Traumatic ventral hernia with small bowel perforation and small and large bowel segmental devascularization.
CT scan of the abdomen and pelvis shows an infraumbilical midline abdominal wall defect containing loops of small bowel (Figure 1) and free fluid in the pelvis (Figure 2). There is no free intraperitoneal air or solid organ injury.
The patient was taken to the operating room for a laparotomy where an infraumbilical midline abdominal wall rupture, with fraying of the fascial edges, was identified. In addition, a 1-cm mid-jejunal perforation, a 5-cm segment of devascularized midileum, and a 10-cm segment of devascularized and deserosalized midtransverse colon were identified. The 2 injured portions of the small bowel were resected and reanastomosed and an extended right hemicolectomy was performed with an ileocolic anastomosis. The abdominal wall defect was repaired primarily in closing.
The patient followed an uneventful recovery and was discharged to home on postoperative day 4.
Traumatic abdominal wall hernia (TAWH) is an uncommon injury resulting from blunt trauma. Three types of TAWH have been described.1 The first type is a small, focal abdominal-wall defect resulting from impalement by a low-energy blunt object, such as a bicycle or motorcycle handlebar. The second type is a large abdominal-wall defect from high-energy deceleration or compression as seen with a seatbelt injury in a motor vehicle collision. A third type results in herniation through the peritoneum only and is related to a fall from height.
In children, the most common low-energy TAWH is the type 1, which results from a bicycle accident where the abdomen impacts upon the end of the handlebars.9 The handlebar end is small enough to penetrate the relatively tense abdominal wall, which may be exacerbated by Valsalva maneuver in anticipation of impact. It is simultaneously blunt enough to not pierce the overlying skin, which is much more elastic. 4,5,6,8,9 The resulting defect was termed a handlebar hernia by Dimyan, et al., in 1980.3
Review of the surgical literature reveals 22 cases of handlebar hernia. The overwhelming majority of reported cases had no associated intra-abdominal injury.1,4,5,6,8,9 This case is only the second handlebar hernia resulting from a bicycle handlebar with associated intra-abdominal injuries. This is in contrast to other types of TAWHs, such as those resulting from high-energy trauma where associated injuries are common.9
Therefore, this patient’s injury is atypical and represents a deviation from expected outcome, since he had multiple associated bowel injuries. We postulate that this individual’s bowel injuries resulted from focused direct compressive force of the invaginating handlebar end in the peritoneal cavity that arose after disruption of the abdominal wall. This raises the question of why associated intra-abdominal injury is so uncommon in the face of bicycle handlebar hernia.
A possible explanation is related to the venue of this patient’s injury. He was riding his bicycle at a skateboard and bicycle park on a half-pipe course, an extreme sport known as BMX freestyle. A half-pipe is a type of ramp fashioned from 2 concave ramps joined by a flat transition in the shape of an elongated “U.” The rider gains speed by going back and forth across the ramp turning 180 degrees at the vertical portions and is able to perform aerial stunts, sometimes 10 or more feet in the air. A fall from such a height onto the end of the handlebars could then produce a force sufficient to cause this individual’s injuries. The only other case of bicycle-related abdominal handlebar hernia with associated intra-abdominal injuries occurred in a 24-year-old BMX stunt bicyclist in the year 2000.10
With the advent of the X games in 1995 and the growing popularity of this and other extreme sports, we need to be sensitive to the possibility of more extensive injuries associated with what may seem to be a simple fall from a bicycle. A CT examination is a useful test for the evaluation of possible handlebar hernia and associated intra-abdominal injuries.2,7
Traumatic ventral hernia is an uncommon handlebar injury that may herald the presence of underlying bowel perforation and/or devascularization. The growing popularity of extreme sports requires a heightened index of suspicion for intra-abdominal injury related to a bicycle fall.