(P67) Renal Trauma During Rugby Tackle

Chief Complaint : Pain in her right lower chest and right flank with nausea after a tackle while playing rugby

History of Present Illness : A 16-year-old female patient was tackled on her right side by another player during a rugby game. She denied any head injury or loss of consciousness. After she went home, she complained of pain in her right lower chest and right flank with associated nausea. No past medical history

Pertinent Physical Exam: Vital signs showed a heart rate of 72 beats/min, respiratory rate of 17 breaths/min, blood pressure of 111/63 mm Hg and oxygen saturation of 100% on room air. On examination, there was tenderness over the right lateral lower ribs and right flank, but there were no signs of peritonism.

Pertinent Laboratory Data: Her blood investigations were normal, with a haemoglobin of 111 x 109 g/l, creatinine of 68 umol/l and lactate of 1.5mmol/l. Plain radiographs of chest and pelvis were normal. E-FAST showed a sliver of free fluid within the right renal capsule, but no free intraperitoneal fluid. There was hyperdensity noted within the urinary bladder which was suggestive of a blood clot. Urinalysis showed gross haematuria. She had a syncopal episode in ED. Repeat haemoglobin was 94 g/l. Computed tomography (CT) scan of abdomen and pelvis was done which showed a complex right lower pole renal laceration with associated retroperitoneal fluid/blood.

Case Discussion: Assessment with urinalysis, haematocrit and creatinine is required during the evaluation of a patient with suspected renal trauma. Haematuria (gross or microscopic) is a good indicator of renal injury, but does not correlate with the degree of injury. CT scan is the imaging modality for diagnosis and grading of renal injury. The indications for radiologic evaluation of renal injury in blunt trauma include 1. clinical signs suggestive of renal trauma e.g. abdominal tenderness, distension, flank pain, ipsilateral lower rib fractures, 2. gross haematuria, 3. microscopic haematuria and one episode of hypotension (pre-hospital or initial ED systolic BP < 90mm Hg) and/or 4. presence of other major injuries. Conservative treatment is the mainstay of therapy. Haemodynamically stable patients with microscopic haematuria, those with low-grade renal injuries (I-III), and even those with high-grade renal injuries (IV-V) can be managed conservatively. Conservative management includes observation, bed rest, serial abdominal examination and assessment of haemoglobin/haematocrit till haematuria resolves. Angiography and selective embolisation have showed a high success rate in the management of patients with high-grade (Grade IV and V) renal injuries with ongoing bleeding or vascular complications. Physicians must discuss the risk of potential complications and long-term sequelae with the patient. Patients who are managed conservatively should avoid sports for at least 6 weeks, while those with high-grade renal injury may take longer time to heal and should avoid return to sports for 6 to 12 months.

References and Acknowledgements (Optional):

References:
1. Harper K, Shah KH. Renal trauma after blunt abdominal injury. J Emerg Med. 2013; 45 (3):400-404. doi: 10.1016/j.jemermed.2013.03.043
2. Freeman CM, Kelly ME, Nason GJ, et al. Renal trauma: the rugby factor. Curr Urol. 2015; 8 (3):133–137. doi: 10.1159/000365704
3. Hagedorn JC, Fox N, Ellison JS, et al. Pediatric blunt renal trauma practice management guidelines: Collaboration between the Eastern Association for the Surgery of Trauma and the Pediatric Trauma Society. J Trauma Acute Care Surg 2019; 86 (5):916-925. doi: 10.1097/TA.0000000000002209