Analysis of the value of imaging as part of the follow-up of splenic injury in children

Updated APSA Guidelines for the Management of Blunt Liver and Spleen Injuries

BACKGROUND

Non-operative management of blunt liver and spleen injuries was championed initially in children with the first management guideline published in 2000 by the American Pediatric Surgical Association (APSA). Multiple articles have expanded on the original guidelines and additional therapy has been investigated to improve care for these patients. Based on a literature review and current consensus, the management guidelines for the treatment of blunt liver and spleen injuries are presented.

METHODS

A recent literature review by the APSA Outcomes committee [2] was utilized as the basis for the guideline recommendations. A task force was assembled from the APSA Committee on Trauma to review the original guidelines, the literature reported by the Outcomes Committee and then to develop an easy to implement guideline.

RESULTS

The updated guidelines for the management of blunt liver and spleen injuries are divided into 4 sections: Admission, Procedures, Set Free and Aftercare. Admission to the intensive care unit is based on abnormal vital signs after resuscitation with stable patients admitted to the ward with minimal restrictions. Procedure recommendations include transfusions for low hemoglobin (<7 mg/dL) or signs of ongoing bleeding. Angioembolization and operative exploration is limited to those patients with clinical signs of continued bleeding after resuscitation. Discharge is based on clinical condition and not grade of injury. Activity restrictions remain the same while follow-up imaging is only indicated for symptomatic patients.

CONCLUSION

The updated APSA guidelines for the management of blunt liver and spleen injuries present an easy-to-follow management strategy for children.

LEVEL OF EVIDENCE

Level 5.

Follow-up strategies for patients with splenic trauma managed non-operatively: the 2022 World Society of Emergency Surgery consensus document

Background

In 2017, the World Society of Emergency Surgery published its guidelines for the management of adult and pediatric patients with splenic trauma. Several issues regarding the follow-up of patients with splenic injuries treated with NOM remained unsolved.

Methods

Using a modified Delphi method, we sought to explore ongoing areas of controversy in the NOM of splenic trauma and reach a consensus among a group of 48 international experts from five continents (Africa, Europe, Asia, Oceania, America) concerning optimal follow-up strategies in patients with splenic injuries treated with NOM.

Results

Consensus was reached on eleven clinical research questions and 28 recommendations with an agreement rate ≥ 80%. Mobilization after 24 h in low-grade splenic trauma patients (WSES Class I, AAST Grades I–II) was suggested, while in patients with high-grade splenic injuries (WSES Classes II–III, AAST Grades III–V), if no other contraindications to early mobilization exist, safe mobilization of the patient when three successive hemoglobins 8 h apart after the first are within 10% of each other was considered safe according to the panel. The panel suggests adult patients to be admitted to hospital for 1 day (for low-grade splenic injuries—WSES Class I, AAST Grades I–II) to 3 days (for high-grade splenic injuries—WSES Classes II–III, AAST Grades III–V), with those with high-grade injuries requiring admission to a monitored setting. In the absence of specific complications, the panel suggests DVT and VTE prophylaxis with LMWH to be started within 48–72 h from hospital admission. The panel suggests splenic artery embolization (SAE) as the first-line intervention in patients with hemodynamic stability and arterial blush on CT scan, irrespective of injury grade. Regarding patients with WSES Class II blunt splenic injuries (AAST Grade III) without contrast extravasation, a low threshold for SAE has been suggested in the presence of risk factors for NOM failure. The panel also suggested angiography and eventual SAE in all hemodynamically stable adult patients with WSES Class III injuries (AAST Grades IV–V), even in the absence of CT blush, especially when concomitant surgery that requires change of position is needed. Follow-up imaging with contrast-enhanced ultrasound/CT scan in 48–72 h post-admission of trauma in splenic injuries WSES Class II (AAST Grade III) or higher treated with NOM was considered the best strategy for timely detection of vascular complications.

Conclusion

This consensus document could help guide future prospective studies aiming at validating the suggested strategies through the implementation of prospective trauma databases and the subsequent production of internationally endorsed guidelines on the issue.

Routine Repeat Imaging of Pediatric Blunt Solid Organ Injuries Is Not Necessary

INTRODUCTION

Nonoperative management of hemodynamically stable patients with blunt splenic and/or hepatic injury has been widely accepted in the pediatric population. However, variability exists in the utilization and timing of repeat imaging to assess for delayed complications during index hospitalization. Recent level-IV evidence suggests that repeat imaging in children should be performed based on a patient's clinical status rather than on a routine basis. The aim of this study is to examine the rate of delayed complications and interventions in pediatric trauma patients with blunt splenic and/or hepatic injuries who undergo repeat imaging prompted either by a clinical change (CC) or non-clinical change (NCC).

