ILLUSTRATIVE CASE
Splenic Injury After Blunt Abdominal Trauma During a Soccer (Football) Game Patricia S. Padlipsky, MD,*† Seth Brindis, MD,*†‡ and Kelly D. Young, MD, MS*† Abstract: The spleen is the most commonly injured abdominal organ in children who sustain blunt abdominal trauma, and pediatric splenic injury may result from minor mechanisms of injury, including sports participation. We present 2 cases of splenic injury in soccer goalies because of blunt abdominal trauma sustained during game play. Although abdominal organ injuries are uncommon in soccer, emergency medicine and primary care physicians must be aware of the possibility. A high index of suspicion and careful physical examination are key in making the diagnosis. Key Words: soccer, splenic injury, trauma (Pediatr Emer Care 2014;30: 725–729)
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he spleen is the most commonly injured abdominal organ in children who sustain blunt abdominal trauma. The most common mechanisms of blunt abdominal trauma in children are motor vehicle accidents, followed by pedestrians struck by cars, falls, and bicycle accidents,1,2 although other mechanisms, such as abuse, assault, and sports-related trauma, may result in abdominal injury. We report 2 pediatric patients who sustained splenic lacerations after blunt abdominal trauma during soccer games who presented to our pediatric emergency department (PED) within a span of 3 months, a review of the literature on soccer-related injuries, and a brief discussion of the diagnosis and management of splenic injury. To our knowledge, there are no previous case reports describing isolated acute splenic injuries in the pediatric population caused by blunt abdominal trauma sustained while playing soccer.
CASE 1 A 15-year-old male with no significant medical history was transferred to our PED from an outside hospital approximately 4 hours after colliding with another player while playing goalie during a soccer game. The patient presented to the outside hospital complaining of diffuse abdominal pain and left shoulder, flank, and chest pain. After arriving at the outside hospital, the patient had a syncopal episode preceded by lightheadedness while walking to the bathroom and was therefore immediately transferred to our PED. The patient denied any head trauma, loss of consciousness, palpitations, shortness of breath, vomiting, visual changes, paresthesias, or back pain. In the PED, physical examination revealed a well-nourished, well-developed, alert male in mild distress secondary to pain. His temperature was 36.4°C, pulse was 104 beats per minute, blood pressure was 112/88 mm Hg, respiratory rate was 15 per minute and oxygen saturation was 100% on room air. Head and neck examination was unremarkable. His chest was tender to palpation From the *David Geffen School of Medicine at UCLA, Los Angeles, CA; †Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA; and ‡Department of Emergency Medicine, CHOC Children's Hospital, Orange, CA. Disclosure: The authors declare no conflict of interest. Reprints: Kelly D. Young, MD, MS, Department of Emergency Medicine, Harbor-UCLA Medical Center, 1000 W. Carson Street, Box 21, Torrance, CA (e‐mail: [email protected]). Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0749-5161
Pediatric Emergency Care • Volume 30, Number 10, October 2014
over the left side including ribs 6 through 8 in the midaxillary line. There was no crepitus over the chest, his chest wall was stable, and there were clear breath sounds bilaterally. The heart examination was unremarkable. His abdomen was soft, nondistended, had normal bowel sounds, but was tender in the left upper quadrant. However, there was no rebound or guarding. Back and extremities examination was significant only for tenderness over the left distal one third clavicle. Skin was warm and dry, and no bruising was noted on chest or abdomen. Neurologic examination was normal. Laboratory tests showed a normal urinalysis, hemoglobin 13 g/dL, hematocrit 37%, hemocue at outside hospital 13.7 g/dL, serial hemocues in the PED 14.4 to 12.4 g/dL. Plain films showed no pneumothorax on chest radiograph, and no fracture, dislocation nor acromioclavicular separation on left shoulder radiograph. Bedside ultrasound showed fluid in Morrison's pouch. Abdominal/ pelvic computed tomography (CT) scan showed a grade IV splenic laceration with capsular rupture and hemoperitoneum. The patient was admitted to the pediatric intensive care unit (PICU) for monitoring. Serial hemoglobins were followed and eventually stabilized at 9.9 g/dL, and the patient was discharged after 3 days. He did not require any blood transfusions. He was ambulating and tolerating a regular diet before discharge. The patient was given a follow-up appointment with trauma surgery for repeat abdomen/pelvis CT scan with intravenous (IV) contrast 1 month after discharge to check for splenic artery pseudoaneurysm. The repeat CT scan showed considerable improvement of perisplenic hematoma and hemoperitoneum and no pseudoaneurysm.
CASE 2 A 17-year-old female without any significant medical history presented to our PED after being kicked in the abdomen while diving for a ball as goalie in a soccer game. She reported falling onto her left side and complained of mild abdominal pain at the time of injury. She denied nausea or vomiting. She did report that she hit the back of her head and had some dizziness after the fall, but denied loss of consciousness. She also reported twisting her ankle at the time of the fall. After the fall, with the help of her coach, she was able to walk but continued to have abdominal pain and a mild headache. She was picked up by her mother at the soccer field and brought to our PED for evaluation a few hours after the incident. On arrival, she reported increasing left sided abdominal pain and back pain. She denied any dizziness, nausea or vomiting, or shortness of breath but did report increased abdominal pain with breathing. On physical examination, she was noted to be in mild distress secondary to abdominal pain. Her vital signs showed a temperature of 36.7 C, heart rate 80 beats per minute, respiratory rate 16/minute, blood pressure 123/58 mm Hg, and oxygen saturation of 100% on room air. She was alert and oriented; head examination revealed no hematomas but mild tenderness to palpation on her left occipital and parietal areas. Remainder of the head and neck examination including pupils was normal. Lung and chest wall examinations were unremarkable. Her abdomen was soft and nondistended, had normal bowel sounds, and no bruising, but revealed diffuse tenderness left greater than right, and guarding in www.pec-online.com
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the left upper quadrant. Back and extremities examination were significant for mild tenderness over lower thoracic vertebrae, right ankle swelling over the lateral aspect with full range of motion, and no point tenderness. Neurological examination was within normal limits. The patient's initial hemocue was 13.8 g/dL. She was given a 1-L normal saline bolus and IV fentanyl for pain. Laboratory tests showed a hemoglobin of 13.7 g/dL, hematocrit of 39.3%, and urinalysis with 4 red blood cells per high power field. Plain radiographs of the ankle were normal, and chest radiograph showed no pneumothorax. Head CT scan was normal, but CT scan of the abdomen and pelvis revealed a grade II splenic laceration. Serial hemocues in the PED were 13.7 to 11.1 g/dL. The patient was admitted to the PICU for observation and serial hemocues. Her vital signs stayed stable in the PICU, and her hemoglobin stabilized at 9.7 g/dL. After 48 hours, she was transferred to the pediatric ward. At the time of transfer, she was still having mild tenderness in the left upper and lower quadrants of her abdomen. She was discharged approximately 72 hours after admission ambulating well, tolerating oral intake, and with much improved abdominal pain. She was given a follow-up with pediatric surgery 2 weeks after discharge and with her private medical doctor.
