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Splenic Rupture
Introduction
The spleen is the most commonly injured intra-abdominal solid organ following blunt trauma, and splenic rupture represents a spectrum of injury ranging from subcapsular hematoma to complete shatter of the parenchyma with life-threatening haemoperitoneum. Although traumatic injury accounts for the majority of cases, spontaneous rupture without antecedent trauma is a well-recognised clinical entity that carries significant mortality. A thorough understanding of splenic anatomy, the mechanisms of injury, clinical presentation, grading, and evolving management strategies is essential for any clinician involved in acute surgical or emergency care.
Anatomy and Surgical Relevance
The spleen occupies the left upper quadrant of the abdomen, lying beneath the diaphragm between the 9th and 11th ribs. Its surfaces carry impressions from adjacent viscera: the gastric, colic, pancreatic, and renal impressions mark the concave visceral surface, while the smooth convex diaphragmatic surface is related posteriorly to the left hemidiaphragm, which in turn separates it from the costodiaphragmatic pleural recess, the inferior lobe of the left lung, and ribs IX to XI.
The spleen is secured in position by three peritoneal ligaments that must be divided surgically during splenectomy:
- Splenorenal ligament - anchors the spleen to the left kidney and transmits the splenic vessels; the tail of the pancreas typically lies within its inferior portion (making it vulnerable to inadvertent injury).
- Gastrosplenic ligament - connects the anterior splenic pole to the greater curvature and posterior surface of the stomach, and contains the short gastric arteries and the left gastro-omental vessels.
- Phrenicocolic ligament - attaches the spleen to the left colic (splenic) flexure and the diaphragm at the level of rib XI.
These relationships are surgically critical: failure to mobilise the spleen carefully risks injury to the tail of the pancreas, stomach, left kidney, left adrenal gland, colon, and mesenteric root. - Gray's Anatomy for Students, p. 5557–5570
Aetiology and Classification of Causes
Splenic rupture results from four broad mechanisms:
- Penetrating trauma - stab wounds and gunshot injuries. The trajectory may traverse the anterior or posterior abdominal wall, the flank, or transthoracically through the pleura and diaphragm.
- Blunt (non-penetrating) trauma - the most common cause overall and an increasing aetiological factor. Road traffic collisions and falls are the predominant mechanisms; injury to the left lower ribs frequently accompanies it.
- Iatrogenic (operative) trauma - well-documented during colectomy, gastric surgery, and any left upper quadrant procedure where adhesions are present. In a 16-year Mayo Clinic review of ~14,000 colectomies, splenic injury requiring splenectomy or repair occurred in 0.4% of cases, with 34% 30-day morbidity and 15% mortality in those who underwent incidental splenectomy. Iatrogenic splenic rupture has also been reported after colonoscopy at a rate of approximately 0.001%.
- Spontaneous rupture - rare but serious. In a review of over 800 spontaneous ruptures, six major aetiological groups were identified: neoplastic (30.3%), infectious (27.3%), inflammatory (20.0%), drug- and treatment-related (9.2%), mechanical (6.8%), and rupture of a pathologically normal spleen (6.4%), with an overall mortality of 12%. - Maingot's Abdominal Operations, p. 1263
Spontaneous Rupture: Key Causes
- Infectious mononucleosis (EBV or CMV): imparts a small but frequently cited risk, with the true incidence potentially under-reported. The presumed mechanism is infiltration of the splenic parenchyma by inflammatory cells, which distorts the fibrous support architecture and thins the capsule, making rupture possible after trivial external force or even a Valsalva manoeuvre.
- Malaria: rupture of a malaria-enlarged spleen is not uncommon in tropical countries. Delayed presentation following seemingly trivial injury is characteristic.
- Other infectious causes: Listeria, dengue, Q fever, fungal infections.
- Neoplastic causes: lymphoma, angiosarcoma.
- Miscellaneous: amyloidosis, pregnancy. - Schwartz's Principles of Surgery, p. 1557
Clinical Presentation
The clinical picture is shaped by the rate and volume of blood loss, the grade of injury, and the presence of associated injuries.
