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Intriguing Gas Shadow From Penetrating Handlebar Injury Of Abdomen

Junaid Ashraf¹, Sarah Newell², Anies Mahomed², Lavanya Vitta³

¹Department of Paediatric Surgery, Leeds General Hospital, Leeds, UK

²Department of Paediatric Surgery, Royal Alexandra Children’s Hospital, Brighton, UK

³Department of Paediatric Radiology, Royal Alexandra Children’s Hospital, Brighton, UK

 

Abstract

Penetrating injuries of the abdomen secondary to bicycle handle bars are uncommon. Due to presence of padded handle grips, deep penetration is exceedingly rare. Reported is a case of a handle bar breaching the anterior abdominal wall, traversing depths of the peritoneal cavity & disrupting the coccyx posteriorly. A large amount of air in the right pararectal and left ischiorectal fossa on plain abdominal X ray and CT scan raised the possibility of bowel perforation. With integrity of the bowel confirmed at laparotomy a discourse on the origins of the air is mandated.

Keywords: penetrating injuries, bicycle handle bars

 

Correspondence

Junaid Ashraf
Department of Paediatric Surgery
Leeds General Hospital
LS1 3EX
Leeds
Tel (Work): 0113 243 2799
Mobile: 07588 778 424
E mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Introduction

Impact with bicycle handlebars (HB) is a significant cause of abdominal trauma in children. This produces an array of injuries and described in this context are; traumatic abdominal wall hernia[1]; renal, intestinal, liver, splenic and pancreatic injuries [2-4]; abdominal wall rupture [5]; abdominal aorta rupture [6]; disruption of the common bile duct and gallbladder [7,8]; and death [9]. Due to the presence of handle grips which protect the end of the HB most of the serious injuries are consequent to blunt abdominal trauma. Penetrating HB injuries are exceedingly rare and thus far only a couple of cases of interest have been reported in the literature [10]. We describe a particularly severe case of trauma from a fall onto a HB. Of greater interest than the injury itself, is the volume and pattern of free air evident on imaging.

Case Summary

A 12 year old boy was brought into A&E by the Helicopter Emergency Medical Service after coming off his mountain bike on a downhill run sustaining a HB laceration to the right lower quadrant of his abdomen. He was haemodynamically stable on admission and was found to have a 4 cm laceration in his right iliac fossa with omental prolapse (Figure 1).

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Figure 1. 12 year old male with omental herniation at the site of penetrating HB injury.

The abdomen was otherwise soft with minimal tenderness on the right hand side. Examination of the back and in particular the gluteal region revealed a tender left ischiorectal fossa with widespread crepitus. A rectal examination excluded fresh bleeding and right femoral pulse was noted to be present in both groins. Plain abdominal radiograph (Figure 2) demonstrated free air in the right para rectal region with a linear pattern of gas in the soft tissue extending from the pelvis to the lateral aspect of the proximal left femur. CT scan of abdomen and pelvis confirmed a disruption of the right anterior abdominal wall (Figure 3) with large amounts of free air peri-rectally, tracking into the pelvic sidewalls and into the left gluteus muscle and ischiorectal fossa (Figure 4,5) .

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Figure 2. X-Ray Pelvis demonstrating linear gas shadow (arrowed) extending from the right side of pelvis to the left gluteus maximus and ischiorectal fossa. Also noted is a fracture of the coccyx.

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Figure 3. Axial contrast enhanced CT of the abdomen demonstrating a rent in the right lower abdominal wall with air in the subcutaneous tissue with surrounding oedema (arrow)

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Figure 4. Axial contrast enhanced CT scan showing large amount of free air surrounding the rectum and tracking into the left gluteus muscle (arrowed) and into the ischiorectal fossa.

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Figure 5. Axial contrast enhanced CT scan abdomen demonstrating distortion consequent to the injury and air accumulation in the soft tissues overlying the gluteus maximus (arrowed).

Also noted was free fluid within the abdomen and pelvis. These findings suggested disruption of a hollow viscus; although a specific perforation was not identified on imaging. A comminuted fracture of his coccyx was also clearly noted. Liver, pancreas, spleen, kidneys and adrenals were all normal in appearance.

