AJR 2002; 179:222
© American Roentgen Ray Society
Trauma Cases from Harborview Medical Center |
Handlebar Injury Causing Pancreatic Contusion in a Pediatric Patient
Joel A. Gross1,
Matthew M. Vaughan1,
Brian D. Johnston2 and
Gregory Jurkovich3
1 Department of Radiology, Harborview Medical Center, 325 Ninth Ave., Box
359728, Seattle, WA 98104-2499.
2 Department of Pediatrics, Harborview Medical Center, Seattle, WA
98104-2499.
3 Department of Surgery, Harborview Medical Center, Seattle, WA
98104-2499.
Received August 9, 2001;
accepted after revision August 9, 2001.
This is another in the continuing series on radiology in trauma cases from
the Harborview Medical Center. Editors: Fred A. Mann, Eric J. Stern, and Lee
B. Talner.
Address correspondence to F. A. Mann.
Introduction
A previously healthy 6-year-old boy presented to the emergency department
complaining of abdominal pain after a low-speed bicycle collision. The boy
reported that the wheel of his bike had turned 90°, and his abdomen was
impacted by the end of the handlebar. On initial examination, a small
abdominal wall contusion was noted in the left upper quadrant. The findings of
the remainder of the examination were normal. Limited abdominal sonography
revealed no free abdominal fluid. Serum amylase and hematocrit levels were
normal. The child was asymptomatic and was discharged from the emergency
department with instructions for follow-up.
He returned the following day with new onset of vomiting and increasing
abdominal pain. His serum amylase level was elevated (twice the normal level),
and abdominal CT (Fig.
1A,1B,1C)
showed peripancreatic fluid. A pancreatic contusion was suspected, and the
patient was admitted. Twelve hours later, his serum amylase level continued to
rise (four times the normal level), and repeated CT showed a suspected
laceration of the mid body of the pancreas. The child was taken to surgery,
which revealed a contused, hemorrhagic pancreatic tail and cloudy ascitic
fluid. No pancreatic laceration was found. A distal pancreatectomy with
splenic salvage was performed. The child did well and was discharged home on
postoperative day 5.
Significant pancreatic injuries can occur with apparently minor handlebar
trauma. Most handlebar injuries occur during low-velocity falls when the
abdomen or thorax is impacted by the end of the handlebar. The energy of the
fall is transmitted through a small surface area, leading to the concentrated
application of blunt force. External bruising is a poor indicator of
underlying organ injury [1]. A
high index of suspicion is required to appropriately evaluate children with
this mechanism of injury.
In a recent case series of 107 pediatric bicyclists with more than minor
injuries admitted to a trauma center, 17 (15.8%) sustained a handlebar impact.
Abdominal injuries were common among those reporting handlebar impact, whereas
head or extremity trauma was rare
[2]. Clarnette and Beasley
[1] reported that handlebars
account for half the blunt abdominal trauma in childhood bicycle accidents.
The most common injury is splenic laceration. Injuries to the liver, pancreas,
kidneys, bowel, urethra, and groin also occur. Handlebar injuries account for
27% of blunt pancreatic trauma in children
[3].
Timely diagnosis of pancreatic injuries is important. A delayed diagnosis
is the greatest determinant of morbidity
[3]. However, serum amylase
levels and the results of initial imaging and clinical examination may be
normal. Initial CT findings may be minimal, even with pancreatic transection,
because the elastic pancreatic parenchyma resumes its normal contour. Repeated
abdominal CT at 24-48 hr can reveal evolving injuries
[4]. In children with
pancreatic injury, serum amylase levels are elevated in most patients by 24 hr
after the injury [3].
Asymptomatic children with a history of handlebar injury who are not
admitted should be scheduled for follow-up in 12-24 hr and instructed to
return sooner if symptoms appear. Rising amylase levels or increasing
abdominal pain heighten suspicion for bowel or pancreatic injury. A negative
finding on an initial imaging study does not exclude injury, and clinicians
should maintain a low threshold for repeated imaging.
References
-
Clarnette TD, Beasley SW. Handlebar injuries in children: patterns
and prevention. Aust N Z J Surg
1997;67:338
-339[Medline]
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Winston FL, Shaw KN, Kreshak AA, Schwarz DF, Gallagher PR, Cnaan A.
Hidden spears: handlebars as injury hazards to children.
Pediatrics
1998;102:596
-601[Abstract/Free Full Text]
-
Arkovitz MS, Johnson N, Garcia VF. Pancreatic trauma in children:
mechanisms of injury. J Trauma
1997;42:49
-53[Medline]
-
Shuman WP. CT of blunt abdominal trauma in adults.
Radiology
1997;205:297
-306[Free Full Text]
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Introduction
References
