Grade V renal trauma management: results from the multi-institutional genito-urinary trauma study.

PURPOSE: To investigate management trends for American Association for the Surgery of Trauma (AAST) grade V renal trauma with focus on non-operative management. METHODS: We used prospectively collected data as part of the Multi-institutional Genito-Urinary Trauma Study (MiGUTS). We included patients with grade V renal trauma according to the AAST Injury Scoring Scale 2018 update. All cases submitted by participating centers with radiology images available were independently reviewed to confirm renal trauma grade. Management was classified as expectant, conservative (minimally invasive, endoscopic or percutaneous procedures), or operative (renal-related surgery). RESULTS: Eighty patients were included, 25 of whom had complete imaging and had independent confirmation of AAST grade V renal trauma. Median age was 35 years (Interquartile range (IQR) 25-50) and 23 (92%) had blunt trauma. Ten patients (40%) were managed operatively with nephrectomy. Conservative management was used in nine patients (36%) of which six received angioembolization and three had a stent or drainage tube placed. Expectant management was followed in six (24%) patients. Transfusion requirements were progressively higher with groups requiring more aggressive treatment, and injury characteristics differed significantly across management groups in terms of hematoma size and laceration size. Vascular contrast extravasation was more likely in operatively managed patients though a statistically significant association was not found. CONCLUSION: Successful use of nonoperative management for grade V injuries is used for a substantial subset of patients. Lower transfusion requirement and less severe injury radiologic phenotype appear to be important characteristics delineating this group.

Improved chest wall trauma taxonomy: an interdisciplinary CWIS and ASER collaboration.

PURPOSE: Chest wall injury taxonomy and nomenclature are important components of chest wall injury classification and can be helpful in communicating between providers for treatment planning. Despite the common nature of these injuries, there remains a lack of consensus regarding injury description. The Chest Wall Injury Society (CWIS) developed a taxonomy among surgeons in the field; however, it lacked consensus and clarity in critical areas and collaboration with multidisciplinary partners. We believe an interdisciplinary collaboration between CWIS and American Society of Emergency Radiology (ASER) will improve existing chest wall injury nomenclature and help further research on this topic. METHODS: A collaboration between CWIS and ASER gathered feedback on the consensus recommendations. The workgroup held a series of meetings reviewing each consensus statement, refining the terminology, and contributing additional clarifications from a multidisciplinary lens. RESULTS: After identifying incomplete definitions in the CWIS survey, the workgroup expanded on and clarified the language proposed by the survey. More precise definitions related to rib and costal cartilage fracture quality and location were developed. Proposed changes include more accurate characterization of rib fracture displacement and consistent description of costal cartilage fractures. CONCLUSIONS: The 2019 consensus survey from CWIS provides a framework to discuss chest wall injuries, but several concepts remained unclear. Creating a universally accepted taxonomy and nomenclature, utilizing the CWIS survey and this article as a scaffolding, may help providers communicate the severity of chest wall injury accurately, allow for better operative planning, and provide a common language for researchers in the future.

Computed tomography-based volume calculations of renal ischemia predicts post-traumatic renal function after renal infarction injury.

OBJECTIVES: To describe a systematic method to quantify the severity of renal infarction injury and assess its association with post-traumatic renal function after blunt trauma. METHODS: We retrospectively reviewed all patients who suffered an AAST grade IV renal infarction injury without active bleeding secondary to blunt trauma between 1/2010 and 10/2020. Only patients with a pre-traumatic eGFR within 12 months of injury and post-traumatic eGFR within 3-12 months were included. Percentage of renal ischemia was defined as: (ischemic volume/total volume) × 100%. Two radiologists reviewed computed tomography images to determine ischemic and overall cross-sectional areas using the polygon region of interest tool. These areas were multiplied by slice thickness to obtain ischemic and total volumes. Intraclass correlation coefficient was used to assess consistency between radiologists. Linear regression analyses were used to assess the association between percentage of renal ischemia and post-traumatic renal function. RESULTS: Thirty-five of 140 (25.0%) patients met inclusion criteria. The median (IQR) pre-trauma eGFR was 107.7 ml/min/1.73m2 (90.6-121.8), percentage of renal ischemia was 8.4% (2.9-30.1), and decrease in eGFR after trauma was 12.9 ml/min/1.73m2 (0.4-32.6). There was excellent reliability in calculating ischemic volume (ICC = 0.987) and total kidney volume (ICC = 0.995) between two radiologists. When adjusting for pre-traumatic eGFR, patient age, and injury severity score, a 10% increase in ischemic volume was associated with a post-injury eGFR value that was 8.0 ml/min/1.73 m2 (95% CI - 11.2, - 4.7) lower. CONCLUSIONS: CT-based volume calculation of renal ischemia may be utilized to quantify kidney injury and be associated with post-traumatic renal function loss.

