Splenic Artery Avulsion in a High School Football Player: A Case Report

Abstract

Objective:

To present the case of a high school football player who sustained avulsion of 2 branches of the splenic artery from his spleen as he was tackled and landed on the football.

Background:

A high school football player was tackled and fell onto the football, left side first. He was examined by a certified athletic trainer and an internist. On evaluation, he had a positive Kehr sign, exquisite left upper abdominal quadrant tenderness, and complaint of nausea. He also exhibited signs of the onset of shock, including diaphoresis, a rapid pulse, and hypotension. He was immediately transported by ambulance to the local emergency facility.

Differential Diagnosis:

Splenic rupture, splenic laceration, splenic artery avulsion, or ruptured viscus.

Treatment:

Emergency surgery was performed, with removal of 2800 mL of blood and ligation of the 2 arterial branches avulsed from the spleen. The patient fully recovered within 6 weeks and was cleared to resume all sports activities.

Uniqueness:

Injury to the spleen in football is a known yet very uncommon injury. Even more unusual is the avulsion of splenic artery branches from the spleen.

Conclusions:

It is critical that athletic trainers and team physicians have an understanding of the mechanisms, signs, and symptoms of splenic injury. Because the spleen is a highly vascular organ, severe hemorrhage can be fatal in just minutes if not recognized and appropriately treated.

The spleen is one of the most vascular organs in the body. Approximately 350 L of blood pass through the adult spleen each day, and at any given time, 1 unit (450 mL, or 0.951 pints) of the body's 12 total units of blood (5400 mL, or 1.4 gallons) is contained in it. Consequently, hemorrhagic injury to the spleen poses a potentially life-threatening situation.^1,2 Splenic injury in sports is uncommon,³ but when it does occur, it usually involves splenic fracture, rupture, or laceration. In rare cases, the perfusing arteries of the spleen are avulsed.¹

Although certified athletic trainers (ATCs) and team physicians are trained to recognize splenic injury, very few sports medicine professionals ever face the reality of managing an injured spleen on the field or sideline. Mueller and Diehl,³ of the National Center for Sport Injury Research, found that only 0.23% of high school football injuries reported in the 1996– 2000 High School Athletic Injury Study involved the spleen, in comparison with 17.28% that involved the ankle. Furthermore, in Mueller's 2001 survey of football deaths at all levels of competition, only 1 player died from a spleen injury, compared with 6 from head injuries.⁴

Our purpose is to present the case of a high school student-athlete who, during a state-playoff football game, avulsed 2 splenic artery branches from his spleen, resulting in significant arterial blood loss into his abdomen. Also, we will reinforce the important role played by the ATC in facilitating proper recognition and referral of this potentially fatal injury.

CASE REPORT

An 18-year-old, male high school football player sustained an injury in the first quarter of a high school football state-playoff game. After catching the football and running several yards with it clutched in his left hand, the athlete was tackled. As he fell to the ground left side first, the left side of his abdomen landed firmly on the football, which remained in his left hand (Figure 1).

Figure 1.

Subject was tackled and fell onto the football.

Having experienced only slight dizziness and no pain in his abdomen as a result of the tackle, the player returned to his feet and continued to play in the football game. A few teammates and staff began to notice a decrease in his aggressiveness on the field during the second quarter of the game. He was asked on more than one occasion if something was wrong. Each time, he responded that he had an upset stomach from having eaten a spicy meal before the game. He later admitted having abdominal pain that began a few plays after the injury, which he also attributed to the spicy meal. In the locker room during halftime, approximately 30 minutes after the injury occurred, he appeared pale and lackluster. He made repeated attempts to defecate without relief. He was then urged by a staff member to leave the locker room for evaluation by the ATC.

