Ruptured Spleen, Delayed Internal Bleeding After Blunt Trauma, and Kehr's Sign¶

The spleen is the single most frequently injured solid organ in blunt abdominal trauma, accounting for up to 40 to 50 percent of all visceral abdominal injuries after motor vehicle collisions, bicycle handlebar impacts, sports tackles, falls, and assaults. Located high in the left upper quadrant of the abdomen just beneath the ninth, tenth, and eleventh ribs, the spleen is an extraordinarily vascular blood-filtering organ that receives roughly 5 percent of the heart's entire cardiac output (filtering 250 to 350 milliliters of blood every minute) while wrapped inside a fragile, paper-thin fibrous capsule. When a ruptured spleen tears open into the free abdominal cavity (hemoperitoneum), a person can bleed to death internally within minutes without a single drop of blood or bruise showing on the outside skin. Even more deceptively, a subcapsular splenic hematoma can stay temporarily sealed underneath the spleen's outer capsule for 2 to 14 days after a seemingly minor fall or sports bump before suddenly bursting open (delayed splenic rupture). If someone who suffered a left-sided rib or belly impact (or has infectious mononucleosis) develops left upper abdominal pain, sharp pain at the tip of the left shoulder (Kehr's sign), dizziness when standing up, pale clammy skin, or a racing pulse, call your local emergency numbers immediately. While awaiting paramedics, review related trauma guidance on shock recognition and first aid, flail chest and rib fractures, and severe bleeding control.

Do this now¶

1. Call your local emergency number immediately and report suspected internal abdominal hemorrhage. Dial 911 in the United States and Canada, 112 across the European Union, 999 in the United Kingdom, 000 in Australia, or check our list of emergency numbers. State clearly: "Suspected ruptured spleen / internal abdominal bleeding after blunt trauma (or mononucleosis): left upper abdominal and left shoulder pain with signs of shock."
2. Lay the person completely flat on their back (supine) and DO NOT let them sit up, stand, or walk. In internal hemorrhagic shock, standing or sitting up causes remaining blood volume to pool in the legs, instantly dropping blood flow to the brain and heart and triggering syncope or cardiac arrest. Even more dangerously, walking or straining increases intra-abdominal pressure and physically pops the fragile blood clot ("sentinel clot") or intact splenic capsule that is currently holding back catastrophic hemorrhage.
3. Ask specifically about pain at the tip of the left shoulder (Kehr's sign), especially when lying flat. Even if the patient has no shoulder injury, free blood pooling under the left dome of the diaphragm irritates the left phrenic nerve, which shares the exact same spinal cord nerve roots (C3, C4, and C5) as the supraclavicular nerves supplying the skin over the top of the left shoulder. Left shoulder tip pain that intensifies when lying flat is a classic hallmark of a ruptured spleen.
4. Keep the patient warm with dry blankets placed BOTH underneath and over their body to prevent the "Lethal Trauma Triad." When a bleeding patient's core body temperature drops below 35 to 36 degrees Celsius (95 to 96.8 degrees Fahrenheit), blood platelets and enzymatic clotting factors stop working (hypothermic coagulopathy), causing the torn spleen to bleed uncontrollably. Insulate the patient from the cold ground or floor immediately.
5. NEVER give aspirin, ibuprofen, naproxen, water, or food (strict NPO). Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or aspirin poison platelet function and worsen internal bleeding, while water or food in the stomach creates a high risk of vomiting and aspiration during emergency general anesthesia for laparotomy or angioembolization.
6. Do NOT press hard or repeatedly palpate the left upper abdomen. Aggressive prodding under the left ribcage can rupture a tense subcapsular splenic hematoma or dislodge an early hemostatic clot. Report any prescription blood thinners (apixaban, rivaroxaban, dabigatran, warfarin, or clopidogrel) and any recent history of sore throat/fever (infectious mononucleosis) to paramedics immediately.

