A 47 yo M presents to the ED after being struck by a vehicle while crossing the street. He fell and hit his head, but reports no LOC. He is complaining of diffuse abdominal pain and back pain. On exam, VS are normal and GCS is 15.  CT scans are obtained given his mechanism and CT A/P is shown below. What's the Diagnosis? (scroll down for answer)

Answer:  Splenic Rupture (more specifically Grade 4 AAST splenic injury with active contrast extravasation)

• Splenic injuries are at high risk of hemorrhage in both blunt and abdominal trauma
• On exam: 
• Patient may complain of LUQ abdominal pain
• Kehr Sign: acute pain in the L shoulder that occurs when patient lying flat and legs elevated  (due to presence of blood in the peritoneal cavity)
• May see hypotension, tachycardia, hemodynamic instability
• Normal exam does not exclude serious intra-abdominal injury!! 
• Diagnosis
• FAST--  beneficial in hypotensive pt w/ blunt abdominal trauma
• CT-- gold standard in stable patient
• AAST Grading of Injury
• Grade I:  Hematoma: Subcapsular, < 10% surface area 
• Grade I:  Laceration: Capsular tear, <1cm in depth into parenchyma
• Grade II: Hematoma: Subcapsular, 10-50% surface area
• Grade II: Laceration: Capsular tear, 1-3 cm in depth, but not involving trabecular vessel 
• Grade III: Hematoma: Subcapsular > 50% surface area OR expanding;  Ruptured subcapsular or parenchymal hematoma OR intraparenchyma hematoma > 5cm or expanding
• Grade III: Laceration: Capsular tear, 3cm to 10cm in depth or involving trabecular vessel
• Grade IV: Hematoma: Subcapsular or central hematoma >10cm
• Grade IV: Laceration: Involving segmental or hilar vessels w/ major devascularization (> 25%)
• Grade V: Hematoma: Shattered spleen
• Grade V: Laceration: Hilar vascular injury which devascularizes spleen

• Treatment
• Nonoperative vs IR embolization vs. surgical intervention 
• Nonoperative managment is treatment of choice for hemodynamically stable patients regardless of age, grade of injury or presence of assoiciated injuries

 References:

Ferroggiaro AA, Ma O. Abdominal Trauma. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020

Gaillard, F., Jones, J. AAST spleen injury scale. Reference article, Radiopaedia.org.