Nonoperative Management in Blunt Splenic Trauma: Can Shock Index Predict Failure?

INTRODUCTION: Predicting failure of nonoperative management (NOM) in splenic trauma remains elusive. Shock index (SI) is an indicator of physiologic burden in an injury but is not used as a prediction tool. The purpose of this study was to determine if elevated SI would be predictive of failure of NOM in patients with a blunt splenic injury. METHODS: Adult patients admitted to a level-1 trauma center from January 2011 to April 2017 for NOM of splenic injury were reviewed. Patients were excluded if they underwent a procedure (angiography or surgery) prior to admission. The primary outcome was requiring intervention after an initial trial of noninterventional management (NIM). An SI > 0.9 at admission was considered a high risk. Univariate and multivariate analyses were used to identify predicators of the failure of NOM. Findings were subsequently verified on a validation cohort of patients. RESULTS: Five hundred and eighty-five patients met inclusion criteria; 7.4% failed NIM. On an univariate analysis, findings of pseudoaneurysm or extra-arterial contrast on computed tomography did not differentiate successful NIM versus failure (8.1% versus 14.0%, P = 0.18). Age, the American Association for the Surgery of Trauma injury grade, and elevated SI were included in multivariate modeling. Grade of injury (OR 3.49, P = 0.001), age (OR 1.02, P = 0.009), and high SI (OR 3.49, P = 0.001) were each independently significant for NIM failure. The risk-adjusted odds of failure were significantly higher in patients with a high risk SI (OR 2.35, P < 0.001). Validation of these findings was confirmed for high SI on a subsequent 406 patients with a c-statistic of 0.71 (95% CI 0.62-0.80). CONCLUSIONS: Elevated SI is an independent risk factor for failure of NIM in those with splenic injury. SI along with age and computed tomography findings may aid in predicting the failure of NIM. Trauma providers should incorporate SI into decision-making tools for splenic injury management.

The American Association for the Surgery of Trauma Renal Grading System-Should Segmental Kidney Infarction be Classified as a Grade IV Injury?

PURPOSE: In 2018 the American Association for the Surgery of Trauma revised renal injury grading. One change was inclusion of segmental kidney infarction under grade IV injuries. We aimed to assess how segmental kidney infarction will change the scope of grade IV injuries and compare bleeding control interventions in those with and without isolated segmental kidney infarction. METHODS: We used high grade renal trauma data from 7 level 1 trauma centers from 2013 to 2018 as part of the Multi-institutional Genito-Urinary Trauma Study. Initial computerized tomography scans were reviewed to regrade the injuries. Injuries were categorized as isolated segmental kidney infarction if segmental parenchymal infarction was the only reason for inclusion under grade IV injury. All other grade IV injuries (including combined injury patterns) were categorized as without isolated segmental kidney infarction. Bleeding interventions were compared between those with and without isolated segmental kidney infarction. RESULTS: From 550 patients with high grade renal trauma and available computerized tomography, 250 (45%) were grade IV according to the 2018 American Association for the Surgery of Trauma grading system. Of these, 121 (48%) had isolated segmental kidney infarction. The majority of patients with isolated segmental kidney infarction (88%) would have been assigned a lower grade using the original 1989 grading system. Rate of bleeding control interventions was lower in isolated segmental kidney infarction compared to other grade IV injuries (7% vs 21%, p=0.002). Downgrading all patients with isolated segmental kidney infarction to grade III did not change the grading system's associations with bleeding interventions. CONCLUSIONS: Approximately half of the 2018 American Association for the Surgery of Trauma grade IV injuries have isolated segmental kidney infarction. Including isolated segmental kidney infarction in grade IV injuries increases the heterogeneity of these injuries without increasing the grading system's ability to predict bleeding interventions. In future iterations of the American Association for the Surgery of Trauma renal trauma grading isolated segmental kidney infarction could be reclassified as grade III injury.

Core curriculum illustration: abdominal wood impalement injury from motor vehicle collision.

This is the 42nd installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at http://www.erad.org/page/CCIP_TOC.

Distal clavicle fracture radiography and treatment: a pictorial essay.

