Splenic Laceration

A splenic laceration is traumatic tearing of the splenic capsule and parenchyma.

The injury can involve:

• Superficial capsule
• Deep parenchyma
• Trabecular vessels
• Segmental vessels
• Hilum

The laceration itself is not synonymous with rupture into the peritoneal cavity. A deep laceration can remain temporarily contained by capsule, clot or surrounding structures.

Splenic injury grading

The current CT based injury scale incorporates both anatomical damage and vascular injury.

Grade I

• Subcapsular haematoma involving less than 10% of splenic surface

or

• Capsular tear or parenchymal laceration less than 1 cm deep

Grade II

• Subcapsular haematoma involving 10% to 50% of surface
• Intraparenchymal haematoma less than 5 cm

or

• Laceration 1 to 3 cm deep

Grade III

• Subcapsular haematoma involving more than 50%
• Ruptured subcapsular haematoma
• Intraparenchymal haematoma at least 5 cm

or

• Laceration greater than 3 cm deep

Grade IV

• Splenic vascular injury such as pseudoaneurysm or arteriovenous fistula
• Active bleeding confined within splenic capsule

or

• Segmental or hilar vascular involvement causing more than 25% splenic devascularisation

Grade V

• Shattered spleen

or

• Splenic vascular injury with active bleeding extending freely beyond the spleen into the peritoneal cavity.

The grade estimates anatomical severity but does not by itself determine whether surgery is required.

Small lacerations can be minimally symptomatic.

Larger injuries produce:

• Left upper abdominal pain
• Guarding
• Referred left shoulder pain
• Tachycardia
• Hypotension
• Syncope
• Haemorrhagic shock

Associated injuries are common in high energy trauma, including:

• Left rib fracture
• Left renal injury
• Pancreatic injury
• Diaphragmatic injury
• Bowel injury
• Thoracic trauma

The presence of another operative abdominal injury can change a splenic laceration from a planned nonoperative case to an operative one.

Contrast enhanced CT: defines grade and vascular abnormalities.

The radiology report should explicitly identify:

• Injury grade
• Active bleeding
• Pseudoaneurysm
• Devascularised segments

rather than merely stating \"splenic laceration\".

Serial assessment

Monitor:

• Blood pressure
• Heart rate
• Abdominal findings
• Haemoglobin
• Transfusion requirement

The haemoglobin trend should be interpreted with clinical physiology rather than used as a single numerical trigger for surgery.

Grade I and II

In a stable patient:

• Nonoperative treatment is preferred
• Routine embolisation is unnecessary without vascular injury or ongoing bleeding
• Mobilise early once clinically stable

Low grade adult injuries generally require only short inpatient observation when there are no significant associated injuries.

Grade III

Stable grade III injury can usually be managed without operation.

Consider splenic artery embolisation when additional risk factors for failure exist, such as:

• Significant transfusion requirement
• Older age
• Anticoagulation
• High overall injury burden
• Large haemoperitoneum
• Falling haemoglobin despite apparent stability

Routine embolisation of every grade III laceration without vascular abnormality is unnecessary.

Grade IV and V

If haemodynamically stable:

Use angiography with a low threshold for splenic artery embolisation, even if the initial scan does not demonstrate obvious extravasation.

If haemodynamically unstable:

Proceed to operative haemorrhage control.

Repeat imaging

Routine repeat CT is unnecessary for every minor injury.

For grade III or higher injuries managed nonoperatively, repeat contrast imaging at approximately 48 to 72 hours is useful for detecting:

• Delayed pseudoaneurysm
• New vascular abnormality
• Ongoing bleeding

especially when initial vascular risk is high.

Repeat imaging immediately at any grade if:

• Haemodynamics deteriorate
• Pain increases substantially
• Haemoglobin falls unexpectedly

VTE prophylaxis

Once bleeding has stabilised, pharmacological thromboprophylaxis should not be withheld indefinitely merely because splenic trauma occurred.

In stable nonoperative patients, LMWH can generally begin within approximately 48 to 72 hours, and often earlier in selected low risk injuries when repeat assessment demonstrates haemostatic stability.

Activity

Activity restriction should reflect injury severity.

Minor injuries generally require several weeks before return to heavy impact activity.

High grade injuries require a longer restriction period and sometimes repeat imaging before:

• Contact sport
• Heavy lifting
• High impact occupational activity

The purpose is prevention of delayed rupture during incomplete splenic healing.