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ACS Case Reviews

Handlebar Hernia: The Need for High Clinical Suspicion

August 1, 2022

Abstract

Background

A male adolescent presented after blunt abdominal trauma from a bicycle handlebar and was found to have a traumatic abdominal wall hernia (TAWH) that was not visualized on initial axial imaging.

Summary

Our patient presented at age 14 after losing control riding his bicycle down a hill and experiencing blunt trauma to his abdomen from the bicycle handlebar. An initial CT scan revealed a pelvic sidewall hematoma without any disruption of the abdominal wall fascia. Approximately 36 hours after presentation, he was noted to have a bulge in his abdominal wall, only seen after standing and waiting 10 to 15 seconds. He was taken to the operating room and found to have a full-thickness Spigelian abdominal wall hernia, which was repaired primarily. He had no underlying intraabdominal injuries. While traumatic abdominal wall hernias have been rarely previously described, most TAWH are diagnosed via imaging. This case is unique because a CT scan of the abdomen was negative, and the diagnosis was made based on a thorough physical exam.

Conclusion

This case emphasizes the importance of not relying exclusively on imaging to make the diagnosis of TAWH, maintaining a high clinical suspicion, and performing a thorough physical exam.

Key Words

pediatric trauma; traumatic abdominal wall hernia; handlebar hernia


Case Description

An otherwise healthy 14-year-old male presented to the emergency department after a bicycling accident. He was riding his bicycle downhill when he lost control of the handlebars and crashed. His left hemiabdomen impacted the handlebars. He was not wearing a helmet but had no head strike or loss of consciousness. He initially presented to a community hospital where he was evaluated using ATLS protocol and, on primary survey, was found to be tachycardic to the low 100s but normotensive. His secondary survey was significant for bruising and pain in the left lower abdomen and the suprapubic region. An extended FAST exam was negative, and CT abdomen/pelvis revealed a left pelvic sidewall hematoma (Figure 1A) as well as anterior abdominal wall subcutaneous fat stranding in the left lower quadrant at the site of his bruising (Figure 1B). Initial labs were unremarkable, with a Hgb of 12.9 and Hct of 39.2, but with a urinalysis that revealed 3+ blood. Given the pelvic hematoma and microscopic hematuria, there was a concern for possible bladder injury and that he might need pelvic embolization. He was therefore transferred to a tertiary care center for further management.

Figure 1. Initial CT Abdomen/Pelvis on Arrival to Emergency Department. Published With Permission

A) Left pelvic sidewall hematoma; and B) subcutaneous fat stranding in left lower quadrant.

After transfer to our institution, a CT cystogram was obtained, which was negative for any evidence of bladder injury. Again the abdominal wall appeared unremarkable. Later that evening, he was noted to have a bulge in his left lower abdominal wall that was only apparent after standing and observing for 10 to 15 seconds (Figure 2). Fascial edges were not palpable, but the bulge was soft and reducible. Given the clinical concern for abdominal wall hernia and the concern for possible underlying occult intraabdominal injury in the setting of abdominal wall impact significant enough to create an abdominal wall hernia and a pelvic hematoma, the patient was taken to the operating room for a diagnostic laparoscopy.

Figure 2. Front and Side Views of Patient's Abdomen After Standing for 15 Seconds. Published With Permission

A diagnostic laparoscopy was performed, with a 12 mm trocar placed at the umbilicus and 5 mm trocars placed in the right lower quadrant and the left subcostal region. The abdominal viscera were inspected, and no occult injuries were identified. The pelvic sidewall hematoma was visualized, and there was a minimal amount of hemoperitoneum in the pelvis. Upon visualization of the left lower abdominal wall, a full-thickness hernia was immediately identified at the left linea semilunaris. The peritoneum and transversalis had defects, and the posterior and anterior rectus sheath had separated from the transversus abdominus aponeurosis, the internal oblique aponeurosis, and the external oblique aponeurosis. Scarpa's fascia and the subcutaneous tissue were directly visualized from the intraperitoneal space (Figure 3). Only some of the abdominal wall layers could be visualized laparoscopically; they had retracted beyond the layer beneath them (i.e., the transversus abdominus and internal oblique were not visualized until we converted to an open approach).

Figure 3. Laparoscopic View of Full-thickness Anterior Abdominal Wall Hernia and Graphic Representation of Laparoscopic View of Abdominal Wall. Published With Permission

Transversus abdominus and internal oblique were not visualized laparoscopically as they had retracted beyond our view.

