Ballance’s sign refers to a fixed area of dullness in the left upper quadrant (LUQ) of the abdomen, detectable by palpation and percussion. This finding is suggestive of a subcapsular or extracapsular hematoma of the spleen, often following splenic rupture, typically due to trauma.

Pathophysiology

Splenic injury leads to bleeding beneath the splenic capsule (subcapsular) or outside the capsule (extracapsular). The accumulation of blood in these locations produces a localized, non-shifting area of dullness on percussion.

• Subcapsular hematoma: Blood is confined beneath the splenic capsule, forming a fixed, immobile mass.

• Extracapsular hematoma: Blood escapes outside the capsule but may remain localized due to surrounding tissues, producing fixed dullness.

• Hemodynamic implication: Significant bleeding can lead to hypovolemia, hypotension, and shock if untreated.

Examination Technique

• Patient positioning: Supine with relaxed abdominal muscles.

• Inspection: Look for abdominal bruising, left flank ecchymosis (Grey-Turner sign), or left shoulder pain (Kehr’s sign).

• Palpation: Gently palpate the LUQ to detect tenderness, splenic enlargement, or a firm mass.

• Percussion: Percuss over the LUQ to detect fixed dullness, which does not shift with position, indicating localized hematoma.

• Assessment of associated signs: Evaluate for guarding, rigidity, or generalized tenderness.

Clinical utility

• Diagnostic indicator: Ballance’s sign supports the suspicion of splenic rupture or hematoma following abdominal trauma.

• Adjunct to imaging: While not definitive, it guides the use of ultrasound, FAST scan, or CT to confirm splenic injury.

• Emergency triage: Helps identify patients at risk of intra-abdominal bleeding, requiring prompt intervention.

Differential Diagnosis

Management

• Immediate care: Stabilize patient hemodynamically; monitor vital signs, oxygen saturation, and urinary output.

• Imaging confirmation: FAST ultrasound or CT abdomen to evaluate hematoma size, splenic integrity, and associated injuries.

• Surgical intervention: Splenectomy or splenic repair may be indicated for hemodynamically unstable patients.

• Nonoperative management: Stable patients with contained hematomas may be observed with serial exams and imaging.

• Adjunct therapy: Blood transfusion and intravenous fluid resuscitation as needed.

Patient counseling

• Explain the significance of LUQ tenderness and dullness as a sign of possible internal bleeding.

• Emphasize the importance of prompt evaluation and imaging to prevent complications.

• Advise about activity restriction after splenic injury and signs of delayed hemorrhage (e.g., dizziness, hypotension, increasing pain).

Pediatric considerations

• Children are more susceptible to splenic rupture due to less protected spleens.

• Ballance’s sign may be subtle; rely on imaging and careful abdominal examination.

Geriatric considerations

• Elderly patients may present with less pronounced pain or tenderness.

• Fixed LUQ dullness is particularly helpful in cases with blunted clinical responses.

Key points

• Ballance’s sign is a classic physical finding indicating subcapsular or extracapsular splenic hematoma.

• It is detected by fixed dullness on percussion and palpation of a firm LUQ mass.

• While not definitive, it guides urgent imaging and intervention for potential splenic injury.

References

1. Ballance A. Observations on the detection of splenic rupture. Br Med J. 1909;2:917–919.

2. Buttaro TM, Tybulski J, Bailey PP, Sandberg-Cook J. Primary Care: A Collaborative Practice. St. Louis, MO: Mosby Elsevier; 2008.

3. McCance KL, Huether SE, Brashers VL, Rote NS. Pathophysiology: The Biologic Basis for Disease in Adults and Children. 8th ed. Maryland Heights, MO: Mosby Elsevier; 2019.

4. Moore EE, Feliciano DV, Mattox KL. Trauma. 9th ed. New York, NY: McGraw-Hill; 2021.

5. Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. New York, NY: McGraw-Hill; 2020.