Pediatric emergency medicine trisk 3313 3313
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of the renal lesion. Additionally, hematuria may be absent in up to 50% of
patients with vascular pedicle injuries and in approximately one-third of patients
with penetrating injuries.
Renal injuries have been described using different classification systems based
on the clinical and radiologic assessment of the patient. In 1989, the Organ Injury
Scaling Committee of the American Association for the Surgery of Trauma
developed an injury severity score for classification of renal trauma with minor
modifications made over the years. This classification system is illustrated in
Figure 108.2 and is summarized below:
Grade I injuries include contusions or subcapsular, nonexpanding hematomas
and comprise 80% of all injuries to the kidney.
Grade II injuries include nonexpanding hematomas confined to the perirenal
fascia (Gerota’s) or lacerations less than 1 cm in depth without extension into
the collecting system or urinary extravasation.
Grade III injuries include lacerations extending more than 1 cm into the renal
cortex without collecting system rupture or urinary extravasation.
Grade IV injuries include lacerations extending into the collecting system,
lacerations of the renal pelvis, ureteropelvic junction (UPJ) disruptions, injuries
to the segmental renal arteries or vein, segmental infarctions due to thrombosis,
or active bleeding beyond the perirenal (Gerota’s) fascia.
Grade V injuries include completely shattered kidneys, avulsions of renal hilum
with devascularization of the kidney, or a devascularized kidney with active
bleeding.
Parenchymal contusions and hematomas are the most common renal injuries,
accounting for 60% to 90% of all lesions from blunt trauma. Lacerations account
for up to 10% of renal injuries and may involve disruption of the capsule,
collecting system, or both. Severe injuries, such as shattered kidney or pedicle
avulsions, constitute approximately 3% of renal injuries. Pedicle injuries result
from sheer force of the kidney with subsequent stretching of the renal vessels.
Initial Assessment
Evaluate all injured children thoroughly using a well-established pediatric trauma
protocol. Assessment of the genitourinary system can be undertaken once lifethreatening conditions have been identified and the child has been resuscitated.
Assess for flank and/or abdominal pain and the presence of flank ecchymosis or a
“seat belt sign,” since all of these findings indicate significant trauma and
possible renal injury.
