Student cases

the Tie goes to the Horse

thanks to Amber Neugebauer for this Student Case of the Week.

Patient is an ~55 y.o. woman who works as a horse trainer.  The animal she was working with kicked her just prior to arrival.  She was sent airborne and actually landed about 5 feet from where she was standing.  She has Left sided back pain at the location she was kicked.

This is similar to the impact phases when patients are hit by cars.  In that case first the legs are struck by the car’s bumper, next the torso and head impact the windshield, and finally the patient lands on the ground injuring just about anything.  In this case we have to consider not just the original site of impact where she was kicked, but also other injuries possible when she landed.

Our patient, however, really complains just of the back/flank pain.  The bruise is to the left flank a little lateral to the mid scapular line at the base of the rib cage.  She denies hitting her head or any concussion symptoms.  There is no neck pain.  She does have some pleurisy, the pain is worse with movement as well.  She denies abdominal discomfort.  She has no numbness or weakness of arms and legs and was able to ambulate to the bathroom on her way in from triage.  You notice as you sit down some pinkish urine in a specimen cup at the bedside.

On physical exam she has fairly normal vitals from a trauma standpoint, 164/85, 80, 18, 100%ra.  There is no evidence of head trauma. There is no discomfort to neck palpation.  Chest is clear though inspiration is somewhat limited by discomfort.  She does have LUQ discomfort on exam as well as discomfort to palpation of the flank in the area of the bruise.  There is no midline TLS pain.  Neuro exam is unimpressive.

A number of exam points.  She is not tachycardic, but she is in her 50’s.  Make sure if you’re going to use a normal heart rate as re-assuring that the patient is not on beta-blockers or other AV nodal agents that can prevent a physiologic tachycardia.  Can we clear her spine clinically?  She denies alcohol, denies head injury and exhibits no head injury symptoms.  She reports no neurologic deficits and has no neck discomfort.  The question is does she have a distracting injury, different providers are going to answer that question differently.  Our patient is ambulatory and comfortable appearing; we felt comfortable with clearing the C spine clinically.  Along those lines though, it’s interesting that she does not report abdominal pain by history but is tender in the LUQ.  She has gross hematuria.  FAST scan did not show free fluid, but was equivocal for a kidney injury; we couldn’t tell if there was a renal cyst or if there was acute pathology.  

Chest x-ray was unimpressive.  We proceeded to CT scan, see anything?

kidlac06

Do initials make it easier?

kidlac06b

The H is on the small hematoma and the L is on part of the (grade 2) renal laceration.

Here’s another view with just a tiny bit of blood between the kidney and the spleen.  The FAST would likely have been positive if we’d repeated it.

kidlac04

Remember, we see patients at one point in time.  Always consider that the condition may worsen; serial exams on patients who don’t appear to require CT is a must.

She also had some transverse process fractures.

kidlac09

As it turned out she had both old well-corticated fractures (1) as well as new fractures that didn’t have bone cortex regrown along the fracture lines (2).

kidlac09ed

There’s a few take-homes on this case.  First is that we didn’t see free fluid; the pt did have a small amount on CT.  Serial exams are a must if your FAST is initially negative.  Second, while we don’t put a lot of stock in microhematuria (in one series of ~1600 patients with blunt trauma, microhematuria, and abdominal CT exactly 3 (about 0.2%) had a significant renal injury) (2), gross hematuria is much more concerning.  In another series 80% of patients with grade 3 and above kidney lacerations had gross hematuria (1).  Between a quarter and a third of patients with kidney injuries will also have a splenic injury (I lost my source for that stat).  Grade 2 and 3 kidney injuries are generally managed non-operatively; we admitted our patient for serial exams and serial hemoglobin checks.  Grade 4’s may be treated non-operatively if the patient is hemodynamically stable.

References:

  • (1) Baverstock et al. Severe blunt renal truama: a 7 year retrospective review from a provincial trauma centre. Can J Urol.  2001  Oct; 8(5): 1372-6.
  • (2) Miller and McAninch. Radiographic Assessment of Renal Trauma: our 15 year experience. J Uro.  1995 Aug; 154(2): 352-355.

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