It’s 2 a.m. on a Friday night and a medic unit responds to a call of a “pedestrian struck.”
On arrival, city law enforcement declares the scene to be safe and directs the unit to the opposite shoulder of the highway. EMS providers find a 35-year-old male lying in the prone position with a moderately damaged mountain bike beside him.
Assessment & Treatment
The patient says he was riding home from his friend’s house when he got “bumped” by a passing car, hit a pothole and fell forward off his bike. Although his breath indicates recent alcohol intake, he’s able to answer questions in a moderately slurred voice. Initially the patient refuses medical evaluation and transport to the hospital, but the medics are able to convince him otherwise. The airway is intact with no debris or blood, and breath sounds are equal bilaterally. His respiratory rate is 22 and pulse oximetry 96% on room air.
A cervical collar is placed on the patient, and he is log-rolled and secured onto a backboard. The heart rate is found to be 110 mmHg with a blood pressure of 136/92. His helmet has an abrasion to the front but is otherwise intact.
Your trauma exam is notable for a 2×3 cm round-shaped wound to the midline epigastric region, just inferior to the xiphoid process, with moderate non-pulsatile bleeding. You note that when the patient exhales following a deep inspiration, there’s a small bulge in the wound that subsequently resolves with the following inspiration. No air movement or bubbling from the wound is detected.
The abdomen is mildly distended with moderate diffuse tenderness and there are multiple partial thickness abrasions to the bilateral elbows, hands and lower extremities. Although he’s clinically intoxicated, his Glasgow Coma Scale (GCS) is determined to be 15.
Once in the mobile unit, you place the patient on 4 lpm oxygen via nasal cannula and a cardiac monitor. You secure a sterile abdominal gauze pad over the open abdominal wound.
The total scene time is 12 minutes, and transport time to the local trauma center is 20 minutes. You place an 18-gauge IV in the patient’s right antecubital fossa and administer 500 ccs of normal saline en route. The dressing controls the bleeding from the abdominal wound, and there’s no significant clinical change in the patient during transport.
Close-up view of the bulging wound, indicating traumatic abdominal hernia.
Trauma Center Care
On arrival to the trauma center, the trauma team repeats the primary and secondary surveys. Vital signs aren’t significantly changed: Heart rate is 112, respiratory rate is 18, blood pressure is 132/88, and pulse oximetry is 100% on room air. The trauma team also performs a focused assessment with sonography for trauma (FAST) exam, which demonstrates a small amount of free fluid in the right upper quadrant, specifically Morrison’s pouch.
A FAST exam, which is regularly performed during a trauma survey, uses four different locations to place the ultrasound and screen for free fluid in 10 distinct potential spaces. Free fluid, often blood in the traumatic patient, is a strong indicator of significant abdominal or thoracic injury, and the FAST exam allows early identification of these patients in order to expedite surgical intervention. Morrison’s pouch is a potential space between the inferior aspect of the liver and superior aspect of the right kidney. It is recognized as the most likely location to identify free fluid associated with a serious intra-abdominal injury.
Given the stable vital signs, a CT scan of the head, cervical spine, chest, abdomen and pelvis is performed to fully evaluate the injuries. The CT scans demonstrate a 2 cm anterior abdominal wall hernia at the site of the open wound, injury to two areas of the small bowel with likely perforation given the surrounding small foci of free air and a grade 2 liver laceration. The patient is immediately taken to the operating room, where he undergoes an exploratory laporatomy with resection of two portions of the small bowel, suture repair of the liver laceration and primary repair of the abdominal hernia with mesh. His post-operative course is uneventful, and the patient is discharged to home one week later.
This CT scan demonstrates a 2 cm anterior fascial defect and associated abdominal wall hernia at the site of the open wound.
At first glance, a fall from a bicycle can often be mistaken as a non-significant mechanism. As is often the case with lateral falls, a low level of energy is being distributed to a large area of the body or to an extremity. However, forward falls from a bicycle are frequently higher energy, which is distributed to a smaller area of the body.
More specifically, the body can be struck in the chest or abdomen by the handlebars or the head by the ground or stationary object. This focused impact in combination with increased abdominal pressure as a result of the initial impact of the bicycle places the patient at significant risk of injury to the abdominal wall and anterior abdominal organs, including the liver, spleen, stomach, bladder, colon and small bowel. Therefore, any patient who falls at a high rate of speed or falls forward off of a bicycle should be considered to have suffered a significant mechanism of injury and treated as such.
Blunt traumatic injuries from a bicycle handlebar are more common in the pediatric population. A two-year retrospective chart review at a major children’s hospital found an average age of 8.8 years for this injury, with 79% of patients in this population being boys. Of the 14 patients who presented for evaluation to the ED, 11 had a ring-shaped ecchymotic area noted in the abdomen with a variety of lacerations and abrasions. After evaluation, it was found that 21% had an intestinal perforation and 21% had an abdominal wall hernia, as large as 5 cm.1 In the multiple case reports published, traumatic abdominal wall hernias due to a handlebar injury more often occur in the lower abdomen and appear as a ring- or circular-shaped ecchymosis, abrasion or open wound.
In the pediatric population, a handlebar injury is the most common cause of a traumatic abdominal hernia and isn’t a reliable indicator for more significant traumatic injuries. In contrast, seatbelt trauma in a motor vehicle collision is the more frequent mechanism for abdominal hernias in adults and is almost always associated with other significant injuries.2
Clinically, a traumatic abdominal wall hernia will appear as a discrete bulge on abdominal exam that may expand and reduce with a change in abdominal pressure or remain constant. It’s important to recognize this clinical sign and its association with significant traumatic injuries, but no other specific care should be performed except for a sterile dressing application to any open wounds. Application of manual pressure or compression of any kind to the mass isn’t advised because it may exacerbate other injuries.
In this case, the ALS unit provided prompt and efficient care for their trauma patient; starting with airway, breathing and circulation (ABCs), and proceeding through spinal immobilization and secondary examination. They recognized the significant mechanism and were able to persuade the patient to receive the care he required. Large-bore IV access was obtained, fluid resuscitation was initiated and appropriate wound care was provided—all while expediting transport to a trauma facility.
In summary, falling forward onto a bicycle places a patient at risk of a handlebar injury and should be considered a significant traumatic mechanism that may cause serious abdominal injuries with no major outward signs of trauma on exam. A traumatic abdominal wall hernia will appear as an area of ecchymosis or small wound with an underlying bulge. Although this doesn’t require specific care, it should be recognized as a significant injury. In adults, it may indicate additional serious abdominal injuries. As such, these patients should be transported expeditiously to the closest trauma center.
1. Karaman I, Karaman A, Aslan M, et al. A hidden danger of childhood trauma: Bicycle handlebar injuries. Surg Today. 2009;39(7):572–574.
2. Haimovici L, Papafragkou S, Kessler E, et al. Handlebar hernia: Traumatic abdominal wall hernia with multiple enterotomies. A case report and review of the literature. J Pediatr Surg. 2007;42(3):567-569.