A 17-year-old male with blunt thigh trauma now has a tender right inguinal swelling, intact testes and penis, and leukocytosis (white blood cell count ≈13 ×10⁹/L); what is the most appropriate next step: surgical exploration of the inguinal region, aspiration to exclude hematoma, or analgesia with reassessment?

Management of Post-Traumatic Right Inguinal Swelling in a 17-Year-Old

The most appropriate next step is ultrasound imaging of the inguinal region followed by surgical exploration if an inguinal hernia with incarceration is confirmed, or conservative management with analgesia and reassessment if imaging reveals only a simple hematoma or soft tissue injury.

Initial Diagnostic Approach

Critical Assessment for Surgical Emergencies

The presence of tender inguinal swelling after blunt trauma with mild leukocytosis (WBC 13K) raises concern for traumatic inguinal hernia with possible incarceration, which requires urgent intervention to prevent bowel strangulation and testicular complications. 1

Key clinical features to assess immediately:

• Signs of incarceration/strangulation: Assess for overlying skin erythema, warmth, inability to reduce the mass, severe tenderness, or systemic symptoms (fever, tachycardia) that would indicate emergency surgical intervention 1
• Abdominal wall rigidity: A critical red flag for complications requiring immediate surgery 1
• Duration of symptoms: Symptomatic periods >8 hours significantly increase morbidity, making time from onset to surgery the most important prognostic factor 1

Imaging Strategy

Ultrasound with Doppler should be the first-line imaging modality in this clinical scenario:

• Ultrasound can differentiate between hematoma, hernia, testicular injury, and other soft tissue pathology 2
• If ultrasound findings are equivocal or suggest hernia with concerning features, CT scanning with contrast is indicated to assess for bowel obstruction or strangulation (56% sensitivity, 94% specificity for reduced wall enhancement predicting strangulation) 1

Laboratory Risk Stratification

The mild leukocytosis (13K) is moderately predictive but non-specific for strangulation. 3 Additional markers to consider if hernia with incarceration is suspected:

• Arterial lactate ≥2.0 mmol/L predicts non-viable bowel 1
• Elevated CPK and D-dimer levels are predictive of bowel strangulation 1
• However, physical stress from trauma alone can elevate WBC counts, making this finding less specific in the acute trauma setting 3

Management Algorithm

If Imaging Confirms Traumatic Inguinal Hernia:

Proceed directly to surgical exploration of the inguinal region through an inguinal incision approach:

• The inguinal approach allows assessment of hernia contents, reduction of incarcerated bowel if present, and definitive repair 1, 4, 5
• Laparoscopic exploration can be considered if the inguinal approach is negative or if intra-abdominal assessment is needed, but the inguinal approach should be first-line for unilateral presentations 4, 5
• Delayed treatment beyond 24 hours is associated with significantly higher mortality rates, particularly if strangulation is present 1

If Imaging Shows Simple Hematoma or Soft Tissue Injury:

Conservative management with analgesia and close reassessment is appropriate:

• Provide adequate pain control and instruct the patient to avoid activities that increase intra-abdominal pressure 1
• Reassess within 24-48 hours to ensure resolution and rule out evolving complications
• If swelling persists or worsens, or if new concerning features develop (increasing tenderness, skin changes, systemic symptoms), proceed to surgical exploration 1

Critical Pitfalls to Avoid

Do Not Perform Aspiration

Aspiration to rule out hematoma is NOT recommended as the primary diagnostic or therapeutic approach:

• Aspiration does not adequately assess for hernia, the most concerning diagnosis in this clinical scenario
• It risks introducing infection and provides limited diagnostic information compared to imaging 1
• If a traumatic hernia is present, aspiration could worsen incarceration or miss bowel involvement

Do Not Delay Evaluation for Signs of Strangulation

Any of the following warrant immediate surgical exploration without delay 1:

• Overlying skin erythema, warmth, or changes
• Inability to reduce the mass
• Abdominal wall rigidity
• Systemic signs (fever, tachycardia, hypotension)
• Symptomatic period >8 hours with worsening pain

Examine Both Groins

Always examine the contralateral groin bilaterally, as occult contralateral hernias occur in 11-50% of cases and can be easily missed 1

Specific Recommendation for This Case

Given the acute traumatic mechanism (football to thigh), tender right inguinal swelling, intact genitalia, and mild leukocytosis, the clinical picture is most consistent with either:

1. Traumatic inguinal hernia (potentially with early incarceration)
2. Inguinal hematoma from direct trauma

The appropriate management sequence is:

1. Obtain urgent ultrasound of the right inguinal region with Doppler assessment
2. If hernia is identified: Proceed to surgical exploration through inguinal approach 1, 4, 5
3. If only hematoma/soft tissue injury: Provide analgesia, activity restriction, and reassess in 24-48 hours with clear return precautions 1

Surgical exploration should not be delayed if any signs of incarceration or strangulation are present, even without definitive imaging. 1