Attempts were made to close the hernia primarily using intracorporeal suturing, but the fascia of the rectus sheath had retracted so far medially that it was difficult to visualize. Therefore, a left paramedian incision was made just above the fascial defect identified laparoscopically. The layers of the abdominal wall were closed in layers. The patient did well and was discharged home on postoperative day 1. The patient was seen in the clinic two weeks after discharge and was doing very well.

Discussion

Traumatic abdominal wall hernias (TAWHs) are defined as the disruption of the abdominal wall musculature and/or fascia, without skin penetration, associated with blunt trauma. These injuries can be secondary to blunt trauma; however, the term "handlebar hernia" was coined in 1980.1 There have been several published case reports and case series of handlebar hernias in the pediatric population. Of these, the vast majority were diagnosed via abdominal imaging. In all prior reports, patients with TAWHs who received imaging had suspicious ultrasound (US) or CT scan findings. TAWHs can be diagnosed via US, but CT scans are being increasingly utilized to diagnose herniae and evaluate for other intraabdominal injuries.

A PubMed search for "traumatic abdominal wall hernia" or "handlebar hernia" since 1990 revealed 43 cases of TAWH as a result of handlebar injuries from bicycles or motorcycles in the pediatric population (Table 1).235 Of these children with "handlebar hernias," the mean age was 10.8 years. (range 4 to 16 years) and 97.4% were male (38/39). The majority (65.7%) of handlebar TAWHs were diagnosed with CT scan (25/38),25,8,1215,17,20,21,23,24,28,29,32,34 23.7% via abdominal ultrasound (9/38),7,11,18,2527,30,33,35 and only 10.5% with physical exam alone (4/38).6,9,10,22  The majority of patients had some findings on physical exam, either ecchymosis, swelling, or bulging. All four cases diagnosed via physical exam alone had a bulge with Valsalva.6,9,10,22 All other patients in our literature review with skin changes or swelling were evaluated further with abdominal imaging. Importantly, all patients with a TAWH who received abdominal imaging, either CT scan or ultrasound, had positive imaging findings revealing either a fascial defect or herniation of abdominal contents. The case we presented above is unique. A CT scan was done on presentation yet revealed no acute findings related to the abdominal wall, only mild subcutaneous tissue stranding. This, therefore, highlights the critical need for clinical suspicion and a thorough physical exam in patients with blunt handlebar trauma to the abdomen. The majority (94.8%, 37/39) of TAWHs occur in the lower abdomen, with only two cases revealing hernias in the upper abdomen.11,20 This has been speculated to be due to the tension of the abdominal wall musculature between the bony prominences of the pelvis, leading to increased susceptibility to traumatic disruption in that area.29

When blunt trauma has enough impact to cause a traumatic abdominal wall hernia, there must also be a clinical concern for underlying intraabdominal injury, including to the bowel, mesentery, and pancreas. A recent retrospective review from a Level I pediatric trauma center revealed an overall incidence of TAWH of 0.1% following blunt abdominal trauma.31 In this series, only 27.3% identified a hernia on physical exam, whereas 80% of hernias were visible on CT (8/10). Only two of these were related to handlebar injury. At this institution, 65% of patients with TAWHs had a concurrent intraabdominal injury requiring operative intervention, including five bowel injuries, four mesenteric injuries, and two urologic injuries.31 In our literature review, 31.6% (12/38) of patients with a handlebar hernia had an underlying intraabdominal injury; two patients had a mesenteric disruption,14,20 five patients had bowel hematomas,21,28,32 and five patients had bowel perforations.8,15,17,18,21 Additionally, one patient developed bowel incarceration within the first 24 hours after injury.26 Almost all patients were treated operatively. Four patients were treated nonoperatively,4,7,23,24 three patients underwent delayed open repair,2,9,35 and the remainder were repaired immediately. One delayed repair was planned, and the other two occurred because the patients presented weeks after their traumatic injury. Of the hernias repaired immediately, 91.4% (32/35) were repaired via open technique.

