Hrev_master Abstract Rugby-related renal trauma is rare and identification of a young patient with renal trauma secondary to sports who requires observa- tion versus further radiological evaluation in the emergency depart- ment (ED) poses a diagnostic challenge. We report a case of a 16- year-old girl who presented to the ED with abdominal pain after being tackled during a game of rugby. Examination revealed tender- ness over the right lateral lower ribs and right flank. Blood tests were normal and bedside ultrasound did not show any free intraperitoneal fluid. Urinalysis showed gross hematuria. She was pain-free after analgesia but had a syncopal episode in the ED. A computed tomog- raphy (CT) scan of the abdomen and pelvis showed a complex right lower pole renal laceration and she was admitted to the Intensive Care Unit. She remained stable and was discharged. Assessment with urinalysis, hematocrit, and creatinine is required during the evaluation of a patient with suspected renal trauma. CT scan is the imaging modality for the diagnosis and grading of renal injury. Conservative treatment is the mainstay of therapy, but some patients require angioembolization of surgical intervention. Patients must discuss with their physician regarding the optimal timing of return to rugby. Rugby-related renal trauma is rare and poses a challenge for emergency physicians regarding their evaluation and management in the ED. AAST-OIS grading of renal trauma on CT imaging helps guide appropriate management decisions. Introduction Patients with renal trauma account for 10% of cases with abdom- inal trauma,1 with kidneys being the third most injured solid organ after liver and spleen. The majority of cases of renal trauma are sec- ondary to road traffic crash, fall from height, and assault. There is an increasing incidence (16-30%) of renal trauma secondary to contact sports.2 We report a case of a traumatic kidney injury in a 16-year-old girl after being tackled during a game of rugby. Case Report A 16-year-old female patient was tackled on her right side by another player during a rugby game. After going home, she com- plained of right flank pain and nausea. On arrival in ED, she was alert and her vital signs showed a heart rate of 72 beats/min, respi- ratory rate of 17 breaths/min, blood pressure of 111/63 mm Hg, and oxygen saturation of 100%. On examination, there was tender- ness over the right lateral lower ribs and right flank, but there were no signs of peritonism. Her blood investigations were normal, with a hemoglobin of 111x109 g/L, creatinine of 68 umol/L, and lactate of 1.5mmol/L. Plain radiographs of the chest and pelvis were normal. Extended focused assessment by sonography in trauma (E-FAST) showed a sliver of free fluid within the right renal capsule (Figure 1A) and hyperdensity noted within the urinary bladder suggestive of a blood clot (Figure 1B). Urinalysis showed gross hematuria. She was given analgesia with a resolution of pain. She attempted to mobilize and had a syncopal episode. Repeat hemoglobin was 94 g/L. Given hematuria, hemoglobin drop, and syncopal episode, a computed tomography (CT) scan of the abdomen and pelvis was done which showed a complex right lower pole renal laceration (AAST Grade III) with associated retroperitoneal fluid/blood (Figure 2), but no active hemorrhage. She was admitted to the Emergency Care Journal 2023; volume 19:11577 [Emergency Care Journal 2023; 19:11577] [page 97] Renal trauma during a rugby tackle Sohil Pothiawala,1,2 Rebecca Schroll3 1Trauma & Emergency Services, Auckland City Hospital, Auckland, New Zealand; 2Department of Emergency Medicine, Woodlands Health, Singapore; 3Trauma Surgeon, Auckland City Hospital, Auckland, New Zealand Correspondence: Sohil Pothiawala, Trauma and Emergency Services, Auckland City Hospital, 2 Park Road, Grafton, Auckland 1023, New Zealand. Tel.: +6593372209. E-mail: drsohilpothiawala@yahoo.com Key words: sports; trauma; kidney; rugby; hematuria. Conflict of interest: the authors declare no potential conflict of inter- est, and all authors confirm accuracy. Contributions: SP conceptualized the manuscript and wrote the ini- tial draft of the manuscript. RS reviewed and edited the manuscript. The final version of the manuscript has been read and approved by all authors. Ethics approval and consent to participate: no ethical committee approval was required for this case report by the Department, because this article does not contain any studies with human partic- ipants or animals. Informed consent was obtained from the patient included in this study. Patient consent for publication: the patient gave her written consent to use her personal data for the publication of this case report and any accompanying images. Availability of data and materials: all data underlying the findings are fully available. Received: 9 July 2023. Accepted: 21 August 2023. Early view: 13 September 2023. