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Kidney Trauma in Martial Arts

A Case Report of Kidney Contusion in Jujitsu
Michael W. Itagaki* and Napoleon B. Knight, MD From the University of Illinois College of Medicine at Urbana-Champaign, Urbana, Illinois, and the Carle Foundation Hospital, Department of Emergency Medicine, Urbana, Illinois

Keywords: kidney contusion; jujitsu; jiu-jitsu; hematuria; judo

CASE REPORT
A 22-year-old white male presented to the emergency department complaining of left-flank pain and dark-colored urine. According to the patient, 3 days earlier he had taken some bad falls while practicing jujitsu and developed mild left-flank soreness. Six hours prior to presenting to the emergency department, he had attended a second jujitsu practice session during which he attempted to perform a throw on his opponent (Fig. 1). He fell awkwardly on his back and felt a sharp, sudden pain in the left flank. The patient continued practice without informing the instructor of his injury and was unconcerned until later in the evening when he experienced frequent urination with abnormal deep red color, which prompted his decision to seek medical care. Vital signs were normal on admission. The patients blood pressure was 105/56 mm Hg, pulse 47/min, respiratory rate 18/min, and temperature 97F. Physical examination was normal except for left-flank tenderness. No evidence of ecchymosis or crepitus was detected. A urine dipstick test detected a large amount of blood. Urinalysis of the cloudy, rust-colored urine showed abnormally elevated red blood cells, protein, and leukocyte esterase. Values obtained are shown in Table 1. A complete blood count was normal, except for a slightly low platelet count. Values obtained are shown in Table 2. Computed tomography (CT) with contrast showed no evidence of renal laceration, extravasation of blood, or fluid collection. The diagnosis of hematuria secondary to kidney contusion was made. A conservative treatment protocol was followed because the patient was stable and in good condition. He was discharged with care instructions for hematuria and was told to avoid trauma to the affected
Test

TABLE 1 Urinalysis Laboratory Resultsa

Value 12,200/l 13/l Small 100 mg/dl Undetectable Undetectable Undetectable Undetectable 1 EU/dl 1.028 7.5 Normal Range 020/l 025/l Undetectable Undetectable Undetectable Undetectable Undetectable Undetectable 0.21 EU/dl 1.0031.033 5.08.0

Red blood cells White blood cells Leukocyte esterase Protein Nitrites Glucose Ketones Bilirubin Urobilinogen Specific gravity pH
a

Abnormal findings are italicized.

TABLE 2 Complete Blood Count Laboratory Resultsa

Test Platelets Red blood cells White blood cells Hemoglobin Hematocrit MCV
a

Value 116,000/mm3 5.2 106/l 7.0 103/l 15.5 g/dl 44.7% 86 fl

Normal Range 150,000400,000/mm3 4.76.1 106/l 4.510 103/l 13.817.2 g/dl 40.750.3% 8095 fl

Abnormal findings are italicized.

area for 1 week. The condition resolved without complications, and the patient currently is continuing his practice of jujitsu.

DISCUSSION
* Address correspondence to Michael W. Itagaki, University of Illinois College of Medicine at Urbana-Champaign, 506 South Matthews Avenue, Urbana, IL 61801 (e-mail: itagaki@uiuc.edu). The American Journal of Sports Medicine, Vol. 32, No. 2 DOI: 10.1177/0363546503258879 2004 American Orthopaedic Society for Sports Medicine

The martial art of jujitsu has its origins in 17th-century Japan. Jujitsu over the centuries evolved into a highly effective form of unarmed combat, using joint locking, throwing, and grappling techniques. The martial arts of jujitsu, judo, and aikido share common origins, and all

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Figure 1. The crab scissors throw. The patient was attacking his opponent with this technique when injured. Here, the attacker lunges from the side and scissors his opponents body using his legs like a crab claw. Both attacker and defender land on their backs. Many martial arts techniques require the defender, the attacker, or both to take high-impact falls.

three martial arts emphasize the use of related throwing techniques.9 Throwing requires the athlete to be able to fall safely without injury. Falling techniques, or ukemi, prevent the broken bones, sprained joints, bruises, and other injuries normally associated with uncontrolled falls. Martial artists learn to position their body prior to hitting the ground to minimize the potential for injury. These techniques are taught and mastered early on, before the student is allowed to be thrown by an opponent. Once mastered, however, it is not unusual for participants to be thrown more than a hundred times during a single session. Falling is a major cause of blunt renal trauma, accounting for about 17% of blunt renal trauma cases, illustrating the ease at which the kidneys can be damaged by deceleration or impact.10 Renal injuries are classified as type I through type IV. Type I represents renal contusion or superficial renal laceration usually warranting no more than observation and rest. Type II injuries represent deeper lacerations involving the collecting system. Surgery is usually not required except in progressing cases. Type III injuries include major laceration, involvement of the pedicle, or a shattered kidney and typically require surgical intervention. Type IV injuries are ureteropelvic junction avulsions and require surgery, frequently resulting in nephrectomy.5 Hematuria is a cardinal presentation of genitourinary injury. Microscopic hematuria is defined as urine with greater than three erythrocytes per high-powered field,

