Splenic trauma
Key points
The spleen is the most frequently injured solid organ in paediatric blunt trauma
Common mechanisms include road traffic collisions and sports injuries
Penetrating trauma is less common
Assessment follows the ABCDE approach with suspicion in patients with left lower rib fractures or left upper quadrant tenderness
Investigations include haemoglobin monitoring, cross-match and coagulation screening
CT with contrast is the gold standard for defining injury
AAST Splenic Injury Grading
Grade I – subcapsular haematoma <10% or laceration <1 cm
Grade II – haematoma 10–50% or laceration 1–3 cm
Grade III – haematoma >50% or laceration >3 cm
Grade IV – segmental or hilar vessel injury causing major devascularisation
Grade V – shattered spleen or hilar vascular injury
Management of Splenic Injury
Non-operative management is standard in haemodynamically stable children and succeeds in more than 90% of cases
This includes close observation, bed rest, serial haemoglobin checks and ICU-level monitoring
Splenectomy is indicated in haemodynamic instability, failure of conservative management, hilar avulsion
Management of splenic injuries if the patient is having a trauma laparotomy for other reasons (e.g. hollow viscus injury:
Grade 1-3, stable, with no head or other serious injury - Splenorraphy
Grade 4 and 5 - Splenectomy
Angioembolisation is used in stable patients with active bleeding or pseudoaneurysm where expertise is available
Splenectomy
Divide short gastrics
Divide splenocolic ligament
Mobilise pancreatic tail
In emergency, can drag spleen into midline, dividing lateral attachments bluntly, and clamp the hilum
Complications
Pleural effusion
Abscess
Overwhelming post-splenectomy infection (OPSI)
Pancreatic fistula
Pancreatitis
Pseudoaneurysm - no need to re-image if asymptomatic - 89% thrombose
Pseudocysts - perform laparoscopic partial splenectomy
Post-Splenectomy Care
Vaccination is essential against Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae type b
Antibiotic prophylaxis with penicillin V or amoxicillin continues until at least age 16 or lifelong as per UK guidelines
Patient education includes awareness of OPSI risk, the need for early presentation with fever and the importance of carrying medical alert identification
OPSI is caused mainly by encapsulated organisms and carries mortality up to 50% in young children
Follow-up imaging to identify splenic artery pseudoaneurysm should be defined by local expertise and protocols
USS with bubble contrast, CT and MRI have been described
Activity Restrictions
No contact sports for 2 weeks after Grade I–II injuries, 4–6 weeks after Grade III–IV injuries and individualised for Grade V
Return to school is usually possible after 1–2 weeks once clinically stable
Page edited by Prof. Ashok Daya Ram MBBS, FRCS, FRCPS, FEBPS, FRCS (Paed Surgery), Consultant Paediatric and Neonatal Surgeon, Norfolk and Norwich University Hospital, Norwich, UK. October 2025
References
Kozar RA, Crandall M, Shanmuganathan K, Zarzaur BL, Coburn M, Cribari C, Kaups K, Schuster K, Tominaga GT; AAST Patient Assessment Committee. Organ injury scaling 2018 update: Spleen, liver, and kidney. J Trauma Acute Care Surg. 2018 Dec;85(6):1119-1122. doi: 10.1097/TA.0000000000002058. Erratum in: J Trauma Acute Care Surg. 2019 Aug;87(2):512. doi: 10.1097/TA.0000000000002419. PMID: 30462622.
Choi, Pamela, et al. "Liver and Spleen Trauma." Pediatric Surgery NaT, American Pediatric Surgical Association, 2022. Pediatric Surgery Library, www.pedsurglibrary.com/apsa/view/Pediatric-Surgery-NaT/829086/all/Liver and Spleen Trauma.
