Author: Mollie Wood, Lou Mitchell / Editor: Yasmin Sultan / Reviewer: Tadgh Moriarty / Codes: RP4, SLO4, TP5Published: 28/05/2020

An 18-year-old man presents with left upper quadrant (LUQ) and left lower chest wall pain following a fall from a skateboard at a height of approximately 4ft. He fell on to the corner of a wall, striking the lateral aspect of his left chest and abdomen. Initially driven by friends to the local Minor Injury Unit, he has been transferred to your Emergency Department (ED) by ambulance, and the MIU team phoned ahead as they were concerned about him. Despite 15mg i.v. morphine, he is complaining of a very severe chin pain in his LUQ, which is exacerbated by any movement.

He is also complaining of left shoulder pain with no apparent shoulder injury.

His primary survey is normal – he does not have any chest pain, shortness of breath or haemoptysis. There was no head or neck injury. He has mobilised since the injury, and you are not clinically concerned about his pelvis.

He has no significant past medical history and is not on any regular medications.

Apart from a tachycardia, the patient’s observations are normal

HR 104
BP 135/74
RR 20
Sa02 99% on air.

Nothing abnormal is detected on examination of his chest.
On inspection of his abdomen there is no abdominal bruising. He is tender in the left upper quadrant and flank, with guarding and rigidity.

Urine dipstick analysis is negative. Nothing abnormal is detected on a venous blood gas; the haemoglobin is within the normal range, and he has a normal lactate and pH. Pain is much better controlled after the addition of i.v. paracetamol 1g, ketorolac 30mg, and 40mg (given as 10mg increments) of ketamine.

You obtain an urgent CT scan of his chest and abdomen. A slice showing the abnormality is shown:

intracapsular haematoma spleen