Introduction

Injuries of abdominal organs are rare in sport. Nonetheless, they can be especially life threatening when missed. Up to 10% of all abdominal injuries are the result of sports-related trauma (¹). Contact or collision sports cause the most injuries to the abdomen (²). Death due to spleen injuries is rare in football. Over a 20-year period ending in 2010, 243 deaths occurring in high school and college football in the United States were reported to the National Center for Catastrophic Sports Injury Research, two of which resulted from splenic rupture (³). Delayed diagnosis is a common occurrence as spleen injuries are hard to diagnose at the time of injury. The examination can be unremarkable, absent of the more common findings such as upper abdominal pain, or even left shoulder pain signifying irritation of the diaphragm. In many cases, worsening symptoms occur outside of the competition or practice arena. The below case presentation illustrates the importance of proper diagnosis, treatment, and return to play.

Case Presentation

A 19-year-old freshman division II football athlete presented to the athletic training staff at a local university with dyspnea, left-upper quadrant abdominal and left-sided chest pain, nausea with emesis, severe diaphoresis, and left shoulder pain. At that time, the athlete denied a direct hit during that day’s practice, stating symptoms came on during film review. He also denied any sore throat, fevers, or recent illness. At the direction of the sports medicine physician, the athletic training staff immediately arranged for transport of the athlete to a local hospital for evaluation.

Upon evaluation in the emergency department, it was revealed by abdomen/pelvis computed tomography (CT) with intravenous (IV) contrast that the athlete sustained a grade III splenic laceration with perisplenic hematoma and free blood seen in abdomen and pelvis (Fig. 1). Laboratory work revealed stable hemoglobin and hematocrit at 14.3 (G/DL) and 42.4 (%) with a slightly elevated WBC (12.2 TH/µL). The remaining laboratory work was negative, including a mono screen test. The athlete’s vitals remained stable and he was treated with IV hydration, and pain and antiemetic medications. As the athlete was deemed hemodynamically stable, transfer to a larger hospital with interventional radiology capabilities was arranged.

Upon frequent questioning, the athlete later remembered a direct hit to his left abdomen that he described as getting the “wind knocked out” of him during a contact practice 2 d prior.

The trauma service at the second hospital reviewed the CT, upgrading the diagnosis to a grade IV laceration. Given the delayed bleeding and large hemoperitoneum, splenic arteriography with transcatheter coil embolization was performed. Splenic arterial assessment revealed a devascularized lower pole of the spleen with stretched splenic arteries in the area of the known laceration (see Fig. 2, left). Upon successful coil embolization procedure, the athlete was admitted to the intensive care unit for postoperative monitoring.

After an uncomplicated postoperative hospital course, the athlete was discharged home symptom free. Given the risk of delayed splenic rupture, the patient was instructed to avoid all strenuous activities for 2 wk. Recommendation for a gradual increase in activity afterward was given. As the athlete wished to return to contact football, CT of the abdomen/pelvis every 4 to 6 wk with serial hemoglobin and hematocrit was ordered for return-to-play monitoring (see Fig. 2, right). Both a trauma specialist and local university team physician monitored the patient through the remaining recovery period. The athlete was cleared for full contact after 111 d and has been participating in full contact collegiate football since.

Discussion

Current return to play considerations lack consensus. The controversy stems from the inability to accurately predict delayed complications and the complete time required for full recovery. Our goal was to examine advisable versus safe return to play considerations. A comprehensive literature review was conducted to assess the current guidelines and recommendations for return to sport after splenic injury and to assess what goes into making these decisions.

Regarding what goes into making return to play decisions, clinical judgment is often the key determinant for Eastern Association for the Surgery of Trauma (EAST) members (⁴). Several other studies also have reported that the main factor in return to play decisions is clinical assessment of the patient, but these studies recognize that follow-up CT scans play a role in those patients that have a greater risk of complications following splenic injury, such as those in contact sports (^5–7). Amaral states that the period of rest and avoidance of contact sports should mainly be determined by the healing demonstrated by CT scan (⁸).

In evaluation of the current recommendations for return to play following splenic injury, it was found that recommendations vary from 3 wk to greater than 6 months, depending on the severity of the injury (⁹). When EAST members were surveyed about their recommendations for athletes returning to full activity, which includes full contact sports, their responses were categorized based on the grade of the laceration (⁴). For grades I and II, the majority of respondents were split between less than 6 wk (37.6%) and 2 to 3 months (39.3%). For grade III lacerations, the majority of respondents (56.04%) recommended 2 to 3 months, and for grades IV and V, 45.8% recommended 2 to 3 months while 31% recommended 4 to 6 months.

In another review article about splenic injuries in athletes, Gannon and Howard suggested that light activity may be warranted in all patients with a splenic injury, regardless of the grade of injury, for the first 3 months (⁷). Gannon and Howard also suggested that at the 3-month mark postinjury, patients may gradually return to full activity.

In another study, Gandhi et al. (¹⁰) discussed a standardized care pathway at Philadelphia Children’s Hospital where it is suggested that the patient be confined to quiet activities at home for 3 wk following the injury, and at 3 months postinjury, patients return to the clinic for one final checkup. If at the 3-month period the patients are doing well clinically, they can return to full activity without restrictions.