Table 1. Review of the Literature. 
Article
Age
Gender
Diagnosis
Visceral Injury
Management
Iinuma et al. (2005)
11
M
CT
N/A
Delayed open surgery
Chen et al. (2005)
9
M
CT
N/A
Open surgery
Litton et al. (2008)
13
M
CT
N/A
Nonoperatively
So et al. (2018)
10
M
CT
N/A
Laparoscopic surgery
Mitchell et al. (2011)
14
M
Physical exam
N/A
Open surgery
Aggelidou et al. (2018)
6
M
US
N/A
Nonoperatively
Shukla et al. (2018)
15
M
CT
Perforated small bowel
Open surgery
van Bemmel et al. (2011)
7
M
Physical exam
N/A
Delayed open surgery
Perez et al. (1998)
11
M
Physical exam
N/A
Open surgery
Yegane et al. (2010)
4
M
US
N/A
Open surgery
Kubota et al. (1999)
9
M
CT
N/A
Open surgery
Mitchiner et al. (1990)
7
M
CT
N/A
Open surgery
Haimovici et al. (2007)
15
M
CT
Mesenteric disruption
Open surgery
Chew et al. (2009)
16
M
CT
Gangrenous jejunum
Open surgery
Klimek et al. (2013)
Unknown, two patients
Unknown
Unknown
N/A
Open surgery
Pederiva et al. (2016)
9
M
CT scan
Ileal perforation
Open surgery
Yaylaci et al. (2014)
11
M
US
Jejunal perforation
Open surgery
Lopez et al. (2011)
14
M
Unknown
N/A
Laparoscopic surgery
Rowell et al. (2011)
14
M
CT
Mesenteric disruption
Laparoscopic surgery
Talutis et al. (2015)
11
M
CT
None
Open surgery
9
M
CT
Jejunal contusion
Open surgery
7
F
CT
Ileal perforation
Open surgery
Tianyi et al. (2017)
8
M
Physical exam
N/A
Open surgery
Upasani et al. (2013)
12
M
CT
N/A
Nonoperatively
Matsu et al. (2007)
9
M
CT
N/A
Nonoperatively
Persano et al. (2014)
6
M
US
N/A
Open surgery
Vincent et al. (2018)
12
M
US
Incarcerated bowel
Open surgery
Decker et al. (2012)
13
M
US
N/A
Open surgery
Rinaldi et al. (2020)
12
M
CT
N/A
Open surgery
13
M
CT
Sigmoid hematoma
Open surgery
Yan et al. (2011)
8
M
CT
N/A
Open surgery
Mancel et al. (2003)
7
M
US
N/A
Open surgery
Hafezi et al. (2020)
Unknown, two patients
Unknown
Unknown
Unknown
Unknown
Rathore et al. (2012)
15
M
CT
Cecal hematoma
Open surgery
15
M
CT
Duodenal hematoma
Open surgery
13
M
CT
N/A
Open surgery
9
M
CT
Cecal hematoma
Open surgery
11
M
CT
N/A
Open surgery
Schmidt et al. (2018)
15
M
US
N/A
Open surgery
Goliath et al. (2004)
11
M
US
N/A
Open surgery
Thakur et al. (2013)
9
M
US
N/A
Delayed open surgery

Conclusion

In the setting of significant blunt abdominal trauma from a handlebar injury, we recommend obtaining an abdominal CT scan, which can be helpful for not only the diagnosis of TAWH but also the diagnosis of underlying abdominal injuries. The vast majority of TAWHs are visible on abdominal CT. A significant proportion of patients with TAWHs have concurrent underlying abdominal injuries, many of whom have suspicious findings on axial imaging. However, in the immediate period after blunt abdominal trauma, abdominal injuries may be missed on axial imaging. Therefore, any worrisome symptoms, including fever, tachycardia, leukocytosis, or worsening abdominal exam, should raise clinical concern for an underlying intraabdominal injury and consideration of diagnostic laparoscopy. Given the risk of underlying intraabdominal injury and the risk of delayed incarceration or strangulation, we believe operative intervention on TAWHs should be the standard of care. Our case report highlights that not all TAWHs are visible on imaging, and a comprehensive physical exam, including an abdominal examination while standing, is essential.

Lessons Learned

Our case presented above emphasizes the importance of not relying exclusively on imaging, maintaining a high index of clinical suspicion, and performing a thorough physical exam.

