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Patterns of splenic injuries seen in skiers
Injury Vol. 26, No. 1, pp. 43-46, 1995 Copyright 8 19% Elsevier Science Ltd Printed m Great Britain. All rights reserved OOZO-1383195 $lO.O@ + 0.00
Patterns K. H. Sartorellil,
of splenic
injuries
seen in skiers
D. B. PilcherZ and F. B. Rogers2
‘Medical Center Hospital of Vermont, Burlington, and ‘University Vermont, USA
Splenic rupture seconday to skiing appears to fall info two distinct epidemiological pafferns: high-speed impact with stationary objects and simple falls (mogul injury). Of 18 splenic injuries seen af a referral hospital over 12 years, six were high-speed collisions with frees, lift towers or other solid objects. Twelve were low-speed falls impacting on moguls, fhe ski frail or low-speed impact with a trailside object (slump or rock). Those who susfained low-speed injuries frequently skied down the mounfain afterwards wifhouf assistance (8/12), and had no other significant concomitant injuries other than minor renal confusions compared wifh fhe collision group (PC 0.005). The rate of splenic salvage was also higher in thisgroup fhan in the collisiongroup (68 per cent us I 7 per cent). The six high-speed collision splenic injury victims were all transported down the mountain by toboggan, and all had significant associated injuries. The incidence of concomifanf renal injuries wifh splenic injuries in both groups was higher than in other reported series (70 of 18 patients). Some of fhose who skied down the mountain themselves sought medical attention only when they experienced haemafuria. There were no significant differences in the length of stay in hospital, or infensive care units (RX), or transfusion requirements or complicafions between groups. If is suggested that those who ski down the mounfain themselves and present in a delayed fashion to medical/first aid facilities may still have serious abdominal injury but have a potentially higher rate of spleen salvage.
of Vermont, College of Medicine, Burlington,
Methods The records of all patients sustaining splenic injuries secondary to ski accidents managed at MCHV during the 1979-1992 ski seasons were reviewed. This hospital is a tertiary care centre for the University of Vermont and has five major ski areas in its catchment area. Information was obtained on the mechanism of injury, rapidity of seeking treatment, treatment modality and outcome. Rapidity of seeking treatment was determined by analysis of medical records and patient interviews. No delay was felt to occur if the patient was taken off the mountain by the ski control or sought immediate attention at the first aid station. A delay in treatment was felt to occur if the patient presented for medical evaluation I h or more after sustaining an injury. Skiers were divided into two groups by mechanism of injury. Group I consisted of skiers who had sustained their injury as the result of low-energy impact with a mogul, the trail, or a trailside object after a fall. Group II was composed of skiers who had sustained injuries in high-speed high-energy collisions with solid objects. Splenic, hepatic, and renal injuries were graded retrospectively using the organ injury scale adopted by the American Association for the Surgery of Trauma (AAST)4.
Results Injury,
1995,
Vol. 26, 43-46,
January
Introduction Alpine skiing is a popular winter recreational activity throughout Europe and North America. Reports of orthopaedic injuries are numerous, but there is a paucity of literature concerning the epidemiology and treatment of abdominal injuries secondary to skiinglP3. At the Medical Center Hospital of Vermont (MCHV) we observed that in the population of skiers who sustained splenic injuries a unique subset existed who would often present on a delayed basis with a splenic injury incurred during a fall while mogul skiing. In order to elucidate better the epidemiology of splenic injuries due to ski accidents, and in an attempt to characterize the ‘mogul injury’ pattern of splenic trauma, a review of all ski-related splenic injuries managed at MCHV over a 12-year period was undertaken.
There were 18 skiers identified by ICD-9 codes at discharge who sustained splenic injuries secondary to skiing treated at MCHV during the 1979-1992 ski seasons. Alpine skiers accounted for 17 of those injured while one person was on a snowboard. All were male. Table I. Demographics and presentation of injury
Number Age (years) Completed ski run Delayed treatment Hours to presentation *Mean
f SD.
‘PC 0.05.