Fractures of the distal clavicle represent 15-30% of all clavicle fractures. The local osseoligamentous anatomy and deforming forces result in increased risk of delayed union and nonunion than fractures in other parts of the clavicle. These factors also contribute to challenges in fracture repair. Understanding these injuries and their imaging features enhances care and ensures patients are directed to appropriate management. We review the anatomy of the distal clavicle and surrounding ligaments, options for radiographic evaluation, relevant classification systems, and current concepts in management. Illustrative examples of specialized views are provided. Pediatric acromioclavicular joint pseudosubluxation is also reviewed, with findings specific to that injury.

Accuracy of outside radiologists' reports of computed tomography exams of emergently transferred patients.

PURPOSE: Growing numbers of patient with advanced imaging being transferred to trauma centers has resulted in increased numbers of outside CT scans received at trauma centers. This study examines the degree of agreement between community radiologists' interpretations of the CT scans of transferred patients and trauma center radiologists' reinterpretation. METHODS: All CT scans of emergency transfer patients received over a 1 month period were reviewed by an emergency radiologist. Patients were classified as trauma or non-trauma and exams as neuro or non-neuro. Interpretive discrepancies between the emergency radiologist and community radiologist were classified as minor, moderate, or major. Major discrepancies were confirmed by review of a second emergency radiologist. Discrepancy rates were calculated on a per-patient and per exam basis. RESULTS: Six hundred twenty-seven CT scans of 326 patients were reviewed. Major discrepancies were encountered in 52 (16.0%, 95% CI 12.2-20.5) patients and 53 exams (8.5%, 95% CI 6.5-10.5). These were discovered in 46 trauma patients (21.6%, 95% CI 16.4-27.9) compared to six non-trauma patients (5.3%, 95% CI 2.2-11.7) (P < 0.001). A significant difference in the major discrepancy rate was also found between non-neuro and neuro exams (12.4 vs 3.3%, respectively, P < 0.001), primarily due to discrepancies in trauma patients, rather than non-trauma patients. CONCLUSIONS: Potentially management-changing interpretive changes affected 16% of transferred patients and 8.5% of CT exams over a 1 month period. Trauma center reinterpretations of community hospital CT scans of transferred patients provide valuable additional information to the clinical services caring for critically ill patients.

Acute shoulder trauma: what the surgeon wants to know.

Many excellent studies on shoulder imaging from a radiologic perspective have been published over the years, demonstrating the anatomy and radiologic findings of shoulder trauma. However, it may not always be clear what the surgeon, who bears the responsibility for treating the injured patient, really needs to know about the injury to predict outcomes and plan management. The authors review the relevant osseous, soft-tissue, and vascular anatomy and describe the clinically relevant concepts that affect management. Familiarity with the Neer classification system for proximal humerus fractures can have a significant impact on treatment. The length and displacement of the medial humeral metaphyseal fragment helps predict the risk of ischemia in proximal humerus fractures. The Nofsinger approach for measuring the area of glenoid fossa bone loss can help the surgeon determine the need for surgical repair of a bony Bankart lesion. The size of Hill-Sachs and reverse Hill-Sachs lesions is also an important predictor of stability. The Ideberg classification system for intraarticular fractures of the glenoid fossa, combined with information on instability and joint incongruity, helps determine the need for surgical fixation of glenoid fossa fractures. Awareness of what matters to the surgeon can help radiologists better determine where to focus their attention and efforts when describing acute shoulder trauma.

Nuclear medicine and the emergency department patient: an illustrative case-based approach.

Radiologists are familiar with the use of radiographs, computed tomography, magnetic resonance imaging and ultrasound in the acute clinical setting. However, there are some specific clinical scenarios which may be found in nuclear medicine imaging problem-solving tools. These clinical scenarios and imaging techniques are less frequent, and the referring clinician from the emergency department may not consider these alternatives. It is important for the radiologist to be aware of these techniques to be able to guide the clinician to use those tools, which may result in optimal patient care. In this article, we will discuss those nuclear medicine studies which have application in the setting of an emergency radiology practice.

Minimal aortic injury of the thoracic aorta: imaging appearances and outcome.

