Working Diagnosis:
Grade 4 Splenic Laceration Case Photo #4 with extravasation and Blush Case Photo #2 on CT
Acute Anemia Secondary to Blood Loss
Cervical Sprain
Stinger, resolved

Treatment:
Emergent coil embolization of the lower pole of the spleen with selective catheterization and diagnostic angiography of the celiac artery and splenic artery including the upper and lower pole segmental arteries.

Outcome:
The athlete was discharged in stable condition after 5 days of hospitalization with instructions to resume gentle activities such as walking and quiet seated activities. He was restricted from any physical activities exposing him to repeat trauma to abdominal area until follow up.
Ultrasound 5 weeks post injury- Stable appearance of the inferior pole splenic laceration with infarct Case Photo #3 from embolization procedure and no evidence of complication. We recommended return to non-contact practice for 2 weeks, then return to full contact practice and game.
He returned to a full contact game 6 weeks post injury after clearance from surgeon without any complaints or complications.

Author's Comments:
Discussion with radiologist over the case showed no apparent compounding factors anatomically. The spleen was of normal size and capsule thickness. This speaks against infectious mononucleosis as a contributing factor. Spleen was in normal position. The mechanism of the stinger injury speaks against direct abdominal trauma. The patient sustained no other witnessed abdominal trauma prior making this case not typical of direct blunt trauma to LUQ.
Return to play was significantly faster than initially expected. The Pediatric Surgeon felt quite confident in a 6 week recovery. Each case is unique as there are no clear guidelines for return to play, monitoring, or follow up imaging. Of note, not even the grade of the injury is a determinant for return to play decisions.

Editor's Comments:
This case is interesting because it is likely trauma was a cause of the splenic injury, but there was no witnessed direct abdominal trauma. A review of 613 cases of splenic rupture in absence of direct abdominal trauma or known underlying risk factors for splenic rupture showed that coughing, vomiting, or seizure can cause splenic rupture (6). This leads credence to the idea that in rare cases the spleen can suffer significant trauma from surrounding anatomic structures and not just from external trauma. In this case, such trauma may have been caused by the right sided torso flexion and twisting mechanism mentioned in the injury description.

References:
1. Juyia, Rushad F., DO, and Hamish A. Kerr. MD "Return to Play After Liver and Spleen Trauma." Sports Health 6.3 (2014): 239-245. Print.

2. Williams, John A., MD, "Traumatic Spleen Injury in a National Football League Player: a Clinical Case Report." NFL Physicians Society Scientific Meetings 2015 (2015): Power Print.

3. Gannon, Elizabeth H., and Thomas Howard. "Splenic Injuries in Athletes: a Review." Current Sports Medicine Reports 9.2 (2010): 111-114. Print.

4. Stassen et al. "Selective Nonoperative Management of Blunt Splenic Injury: an Eastern Association for the Surgery of Trauma Practice Management Guideline." Trauma Acute Care Surg 73.5.4 (2012): Print.

5. Fata P, Robinson L, Fakhry SM. “A Survey of EAST member practices in blunt splenic injury: a description of current trends and opportunities for improvement.” J Trauma. 59 (2005): 836-841. Print.

6. Aubrey-Bassler and Sowers. 613 cases of splenic rupture without risk factors or previously diagnosed disease: a systematic review. BMC Emergency Medicine (2012) 12:11. PDF.

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