What are the symptoms and treatment for a suspected splenic laceration due to a rib injury?

Symptoms and Treatment of Splenic Laceration from Rib Injury

Clinical Presentation

Suspect splenic laceration in any patient with left-sided rib fractures who presents with left upper quadrant pain, hemodynamic instability, or referred left shoulder pain (Kehr's sign). 1, 2

Key Symptoms to Assess

• Abdominal pain: Left upper quadrant tenderness is the most common presenting symptom 3
• Referred pain: Left shoulder pain when the left upper quadrant is palpated (Kehr's sign) indicates diaphragmatic irritation from blood 3
• Hemodynamic instability: Hypotension (systolic BP <90 mmHg), tachycardia, altered consciousness, skin vasoconstriction, or shortness of breath 1, 2
• Non-specific presentations: Neck pain, upper shoulder pain, or headache may be the only initial complaints, making diagnosis challenging 3
• Delayed presentation: Symptoms may appear 4-10 days after initial injury (delayed splenic rupture), though most occur within the first 48 hours 1, 4

Critical Pitfall

Patients may present with minimal or atypical symptoms initially, particularly with delayed splenic rupture. The asymptomatic period between injury and hemorrhage can lead to missed diagnosis. 4 Additionally, manipulation during thoracic procedures (such as VATS for rib fixation) can cause or worsen splenic injury even when no initial splenic trauma was detected. 5

Diagnostic Approach

Immediate Assessment

• Verify hemodynamic stability first: Check blood pressure, heart rate, capillary refill, mental status, and shock index 1, 2
• E-FAST ultrasound: Rapid detection of free fluid in hemodynamically unstable patients 6
• Contrast-enhanced CT scan: Gold standard with 90-95% sensitivity and specificity, showing peripheral wedge-shaped low-density areas 1, 2

Follow-up Imaging

• Repeat CT scanning is indicated for moderate/severe lesions, decreasing hematocrit, vascular anomalies, underlying splenic pathology, coagulopathy, or neurologic impairment 1
• Doppler ultrasound and contrast-enhanced ultrasound are useful adjuncts for evaluating splenic vascularization and follow-up 2

Treatment Algorithm

For Hemodynamically Stable Patients

Non-operative management (NOM) is the first-line treatment for all hemodynamically stable patients, regardless of injury grade. 7, 6

NOM Protocol Requirements:

• Admission to facility with 24/7 emergency intervention capacity 2
• Continuous ICU monitoring for at least 24 hours 2
• Bed rest for 48-72 hours 1, 2
• Clinical and laboratory observation for minimum 3-5 days 2
• Serial hematocrit measurements and vital signs monitoring 1
• Immediately available operating room and trained surgeons 6

Angiography/Angioembolization (AG/AE):

• Perform AG/AE in stable patients with vascular injuries identified on CT scan 1, 8
• AG/AE is safe and effective regardless of embolization location (main splenic artery or hilar branches), though hilar embolization has higher infarction rates (47.3% vs 12.5%) 8
• AG/AE has significantly lower infectious complications (4.2%) compared to splenectomy (32.0%) 7
• AG/AE preserves splenic immunological function despite elevated leukocyte and platelet counts 7

For Hemodynamically Unstable Patients

Immediate operative management (splenectomy) is required for patients who remain unstable despite resuscitation. 7, 6

Absolute Indications for Surgery:

• Unresponsive hemodynamic instability despite fluid resuscitation 7, 6
• Significant drop in hematocrit or continuous transfusion requirements 7, 1
• NOM failure with continued bleeding 7
• Splenic rupture with hemorrhage 1, 6
• Splenic abscess formation poorly responsive to antibiotics 1
• Peritonitis or hollow organ injuries 6

Surgical Considerations:

• Splenectomy is preferred when NOM fails, with overall hospital mortality near 2% 7
• Laparoscopic splenectomy cannot be recommended in early trauma scenarios with active bleeding 7
• Partial splenic salvage is debated and not routinely suggested 7

Special Populations

For patients with concomitant severe traumatic brain injury (STBI) or blunt spinal trauma (BST):

• In centers without AG/AE availability: Immediate splenectomy for grade IV-V injuries shows survival benefit 7
• In centers with AG/AE availability: NOM with AG/AE is appropriate regardless of injury grade, as immediate splenectomy does not improve survival 7

Post-Treatment Management

Activity Restriction

• Minor injuries (grades I-II): 4-6 weeks restriction 1, 6
• Moderate-to-severe injuries (grades III-V): 2-4 months restriction 1, 6
• Complete healing: 12.5 days for grades I-II; 37.2 days for grades III-V 1

Thromboprophylaxis

• Mechanical prophylaxis should be used in all patients without absolute contraindications 7, 6
• LMWH-based prophylactic anticoagulation started as soon as possible in selected NOM patients 6

Follow-up Imaging

• Routine post-discharge imaging not necessary for low-grade injuries 6
• CT follow-up before discharge recommended for moderate-to-severe injuries, underlying splenic pathology, coagulopathy, or neurological impairment 1, 6

Monitoring for Complications

• Watch for persistent fever, ongoing abdominal pain, or bacteremia, which suggest splenic abscess progression 1
• Monitor for abdominal compartment syndrome 2
• Remain vigilant for delayed rupture, particularly days 4-10 post-injury 1, 4