nausea and abdominal cramping resolved upon discharge. Nine days later, patient had left pleuritic flank pain and found to have left lower lobe pneumonia for which he was treated as an outpatient with Augmentin.

Outcome:
Six months post splenic injury, the patient was cleared for full activity without restriction.

Author's Comments:
25% of splenic injuries are due to abdominal trauma. Although rare, abdominal trauma in sports requires thorough assessment with high suspicion for intra-abdominal injury. Complete evaluation should include mechanism of injury, area of impact, and pain patterns. Abdominal wall injuries typically are localized with immediate onset, whereas visceral injury can have a delayed onset of pain. Kehr's sign (pain radiating to shoulder from diaphragmatic irritation of free blood in abdomen) should raise concern for splenic injury and escalation of care for imaging. Splenic injuries are categorized as grade I-V. Hemodynamic stability determines operative, procedural intervention, or nonoperative treatment.

Editor's Comments:
Although thorough injury evaluation is important, when findings suggestive of intra-abdominal trauma and hemorrhage (such as this athlete's remarkably narrow pulse pressure and hypotension) rapid transfer of the injured athlete should be completed. The team physician or sports medicine staff should ideally utilize emergency medical services to transfer an athlete suspected to have intra-abdominal injury to a location with services for definitive care (i.e. emergency department with trauma care capabilities). In contrast to other sport related injuries, splenic injuries are the leading cause of death in sport-related abdominal injuries and thus warrant rapid evaluation and treatment.

Spontaneous splenic rupture in athletes may also occur with infection, especially in cases of infectious mononucleosis. Up to 90% of infectious mononucleosis is due to Epstein-Barr virus and treatment is typically symptomatic. But, extra care should be provided to ensure adequate limitation of strenuous activity to prevent the feared complication of splenic rupture.

References:
1. Adam J, De Luigi AJ. Blunt Abdominal Trauma in Sports. Curr Sports Med Rep. 2018;17(10):317-319.

2. Gannon EH, Howard T. Splenic injuries in athletes: a review. Curr Sports Med Rep. 2010;9(2):111-114.

3. Rifat SF, Gilvydis RP. Blunt abdominal trauma in sports. Curr Sports Med Rep. 2003;2(2):93-97.

4. Juyia RF, Kerr HA. Return to play after liver and spleen trauma. Sports Health. 2014;6(3):239-245.

5. Priestley, EM, et.al. Pulse Pressure as an Early Warning of Hemorrhage in Trauma Patients. J Am Coll Surg. 2019;229(2):184-191.

Return To The Case Studies List.