How to handle "handlebar injuries"

How To Handle "Handlebar Injuries" In Children

References

Sifrance Tran, MD

Pediatric Surgery Fellow

Thank you

Mechanisms of Injury

Overview

Management Algorithm

• Blunt trauma by handlebar
• Abdominal skin bruise or abrasion
• Abdominal pain on physical exam

History and Physical

Index of Suspicion

Direct Impact!

Primary Investigation

Labs: CBC, BMP, LFT, Lipase, and UA

Imaging: Abdominal x-ray or ultrasound

A Lethal Weapon?

Intra-abdominal injuries may take up to 23 hours to manifest its severity

Patients may be stable on initial presentation

Just letting you know. I'm on to you!

Cross-bar

Stem Crown

Handlebar end

Mechanism of Injury

Health Care Costs

The Hidden Spear

Abnormal US

70% of handlebar related injures are by direct impact by the end of the handlebar

Normal Exam

Abnormal Labs

Normal US

Abnormal Exam

Normal Labs

Normal US

Normal Exam

Normal Labs

Normal US

$9.6 million in annual hospital charges

$10 million in lifetime medical costs

$11.5million in estimated lifetime productively losses

Striking the the handlebar allows a significant amount of concentrated force to transmit into a small area

Bicycle Trauma

“Get a bicycle. You will certainly not regret it, if you live.” ~ Mark Twain

Is it really that serious?

US Census

• More than 27 million children ride bicycles
• There are 319 million people that live in the US.

• Nadler et al. “The high morbidity associated with handlebar injuries in children.” J Trauma 2005: (58)1171-1174.

• Arbogast et al. “Protecting the child’s abdomen: a retractable bicycle handlebar.” Accid Anal Prevent 2001: (33) 753-757.

• Winston et al. “Estimates of the incidence and costs associated with handlebar-related injuries in children.” Arch Pediatr Adolesc Med 2002: (156) 922-928.

• Winston et al. “Hidden Spears: handlebars as injury hazards to children.” Pediatrics 1998: (102) 596-601.

• Stylianos, S: “Outcomes from pediatric solid organ injury: role of standarized care guidelines.” Curr Opin Pediatr 2005: (17) 402-406.

• Stylianos et al. “Compliance with evidence-based guidelines in children with isolated spleen or liver injury: a prospective study.” J Ped Surg 2002: (37) 453-456.

External signs of injury may be absent

8% of the population!

Low Speed Injury

• Isolated falls
• No cars involved
• Handlebars

Blunt injury to Head, chest, abdomen, or pelvis

High Speed Injury

• Ejection
• MVC
• Collision

Multi-system injury and/or head trauma

Incidence

• Bike accidents contribute to a large proportion of pediatric trauma

Discordance exists between apparently minor circumstances of handlebar trauma the severity of injury sustained by the bicyclist

430,000 hospital visits per year

275 deaths per year

Observation 24 hours and/or Consider CT scan

Discharge home

Trauma Cases

Spectrum of Injuries

Prevention

Initial Presentation

Vitals: BP 91/64 | Pulse 60 |Temp 36.9 | Resp 20 | Wt 26.3kg

EXAM

General: Moderate distress secondary to pain and vomiting

Abdomen: Soft, non-distended, and epigastric tenderness

Skin: Superficial abrasion just above the umbilicus

Patient Education

Initial Presentation

Labs

Vitals: BP 121/79 | Pulse 132 |Temp 38.2 | Resp 28 | Wt 19 kg

EXAM

WBC: 11.4 > 14.0 < 249

BMP: 137/3.8/105/24/13/0.4/128

Lipase: 25,712

UA: Negative for blood

General: Non-toxic, minimal distress secondary to pain

Abdomen: distended and diffusely tender rigid

Skin: No abrasions or marks on the abdominal skin

Solid organ injury occurs in 30% of cases

• Majority of liver and splenic lacerations due to blunt trauma may be managed expectantly in hemodynamically stable patients
• Embolization may be considered in selected cases of contrast extravasation
• Operative intervention is reserved for hemodynamically unstable patients

CT Scan

• Use proper size and type of bike for age and skill level
• Avoid bikes with full rotation of handlebars
• Purchase handlebar bumpers and guards

Labs

• Liver
• Spleen
• Pancreas
• Duodenum

WBC: 13.9 > 11.2 < 260

LFTs: ALT 8 | AST 29 | Tbil 0.8

Lipase: >3000

Peripancreatic fluid and with pancreatic injury involving the head of the pancreas

OSH CT Scan

Free air and fluid in the abdomen and pelvis. Hematoma in the region near the head of the pancreas and duodenum.

Hospital Course

Trauma Case 2

Trauma Case 1

Managed non-operatively

• NPO
• TPN
• Serial exams
• Serial Lipases

Failed Enteral Nutrition

Operative Course

HPI: 4 year old male presenting 2 days after falling forward while riding his bike and hitting is abdomen on the handlebars.

HPI: 8 year old male riding down a hill at his parents house on a bicycle, standing on the pedals, not wearing a helmet, an using no hands.

• Small bowell
• Colon
• Kidneys
• Urethra
• Abdominal wall
• Major vessels

Diagnostic laparoscopy

• Purulent debris throughout abdomen
• Large hematoma in colonic mesentary
• Questionably viable transverse colon

Conversion to laparotomy

• Retroperitoneal hematoma adjacent to head of pancreas, however, pancreas intact
• Segmental resection of ascending, hepatic flexure, and mid-transverse colon with primary anastamosis

He developed abdominal pain the following day and his mother brought him to an OSH ED, but left prior to being seen because of the long wait time.

Placement of nasojejunal tube and initiation of trickle tube feeds exacerbated his pancreatitis resulting in pain and nausea

Retractable Handlebar Design

Magnetic Resonance Cholangiopancreatography

Somehow he fell and was bluntly struck in the abdomen with the tip of the handlebar.

Up to 30-40% of direct-impact handlebar injuries require operative intervention

• Mainly intestinal perforations and pancreatic injuries
• Intestinal and pancreatic injuries are more likely to have a delayed presentation

Pancreatic pseudocyst identified in the head of the pancreas 1 week post-injury

Hospital Course

Due to persistent abdominal pain, she returned to the OSH ED 2 days post-injury for formal evaluation. Transferred to Lurie for further medical management.

• NPO with bowel rest post-operatively
• Supported with TPN until return of bowel function
• Lipase normalized and diet advanced
• Length of stay 10 days

20-30 minutes later he developed persistent emesis, prompting his parents to take him to Silver Cross.

Endoscopic Interventions

This design absorbs significant energy that would otherwise be transferred to the child's abdomen when impacting the handlebar

Endoscopic Retrograde Cholangiopancreatography

1 week post-injury

Sphincterotomy and stent placement

Hot topic in 2001 but has not been produced for purchase by manufacturers

Abdominal wall hernias occur in up to 20% of cases

• Thought to be due to blunt trauma that causes separation of muscle and fascia, while sparing the overlying skin

Endoscopic Cystduodenostomy

1 month post-injury