Group I
Group II
12
6 20.7 f 8.3
20.4?~ 4.9’ 8/l 2
6/l 2 3.75+2.2 (range 1-J h)
O/6’
O/6+ Of
44
Injury:
International
There were no significant differences in the ages of skiers in either of the two groups (T&e I). The 12 Group I skiers were injured in falls in which they struck moguls (six), landed on the trail (four), or struck a trailside object (one rock, one stump) at low speed after falling on the trail. The six Group II skiers sustained injuries in high speed collisions with trees (three) or stationary objects (three). These objects included a chair lift pole, a snow-making machine, and a snow fence. Eight of the 12 Group I skiers were able to get up and ski down the mountain without assistance, the other four were transported down the mountain by the ski patrol on a toboggan (Table I). Of eight who completed their ski run, two people sought immediate medical attention, while six had significantly delayed presentations for care (Table I). The average delay in seeking medical attention for these six skiers was 3.75 f 0.8 h which was significantly longer than Group II (Table I). The six Group II skiers were transported down the mountain by toboggan (Table r). There was no significant delay in medical treatment in this group (Table I). Four of these people were initially taken to outlying hospitals and then transferred to MCHV for definitive management. One patient underwent a splenectomy at an outlying hospital and was then transferred for management of multiple injuries. No other Group II patients underwent surgery at outlying facilities. Two Group I patients and one Group II patient arrived in shock (systolic blood pressure < 100 mm Hg). The mean admission haematocrit of Group I was 37.6 f 2.0 compared to 36.1 f 1.2 for Group II. Evaluation of abdominal injuries was performed using diagnostic peritoneal lavage (DPL) (seven Group I, five Group II), computed tomography (three Group I, one Group II), and radionuclide liver/spleen scan (two Group I). DPL and liver-spleen scans were widely used prior to the advent of computed tomography (CT) scanning as a diagnostic modality. Haematuria was worked up as part of the abdominal CT scan or by intravenous pyelography (IVP). The 12 Group I patients sustained seven isolated splenic injuries while five (42 per cent) patients had an additional injury (Table II). All five of these additional injuries were renal contusions. Two patients presented with gross haematuria as their primary complaint. Three had microscopic haematuria (> 20 red blood cells/high power field). The Group II patients sustained a significantly greater number of injuries than the Group I patients. All six patients suffered at least one other injury in addition to their splenic injury, while 4/6 (67 per cent) had at least two additional injuries (Table IU). The injuries in Group II included five patients with renal injuries, five with rib fractures, three with long-bone fractures, two with pulmonary contusions, two with haemothoraces, one closed head injury, one hepatic laceration, and one brachial artery injury (Table 110. The mean injury severity score (ISS) for Group II was significantly higher than for Group I (21.7 f 3.7
vs. 11.8 f
Journal
of the Care of the Injured
Vol. 26/No.
1
three grade IV, two grade III, and one grade II. The five patients evaluated with diagnostic peritoneal lavage and the one evaluated by CT scan all underwent surgery. The patient evaluated by CT was initially treated nonoperatively but became hypotensive while undergoing a prolonged orthopaedic procedure under general anaesthesia and a decision was made to explore his abdomen. Management of the splenic injuries in Group II consisted of five splenectomies and one splenorrhaphy (17 per cent splenic salvage rate). A failed splenorrhaphy necessitated Table II. Group I (low impact) injuries and treatment to injured spleen Age
Mechanism
Injuries
16
Fell on trail
17
Fell on mogul
20
Fell on trail
18 60 17
Fell on mogul Fell on mogul Fell on trail
16
Fell on mogul
17 18
Fell on mogul Fell on mogul
7
Fell on trail
18
Fell on struck Fell on struck
Lower pole spleen avulsed Splenic lac Renal contusion Splenic lac Renal contusion Splenic lac Splenic lac Splenic lac Renal contusion Splenic lac Renal contusion Splenic lac Splenic lac Renal contusion Spleen; lower pole avulsion Splenic lac
Splenectomy
Splenic
Observation
13
lac=
trail, stump trail, rock
lac
rendered
Treatment Partial splenectomy/ splenorrhaphy Splenorrhaphy Splenectomy Splenectomy Splenectomy Observation Observation Observation Splenectomy Splenorrhaphy
laceration
TableIII. Group II (high rendered to injured spleen
impact)
injuries
and
treatment
Age
Mechanism
injuries
Treatment
46
Struck
Splenectomy ORIF leg fx
17
Hit chairlift pole
16
Struck
pipe
11
Struck fence
snow
18
Hit tree
31
Hit tree
Splenic lac Renal contusion Open tib-fib fx Rib fxs Splenic lac Left haemothorax Left pulmonary contusion Multiple left rib fx Concussion Splenic lac Multiple left rib fx Left haemothorax Left humerus fx Left brachial artery injury Renal contusion Splenic lac Left femur fx Liver lac Left kidney lac Renal laceration Bladder contusion Splenic lac Renal contusion Cardiac contusion Multiple left rib fx Splenic lac fx left tenth rib
tree
1.7).
