画像は並び替えてある．周囲に血腫を伴う左腎損傷があるが，完全離断（図１７〜図１９：▲）を示しているにかかわらずextravasationを認めない症例である．晩期相（Delayed）の図１８〜図２４で尿管（↑）も描出されているので尿漏も否定できる．

翌日のCT（図２５〜図２８）で血腫の増量や尿漏を認めず，6週間後（図２９〜図３２）には血腫は吸収され消失した．Hb：13.0→9.9g/dl．

参考症例（右腎損傷 IIIc．肝損傷 IIIa ）：17歳女性．乗用車とバイクの衝突事故で右側腹部を打撲し，腹痛が増強したので来院．Vital signsは安定，腹部右側に圧痛を認めるが軟．Single phase 造影CT．
図１で肝右葉後区域に損傷を認めるが，extravasationはなく，周囲の腹水も少量である．右腎は粉砕型の損傷を示し，Gerota筋膜内（傍腎腔）に相当量の血腫を伴う．図５でIVCを超え大動脈周囲まで広がる（↑）のでH3 に相当し，手術の適応となる場合が多いとされるがextravasationを認めない．図２と図３の△は腎静脈で，図７と図８の▲は尿管であり，その他の造影効果を受ける組織は腎実質である．安静だけで順調に経過した．Hb：12.4→8.8g/dl．Double phase 造影CTの方がより安心して保存的治療ができる．

文献考察：小児の鈍的腎外傷のCT検査の適応
１）Urol Clin North Am. 2006 Feb;33(1):33-40
The diagnosis, management, and outcomes of pediatric renal injuries.
Buckley JC, McAninch JW.

Most pediatric renal trauma is minor and poses no significant danger to the child. A small percentage of children sustain a severe renal injury that demands immediate evaluation and decision of operative versus nonoperative management. Selective management of pediatric renal trauma based on mechanism of injury, hemodynamic stability,associated nonrenal injuries, and CT imaging has led to a renal exploration rate of 5%to 11% with renal salvage rates of more than 98%.PMID: 16488278
要旨：循環動態が安定しており，血尿または尿沈渣で赤血球：>50/hpf，転落や交通事故などの急な減速による外傷はCT検査（表１）．

２）J Urol. 2002 Jun;167(6):2543-6; discussion 2546-7.
Blunt traumatic hematuria in children. Is a simplified algorithm justified?
Perez-Brayfield MR, Gatti JM, Smith EA, Broecker B, Massad C, Scherz H, Kirsch AJ.

PURPOSE: We determined whether radiographic evaluation is indicated in all children with traumatic hematuria. MATERIALS AND METHODS: We retrospectively reviewed the records of 110 children from 1992 to 1999 diagnosed with blunt trauma and hematuria. It is routine practice at our emergency department to perform radiographic evaluation in all children with hematuria regardless of the degree. Each chart was evaluated for the mechanism of injury, degree of hematuria, hypotension, imaging studies, renal injury, renal anomalies, associated injuries and outcome. RESULTS: A total of 110 patients 1 to 18 years old (mean age 9) were identified. The most common mechanism of injury was motor vehicle accident in 37 children (34%), followed by a fall in 32 (29%). Grades I to V renal injury was present in 5, 6, 6, 6 and 1 cases, respectively (22%), while 1 (0.9%) involved ureteropelvic junction avulsion. No child had renal pedicle injury. In 9 patients renal anomalies were detected incidentally. Of the 110 patients 101 underwent radiographic evaluation, including computerized tomography in 97 (88%). The 24 patients (22%) with significant renal injury and all with incidentally diagnosed renal anomalies had 50 or greater red blood cells per high power field on urinalysis, while 1 with ureteropelvic junction avulsion presented without hematuria. Hypotension was present in only 3 patients (2.7%), who also had associated injuries, including 2 who presented with renal injury. All 3 with associated injuries. Associated injuries were identified in 11 of 25 patients (44%). The 9 patients (8%) who did not undergo radiographic imaging had negative results on repeat urinalysis with an excellent outcome. CONCLUSIONS: We recommend that radiological evaluation consisting of abdominal and pelvic computerized tomography should be performed only in patients with 50 or greater red blood cells on urinalysis, hypotension at presentation to the emergency room or based on the severity of mechanism of injury, for example high speed motor vehicle accident deceleration injuries. The patient who presented with ureteropelvic junction avulsion without hematuria would have undergone imaging considering the mechanism of injury and number of associated injuries.PMID: 11992085
要旨：上記文献と同様なCT検査の適応（表２）．