Blunt abdominal trauma: Grade III spleen injury with active hemorrhage

Case contribution: Dr Radhiana Hassan


  • A 25 years old man
  • Involved in MVA, motorbike skidded
  • Noted to have multiple abrasion wounds at abdomen
  • CXR revealed a fracture of left posterior 10th rib
  • Patient was discharged home
  • A few hours later fainted at home. Prior to that complaint of abdominal pain and shortness of breath
  • In ED, noted to be pale. Hb drop from initial reading of 12.7 gm/dL to to 9.6 gm/dL
  • BP=108/62mmHg and PR=86bpm
CT scan abdomen pelvis in axial plane post contrast soft tissue window

CT scan findings:

  • Multiple lacerations within the spleen (yellow arrows) more than 3 cm in parenchymal depth, no involvement of the hilum with normal homogenous enhancement of the spleen.
  • There is contrast extravasation (red arrows) suggestive of active hemorrhage.
  • Massive hemoperitoneum (white arrows) also noted with blood pooling at perihepatic, perisplenic, both paracolic gutter and pelvis.
  • Sentinel clot sign seen with higher density of hemoperitoneum at perisplenic region suggestive the site of bleed.
  • No other organ injuries.
  • Non-displaced left 10th rib fracture on the left side (image not shown)

Intraoperative findings:

  • Patient developed hypovolaemic shock on table, BP drop to 40/20 mmHg
  • Active resuscitation done
  • Massive hemoperitoneum, blood loss of 3L.
  • Splenic injury with lacerations approaching hilar region
  • Liver, pancreas, stomach and bowels
  • Splenectomy done


  • Spleen injuries were reported in 30-49% of all visceral injuries in blunt abdominal trauma.
  • Associated injuries include: left lobe of liver, left hemidiaphragm, left adrenal gland and pancreatic tail
  • Grade III injury defined as lacerations more than 3 cm or intraparenchymal haematoma less than 5 cm. Presence of >50% surface area subcapsular haematoma or ruptured subcapsular haematoma also included in this grade.
  • In hemodynamically stable patients, most splenic injuries are treated non-operatively. However, in haemodynamically unstable patients, practice varies from institution to institution and case to case basis.
Author: radhianahassan