Heidi Harbison

Gillian Lieberman, MD
April 2002
Renal Trauma
Heidi Harbison, Harvard Medical School year III
Gillian Lieberman, MD
Heidi Harbison
Gillian Lieberman, MD
Anatomy of the Kidney
Be suspicious of renal
injury with broken ribs
Renal blood supply
Renal arteries
Renal veins
IVC
Ureter
Image from www.radiology.wisc.edu
Image from www.trauma.org
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Heidi Harbison
Gillian Lieberman, MD
Anatomy of the Kidney
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Heidi Harbison
Gillian Lieberman, MD
10-20% of trauma pts. have GU involvement
45% of GU trauma is renal
20-30% of renal trauma pts. have associated
abdominal injury

Prevalence of Renal Trauma

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Heidi Harbison
Gillian Lieberman, MD
Mechanisms of Renal Trauma
Blunt trauma (80%): MVA, falls, assaults
Penetrating trauma (20%): gunshot, stabbing,
impalement
Predisposing factors: preexisting renal conditions
(tumors, hydronephrosis), children, associated
abdominal injuries

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Heidi Harbison
Gillian Lieberman, MD
Clinical Presentation of Renal Trauma
Gross or microscopic hematuria (absent in 5%)
Flank pain/ecchymosis
Hemodynamic instability
Presence of other abdominal injuries

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Heidi Harbison
Gillian Lieberman, MD
Patient 1: An illustration of imaging modalities
18 yo male sustained stab
wound to R flank
P=180, BP 130/80, Hct 36
CXR nl.
Why image and with which
modality?
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Heidi Harbison
Gillian Lieberman, MD
Indications for Imaging
Gross hematuria
Microscopic hematuria with
hemodynamic instability
Persistent microscopic hematuria
Significant MOI
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Heidi Harbison
Gillian Lieberman, MD
Radiologic Imaging of Renal Trauma
CT with IV contrast
Gold standard, high sensitivity
Immediate and delayed post-contrast
images to view collecting system
Images abdomen and retroperitoneum
Allows diagnosis and staging
Not for hemodynamically unstable pts.
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Heidi Harbison
Gillian Lieberman, MD
Patient 1: CT with IV contrast
Peri-renal
hemorrhage
Normal attenuating
kidney
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Heidi Harbison
Gillian Lieberman, MD
Patient 1: CT with IV contrast
Contrast
extravasation
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Heidi Harbison
Gillian Lieberman, MD
Renal laceration
with extravasation
of contrast
Retroperitoneal
hematoma
Patient 1: CT with IV contrast
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Heidi Harbison
Gillian Lieberman, MD
Intravenous pyelography
Extravasation of contrast from R kidney
Image from Trauma.org
Inadequate for
grading renal injury
Used in unstable pts prior to
surgery to identify functioning
contralateral kidney
Unable to evaluate abdomen
and retroperitoneum
Radiologic Imaging of Renal Trauma Cont.
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Heidi Harbison
Gillian Lieberman, MD
Renal Angiography
Devascularization of L kidney
Image fromTrauma.org
Delineates vascular injury
(intimal tears, pseudoaneurysm,
AV fistula)
Use when CT equivocal
and continued hemorrhage
Use for endovascular repair
(embolization, stenting)
Radiologic Imaging of Renal Trauma Cont.
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Heidi Harbison
Gillian Lieberman, MD
Renal ultrasound
Bedside US in ED allows
evaluation of abd/pelvic
injury/fluid accumulation
High false neg. rate
for renal injury
Used in areas without
CT, or for follow up
Radiologic Imaging of Renal Trauma Cont.
kidney
Subcapsular hematoma
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Heidi Harbison
Gillian Lieberman, MD
17 yo unrestrained driver
MVA c/o RLQ pain
VSS
Hct 45.7, BUN 15, Cr 1.2
CXR, cervical, lumbar, pelvic
plain films nl.
CT demonstrates renal
laceration
How severe? How manage?
Patient 2: An Illustration of Injury Staging
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Heidi Harbison
Gillian Lieberman, MD
Grade I Contusion: Microscopic or gross hematuria, urological studies normal
Hematoma: Subcapsular, nonexpanding without parenchymal laceration
Grade II Hematoma: Nonexpanding perirenal hematoma confined to renal retroperitoneum
Laceration: <1cm parenchymal depth of renal cortex without urinary extravasation
AAST Organ Injury Scale - Renal Injury
Grade I and II injuries managed conservatively (observation, ser Grade I and II injuries managed conservatively (observation, serial ial Hct Hct) )
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Heidi Harbison
Gillian Lieberman, MD
Grade III Laceration: >1cm depth of renal cortex, without collecting system rupture
or urinary extravasation
Grade IV Laceration: Parenchymal laceration extending through the renal cortex,
medulla and collecting system
Vascular: Main renal artery or vein injury with contained hemorrhage
AAST Renal Injury Scale Cont.
Grade III and IV injuries are now managed conservatively Grade III and IV injuries are now managed conservatively
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Heidi Harbison
Gillian Lieberman, MD
Grade V Laceration: Completely shattered kidney
Vascular: Avulsion of renal hilum which devascularizes kidney
AAST Renal Injury Scale Cont.
Surgery! Salvage vs. Surgery! Salvage vs. nephrectomy nephrectomy
Image from www.trauma.org
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Heidi Harbison
Gillian Lieberman, MD
Patient 2: Grading the Renal Injury
Adrenal
hemorrhage
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Heidi Harbison
Gillian Lieberman, MD
Patient 2: Grading the Renal Injury
Laceration renal cortex >1cm
No involvement of collecting
system or hilar vasculature
Grade III
Conservative management
Renal
laceration
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Heidi Harbison
Gillian Lieberman, MD
Patient 1: Grading/Management
Laceration of renal
cortex extending into
collection system
Large perirenal and
retroperitoneal hemorrhage
Grade IV
Conservative
management with
resolution in 2 mo
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Heidi Harbison
Gillian Lieberman, MD
Renal Trauma Conclusions
CT with contrast
Look for renal trauma in pts with
abdominal trauma and significant MOI
Grade severity of injury
80-90% renal injuries treated conservatively
with remarkable resolution!

Injuries requiring surgery: vascular injury,

shattered kidney, expanding hematoma
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Heidi Harbison
Gillian Lieberman, MD
References
Renal trauma at http://www.trauma.org
Abdominal and pelvic CT at http://brighamrad.harvard.edu
Genitourinary trauma. Emergency clinics of North America 19:3.
August 2001.
Upper genitourinary trauma at www.eMedicine.com
Helical CT of abdominal trauma. Advances in Emergency Radiology.
Radiologic clinics of North America. May 1999.
Trauma. Advances in Uroradiology. Radiologic clinics of North
America. Nov. 1996.
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Heidi Harbison
Gillian Lieberman, MD
Acknowledgments
J im Busch, MD and Matt Spenser, MD
Gillian Lieberman, MD
Pamela Lepkowski
Larry Barbaras and Cara Lyn Damour
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