and gross hematuria is defined as urine containing readily visible blood.3 In the sports medicine setting, adult patients with microscopic hematuria due to blunt trauma without shock or other complicating factors usually represent renal contusion or other low-grade renal injury (type I).1 The presence of gross hematuria or microscopic hematuria with shock increases the likelihood of major renal injury, including lacerations and renal vascular injury. Radiographic evaluation is then warranted to stage the injury, with CT typically being the most informative study. A complete history should be obtained from athletes presenting with hematuria to rule out exercise-induced hematuria (runners hematuria), a transient, spontaneously resolving condition caused by strenuous exercise.8 One would expect that martial artists in styles that involve substantial falling like jujitsu, judo, and aikido would be susceptible to kidney trauma. De Meersman and Wilkersons study supports this expectation, finding that among judo players that fell 100 times on a standard 2.5cm thick mat, 89% had hematuria with greater than 50 erythrocytes per high-powered field.4 None of the control group that fell on a thicker 10-cm mat had hematuria. The data suggest that subclinical trauma-induced hematuria may be a very common phenomenon in martial arts that involve falling. Surprisingly, the incidence of reported kidney trauma is very low. In a recent martial arts survey that included 15,017 participants representing 24,027 training years,

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kidney injury accounted for only 1 in 5700 reported injuries.2 In contrast, cerebral concussions, a relatively rare injury but one that is easily recognized, accounted for 1 in 95 reported injuries. The study included all martial arts, including those that do not involve falling. Although data on aikido and jujitsu were not reported, 7% (1050) of the study participants were judo players. Martial artists are usually quite stoic and tend to accept pain and discomfort without complaint. Peer pressure and fear of being perceived as weak can make it difficult for an athlete to retire from practice due to a nebulous complaint like flank pain. Thus, cultural factors may be a significant challenge for detection and treatment of kidney injury in martial artists. At least one reported case describes a 73year-old policeman who had lived and practiced judo for 30 years with lower-back pain. Only when the pain became debilitating did he seek care and learn that he had an old, large extracapsular perirenal hematoma.6 A study conducted in Japan noted that 60% of skilled judo players complain of mild lumbar pain of unknown origin, but many do not seek appropriate care.7

In cases of adult blunt abdominal trauma with gross hematuria or microscopic hematuria and shock, immediate CT is indicated to aid in diagnosis. Type I renal injuries warrant rest for 1 to 2 weeks. Type II injuries usually call for rest and observation, with surgery in progressive cases. Types III and IV typically require surgery. Athletes who repeatedly sustain kidney injuries should be advised to give up the sport, as repeated parenchymal injury can eventually require nephrectomy. Increased awareness of the potential for kidney trauma among martial artists and physicians is the first step in minimizing its occurrence.

ACKNOWLEDGMENT
The authors would like to thank Dr. Jane S. Y. Tan, MD, for her very constructive comments.

REFERENCES
1. Ahn JH, Morey AF, McAninch JW: Workup and management of traumatic hematuria. Emerg Med Clin North Am 16: 145160, 1998 2. Birrer RB: Trauma epidemiology in the martial arts: The results of an eighteen year international survey. Am J Sports Med 24: S72S79, 1996 3. Campbell MF, Walsh PC, Retik AB (eds): Campbells Urology. Eighth edition. Baltimore, WB Saunders, 2002, pp 100103 4. De Meersman RB, Wilkerson JE: Judo nephropathy: Trauma versus Non-trauma. J Trauma 22: 150152, 1982 5. Dreitlein DA, Suner S, Basler J: Genitourinary trauma. Emerg Med Clin North Am 19: 569590, 2001 6. Fujita S, Kusunoki M, Yamamura T, et al: Perirenal hematoma following judo training. NY State J Med 88: 3334, 1988 7. Ichikawa N, Taniguchi T, Shimada N: Sports injuries in judo (in Japanese). Kikan Kansetsu Geka 1: 91, 1984 8. Marx JA, Hockberger RS, Walls RM: Rosens Emergency Medicine: Concepts and Clinical Practice. Fifth edition. St. Louis, Mosby, 2002, p 1431 9. Musser D, Lang TA: Jujitsu Techniques and Tactics. Champaign, IL, Human Kinetics, 1999, pp 1318 10. Nicolaisen G, McAninch JW, Marshall GA, et al: Renal trauma: Reevaluation of the indications for radiographic assessment. J Urol 133: 183187, 1985

CONCLUSION
Education is the key to prevention. Students and instructors alike should be taught about the signs and dangers of kidney trauma, and medical directors at tournaments should be aware of the potential for this kind of injury. Sharp flank pain due to a fall is potentially serious. The martial artist should withdraw from practice or at the very least alter the exercises to avoid continued trauma to the region. Abnormally dark or red-colored urine following practice is cause to consult a physician, as is ecchymosis or broken ribs. The falling surface should be appropriate and well maintained. Old, brittle wrestling mats over a concrete floor do not provide adequate cushioning for falling. Spring-loaded judo mats, a relatively recent innovation, are ideal, offering good impact absorption while not being so soft as to retard movement. For beginners learning falls, extra-thick crash pads can make falling enjoyable and safe.