The ATC initially observed that the patient had a diaphoretic appearance and was somewhat disoriented. A brief injury history was obtained from the patient that identified abdominal pain and the urge to defecate, both having escalated in the ensuing 30 minutes since the time of the tackle. The patient was laid supine on a bench in a bent-knee position and his abdomen palpated: exquisite tenderness and slight guarding were noted in the left upper quadrant. The ATC recognized the possibility of a spleen injury. Inquiring for the presence of the Kehr sign, the ATC asked the patient if he had pain or altered feeling anywhere else in his body other than his abdomen. The patient stated that he felt a strange pain in his left upper arm, shoulder, and neck.

At that time, an internist who had been observing from the stands came to the side of the athlete. After being quickly briefed by the ATC, the physician performed a rapid reexamination of the patient's abdomen and level of consciousness. Vital signs were also assessed. The patient's pulse was rapid and thready, and his respirations were deep and deliberate. He was placed on a gurney and transported to the nearby emergency facility by the advanced life support emergency medical system that was on site. His vital signs were monitored, and fluids were administered intravenously during transport. The patient's systolic blood pressure en route to the emergency facility was 100 mm Hg, and his heart rate was 110 beats per minute.

Upon arrival at the emergency facility, pulse was 125 beats per minute, blood pressure was 105/50 mm Hg, and respiration rate was 18. He was noted by the attending physician to be “shocky,” presumably identifying a mild state of shock. The abdomen was soft and not distended, but remarkable tenderness was noted in the left upper quadrant. No external trauma or ecchymosis was noted in the abdominal region. The spleen was not palpable. X-ray films of the chest and abdomen were negative.

Abdominal and pelvic computed tomography (CT) scans with contrast were performed and interpreted as showing “an abdomen full of fluid (blood) probably from a splenic laceration” (Figure 2). More specifically, the report indicated that the patient had sustained “laceration of the spleen … with extensive free fluid due to hemorrhage into the peritoneal cavity … down into the pelvis.” The surgeon elected to take the patient to the operating room urgently for diagnostic laparotomy.

Figure 2.

Computed tomography scan showing free fluid.

Laparotomy was performed under general anesthesia. The patient's systolic blood pressure was 60 mm Hg. A total of 2800 mL of blood (approximately 52% of the patient's total blood volume) was found within the abdomen at the time of exploration, much of which was suctioned with an autotransfusion device and returned to the patient's circulation. Once the spleen was located and appropriately visualized, the surgeon initially identified a spleen tip avulsion, which was controlled with electrocautery. More significantly, 2 arterial branches were avulsed from the spleen at the inferior portion of the hilum (Figure 3) and were actively bleeding. These were ligated with sutures, and excellent hemostasis was achieved. At the time of wound closure, the patient's systolic blood pressure had improved to 150 mm Hg and his pulse was 65 and regular. The attending surgeon classified the subject's case as a grade III splenic injury (Table).⁵

Figure 3.

Anatomy of the spleen.

Splenic Injury Scale*

The patient was discharged from the hospital 7 days postoperatively, at which time he was tolerating a full liquid diet and had resumed bowel function. In the ensuing weeks, the patient appropriately recovered his appetite, energy, and strength and returned to activities of daily living. He continued a liquid diet for 4 days before resuming a normal diet as tolerated. Skin-closure staples were removed 2 weeks postoperatively. The patient was restricted from driving for 2 weeks and from lifting or straining for 6 weeks. Although the splenic repairs healed quickly, 6 to 8 weeks were required for adequate healing of the abdominal wall musculature. At 6 weeks postoperatively, he was released by the surgeon to resume all sports activities. The football season had concluded 1 week after our subject's injury, but he returned to other athletic endeavors at this point. At the time of this writing, more than 4 months since the injury, the athlete had resumed all recreational and competitive activities without consequences.