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Emergency Care Journal 2023; 19:11577 doi:10.4081/ecj.2023.11577 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. Non -co mmerc ial us e o nly Intensive Care Unit for observation, and serial hemoglobin mea- surements did not show any further drop. The patient remained sta- ble and was discharged after 4 days. She was advised to avoid sports for 6 weeks, and given an outpatient follow-up with urology. She was stable during her follow-up assessments. Discussion Contact sports like rugby, boxing, football/soccer, hockey, gymnastics, and horse riding can lead to renal trauma. Children are at higher risk for renal injury than adults,3 and the majority of kid- ney injuries from rugby/football have been noted in patients in the 16–18-year age group.4 Most patients with kidney injury have relatively minor injuries. A significant indicator of renal trauma is a direct blow to the abdomen, flank, or mid/lower back, as seen during a tackle in rugby. Vital signs documentation during the evaluation of the patient helps assess for hemodynamic stability. Physical examina- tion may reveal abdominal tenderness, distention, guarding, bruis- ing around the flank, or other associated injuries. Traumatic kidney injury is more likely in patients with pre-existing kidney abnormal- ities.5 Urinalysis must be done in all patients suspected to have renal trauma, along with measurement of hematocrit and creatinine. Hematuria (gross or microscopic) is a good indicator of renal injury but does not correlate with the degree of injury. Counterintuitively, patients with major kidney injuries such as renal pedicle injury, disruption of the urethra-pelvic junction, renal artery laceration or avulsion, and/or arterial thrombosis may not have hematuria.6,7 Moreover, false negative urinalysis is found in 3-10% of the patients.5 Bedside FAST is used to identify hemoperitoneum, but can also identify kidney laceration or perinephric hematoma. Although challenging to determine the extent of renal injury on ultrasound, it is useful to identify patients who may benefit from further radi- ological evaluation. Hemodynamically stable patients with gross hematuria must undergo further evaluation with a CT scan with contrast to look for kidney injury, grade the renal injury, detect active extravasation of blood, and identify injuries to other organs.1,8 The American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS)9 is the most widely used CT cor- related grading system for renal trauma (Table 1). The indications for radiologic evaluation of renal injury in blunt trauma include: i) clinical signs suggestive of renal trauma e.g., abdominal tenderness, distension, flank pain, ipsilateral lower rib fractures; ii) gross hematuria; iii) microscopic hematuria and one episode of hypotension (pre-hospital or initial ED systolic BP <90mm Hg); iv) presence of other major injuries Hemodynamically stable patients with microscopic hematuria, those with low-grade renal injuries (I-III), and even those with high-grade renal injuries (IV-V) can be managed conservatively. Case Report Figure 1. E-FAST showing a sliver of free fluid within the right renal capsule (A) and hyperdensity within the urinary bladder suggestive of a blood clot (B). Figure 2. Computed tomography (CT) scan of abdomen and pelvis showing a complex right lower pole renal laceration (AAST Grade III). [page 98] [Emergency Care Journal 2023; 19:11577] Non -co mmerc ial us e o nly Conservative management includes observation, bed rest, serial abdominal examination, and assessment of hemoglobin/hematocrit till hematuria resolves. Monitoring hemoglobin trends is useful for decision-making, either to continue conservative management or transition to further intervention. Primary non-operative manage- ment is not associated with any increase in immediate or long-term morbidity and is associated with a reduced rate of renal loss and blood transfusion compared to operative management.2, 3 As our patient had a Grade III laceration of the lower pole of the right kid- ney with intact vascular structures and no active hemorrhage, she was admitted and managed conservatively. The urologist review suggested no need for any intervention. Her serial abdominal examinations were normal and