There were four grade IV, seven grade III, and one grade II splenic lacerations in Group I. Operative intervention occurred in 6/7 patients evaluated with diagnostic peritoneal lavage and 2/5 patients evaluated radiographically. Management of the Group I spleen injuries consisted of five splenectomies, three splenorrhaphies, and four patients treated non-operatively (58.3 per cent splenic salvage rate). The splenic injuries in Group II included
(1995)
lac=
laceration;
fx=fracture.
Splenorraphy
Splenectomy
Splenectomy
Splenectomy
Splenectomy
Sartorelli
et al.: Splenic
injuries
in skiers
45
Table IV. Transfusion requirements, length of stay and 1% Group Shock (SBP
I
Group
II
2 (17 per cent)
2 (33 per cent)
37.6 zk 5.5’
36.1 k2.9
1 .I + 1 .o 7.7f3.1 1.3zk1.7 11.8rt5.9
2.7 f 2.5 13.5 + 10.5 2.5&2.5 21.8f9.1’
‘Mean+so. + P< 0.05.
splenectomy in one case. Despite Group II patients sustaining multiple and more severe injuries than those in Group I, there were no significant differences in bloodtransfusion requirements, the length of ICU stay, and the length of hospital stay between groups (Table Iv). There were no deaths in either of the groups. Complications occurred in five patients; two Group I patients and three Group II patients (17 per cent vs 50 per cent). Though there was no significant difference in the complication rate between groups, the Group II patients incurred a greater degree of morbidity from their complications. The complications in Group I consisted of two patients who developed pneumonia. They responded to antibiotic therapy and recovered without sequelae. They both had delayed presentation for treatment of their splenic injuries. Complications in Group II included: one patient developed a urinoma from a renal laceration, and also a pleural effusion requiring drainage; one had an upper extremity neurological deficit following a vascular injury; and one developed a postoperative coagulopathy which corrected with blood component therapy. This patient also sustained a pulmonary contusion and subsequently developed pneumonia requiring mechanical ventilation.
Discussion The spleen is the most commonly injured abdominal organ in blunt trauma5. Despite this, splenic injuries secondary to skiing accidents appear to be rare”-8. Scharlplatz et al.’ reported seven splenic injuries in 30 skiers treated at a Swiss hospital over a I2-year period. Jurkovich et a1.6 reported 13 splenic injuries in a series of 44 skiers who sustained thoracoabdominal injuries from ski accidents treated at a single centre over an B-year period. A review of skier deaths in Vermont occurring during the 19791992 ski seasons revealed splenic injuries in two of 41 fatalities’. In only one case was death felt to be secondary to the splenic injury (personal communication from Vermont State Chief Medical Examiner). Analysis of the MCHV data suggests that the occurrence of splenic injuries secondary to ski trauma falls into two distinct patterns related to the mechanism of injury. Skiers who sustained splenic injuries by falling on moguls or the trail were likely to incur an isolated spleen injury. Additional injuries, if they occurred, were usually minor renal contusions. There were other unique characteristics noted in skiers who sustained low-speed falls. The first was that the majority (67 per cent) were able to get up and complete their ski run without assistance. A second was that 75 per cent of those who suffered a low-speed fall and
then completed their ski run presented for medical care on a delayed basis. Overall a delayed presentation for medical care was seen in 50 per cent of skiers sustaining a low-speed fall. The second pattern of splenic injury demonstrated by the MCHV data occurred in skiers whose mechanism of injury was a high-speed, high-energy collision with a tree or other solid object. These skiers were likely to sustain significant multi-system trauma in addition to their splenic injuries. This point is underscored by the significantly greater ISS present in the Group II skiers. Patients injured in high-energy collisions presented immediately for care and a high degree of morbidity from complications. Despite the Group II skiers having sustained significantly more severe injuries, differences in treatment variable and outcome could not be demonstrated compared with Group 1. The average number of units of blood transfused, as