Symptoms:
- Left upper quadrant pain, which may be mild in low-grade injuries
- Kehr's sign - pain referred to the left shoulder tip due to diaphragmatic irritation from sub-phrenic blood or haematoma. It is particularly elicited when the patient is placed in the Trendelenburg position. - Mulholland and Greenfield's Surgery, p. 2079; Goldman-Cecil Medicine
- Generalised abdominal pain if free haemoperitoneum is large
Signs:
- Tachycardia and tachypnoea (early haemodynamic compromise)
- Percussion tenderness over the left upper quadrant
- Pallor and hypotension in significant haemorrhage
- Left lower rib fractures (in blunt trauma)
Investigations:
- Serial haematocrit - a falling trend suggests continued intraperitoneal haemorrhage
- White cell count - often elevated to >15,000/mm³
- Plain abdominal films: fractured left lower ribs, elevated left hemidiaphragm, enlarged splenic shadow, medial displacement of the stomach, widening between the splenic flexure and preperitoneal fat pad - suggestive but non-specific
- FAST ultrasound (Focused Assessment with Sonography in Trauma): rapidly identifies free peritoneal fluid; the investigation of choice in the haemodynamically unstable patient
- CT scan with intravenous contrast: the gold standard for the haemodynamically stable patient. It accurately delineates the grade of injury, the volume of haemoperitoneum, the presence of active contrast extravasation ("blush") or pseudoaneurysm, and associated organ injuries. - Maingot's Abdominal Operations, p. 1264
Grading of Splenic Injury
The American Association for the Surgery of Trauma (AAST) Organ Injury Scale is the universally accepted grading system, last updated in 2018:
| Grade | Description |
|---|---|
| I | Subcapsular haematoma <10% surface area; parenchymal laceration <1 cm depth; capsular tear |
| II | Subcapsular haematoma 10-50% surface area; intraparenchymal haematoma <5 cm; parenchymal laceration 1-3 cm (not involving trabecular vessels) |
| III | Subcapsular haematoma >50% or expanding; ruptured subcapsular or intraparenchymal haematoma ≥5 cm; parenchymal laceration >3 cm depth or involving trabecular vessels |
| IV | Laceration involving segmental or hilar vessels with >25% devascularisation; any injury with splenic vascular injury or active bleeding confined within the capsule |
| V | Shattered spleen; hilar laceration devascularising the entire spleen; any injury with active bleeding extending beyond the spleen into the peritoneum |
Advance one grade for multiple injuries up to Grade III. - Current Surgical Therapy 14e, p. 1364; Mulholland and Greenfield's Surgery, p. 2092–2095
Delayed Splenic Rupture
Delayed (two-stage) rupture is a clinically important phenomenon where the initial injury is contained by a subcapsular haematoma that subsequently ruptures, often hours to days after the index event. Delayed rupture following trauma typically occurs within two weeks of injury. The majority of nonoperative management failures occur within the first 3 to 5 days. In one study with up to 6 months of follow-up, the rate of outpatient rupture was 1.4%. Patients discharged after nonoperative management must be counselled about this risk. - Mulholland and Greenfield's Surgery, p. 3820; Essentials of Forensic Medicine and Toxicology, p. 6254
Management
Operative Indications
The decision between operative and nonoperative management is primarily driven by haemodynamic stability and injury grade.
Immediate laparotomy and likely splenectomy is indicated for:
- All penetrating splenic injuries
- Haemodynamically unstable blunt trauma patients with haemoperitoneum or peritonitis
- High-grade injuries (Grades IV and V) in most centres
Nonoperative Management (NOM)
NOM has become the standard of care for haemodynamically stable patients with blunt splenic injury and no peritonitis. Approximately 80% of blunt splenic injuries in adults (and 90-95% in children) are successfully managed nonoperatively. - Mulholland and Greenfield's Surgery, p. 2084
Criteria for NOM (Western Trauma Association):
- Haemodynamic stability
- Documented CT classification of injury
- No associated injuries requiring operative intervention
- Transfusion requirement of fewer than 2 units of packed red blood cells
- Current Surgical Therapy 14e, p. 1364
Success rates by grade:
- Grade I: >95%
- Grade II: >90%
- Grade III: >80%
- Grade IV: ~40% (highly variable)
- Grade V: ~26%
Patients must be monitored with serial vital signs, physical examinations, and haematocrit measurements. Any haemodynamic deterioration, progressive fall in haemoglobin, or worsening pain mandates immediate reassessment and likely operative intervention.
The Western Trauma Association recommends a repeat CT scan at 48-72 hours to exclude a new or persistent pseudoaneurysm, particularly in high-grade injuries and before discharge in athletes or workers with physically demanding occupations.
Splenic Artery Angioembolisation
Angioembolisation has become a major adjunct to NOM, achieving haemorrhage control in up to 90% of selected patients without significant loss of splenic function.
Indications for angiography:
- Grade III injury and above
- Contrast "blush" (active extravasation) on CT
- Moderate haemoperitoneum
- Evidence of pseudoaneurysm or arteriovenous fistula
Technique:
- Proximal embolisation - reduces overall parenchymal flow; faster and associated with fewer complications; preferred when no localised lesion is identified; disadvantage is inability to re-intervene intravascularly in case of rebleeding.
- Distal embolisation - more targeted for a localised lesion; higher success rate for haemorrhage control but carries greater risk of splenic infarction and abscess.
