Photo Quiz

A Helmet to the Flank

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Am Fam Physician. 2014 Jul 15;90(2):119-120.

A 16-year-old boy presented to the emergency department approximately 30 minutes after he was injured during a football game. He was hit in the left flank by a helmet during a tackle. He felt short of breath and had sharp, stabbing pain on deep inspiration. He was able to speak in full sentences. He was healthy and was not taking any medications or supplements.

Physical examination revealed a heart rate of 82 beats per minute, respiratory rate of 20 breaths per minute, and a blood pressure of 130/74 mm Hg. His left flank was tender to palpation, but there was no ecchymosis or palpable abdominal mass. Urinalysis and serum creatinine findings were normal. Computed tomography was performed (Figures 1 and 2).

Figure 1.

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Figure 1.

Figure 1.

Figure 2.

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Figure 2.

Figure 2.


Based on the patient's history, physical examination, imaging, and laboratory findings, which one of the following is the most likely diagnosis?

A. Congenital ureteropelvic junction obstruction.

B. Congenital ureterovesical junction obstruction.

C. Renal cell carcinoma.

D. Renal papillary necrosis.

E. Traumatic kidney rupture.

Address correspondence to T. Keefe Davis, MD, at Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


1. Brown T, et al. Neonatal hydronephrosis in the era of sonography. AJR Am J Roentgenol. 1987;148(5):959–963.

2. Smith M, et al. Trauma cases from Harborview Medical Center. Rupture of a ureteropelvic junction-obstructed kidney in a 15-year-old football player. AJR Am J Roentgenol. 2003;180(2):504.

3. Manzoni C. Megaureter. Rays. 2002;27(2):83–85.

4. Ganick DJ, et al. Index of suspicion: case 1: abdominal trauma, pain, and tenderness associated with anemia and hematuria in a 14-year-old boy. Case 2: ptosis, diplopia, tremors, and mild exophthalmos in a 9-year-old girl. Case 3: persistent cough, shortness of breath, and localized decreased aeration in an 18-year-old girl. Pediatr Rev. 2011;32(11):495–501.

5. Grovas A, et al. The National Cancer Data Base report on patterns of childhood cancers in the United States. Cancer. 1997;80(12):2321–2332.

6. Jung DC, et al. Renal papillary necrosis: review and comparison of findings at multi-detector row CT and intravenous urography. Radiographics. 2006;26(6):1827–1836.

7. Shewakramani S, et al. Genitourinary trauma. Emerg Med Clin North Am. 2011;29(3):501–518.

Contributing editor for Photo Quiz is John E. Delzell, Jr., MD, MSPH.

A collection of Photo Quizzes published in AFP is available at

The editors of AFP welcome submissions for Photo Quiz. Guidelines for preparing and submitting a Photo Quiz manuscript can be found in the Authors' Guide at To be considered for publication, submissions must meet these guidelines. E-mail submissions to

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