Medicolegal aspects of blunt splenic trauma with special reference to delayed rupture/presentation [a prospective study]

ABSTRACT

Deaths due to splenic rupture are still reported in hospital statistics. It is either acute or delayed rupture. Delayed splenic injury includes either true delayed rupture that represents an actually delayed development of an initially latent, insignificant, splenic injury [i.e. injury in evolution] minor enough to go undetected on initial CT scans of the abdomen, or delayed presentation which represents an initially missed injury [i.e. delay in diagnosis]. We had encountered a number of patients presented with splenic rupture days after blunt abdominal trauma. We conducted this study to review the experience with this clinical entity of blunt splenic rupture with special emphasis on delayed rupture/presentation for patients presented 48 hours or more after trauma. Ninty five emergency examinations were performed for the sole purpose of detecting splenic rupture in patients who had experienced blunt abdominal trauma during a period of 8 years. Twenty three patients out of the ninty five underwent urgent laparotomy and splenectomy within 48 hours from the occurrence of the trauma [24.2%] due to hemodynamic instability as a result of continuously bleeding splenic injury. Left rib fracture was encountered in 47.8% of the cases and bowel and mesenteric injury was found in 17.4% of the cases. Nine patients presented with delayed rupture/presentation of spleen 48 hours or more after the initial trauma [9.4%] were analyzed and formed the basis of this study. The mechanisms of injury and accompanying injuries were documented. The time lag from trauma to operation and the cause of delay were also documented. Regarding the cases of delayed rupture, abdominal computed tomography [CT] was performed in eight hemodynamically stable patients, as the 9[th] patient presented in shock with acute abdomen and emergency laparotomy was performed after positive diagnostic peritoneal lavage. CT demonstrated hemoperitoneum in 7 patients, 2 had subcapsular hematoma, 2 had grade II injury, 2 had grade III injury and one patient had grade IV injury with multiple pseudoaneurysms. Emergency laparotomy was performed for 2 patients due to hemodynamic instability. Three patients were operated upon after a brief period; the reaons for operating were hemodynamic instability or they showed manifestations of diffuse peritoneal irritations. Two patients were diagnosed to have true delayed rupture of sleen and managed initially conservatively; unfortunately, nonoperative management failed because of deterioration of clinical condition in one patient and repeated blood transfusions in the other patient. Splenectomy was performed in 8 patients. The last patient was managed nonoperatively and followed with repeat CT scans. In conclusion, Splenic rupture is frequently associated with collapse and other organ injury specially left rib fractures. This may be a useful marker for suspecting cases of delayed rupture. Also, delayed splenic rupture/presentation represents either an actually delayed development of an initially latent, minor splenic injury or an initially missed injury with late presentation. Patients may be displaced from one grade to another within few days. So, a high index of suspicion, observation, follow up of hematological parameters and liberal utilization imaging techniques are essential for the identification of delayed splenic rupture, which may be hazardous to patients life, and an actual challenge for physicians to avoid being condemned with negligence or malpractice