discussions of abdominal injuries as a result of playing soccer,19 and when mentioned, injuries are often grouped with trunk injuries without description of the specific injury. Data looking at pediatric soccer-related injuries presenting to U.S. emergency departments from 1990 to 2003 showed that internal organ injury occurred in 3.2% of 2- to 18-year-olds.17 Again, the organ injured was not specified. One death caused by splenic rupture resulting from blunt abdominal trauma during a soccer game was mentioned but not discussed. Splenic injury from blunt abdominal trauma sustained during sports including soccer appears to be a rare injury. A trauma registry from a regional pediatric trauma center in New York looked at recreational injuries and found only 0.73% of the children aged 5 to 18 years had genitourinary or abdominal injuries.20 Hockey, football, snowboarding, sledding, skiing, and bicycling accounted for most injuries. The kidney was the most commonly injured organ (44%), followed by the spleen (36%) and liver (20%). No injuries were related to basketball or soccer in this registry. However, a study using the National Pediatric Trauma Registry looked at children aged 5 to 18 years brought to participating pediatric trauma centers who sustained an injury related to contact sports over a 10-year period.21 Of the 5439 injuries caused by contact (team and individual) sports, abdominal injuries were reported in 458 cases, with 190 occurring from contact sports, and 25 from soccer specifically. The spleen was the most common organ injured (96), followed by the kidney (42), liver (13), and pancreas (11), with 28 nonspecified abdominal injuries. American football was the leading sport associated with intra-abdominal injury (49.7% of contact sport-related abdominal injury), but soccer injuries accounted for 13.5%, and 77% of soccer-associated abdominal injuries were splenic injuries. Both of our patients were goalies, and soccer goalies may have increased risk of sustaining blunt abdominal trauma because of diving for the ball and increased contact with opposition players attempting to score.22 Although a rare occurrence, it is important for physicians to be aware of the possibility of sports-related splenic injury because a delay in diagnosis can result in hemorrhagic shock and possibly death. Emergency medicine practitioners must be aware of current concepts related to diagnosis and management of patients with splenic injuries. Diagnosing splenic injury can be difficult because presentations are variable. A thorough history and physical examination are essential for the recognition of a possible splenic injury. Even patients sustaining minor trauma should be asked about abdominal pain and examined thoroughly.23 Diseases that increase the size of the spleen, such as mononucleosis, lymphoproliferative diseases, sickle cell disease, and systemic lupus erythematous, can predispose patients to splenic injury even after minor trauma.24 One of our patients had been kicked directly in the mid-abdomen, whereas the other collided with another player and fell to the ground, relatively minor mechanisms compared to motor vehicle accidents or falls from a height. Both of our patients complained of abdominal pain, and both had abdominal tenderness in the left upper quadrant. Other possible presenting signs and symptoms include abdominal abrasions or bruising, abdominal pain that radiates to the left shoulder because of diaphragmatic or phrenic nerve irritation by peritoneal blood (Kehr sign), left upper quadrant fullness, or abdominal distention. Approximately 40% to 60% of patients with splenic injury occurring from blunt abdominal trauma have other associated injuries, usually orthopedic or other abdominal organs (in order of decreasing frequency, liver, kidney, and bowel/mesentery).25 Left lower rib fractures from blunt trauma are associated with a 20% incidence of splenic injury,26 but children are less likely than adults to have
DISCUSSION The 2 cases presented illustrate that significant splenic injury can occur in children from blunt abdominal trauma during soccer games. Review of case summaries on blunt abdominal injuries in children sustained while playing soccer reveals a case of duodenal intramural hematoma,3 transverse colon rupture,4 pancreatic injuries,5,6 torsion of the gallbladder,7 abdominal aortic rupture,8 and 1 case of blunt abdominal soccer trauma causing splenic and other intra-abdominal injuries.6 In this latter case, an 18-year-old male kneed in the abdomen sustained multiple injuries including to his gallbladder, pancreas, and a splenic artery laceration. It is important to recognize, as seen in our cases, that isolated splenic injury may occur after the blunt abdominal trauma sustained while playing soccer and that patients may present in a stable fashion with abdominal pain and tenderness as the sole symptoms of splenic injury. Soccer (known as football outside the United States) is one of the most popular team sports in the world. Two national youth soccer organizations (American Youth Soccer Organization and United States Youth Soccer Association) have registered 600,0009 and 3.2 million10 participants younger than 19 years, respectively. More than 780,000 girls and boys played soccer in U.S. high schools in 2011 to 2012, with a 7% increase in participants since 2007.11 As soccer participation continues to increase, so will the number of children at risk for soccer-related injuries. The U.S. Consumer Product Safety Commission's National Electronic Injury Surveillance System estimated that there were 226,142 soccer-related injuries in 2010.12 Approximately 82% of these injuries affected those younger than 24 years, and about 43% occurred in participants younger than 15 years. Soccer is considered a moderate-intensity to high-intensity contact sport13 with most injuries occurring from player contact with another player, the ground, the ball, or the goalpost, rather than from overuse injury.14,15 It is estimated that more than 75% of the soccerrelated injuries are sprains, strains, contusions, abrasions, and blisters, often requiring only basic first aid.16–19 Fractures make up approximately 4% to 20% of injuries. Injuries to the lower extremities, especially the ankle and knee, are the most common and account for 60% to 80% of all injuries. Anterior cruciate ligament injury is particularly problematic. Upper extremity injuries account for approximately 3% to 15% of total injuries. Concussions are another commonly sustained injury. There are limited
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TABLE 1. AAST-Adopted Classification of Splenic Injuries Based on CT Scan Grade System31 Grade 1
Extent of Splenic Injury Hematoma: subcapsular, nonexpanding, < 10% of surface area Laceration: capsular tear, nonbleeding, < 1 cm of parenchymal depth Hematoma: subcapsular, nonexpanding, < 10%–50% of surface area; intraparenchymal, non expanding, < 2 cm in diameter Laceration: capsular tear, active bleeding, 1–3 cm of parenchymal depth that does not involve a trabecular vessel. Hematoma: subcapsular, > 50% of surface area or expanding, ruptured subcapsular hematoma with active bleeding, intraparenchymal hematoma, > 2 cm or expanding. Laceration: > 3 cm of parenchymal depth or involving trabecular vessels Hematoma: ruptured intraparenchymal hematoma with active bleeding Laceration: laceration involving segmental or hilar vessel producing major devascularization ( >25 of the spleen) Hematoma: completely shattered spleen Laceration: hilar vascular injury that devascularizes the spleen
2
3
4
5
AAST indicates American Association of Trauma.
