Trauma

Question 1

i )Most common mechanism of renal trauma
ii) Does haematuria indicate severity of renal injury?

Answer 1

i) Blunt - 80%
ii) No
- 13% penetrating renal truama have no haematuria
- 12.5% of patients with multisystem trauma have confirmed renal trauma

Question 2

History taking / Examination in renal trauma

Answer 2

History:
i) Mechanism, Time-Line
ii) pre-existing renal abnormalities

Examination:
i) haematuria, Flank pain/tenderness
ii) Ecchymosis
iii) Ribfractures

Question 3

When to image in suspected renal trauma

Answer 3

i) VH (In Paeds - NVH also)
ii) NVH and
SBP< 90mmHg/ OR Major associated injuries
iii) Mechanism - Rapid Deceleration, Hihglikelihood, Pentrating abdominal/torso trauma

Question 4

Imaging in renal trauma:
i) Gold Standard
ii) Unstable going to laparotomy?

Answer 4

i) CT Triple Phase with Delayed Phase (Urographic)
ii) One shot IVU (2 ml/kg contrast and then single film after 10 mins)

Question 5

What do the following indicate in context of renal trauma:
i) Lack of contrast enhancement
ii) Haematoma medial to kidney / Displacing vasculature

Answer 5

i) Pedicle Injury
ii) Renal Vein Injury

Question 6

AAST Classification of renal Trauma

Answer 6

1 - Bruse
2 - Small Cut
3 - Big Cut
4 - Wet Cut
5 - Shattered

Question 7

Management:
i) Grade 1-4 Blunt/ Grade 1-3 Penetrating Stable
ii) HD Unstable, Grade V Renal Injury
iii) Expanding / Pulsatile Haematoma at time of of laparotomy
iv) Solitary Injury with contrast extravasation
v) Bilateral Grade 4-5 Injury
vi) Solitary Kidney Renal Artery Injury

Answer 7

i) Conservative - Antibiotics, Bedrest, Monitoring
ii) Intervention - SAE, Repeat SAE, Before Surgical Exploration
iii) Exploration -> Renoraphy/ Repair / Laparotomy
iv) Can manage conservatively. >90% Extravasation Spontaneously resolved.
v) Consider Renal Artery Repair
vi) Consider Renal Artery Repair

Question 8

What is the incidence of nephrectomy if surgical exploration is chosen?

Answer 8

75%

Question 9

Can you embolise the main renal artery?

Answer 9

Yes:
- Can be definitive procedure if not suitable for surgery
- Can be a bridge to interval nephrectomy

Question 10

Surgical Approach for Emergency Nephrectomy

Answer 10

Ideally Transperitoneal
- Control pedicle before exploring haematoma
- Retropertioneal incision over aorta superior to IMA OR Incision can be made medial to IMV

Question 11

Indications for SAE

Answer 11

Active Haemorrhace
Pseudoaneurysm
AV Fistula

Question 12

FU after conservative management of renal trauma

Answer 12

Major Injuries require FU
i) Repeat Imaging (2-4 days)
ii) 3 months - Renogram (Functional Recovery), Creatinine, BP (renovascular HTN)

Question 13

Causes of iatrogen ureteric injury

Answer 13

Suture - Ligation/Kinking
Crushing - Clamps
Transection
Thermal Injury
Ischaemia due to devasuclarisation

Question 14

Ix for iatrogenic ureteric injury

Answer 14

Intraop:
Cystoscopy + RGS
Direct Visualisation
IV Methylene Blue

Post-Op:
CTU
Cystoscopy/EUA/RGS

Question 15

Classification of ureteric trauma

Mx
Surgical Technique

Answer 15

AAST Classification:
1 - Haematoma
2 - Laceration <50%
3 - Laceration >50%
IV - Complete tear <2cm
V - Complete Tear >2cm

Mx:
I-II - Stent
II - III - Stent + Primary Closure
III-IV - Stent/Reconstruction

Proximal : Uretero-Ureterostomy/ Ureterocalycstostomy
Middle - Uretero-Ureterostomy/Boari Flap/Transureteroureterostomy
Distal - Psoas Hitch/Reimplantation/Transureteroureterostomy
Complete - Ilieal Interposition/ Autotransplantation

Question 16

Re-stenosis rate / Revision Rate post ureteric reconstruction

Answer 16

Stenosis rate - 4%
Revision - 10%

Question 17

Bladder Trauma:
History
Exam
Ix

Answer 17

History - Trauma, Pelvic Fracture, Penetrating Injuries (?Other organs involved)
Exam - Low abdominal tenderness/distension/low UO
Ix - Cystogram/ CT Cystogram

Question 18

Evidence of intraoperative bladder injury

Answer 18

Laparoscopy - Blood/gas in catheter bag
Cystoscopic:
- Dark space between detrussor fibres, Bladder not distending, Irrigation fluid not returning,

Question 19

Investigations for suspected bladder injury

Answer 19

Cystogram ( 350 ml of contrast)
- Need AP/Oblique and post-drainage film
Cystoscopy

Question 20

Types of bladder injury

Answer 20

Extraperitoneal (60%)
- Ax with pelvic fracture, Urine extravasation confined to perivesical space
Intraperitoneal (30%)
- Blunt trauma to full bladdder, Urine extravasation into peritoneal cavity

10% have combined injury

Question 21

Classification of bladder injury

Answer 21

1 - Hamatoma/ Partial Thickness LAceration
2- EP Laceration <2cm
3 - EP Laceration >2cm or IP laceration <2cm
4 - IP Laceration >2cm
5- Laceration extending to bladde neck or ureteric orifice

Question 22

Mx of:
EP Bladder Injury
IP Bladder Injury

Answer 22

EP
Conservative -2/52 catheter + Abx
Surgical if:
- Open Pelvis Fracture, Bone in bladder, Other pelvic visceral injury, Penetrating injury, BN Injury, Failed Conservative management

IP
TP Repair + Either urethra/SPC afterward
If small defect then catheter and monitor

Question 23

Testicular Trauma - when to manage:
Conservatively
Surgically

Answer 23

i) Conservative:
Tunica Intact, Haematocele <3 times that of testis, Small intratesticular haematoma
Mx - NSAIDS + Scrotal Support

ii) Surgical:
Tunica disrupted, Dx uncertainty, Large/Expanding haematoma, Penetrating injury, degloving injury, testicular dislocation
Mx - Remove devitalised tissue and close tunica, Orchidectomy if shattered/infarcted, Fixation if testicular dislocation

Question 24

Mx of Zipper Injury

Answer 24

Children GA/ Adult LA

Divide median bar of zipper - seperate faceplates

Question 25

Unstable patient suspected ureteric/ bladder trauma

Answer 25

Best to tie off ureters and leave BL nephrostomies