METHODS

A 9-year (2011-2019), retrospective, dual-institution study was performed of children (0-17 years) with blunt splenic and/or hepatic injuries. Patients were grouped based on reason for repeat imaging: CC or NCC. The rate of organ-specific delayed complications and interventions was examined by reason for scan.

RESULTS

A total of 307 injuries were included in the study period (174 splenic, 113 hepatic, and 20 both). Of 194 splenic injuries, 30(15.5%) underwent repeat imaging (CC = 19; NCC = 11). Of 133 hepatic injuries, 27(20.3%) underwent repeat imaging (CC = 21; NCC = 6). There was no difference in the incidence of organ-specific delayed complications between the CC and NCC groups. Of the 4 patients with complications necessitating intervention, only one was identified based on NCC.

CONCLUSIONS

Our data suggest routine repeat imaging is unnecessary in children with blunt splenic and/or hepatic injuries; therefore, practitioners may rely on a patient's clinical change.

Non-operative management of solid organ injuries in children: An American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee systematic review

PURPOSE

The American Pediatric Surgical Association (APSA) guidelines for the treatment of isolated solid organ injury (SOI) in children were published in 2000 and have been widely adopted. The aim of this systematic review by the APSA Outcomes and Evidence Based Practice Committee was to evaluate the published evidence regarding treatment of solid organ injuries in children.

METHODS

A comprehensive search strategy was crafted and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were utilized to identify, review, and report salient articles. Four principal questions were examined based upon the previously published consensus APSA guidelines regarding length of stay (LOS), activity level, interventional radiologic procedures, and follow-up imaging. A literature search was performed including multiple databases from 1996 to 2016.

RESULTS

LOS for children with isolated solid organ injuries should be based upon clinical findings and may not be related to grade of injury. Total LOS may be less than recommended by the previously published APSA guidelines. Restricting activity to grade of injury plus two weeks is safe but shorter periods of activity restriction have not been adequately studied. Prophylactic embolization of SOI in stable patients with image-confirmed arterial extravasation is not indicated and should be reserved for patients with evidence of ongoing bleeding. Routine follow-up imaging for asymptomatic, uncomplicated, low-grade injured children with abdominal blunt trauma is not warranted. Limited data are available to support the need for follow-up imaging for high grade injuries.

CONCLUSION

Based upon review of the recent literature, we recommend an update to the current APSA guidelines that includes: hospital length of stay based on physiology, shorter activity restrictions may be safe, minimizing post-injury imaging for lower injury grades and embolization only in patients with evidence of ongoing hemorrhage.

TYPE OF STUDY

Systematic Review.

LEVELS OF EVIDENCE

Levels 2-4.

Can time to healing in pediatric blunt splenic injury be predicted?

BACKGROUND

Current consensus guidelines do not recommend routine follow-up imaging for blunt splenic injury (BSI) in children. However, repeat imaging is recommended based on persistent symptoms. Wide variation of practice continues to exist among surgeons. By defining the natural evolution of BSI, we sought to identify patients at higher risk for delayed healing who could benefit from outpatient imaging.

METHODS

A retrospective review of all children with BSI at a Level 1 Pediatric Trauma Center was completed. Grade of injury, hospital course, laboratory values and follow-up imaging results were obtained. Injured spleens were classified as 'healed', 'healing' (with echogenic scar), or 'non-healing' with persistence of parenchymal abnormalities.

RESULTS

Between 2000 and 2014, 222 patients with BSI were identified. Seven patients (3%) underwent immediate splenectomy. Packed red blood cell transfusion was required in 13 (6%) of the 222 patients, and 3 (2%) of 145 with isolated splenic injuries. Seventy-one percent of patients underwent additional imaging 2-74 weeks post-injury. A receiver operating characteristics (ROC) curve was used to establish the relationship between sensitivity and specificity of capturing non-healing spleens over time. Optimal timing for post-injury imaging for grades I-II was 7-8 weeks; healing of higher-grade injuries could not accurately be predicted.

