|Year : 2014 | Volume
| Issue : 1 | Page : 76-77
An unusual case of handle bar injury of abdomen in a child: A case report and review of literature
Sudhir K Thakur, Shwetank Agarwal, Madhubala K Karne, Gopal
Department of Surgery, Saraswathi Institute of Medical Sciences, Hapur, Ghaziabad, Uttar Pradesh, India
|Date of Web Publication||10-Dec-2013|
Sudhir K Thakur
Department of Surgery, Saraswathi Institute of Medical Sciences, Hapur, Ghaziabad, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
The handle bar injury is quite common in pediatric age group. The nature of injury may vary from minor abrasions to life-threatening acute abdomen. We present a case who came to us after five days of sustaining such injury with anterior abdominal wall hematoma and surprisingly, we found free gas under the right dome of diaphragm. We successfully treated the patient conservatively and the patient is being followed up at regular interval.
Keywords: Gas under diaphragm, handle bar injury, traumatic perforation
|How to cite this article:|
Thakur SK, Agarwal S, Karne MK, Gopal. An unusual case of handle bar injury of abdomen in a child: A case report and review of literature. Med J DY Patil Univ 2014;7:76-7
| Introduction|| |
Head injury is the commonest cause of mortality and morbidity after sustaining fall from a bicycle during childhood.  It can result in surgical emergency due to internal injury to liver, spleen, kidney, gut, and Spigelia More Detailsn hernia.  This case presented five days after sustaining trauma and that too due to hematoma in anterior abdominal wall and pain, without any clinical evidence related with perforation of a hollow viscus. We found free gas under the right dome of the diaphragm. This case report is unique in the sense that even after perforation of hollow viscus, which was detected on 5 th day after trauma, the patient had no symptom of peritonitis at any point of time since injury.
| Case Report|| |
A 12-year-old child reported to Surgical OPD with pain in abdomen since last two days. He had a history of fall from bicycle 5 days back and one episode of vomiting a day back. The patient had impression of handle bar injury in right lower abdomen with surrounding hematoma of 6-cm diameter. There was no breach in the abdominal wall. His abdomen was soft and bowel sound was normal. He was taking regular diet and his bowel was moving regularly. We got his routine investigations including Ultrasound of abdomen done. Surprisingly, there was free gas under the right dome of diaphragm but ultrasonography did not reveal any collection. Assuming that the free gas under right dome was due to small perforation of hollow viscus which had sealed, we continued with the conservative treatment with IV fluid, antibiotics, and pain killer. Though the patient was already on normal diet, we stopped it as a precautionary measure and allowed only liquid diet for the first two days. Gradually, the hematoma in anterior abdominal wall resolved and the patient was discharged 5 days after the admission. After two days, the patient again reported in the casualty wing of our hospital in the evening with features of Subacute Intestinal Obstruction. The radiograph of the abdomen and chest did not reveal any free gas under the diaphragm but dilated loops of small bowel were visible. The Ultrasound again did not show any collection in peritoneal cavity. The patient confessed to having ten bananas at a time. We started the conservative treatment again and by morning, the patient was quite well. The patient was kept under observation, the hematoma resolved completely, with only the pattern bruising of original injury [Figure 1].
|Figure 1: Clinical photograph of anterior abdominal wall of the patient, taken six weeks after sustaining the injury showing the scar in the shape of butt end of handle bar of bicycle (London's Sign)|
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| Discussion|| |
Handlebar injury is a specific type of injury sustained due to impact of any part of body against a bicycle handle bar. As far as abdominal injury is concerned, it is quite easy to diagnose in the case presenting with acute abdomen but not always so. The definitive radiological investigation of major abdominal trauma in a hemodynamically stable child is a CT scan with intravenous contrast. In this case, reverse was the situation, as the radiological evidence of perforation of hollow viscus was present without any clinical or ultrasonic evidence of peritonitis in the patient. On the other hand, delayed presentation of hollow viscus perforation has been reported in the literature and the poor prognosis arising out of delayed diagnosis has often been emphasized upon.  Once the diagnosis of perforation of hollow viscus is confirmed, almost all the surgeons agree on early exploration of the abdomen. We would have done the same, had the patient reported on the day of injury. The patient reported five days later. He was taking normal diet and passing stool regularly. The only explanation in this case was that probably at the time of impact there was small leak from somewhere, which got sealed immediately. Since the abdomen was soft and bowel was moving, we decided to continue with conservative management. When the patient was back after two days of discharge with features of subacute intestinal obstruction, we suspected band and adhesion due to the previous injury. The radiograph showed no gas under the diaphragm but dilated loops of small bowel. The ultrasonography of the abdomen was within normal limit. This subacute obstruction could have been due to the ten bananas eaten at a time. We conclude that every clinician should keep in mind this type of unusual presentation after handle bar injury and decision to operate on a case depends not only on imaging finding but also on overall clinical condition of the patient.
| References|| |
|1.||Lam JP, Eunson GJ, Munro FD, Orr JD. Delayed presentation of handlebar injuries in children. BMJ 2001;322:1288-9. |
|2.||Thakur SK, Gupta S, Goel S. Traumatic Spigelian Hernia due to Handlebar injury in a child: Acase report and review of literature. Indian J Surg 2012 Sept. Available from http://link.springer.com/article/10.1007/s12262-012-0734-y [Last accessed on 2012]. |
|3.||Sule AZ, Kidmas AT, Awani K, Uba F, Misauno M. Gastrointestinal perforation following blunt abdominal trauma. East Afr Med J 2007;84:429-33. |