her hematocrit remained stable, and she was discharged upon resolution of hematuria. Angiography and selective embolization have shown a high success rate in the management of patients with high-grade (Grade IV and V) renal injuries with ongoing bleeding or vascular compli- cations.3,10 Patients with significant extravasation of urine on CT scan should be treated with retrograde ureteral stents to prevent development of a urinoma.2 Surgical intervention is required in less than 5% of patients, especially for hemodynamically unstable patients, or those with complete avulsion of the ureteropelvic junc- tion, or an expanding/pulsatile retroperitoneal hematoma sugges- tive of renal pedicle injury, to control hemorrhage and salvage the kidney.1 3-10% of patients with renal trauma develop complications like urinoma, delayed bleeding, hypertension, hydronephrosis, pyelonephritis, perinephric abscess, arteriovenous fistula, urinary fistula, and pseudoaneurysm.11 As the risk of complications is higher in patients with high-grade injuries, these patients should be discharged with appropriate follow-up with trauma/general surgery and/or urologist. Physicians must discuss the risk of poten- tial complications and long-term sequelae with the patient. Patients who are managed conservatively should avoid sports for at least 6 weeks, while those with high-grade renal injury may take longer time to heal and should avoid returning to sports for 6 to 12 months. However, the decision regarding the appropriate time to resume contact sports must be decided on a case-by-case basis, depending on the severity of the injury. Conclusions Rugby-related renal trauma is rare and poses a challenge for emergency physicians regarding their evaluation and management in the ED. AAST-OIS grading of renal trauma on CT imaging helps guide appropriate management decisions. Conservative treatment is the mainstay of therapy, but some patients may require angioembolization or surgical intervention. Physicians must advise the patient regarding the long-term sequelae, and the optimal time to resume rugby. References 1. Harper K, Shah KH. Renal trauma after blunt abdominal injury. J Emerg Med 2013;45:400-4. 2. Freeman CM, Kelly ME, Nason GJ, et al. Renal trauma: the rugby factor. Curr Urol 2015;8:133–7. 3. Hagedorn JC, Fox N, Ellison JS, et al. Pediatric blunt renal trauma practice management guidelines: Collaboration between the Eastern Association for the Surgery of Trauma and the Pediatric Trauma Society. J Trauma Acute Care Surg 2019;86:916-25. 4. Kim JK, Koyle MA, Lee MJ, et al. A systematic review of gen- itourinary injuries arising from rugby and football. J Pediatr Urol 2020;16:130-48. 5. Kitrey ND, Campos-Juanatey F, Hallscheidt P, et al. EAU guidelines on urological trauma. Accessed 5th July 2023. Available from: https://uroweb.org/guidelines/urological-trau- ma/panel. 6. Alsono RC, Nacenta SB, Martinez PD, et al. Kidney in danger: CT findings of blunt and penetrating trauma. Radiographics 2009;29:2033–53. 7. McAndrew JD, Corriere JN Jr. Radiographic evaluation of renal trauma: evaluation of 1103 consecutive patients. Br J Urol 1994;73:352–4. 8. Hardeman SW, Husmann DA, Chinn HK, Peters PC. Blunt uri- nary tract trauma: identifying those patients who require radi- ological diagnostic studies. J Urol 1987;138:99–101. 9. Kozar RA, Crandall M, Shanmuganathan K, et al. Organ injury scaling 2018 update: Spleen, liver, and kidney. J Trauma Acute Care Surg 2018;85:1119-22. 10. Hom J. The risk of intra-abdominal injuries in pediatric patients with stable blunt abdominal trauma and negative abdominal computed tomography. Acad Emerg Med 2010;17:469–75. 11. Alhazmi HH. Sport-related renal injuries among children: A review of literature. Saudi J Sports Med 2016;16:93-100. Case Report [Emergency Care Journal 2023; 19:11577] [page 99] Table 1. AAST-OIS for renal trauma. Grade Type Description I Contusion Microscopic or gross hematuria. Normal urological studies Haematoma Subcapsular, non-expanding without parenchymal laceration II Haematoma Non-expanding perirenal haematoma confined to renal retroperitoneum Laceration <1 cm parenchymal depth of renal cortex without urinary extravasation III Laceration >1 cm parenchymal depth of renal cortex without collecting system rupture or urinary extravasation IV Laceration Parenchymal laceration extending through the renal cortex, medulla, collecting system Vascular Main renal artery or vein injury with contained hemorrhage V Laceration Completely shattered kidney Vascular Avulsion of renal hilum that vascularized kidney Non -co mmerc ial us e o nly