CONCLUSIONS

If return to full physical activity, in particular contact sports, is contingent upon documented healing of the splenic parenchyma after blunt trauma in the pediatric population, follow-up imaging for low-grade injuries is best obtained around 7-8 weeks. No such recommendations can be made for high-grade splenic injuries, as the exact time to healing cannot be predicted based on initial data.

LEVEL OF EVIDENCE

IV. Diagnostic test.

Splenic trauma: WSES classification and guidelines for adult and pediatric patients

Spleen injuries are among the most frequent trauma-related injuries. At present, they are classified according to the anatomy of the injury. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic derangement, and the associated injuries. The management of splenic trauma patients aims to restore the homeostasis and the normal physiopathology especially considering the modern tools for bleeding management. Thus, the management of splenic trauma should be ultimately multidisciplinary and based on the physiology of the patient, the anatomy of the injury, and the associated lesions. Lastly, as the management of adults and children must be different, children should always be treated in dedicated pediatric trauma centers. In fact, the vast majority of pediatric patients with blunt splenic trauma can be managed non-operatively. This paper presents the World Society of Emergency Surgery (WSES) classification of splenic trauma and the management guidelines.

Blunt splenic trauma: Assessment, management and outcomes

BACKGROUND

The approach for diagnosis and management of blunt splenic injury (BSI) has been considerably shifted towards non-operative management (NOM). We aimed to review the current practice for the evaluation, diagnosis and management of BSI.

METHODS

A traditional narrative literature review was carried out using PubMed, MEDLINE and Google scholar search engines. We used the keywords "Traumatic Splenic injury", "Blunt splenic trauma", "management" between December 1954 and November 2014.

RESULTS

Most of the current guidelines support the NOM or minimally approaches in hemodynamically stable patients. Improvement in the diagnostic modalities guide the surgeons to decide the timely management pathway Though, there is an increasing shift from operative management (OM) to NOM of BSI; NOM of high grade injury is associated with a greater rate of failure, prolonged hospital stay, risk of delayed hemorrhage and transfusion-associated infections. Some cases with high grade BSI could be successfully treated conservatively, if clinically feasible, while some patients with lower grade injury might end-up with delayed splenic rupture. Therefore, the selection of treatment modalities for BSI should be governed by patient clinical presentation, surgeon's experience in addition to radiographic findings.

CONCLUSION

About one-fourth of the blunt abdominal trauma accounted for BSI. A high index of clinical suspicion along with radiological diagnosis helps to identify and characterize splenic injuries with high accuracy and is useful for timely decision-making to choose between OM or NOM. Careful selection of NOM is associated with high success rate with a lower rate of morbidity and mortality.

Blunt Spleen and Liver Trauma

Blunt abdominal trauma is an important cause of pediatric morbidity and mortality. The spleen and liver are the most common abdominal organs injured. Trauma to either organ can result in life-threatening bleeding. Controversy exists regarding which patients should be imaged and the correct imaging modality depending on the level of clinical suspicion for injury. Nonoperative management of blunt abdominal trauma is the standard of care for hemodynamically stable patients. However, the optimal protocol to maximize patient safety while minimizing resource utilization is a matter of debate. Adjunctive therapies for pediatric spleen and liver trauma are also an area of ongoing research. A review of the current literature on the diagnosis, management, and follow-up of pediatric spleen and liver blunt trauma is presented.

Results of non-operative management of splenic trauma and its complications in children

Introduction:

Non-operative management (NOM) of splenic trauma in children is currently the treatment of choice.

Purpose:

We report a series of 83 cases in order to compare our results with literature data.

Patients and Methods:

For this, we conducted a retrospective study of 13 years and collected 83 cases of children with splenic trauma contusion, managed at Lapeyronie Montpellier Hospital in Visceral Pediatric Surgery Department. The studied parameters were age, sex, circumstances, the blood pressure (BP), hematology, imaging, associated injuries, transfusion requirements, treatment, duration of hospital stay, physical activity restriction and evolution.

Results:

NOM was successful in 98.7% of cases. We noted 4 complications including 3 pseudo aneurysms (PSA) of splenic artery and 1 pseudocyst spleen with a good prognosis. There was no mortality in our series.

Conclusion:

NOM is the treatment of choice for splenic trauma in children with a success rate of over 90%. Complications are rare and are dominated by the PSA of splenic artery.

Return to play after liver and spleen trauma

CONTEXT

Sport-related spleen and liver injuries pose a challenge for the physician. Although rare, these injuries can have serious and even life-threatening outcomes if not accurately diagnosed and managed in a timely fashion. Currently, there are no evidence-based guidelines on duration and intensity of restricted activity and return to play after spleen and liver injury. In addition, there is controversy on follow-up imaging after injury.