- Combined embolisation - has fallen out of favour due to high complication rates.
Embolisation materials include metallic coils and gel foam. A meta-analysis found lower complication rates with coils, whereas gel foam was associated with slightly better overall NOM success rates. A meta-analysis of >10,000 blunt splenic injury patients found that splenic artery embolisation significantly improved splenic salvage rates for high-grade injuries. - Current Surgical Therapy 14e, p. 1365
Splenic Salvage (Splenorrhaphy)
Where operative intervention is unavoidable, splenic salvage should be attempted if:
- Haemostasis can be achieved
- More than one-third of the splenic mass can be preserved
- No other intra-abdominal injuries (e.g., pancreatic trauma) mandate splenectomy
Splenectomy
Total splenectomy is performed when splenic salvage is not feasible. The first total splenectomy for trauma was performed by Nicolaus Matthias in 1678 in Cape Town. Splenectomy carries the risk of Overwhelming Post-Splenectomy Infection (OPSI).
Complications of Splenectomy
Overwhelming Post-Splenectomy Infection (OPSI)
OPSI is the most feared late complication of splenectomy. The reported incidence in adults undergoing splenectomy for all causes is approximately 0.9%, with a mortality of 0.8%. The risk is higher following splenectomy for haematological disorders than for trauma. Children are disproportionately affected. - Current Surgical Therapy 14e, p. 1323
The causative organisms are encapsulated bacteria:
- Streptococcus pneumoniae (most common)
- Neisseria meningitidis
- Haemophilus influenzae
OPSI carries a mortality rate of approximately 50%. - Fischer's Mastery of Surgery, p. 2168-2175
Vaccination protocol post-splenectomy:
- 23-valent pneumococcal vaccine (anyone >2 years of age); one-time booster 5 years later
- H. influenzae type b vaccine (one-time dose)
- Meningococcal vaccine (one-time dose)
- Children should also receive prophylactic penicillin V 125 mg twice daily until 3 years of age, then 250 mg twice daily until 5 years of age.
Vaccination is also recommended for all patients who undergo splenic artery embolisation.
Other Complications
- Splenic abscess (post-embolisation, incidence 0.14-0.76%)
- Splenic infarction
- Delayed splenic rupture (after NOM)
- Adjacent organ injury (pancreatic fistula, gastric injury)
- DVT/PE (DVT prophylaxis can generally be initiated safely within 48 hours of NOM)
Special Considerations
Malarial Spleen Rupture
In endemic tropical regions, spontaneous or traumatic rupture of a malaria-enlarged spleen is well recognised. Delayed presentation after trivial injury is common. Surgical technique demands early ligation of the splenic vessels along the superior border of the pancreatic body before disturbing the perisplenic haematoma, as rupture of the haematoma carries a worse prognosis. Radiological embolisation may be used where available. - Bailey and Love's Short Practice of Surgery, p. 1248
Paediatric Splenic Trauma
Children have a higher rate of successful NOM (90-95%) compared to adults. The American Pediatric Surgical Association (APSA) recommends graded activity restriction based on injury grade.
Splenic Rupture in Infectious Mononucleosis
The risk of splenic rupture in EBV mononucleosis is approximately 0.5-1.0%, most ruptures occurring between weeks 4 and 6 of infection. Physical examination is inferior to ultrasound for assessing spleen size and identifying subcapsular haematoma. Contact sports and strenuous activity must be restricted for a minimum of 3-4 weeks and until splenomegaly has resolved. - Swanson's Family Medicine Review
Summary
Splenic rupture ranges from contained subcapsular haematoma to catastrophic haemoperitoneum. The AAST injury scale guides management: haemodynamically unstable patients or those with high-grade injuries proceed to laparotomy, while haemodynamically stable patients are candidates for NOM with or without angioembolisation. Splenic salvage is preferred whenever possible given the long-term risk of OPSI following splenectomy. Delayed rupture remains a critical hazard in the post-discharge period, and all patients undergoing NOM must receive structured follow-up and counselling. Post-splenectomy vaccination against encapsulated organisms is mandatory.
Sources:
- Maingot's Abdominal Operations - Splenic Trauma and Rupture chapter
- Bailey and Love's Short Practice of Surgery 28th Ed. - Splenic rupture due to trauma
- Current Surgical Therapy 14e - Nonoperative management and OPSI sections
- Mulholland and Greenfield's Surgery 7e - Trauma to the Spleen chapter
- Schwartz's Principles of Surgery 11e - Miscellaneous Disorders and Lesions
- Gray's Anatomy for Students - Splenic anatomy and Kehr sign
- Pastak M et al. "Spontaneous Splenic Ruptures: A Contemporary Systematic Review." J Surg Res 2026 [PMID: 41564834]
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