Splenic injuries

Editor – I read with interest the case report by Carey and Nelatu titled ‘Spontaneous splenic rupture secondary to dabigatran: the last in a series of unfortunate events’ and postulate whether the splenic rupture was truly spontaneous or acute deterioration of an occult splenic injury sustained during the fall and worsened by direct oral anticoagulation (DOAC) therapy.

Blunt splenic trauma is common after falls¹ and is usually elicited by history and examination, however, a negative history and unremarkable physical examination does not exclude splenic injury.² For this reason, evaluation of the trauma patient should use focused assessment with sonography in trauma examination and computed tomography to assess the spleen.

The American Association for the Surgery of Trauma classifies splenic injuries as grade I–V; with I representing a subcapsular hematoma involving less than 10% of the surface area or capsular laceration less than one centimeter in depth.³ Furthermore, in a multi-center cohort study, bleeding of a subscapular hematoma occurred in 5% of non-operatively managed patients with splenic injury 4 days post diagnosis.⁴ Therefore, it’s difficult to classify a patient as having spontaneous splenic rupture secondary to DOAC, without confidently excluding occult splenic injury or subcapsular hematoma in an elderly patient with a mechanism of fall significant enough to cause bimalleolar ankle fracture.