EVIDENCE ACQUISITION

PubMed was searched using the terms splenic or spleen and trauma and hepatic or liver and trauma from 1980 to 2013. The citations from sentinel papers were also reviewed.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 3.

RESULTS

Ultrasound is ideal in the unstable athlete. Nonoperative management of blunt splenic and hepatic injuries is recommended for hemodynamically stable patients regardless of injury grade, patient age, or presence of associated injuries. Follow-up imaging is not routinely recommended unless clinically indicated. Athletes may engage in light activity for the first 3 months after injury and then gradual return to unrestricted activity as tolerated. High-level athletes may choose splenectomy or serial imaging for faster return to play.

CONCLUSION

Intravenous contrast-enhanced computed tomography is the diagnostic imaging modality of choice in stable athletes with blunt abdominal trauma.

STRENGTH-OF-RECOMMENDATION TAXONOMY

C.

Traumatic pseudoaneurysms of the liver and spleen in children: is routine screening warranted?

BACKGROUND

Although blunt injury to the spleen and liver can lead to pseudoaneurysm formation, current surgical guidelines do not recommend follow-up imaging. Controversy exists regarding the clinical implications of these traumatic pseudoaneurysms as well as their management.

METHODS

Retrospective review of children treated nonoperatively for isolated blunt liver and spleen trauma between 1991 and 2008 was undertaken. Patient demographics, grade of injury, and follow-up Doppler ultrasound results were obtained.

RESULTS

Three hundred sixty-two children were identified. One hundred eighty-six of them had splenic injuries, and 10 (5.4%) developed pseudoaneurysms. They were associated with grade III (3/39 [8%]) and grade IV (7/41 [17%]) injuries. In 7 patients, the pseudoaneurysm thrombosed spontaneously. Angiographic embolization was required in 2 children, and one underwent emergency splenectomy for delayed hemorrhage. Of the 176 patients who had liver injuries, 3 (1.7%) developed pseudoaneurysms. All 3 were associated with grade IV injuries (3/11 [27%]). One child underwent early embolization, while 2 developed delayed hemorrhage requiring emergent treatment.

CONCLUSIONS

Pseudoaneurysm development after blunt abdominal trauma is associated with high-grade splenic and liver injuries. Routine screening of this group of patients before discharge from hospital may be warranted because of the potential risk of life-threatening hemorrhage.

The significance of pseudoaneurysms in the nonoperative management of pediatric blunt splenic trauma

PURPOSE

Nonoperative management is the standard of care for hemodynamically stable pediatric and adult blunt splenic injuries. In adults, most centers follow a well-defined protocol involving repeated imaging at 24 to 48 hours, with embolization of splenic pseudoaneurysms (SAPs). In children, the significance of radiologically detected SAP has yet to be clarified.

METHODS

A systematic review of the medical literature was conducted to analyze the outcomes of documented posttraumatic SAP in the pediatric population.

RESULTS

Sixteen articles, including 1 prospective study, 4 retrospective reviews, and 11 case reports were reviewed. Forty-five SAPs were reported. Ninety-six percent of children were reported as stable. Yet, 82% underwent splenectomy, splenorrhaphy, or embolization. The fear of delayed complications owing to SAP was often cited as the reason for intervention in otherwise stable children. Only one child with a documented pseudoaneurysm experienced a delayed splenic rupture while under observation. No deaths were reported.

CONCLUSIONS

There is no evidence to support or dispute the routine use of follow-up imaging and embolization of posttraumatic SAP in the pediatric population. At present, the decision to treat SAP in stable children is at the discretion of the treating physician. A prospective study is needed to clarify this issue.

Pediatric blunt splenic trauma: a comprehensive review

Abdominal trauma is a leading cause of death in children older than 1 year of age. The spleen is the most common organ injured following blunt abdominal trauma. Pediatric trauma patients present unique clinical challenges as compared to adults, including different mechanisms of injury, physiologic responses, and indications for operative versus nonoperative management. Splenic salvage techniques and nonoperative approaches are preferred to splenectomy in order to decrease perioperative risks, transfusion needs, duration/cost of hospitalization, and risk of overwhelming postsplenectomy infection. Early and accurate detection of splenic injury is critical in both adults and children; however, while imaging findings guide management in adults, hemodynamic stability is the primary determinant in pediatric patients. After initial diagnosis, the primary role of imaging in pediatric patients is to determine the level and duration of care. We present a comprehensive literature review regarding the mechanism of injury, imaging, management, and complications of traumatic splenic injury in pediatric patients. Multiple patients are presented with an emphasis on the American Association for the Surgery of Trauma organ injury grading system. Clinical practice guidelines from the American Pediatric Surgical Association are discussed and compared with our experience at a large community hospital, with recommendations for future practice guidelines.