well as average length of hospital and ICU stays, were nearly twice as long for Group II as Group I. The failure to demonstrate statistically significant differences for these variables between the two groups may in part be related to the low number of Group II patients. No differences were observed between groups concerning operative rates and splenic salvage. The reasons for this appear to be multifactorial and may in part reflect historical changes in the diagnostic and therapeutic options available to manage splenic injury. The evolution in the treatment of splenic injuries during the period encompassed by this study may have exerted influence on the way these injuries were managed. The high incidence of laparotomy for splenic injury (75 per cent Group I, 100 per cent Group II, 78 per cent overall) in part reflected the frequent use of DPL as a diagnostic test for intra-abdominal injury in the earlier years of this study. Positive DPL results were followed by laparotomy and splenectomy if a splenic injury was present. In the later years of this study the increased use of CT as a diagnostic modality coupled with emphasis on splenic conservation appeared to result in more frequent splenic salvage in the less seriously injured skiers. Nonoperative management was carried out in four Group I patients and splenorrhaphy in three for an overall Group I spleen salvage rate of 58 per cent. This is in contrast to a single successful splenorrhaphy in Group II for a 17 per cent spleen salvage rate. Though the Group I spleen salvage rate was higher than Group II it did not reach statistical significance and this may in part be due to the low number of patients seen in this study. Renal injuries were more frequently observed in the MCHV patient population (42 per cent Group I, 83 per cent Group II, 56 per cent overall) than in the series reported by Scharlplatz et al8 (27 per cent) or Jurkovich et a1.6 (43 per cent). Two patients who sustained low-speed falls with splenic injury had gross haematuria as the primary symptom that forced them to seek care. Haematuria has been recognized as a marker for splenic injury in paediatric injury patients9 and appears to be suggestive of splenic injury in this study. The implications of this study relate primarily to the pre-hospital personnel and emergency room physicians who attend to the skier who presents after a low-impact fall. An appreciation of the possibility of an underlying splenic injury, especially in someone with gross or microscopic haematuria should trigger appropriate diagnostic tests. With close monitoring and splenic salvage techniques more of these relatively isolated injuries should be able to be salvaged.
46
Injury:
International
Conclusions Splenic injuries secondary to skiing appear to occur in two distinct patterns related to mechanism of injury. There appears to be a group of skiers who sustain splenic injuries in low-energy falls. These skiers will usually have an isolated splenic injury and often present in a delayed manner for medical attention. They may present for evaluation of other symptoms such as haematuria as their primary complaint. The second category of ski-related spleen injury is seen in people involved in high-energy, high-speed collisions. These people sustain multiple injuries and present for prompt medical care.
Journal
of the Care of the Injured
(1995) Vol. 26/No.
1
3 Ellison AE. Skiing injuries. JAMA 1973; 223: 917. 4 Moore EE, Shackford SR, Pachter HL, et al. Organ injury scaling: spleen, liver, kidney. ] Trauma 1989; 29: 1664. 5 Lucas CE. Splenic trauma: choice for management. Ann Surg 1989; 213: 98. 6 Jurkovich GJ, Pearce WH, Cleveland HC. Thoracic and abdominal injuries in skiers: the role of air evacuation. ] Trauma 1983; 23: 844. 7 Morrow PL, McQuillen EN, Eaton LA, Bernstein CJ. Downhill ski fatalities: the Vermont experience. J Trauma 1988; 28: 95. 8 Scharplatz D, Thurleman K, Enderlin F. Thoracoabdominal trauma in ski accident. lnju y 1979; 10: 86. 9 Taylor GA, Eichelberger MR, Potter BM. Hematuria: a marker of abdominal injury in children after blunt trauma. ] Trauma 1988; 208: 688.
References
Paper accepted 5 August 1994.
1 Erskine LA. Recent changes in the pattern of skiing injuries. ] Trauma 1974; 14: 79. 2 Gutman J, Weisbuch J, Wolf M. Ski injuries in 1972-1973: a repeat analysis of a major health problem. JAMA 1974; 230: 1423.