rib fractures because of increased chest wall elasticity. Signs of peritoneal irritation (diffuse abdominal pain, rebound, and guarding) or shock should raise concern for hemoperitoneum.27 Initial hemoglobin and hematocrit are important to obtain but their levels can be normal in children with significant bleeding because it can take hours for body fluid spaces to equilibrate. Serial hemoglobin and hematocrit measurements are much more useful and can reflect the presence of ongoing blood loss. Routine “Trauma Panels,” are often nonspecific, and their use is controversial.28 Elevated hepatic transaminase and elevated serum amylase and lipase may suggest hepatic and pancreatic injury, respectively, but do not aid in the diagnosis of splenic injuries. Hematuria is an important marker of serious intra-abdominal injury (both renal and nonrenal) in children. In 1 study of 378 children after blunt abdominal trauma, of those with microscopic hematuria, the most commonly injured was the spleen (11%), followed by the liver (10%), and lastly, the kidney (8%).29 With gross hematuria, renal
Splenic Injury After Soccer-Related Trauma
injury was found in 22%, splenic injury in 17%, and liver injury in 8%. However, all children with hematuria and organ injury had other indications prompting CT scan, such as abdominal pain or an abnormal abdominal examination. History and physical examinations lead to the suspicion of splenic injury but are not diagnostic. Findings on chest and abdominal radiographs are often nonspecific in the detection of splenic injuries and have been found to be normal in greater than 95% in those with blunt abdominal trauma.30 As mentioned above, radiographs that show left lower rib fractures signify high impact trauma to the left upper quadrant and are often associated with splenic injury. The triad of left diaphragmatic elevation, left lower lobe atelectasis, and left pleural effusion has been seen with splenic rupture.27 Other plain film radiographic signs include medial displacement of gastric bubble, inferior displacement of the splenic flexure, and loss of the psoas margin if a large hemoperitoneum is present.29 Ultrasonography is quick, inexpensive, and usually easily accessible, but it does have limited sensitivity in the diagnosis of splenic parenchymal injuries. It is most useful in the detection of hemoperitoneum. The bedside focused abdominal sonography for trauma examination has been shown to be the most useful to look for hemoperitoneum in the unstable patient. It can also be used in a stable patient when splenic injury is suspected.27 In our first case, bedside ultrasound revealed blood in Morrison's pouch, which then lead to the CT scan. The abdominal CT scan with IV contrast remains the gold standard to diagnose splenic injury. It is fast, usually available, accurate, and relatively noninvasive. The child does need to be stable, cooperative or sedated, and be able to be transported to the CT scanner.27 However, because of the risks of radiation exposure, only patients with significant suspicion for intra-abdominal injury should be scanned. Splenic injuries are classified by findings on CT scan as described by the American Association of Trauma31 (see Table 1). When splenic injury is suspected or diagnosed, consultation with a surgeon with pediatric trauma experience is imperative. In the pediatric patient, the patient's hemodynamic stability dictates the management of the injury, not the grade of the splenic injury. Children with hemodynamic instability despite aggressive resuscitation should undergo exploratory laparotomy. It is recommended that at the time of exploration, attempts should be made to preserve the spleen whenever possible. There is a trend toward increased non-operative management and use of angiography.32 The benefits of predominantly nonoperative management include avoidance of perioperative risks and surgical costs, fewer blood transfusions, shorter hospital stays, and prevention of overwhelming postsplenectomy infections,33 which are estimated to occur at a rate of 0.23% to 0.42% per year with a lifetime risk of 3% to 5%, and mortality rate of 38% to 69%.34 Nonoperative management of isolated splenic injuries has become the standard
TABLE 2. APSA Evidence-Based Guidelines for Recommended Hospital Stay, Follow-Up Imaging, and Activity Restrictions for Solid Organ Injury35,36 Grade of Injury by CT Scan Grade I Grade II Grade III Grade IV
Days in ICU
Days in Hospital (Injury Grade + I day)
Predischarge and Postdischarge Imaging
Weeks of Activity Restriction (Injury Grade + 2 weeks)
None None None 1
2 3 4 5
None None None None
3 4 5 6
APSA indicates American Pediatric Surgical Association; ICU, intensive care unit.
