Abby E. Milton, Dr. Pamela J. Hansen, Dr. Kevin C. Miller, Dr. Yeong S. Rhee North Dakota State University

1. Grade III Liver Laceration in an Intercollegiate Volleyball Player: A Case Report Abby E. Milton, Dr. Pamela J. Hansen, Dr. Kevin C. Miller, Dr. Yeong S. Rhee North Dakota State University Department of Health, Nutrition and Exercise Sciences, Fargo, ND NDSU AthleticTraining Uniqueness Abstract Background Background: A 20 year old, female collegiate volleyball athlete (body mass=74.8 kg; height=177.8 cm), with no previous history of abdominal injury, dove for a ball and was struck in the anterolateral abdominal region during a match by a teammate’s knee. She experienced a solar plexus spasm, shortness of breath, and nausea. She was assisted off the court by the Athletic Trainer. On-site evaluation revealed sharp pain in the right upper quadrant and epigastric area, pallor, continued nausea, and excessive sweating. No radiating pain was noted, but anterior and lateral compression tests of the ribs were positive for pain and crepitus. An ice bag was administered to the right abdominal region and she was transported to the local emergency department. Differential Diagnosis: Rib fracture, xiphoid process fracture, costochondral separation, splenic injury, and/or solar plexus injury. Treatment: Upon arrival to the emergency department, an abdominal/pelvic CT scan with IV contrast, complete blood count including platelets, Basic Panel 8, and a prothrombin time/International Normalized Ratio (PT/INR) tests were ordered. The abdominal/pelvic CT scan showed a small amount of fluid along the posteromedial surface of the liver indicating a subcapsular hematoma. A trace amount of free fluid in the right paracolic gutter and pelvis was also noted suggesting a hemoperitoneum. The athlete was diagnosed with a Grade 3 laceration (>3 cm parenchymal depth) on the right lobe of the liver. She was hemodynamically stable although potassium and bicarbonate were low and glucose was high (potassium, 3.1 mmol/L [normal=3.5-5.3 mmol/L]; bicarbonate, 22 mmol/L [normal= 23-32 mmol/L]; glucose, 132 mg/dL [normal=70-100 mg/dl]). Her vitals were stable ~ 2.5 hours post-injury (BP, 118/76 mm Hg; HR, 68/min; RR, 16/min; tympanic temperature, 36.3°C). The athlete was admitted into the ICU for observation and the attending physician decided on a conservative, non-operative approach to treatment. Forty-eight hours post-injury, a second abdominal/pelvic CT scan and blood work was performed and showed that the athlete was stable. She was admitted for an additional 2 days for observation. After being discharged from the hospital, she was prohibited from practicing until a third abdominal/pelvic CT scan was performed and showed no residual injury to the liver (5 weeks post-injury). The physician cleared the athlete to begin a progressive rehabilitation protocol focusing on cardiorespiratory and low intensity sport-specific exercise. The athlete returned to play 6 weeks post-injury without complications; however, she continued performing rehabilitation focusing on cardiorespiratory endurance. Uniqueness: Blunt abdominal injuries are rare in non-contact sports such as volleyball. Abdominal injury rates in volleyball competitions occur 1:25,000 athlete exposures and are usually muscular strains. Contact and collision sports have a higher risk of blunt abdominal trauma, which would include liver injuries. Conclusions: Blunt abdominal injuries, such as liver lacerations, can occur to any athlete regardless of sport. Athletic Trainers working with non-contact sports must be cognizant that abdominal injuries can occur and can be life threatening. Proper recognition of the signs and symptoms of internal organ injuries, like liver lacerations, and the administration of proper emergency care are critical. If the athlete is hemodynamically stable, a conservative non-operative approach following a liver laceration yields successful results. • 20-year-old female (body mass = 74.8 kg; ht = 177.8 cm), Division 1 volleyball setter, with no prior history of abdominal injury, was struck in right upper quadrant by a teammate’s knee. • Signs, Symptoms, & Positive Special Tests: • 1. Solar plexus spasm 4. Sharp pain in right upper quadrant 7. Diaphoresis • 2. Shortness of breath 5. Point tender along lower costal margin 8. Rib compression tests (+) for pain • 3. Nausea 6. Pallor • Ice administered and athlete was referred for further diagnostic testing. • Blunt abdominal injuries in volleyball are rare. • 1:25,000 athlete exposures (usually strains)2 • Athlete returned to play 6 weeks post-injury. • Some clinicians recommend no activity for 12-24 weeks following hepatic injury.1 • No extraordinary measures or exercises were performed during rehabilitation to accelerate recovery. Diagnosis and Treatment • Vital signs were stable & laboratory tests confirmed hemodynamic stability. • CT scan 2.5 hours post-injury revealed a small subcapsular hematoma along the posteromedial surface of the liver and a hemoperitoneum in right paracolic gutter & pelvis (Figure 1 & 2). • Grade III laceration on right lobe of the liver was diagnosed. • Grade III lacerations characterized by simple hepatic parenchymal laceration, hemoperitoneum <500 mL, absence of hepatic hemorrhaging, and no or limited need for liver related blood transfusion.1 • Treatment: • Admitted into ICU for 4 days of observation. • Physician recommended no physical activity or strenuous sport specific exercise for 12 weeks. • Rehabilitation focused on maintaining cardiovascular endurance. • Outcome: • 5 weeks post-injury, CT scan showed no residual liver damage (Figure 3 & 4). • Athlete began a progressive rehabilitation protocol. • Returned to play 6 weeks post-injury without complications. Conclusions • Liver lacerations can occur to any athlete, regardless of sport. • If the athlete is hemodynamically stable, conservative, non-operative management following a liver laceration yields favorable results. • Return to play following liver injury depends on the liver’s ability to heal itself. Clinical Significance • Athletic Trainers working with non-contact sports must be cognizant that abdominal injuries can occur and can be life threatening. • Proper recognition of the signs and symptoms of abdominal injuries and the administration of proper emergency care are critical. Figure 3 Figure 1 References Carrillo EH, Platz A, Miller FB, Richardson JD, Polk HC. Non-operative management of blunt hepatic trauma. Br J Surg. 1998;85:461-468. Agel J, Palmieri-Smith RM, Dick R, Wojtys EM, Marshall SW. Descriptive epidemiology of collegiate women’s volleyball injuries: national collegiate athletic association injury surveillance system, 1988-1989 through 2003-2004. J Ath Train. 2007;42(2):295-302. Differential Diagnosis • Rib fracture • Xiphoid process fracture • Costochondral separation • Splenic injury • Solar plexus injury Figure 2 Figure 4 2011 NATA Annual Meeting & Clinical Symposia, New Orleans, LA