A 62 yo. male past history of HTN, CVA, on warfarin presents after he was struck by a pick-up truck on his left side while crossing the street.  He complains of left-sided sharp chest pain.  He has left chest, flank, and upper quadrant tenderness as well as abdominal distention.  A CT is shown.  What's the diagnosis?  Scroll down for answer

Answer: left renal subcapsular hematoma (thick arrow) with left retroperitoneal and pelvic sidewall hematoma (thin arrow)

Subcapsular Renal Hematoma

Etiology:  Most commonly blunt trauma (fall, MVC) less often penetrating trauma (GSW)

Presentation:  Patients c/o flank, abdominal and chest pain.  May have hematuria, bruising (seat belt sign) over lower ribs, upper abdomen.

Diagnosis: Most often made by CT

• Grade 1: Subcapsular hematoma and, or renal contusion
• Grade 2: Cortex laceration </= 1 cm in depth
• Grade 3: Cortex laderation > 1 cm with involvement of corticomedullary junction
• Grade 4: Laceration involving the collecting system with urinary extravasation
• Grade 5: Shattered or devascularized kidney with active bleeding; main renal vascular laceration or avulsion

Management: As trauma patient (IV access, resuscitation, consider other injuries and imaging.  Labs including CBC, chemistry, coags, UA, type and screen).  Transfer to trauma center/ service.  Management in consultation.

• Grade 1 and 2: non-operative, bedrest until hematuria resolves
• Grade 3 and 4: to consider surgical managment, antibiotics for Grade 4
• Grade 5: surgical intervention, antibiotics

Managment interventions include surgery, stenting, selective angiographic embolization to control hemorrhage

Resources: 

Armenakas, Noel. Renal Injuries. Merck Manuals. https://www.merckmanuals.com/professional/injuries-poisoning/genitourinary-tract-trauma/renal-trauma

Erlich T, Kitrey ND. Renal trauma: the current best practice. Ther Adv Urol. 2018;10(10):295-303. Published 2018 Jul 10. doi:10.1177/1756287218785828