Presentation:
In their first bout for the World Heavyweight Boxing Championship, Adonis Creed, the reigning champion, and son of the late Apollo Creed, faces Viktor Drago. Ivan, the father of Viktor Drago, holds a notorious legacy as the man behind Apollo Creed’s fatal defeat in the ring years ago. Adonis, at the peak of his career, grapples with a whirlwind of emotions. He is not only seeking to avenge his father’s death but also aims to prove himself against the son of his father’s killer, all while shouldering the immense burden of honouring his father’s renowned legacy. Viktor Drago presents a daunting challenge. Towering over Creed with his superior size and strength, his approach in the ring is marked by aggression and an unyielding offensive. Creed struggles against Viktor’s strength and is overpowered in the initial rounds. The fight reaches a critical moment when Viktor lands illegal blows on Creed, leading to his disqualification and resulting in Creed retaining his championship by default. He was subsequently transported to the hospital by Emergency Health Services (EHS).
In the ED, the 28-year-old previously healthy Adonis, presents with left-sided flank pain. This pain was a direct result of multiple unguarded punches to his abdomen, particularly the left flank and left hypochondriac regions. Approximately 40 minutes following the conclusion of his match, Adonis was transported by EHS to the hospital. Upon arrival, his vital signs were remarkably stable, reflecting his excellent physical conditioning. His Glasgow Coma Score was recorded at 15 and his pupils responded normally to light, being bilaterally reactive. When questioned, Adonis demonstrated full alertness and orientation, a testament to his resilience despite the recent trauma. He reported experiencing unilateral periorbital pain localized to the left eye, accompanied by a mild headache, neck pain, and pain upon inspiration. Notably, his left flank pain had intensified, and he described his urine as grossly bloody. However, he denied any difficulty in voiding, chest pain, dizziness, gastrointestinal symptoms, fevers, or chills. Despite his career involving 25 professional fights, Adonis had no history of prior traumatic injuries.
His physical examination revealed him to be neurologically intact. However, he displayed apparent signs of trauma, such as unilateral periorbital pain, edema, and ecchymosis around the left eye. Further examination revealed left costovertebral angle tenderness (CVA) and ecchymosis over the left flank area. His abdominal examination was unremarkable, with normal bowel sounds and no evidence of distention. Notably, no active bleeding was noted in any other areas, and his digital rectal examination (DRE) was unremarkable.
Which investigations are appropriate in suspected blunt-force renal injury?
While there are many suspected concomitant pathologies that Adonis presents with today, the purpose of this article will be to focus on his worsening left flank and hematuria, his chief complaints. Creed’s symptoms are indicative of blunt renal trauma, a common injury in high-contact sports such as professional boxing, where sustained blunt-force trauma is prevalent.
Initial Assessment and Diagnostic Considerations:
The approach to suspected renal injury hinges on the patient’s hemodynamic stability. Upon presentation, it is essential to commence the evaluation of any trauma patient with a thorough assessment of their Airway, Breathing, and Circulation (ABCs), followed by a complete primary and a detailed head-to-toe secondary survey as recommended in Advanced Trauma Life Support (ATLS). This systematic approach is critical in identifying immediate life-threatening injuries and guiding subsequent management steps.1
A Focused Assessment with Sonography for Trauma (FAST) is an invaluable tool in the initial trauma assessment. The primary objective of the FAST exam is to rapidly identify the presence of abnormal fluid collections in the pericardial, intrathoracic, or intraperitoneal regions, or the presence of a pneumothorax.2,3 However, when a patient presents with flank pain and hematuria, raising concerns of blunt renal trauma, the FAST exam typically falls short in detecting retroperitoneal bleeding.4
In the context of a professional boxer like Adonis, presenting with flank pain and hematuria following a fight, a thorough evaluation was imperative to consider a broad spectrum of potential injuries. This included key differential diagnoses such as traumatic injuries to the spleen or liver, like ruptures, hematomas, or lacerations, which are particularly vulnerable in blunt force abdominal trauma. Other significant injuries to consider were genitourinary trauma, gastrointestinal perforations, vascular injuries, diaphragmatic rupture, pelvic fractures, and abdominal compartment syndrome.5
Upon arrival, Adonis was able to maintain his airway and showed stable vital signs, indicating hemodynamic stability. Despite the hematuria from blunt abdominal trauma indicating potential bladder rupture, Adonis’s normal voiding and lack of suprapubic tenderness reduced the likelihood of a bladder injury. This clinical picture was corroborated by the pelvic view from his FAST scan performed concurrently with the primary survey, which revealed a full bladder without any free fluid in the abdomen.
What is the Appropriate Imaging Technique?
Dual-phase CT scanning is the gold standard for staging traumatic renal injuries according to American and Canadian recommendations.6,7 Intravenous pyelography is viewed as a less effective imaging technique than CT, primarily because of its lower-quality imaging. Although MRI scans offer diagnostic accuracy comparable to CT, their logistical challenges render them impractical for use in acute trauma situations.7,8
How are renal injuries classified?
Renal injuries are classified according to The American Association for the Surgery of Trauma (AAST) classification (Table 1).
Table 1: AAST renal injury grading system.9,10
In this case…
Adonis presented to the emergency department with left-sided flank pain, hematuria, and abdominal bruising. His primary survey found he is hemodynamically stable, appears well, and is otherwise healthy. His features would meet the criteria for CT renal imaging with contrast to accurately identify the grade of renal injury. His wife Bianca was told by the doctor that he had a “ruptured kidney”, and that “his injuries will heal with rest and time”. Given current evidence, we hypothesize that he sustained a grade 1 or 2 kidney injury.
