Discussion
Bicycle injuries constitute to be a common cause of childhood trauma
presenting to the emergency department. Among them, handlebar injuries
are an uncommon variety, found to be 1.15 per 100,000
cases.7 It results when the body of the child strikes
the handlebar of the cycle as the child falls off. During this, force
transmitted through the handlebar may cause significant injuries even
with low speed.2 Common abdominal injuries due to it
includes injuries to the pancreas, small bowel, mesentery, liver, and
spleen.8
Retroperitoneal bleeding secondary to handlebar injury, however, is less
common with one reported case of retroperitoneal hematoma, where
conservative management was opted. Retroperitoneal hematoma encountered
in trauma are mostly caused by blunt injuries. Majority of them are due
to renal injuries and other causes such as vascular injuries, pelvic
injuries and rarely blunt trauma to retroperitoneal structures as
duodenum and pancreas.6
In a study by Clarnette et al, 32 children with blunt abdominal trauma
due to handlebar injuries were identified and among them nine had
splenic trauma and rest involved liver, pancreas, kidney, urethral and
bowel injuries. However, none of them were reported to have
retroperitoneal hematoma or mesenteric injuries.9
CT scan is an important modality in case of abdominal trauma for further
assessment and appropriate management. Though in cases of
hemodynamically unstable patients following blunt abdominal trauma with
eFAST scan positive, immediate exploratory laparotomy should be done.
However, in our case, CT scan was done later once hemodynamically
stability of the patient was achieved. As CT scan showed mesenteric
injury with retroperitoneal hematoma, it assisted surgeons for prior
discussion of the operative approach in this case. This case not only
highlights the importance of CT scan but also the fact that in cases
where CT scan is not feasible, retroperitoneal hematoma though uncommon
in bicycle handlebar injury should be suspected. In absence of CT scan,
high suspicion is to be accounted when the intraoperative finding is not
proportionate to the clinical picture of the patient. In such cases,
retroperitoneal approach may be needed. As the mortality rate ranges
from 18-60 % with traumatic retroperitoneal hematoma, this emphasizes
its importance of early recognition and management.5
Furthermore, the clear history of handlebar injury in our patient helped
us to suspect major abdominal injury in this case. Hence, a detailed
history to recognize the mechanism of injury, whether it involves
handlebar-related injuries or not might aid the practitioner in early
diagnosis of serious abdominal injuries in child bicyclists.
This case particularly highlights upon the unusual instance where
retroperitoneal hematoma due to mesenteric vascular injury occurred in
the absence of any solid or hollow viscus injury. The crucial role of
imaging studies in such cases need to be over-emphasized. Prompt
decision making for initial resuscitation and eventual surgical
management is key, owing to this infrequent nature of blunt abdominal
trauma.