The aim of this study is to describe the frequency, computed tomographic angiography (CTA) imaging appearance, management, and outcome of patients who present with minimal thoracic aortic injury. This retrospective study was Institutional Review Board-approved. Eighty-one patients with blunt traumatic aortic injuries (BTAI) were identified between 2004 and 2008, comprising 23 patients with minimal aortic injury (MAI) (mean age, 43.2 years ±18.2 years; 12 males and 11 females) and 58 patients with non-minimal aortic injury (mean age, 42.6 years ±22.7 years). CTA imaging was reviewed for each patient to differentiate those with MAI from those with non-MAI BTAI. Inclusion criteria for MAI on CTA were: post-traumatic abnormality of the internal contour of the aorta wall projecting into the lumen, intimal flap, intraluminal filling defect, intramural hematoma, and no evidence of an abnormality to the external contour of the aorta. Relevant follow-up imaging for MAI patients was also reviewed for resolution, stability, or progression of the vascular injury. The electronic medical record of each patient was reviewed and mechanism of injury, injury severity score, associated injuries, type and date of management, outcome, and days from injury to last medical consultation. Minimal aortic injury represented 28.4 % of all BTAI over the study period. Mean injury severity score (37.1), age (43.2 years), and gender did not differ significantly between MAI and non-MAI types of BTAI. Most MAI occurred in the descending thoracic aorta (16/23, 69 %). Without operative or endovascular repair, there was no death or complication due to MAI. One death occurred secondary to MAI (4.4 %) in a patient who underwent endovascular repair and surgical bypass, compared with an overall mortality rate of 8.6 % in the non-MAI BTAI group (p = 0.508). The most common CT appearance of MAI was a rounded or triangular intra-luminal aortic filling detect (18/23 patients, 78 %). In a mean of 466 days of clinical follow-up, no complications were observed in survivors treated without endovascular repair or operation. Minimal aortic injury is identified by multi-detector row CT in more than a quarter of cases of BTAI and has a low mortality. Conservative management is associated with an excellent outcome.

PROPOSED REVISION OF THE AMERICAN ASSOCIATION FOR SURGERY OF TRAUMA RENAL TRAUMA ORGAN INJURY SCALE: SECONDARY ANALYSIS OF THE MULTI-INSTITUTIONAL GENITOURINARY TRAUMA STUDY.

BACKGROUND: This study updates the American Association for Surgery of Trauma (AAST) Organ Injury Scale (OIS) for renal trauma using evidence-based criteria for bleeding control intervention. METHODS: This was a secondary analysis of a multi-center retrospective study including patients with high grade renal trauma from 7 Level-1 trauma centers from 2013-2018. All eligible patients were assigned new renal trauma grades based on revised criteria. The primary outcome used to measure injury severity was intervention for renal bleeding. Secondary outcomes included intervention for urinary extravasation, units of packed red blood cells (PRBCs) transfused within 24 hours, and mortality. To test the revised grading system, we performed mixed effect logistic regression adjusted for multiple baseline demographic and trauma covariates. We determined the area under the receiver-operator curve (AUC) to assess accuracy of predicting bleeding interventions from the revised grading system and compared this to 2018 AAST organ injury scale. RESULTS: based on the 2018 OIS grading system, we included 549 patients with AAST Grade III-V injuries and CT scans (III: 52% (n = 284), IV: 45% (n = 249), and V: 3% (n = 16)). Among these patients, 89% experienced blunt injury (n = 491) and 12% (n = 64) underwent intervention for bleeding. After applying the revised grading criteria, 60% (n = 329) of patients were downgraded and 4% (n = 23) were upgraded; 2.8% (n = 7) downgraded from grade V to IV, and 69.5% (n = 173) downgraded from IV to III. The revised renal trauma grading system demonstrated improved predictive ability for bleeding interventions (2018 AUC = 0.805, revised AUC = 0.883; p = 0.001) and number of units of PRBCs transfused. When we removed urinary injury from the revised system, there was no difference in its predictive ability for renal hemorrhage intervention. CONCLUSIONS: A revised renal trauma grading system better delineates the need for hemostatic interventions than the current AAST OIS renal trauma grading system. LEVEL OF EVIDENCE: II.

Shattered Kidney After Renal Trauma: Should It Be Classified As an American Association for the Surgery of Trauma Grade V Injury?

OBJECTIVE: To study the prevalence and management of shattered kidney and to evaluate if the new description of "loss of identifiable renal anatomy" in the 2018 American Association for the Surgery of Trauma (AAST) organ injury scale (OIS) would improve the ability to predict bleeding control interventions. METHODS: We used high-grade renal trauma data from 21 Level-1 trauma centers from 2013 to 2018. Initial CT scans were reviewed to identify shattered kidneys, defined as a kidney having ≥3 parenchymal fragments displaced by blood or fluid on cross-sectional imaging. We further categorized patients with shattered kidney in two models based on loss of identifiable renal parenchymal anatomy and presence or absence of vascular contrast extravasation (VCE). Bleeding interventions were compared between the groups. RESULTS: From 861 high-grade renal trauma patients, 41 (4.8%) had shattered kidney injury. 25 (61%) underwent a bleeding control intervention including 18 (43.9%) nephrectomies and 11 (26.8%) angioembolizations. 18 (41%) had shattered kidney with "loss of identifiable parenchymal renal anatomy" per 2018 AAST OIS (model-1). 28 (68.3%) had concurrent VCE (model-2). Model-2 had a statistically significant improvement in area under the curve over model-1 in predicting bleeding interventions (0.75 vs 0.72; P = .01). CONCLUSION: Shattered kidney is associated with high rates of active bleeding, urinary extravasation, and interventions including nephrectomy. The definition of shattered kidney is vague and subjective and our definition might be simpler and more reproducible. Loss of identifiable renal anatomy per the 2018 AAST OIS did not provide better distinction for bleeding control interventions over presence of VCE.

