From the Guidelines
Kehr's sign is a critical clinical indicator of potential splenic rupture or intra-abdominal bleeding, necessitating immediate medical evaluation and imaging studies. The presence of Kehr's sign, characterized by left shoulder pain due to diaphragmatic irritation from blood or fluid in the peritoneal cavity, is a significant finding in trauma assessment, as highlighted in the management of splenic trauma patients 1, 2.
Clinical Presentation
The pain associated with Kehr's sign is referred to the shoulder because the phrenic nerve, which supplies the diaphragm, shares cervical nerve roots (C3-C5) with nerves that supply sensation to the shoulder. When blood irritates the diaphragm, particularly the left hemidiaphragm, pain signals travel along the phrenic nerve and are perceived as shoulder pain. This sign is particularly important in trauma assessment, as it may be the only indication of internal bleeding in an otherwise stable patient.
Management
The presence of Kehr's sign should prompt immediate medical attention and imaging studies such as ultrasound or CT scan to evaluate for intra-abdominal hemorrhage, as emphasized in the World Society of Emergency Surgery (WSES) classification of splenic trauma and management guidelines 2. The intensity of the shoulder pain often increases when the patient is lying flat and decreases when sitting upright, as the blood pools away from the diaphragm in the upright position.
Key Considerations
- The management of splenic trauma patients aims to restore homeostasis and normal physiopathology, considering the hemodynamic status, anatomic derangement, and associated injuries 1.
- A multidisciplinary approach to trauma management is crucial, taking into account both the anatomical injury and its physiologic effects.
- The WSES guidelines recommend a conservative approach to splenic trauma management, with consideration for non-operative management (NOM) in appropriate cases, especially in pediatric patients 2. Given the potential for severe morbidity and mortality associated with splenic rupture or intra-abdominal bleeding, prompt recognition and management of Kehr's sign are essential to improve patient outcomes.
From the Research
Definition and Presentation of Kehr's Sign
- Kehr's sign is a clinical sign that presents as pain in the left shoulder, often associated with splenic rupture or abscess 3, 4.
- It is a classical example of referred pain, resulting from irritation of the diaphragm, which is signaled by the phrenic nerve as pain in the area above the clavicle 3.
- Kehr's sign can be accompanied by other symptoms such as abdominal pain, hemodynamic instability, and positive findings on computed tomography scans 5, 4.
Clinical Significance and Diagnosis
- Kehr's sign is an important diagnostic clue for splenic rupture or abscess, particularly in cases of blunt abdominal trauma 5, 4.
- Computed tomography is the investigation of choice for diagnosing splenic rupture or abscess, and Kehr's sign can be a useful indicator for further imaging studies 5, 4.
- Delayed splenic rupture can present with Kehr's sign, abdominal pain, and hemodynamic instability, often requiring splenectomy as treatment 5, 4.