References

  1. Dimyan W, Robb J, MacKay C. Handlebar hernia. J Trauma. 1980;20(9):812-813. doi:10.1097/00005373-198009000-00020
  2. Iinuma Y, Yamazaki Y, Hirose Y, et al. A case of a traumatic abdominal wall hernia that could not be identified until exploratory laparoscopy was performed. Pediatr Surg Int. 2005;21(1):54-57. doi:10.1007/s00383-004-1264-x
  3. Chen HY, Sheu MH, Tseng LM. Bicycle-handlebar hernia: a rare traumatic abdominal wall hernia. J Chin Med Assoc. 2005;68(6):283-285. doi:10.1016/S1726-4901(09)70152-2
  4. Litton K, Izzidien AY, Hussien O, Vali A. Conservative management of a traumatic abdominal wall hernia after a bicycle handlebar injury (case report and literature review). J Pediatr Surg. 2008;43(4):e31-e32. doi:10.1016/j.jpedsurg.2007.12.059
  5. So HF, Nabi H. Handlebar hernia - A rare complication from blunt trauma. Int J Surg Case Rep. 2018;49:118-120. doi:10.1016/j.ijscr.2018.06.003
  6. Mitchell PJ, Green M, Ramesh AN. Handlebar hernia in children. Emerg Med J. 2011;28(5):439-440. doi:10.1136/emj.2009.089870
  7. Aggelidou M, Deftereos S, Foutzitzi S, Oikonomou P, Kambouri K. Handlebar hernia in children: a conservative approach. Case report and literature review. J Surg Case Rep. 2018;2018(4):rjy075. Published 2018 Apr 20. doi:10.1093/jscr/rjy075
  8. Shukla A, Verma V, Lal Kapoor K, Gupta B, Chaudhry R. Handlebar Hernia with Triple Herniation and Perforation: A Case Report and Literature Review. Bull Emerg Trauma. 2018;6(3):257-261. doi:10.29252/beat-060313
  9. van Bemmel AJ, van Marle AG, Schlejen PM, Schmitz RF. Handlebar hernia: a case report and literature review on traumatic abdominal wall hernia in children. Hernia. 2011;15(4):439-442. doi:10.1007/s10029-010-0665-0
  10. Perez VM, McDonald AD, Ghani A, Bleacher JH. Handlebar hernia: a rare traumatic abdominal wall hernia. J Trauma. 1998;44(3):568. doi:10.1097/00005373-199803000-00032
  11. Yegane RA, Peyvandi H, Nowrouzi S, Mosavian SA. Handlebar hernia: a rare type of abdominal wall hernia. Acta Med Iran. 2010;48(5):351-352.
  12. Kubota A, Shono J, Yonekura T, et al. Handlebar hernia: case report and review of pediatric cases. Pediatr Surg Int. 1999;15(5-6):411-412. doi:10.1007/s003830050616
  13. Mitchiner JC. Handlebar hernia: diagnosis by abdominal computed tomography. Ann Emerg Med. 1990;19(7):812-813. doi:10.1016/s0196-0644(05)81709-3
  14. Haimovici L, Papafragkou S, Kessler E, Angus G. 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. doi:10.1016/j.jpedsurg.2006.10.092
  15. Chew KS, Amin NM. Handlebar herniation: a case of near missed abdominal injury. Med J Malaysia. 2009;64(2):170-171.
  16. Klimek PM, Lutz T, Stranzinger E, Zachariou Z, Kessler U, Berger S. Handlebar injuries in children. Pediatr Surg Int. 2013;29(3):269-273. doi:10.1007/s00383-012-3227-y
  17. Pederiva F, Guida E, Maschio M, Rigamonti W, Gregori M, Codrich D. Handlebar injury in children: The hidden danger. Surgery. 2016;159(5):1477. doi:10.1016/j.surg.2015.08.009
  18. Yaylaci S, Ercelik H, Seyit M, Kocyigit A, Serinken M. Handlebar trauma causing small bowel hernia with jejunal perforation. West J Emerg Med. 2014;15(4):367-368. doi:10.5811/westjem.2014.4.22096
  19. Lopez R, King S, Maoate K, Beasley S. Laparoscopic repair of paediatric traumatic Spigelian hernia avoids the need for mesh. ANZ J Surg. 2011;81(5):396-397. doi:10.1111/j.1445-2197.2011.05720.x
  20. Rowell EE, Chin AC. Laparoscopic repair of traumatic abdominal wall hernia from handlebar injury. J Pediatr Surg. 2011;46(5):e9-e12. doi:10.1016/j.jpedsurg.2011.01.031
