You've picked up a competitor from the track following a collision that occurred on the exit of a high speed turn. He's now at the medical centre and has begun to complain of flank pain. He's certainly pretty tender over his right lower ribs posteriorly and on further examinations there's a little bit of blood where wee usually comes out.

Eeek! He might have blunt renal tract trauma.

Luckily, you've just been to this website and read through the material below. Having taken care of the core resuscitation, here's the low-down on renal tract trauma.


Anatomy

Renal - Ureters - Bladder - Urethra
Relatively protected due to the retroperitoneal anatomy.


Mechanism

More commonly blunt or deceleration mechanism (These are our patients).
Typically falls, motor vehicle collisions and straddle injuries.

Clues include:
  • Lower rib fractures
  • Flank pain, tenderness or bruising
  • Low T or L-spine fractures
  • Pelvic ring fractures, especially AP compression (pubic diastasis, pubic rami butterfly fracture)
  • Haematuria - Microscopic haematuria is generally not indicative of significant injury and is usually ignored. Macroscopic haematuria needs investigation. 5% of renal injuries produce no haematuria.


Blunt Kidney Injury

Kidney injury needs a little extra information, so here you are:



Management of renal trauma

Surgeons are generally reluctant to operatively explore renal trauma as it is associated with 65% incidence of subsequent nephrectomy regardless of intent of the exploration. Non-operative management is increasingly preferred even for high grade injuries.

The evidence base for management recommendations is poor, consisting mainly of retrospective analyses and single centre studies.

Ongoing evolution of approaches and techniques, with increasing controversy proportional to the grade of injury. There are significant differences in the imaging choices, management approach and interventional techniques used by trauma surgeons and urologists (See the referenced article at the end).

Interventional radiology, endovascular techniques and cystoscopic approaches are constantly evolving.

Generally agreed that key indications for operative management are:
  • Haemodynamic instability (usually associated with other intra-abdominal injuries)
  • Renal pelvic avulsion - usually results in nephrectomy
  • Expanding, non-contained haematoma.
However, this too is evolving.

With increasing non-operative management, the role of the routine follow-up CT 4-6 days post injury also causes controversy.
  • One paper showed the incidence of operative management was <1% for blanket routine follow-up CT and around 20% when selected for clinical indication.
  • A second paper showed no complications occurred if the initial injury Grade was I-III or the patient was assymptomatic.
  • Again, retrospective analyses rather than RCTs.
So there you go. This may not change what you do at the track or circuit in terms of interventions, but maybe your index of suspicion and trauma referral practice might go up a notch or two.


References
  1. Haematuria in trauma - https://lifeinthefastlane.com/ccc/haematuria-in-trauma/
  2. Evaluation of Hematuria in Blunt Trauma - http://regionstraumapro.com/post/1601798416/hematuria
  3. Thoughts On Traumatic Hematuria: Part 1 - http://regionstraumapro.com/post/163906343900/thoughts-on-traumatic-hematuria
  4. AAST Revises Renal Injury Grading - http://regionstraumapro.com/post/2909024096
  5. Renal trauma - http://www.trauma.org/archive/abdo/renal/intro.html
  6. Management of blunt renal injury - what is new?. Eur J Trauma Emerg Surg (2015) 41:251–258
  7. Contemporary management of renal trauma - Differences between urologists and trauma surgeons. AAST 2011 PLENARY PAPER. J Trauma Volume 72, Number 1, Pg 68-77.