Requestsfor reprints should be addressed to: Frederick B. Rogers, MD, University of Vermont, College of Medicine, Given D-319, Burlington, Vermont 05405, USA. FACS,
Patterns K. H. Sartorellil,
of splenic
injuries
seen in skiers
D. B. PilcherZ and F. B. Rogers2
‘Medical Center Hospital of Vermont, Burlington, and ‘University Vermont, USA
Splenic rupture seconday to skiing appears to fall info two distinct epidemiological pafferns: high-speed impact with stationary objects and simple falls (mogul injury). Of 18 splenic injuries seen af a referral hospital over 12 years, six were high-speed collisions with frees, lift towers or other solid objects. Twelve were low-speed falls impacting on moguls, fhe ski frail or low-speed impact with a trailside object (slump or rock). Those who susfained low-speed injuries frequently skied down the mounfain afterwards wifhouf assistance (8/12), and had no other significant concomitant injuries other than minor renal confusions compared wifh fhe collision group (PC 0.005). The rate of splenic salvage was also higher in thisgroup fhan in the collisiongroup (68 per cent us I 7 per cent). The six high-speed collision splenic injury victims were all transported down the mountain by toboggan, and all had significant associated injuries. The incidence of concomifanf renal injuries wifh splenic injuries in both groups was higher than in other reported series (70 of 18 patients). Some of fhose who skied down the mountain themselves sought medical attention only when they experienced haemafuria. There were no significant differences in the length of stay in hospital, or infensive care units (RX), or transfusion requirements or complicafions between groups. If is suggested that those who ski down the mounfain themselves and present in a delayed fashion to medical/first aid facilities may still have serious abdominal injury but have a potentially higher rate of spleen salvage.
of Vermont, College of Medicine, Burlington,
Methods The records of all patients sustaining splenic injuries secondary to ski accidents managed at MCHV during the 1979-1992 ski seasons were reviewed. This hospital is a tertiary care centre for the University of Vermont and has five major ski areas in its catchment area. Information was obtained on the mechanism of injury, rapidity of seeking treatment, treatment modality and outcome. Rapidity of seeking treatment was determined by analysis of medical records and patient interviews. No delay was felt to occur if the patient was taken off the mountain by the ski control or sought immediate attention at the first aid station. A delay in treatment was felt to occur if the patient presented for medical evaluation I h or more after sustaining an injury. Skiers were divided into two groups by mechanism of injury. Group I consisted of skiers who had sustained their injury as the result of low-energy impact with a mogul, the trail, or a trailside object after a fall. Group II was composed of skiers who had sustained injuries in high-speed high-energy collisions with solid objects. Splenic, hepatic, and renal injuries were graded retrospectively using the organ injury scale adopted by the American Association for the Surgery of Trauma (AAST)4.
Results Injury,
1995,
Vol. 26, 43-46,
January
Introduction Alpine skiing is a popular winter recreational activity throughout Europe and North America. Reports of orthopaedic injuries are numerous, but there is a paucity of literature concerning the epidemiology and treatment of abdominal injuries secondary to skiinglP3. At the Medical Center Hospital of Vermont (MCHV) we observed that in the population of skiers who sustained splenic injuries a unique subset existed who would often present on a delayed basis with a splenic injury incurred during a fall while mogul skiing. In order to elucidate better the epidemiology of splenic injuries due to ski accidents, and in an attempt to characterize the ‘mogul injury’ pattern of splenic trauma, a review of all ski-related splenic injuries managed at MCHV over a 12-year period was undertaken.
There were 18 skiers identified by ICD-9 codes at discharge who sustained splenic injuries secondary to skiing treated at MCHV during the 1979-1992 ski seasons. Alpine skiers accounted for 17 of those injured while one person was on a snowboard. All were male. Table I. Demographics and presentation of injury
Number Age (years) Completed ski run Delayed treatment Hours to presentation *Mean
f SD.
‘PC 0.05.
