Working Diagnosis:
Grade 3 renal laceration with associated peri-nephric hematoma

Treatment:
The patient was admitted overnight with consultation with urology and general surgery. He received intravenous fluids and pain medications. He was monitored for any worsening flank pain, abdominal distention, or fever. He remained symptomatically stable overnight. His lab values normalized including serum creatinine. He did not require surgical intervention and was discharged in stable condition on the evening of second day.

Outcome:
The patient was held out of all contact sports activity for 12 weeks. He had a follow up appointment with urology at 5 weeks and repeat CT of the abdomen and pelvis with contrast was recommended. Pending imaging, he may be cleared by urology and general surgery to return to non-contact play. But, the team physician also cleared in agreement with urology and general surgery for the athlete to start a return-to-play protocol at 12 weeks. He returned to full contact sports without residual issues.

Author's Comments:
Blunt abdominal trauma is a common cause of injury in contact sports. Renal injuries are statistically less common, however often require imaging and urological evaluation when they do occur. Renal lacerations tend to present with flank pain and gross hematuria. The American Association for the Surgery of Trauma (AAST) grades renal lacerations from 1-5 based on contusion, hematoma formation, laceration depth, extent of genitourinary system involvement, and vascular injury.

This athlete's renal laceration was a grade 3 injury due to the laceration being greater than 1 cm deep (over grade 2), association with hematoma confined to the peri-nephric fascia (grade 3), and the lack of involvement with the renal pelvis or ureteral collecting system (under grade 4).

Editor's Comments:
This highlights the importance of high index of suspicion for traumatic abdominal injury despite a normal exam using the mechanism of injury along with the history. Close follow-up and return to play guidelines were followed based on the diagnosis. It is important to note that the spleen and the liver are the most commonly injured abdominal organs in the face of trauma.

References:
Bernard JJ. Renal trauma: evaluation, management, and return to play. Curr Sports Med Rep. 2009;8(2):98-103.

Bodhit AN, Bhagra A, Stead LG. Abdominal trauma: never underestimate it. Case Rep Emerg Med. 2011;2011:850625.

Harper K, Shah KH. Renal trauma after blunt abdominal injury. J Emerg Med. 2013;45(3):400-404.

Wexler RK, Parmar A. Renal laceration in a high school football player. Phys Sportsmed. 2003;31(2):43-46.

Zanchi C, Boscarelli A, Cattaruzzi E, Barbi E. Adolescent Male With Severe Renal Trauma. Ann Emerg Med. 2021;77(6):592-630.

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