Deena C. Casiero, MD^abcde∗

^aProHEALTH Care Associates, 2800 Marcus Avenue, Lake Success, NY 11042, USA. E-mail address: Dcasiero@prohealthcare.com

^bUSA Seven’s Women’s Rugby, Arapahoe Avenue Boulder, Colorado 80302, USA

^cHofstra University, Fulton Avenue, Hempstead, NY 11549, USA

^dUS Open Tennis Championships, Flushing Meadow, Corona Park Road, Flushing, NY, USA

^eNew York Islanders, Hempstead Turnpike, Uniondale, NY 11553, USA

^∗2800 Marcus Avenue, Suite 102 Lake Success, NY 11042, USA.

Abdominal trauma is a rare but potentially fatal occurrence in sports-related activity. Up to 10% of reported abdominal injuries are caused by trauma during athletic events.1,2 The liver is the most commonly injured organ in blunt abdominal trauma.³ Contact and collision sports, such as rugby, soccer, and football, account for most closed liver injuries caused by direct trauma to the abdomen.^1,2 Noncontact sports, such as skiing and snowboarding, can cause liver trauma secondary to a deceleration mechanism.²

Most closed liver injuries are minor and can be treated nonoperatively with observation alone or with adjunctive treatment using arteriography and embolization of bleeding vessels.3–15 As few as 10% to 14% of patients with liver injuries require operative intervention due to hemodynamic instability or failure of nonoperative management.^7,16 Because of the potentially fatal nature of some closed liver injuries, it is imperative that sports medicine physicians be adept at evaluating and appropriately triaging these injuries. The goal of this article is to review the mechanisms of injury, signs, symptoms and the appropriate referral of potentially fatal closed liver injuries.

There are several pathophysiologic mechanisms that can occur during sports-related trauma that may result in closed liver injury. The application of blunt forces exerted against the anterior abdominal wall can cause compression of the underlying viscera against the posterior thoracic wall or the vertebral column. This can result in crush injuries that cause subcapsular or intraparenchymal hematomas in the underlying liver.1,17 Sports that involve high-intensity acceleration and deceleration forces can cause lacerations of the liver at its points of attachment to the peritoneum or stretch injuries to the intima and media of nearby arteries.^1,17

Sports medicine physicians on the sidelines of athletic events may be charged with trying to discern benign abdominal wall injuries from potentially fatal closed liver trauma. This is a challenging task because most severe abdominal injuries have a subtle initial presentation. In most cases, the definitive diagnosis can only be made in the emergency room or with advanced imaging. The decision to allow athletes to return to play versus removed from the competition and transported to a hospital for further evaluation, however, is in the hands of sports medicine physicians, highlighting the importance of the sideline physician’s comfort level with evaluation and management of closed liver injuries (Box 1).

As with most athletic injuries, the mechanism of injury, history, and physical examination are essential parts of the diagnostic puzzle.

When evaluating athletes with blunt abdominal trauma, it is imperative to consider associated injuries. One recent study showed that 80% of patients with hepatic trauma had at least one concomitant injury.⁸ Examples of other injuries that are commonly associated with liver injury are spleen injuries, lower rib fractures, pelvic fractures, and spinal cord injury.

The sideline physician must always keep in mind that the absence of physical findings does not preclude an underlying liver injury and that no sign exists that is exclusively diagnostic of a liver injury.19–21 Therefore, a thorough and comprehensive evaluation is needed to ensure that a closed liver injury is not missed. The initial evaluation should always start with the primary survey: airway, breathing, circulation, disability (neurologic status), and exposure. If, based on the primary assessment, a patient is found hemodynamically unstable, the patient should be transported to the hospital immediately for continued evaluation and treatment. Details regarding the treatment of the hemodynamically unstable patient with liver trauma are beyond the scope of this article.

In the cases of hemodynamically stable patients with suspected liver injury, many studies concur that diagnostic imaging confirming the diagnosis and close observation in a monitored setting are the standard of care.3–5,7–14