The patient was taken for laparotomy and approximately 1 litre of free blood was evacuated from the peritoneal cavity. A significant right retroperitoneal and right lateral pelvic wall haematomata were also noted. Also documented were two serosal injuries in the small bowel with another in the caecum. Closer inspection of the pelvis revealed an extensive tear of the posterior peritoneum starting just to the right of the rectum at the level of the sacral promontory extending postero-inferiorly behind the rectum and to the left. Despite the extensive injuries the rectal wall was confirmed to be intact. This was subsequently confirmed by a limited sigmoidoscopy conducted at the end of the procedure. A comminuted fracture of the coccyx with loose bony fragments was noted. Interestingly a piece of the patient’s trouser, most likely embedded by the HB was retrieved from the coccygeal fragments. The tract was comprehensively debrided and washed out and the anterior abdominal rent was repaired before closure of the midline laparotomy.

Post operatively intravenous antibiotics were maintained for five days and feeding was resumed on day 4. Just prior to discharge on day 7 the patient confirmed that he was riding his bicycle without HB grips.

Discussion

Although bicycle accidents are a common mechanism of injury in children, the incidence is variable and the experience limited to individual health care settings [11]. In 1997, a census of hospital discharge data from paediatric trauma centres of 19 States in the United States was extrapolated to determine national estimates of incidence [12]. This study noted that 1147 subjects, 1.49 per 100,000, 19 years and younger had serious non–motor vehicle bicycle-related, abdominal or pelvic organ injury leading to hospitalization. Of these, 886 or 1.15 per 100,000, 19 years and younger, may have been associated with HB injuries.

A 5 year retrospective review of children with HB injuries described various patterns of intraabdominal damage with the majority consequent to blunt injury and a minority presenting with superficial lacerations [2]. Conceivably with blunt HB injury, any intra-abdominal structure could be damaged but commonly seen were injuries of the liver and spleen, bowel perforation, traumatic pancreatitis, transection of the pancreas, renal contusion and duodenal haematoma. On the other hand, penetrating HB injuries appear to be exceedingly rare [10,13]. In this context, hollow viscus injuries occur more frequently with the colon being particularly vulnerable to damage [14,15].

In the early evaluation of abdominal trauma, CT has become the mainstay imaging modality and is particularly useful for characterization of bowel injuries [16]. Notwithstanding this, CT has limitations and findings may be difficult to interpret. In a prospective study where CT scans were undertaken to ascertain peritoneal violation in 200 haemodynamically stable patients with penetrating abdominal trauma (86 gunshots, 111 stabs, 3 impalements), the investigation had a sensitivity of 97%, specificity of 98% and accuracy rate of 98% [17]. Interestingly, laparotomy performed on the basis of suspected CT findings of bowel injury on 38 of these patients, was therapeutic in only 87%. Likewise, in a retrospective study to determine the significance of CT detected pneumoperitoneum following blunt abdominal trauma, of 118 consecutive scans performed over a year, 7 patients (5.9%) had evidence of extra luminal air. However, none of these cases had evidence of bowel perforation at laparotomy (2 cases) or on clinical follow-up (5 cases) [18].

The clinical assessment of HB injuries is equally difficult with reports stressing the dichotomy between the benign external appearance and potentially serious intra-abdominal injury [11, 19]. The presented case is interesting as the sheer volume of free air within the pelvis and soft tissues suggested a likely hollow viscus injury. The fact that integrity of the bowel was confirmed at laparotomy and subsequent endoscopy suggests an external origin for the air. In the absence of bowel perforation, impalement with a sharp object, on its own, is unlikely to produce this quantity of air. However, we postulate that a fall onto an unprotected HB with the opposite end occluded will result in a significant amount of air being forced down the path of the penetrating cylinder into the falling body. A contributing factor to the resultant air pattern is the profound tissue disruption produced by the substantial width of the impaling HB and its depth of penetration. Air trapping along this tract made for intriguing radiographic images.

Two important learning points from this case are, firstly, the presence of free air within soft tissues and in the abdominal cavity following HB injury does not automatically imply hollow viscus injury and secondly impalement from a firm hollow cylinder may result in the injection of significant amounts of air down the impalement tract making for both interesting but difficult to interpret radiology.

 

 

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