Pediatric emergency medicine trisk 3312 3312
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Blunt trauma accounts for more than 90% of renal injuries in children. The
majority result from motor vehicle accidents; falls, sports-related incidents, and
direct blows are also common mechanisms of injury. In these scenarios, the
kidneys are crushed against the ribs or vertebral column from their relatively
fixed position within Gerota fascia. Injuries include contusions, renal lacerations,
and rarely stretching of the vascular pedicle causing renal vein or artery injuries.
Penetrating trauma accounts for the 10% of remaining cases. Approximately 10%
of penetrating abdominal injuries involve the kidney.
Minor renal injuries account for 85% of total injuries, lacerations in 10%, and
severe kidney ruptures, fractures of pedicle injuries in less than 5% of cases.
Associated extrarenal injuries often occur, with head injuries being the most
common. Associated intraperitoneal injuries occur in 80% of patients with
penetrating renal trauma and 20% of patients with blunt renal trauma. In general,
the hospital length of stay is determined by the associated injuries and not the
renal injuries.
Historically, pre-existing anomalies have been believed to increase the risk and
severity of injury to the kidney. Coincidental congenital renal anomalies and
intrarenal tumors have been reported in up to 20% of children with renal injuries.
However, it appears that in most patients, congenital genitourinary anomalies
associated with renal injury are incidental findings and do not increase morbidity.
More accurate recent reviews show that the incidence rate is closer to 1%.
Nevertheless, a high index of suspicion should be maintained in any child who
presents with gross hematuria after a relatively minor trauma. Other patients may
present with an acute abdomen due to intraperitoneal rupture of a hydronephrotic
kidney.
Clinical Considerations
Clinical Recognition
Children who sustain significant renal injuries usually present with localized
signs such as flank tenderness, hematoma, palpable mass, or ecchymosis.
However, since kidney injuries are often associated with injuries to other organs,
generalized abdominal tenderness, rigidity of the abdominal wall, paralytic ileus,
and hypovolemic shock may all be part of the clinical picture. Penetrating injuries
to the chest, abdomen, flank, and lumbar regions should alert the clinician to the
possibility of a renal injury.
Hematuria has long been considered the cardinal marker of renal injury and
98% of pediatric patients suffering a renal injury will have some degree of
hematuria. However, the degree of hematuria does not correlate with the severity
