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Renal Trauma
Pediatric GU Review
UCSD Pediatric UrologyGeorge Chiang MD
Sara Marietti MD
Outlined from The Kelalis-King-Belman Textbook of Clinical Pediatric Urology 2007
(not for reproduction, distribution, or sale without consent)
Pediatric Renal Trauma
• Most commonly injured abdominal organ in blunt trauma– Fetal lobulations predispose to renal separation– Less protection by pliable thoracic cage and less
developed musculature– Higher incidence of pedicle injury
• 80% with renal injury have associated nonrenal injuries
Pediatric Renal Trauma
• Shock unreliable indicator of significant injury• Controversy exists when to image pediatric
renal trauma patients.• Some advocate imaging ALL ALL children with
microscopic hematuria• Dr. Morey and others have suggested
observation in stable patients with <50rbc/hpf and mild trauma
Mechanisms of Injury
• Blunt trauma– 85-95% of renal trauma– Direct blow / Assault– Bony spicules of ribs or
vertebrae– MVA: speed; driver,
passenger, degree of deceleration
– Falls
Giambologna, Hercules and the Centaur, 1550
Mechanisms of Injury• Penetrating trauma
– ~ 10% of renal trauma– Gunshot injury from bullet, – fragments, or blast effect– Stab wounds: size of knife– KE = ½ MV2
Mantegna, St. Sebastian, 1470
Pediatric Renal Trauma
• Preexisting renal abnormalities (i.e. UPJ Obstruction, hydro, horseshoe kidney) are 3-5 X more common in peds patients undergoing screening CT for trauma than in adults
• Classically, congenital renal abnormality presents with hematuria disproportionate to severity of trauma
( Chopra et al, 2002 ; McAleer et al, 2002 ; Heyns, 2004 ; Santucci et al, 2004).
American Association for the Surgery of Trauma Organ Injury Severity Scale for the Kidney
Grade Description of Renal Injury
I Contusion : hematuria with normal radiological studies.
Hematoma : subcapsular and non expanding.
II Hematoma : perirenal ,confined to retroperitoneum.
Laceration : < 1 cm depth without extravasation
IIILaceration : > 1cm depth without collecting system injury or extravasation.
IV Laceration : through renal cortex, medulla, collecting system.
Vascular : renal artery or vein injury : contained hemaorrhage.
V Laceration : shattered destroyed kidney
Vascular : renal arterial and venous avulsion.
Moore, Shackford, J Trauma, 1989
Organ Injury Scale
Hematuria in Children
• Unreliable in determining who to screen for renal injuries
• Some studies have failed to find any evidence of either gross or microscopic hematuria in up to 70% of children sustaining grade 2 or higher renal injury.
• Hematuria alone cannot determine need for radiographic studies
( Morey et al, 1996 ; Buckley and McAninch, 2004 ).
Radiographic Trauma Assessment1. All penetrating abdominal trauma, 2. Blunt trauma victims who have either:
• Significant deceleration or high-velocity injury • fractures of thoracic rib cage, spine, pelvis, or
femur, or bruising of the torso/perineum, or signs of peritonitis
• Gross hematuria • Microscopic hematuria (>50 red blood cells per
high-powered field) and shock (SBP<90mm Hg)
Santucci and associates (2004a)
J Pediatr Surg. 2002 May;37(5):779-82 Chopra P, et al. (Montreal, Quebec)
PURPOSE: quantify pathologic lesions of the kidney found incidentally during blunt trauma w/u
METHODS: Retrospective review of 103 patients (0 to 18 years) with blunt renal injuries.
• US in all cases and CT as indicated
RESULTS: Coexisting urogenital lesions were identified in 13 of 103 (12.6%) patients, and 7 (54%) required surgical treatment.
• Majority - 9 of 13 (69%) suffered minimal trauma. • Gross hematuria was main symptom. • UPJ Obstruction was most common anomaly
CONCLUSIONS: Pathologic lesions of the urinary tract are uncommon; however, they may complicate an otherwise negligible renal trauma.
Brown SL, et al. in World J Surg. 2001 Dec;25(12):1557-60 Radiologic evaluation of pediatric blunt renal trauma in patients
with microscopic hematuria.
• Reviewed 1200 children with blunt abdominal trauma, 35 had CT
Results• 3 with grade II-V renal injuries, 32 were normal or had renal contusions • 1/3 patients with gross hematuria evaluated with CT sustained significant renal
injury without other associated injuries.
Conclusions:• The degree of hematuria did not correlate with the grade of renal injury. • Pediatric patients with blunt trauma, microscopic hematuria, and no associated
injuries do not require radiologic evaluation, as significant renal injuries are unlikely.
• However, children who present with associated injuries and microscopic hematuria after blunt trauma may have significant renal injuries and should undergo radiologic evaluation.
• Methods:– 14,763 pts reviewed
• Results:– 193 with imaging or direct evidence of renal injury at surgery (32)– 69% had associated injuries– 17 (8.3%) congenital GU anomalies found in series
• CONCLUSIONS:– 1.3% of pediatric trauma pts have renal injuries– 8.3% had congenital anomalies– UPJ Obstruction was most common abnormality (~33%) – Congenital anomalies may not increase risk of morbidity due to
renal trauma
Master, McAnich; Urol Clin N Am, 2006
Master, McAnich; Urol Clin N Am, 2006
Master, McAnich; Urol Clin N Am, 2006
Master, McAnich; Urol Clin N Am, 2006
Master, McAnich; Urol Clin N Am, 2006