Why is Jason Witten's spleen laceration so serious?

I'm back!

Jason Witten suffered of the Dallas Cowboys an unusual injury - a lacerated spleen - in an exhibition game against the Oakland Raiders when he was hit by Rolando McClain in what looked like a relatively clean, legal and solid tackle.

Between the incident and until he gets examined again, he's not allowed to engage in any form of physical contact, including running drills, working out or practicing. Cowboys' coach Jason Garrett stated "he has to stay very idle." He's played through multiple injuries including what was likely a painful rib fracture in the past.

What's the difference now? In short, the spleen is an organ you don't want to mess with.

Let's start by examining the diagnosis and management of a spleen laceration.

Presentation: Typically, damage to the spleen presents due to blunt trauma to the abdomen or left flank. Most commonly this type of injury is seen in motor vehicle accidents, but can also occur in high impact sports or assault.

It makes sense that the patient would complain of left-sided pain, and sometimes left shoulder pain. The left shoulder pain is part of "Kehr's sign" which is a "classical" (anyone know sensitivity/specificity?) presentation of intraabdominal bleeding that causes left shoulder pain when the legs are elevated. This pattern occurs because irritation of the diaphragm (by blood in the abdomen or trauma) causes referred pain into the shoulder.

The patient will usually also complain of abdominal pain or have other signs of peritonitis (or intraabdominal bleeding or inflammation), but all of the above symptoms are not sensitive or specific for splenic injury. Combining clues from the history and physical should make the physician suspicious of a possible splenic injury.

Figure 1: A splenic injury causing bleeding in the abdomen
 and a "mass effect"  pushing the spleen towards the back
Credit: eMedicine 

Diagnosis: Diagnostic imaging is needed to visualize injury to the spleen. In a badly injured (unstable) patient who cannot wait for a CT scan, a mobile ultrasound (aka FAST) can be done to initially evaluate the possibility, but cannot effectively rule out the injury if nothing is seen, in which case, they would have to proceed to immediate surgery.
In a stable patient, a CT scan with contrast would be done to effectively rule in or rule out a splenic injury, and also to grade its severity which is important for management.
Figure 1 (from eMedicine) shows a CT visualizing the spleen on the patient's left (your right) side. The dark material around the spleen is blood surrounding it, pushing it into a bizarre shape and out of place.

Treatment: Management of a splenic injury is typically either surgery or watchful waiting to ensure it heals on its own. Whether surgery or medical management is chosen depends on a number of factors including:
- hemodynamic stability -- i.e. is the patient rapidly losing blood or in shock?
- Grade on the American Association for the Surgery of Trauma Spleen Injury Scale - this predicts how likely non-surgical management will suffice in treating the injured spleen. For example, grade I injuries have a 5% chance of failing and needing surgery while 40% of grade IV injuries will require surgery.
- the amount of abdominal bleeding seen on CT scan
In total, non-operative management of spleen injuries has a failure rate of 10-15%.
More recently, there have been some non-invasive procedures utilized to increase the likelihood non-surgical management will succeed but I won't go into that right now.

What do you do while you wait? What happens when it fails?
The patient would have to be closely monitored for a number of days under close medical care, often admitted to hospital. They are checked for signs of blood loss and staff ensure their vitals remain stable. One large trial found 86% of cases of non-operative management failed within 96 hours. Needless to say, he or she should not be playing football or working out.
Failure of observation can result in a "delayed splenic rupture" which can result in massive blood loss and the patient possibly going into shock.


While we don't know the details of Witten's injury or the severity of it, it's fortunate he hasn't required surgery. Despite things looking up so far, he's not out of the woods just yet and he'll have to see what his doctors say in the coming days when they re-evaluate him. In fact, many patients (of course depending on the injury) are advised to not resume high-risk activities for a period of three months. I should mention though that this recommendation is based on expert opinion and the hypothesis the spleen could easily re-injure.


Sources:
UpToDate
Tintinalli's Emergency Medicine, 7th edition

Coming back

After being overwhelmed with an erratic schedule through February - July, I tapered off big time on this blog. There was some uncertainty whether I'd even continue it as I considered a career in psychiatry.

Fortunately, I'll be able to see more bumps and bruises in my career and as a result I think it'd be fun and informative to keep this thing going. I don't watch much baseball, and that's essentially the only North American sport going on right now, but I'll keep tabs on the other big three leagues and see what goes down.

Matt Schaub - Lisfranc fracture dislocation

I'm really behind on this post but I'd still like to write it up anyways given that it doesn't seem very common.

In Week 10 against the Tampa Bay Buccaneers, QB Matt Schaub of the Houston Texans sustained a Lisfranc fracture. It's not a very common injury, and is actually often missed.