Group I
Group II
12
6 20.7 f 8.3
20.4?~ 4.9’ 8/l 2
6/l 2 3.75+2.2 (range 1-J h)
O/6’
O/6+ Of
44
Injury:
International
There were no significant differences in the ages of skiers in either of the two groups (T&e I). The 12 Group I skiers were injured in falls in which they struck moguls (six), landed on the trail (four), or struck a trailside object (one rock, one stump) at low speed after falling on the trail. The six Group II skiers sustained injuries in high speed collisions with trees (three) or stationary objects (three). These objects included a chair lift pole, a snow-making machine, and a snow fence. Eight of the 12 Group I skiers were able to get up and ski down the mountain without assistance, the other four were transported down the mountain by the ski patrol on a toboggan (Table I). Of eight who completed their ski run, two people sought immediate medical attention, while six had significantly delayed presentations for care (Table I). The average delay in seeking medical attention for these six skiers was 3.75 f 0.8 h which was significantly longer than Group II (Table I). The six Group II skiers were transported down the mountain by toboggan (Table r). There was no significant delay in medical treatment in this group (Table I). Four of these people were initially taken to outlying hospitals and then transferred to MCHV for definitive management. One patient underwent a splenectomy at an outlying hospital and was then transferred for management of multiple injuries. No other Group II patients underwent surgery at outlying facilities. Two Group I patients and one Group II patient arrived in shock (systolic blood pressure < 100 mm Hg). The mean admission haematocrit of Group I was 37.6 f 2.0 compared to 36.1 f 1.2 for Group II. Evaluation of abdominal injuries was performed using diagnostic peritoneal lavage (DPL) (seven Group I, five Group II), computed tomography (three Group I, one Group II), and radionuclide liver/spleen scan (two Group I). DPL and liver-spleen scans were widely used prior to the advent of computed tomography (CT) scanning as a diagnostic modality. Haematuria was worked up as part of the abdominal CT scan or by intravenous pyelography (IVP). The 12 Group I patients sustained seven isolated splenic injuries while five (42 per cent) patients had an additional injury (Table II). All five of these additional injuries were renal contusions. Two patients presented with gross haematuria as their primary complaint. Three had microscopic haematuria (> 20 red blood cells/high power field). The Group II patients sustained a significantly greater number of injuries than the Group I patients. All six patients suffered at least one other injury in addition to their splenic injury, while 4/6 (67 per cent) had at least two additional injuries (Table IU). The injuries in Group II included five patients with renal injuries, five with rib fractures, three with long-bone fractures, two with pulmonary contusions, two with haemothoraces, one closed head injury, one hepatic laceration, and one brachial artery injury (Table 110. The mean injury severity score (ISS) for Group II was significantly higher than for Group I (21.7 f 3.7
vs. 11.8 f
Journal
of the Care of the Injured
Vol. 26/No.
1
three grade IV, two grade III, and one grade II. The five patients evaluated with diagnostic peritoneal lavage and the one evaluated by CT scan all underwent surgery. The patient evaluated by CT was initially treated nonoperatively but became hypotensive while undergoing a prolonged orthopaedic procedure under general anaesthesia and a decision was made to explore his abdomen. Management of the splenic injuries in Group II consisted of five splenectomies and one splenorrhaphy (17 per cent splenic salvage rate). A failed splenorrhaphy necessitated Table II. Group I (low impact) injuries and treatment to injured spleen Age
Mechanism
Injuries
16
Fell on trail
17
Fell on mogul
20
Fell on trail
18 60 17
Fell on mogul Fell on mogul Fell on trail
16
Fell on mogul
17 18
Fell on mogul Fell on mogul
7
Fell on trail
18
Fell on struck Fell on struck
Lower pole spleen avulsed Splenic lac Renal contusion Splenic lac Renal contusion Splenic lac Splenic lac Splenic lac Renal contusion Splenic lac Renal contusion Splenic lac Splenic lac Renal contusion Spleen; lower pole avulsion Splenic lac
Splenectomy
Splenic
Observation
13
lac=
trail, stump trail, rock
lac
rendered
Treatment Partial splenectomy/ splenorrhaphy Splenorrhaphy Splenectomy Splenectomy Splenectomy Observation Observation Observation Splenectomy Splenorrhaphy
laceration
TableIII. Group II (high rendered to injured spleen
impact)
injuries
and
treatment
Age
Mechanism
injuries
Treatment
46
Struck
Splenectomy ORIF leg fx
17
Hit chairlift pole
16
Struck
pipe
11
Struck fence
snow
18
Hit tree
31
Hit tree
Splenic lac Renal contusion Open tib-fib fx Rib fxs Splenic lac Left haemothorax Left pulmonary contusion Multiple left rib fx Concussion Splenic lac Multiple left rib fx Left haemothorax Left humerus fx Left brachial artery injury Renal contusion Splenic lac Left femur fx Liver lac Left kidney lac Renal laceration Bladder contusion Splenic lac Renal contusion Cardiac contusion Multiple left rib fx Splenic lac fx left tenth rib
tree
1.7).
