Bilateral traumatic renovascular injury
50 year old male presents post motorcycle vs car accident. He was markedly hypotensive. A CT trauma series was performed.
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- Avulsion of the three main right renal arteries with active bleeding, a large pararenal hematoma and absent right renal perfusion.
- Superior segmental vascular injury to the left kidney without evidence of active bleeding.
- Right adrenal hematoma.
- Right hemopneumothorax with extensive displaced right rib fractures (1,3-12) and a right intercostal chest tube which is surrounded by lung parenchyma. This finding may be due to lung folding around the drain in the pleural space or possibly the drain is intra parenchymal.
- Rupture of the right postero-lateral abdominal wall.
- Right intertrochanteric femoral fracture.
1 case question available
Traumatic renal injury is a relatively uncommon occurrence, which is found in 1-5% of all traumas3. They are typically caused by blunt injury mechanisms, in particular, motor vehicle accidents and falls from height.
Traumatic renal injury can be graded from 1 though to 5. The grading system is defined as follows4:
- Grade I - Contusion or non-expanding subcapsular hematoma; No laceration
- Grade 2 - Non-expanding perirenal hematoma; Cortical laceration <1cm deep without extravasation
- Grade 3 - Cortical laceration > 1 cm without urinary extravasation
- Grade 4 - Laceration through corticomedullary junction into collecting system OR Vascular segmental renal artery or vein injury with contained hematoma
- Grade 5 - Shattered kidney OR renal pedicle injury or avulsion
This patient has a right sided grade 5 shattered kidney with complete devascularisation of the right kidney. Note the heterogenously enhancing mass located medial to the right kidney. This represents a large para-pelvic hematoma which has active extravasation of contrast, representing active bleeding. He also has a left sided grade 4 segmental renal artery injury with partial devascularisation of the kidney. This patient proceeded to right nephrectomy with conservation of his left kidney.
Traumatic adrenal injury is an uncommon traumatic finding, mainly due to its protected, retroperitoneal location1. It has been noted to occur in 2-3% of blunt abdominal injury2, with motor vehicle accident being the most common cause.
It is worth noting that right sided adrenal trauma is much more common than the left, with a ratio of 3-4:1 being quoted1. This has been suggested to be caused by the short adrenal vein which directly connects to the inferior vena cava. In blunt trauma, rapid increases in IVC pressure are likely associated with right adrenal trauma.
Complications of adrenal injury include uncontrolled hemorrhage and adrenal insufficiency.
In this patient, note the hypodense, enlarged adrenal glands sitting superior to the right kidney hematoma. This represents the devascularised adrenal gland with significant old non-enhancing blood contained within.
This patient also has a traumatic hemothorax. Traumatic haemotoraces are a common finding in both blunt and penetrating trauma. This is because chest trauma is found in up to 60% of trauma cases5.
Chest tube insertion for drainage of the hemothorax is the mainstay of management. That being said, insertion of chest tubes has a high complication rate, with figures of 21-30% quoted in the literature8. This patient has a chest tube which could be intraparenchymal, or could be intrapleural but surrounded by the lung parenchyma.
In patients who have excessive blood loss (1500mL in 24 hours or 200mL per hour for successive hours), surgical exploration is indicated6. This can be with video-assisted thorascopic surgery (VATS) in haemodynamically stable patients, or thoracotomy in unstable patients.
After initial management, certain patients will have persistent thoracic clot loculation. If these clots are greater than 500mL in volume or account for over 1/3 of the hemithoracic volume, surgical intervention is required, either VATS or thoracotomy7.
Case contributed by A/Prof. Pramit Phal.
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