Page 14 - 63 craniocerebral-and-spinal-trauma30-35_opt

Urogenital and Perineal Trauma 203

surgery. 5,6,7 In fact, with a delayed approach, the risk of early nephrec-
tomy is avoided. However, delayed surgery is necessary in up to 13%
1,2
of cases. Nonoperative management is generally favoured in children
with major blunt renal trauma, except in the presence of haemodynamic
7,8
instability. Central to the nonoperative management of renal and other
solid organ trauma is the use of serial CT scanning. Operative manage-
ment should not be overdelayed, however, due to the general unavail-
4
ability of CT scanners in most hospitals in Africa.
Penetrating Renal Injuries
Penetrating renal injuries should be explored immediately (Figure
31.2). This is especially true in children who sustain a gunshot wound
to the flank in which there is a high incidence of associated intraab-
dominal injuries and complex renal injuries. Adequate debridement of
devitalised tissues must be carried out.
Ureteric Injuries (A)
Injuries to the ureters are not common in children. Rapid decelera-
1,2
tion accidents (falls or motor vehicle accidents) may result in severe
hyperextension of the trunk and possible disruption of the pelviureteric
junction by stretch-induced injury. In cases of isolated ureteral injury,
one must have a high index of suspicion to make this diagnosis, as
patients may present in a delayed fashion with fever, ileus, sepsis, and
flank pain. Severe blunt trauma may be associated with fractures of
ribs, spine, and pelvis, which can also injure the ureters, much like
penetrating trauma. Penetrating trauma to the flank and abdomen may
transect or destroy a significant segment of the ureter. The cavitation
effect of high-velocity gunshot wounds can result in ureteral necrosis
and require extensive reconstruction.
Once the diagnosis of pelviureteric junction disruption is made,
the best course of action is to perform an immediate primary repair by
using the dismembered pyeloplasty technique. If there is extensive loss
of a portion of the ureter, one may need to perform one or more of the (B)
following procedures:
• For distal ureteral injuries, one may be able to excise and reimplant
the ureter into the bladder.
• For lower-half ureteral injuries, a bladder Boari flap, with or with-
out a psoas hitch technique, may be required.
• For more extensive injuries, the kidney may be mobilised and neph-
ropexy may allow several additional centimetres of length.
• If just the upper ureter remains, a trans-uretero-ureterostomy can be
performed.
• If there is significant damage to the renal pelvis and pelviureteric
junction, a ureterocalicostomy may be employed with wide amputa-
tion of the inferior-most renal parenchyma and anastomosis of the
ureter to the lower pole calyx. (C)
Figure 31.2: (A) Child who sustained a stab wound to left flank. (B) Renal
• With complete loss of the ureter, one may be required to place a exploration revealed laceration of the kidney. (C) Following repair of the renal
segment of tapered ileum as an interposition tube flap. The appen- laceration, omentum is placed into the wound to promote healing and prevent
dix has also been used as an interposition tube flap for midureteral urine leakage.
injuries on the right side. As a last resort, autotransplantation of the
9
kidney to the iliac vessels can be performed.
have associated pelvic fractures in 75–90% of the cases. About one-half
Bladder Injury of bladder injuries in children are associated with other intraabdominal
organ injuries.
The bladder is an intraabdominal organ in young children; therefore, it
can be easily injured in trauma to the abdomen, regardless of whether Classification
it is full or empty. As the bony pelvis grows, the bladder becomes more Bladder injuries in children can be classified as blunt or penetrating.
protected from injury. Blunt trauma is responsible for most bladder Blunt trauma
injuries. Road traffic accidents and falls from heights are the most com- In a contusion, there is a disruption in bladder muscularis without loss
mon causes of bladder injury in the paediatric age group in the African of continuity of the wall. With a rupture, there is complete disruption
setting. Pelvic fractures cause injury near the bladder neck, whereas of the bladder wall.
the dome of the bladder is usually affected by direct blow to the lower The cystogram is the ideal radiographic study to diagnose intra- or
abdomen. Only a small number of patients with pelvic fractures sustain extraperitoneal rupture. As previously mentioned, the bladder must be
bladder injury. Patients who present with bladder injury are found to filled to at least one-half the expected capacity in a child, or more than 350