Decision tree: blunt left-sided trauma, Kehr's sign, and splenic rupture triage¶

flowchart TD
    Start["Blunt Impact to Left Upper Abdomen, Left Flank, or Lower Left Ribs (Ribs 9-12) OR Spontaneous Left Belly Pain in Infectious Mononucleosis, Malaria, or Leukemia"] --> CheckShock{"Step 1: Check Hemorrhagic Shock & Rupture Signs: Left upper quadrant pain, Left shoulder tip pain (Kehr sign), dizziness on standing, Heart rate over 100 bpm, pale clammy skin, or low BP?"}

    CheckShock -->|"YES to ANY sign"| Emergency["ACTIVE OR IMPENDING SPLENIC RUPTURE: Call Emergency Services (911 / 112 / 999) Immediately"]

    CheckShock -->|"NO: Mild left rib soreness only, normal HR and BP, no shoulder pain, no dizziness"| HighRiskMechanism{"Step 2: High-Risk Mechanism or Patient? Fractured lower left ribs, bicycle handlebar mark, blood thinners, or Infectious Mononucleosis?"}

    HighRiskMechanism -->|"YES"| UrgentED["Require Same-Day Hospital Emergency Department Evaluation: FAST Ultrasound and Contrast-Enhanced Abdominal CT Scan to rule out occult subcapsular splenic hematoma"]

    HighRiskMechanism -->|"NO"| WatchDelayed["Strict Activity Restriction & Delayed Rupture Watch (14 Days): No contact sports or heavy lifting; call 911 immediately if left belly pain, left shoulder pain, or lightheadedness develops"]

    Emergency --> SupineWarm["1. Lay Flat on Back (Supine) & Prohibit Walking or Sitting Up: Wrap in warm blankets to prevent hypothermia, keep strictly NPO, NEVER give ibuprofen or aspirin, and do not press hard on abdomen"]

    SupineWarm --> HospitalPath["2. Hospital Trauma Resuscitation & AAST Grading: Bedside eFAST Ultrasound, Balanced Blood Transfusion, IV Tranexamic Acid (TXA); Unstable gets Immediate Laparotomy; Stable gets Contrast CT and Splenic Artery Angioembolization"]

Anatomy and pathophysiology: why the spleen bleeds so catastrophically¶

The adult spleen is a fist-sized, dark-purple wedge of lymphoid and vascular tissue weighing approximately 150 to 200 grams, tucked high in the left upper quadrant (LUQ) of the abdomen beneath the diaphragm and protected laterally by the 9^th, 10^th, and 11^th left ribs. It is tethered in place by three peritoneal ligaments (the splenorenal, gastrosplenic, and phrenicocolic ligaments) that carry its blood vessels, notably the large, tortuous splenic artery (branching directly off the celiac trunk of the abdominal aorta) and the short gastric arteries.

1. Why lower left rib fractures and bicycle handlebars tear the spleen¶

Two biomechanical forces rupture the spleen during blunt trauma:

• Direct crushing impact (Rib fractures and handlebars): Any direct blow to the left lower chest or left upper abdomen (such as a steering wheel, a baseball bat, a football helmet, or a child falling forward over the end of a bicycle handlebar) compresses the fragile splenic pulp against the rigid vertebral column behind it. Notably, roughly 20 percent of patients with fractures of the lower left ribs (ribs 9, 10, or 11) have an underlying splenic laceration, because the inward-bending or jagged rib bones punch directly into the splenic capsule.
• Rapid deceleration shear (Motor vehicle crashes and falls from height): When a fast-moving vehicle stops abruptly or a person falls from a ladder, the mobile body of the spleen continues moving forward while its vascular pedicle (the splenic hilum) remains anchored to the back wall of the abdomen, tearing the spleen right across its major hilar blood vessels.

2. Neuroanatomy of Kehr's Sign (Why a bleeding spleen hurts in the left shoulder)¶

First described by German surgeon Hans Kehr, Kehr's sign is acute referred pain felt at the top tip of the left shoulder (over the acromion and supraclavicular fossa) caused by blood or inflammatory fluid irritating the underside of the left diaphragm.

Why does the brain mistake blood in the belly for a shoulder injury? - The underside of the left hemidiaphragm is innervated by sensory fibers of the left phrenic nerve, which originates high in the neck from spinal cord segments C3, C4, and C5 ("C3, 4, 5 keep the diaphragm alive"). - Those exact same C3 and C4 spinal cord segments also receive skin sensation from the supraclavicular nerves, which cover the top cap of the left shoulder. - Because the human brain is not accustomed to receiving pain signals from the diaphragm, when liquid blood pools against the left diaphragm and stimulates the phrenic nerve, the spinal cord dorsal horn neurons project that pain directly onto the C3-C4 shoulder dermatome. - Clinical pearl: Kehr's sign is present in 50 to 75 percent of splenic ruptures, and it characteristically gets much worse when the patient lies flat on their back (or has their legs slightly elevated), because gravity allows the liquid blood inside the abdomen to slide upward under the ribcage and bathe the left diaphragm.

