Nonoperative Management of Pediatric Blunt Splenic Trauma in Relation to their CT Grading

Purpose: To evaluate the complications and consequences of nonoperative management of pediatric blunt splenic trauma in relation to their CT-grading, a case series of two institutions was analyzed retrospectively.

Methods: 84 patients under age 18 years suffered blunt abdominal trauma with a splenic injury between 1985 and 1995 at Hasbro Childrens Hospital, Rhode Island, and between 1996 and 2002 at the Floating Hospital for Children, Boston. Injuries were documented either by CT-scan of the abdomen or by findings at celiotomy. Baseline data were recorded. 80 patients (92%) were treated nonoperatively. The number of cases with delayed operative management, early and late complications on follow up were then analyzed and results of follow-up CT-scans and sonograms evaluated.

Results: Two of 80 patients treated nonoperatively required operative intervention. Both had CT-scans showing subcapsular hematomas. Of the 78 patients successfully treated nonoperatively, early consequences and complications included three cases of pneumonia, 8 cases of asymptomatic atelectasis or pleural effusions on chest x-ray and 3 cases of ileus. Late complications included one splenic abscess and one delayed hemorrhage after 14 days, both with subcapsular hematomas. Other late complications were persistent lesions on CT-scan, one in a case of hilar injury and three in cases of subcapsular hematomas.

Conclusions: The overall complication rate of nonoperative treatment of pediatric blunt splenic trauma is relatively low (15%) and most complications are minor morbidities. Subcapsular hematomas on initial assessment appears significantly more likely to develop late complications or persistent lesions past 6 months. Increased clinical suspicion in cases of subcapsular hematoma on initial CT assessment appears justified. Based on this, we advise against a standard approach towards the management of splenic lacerations based on the imaging characteristic for a "grade I" lesion alone.