DISCUSSION

Anatomy and Physiology

The spleen is a solid visceral organ weighing 75 to 150 g that receives 5% to 6% of the cardiac output.⁶ It filters an estimated 10% to 15% of total blood volume every minute, removing old blood cells and other cellular debris.⁶ On average, it may hold 40 to 50 mL of red blood cells. As many as 25% of the circulating platelets are estimated to be held in reserve in the spleen.⁶ During infancy, the spleen produces red blood cells until production of erythrocytes in the bone marrow matures.⁶ Through its production of IgM antibodies, the spleen supports the immune system.^7,8 The spleen has specialized functions in immunologic responses (bodily defense reactions that recognize antigens and produce antibodies against the antigens), hematopoiesis (synthesis of blood cells), and phagocytosis (cellular ingestion of foreign particulates).⁹ It produces proteins that enhance the ability of neutrophils to destroy encapsulated bacteria during phagocytosis.¹⁰ Infections with encapsulated bacteria such as Pneumococcus, Haemophilus influenzae type b, and Neisseria meningitidis are major causes of sepsis (a toxic condition resulting from the spread into the bloodstream of bacteria or their products from a focus of infection) in infants and children and can occur after surgical removal of the spleen (splenectomy). The risk of sepsis in such a patient, termed overwhelming postsplenectomy infection (OPSI), is about 12 times the normal incidence. This is largely due to generalized weakening of the immune system. The mortality rate of OPSI is approximately 50%. Therefore, precautions should be taken to protect patients after splenectomy. These should include antibiotic prophylaxis, immunizations from the above-mentioned encapsulated bacteria, and protection from exposure to malaria.⁶

The spleen is located in the left upper quadrant of the abdomen (Figure 4). In adolescents and adults, the spleen is well-protected by the rib cage. In infants and young children, it is not completely covered by the rib cage and lacks adequate adipose and muscle tissue for protection. In addition, the cartilaginous makeup of the rib cage in infants and children lacks the strength to provide protection from blunt traumatic forces. These physical differences make the spleen especially vulnerable to blunt injury until complete physical maturity has occurred.⁹

Figure 4.

Comparison of spleen location in children and in adults.

The spleen (see Figure 3) consists of the parenchyma (the body of the organ) and the capsule (the fibrous tissue enclosing the parenchyma). The spleen is perfused by the splenic artery and drained by the splenic vein. The hilum of the spleen includes these arterial and venous pathways and provides structure and support. Each segment of the spleen is perfused by branches of the splenic artery, which provide the spleen with multiple entry sites for an oxygen-rich blood supply and, thus, the potential for marked hemorrhage if the spleen is injured.

Epidemiology

Blunt abdominal injury is common in collision sports such as football, soccer, and ice hockey. Absorbed energy may force the abdominal organs against the rigid spine and cause laceration or avulsion to an organ, most commonly the spleen, with subsequent bleeding into the abdomen.⁹ Rarely, however, is the magnitude of this absorbed energy so great that the organ is actually torn from its arterial and venous vessels, rapidly leading to exsanguination (extreme blood loss) and death.⁹

On-Field Assessment

An athlete with a significant splenic injury typically has the acute onset of left upper quadrant pain caused by blunt impact to that region. The history may include the Kehr sign (referred pain in the left shoulder and proximal one third of the left arm as a result of free blood in the abdomen, irritating the diaphragm and the phrenic nerve), shock, disorientation, nausea, vomiting, and the urge to defecate.^9,11–13 The Kehr sign often occurs approximately 30 minutes after splenic injury, as the amount of free blood in the abdomen increases.^9,11–13 On physical examination, the athlete typically has tenderness in the left upper quadrant of the abdomen from peritoneal irritation from bleeding, often accompanied by muscle spasm or rigidity.^9,11–13 Other physical findings, including abdominal distention and discoloration, are not always immediately apparent and may not develop if bleeding is contained within the capsular membrane of the spleen. Ecchymosis in the periumbilical area (Cullen sign) and the lateral abdominal wall (Turner sign) are caused by dissection of intra-abdominal blood into the subcutaneous tissue. Careful and frequent reassessment aids in detecting an evolving splenic injury.⁹ In cases of left upper quadrant injury, the possibility of splenic injury must always be considered when performing the history and physical examination.