3. Ballance's Sign and the Cullen / Grey Turner signs¶

Alongside Kehr's sign, classic trauma semiology identifies three additional bedside signs of intra-abdominal or retroperitoneal hemorrhage: - Ballance's Sign: Dullness to percussion in both flanks that stays fixed in the leftupper quadrant / left flank (due to a solid mass of clotted blood around the torn spleen) while shifting with position in the right flank (due to liquid blood moving across the peritoneal cavity). - Left Upper Quadrant Guarding and Rebound: Liquid blood is a chemical irritant to the parietal peritoneum, causing involuntary tightening (muscular guarding) of the left abdominal wall, though 30 to 40 percent of early splenic bleeds have a deceptively soft belly. - Cullen's Sign (bluish bruising around the navel) and Grey Turner's Sign (bruising along the flanks): Late signs (appearing 24 to 48 hours after bleeding starts) indicating blood tracking into the retroperitoneal space or umbilical ligament.

Recognizing silent hemorrhagic shock: why blood pressure is the LAST sign to fall¶

The adult human body contains approximately 5 liters (10.5 pints) of blood (roughly 70 mL per kilogram of body weight). Because the abdominal cavity (peritoneum) is a vast, compliant space that can hold all 5 liters of a person's blood without showing external swelling to the untrained eye, bystanders must know the American College of Surgeons ATLS (Advanced Trauma Life Support) 4 Classes of Hemorrhagic Shock so they do not get fooled by a "normal" blood pressure reading in a young or healthy person:

Non-traumatic and low-impact splenic rupture: Infectious Mononucleosis (EBV) and splenomegaly¶

A spleen does not always require a high-speed car crash to rupture. When a medical condition causes the spleen to swell to 2 to 4 times its normal size (splenomegaly), two dangerous structural changes happen simultaneously: 1. The swollen spleen expands downward out from underneath the protective cage of the lower left ribs into the unprotected soft belly. 2. The enlarged pulp stretches the outer fibrous capsule drum-tight and thins it out like tissue paper, while lymphocytic infiltration weakens the structural trabeculae.

In an enlarged, fragile spleen, spontaneous (atraumatic) rupture or rupture from a trivial everyday movement (such as coughing hard, vomiting, straining on the toilet, rolling over in bed, or a minor bump during a casual game) can cause sudden life-threatening internal hemorrhage.

Top medical causes of fragile splenomegaly and spontaneous rupture¶

Hospital diagnosis, AAST grading (Grades I to V), and modern spleen-saving treatment¶

Over the past three decades, trauma surgery has undergone a major paradigm shift. Because removing the entire spleen (total splenectomy) leaves the patient with a lifelong vulnerability to fulminant bacterial infections, modern Trauma Centers follow World Society of Emergency Surgery (WSES) and EAST (Eastern Association for the Surgery of Trauma) guidelines to save the spleen (Non-Operative Management / NOM) whenever the patient is hemodynamically stable.

1. Immediate Emergency Department triage: eFAST Ultrasound vs. Contrast CT¶

• If the patient is hemodynamically UNSTABLE (systolic BP <90 mmHg, unresponsive to fluids, or peritonitis): There is no time for a CT scanner ("the tunnel of death" for unstable bleeding patients). The trauma team performs a 30-second bedside eFAST ultrasound (Extended Focused Assessment with Sonography for Trauma) looking at the splenorenal recess and pelvis for black free blood, starts 1:1:1 balanced blood transfusions (packed red blood cells, plasma, and platelets) plus intravenous Tranexamic Acid (TXA, 1 gram IV within 3 hours of injury), and takes the patient straight to the operating room for an emergency exploratory laparotomy and splenectomy (or splenorrhaphy).
• If the patient is hemodynamically STABLE (or stabilizes rapidly after initial resuscitation): The patient undergoes a Multiphasic Intravenous Contrast-Enhanced Abdominal CT Scan, which grades the splenic injury on the AAST (American Association for the Surgery of Trauma) Organ Injury Scale (Grades I to V) and detects any active arterial "contrast blush" or pseudoaneurysm.

2. The AAST Splenic Injury Grading Scale and Treatment Pathway¶

Life after splenectomy: preventing Overwhelming Post-Splenectomy Infection (OPSI)¶

If a patient's spleen must be surgically removed (or is rendered non-functional by extensive embolization), they can live a normal, active life, provided they follow strict lifelong infection precautions.