Firstly, the loose term of "Lisfranc joint" can be applied to the connection between the metatarsals (most proximal long bones of the foot; analogous to the metacarpals that are the bones in the palm of the hand) and cuneiforms (analogous to the carpals, or wristbones, of the hand).
The Lisfranc ligament is what connects this joint and goes from the first (medial) cuneiform) to the second metatarsal. No other ligaments connect the cuneiforms and the metatarsals to each other.

Clear as mud?

How does it occur? Intuitively, since this ligament is all that connects the metatarsals and cuneiforms together, it is prone to injury. This usually occurs either by a direct blow to the joint itself or an increased load to the joint (think of when you're on your toes) accompanied by a rotational force. An example could be of a horseback rider falling while their foot is stuck in the stirrup.

What is the injury? There is a spectrum of injuries that can happen to the Lisfranc ligament.
- Grade I sprain: Pain at joint, no swelling
- Grade II sprain: Increased paint at joint, some swelling, slight laxity but no instability
- Grade III sprain: Complete disruption of ligament; could include a fracture dislocation (this is what Schaub sustained). Any injury of above Grade III doesn't affect prognosis.

How is it diagnosed? A good history of the mechanism of injury should raise suspicion of its possibility. It may present as simply as swelling and the inability to weight bear. The physician should palpate the joints within the foot and do his/her best to localize tenderness.
In terms of the fracture-dislocation, it can be diagnosed by X-ray which would show disruption of the normal alignment of the joint and possibly a bone chip caused by the ligament breaking off from one end.

CT scan can be used to better visualize the injury or if the X-ray is inconclusive.

How is it treated? Most sprains that are stable and not displaced can be treated medically with analgesia and rehabilitation. In athletes, there is a low threshold for treating it surgically given that no surgery can lead to instability, severe pain and damage in the future. The surgery performed is to fixate the joint with screws or wires. In terms of healing, the patient needs to wear a cast and cannot weight-bear for six weeks as the joint heals. Activity and rehabilitation can be increased as symptoms abate.


Sources:
eMedicine
American Association of Family Physicians

Derek Boogard - chronic traumatic encephalopathy

When news broke of Boogard's autopsy results of chronic traumatic encephalopathy, I thought of writing a post. Since then, I read an excellent article in the New York Times about this matter and more. It's exceptionally written and it details Boogard's last few years before he died. Really sobering.

It is a must-read. You'll never see fighting in hockey the same way again.

Peyton Manning update

Apologies, folks. It's been a while since I've posted here with any sort of substance. The last few rotations have been a lot busier, and we've been going through residency applications which is its own monster.

As news broke earlier this week, Peyton Manning is entering his next stage of rehab following his X-ray and CT scans that have revealed appropriate fusion of his vertebrae from surgery.

He has mentioned he will likely start throwing and lifting weights in the start of this next phase of what I'm sure will be intense physical therapy needed for a high performance athlete to return to optimal function. Considering he hasn't been able to do any practice for so long, his muscles likely have a lot of catching up to do.

As I mentioned in my previous post on this topic, the long-term prognosis after this surgery is not certain. However, like most sports injuries, how he does with his rehabilitation in these next few months will be an enormous factor in the success of this treatment.

He's back.

As per TSN.ca, Sidney Crosby will be in the lineup to face the New York Islanders on Monday.

I'm sure everyone is happy the best player in hockey is returning. Too often are careers (and lives) cut short by repeated concussions.

He's not out of the woods quite yet though. Everyone will be holding their collective breath when he gets hit for the first time tomorrow.

If ever he gets another concussion though...

James Reimer - "headaches"

Hey folks. Just thought I'd write a quick note on James Reimer, goaltender for the Toronto Maple Leafs (a.k.a. guy with one of the most badass nicknames in sports... with the exception of Calvin "Megatron" Johnson).

As you know, he was involved in a collision in a game against the Canadiens' last Saturday primarily involving his head. There has been no official statement released if he has had a concussion, post-concussion symptoms, etc.

Apparently today he developed headaches while at practice which worsened as it continued. Obviously with a combination of impact to the head + headache a few days later makes everyone jump to a concern of concussion but it's really only speculation at this point. When it comes to concussions, it involves a full clinical history (especially the day of injury at the time of the collision and hours after) and likely a number of symptoms rather than just relying on headaches alone.

If there was no evidence of a concussion last Saturday AND if he only had an isolated bout of headaches today, it makes it very difficult to claim that a concussion is the most likely diagnosis. With that said, if he had a concussion on Saturday and he's developing symptoms with activity today, there obviously has to be concern they're related. Confused yet?

So either the Maple Leafs are trying to keep a concussion out of the spotlight, or Reimer just got some unrelated headaches today. Either way, they're playing it safe which is a very very good idea.

I'll write more if/when more details become available.