With these current recommendations in mind, it is important to consider the required time for splenic healing following blunt splenic injury. In a study by Lynch et al. (¹¹), 58 patients at Children’s Hospital of Pittsburgh with blunt splenic injury were evaluated using CT scan to establish an injury grade. Ultrasound was then used as a follow-up tool to evaluate healing. The study found that mean healing time was 3.1 wk for grade I splenic injuries, 8.2 wk for grade II splenic injuries, 12.1 wk for grade III splenic injuries, and 20.7 wk for grade IV splenic injuries.

Pranikoff et al. (¹²) also studied healing time for splenic injury following nonoperative management. Fifty children admitted to Henry Ford Hospital and the University of Michigan Medical Center with blunt splenic injuries that were treated nonoperatively between 1984 and 1992 were reviewed retrospectively. Of the 50 patients, 25 of them had a CT scan both at the time of injury and 6 wk postinjury. This study found that 11 patients had complete resolution of their splenic injury at the 6-wk follow-up CT scan. This included 10 (77%) of 13 of grades I and II injuries and 1 (8%) of 12 grades III to V injuries.

In a third study looking at healing time for blunt splenic injury, Savage et al. (¹³) looked at the trauma registry at a level one trauma center for patients diagnosed with blunt splenic injury who were managed nonoperatively. The splenic injuries were grouped as mild (grades I and II) and severe (grades III to V). This study found that those with mild splenic injury began demonstrating healing at a mean of 12.5 d, with 80% showing complete healing by 50 d, and those with severe splenic injury began demonstrating healing at a mean of 37.2 d, with 80% showing complete healing by 75 d.

One major complication following blunt splenic injury is delayed splenic rupture. This is defined as a rupture occurring greater than 48 h following injury (¹⁴). Several studies have evaluated delayed splenic rupture cases and when they most commonly occur. In a study by Brown et al. (¹⁵), a 12-year-old boy was involved in a skiing accident and was diagnosed with a grade II splenic laceration. Thirty-eight days following injury, the patient dived into the water at a swimming pool and developed abdominal pain, nausea, and diaphoresis 6 h later. After examination in the emergency department, the patient was taken in for surgery and was found to have a ruptured spleen.

Flik and Callahan (¹⁶) discussed a case involving a 37-year-old male that was woken up by a sudden onset of severe abdominal pain. The patient also says he experienced bilious vomiting, diarrhea, and one syncopal episode. Following a history and physical at the emergency department, the patient agreed to a diagnostic laparoscopy. This laparoscopy demonstrated a ruptured, bleeding spleen. Following surgery, the patient was questioned and recalled an incident 3 wk prior when he was playing hockey and suffered a blow to the left upper abdomen when checked into the boards.

Resteghini et al. (¹⁴) discussed a case of a 63-year-old male that sustained a splenic injury due to hitting a snow bank while skiing. Seventy days following the injury, he experienced a sudden onset of severe abdominal pain and presented to an emergency department. CT scan showed that he had a significant splenic laceration with a large hemoperitoneum.

Fernandes (¹⁷) reported a case about a 34-year-old male who presented to the emergency department after 2 h of abdominal pain that woke him from sleep. He also complained of vomiting. The patient’s history was significant for splenic injury 2 years prior, and he denied any trauma to the abdomen since that time. An abdominal ultrasound demonstrated a ruptured spleen. He underwent splenectomy, and a later pathology report showed fibrosis and hemosiderin deposition consistent with previous splenic injury along with an acute splenic hematoma.

In the evaluation of return to play recommendations, it also is important to learn from past cases. Silvis et al. (¹⁸) discussed two hockey players who suffered grade III splenic injuries after being checked against the boards (¹⁸). One player was cleared for full activity after 59 d, and the other was cleared after 61 d, both following demonstration of complete healing on CT scan. Neither of these players had complications after returning to full activity.

In another case, Terrell and Lundquist (¹⁹) reported on a 22-year-old college football player who suffered a grade III splenic laceration after sustaining a blow to the left upper quadrant during practice. Initially, nonoperative management was chosen for this patient, but due to the patient’s desire to quickly return to the field, it was decided that a laparoscopic splenectomy would be performed. The patient returned to full contact football practice at 19 d following the operation, 28 d postinjury. The player competed without any problems for the remainder of the football season.

Conclusions

Our conclusion is that recommendations for returning to activity following splenic injury are difficult to generalize and should be considered on a case-by-case basis. Time to healing and therefore recommendations for returning to activity are largely based on the severity of the injury. Making the decision that a patient can return to full activity is a difficult one. Several studies have suggested that follow-up imaging plays a very small role, if any, for determining whether a patient should be cleared and that this decision is one that should be made mostly from a clinical perspective (^4–7). However, those who have suggested this also have indicated that follow-up imaging should be more frequently used as the severity of injury increases and also for those who are at a greater risk of complications following splenic injury, and one study suggests that follow-up imaging is crucial to the decision (⁸).

Many great studies were evaluated during this literature review, but there is no doubt that more evidence is needed to ensure the very best guidelines for treating splenic injuries in athletes for the future. The athlete discussed in our case study was certainly treated in alignment with current recommendations, but as suggested above, decisions should be made on a case-by-case basis to determine the best need for each individual person. There is great value in evaluating the current literature to better understand what options are available. Proper diagnosis and treatment is vital to the long-term health of the athlete and to getting them back on the field in their respective sport.