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of care in pediatric trauma centers and is successful in 90% to 95% of cases.33 Conservative management generally includes hospital admission, 2 to 5 days of bed rest with early progressive mobilization, IV fluid hydration, frequent examinations, monitoring of serial hemoglobins and vital signs, and close supervision by a surgeon. The American Pediatric Surgical Association Liver/ Spleen Trauma study group have issued validated guidelines for the conservative management of splenic injury in the stable patient35,36 (see Table 2). Routine follow-up repeat CT scans are usually not recommended. The spleen heals quickly; studies have shown that 6 weeks after injury there is complete healing in 50% of all splenic injuries, and by 3 months after the injury in 100%.37 Emergency physicians should also be aware of complications that can occur after splenic injuries. Delayed complications occur at least 48 hours after the initial injury and include pseudocysts, abscesses, pseudoaneurysms, and delayed rupture. In adults, delayed splenic rupture has been shown to occur in 5% to 6% of those managed conservatively,38 but this complication is much more rare in children.39 One fatal pediatric case, however, has been reported following playing soccer.40
10. US Youth Soccer Association. History: US soccer. Available at www. usyouthsoccer.org/aboutus/WhatisYouthSoccer.asp Accessed December 27, 2012
CONCLUSIONS Pediatricians and emergency medicine physicians should be aware that splenic injury, although rare, can occur as a result of blunt abdominal trauma while playing sports, including soccer. Children presenting with a history or physical examination suggesting the possibility of splenic injury, multisystem injury, hemodynamic instability, hematuria, or left lower rib fractures should be considered for an abdominal CT scan with IV contrast. It is important to keep in mind that splenic injury presentation can be variable, that these injuries can be unrecognized initially, and that splenic injury can occur from relatively minor blunt abdominal trauma. If splenic injury is suspected or diagnosed, a surgeon with pediatric expertise should be consulted, but conservative nonoperative management is the standard of care in the hemodynamically stable pediatric patient. REFERENCES 1. Rothrock SG, Green SM, Morgan R. Abdominal trauma in infants and children: prompt identification and early management of serious and life-threatening injuries. Part I: injury patterns and initial assessment. Pediatr Emerg Care. 2000;16:106–115. 2. Holmes JF, Sokolove PE, Brant WE, et al. Identification of children with intra-abdominal injuries after blunt trauma. Ann Emerg Med. 2002; 39:500–509. 3. Kocaoglu M, Ors F, Bulakbasi N, et al. Duodenal intramural hematoma due to blunt abdominal trauma. Ulus Travma Acil Cerrahi Derg. 2005:165–168. 4. Dutson SCM. Transverse colon rupture in a young footballer. Br J Sports Med. 2006;40:e6.
11. National Federation of High Schools. 2011–2012 High School Athletics Participation Study. Available at: www.nfhs.org/content.aspx?id=3282. Accessed December 27, 2012. 12. Consumer Product Safety Commission National Electronic Injury Surveillance System Data Highlights 2010. Available at: http://www.cpsc. gov/neiss/2010highlights.pdf. Accessed March 30, 2013. 13. American Academy of Pediatrics; American Academy of Orthopedic Surgeons. Care of the Young Athlete. Sullivan JA, Anderson SJ, eds. Elk Grove Village, IL: American Academy of Pediatrics; 2000. 14. Le Gall F, Carling C, Reilly T. Injuries in young elite female soccer players: an 8-season prospective study. Am J Sports Med. 2008; 36:276–284. 15. Kakavelakis KN, Vlazakis S, Vlahakis I, et al. Soccer injuries in childhood. Scand J Med Sci Sports. 2003;13:175–178. 16. Giza E, Micheli LJ. Soccer injuries. Med Sports Sci. 2005;49:140–169. 17. Leininger RE, Knox CL, Comstock RD. Epidemiology of 1.6 million pediatric soccer-related injuries presenting to US emergency department from 1990–2003. Am J Sports Med. 2007;35:288–293. 18. Paterson A. Soccer injuries in children. Pediatr Radiol. 2009;39: 1286–1298. 19. Koutures CG, Gregory A. Injuries in youth soccer. Pediatrics. 2010; 125:410–414. 20. Wan J, Corvino T, et al. The incidence of recreational and genitourinary and abdominal injuries in the Western New York Pediatric Population. J Urol. 2003;170(4 pt 2):1525–1527. 21. Wan J, Corvino T, et al. Kidney and testicle injuries in team and individual sports: data from the National Pediatric Trauma Registry. J Urol. 2003; 170(4 pt 2):1528–1532. 22. Hunt M, Fulford S: Amateur soccer: injuries in relation to field position. Br J Sports Med. 1990;24:265. 23. Young KD, Seidel JS. Delayed diagnosis of splenic injury after falls from less than 10 feet. Pediatr Emerg Care. 1998;14:413–415. 24. Sill RH. The spleen and lympth nodes. In: McMillan JA, Feigin Rd, Oski FA, et al. (eds) Oski pediatrics: principles and practice, 4th ed. Lippincott Williams and Wilkins: Baltimore; 1717–1720. 25. Tataria M, Nance ML, Holmes JH, et al. Pediatric blunt abdominal injury: age is irrelevant and delayed operation is not detrimental. J Trauma. 2007;63:608–614. 26. Dupuy DE, Raptopoulos V, Fink MP. Current concepts in splenic trauma. J Intensive Care Med. 1995;10:76–90. 27. Lynn KN, Werder Gm, Callaghan RM, et al. Pediatric blunt splenic trauma: a comprehensive review. Pediatr Radiol. 2009;39:904–916. 28. Capraro AJ, Mooney D, Waltzman ML. The use of routine laboratory studies as screening tools in pediatric abdominal trauma. Pediatr Emerg Care. 2006;22:480–484 (Retrospective review, 382 patients).
5. Rawls De, Custer MD. Panacreatic trauma: an unusual soccer injury. South Med J. 2001;94:741–743.
29. Taylor GA, Eichelberger MR, Potter BM. Hematuria: a marker of abdominal injury in children after blunt trauma. Ann Surg. 1988;208: 688–693 (Retrospective review, 378 consecutive patients).