Because the spleen is the body's specialized filter for stripping protective sugar capsules off encapsulated bacteria in the bloodstream and producing opsonizing IgM antibodies, a person without a spleen is at lifelong risk for Overwhelming Post-Splenectomy Infection (OPSI): a fulminant sepsis syndrome that starts like a mild flu or fever and progresses to septic shock, disseminated intravascular coagulation (DIC), and death within 12 to 24 hours (carrying a 50 percent mortality rate).

The 3 Mandatory Lifelong Safety Rules for Anyone Without a Spleen (Asplenia)¶

1. Receive all required "Encapsulated Bacteria" Vaccinations (The "SHiN" Vaccines): Administered either 14 days AFTER an emergency trauma splenectomy (so the immune system has recovered from surgical stress to mount a strong antibody response) or before hospital discharge if follow-up is uncertain, with scheduled boosters:
2. S - Streptococcus pneumoniae (Pneumococcal conjugate vaccines PCV20 or PCV15 + PPSV23)
3. Hi - Haemophilus influenzae type b (Hib vaccine)
4. N - Neisseria meningitidis (Quadrivalent Meningococcal MenACWY vaccine PLUS Meningococcal Serogroup B [MenB] vaccine)
5. Plus the annual Influenza vaccine (since flu predisposes to secondary pneumococcal pneumonia).
6. Keep an emergency "Pill-in-the-Pocket" standby antibiotic supply at home and when traveling: Every splenectomized patient should carry a prescribed emergency dose of high-dose amoxicillin-clavulanate (Augmentin) or levofloxacin/moxifloxacin at home. At the very first sign of any unexplained fever (>38.0°C / 100.4°F), shaking chills, malaise, or any dog/animal bite (high risk of Capnocytophaga canimorsus sepsis), the patient must swallow their standby antibiotic dose immediately and go straight to the nearest hospital emergency department for intravenous ceftriaxone/vancomycin and blood cultures.
7. Wear a Medical Alert Bracelet or carry an Asplenia Wallet Card stating "Asplenic / Spleen Removed: High Risk for Overwhelming Sepsis."

Regional emergency numbers and agency protocols¶

Suspected splenic rupture requires immediate ambulance transport to a designated Trauma Center with 24-hour general/trauma surgery, interventional radiology (angioembolization), and blood bank capabilities:

• United States and Canada: Dial 911. EMS paramedics follow ACS-COT / PHTLS guidelines for permissive hypotension in non-head-injured internal hemorrhage (targeting systolic BP 80 to 90 mmHg during rapid transport so excessive IV crystalloid fluids do not pop the forming splenic clot or dilute clotting factors) and administer intravenous Tranexamic Acid (TXA).
• United Kingdom: Dial 999 for an emergency ambulance to a Major Trauma Centre (MTC) or acute Trauma Unit under NICE Guideline NG39 (Major Trauma: Assessment and Initial Management). Post-splenectomy vaccination and prophylaxis follow the UK Health Security Agency (UKHSA) Green Book Chapter 7 guidelines.
• European Union: Dial 112. Managed under the European Guideline on Management of Major Bleeding and Coagulopathy Following Trauma and WSES Spleen Trauma Guidelines.
• Australia and New Zealand: Dial 000 in Australia or 111 in New Zealand. Post-splenectomy patients are registered with Spleen Australia for lifelong vaccination and antibiotic guidance.
• India and Asia-Pacific: Dial 112 (or 108 in India), 995 in Singapore, 119 in Japan and South Korea, or 999 in Malaysia and Hong Kong. Proceed directly to a tertiary trauma center with 24-hour CT, blood bank, and surgical operating theaters.

Frequently asked questions¶

Why does a ruptured spleen cause sharp pain at the tip of the left shoulder (Kehr's sign)?¶

When the spleen bleeds inside the upper left abdomen, liquid blood pools against the underside of the left diaphragm and irritates the left phrenic nerve. The phrenic nerve enters the spinal cord in the neck at levels C3, C4, and C5, which are the exact same spinal cord segments that receive touch and pain signals from the skin over the top of the left shoulder (via the supraclavicular nerves). Because the brain cannot localize pain coming from the diaphragm, it interprets the signal as sharp pain right at the tip of the left shoulder, especially when the person lies flat on their back and blood slides up under the ribcage.