The hemodynamic status of an individual with a traumatic spleen injury may be stable or unstable. Clinical signs of hemodynamic instability include a weak and thready pulse, low blood pressure for age, cool skin, poor tissue perfusion indicated by prolonged capillary refill (pressure applied to the nailbed until it turns white, followed by a measure of the time after the pressure is removed for the pink color to return to the nailbed, typically less than 2 seconds), diminished peripheral pulses, and changes in level of consciousness. Hypotension does not occur until blood loss totals 25% of circulating volume. It can occur very quickly but is typically seen as a late clinical sign of splenic injury.⁹

Influence of Diagnostic Studies on Management Decisions

Abdominal CT is the diagnostic “gold standard” for determining the severity of a splenic injury and for staging the injury.^14–17 Contrast material is given to the patient before the procedure (typically intravenously in emergent situations) to enhance visualization of the abdominal structures and vascularized areas. The CT scan is then used to determine the presence of free fluid (eg, blood), the size and shape of the spleen, and the presence of damage to the other abdominal contents.

Before the advent of CT scanning, the principal diagnostic methods for intra-abdominal hemorrhage consisted of physical examination and procedures such as diagnostic peritoneal lavage and ultrasonography. Minor splenic injury was probably frequently missed, whereas major splenic injury typically prompted laparotomy (surgical sectioning of the abdominal wall).^9,18

Splenic Injury Scale

The severity of splenic injury is graded according to the depth of the fracture and is related to the degree of compression.⁵ The Splenic Injury Scale (see Table) outlines the 5 levels of severity and the description of each.⁵ Although the circumstances surrounding the injury described in this case report were seemingly ordinary, the player sustained a potentially fatal grade III splenic injury. It is important for the ATC and team physician to appreciate that significant splenic injury may occur under benign-appearing circumstances.

Management of Splenic Injuries

Splenic injuries are treated by splenic removal (splenectomy), splenic repair (splenorrhaphy), or splenic resection (partial splenectomy) or nonoperatively, depending on the extent of the injury and the condition of the patient.¹⁸

Because of the immunologic functions of the spleen, interest in the past few decades has turned to salvage of the spleen rather than splenectomy.⁶ Fortunately, most sport-related splenic injuries that require surgery allow salvage of the spleen.⁶ An even more recent trend is toward nonoperative management (NOM) of splenic injuries, which is now the rule rather than the exception. Up to 90% of children and young adults are treated in this manner.¹⁸ The high risk of OPSI coupled with a high rate of success with NOM in the pediatric population fostered this approach. In recent years, NOM of splenic injury in the adult population has been met with growing success. Before 1990, only 13% of adult patients with splenic injury were managed nonoperatively. Since 1990, that has increased to 54% of patients, with a success rate for NOM of 98%.⁸

Factors associated with successful NOM outcomes include a low splenic injury grade, a small amount of hemoperitoneum (blood in the abdomen), a systolic blood pressure greater than 100 mm Hg, and a near-normal hematocrit.¹⁹ As with the patient described in this case report, urgent surgical intervention is indicated when the patient has a life-threatening condition. This is typically characterized by a high splenic injury grade, shock (due to a large hemoperitoneum), tachycardia (heart rate at or above 100 beats per minute), and hypotension (systolic blood pressure at or below 100 mm Hg).^19,20 A low hematocrit (less than 30%) would play an important role in decision making in the absence of these more acutely life-threatening findings. However, a decrease in hematocrit may lag several hours behind other diagnostic factors.^19,20

CONCLUSIONS

It is critical that ATCs and team physicians have an understanding of the mechanisms, signs, and symptoms of splenic injury. Because it is one of the most vascular organs in the body, trauma to the spleen can cause fatal injury in just a matter of minutes if not recognized and treated. Careful and frequent reassessment of the signs and symptoms of splenic injury aids in detecting an evolving emergency. A CT scan, when indicated, is the current gold standard for diagnosing splenic injury. Care of a non–life-threatening splenic injury has tended toward nonoperative management. When surgery is indicated due to the severity of injury or quantity of hemorrhage, the spleen may be either salvaged or removed. An athlete who has sustained a significant splenic injury characteristically is able to return to unrestricted sports activities within 6 to 8 weeks after injury.