There were four grade IV, seven grade III, and one grade II splenic lacerations in Group I. Operative intervention occurred in 6/7 patients evaluated with diagnostic peritoneal lavage and 2/5 patients evaluated radiographically. Management of the Group I spleen injuries consisted of five splenectomies, three splenorrhaphies, and four patients treated non-operatively (58.3 per cent splenic salvage rate). The splenic injuries in Group II included
(1995)
lac=
laceration;
fx=fracture.
Splenorraphy
Splenectomy
Splenectomy
Splenectomy
Splenectomy
Sartorelli
et al.: Splenic
injuries
in skiers
45
Table IV. Transfusion requirements, length of stay and 1% Group Shock (SBP
I
Group
II
2 (17 per cent)
2 (33 per cent)
37.6 zk 5.5’
36.1 k2.9
1 .I + 1 .o 7.7f3.1 1.3zk1.7 11.8rt5.9
2.7 f 2.5 13.5 + 10.5 2.5&2.5 21.8f9.1’
‘Mean+so. + P< 0.05.
splenectomy in one case. Despite Group II patients sustaining multiple and more severe injuries than those in Group I, there were no significant differences in bloodtransfusion requirements, the length of ICU stay, and the length of hospital stay between groups (Table Iv). There were no deaths in either of the groups. Complications occurred in five patients; two Group I patients and three Group II patients (17 per cent vs 50 per cent). Though there was no significant difference in the complication rate between groups, the Group II patients incurred a greater degree of morbidity from their complications. The complications in Group I consisted of two patients who developed pneumonia. They responded to antibiotic therapy and recovered without sequelae. They both had delayed presentation for treatment of their splenic injuries. Complications in Group II included: one patient developed a urinoma from a renal laceration, and also a pleural effusion requiring drainage; one had an upper extremity neurological deficit following a vascular injury; and one developed a postoperative coagulopathy which corrected with blood component therapy. This patient also sustained a pulmonary contusion and subsequently developed pneumonia requiring mechanical ventilation.
Discussion The spleen is the most commonly injured abdominal organ in blunt trauma5. Despite this, splenic injuries secondary to skiing accidents appear to be rare”-8. Scharlplatz et al.’ reported seven splenic injuries in 30 skiers treated at a Swiss hospital over a I2-year period. Jurkovich et a1.6 reported 13 splenic injuries in a series of 44 skiers who sustained thoracoabdominal injuries from ski accidents treated at a single centre over an B-year period. A review of skier deaths in Vermont occurring during the 19791992 ski seasons revealed splenic injuries in two of 41 fatalities’. In only one case was death felt to be secondary to the splenic injury (personal communication from Vermont State Chief Medical Examiner). Analysis of the MCHV data suggests that the occurrence of splenic injuries secondary to ski trauma falls into two distinct patterns related to the mechanism of injury. Skiers who sustained splenic injuries by falling on moguls or the trail were likely to incur an isolated spleen injury. Additional injuries, if they occurred, were usually minor renal contusions. There were other unique characteristics noted in skiers who sustained low-speed falls. The first was that the majority (67 per cent) were able to get up and complete their ski run without assistance. A second was that 75 per cent of those who suffered a low-speed fall and
then completed their ski run presented for medical care on a delayed basis. Overall a delayed presentation for medical care was seen in 50 per cent of skiers sustaining a low-speed fall. The second pattern of splenic injury demonstrated by the MCHV data occurred in skiers whose mechanism of injury was a high-speed, high-energy collision with a tree or other solid object. These skiers were likely to sustain significant multi-system trauma in addition to their splenic injuries. This point is underscored by the significantly greater ISS present in the Group II skiers. Patients injured in high-energy collisions presented immediately for care and a high degree of morbidity from complications. Despite the Group II skiers having sustained significantly more severe injuries, differences in treatment variable and outcome could not be demonstrated compared with Group 1. The average number of units of blood transfused, as well as average length of hospital and ICU stays, were nearly twice as long for