How can someone have a ruptured spleen that bursts a week after a car crash or sports injury?¶

In a two-stage or delayed splenic rupture (occurring in 1 to 10 percent of blunt splenic injuries), the initial blow tears the soft inner vascular pulp of the spleen, but the tough outer fibrous capsule stays intact and traps the bleeding inside a subcapsular hematoma. For 2 to 14 days (Baudet's latent period), the person may feel only mild left rib soreness. As the red blood cells trapped inside the hematoma break down over days, osmotic pressure draws extra fluid into the pocket until the stretched capsule suddenly rips open, flooding the abdominal cavity with blood and causing sudden shock.

Why is infectious mononucleosis ("mono") so dangerous for athletes?¶

Infectious mononucleosis (caused by the Epstein-Barr virus) causes the spleen to swell to 2 to 3 times its normal size in over half of patients, pushing the fragile organ down below the protective left ribcage and stretching its outer capsule paper-thin. Between Day 4 and Day 21 of the illness (and sometimes up to 4 to 8 weeks), a minor tackle, fall, heavy weightlifting strain, or even a hard cough can rupture the swollen spleen. Athletes with mono must strictly avoid all contact sports, weightlifting, and strenuous exertion for at least 3 to 4 weeks and until a physician confirms recovery.

Why shouldn't you let someone with suspected internal bleeding stand up or walk to the car?¶

Allowing a person with a suspected splenic injury to stand up or walk is dangerous for two reasons. First, if they have already lost 20 to 30 percent of their blood volume into their abdomen, standing up causes remaining blood to pool in the legs, triggering an immediate crash in blood flow to the brain and heart. Second, contracting the abdominal muscles to stand or walk spikes intra-abdominal pressure and physically pops open a fragile subcapsular hematoma or dislodges the soft blood clot that is temporarily sealing the torn spleen.

Does every ruptured spleen require surgery to remove the spleen?¶

No. Today, 70 to 85 percent of patients with blunt splenic injuries who arrive at a Trauma Center with stable blood pressure are treated successfully without removing the spleen (Non-Operative Management). For lower-grade tears (Grades I to III), strict hospital observation allows the spleen to heal on its own. For deeper tears with an active bleeding vessel (Grade IV), interventional radiologists thread a tiny catheter through an artery in the groin or wrist into the splenic artery and deploy microscopic coils to seal the bleeding branch while keeping the rest of the spleen alive and preserving immune function.

Why can a young person with severe internal bleeding still have a normal blood pressure of 120/80 mmHg?¶

Children, teenagers, and healthy young adults have remarkably strong sympathetic nervous systems and elastic arteries that constrict tightly when bleeding starts, keeping systolic blood pressure completely normal until they have lost 30 percent (1,500 milliliters) of their total blood volume. Instead of waiting for blood pressure to drop, look for the early compensated shock signs: a resting heart rate over 100 beats per minute, cool pale or clammy skin, a narrowed gap between systolic and diastolic blood pressure, thirst, and dizziness when sitting up.

Sources and official guidance¶

• World Society of Emergency Surgery (WSES, International): WSES Classification and Guidelines for Adult and Pediatric Patients with Splenic Trauma (Coccolini et al., World Journal of Emergency Surgery, non-operative management, angioembolization, and operative indications).
• American Association for the Surgery of Trauma (AAST) & Eastern Association for the Surgery of Trauma (EAST, United States): 2018 Revision of the AAST Organ Injury Scale for Spleen Trauma and EAST Practice Management Guidelines for the Nonoperative Management of Blunt Injury to the Liver and Spleen.
• American College of Surgeons (ACS, United States): Advanced Trauma Life Support (ATLS) Student Course Manual, 10^th Edition (Abdominal trauma, eFAST ultrasound, 4 classes of hemorrhagic shock, and balanced resuscitation).
• Centers for Disease Control and Prevention (CDC, United States) & UK Health Security Agency (UKHSA): Advisory Committee on Immunization Practices (ACIP) / Green Book Guidelines for Vaccinations and Antibiotic Prophylaxis in Asplenia and Hyposplenia (Prevention of OPSI).
• American Medical Society for Sports Medicine (AMSSM): Position Statement on Mononucleosis, Splenomegaly, and Return-to-Play Timelines in Athletes.

Related guides¶

• Shock recognition and emergency first aid
• Flail chest, rib fractures, and blunt thoracic trauma
• Pelvic fracture stabilization and internal hemorrhage control
• Abdominal evisceration and open stomach wound care
• Sepsis and septic shock recognition and emergency triage