Imaging children with abdominal trauma

OBJECTIVE

Trauma is a leading cause of morbidity and mortality in children. The abdomen is the second most common site of injury. This article discusses abdominal trauma in children.

CONCLUSION

The clinical evaluation of children with potential blunt abdominal injury presents a challenging task. Therefore, imaging plays an essential role in the evaluation of such children.

Management of pediatric blunt splenic injuries in Canada--practices and opinions

PURPOSE

The aim of the study was to compare the self-reported practice patterns of Canadian general surgeons (GSs) and pediatric general surgeons (PGSs) in treating blunt splenic injuries (BSIs) in children.

METHODS

Forty-five PGSs and 690 GSs were surveyed (internet and hard copy). chi(2) was used to compare groups; logistic regression was performed to determine independent factors influencing management variables.

RESULTS

Thirty-three PGSs and 191 GSs completed the survey, for a response rate of 30%. Pediatric general surgeons are more likely than GSs to follow American Pediatric Surgical Association guidelines (52% vs 11%; P < .0001). In diagnosing BSIs, PGSs and GSs are equally likely to use computed tomography (CT) over ultrasound for initial imaging. Pediatric general surgeons are less likely to consider CT injury grade in deciding on nonoperative management (NOM) (odds ratio [OR], 0.2; confidence interval [CI], 0.07-0.5; P = .002) and are more likely to continue NOM for patients with contrast blush on CT (OR, 6.5; CI, 2.5-17; P = .0002). Pediatric general surgeons report more selective intensive care unit use, hospital stay, follow-up imaging, and activity restrictions. No differences were found in the management of splenic artery pseudoaneurysms.

CONCLUSION

Differences exist between PGSs and GSs in the management of pediatric BSIs, resulting in higher operative rates, use of resources, and radiation exposure. Further education of GSs in NOM and establishment of management guidelines are indicated.

Clinical decision rules in radiology

Clinical decision rules to guide physicians in the appropriate use of diagnostic imaging studies need to be developed, in part, to control the overutilization of imaging studies. These rules need to be evidence based. Randomized control trials can be designed to assess the value of imaging studies and interventional procedures at levels five and six, patient outcome and societal efficacies, in Fryback and Thornbury's hierarchical model of efficacy. Results of these trials can be used to develop clinical decision rules. However, the efficacy of most diagnostic imaging studies can be assessed better at levels three and four, diagnostic thinking and therapeutic efficacies. Studies can be designed to determine clinical situations in which imaging studies will be of no value or to determine clinical criteria for the use of imaging studies. Systematic reviews of the literature and other techniques of analysis of evidence, such as decision trees, also can be used to develop evidence-based clinical decision rules for the use of diagnostic imaging procedures.

CURRENT MANAGEMENT OF BLUNT SPLENIC TRAUMA IN CHILDREN

BACKGROUND

Non-operative management of the great majority of blunt splenic injuries in children has become routine. Debate continues on the need for intensive care unit (ICU) admission, follow-up imaging and the duration of physical activity restrictions following injury. The purpose of this study was to review the recent experience of an Australian Paediatric Trauma Centre with splenic trauma to define current practice.

METHODS

A retrospective chart review of patients with splenic trauma admitted to the Children's Hospital at Westmead between November 1995 and December 2003.

RESULTS

A total of 39 patients with blunt splenic trauma were identified: 20 (51%) were multiply injured. Thirty-three (85%) children were managed non-operatively. The most common initial imaging method was computed tomography (n = 28, 72%). Fourteen patients (36%) were admitted to the ICU with a mean length of stay (LOS) of 4.1 days (range 1-13 days). The overall mean LOS was 10.8 days (range 1-43 days). Nineteen patients (50%) had imaging studies performed after diagnosis but before discharge. Further post-discharge imaging was carried out in 21 cases (54%). There were no deaths, but 10 patients developed complications. The mean documented activity restriction was 7.4 weeks (range 1-16 weeks).