6. Kara E, Icoz G, Ersin S, et al. Life-threatening abdominal injury during a soccer game: a rare clinical case. Ulus Travma Acil Cerrahi Derg 2011; 17:180–182.
30. Rothrock SG, Green SM, Hummel CB. Plain abdominal radiography in the detection of major disease in children: a prospective analysis. Ann Emerg Med. 1992;21:1423–1429 (Retrospective review, 354 patients).
7. Salman AB, Yildirgan MI, Celebi F. Posstraumatic gallbladder torsion in a child. J Pediatr Surg. 1996;31:1586. 8. Harkin DW, Kirk G, Clements WD. Abdominal aortic rupture in a child after blunt trauma on a soccer field. Injury. 1999;30:303–304.
31. Tinkoff G, Esposito TJ, Reed J, et al. American Association for the Surgery of Trauma Organ Injury Scale 1: spleen, liver and kidney, validation based on the National Trauma Data Bank. J Am Coll Sur. 2008; 207:646–655.
9. American Youth Soccer Organization. About AYSO. Available at: www. ayso.org/About AYSO.org. Accessed December 27, 2012
32. Lee J, Moriarty KP, Tashjian DB. Less is more: management of pediatric splenic injury. Arch Surg. 2012;147:437–441.
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33. Muniz A. Evaluation and management of pediatric abdominal trauma. Pediatric Emerg Med Pract. 2008;5:1–32.
37. Pranikoff T, Hirschl RB, Schlesinger AE, et al. Resolution of splenic injury after nonoperative management. J Pediatr Surg. 1994;29:1366–1369.
34. Peitzman AB, Ford HR, Harbrecht BG, et al. Injury to the spleen. Curr Probl Surg. 2001;38:932–1008.
38. Cocanour Cs, Moore FA, Ware DN, et al. Delayed complications of nonoperative management of blunt adult splenic trauma. Arch Surg. 1998;133:619–624.
35. Stylianos S, the APSA Liver/Spleen Trauma Study Group, Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury. J Pediatr Surg. 2000;35:164–169. 36. Stylianos S, the APSA Liver/Spleen Trauma Study Group, Compliance with evidence-based guidelines in children with isolated spleen or liver injury: a prospective study. J Pediatr Surg. 2002;37:453–456.
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39. Davies DA, Fecteau A, Himidan S, et al. What’s the incidence of delayed splenic bleeding in children after blunt trauma: An institutional experience and review of the literature. J Trauma. 2009;67:573–577. 40. Eren B, Türkmen N, Gündogmus UN: Delayed spleen rupture after blunt abdominal trauma (case report). Georgian Med News. 2012;206:22–24.
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Splenic Injury After Blunt Abdominal Trauma During a Soccer (Football) Game Patricia S. Padlipsky, MD,*† Seth Brindis, MD,*†‡ and Kelly D. Young, MD, MS*† Abstract: The spleen is the most commonly injured abdominal organ in children who sustain blunt abdominal trauma, and pediatric splenic injury may result from minor mechanisms of injury, including sports participation. We present 2 cases of splenic injury in soccer goalies because of blunt abdominal trauma sustained during game play. Although abdominal organ injuries are uncommon in soccer, emergency medicine and primary care physicians must be aware of the possibility. A high index of suspicion and careful physical examination are key in making the diagnosis. Key Words: soccer, splenic injury, trauma (Pediatr Emer Care 2014;30: 725–729)
T
he spleen is the most commonly injured abdominal organ in children who sustain blunt abdominal trauma. The most common mechanisms of blunt abdominal trauma in children are motor vehicle accidents, followed by pedestrians struck by cars, falls, and bicycle accidents,1,2 although other mechanisms, such as abuse, assault, and sports-related trauma, may result in abdominal injury. We report 2 pediatric patients who sustained splenic lacerations after blunt abdominal trauma during soccer games who presented to our pediatric emergency department (PED) within a span of 3 months, a review of the literature on soccer-related injuries, and a brief discussion of the diagnosis and management of splenic injury. To our knowledge, there are no previous case reports describing isolated acute splenic injuries in the pediatric population caused by blunt abdominal trauma sustained while playing soccer.
CASE 1 A 15-year-old male with no significant medical history was transferred to our PED from an outside hospital approximately 4 hours after colliding with another player while playing goalie during a soccer game. The patient presented to the outside hospital complaining of diffuse abdominal pain and left shoulder, flank, and chest pain. After arriving at the outside hospital, the patient had a syncopal episode preceded by lightheadedness while walking to the bathroom and was therefore immediately transferred to our PED. The patient denied any head trauma, loss of consciousness, palpitations, shortness of breath, vomiting, visual changes, paresthesias, or back pain. In the PED, physical examination revealed a well-nourished, well-developed, alert male in mild distress secondary to pain. His temperature was 36.4°C, pulse was 104 beats per minute, blood pressure was 112/88 mm Hg, respiratory rate was 15 per minute and oxygen saturation was 100% on room air. Head and neck examination was unremarkable. His chest was tender to palpation From the *David Geffen School of Medicine at UCLA, Los Angeles, CA; †Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA; and ‡Department of Emergency Medicine, CHOC Children's Hospital, Orange, CA. Disclosure: The authors declare no conflict of interest. Reprints: Kelly D. Young, MD, MS, Department of Emergency Medicine, Harbor-UCLA Medical Center, 1000 W. Carson Street, Box 21, Torrance, CA (e‐mail: [email protected]). Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0749-5161
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over the left side including ribs 6 through 8 in the midaxillary line. There was no crepitus over the chest, his chest wall was stable, and there were clear breath sounds bilaterally. The heart examination was unremarkable. His abdomen was soft, nondistended, had normal bowel sounds, but was tender in the left upper quadrant. However, there was no rebound or guarding. Back and extremities examination was significant only for tenderness over the left distal one third clavicle. Skin was warm and dry, and no bruising was noted on chest or abdomen. Neurologic examination was normal. Laboratory tests showed a normal urinalysis, hemoglobin 13 g/dL, hematocrit 37%, hemocue at outside hospital 13.7 g/dL, serial hemocues in the PED 14.4 to 12.4 g/dL. Plain films showed no pneumothorax on chest radiograph, and no fracture, dislocation nor acromioclavicular separation on left shoulder radiograph. Bedside ultrasound showed fluid in Morrison's pouch. Abdominal/ pelvic computed tomography (CT) scan showed a grade IV splenic laceration with capsular rupture and hemoperitoneum. The patient was admitted to the pediatric intensive care unit (PICU) for monitoring. Serial hemoglobins were followed and eventually stabilized at 9.9 g/dL, and the patient was discharged after 3 days. He did not require any blood transfusions. He was ambulating and tolerating a regular diet before discharge. The patient was given a follow-up appointment with trauma surgery for repeat abdomen/pelvis CT scan with intravenous (IV) contrast 1 month after discharge to check for splenic artery pseudoaneurysm. The repeat CT scan showed considerable improvement of perisplenic hematoma and hemoperitoneum and no pseudoaneurysm.
