Presentation
Unrestrained passenger. Severe upper abdominal and back pain.
Patient Data
Chest, Abdomen and Pelvis
Chest
- Small right hemothorax.
- Tiny pneumomediastinum
- Fractures of the right T7-T9 transverse processes
- Fracture through the right posterolateral superior corner of the T10 vertebral body.
Abdomen/Pelvis
- Devascularisation of the left kidney secondary to dissection of the left renal artery (AAST Grade V). Traumatic transection thought less likely given the absence of a large perivascular hematoma or contrast blush. No urinary contrast so a collecting system injury can’t be ruled out.
- Linear region of contrast in the posterior mid left kidney likely represents a small region of perfusion rather than a renal laceration with active bleeding given the absence of surrounding fluid or stranding.
- Left adrenal hematoma.
- Transection of the pancreatic body (AAST Grade III). High risk of pancreatic duct injury.
- Splenic laceration (AAST Grade I) and left lobe of liver laceration (AAST Grade I). No active contrast extravasation.
- Retroperitoneal hematoma tracking into the lienorenal and gastrosplenic ligaments.
- Small hemoperitoneum
Incidental findings
- Tampon in situ
- Cholecystectomy
Case Discussion
When trauma to the kidneys is identified whilst the patient is on the CT scanner, it is advisable to do a delayed scan through the collecting system to assess for a leak. Whilst this was performed in this case, no contrast was excreted into the left collecting system so an injury could not be excluded.
Devascularisation of the kidney is an AAST Grade 5 injury. It is an uncommon occurrence, occurring in 2.5-4% of traumatic renal injuries. Management for renal artery injury is controversial. There are three main options 1:
- nephrectomy - only in well patients with two kidneys
- vascular repair
- conservative monitoring: can be complicated by renovascular hypertension 2
CT findings of pancreatic injury can be subtle initially however early diagnosis is critical in reducing morbidity and mortality. Main pancreatic duct disruption is the greatest predictor for complications. Direct findings of pancreatic injuries include: enlargement of the pancreas; a laceration (focal linear non-enhancement); comminution (fracture) and inhomogeneous enhancement. Secondary findings include: peripancreatic fluid and stranding; fluid between the splenic vein and pancreas; peripancreatic hemorrhage; thickening of the left anterior pararenal fascia and injuries to adjacent structures.
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