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Special Feature
July 2011

Image of the Month—Diagnosis

Arch Surg. 2011;146(7):881-882. doi:10.1001/archsurg.2011.162-b
Answer: Delayed Splenic Rupture

The CT scan identified a significant amount of blood in the pelvis and acute hemorrhage from the spleen as well as the previously noted small left pleural effusion seen on chest x-ray. Based on the patient's history of prior splenic trauma, his acute presentation of hypotension, and the CT scan showing splenic hemorrhage, we immediately took the patient to the operating room for exploratory laparotomy and splenectomy. In the operating room, we discovered a significant amount of blood that had pooled in the pelvis and active bleeding from the splenic parenchyma (Figure 2). Hilar control was obtained and a splenectomy performed. The patient required transfusion of 4 units of packed red blood cells. He was observed in the intensive care unit overnight and was transferred to the trauma surgical floor the following morning. He received Haemophilus influenza, meningococcal, and pneumococcal vaccines prior to discharge.

Figure 2. Intraoperative photograph showing ruptured splenic hematoma.

Figure 2. Intraoperative photograph showing ruptured splenic hematoma.

On further questioning of the patient after the surgery, we discovered that the night prior to visiting the emergency department, the patient had been playing a series of sports games including tennis, baseball, and golf on the gaming console Wii (Nintendo, Redmond, Washington).

Newer gaming consoles require players to manipulate images on the screen not only with the use of a handheld controller but also with body movements. While several reports of musculoskeletal injuries1,2 have been reported with the use of these gaming consoles, only a few reports3,4 have been made of more severe or life-threatening injuries. Here, we present a case of a 51-year-old man who had a delayed splenic hemorrhage temporally related to the use of the gaming console Wii.

The spleen is the most commonly injured organ among blunt abdominal trauma cases across all age groups, occurring in as many as 25% of admissions for blunt trauma per year in level I trauma centers.5 There is consensus that the advent of CT imaging has made conservative management of traumatic splenic injuries safer. However, our patient underwent successful conservative management for his original splenic injury only to bleed from a subcapsular hematoma after vigorous exercise several months later.

Traditionally, we advise patients to avoid contact sports for 2 to 6 months after splenic injury. This recommendation is based on experimental evidence that the spleen recovers its normal strength about 6 to 8 weeks after injury.6 But the advent of this new generation of video game systems such as the Nintendo Wii that encourages users to be wholly physically involved in the game raises concerns about how we should advise patients who complete nonoperative management of splenic injuries. Specifically, our patient played a game on the Wii that required him to simulate the swinging motions of a tennis racquet, baseball bat, and golf club. These large and forceful movements presumably induced the splenic hematoma to rupture. Patients should be advised of the warning symptoms such as dizziness or abdominal pain that could herald bleeding from the healing spleen, and they should immediately seek medical care. Perhaps we should advise patients that any strenuous activity can place them at risk for bleeding after their initial injury.

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Article Information

Correspondence: Jennifer Hartwell, MD, Department of Surgery, University of Illinois at Chicago, 840 S Wood St, Ste 376-N CSN, Chicago, IL 60612 (hartwell.jennifer@gmail.com).

Accepted for Publication: March 16, 2010.

Author Contributions:Study concept and design: Hartwell and Salzman. Analysis and interpretation of data: Gangemi and Salzman. Drafting of the manuscript: Hartwell, Gangemi, and Salzman. Critical revision of the manuscript for important intellectual content: Hartwell, Gangemi, and Salzman. Administrative, technical, and material support: Hartwell and Salzman. Study supervision: Gangemi and Salzman.

Financial Disclosure: None reported.

References
1.
Harrison M. No Wii cause for concern.  Emerg Med J. 2009;26(2):150PubMedArticle
2.
Robinson RJ, Barron DA, Grainger AJ, Venkatesh R. Wii knee.  Emerg Radiol. 2008;15(4):255-257PubMedArticle
3.
Peek AC, Ibrahim T, Abunasra H, Waller D, Natarajan R. White-out from a Wii: traumatic haemothorax sustained playing Nintendo Wii.  Ann R Coll Surg Engl. 2008;90(6):W9-10PubMedArticle
4.
Wells JJ. An 8-year-old girl presented to the ER after accidentally being hit by a Wii remote control swung by her brother.  J Trauma. 2008;65(5):1203PubMedArticle
5.
Bjerke HS, Geibel J. Splenic rupture. Medscape Reference Web site. http://emedicine.medscape.com/article/432823-overview. Updated August 6, 2009. Accessed September 23, 2009
6.
Feliciano D, Mattox K, Moore E. Trauma. 6th ed. New York, NY: McGraw-Hill; 2007
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