MedPix® Patient Chart - Case No: 8227 :: - Review Images

15 yo wrestler s/p blunt trauma to the left abdomen 7 days ago, with persistent left chest wall pain

- Review Images for PT: 8227

Extensive splenic hypodensity with well-defined margins, extending from the splenic hilum to the lateral capsule. Splenic vessels show normal contrast opacification.

- Review Images for PT: 8227

Grade II vs Grade IV splenic laceration
Splenic Infarction
Lymphoma

- Review Images for PT: 8227

Dx: Splenic Laceration, Grade III

Dx Confirmed by: CT images are diagnostic, with the laceration measuring more than 3cm and therefore Grade III

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Conservative management, given proven hemodynamic stability.

If the patient is hemodynamically stable, conservative management is preferred to avoid the risks of surgery and to avoid post-splenectomy susceptibility to pneumococcus.

Spleen injuries typically occur in the setting of blunt trauma, with clinical findings of hemodynamic instability, left flank pain, and an expanding left upper quadrant mass. Predisposing conditions include mononucleosis and lymphoma. Currently, conservative therapy is favored to preserve immune function and avoid post-splenectomy sepsis and pneumococcal infections, as well as to reduce the number of nontherapeutic laparotomies and laparotomy complications. Persistent hemodynamic instability typically requires resection, and surgery has been advocated to avoid missing other intraabdominal injuries.
CT findings include subcapsular hematomas deforming the spleen margin, hypodense fracture planes, and regions of nonenhancing parenchyma, which indicate devascularization. Intravenous contrast is important to help determine the severity, and an intraparenchymal blush has been associated with a greater need for surgical exploration.
Associated injuries include other sequelae of blunt trauma. Approximately 40 percent of splenic injury patients have left-sided rib fracture, and renal injury is not uncommon. Delayed splenic rupture may represent a previously missed diagnosis, and occurs several weeks following the initial event. A low threshold should be kept for reimaging in the appropriate clinical setting.
The American Association for the Surgery of Trauma grades splenic injuries from I-V, with measurements of hematoma and laceration size differentiating the various grades. Increasing grade is associated with higher percentages of patients requiring surgery, but even grade IV injuries are frequently managed conservatively if the patient is hemodynamically stable.