  21. Talutis SD, Muensterer OJ, Pandya S, McBride W, Stringel G. Laparoscopic-assisted management of traumatic abdominal wall hernias in children: case series and a review of the literature. J Pediatr Surg. 2015;50(3):456-461. doi:10.1016/j.jpedsurg.2014.10.020
  22. Tianyi FL, Agbor VN, Njim T. Motorbike-handlebar hernia - a rare traumatic abdominal wall hernia: a case report and review of the literature. J Med Case Rep. 2017;11(1):87. Published 2017 Mar 31. doi:10.1186/s13256-017-1245-z
  23. Upasani A, Bouhadiba N. Paediatric abdominal wall hernia following handlebar injury: should we diagnose more and operate less?. BMJ Case Rep. 2013;2013:bcr2012008501. Published 2013 Apr 19. doi:10.1136/bcr-2012-008501
  24. Matsuo S, Okada S, Matsumata T. Successful conservative treatment of a bicycle-handlebar hernia: report of a case. Surg Today. 2007;37(4):349-351. doi:10.1007/s00595-006-3375-6
  25. Persano G, Pinzauti E, Lo Piccolo R, Messineo A, Ghionzoli M. Traumatic abdominal wall hernia. Indian J Pediatr. 2014;81(12):1409-1410. doi:10.1007/s12098-014-1440-5
  26. Vincent K, Cheah SD. Traumatic abdominal wall hernia - a case of handlebar hernia. Med J Malaysia. 2018;73(6):425-426.
  27. Decker S, Engelmann C, Krettek C, Müller CW. Traumatic abdominal wall hernia after blunt abdominal trauma caused by a handlebar in children: a well-visualized case report. Surgery. 2012;151(6):899-900. doi:10.1016/j.surg.2011.02.020
  28. Rinaldi VE, Bertozzi M, Magrini E, Riccioni S, Di Cara G, Appignani A. Traumatic Abdominal Wall Hernia in Children by Handlebar Injury: When to Suspect, Scan, and Call the Surgeon. Pediatr Emerg Care. 2020;36(9):e534-e537. doi:10.1097/PEC.0000000000001153
  29. Yan J, Wood J, Bevan C, Cheng W, Wilson G. Traumatic abdominal wall hernia--a case report and literature review. J Pediatr Surg. 2011;46(8):1642-1645. doi:10.1016/j.jpedsurg.2011.04.004
  30. Mancel B, Aslam A. Traumatic abdominal wall hernia: an unusual bicycle handlebar injury. Pediatr Surg Int. 2003;19(11):746-747. doi:10.1007/s00383-003-1064-8
  31. Hafezi N, Raymond JL, Mayo ED, Rouse TM, Billmire DF, Gray BW. Traumatic abdominal wall hernias in children: A case for early exploration. J Pediatr Surg. 2021;56(5):1004-1008. doi:10.1016/j.jpedsurg.2020.06.046
  32. Rathore A, Simpson BJ, Diefenbach KA. Traumatic abdominal wall hernias: an emerging trend in handlebar injuries. J Pediatr Surg. 2012;47(7):1410-1413. doi:10.1016/j.jpedsurg.2012.02.003
  33. Schmidt MS, Rosenberg J, Tolver MA. [Traumatic bicycle handlebar hernia in a child}. Ugeskr Laeger. 2018;180(8):V08170616.
  34. Goliath J, Mittal V, McDonough J. Traumatic handlebar hernia: a rare abdominal wall hernia. J Pediatr Surg. 2004;39(10):e20-e22. doi:10.1016/j.jpedsurg.2004.06.039
  35. Thakur SK, Gupta S, Goel S. Traumatic spigelian hernia due to handlebar injury in a child: a case report and review of literature. Indian J Surg. 2013;75(Suppl 1):404-406. doi:10.1007/s12262-012-0734-y

Authors

Mueller JL; Cavallaro PM; Kelleher CM; Ryan DP

Author Affiliations

Massachusetts General Hospital, Boston, MA 02114

Corresponding Author

Jessica L. Mueller, MD
Massachusetts General Hospital
55 Fruit Street GRB-425
Boston, MA 02114
Phone: (617) 726-2800
Email: jmueller2@mgh.harvard.edu

Disclosure Statement

The authors have no conflicts of interest to disclose.

Funding/Support

The authors have no relevant financial relationships or in-kind support to disclose.

Received: December 11, 2020
Revision received: February 8, 2021
Accepted: March 4, 2021