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Handlebar injury in children: The hidden danger
ARTICLE IN PRESS
Handlebar injury in children: The hidden danger Federica Pederiva, MD, PhD,a Edoardo Guida, MD,a Massimo Maschio, MD,b Waifro Rigamonti, MD,a Massimo Gregori, MD,c and Daniela Codrich, MD, PhD,a Trieste, Italy
From the Pediatric Surgery,a Departments of Pediatrics,b and Radiology,c Institute for Maternal and Child Health, IRCCS ‘‘Burlo Garofolo,’’ Trieste, Italy
A 9-YEAR-OLD BOY WAS REFERRED TO OUR HOSPITAL 24 HOURS AFTER AN ABDOMINAL TRAUMA CAUSED BY A HANDLEBAR. He was apyrexial and hemodynamically stable. On examination, a lump and a circular bruise were seen on the left lower quadrant where the handlebar had hit his abdomen. The diffuse abdominal tenderness was accompanied by lack of bowel sounds. There were no other associated injuries. Apart from an increased C-reactive protein level, blood tests, including the serum amylase levels, were normal. Computed tomography (CT) scan revealed an abdominal wall hematoma with an underlying defect through rectus sheath between left rectus abdominis and internal and external oblique. Intra-abdominal fat was herniated through the defect, but no bowel loops were involved. No free air or other solid organ injuries was found (Fig). A laparotomy was performed, wherein the rupture of the rectus fascia was confirmed and closed with interrupted Vicryl 2/0 sutures; moreover, a covered ileal perforation, not diagnosed at CT, was repaired by resection of 4 cm of damaged bowel. The patient was discharged 7 days after the surgery and recovered uneventfully. Traumatic abdominal hernia as a consequence of handlebar injury might be a challenging diagnosis, because patients can be relatively asymptomatic; however, concomitant internal injuries are reported in 25–70% of case reports.1 Pediatricians should consider the possibility of a traumatic abdominal wall hernia in any child who presents to the emergency department after a blunt trauma to the abdomen.2,3 Although conservative management
Fig. Axial-enhanced CT image showing the traumatic abdominal wall hernia with herniated fat.
has been reported in the literature,4 we recommend acute repair of the hernia to avoid complications and not to miss associated injuries of the abdominal content such as bowel perforation. REFERENCES 1. Rathore A, Simpson BJ, Diefenbach KA. Traumatic abdominal wall hernias: an emerging trend in handlebar injuries. J Pediatr Surg 2012;47:1410-3. 2. Klimek PM, Lutz T, Stranzinger E, Zachariou Z, Kessler U, Berger S. Handlebar injuries in children. Pediatr Surg Int 2013;29:269-73. 3. Talutis SD, Muensterer OJ, Pandya S, McBride W, Stringel G. Laparoscopic-assisted management of traumatic abdominal wall hernias in children: case series and a review of the literature. J Pediatr Surg 2015;50:456-61. 4. Litton K, Izzidien AY, Hussien O, Vali A. Conservative management of a traumatic abdominal wall hernia after a bicycle handlebar injury (case report and literature review). J Pediatr Surg 2008;43:e31-2.
Accepted for publication August 6, 2015. Reprint requests: Dr Daniela Codrich, MD, PhD, Institute for Maternal and Child Health, IRCCS ‘‘Burlo Garofolo,’’ Via dell’Istria 65/1, 34137 Trieste, Italy. E-mail: [email protected]. Surgery 2015;j:j. 0039-6060/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2015.08.009
SURGERY 1
Handlebar injury in children: The hidden danger Federica Pederiva, MD, PhD,a Edoardo Guida, MD,a Massimo Maschio, MD,b Waifro Rigamonti, MD,a Massimo Gregori, MD,c and Daniela Codrich, MD, PhD,a Trieste, Italy
From the Pediatric Surgery,a Departments of Pediatrics,b and Radiology,c Institute for Maternal and Child Health, IRCCS ‘‘Burlo Garofolo,’’ Trieste, Italy
A 9-YEAR-OLD BOY WAS REFERRED TO OUR HOSPITAL 24 HOURS AFTER AN ABDOMINAL TRAUMA CAUSED BY A HANDLEBAR. He was apyrexial and hemodynamically stable. On examination, a lump and a circular bruise were seen on the left lower quadrant where the handlebar had hit his abdomen. The diffuse abdominal tenderness was accompanied by lack of bowel sounds. There were no other associated injuries. Apart from an increased C-reactive protein level, blood tests, including the serum amylase levels, were normal. Computed tomography (CT) scan revealed an abdominal wall hematoma with an underlying defect through rectus sheath between left rectus abdominis and internal and external oblique. Intra-abdominal fat was herniated through the defect, but no bowel loops were involved. No free air or other solid organ injuries was found (Fig). A laparotomy was performed, wherein the rupture of the rectus fascia was confirmed and closed with interrupted Vicryl 2/0 sutures; moreover, a covered ileal perforation, not diagnosed at CT, was repaired by resection of 4 cm of damaged bowel. The patient was discharged 7 days after the surgery and recovered uneventfully. Traumatic abdominal hernia as a consequence of handlebar injury might be a challenging diagnosis, because patients can be relatively asymptomatic; however, concomitant internal injuries are reported in 25–70% of case reports.1 Pediatricians should consider the possibility of a traumatic abdominal wall hernia in any child who presents to the emergency department after a blunt trauma to the abdomen.2,3 Although conservative management
Fig. Axial-enhanced CT image showing the traumatic abdominal wall hernia with herniated fat.
has been reported in the literature,4 we recommend acute repair of the hernia to avoid complications and not to miss associated injuries of the abdominal content such as bowel perforation. REFERENCES 1. Rathore A, Simpson BJ, Diefenbach KA. Traumatic abdominal wall hernias: an emerging trend in handlebar injuries. J Pediatr Surg 2012;47:1410-3. 2. Klimek PM, Lutz T, Stranzinger E, Zachariou Z, Kessler U, Berger S. Handlebar injuries in children. Pediatr Surg Int 2013;29:269-73. 3. Talutis SD, Muensterer OJ, Pandya S, McBride W, Stringel G. Laparoscopic-assisted management of traumatic abdominal wall hernias in children: case series and a review of the literature. J Pediatr Surg 2015;50:456-61. 4. Litton K, Izzidien AY, Hussien O, Vali A. Conservative management of a traumatic abdominal wall hernia after a bicycle handlebar injury (case report and literature review). J Pediatr Surg 2008;43:e31-2.
Accepted for publication August 6, 2015. Reprint requests: Dr Daniela Codrich, MD, PhD, Institute for Maternal and Child Health, IRCCS ‘‘Burlo Garofolo,’’ Via dell’Istria 65/1, 34137 Trieste, Italy. E-mail: [email protected]. Surgery 2015;j:j. 0039-6060/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2015.08.009
SURGERY 1