CASE 2 A 17-year-old female without any significant medical history presented to our PED after being kicked in the abdomen while diving for a ball as goalie in a soccer game. She reported falling onto her left side and complained of mild abdominal pain at the time of injury. She denied nausea or vomiting. She did report that she hit the back of her head and had some dizziness after the fall, but denied loss of consciousness. She also reported twisting her ankle at the time of the fall. After the fall, with the help of her coach, she was able to walk but continued to have abdominal pain and a mild headache. She was picked up by her mother at the soccer field and brought to our PED for evaluation a few hours after the incident. On arrival, she reported increasing left sided abdominal pain and back pain. She denied any dizziness, nausea or vomiting, or shortness of breath but did report increased abdominal pain with breathing. On physical examination, she was noted to be in mild distress secondary to abdominal pain. Her vital signs showed a temperature of 36.7 C, heart rate 80 beats per minute, respiratory rate 16/minute, blood pressure 123/58 mm Hg, and oxygen saturation of 100% on room air. She was alert and oriented; head examination revealed no hematomas but mild tenderness to palpation on her left occipital and parietal areas. Remainder of the head and neck examination including pupils was normal. Lung and chest wall examinations were unremarkable. Her abdomen was soft and nondistended, had normal bowel sounds, and no bruising, but revealed diffuse tenderness left greater than right, and guarding in www.pec-online.com
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the left upper quadrant. Back and extremities examination were significant for mild tenderness over lower thoracic vertebrae, right ankle swelling over the lateral aspect with full range of motion, and no point tenderness. Neurological examination was within normal limits. The patient's initial hemocue was 13.8 g/dL. She was given a 1-L normal saline bolus and IV fentanyl for pain. Laboratory tests showed a hemoglobin of 13.7 g/dL, hematocrit of 39.3%, and urinalysis with 4 red blood cells per high power field. Plain radiographs of the ankle were normal, and chest radiograph showed no pneumothorax. Head CT scan was normal, but CT scan of the abdomen and pelvis revealed a grade II splenic laceration. Serial hemocues in the PED were 13.7 to 11.1 g/dL. The patient was admitted to the PICU for observation and serial hemocues. Her vital signs stayed stable in the PICU, and her hemoglobin stabilized at 9.7 g/dL. After 48 hours, she was transferred to the pediatric ward. At the time of transfer, she was still having mild tenderness in the left upper and lower quadrants of her abdomen. She was discharged approximately 72 hours after admission ambulating well, tolerating oral intake, and with much improved abdominal pain. She was given a follow-up with pediatric surgery 2 weeks after discharge and with her private medical doctor.
discussions of abdominal injuries as a result of playing soccer,19 and when mentioned, injuries are often grouped with trunk injuries without description of the specific injury. Data looking at pediatric soccer-related injuries presenting to U.S. emergency departments from 1990 to 2003 showed that internal organ injury occurred in 3.2% of 2- to 18-year-olds.17 Again, the organ injured was not specified. One death caused by splenic rupture resulting from blunt abdominal trauma during a soccer game was mentioned but not discussed. Splenic injury from blunt abdominal trauma sustained during sports including soccer appears to be a rare injury. A trauma registry from a regional pediatric trauma center in New York looked at recreational injuries and found only 0.73% of the children aged 5 to 18 years had genitourinary or abdominal injuries.20 Hockey, football, snowboarding, sledding, skiing, and bicycling accounted for most injuries. The kidney was the most commonly injured organ (44%), followed by the spleen (36%) and liver (20%). No injuries were related to basketball or soccer in this registry. However, a study using the National Pediatric Trauma Registry looked at children aged 5 to 18 years brought to participating pediatric trauma centers who sustained an injury related to contact sports over a 10-year period.21 Of the 5439 injuries caused by contact (team and individual) sports, abdominal injuries were reported in 458 cases, with 190 occurring from contact sports, and 25 from soccer specifically. The spleen was the most common organ injured (96), followed by the kidney (42), liver (13), and pancreas (11), with 28 nonspecified abdominal injuries. American football was the leading sport associated with intra-abdominal injury (49.7% of contact sport-related abdominal injury), but soccer injuries accounted for 13.5%, and 77% of soccer-associated abdominal injuries were splenic injuries. Both of our patients were goalies, and soccer goalies may have increased risk of sustaining blunt abdominal trauma because of diving for the ball and increased contact with opposition players attempting to score.22 Although a rare occurrence, it is important for physicians to be aware of the possibility of sports-related splenic injury because a delay in diagnosis can result in hemorrhagic shock and possibly death. Emergency medicine