What management did/should Adonis receive?
A hemodynamically stable patient with renal trauma should generally be managed conservatively and nonoperatively (Figure 1).
What constitutes conservative management?
A conservative management approach encompasses rest, supportive care, regular clinical evaluations, and ongoing laboratory monitoring with repeat imaging. Furthermore, a urinalysis, CBC and baseline creatinine should be obtained.10 The aim of conservative management in renal injuries is to avoid unnecessary surgical interventions, reduce the incidence of unwarranted nephrectomies and ultimately preserve renal function.11
When is surgical intervention indicated?
The decision to pursue surgical intervention is primarily influenced by the severity of the injury. The guidelines for surgical exploration of a damaged kidney are nuanced and vary based on several factors. For most renal trauma cases, particularly those classified as low (grade I, II) or intermediate grade (grade III), non-interventional management is typically recommended.10
However, the consensus on managing high-grade blunt injuries (Grade IV, V) is less definitive, and the choice between operative and non-operative management often becomes a subject of clinical debate.10 Surgical intervention is generally considered under specific conditions, such as persistent bleeding, bilateral kidney injuries, severe damage to a single kidney, and continuous or worsening urine extravasation. Additionally, immediate surgical attention is warranted if there is any suspicion of injury to the renal pelvis or ureter.12
Several risk factors increase the likelihood of surgical intervention. These include the size of the hematoma, evidence of penetrating trauma, leakage of vascular contrast, extension of the hematoma beyond the renal capsule, concurrent injuries, and the presence of shock.13,14 In cases where a patient remains hemodynamically unstable despite resuscitation efforts, surgical intervention is indicated.15 The primary goals of such surgical procedures are to repair the kidney, if feasible, and to establish vascular control, thus mitigating the risk of further complications and preserving renal function.10
What are the types of surgical interventions?
In the treatment of blunt renal trauma, interventions are generally categorized into two main types: angioembolization and surgical management.15 Angioembolization, a minimally invasive procedure, plays a crucial role, especially for hemodynamically stable patients experiencing ongoing bleeding.10 It combines the techniques of angiography, which involves imaging blood vessels, with embolization, a process that entails blocking off small blood vessels supplying abnormal tissue. Performed by interventional radiologists, this minimally invasive technique aims to achieve hemostasis and maintain the integrity of the renal parenchyma.16
In situations with continuous urinary extravasation, the treatment strategy may involve the placement of a stent or performing percutaneous drainage, depending on the specific clinical context.10,17,18 It’s noteworthy that catheterization is not routinely required for stable patients with low-grade injuries. However, for those presenting with severe visible hematuria, catheterization could be beneficial, particularly for monitoring purposes or if stenting is necessitated. Once the hematuria resolves and the patient regains mobility, the catheter should be promptly removed to prevent any associated complications.10
Regarding surgical management, renorrhaphy is the preferred technique for repairing damaged or lacerated kidneys. This method involves careful stitching or suturing of the renal tissue. In cases where renal tissue is deemed non-viable, a partial nephrectomy may be required to remove the affected portion of the kidney.10
In more severe scenarios, such as unstable patients with blunt renal injuries and significant hemorrhage characterized by a pulsatile, expanding hematoma, a nephrectomy is often indicated.19 This surgical removal of the kidney is a critical intervention in managing life-threatening conditions and stabilizing the patient.
Is follow-up imaging needed?
In managing blunt renal trauma, the follow-up protocol is a critical component, involving a comprehensive physical examination, urinalysis, diagnostic imaging, blood pressure measurement, and serum creatinine evaluation. Within this framework, ultrasonography emerges as a viable option for follow-up imaging as a readily available modality with no radiation.10 Additionally, assessing renal function through functional nuclear scanning approximately three to four months post-injury has been reported to be beneficial.10 This approach is key in identifying potential complications, which are primarily detected through imaging. However, it’s important to note that in cases of low-grade, uncomplicated renal injuries, routine follow-up imaging is not typically recommended.10 Routine re-imaging for renal trauma patients after the initial 48 hours, without specific clinical reasons, is generally not beneficial and alters treatment in less than 1% of cases. For injuries graded 1-4, repeat imaging can usually be safely skipped if the patient remains clinically stable. However, for more severe grade 5 parenchymal injuries, routine re-imaging might be helpful for early detection of complications such as pseudo-aneurysms, despite low diagnostic yield.10,20
In this case…
Adonis Creed suffered blunt renal trauma, and his medical management at the hospital was indicative of a conservative approach typically adopted for such injuries. His physician informed his wife, Bianca, that Adonis’s kidney required rest and time to heal, emphasizing that surgical intervention was not necessary at the current stage. However, as a precautionary measure, Adonis was to be monitored closely for the next 48 hours to ensure no complications arose. The use of surgery was deemed unlikely, but vigilance in monitoring his condition was crucial. Given his stable condition and low-grade injury, both a catheter and follow-up imaging were not indicated. To manage his pain, Adonis was administered morphine, a standard analgesic in trauma care, which is effective in alleviating severe discomfort.
In due course, Adonis made a complete recovery and returned to his training with his mentor and long-time coach, Rocky Balboa. He eventually faced and triumphed over his rival, Viktor Drago, in a rematch. This case highlights a critical aspect of medical practice, especially in the context of high-risk professions like professional fighting. As medical providers, it is imperative to educate our patients about the health risks associated with such activities.
Figure 1: Treatment algorithm for renal injury (source: https://www.uptodate.com/contents/management-of-blunt-and-penetrating-renal-trauma?search=renal%20injury&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1e)
This post was copy-edited by Noaah Reaume.
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