CHEST WALL PAIN - FOOTBALL

Abstract

HISTORY A 16-year-old varsity high school football player was struck by an opponent in the right anterior chest wall while running down field to make a block on punt return. The hit lifted him up off his feet, he landed flat on his back and he had immediate pain in the right anterior chest wall. He required assistance to get off the field and did not play again in that game. Three days later player presented to the Sports Medicine office. Player complained of right anterior chest wall and right upper quadrant pain with deep inspiration since hit. PHYSICAL EXAMINATION Examination in the office revealed a well-developed male in no apparent distress and within normal vital signs. He had no chest or abdominal wall deformity or ecchymosis. He was tender to palpation on the right anterior chest wall over fourth through sixth ribs in the midclavicular line, right anterior costochondral junction T7-T8, and in the right upper quadrant of abdomen. Bowel sounds were present, abdomen was soft and flat, without rigidity or guarding. Liver and spleen were non-palpable. There was negative Cullen Sign and negative Gray Turner Sign. Heart was regular rate and rhythm and lungs were clear to auscultation and percussion. DIFFERENTIAL DIAGNOSIS Chest wall contusion Occult rib fracture Liver contusion Liver hematoma TESTS AND RESULTS Chest and rib detail radiographs were unremarkable. Labs revealed: WBC 10.8, Lymphocytes 15.5, Hemoglobin 14.5, Hematocrit 43.6, AST 95, ALT 237. Repeat blood tests one week later revealed normal CBC and liver function tests. INTERIM EVENTS: Player was restricted from contact/collision and strenuous non-contact activities. Three weeks into treatment he attempted to run a timed mile. He developed nausea and increased right upper quadrant abdominal pain. Additional tests were immediately performed. Abdominal ultrasound: parenchymal hematoma in the anterior segment of right lobe of liver, possible underlying liver laceration. Abdominal CT: 7.0 × 2.3 cm liver laceration at the junction between medial segment left hepatic lobe and anterior segment right hepatic lobe, with 1 cm parenchyma more superficial to the laceration. No perihepatic fluid collection. FINAL/WORKING DIAGNOSIS Liver laceration and hematoma TREATMENT AND OUTCOMES Disqualification from football for remainder of season No vigorous activities for at least 8 weeks Observation and education of player and family of warning signs that would require immediate evaluation Repeat liver CT in 2 months