practitioners must be aware of current concepts related to diagnosis and management of patients with splenic injuries. Diagnosing splenic injury can be difficult because presentations are variable. A thorough history and physical examination are essential for the recognition of a possible splenic injury. Even patients sustaining minor trauma should be asked about abdominal pain and examined thoroughly.23 Diseases that increase the size of the spleen, such as mononucleosis, lymphoproliferative diseases, sickle cell disease, and systemic lupus erythematous, can predispose patients to splenic injury even after minor trauma.24 One of our patients had been kicked directly in the mid-abdomen, whereas the other collided with another player and fell to the ground, relatively minor mechanisms compared to motor vehicle accidents or falls from a height. Both of our patients complained of abdominal pain, and both had abdominal tenderness in the left upper quadrant. Other possible presenting signs and symptoms include abdominal abrasions or bruising, abdominal pain that radiates to the left shoulder because of diaphragmatic or phrenic nerve irritation by peritoneal blood (Kehr sign), left upper quadrant fullness, or abdominal distention. Approximately 40% to 60% of patients with splenic injury occurring from blunt abdominal trauma have other associated injuries, usually orthopedic or other abdominal organs (in order of decreasing frequency, liver, kidney, and bowel/mesentery).25 Left lower rib fractures from blunt trauma are associated with a 20% incidence of splenic injury,26 but children are less likely than adults to have
DISCUSSION The 2 cases presented illustrate that significant splenic injury can occur in children from blunt abdominal trauma during soccer games. Review of case summaries on blunt abdominal injuries in children sustained while playing soccer reveals a case of duodenal intramural hematoma,3 transverse colon rupture,4 pancreatic injuries,5,6 torsion of the gallbladder,7 abdominal aortic rupture,8 and 1 case of blunt abdominal soccer trauma causing splenic and other intra-abdominal injuries.6 In this latter case, an 18-year-old male kneed in the abdomen sustained multiple injuries including to his gallbladder, pancreas, and a splenic artery laceration. It is important to recognize, as seen in our cases, that isolated splenic injury may occur after the blunt abdominal trauma sustained while playing soccer and that patients may present in a stable fashion with abdominal pain and tenderness as the sole symptoms of splenic injury. Soccer (known as football outside the United States) is one of the most popular team sports in the world. Two national youth soccer organizations (American Youth Soccer Organization and United States Youth Soccer Association) have registered 600,0009 and 3.2 million10 participants younger than 19 years, respectively. More than 780,000 girls and boys played soccer in U.S. high schools in 2011 to 2012, with a 7% increase in participants since 2007.11 As soccer participation continues to increase, so will the number of children at risk for soccer-related injuries. The U.S. Consumer Product Safety Commission's National Electronic Injury Surveillance System estimated that there were 226,142 soccer-related injuries in 2010.12 Approximately 82% of these injuries affected those younger than 24 years, and about 43% occurred in participants younger than 15 years. Soccer is considered a moderate-intensity to high-intensity contact sport13 with most injuries occurring from player contact with another player, the ground, the ball, or the goalpost, rather than from overuse injury.14,15 It is estimated that more than 75% of the soccerrelated injuries are sprains, strains, contusions, abrasions, and blisters, often requiring only basic first aid.16–19 Fractures make up approximately 4% to 20% of injuries. Injuries to the lower extremities, especially the ankle and knee, are the most common and account for 60% to 80% of all injuries. Anterior cruciate ligament injury is particularly problematic. Upper extremity injuries account for approximately 3% to 15% of total injuries. Concussions are another commonly sustained injury. There are limited
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Pediatric Emergency Care • Volume 30, Number 10, October 2014
TABLE 1. AAST-Adopted Classification of Splenic Injuries Based on CT Scan Grade System31 Grade 1
Extent of Splenic Injury Hematoma: subcapsular, nonexpanding, < 10% of surface area Laceration: capsular tear, nonbleeding, < 1 cm of parenchymal depth Hematoma: subcapsular, nonexpanding, < 10%–50% of surface area; intraparenchymal, non expanding, < 2 cm in diameter Laceration: capsular tear, active bleeding, 1–3 cm of parenchymal depth that does not involve a trabecular vessel. Hematoma: subcapsular, > 50% of surface area or expanding, ruptured subcapsular hematoma with active bleeding, intraparenchymal hematoma, > 2 cm or expanding. Laceration: > 3 cm of parenchymal depth or involving trabecular vessels Hematoma: ruptured intraparenchymal hematoma with active bleeding Laceration: laceration involving segmental or hilar vessel producing major devascularization ( >25 of the spleen) Hematoma: completely shattered spleen Laceration: hilar vascular injury that devascularizes the spleen
2
3
4
5
AAST indicates American Association of Trauma.