Software Aids for radiologists: Part 1, Useful Photoshop skills.

OBJECTIVE: The purpose of this review is to describe the use of several essential techniques and tools in Adobe Photoshop image-editing software. The techniques shown expand on those previously described in the radiologic literature. CONCLUSION: Radiologists, especially those with minimal experience with image-editing software, can quickly apply a few essential Photoshop tools to minimize the frustration that can result from attempting to navigate a complex user interface.

Imaging of trauma: Part 1, Pseudotrauma of the spine--osseous variants that may simulate injury.

OBJECTIVE: Anatomic variants and incomplete ossification and fusion of the developing spine may result in an erroneous diagnosis of injury or disease. This article reviews some of the more common imaging findings that may present as pseudotrauma. Normal development of the spine is reviewed, including synchondroses and ossification centers. Imaging of common variants is presented, with a focus on CT. CONCLUSION: Recognition of the normal developing spine and variants can prevent an incorrect diagnosis of injury and inappropriate treatment.

Utility of ultrasound for evaluating the appendix during the second and third trimester of pregnancy.

This study aims to retrospectively evaluate the right lower quadrant ultrasounds in women presenting during the second or third trimester of pregnancy for the frequency of appendix visualization and accuracy in diagnosing appendicitis. Institutional Review Board approval was obtained for this Health Insurance Portability and Accountability Act-compliant study. We reviewed imaging records from 99 consecutive pregnant women from 2001 to 2011 who presented during the second (≥14 weeks gestation) or third trimester for right lower quadrant ultrasound to evaluate the appendix. Visualization of the appendix as well as the size and compressibility, if identified, were recorded. The medical records and labs related to the initial patient presentation, subsequent management, and follow-up were reviewed for surgical and clinical outcomes. Pathology records were reviewed to determine if appendicitis was present when appendectomy was performed. Patients who underwent appendectomy were considered to have appendicitis based on pathology results, and patients managed non-operatively with symptom improvement and those with a normal appendix at pathology were considered to not have appendicitis. During the study period, 99 women meeting inclusion criteria presented to our institution for right lower quadrant ultrasound to evaluate the appendix during the second or third trimester of pregnancy. The mean gestational age at presentation was 23 weeks (±7 weeks). The mean maternal age was 28 years (±6.6 years). The appendix was not visualized in 97% (96/99) of right lower quadrant ultrasound examinations. Of the three studies in which the appendix was visualized, two were considered positive for appendicitis and one was considered negative. Eight patients in this group ultimately underwent appendectomy, including the two patients with positive right lower quadrant ultrasounds, and appendicitis confirmed at pathology in seven of these cases (87.5%). Right lower quadrant ultrasound successfully demonstrated an abnormal appendix in 28.7% (two of seven) of surgically confirmed cases; however, this technique did not detect appendicitis in 71% (five of seven) of patients with surgically proven disease due to nonvisualization of the appendix. Retrospective review of right lower quadrant ultrasounds performed during the second and third trimester of pregnancy suggests that this modality has limited utility for diagnosing appendicitis due to infrequent visualization of the appendix.

A Piercing Diagnosis - Occult Foreign Body as the Cause of Acute Inguinal Pain.

CASE PRESENTATION: A 35-year-old woman presented to the emergency department with severe right inguinal pain. Her medical history was non-contributory and there was no known trauma or injury to the region. Amid concern for an incarcerated inguinal hernia, a computed tomography was obtained revealing a linear foreign body (FB) lateral to the femoral vessels. The FB was removed without complication at bedside and found to be a beading needle likely occultly lodged three days prior. DISCUSSION: Occult inguinal FBs are rare but can lead to deep venous thrombosis or pulmonary embolism if in or near vessels. By nature of being occult, an absence of ingestion, insertion, or penetrative history should not preclude consideration of a FB etiology. Computed tomography imaging is crucial in determining the urgency of, and approach to, inguinal foreign body removal.