CONCLUSION

The majority of children who had suffered blunt splenic trauma were safely managed non-operatively outside an ICU. In stable patients, there appeared to be no benefits associated with repeated imaging following the diagnosis of splenic trauma. Physical activity restriction in excess of 3-4 weeks did not appear to be warranted.

Role of Repeat Computerized Tomography in Nonoperative Management of Solid Organ Trauma

Nonoperative management (NOM) of blunt spleen and liver trauma is currently well accepted. CT imaging is helpful in selecting treatment options and to evaluate resolution of solid organ trauma. This 8-year study was undertaken to assess the role of repeat CT scans in NOM by analyzing indications of surgery in NOM failures. NOM was undertaken in 221 patients with spleen/liver trauma. After initial CT scans, 82 (37%) scans were repeated in 65 patients. There was failure of NOM (NOMF) in 11 patients. Follow-up imaging was done prior to delayed surgery in 4 (36%) patients, 4.9 per cent of repeat scans. Two of these patients had hemodynamic instability and, in the other two, there were clinical signs of peritonitis. The remaining seven patients had delayed surgery due to hemodynamic instability. There is a limited role of repeat CT scans in NOM of spleen and liver trauma. Repeat CT should be done more liberally in patients with suspected intestinal and mesenteric trauma, unexplained blood loss, complex hepato-biliary trauma, and in patients with neurological or pharmacological paralysis.

Nonoperative Management of Neonatal Splenic Rupture

Neonatal injury of the spleen is an uncommon but serious condition. Although the standard management of children with splenic injury is nonoperative, there is scant evidence in the literature to support handling neonates in the same way. We report a case of neonatal splenic rupture that was managed nonoperatively. A 3.6-kg full-term female born vaginally became tachycardic and pale on the second day of life. She had a distended abdomen and a hemoglobin of 5.8 g/dL. Her blood pressure remained within normal limits. She was transfused 20 cc/kg packed red blood cells. CT scan showed a grade V splenic rupture. Coagulopathy workup was negative. The assumption was that she had a ruptured spleen secondary to a traumatic delivery. She remained stable after the transfusion. It took 32 weeks for a CT scan to show complete healing. Traditionally, neonatal splenic rupture has been treated with splenectomy or splenorrhaphy. The first case of a neonate to be treated nonoperatively was reported in 2000. Our patient is only the second reported case. We chose to follow her with imaging to document healing and to rule out a tumor, as epidermoid cysts and hemangioendotheliomas can cause neonatal splenic rupture. We also review the literature to try to gain some insight into the management of this rare problem.

Conservative management of splenic trauma: history and current trends

Evolution of the present-day policy of conservative management of ruptured spleen has been hailed as one of the most notable advances in pediatric surgery. Until 1971, routine splenectomy used to be the sacrosanct treatment for splenic trauma. It was universally believed that non-operative management carried a high mortality of 90 to 100%. Sporadic reports of successful conservative treatment appeared in the early twentieth century, but regrettably, these were ignored. Likewise, experimental studies pointing to the danger of post-splenectomy sepsis were also disregarded. Dominant surgical opinion continued to practice removal of the injured spleen. In 1968, Upadhyaya and Simpson, based on a well-designed clinical analysis of 52 children made a convincing plea for conservative management. In 1971, Upadhyaya et al. presented results of a corroborative experimental study, which provided the conclusive evidence that isolated splenic tears are well tolerated and heal spontaneously by first intention. Seeing the surge of publications that followed this presentation, it becomes apparent that this study constituted the real turning point that changed the world opinion in favour of salvage of the ruptured spleen. By 1979, numerous authors had reported the safety of non-operative management in hundreds of children all over the world. Currently, the policy of routine splenectomy has been universally abandoned; and the reported salvage rate of ruptured spleen is more than 90%. This paper traces the historical perspectives in the management of injured spleen from the times of Aristotle to the present day.

Abdominal and pelvic trauma in children

Trauma is the leading cause of death and disability in children. More than 90% of pediatric trauma admissions are the result of a blunt mechanism. Although injury to the abdomen and pelvis account for only 10% of injuries sustained by victims of pediatric trauma, they can be potentially life threatening. Optimal evaluation of the injured child may require the use of multiple diagnostic modalities. The spleen is the most frequently injured intra-abdominal organ, followed by the liver, intestine, and pancreas. Fortunately, the majority of injuries to the spleen and liver can be treated nonoperatively. Conversely, injuries involving the intestine and pancreas often require operative intervention.