rib fractures because of increased chest wall elasticity. Signs of peritoneal irritation (diffuse abdominal pain, rebound, and guarding) or shock should raise concern for hemoperitoneum.27 Initial hemoglobin and hematocrit are important to obtain but their levels can be normal in children with significant bleeding because it can take hours for body fluid spaces to equilibrate. Serial hemoglobin and hematocrit measurements are much more useful and can reflect the presence of ongoing blood loss. Routine “Trauma Panels,” are often nonspecific, and their use is controversial.28 Elevated hepatic transaminase and elevated serum amylase and lipase may suggest hepatic and pancreatic injury, respectively, but do not aid in the diagnosis of splenic injuries. Hematuria is an important marker of serious intra-abdominal injury (both renal and nonrenal) in children. In 1 study of 378 children after blunt abdominal trauma, of those with microscopic hematuria, the most commonly injured was the spleen (11%), followed by the liver (10%), and lastly, the kidney (8%).29 With gross hematuria, renal
Splenic Injury After Soccer-Related Trauma
injury was found in 22%, splenic injury in 17%, and liver injury in 8%. However, all children with hematuria and organ injury had other indications prompting CT scan, such as abdominal pain or an abnormal abdominal examination. History and physical examinations lead to the suspicion of splenic injury but are not diagnostic. Findings on chest and abdominal radiographs are often nonspecific in the detection of splenic injuries and have been found to be normal in greater than 95% in those with blunt abdominal trauma.30 As mentioned above, radiographs that show left lower rib fractures signify high impact trauma to the left upper quadrant and are often associated with splenic injury. The triad of left diaphragmatic elevation, left lower lobe atelectasis, and left pleural effusion has been seen with splenic rupture.27 Other plain film radiographic signs include medial displacement of gastric bubble, inferior displacement of the splenic flexure, and loss of the psoas margin if a large hemoperitoneum is present.29 Ultrasonography is quick, inexpensive, and usually easily accessible, but it does have limited sensitivity in the diagnosis of splenic parenchymal injuries. It is most useful in the detection of hemoperitoneum. The bedside focused abdominal sonography for trauma examination has been shown to be the most useful to look for hemoperitoneum in the unstable patient. It can also be used in a stable patient when splenic injury is suspected.27 In our first case, bedside ultrasound revealed blood in Morrison's pouch, which then lead to the CT scan. The abdominal CT scan with IV contrast remains the gold standard to diagnose splenic injury. It is fast, usually available, accurate, and relatively noninvasive. The child does need to be stable, cooperative or sedated, and be able to be transported to the CT scanner.27 However, because of the risks of radiation exposure, only patients with significant suspicion for intra-abdominal injury should be scanned. Splenic injuries are classified by findings on CT scan as described by the American Association of Trauma31 (see Table 1). When splenic injury is suspected or diagnosed, consultation with a surgeon with pediatric trauma experience is imperative. In the pediatric patient, the patient's hemodynamic stability dictates the management of the injury, not the grade of the splenic injury. Children with hemodynamic instability despite aggressive resuscitation should undergo exploratory laparotomy. It is recommended that at the time of exploration, attempts should be made to preserve the spleen whenever possible. There is a trend toward increased non-operative management and use of angiography.32 The benefits of predominantly nonoperative management include avoidance of perioperative risks and surgical costs, fewer blood transfusions, shorter hospital stays, and prevention of overwhelming postsplenectomy infections,33 which are estimated to occur at a rate of 0.23% to 0.42% per year with a lifetime risk of 3% to 5%, and mortality rate of 38% to 69%.34 Nonoperative management of isolated splenic injuries has become the standard
TABLE 2. APSA Evidence-Based Guidelines for Recommended Hospital Stay, Follow-Up Imaging, and Activity Restrictions for Solid Organ Injury35,36 Grade of Injury by CT Scan Grade I Grade II Grade III Grade IV
Days in ICU
Days in Hospital (Injury Grade + I day)
Predischarge and Postdischarge Imaging
Weeks of Activity Restriction (Injury Grade + 2 weeks)
None None None 1
2 3 4 5
None None None None
3 4 5 6
APSA indicates American Pediatric Surgical Association; ICU, intensive care unit.
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of care in pediatric trauma centers and is successful in 90% to 95% of cases.33 Conservative management generally includes hospital admission, 2 to 5 days of bed rest with early progressive mobilization, IV fluid hydration, frequent examinations, monitoring of serial hemoglobins and vital signs, and close supervision by a surgeon. The American Pediatric Surgical Association Liver/ Spleen Trauma study group have issued validated guidelines for the conservative management of splenic injury in the stable patient35,36 (see Table 2). Routine follow-up repeat CT scans are usually not recommended. The spleen heals quickly; studies have shown that 6 weeks after injury there is complete healing in 50% of all splenic injuries, and by 3 months after the injury in 100%.37 Emergency physicians should also be aware of complications that can occur after splenic injuries. Delayed complications occur at least 48 hours after the initial injury and include pseudocysts, abscesses, pseudoaneurysms, and delayed rupture. In adults, delayed splenic rupture has been shown to occur in 5% to 6% of those managed conservatively,38 but this complication is much more rare in children.39 One fatal pediatric case, however, has been reported following playing soccer.40
10. US Youth Soccer Association. History: US soccer. Available at www. usyouthsoccer.org/aboutus/WhatisYouthSoccer.asp Accessed December 27, 2012
CONCLUSIONS Pediatricians and emergency medicine physicians should be aware that splenic injury, although rare, can occur as a result of blunt abdominal trauma while playing sports, including soccer. Children presenting with a history or physical examination suggesting the possibility of splenic injury, multisystem injury, hemodynamic instability, hematuria, or left lower rib fractures should be considered for an abdominal CT scan with IV contrast. It is important to keep in mind that splenic injury presentation can be variable, that these injuries can be unrecognized initially, and that splenic injury can occur from relatively minor blunt abdominal trauma. If splenic injury is suspected or diagnosed, a surgeon with pediatric expertise should be consulted, but conservative nonoperative management is the standard of care in the hemodynamically stable pediatric patient. REFERENCES 1. Rothrock SG, Green SM, Morgan R. Abdominal trauma in infants and children: prompt identification and early management of serious and life-threatening injuries. Part I: injury patterns and initial assessment. Pediatr Emerg Care. 2000;16:106–115. 2. Holmes JF, Sokolove PE, Brant WE, et al. Identification of children with intra-abdominal injuries after blunt trauma. Ann Emerg Med. 2002; 39:500–509. 3. Kocaoglu M, Ors F, Bulakbasi N, et al. Duodenal intramural hematoma due to blunt abdominal trauma. Ulus Travma Acil Cerrahi Derg. 2005:165–168. 4. Dutson SCM. Transverse colon rupture in a young footballer. Br J Sports Med. 2006;40:e6.
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31. Tinkoff G, Esposito TJ, Reed J, et al. American Association for the Surgery of Trauma Organ Injury Scale 1: spleen, liver and kidney, validation based on the National Trauma Data Bank. J Am Coll Sur. 2008; 207:646–655.
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33. Muniz A. Evaluation and management of pediatric abdominal trauma. Pediatric Emerg Med Pract. 2008;5:1–32.
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39. Davies DA, Fecteau A, Himidan S, et al. What’s the incidence of delayed splenic bleeding in children after blunt trauma: An institutional experience and review of the literature. J Trauma. 2009;67:573–577. 40. Eren B, Türkmen N, Gündogmus UN: Delayed spleen rupture after blunt abdominal trauma (case report). Georgian Med News. 2012;206:22–24.
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