Group II as Group I. The failure to demonstrate statistically significant differences for these variables between the two groups may in part be related to the low number of Group II patients. No differences were observed between groups concerning operative rates and splenic salvage. The reasons for this appear to be multifactorial and may in part reflect historical changes in the diagnostic and therapeutic options available to manage splenic injury. The evolution in the treatment of splenic injuries during the period encompassed by this study may have exerted influence on the way these injuries were managed. The high incidence of laparotomy for splenic injury (75 per cent Group I, 100 per cent Group II, 78 per cent overall) in part reflected the frequent use of DPL as a diagnostic test for intra-abdominal injury in the earlier years of this study. Positive DPL results were followed by laparotomy and splenectomy if a splenic injury was present. In the later years of this study the increased use of CT as a diagnostic modality coupled with emphasis on splenic conservation appeared to result in more frequent splenic salvage in the less seriously injured skiers. Nonoperative management was carried out in four Group I patients and splenorrhaphy in three for an overall Group I spleen salvage rate of 58 per cent. This is in contrast to a single successful splenorrhaphy in Group II for a 17 per cent spleen salvage rate. Though the Group I spleen salvage rate was higher than Group II it did not reach statistical significance and this may in part be due to the low number of patients seen in this study. Renal injuries were more frequently observed in the MCHV patient population (42 per cent Group I, 83 per cent Group II, 56 per cent overall) than in the series reported by Scharlplatz et al8 (27 per cent) or Jurkovich et a1.6 (43 per cent). Two patients who sustained low-speed falls with splenic injury had gross haematuria as the primary symptom that forced them to seek care. Haematuria has been recognized as a marker for splenic injury in paediatric injury patients9 and appears to be suggestive of splenic injury in this study. The implications of this study relate primarily to the pre-hospital personnel and emergency room physicians who attend to the skier who presents after a low-impact fall. An appreciation of the possibility of an underlying splenic injury, especially in someone with gross or microscopic haematuria should trigger appropriate diagnostic tests. With close monitoring and splenic salvage techniques more of these relatively isolated injuries should be able to be salvaged.
46
Injury:
International
Conclusions Splenic injuries secondary to skiing appear to occur in two distinct patterns related to mechanism of injury. There appears to be a group of skiers who sustain splenic injuries in low-energy falls. These skiers will usually have an isolated splenic injury and often present in a delayed manner for medical attention. They may present for evaluation of other symptoms such as haematuria as their primary complaint. The second category of ski-related spleen injury is seen in people involved in high-energy, high-speed collisions. These people sustain multiple injuries and present for prompt medical care.
Journal
of the Care of the Injured
(1995) Vol. 26/No.
1
3 Ellison AE. Skiing injuries. JAMA 1973; 223: 917. 4 Moore EE, Shackford SR, Pachter HL, et al. Organ injury scaling: spleen, liver, kidney. ] Trauma 1989; 29: 1664. 5 Lucas CE. Splenic trauma: choice for management. Ann Surg 1989; 213: 98. 6 Jurkovich GJ, Pearce WH, Cleveland HC. Thoracic and abdominal injuries in skiers: the role of air evacuation. ] Trauma 1983; 23: 844. 7 Morrow PL, McQuillen EN, Eaton LA, Bernstein CJ. Downhill ski fatalities: the Vermont experience. J Trauma 1988; 28: 95. 8 Scharplatz D, Thurleman K, Enderlin F. Thoracoabdominal trauma in ski accident. lnju y 1979; 10: 86. 9 Taylor GA, Eichelberger MR, Potter BM. Hematuria: a marker of abdominal injury in children after blunt trauma. ] Trauma 1988; 208: 688.
References
Paper accepted 5 August 1994.
1 Erskine LA. Recent changes in the pattern of skiing injuries. ] Trauma 1974; 14: 79. 2 Gutman J, Weisbuch J, Wolf M. Ski injuries in 1972-1973: a repeat analysis of a major health problem. JAMA 1974; 230: 1423.
Requestsfor reprints should be addressed to: Frederick B. Rogers, MD, University of Vermont, College of Medicine, Given D-319, Burlington, Vermont 05405, USA. FACS,