|Year : 2012 | Volume
| Issue : 1 | Page : 42-44
Handlebar hernia: A case report and review of literature
Khalid Lawal, Ahmed Adamu
Department of Surgery, Division of General Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
|Date of Web Publication||22-Sep-2012|
Department of Surgery, Division of General Surgery, Ahmadu Bello University Teaching Hospital, Zaria
Source of Support: None, Conflict of Interest: None
Introduction: Handlebar hernia is a specific type of traumatic abdominal wall hernia that is caused by impact of the abdominal wall against a blunt object, usually bicycle handlebars. The rarity of handlebar hernia and its frequent presentation without physical signs makes it highly susceptible to misdiagnosis which may be attended with serious consequences. We discuss the presentation and management of a case of handlebar hernia and a review of literature.
Case Report: A 14-year-old boy presented to emergency department with pain at right inguinal area where the abdomen had impacted on the handlebar of the bicycle. Immediately after the accident, he noticed a swelling at the site of impact. He had no history of inguinal hernia. His examination revealed normal vital signs. There was abrasion in the right inguinal region and a reducible swelling with positive cough impulse. Abdominal ultrasound showed normal abdominal viscera and the swelling was noted to contain loop of bowel. A diagnosis of handlebar hernia was made. Through an incision over the bulge, a 10 cm loop of normal bowel found in the subcutaneous plane was reduced and the 5-cm defect in the anterior abdominal wall muscles repaired in layers. The boy remains well at 2½ years of follow-up.
Conclusion: Handlebar hernia can be diagnosed based on history of mechanism of injury, careful physical examination, and high index of suspicion. Abdominal ultrasound or computed tomography is an important adjunct of management. Prompt surgical repair of the hernia is recommended to prevent incarceration or strangulation.
Keywords: Diagnosis, handlebar hernia, treatment
|How to cite this article:|
Lawal K, Adamu A. Handlebar hernia: A case report and review of literature. Arch Int Surg 2012;2:42-4
| Introduction|| |
Blunt or cavitating trauma to the abdomen often causes damage to the intestines and other abdominal viscera. However, when the directed force is of moderate intensity that is insufficient to penetrate the skin because of its inherent elasticity, the force may still be able to disrupt deeper muscles and fascia, resulting in traumatic abdominal wall hernia (TAWH).  TAWH can be classified based on the defect size, location, or mechanism of injury. , Wood et al. classified TAWHs into three major types.  The first type is a small, localized abdominal wall defect resulting from impalement by a low-energy blunt object, such as a bicycle or motorcycle handlebar. This is infrequently associated with intra-abdominal organs' injury. 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 accident. The third type results in herniation through an isolated peritoneal defect and is related to a fall from height. 
In children, the most common type of TAWH is associated with low energy which results from a bicycle accident where the abdomen impacts on the end of the handlebars. , In these children, the handlebar is small enough to penetrate the tense abdominal wall muscles, but too blunt to penetrate the overlying elastic skin. The resulting defect was termed a handlebar hernia by Dimyan et al. in 1980.  However, Selby reported the first case of handlebars causing a traumatic hernia to the abdominal wall in 1906, when he described a hernia resulting from impact upon a wheelbarrow handle in a 32-year-old laborer.  The child with handlebar hernia may present no physical sign or external evidence of injury and the diagnosis can be missed, with the attendant risk of strangulation or incarceration of the hernia. We discuss the presentation and management of a typical case of handlebar hernia in a 14-year-old boy and a review of literature. Awareness of this rare and potentially serious traumatic injury will be beneficial to clinicians in accident and emergency departments, general surgery, and pediatrics.
| Case Report|| |
A 14-year-old boy presented at the emergency department with 2-h history of pain at right inguinal region following a fall from a bicycle. He was riding the bicycle when he crashed and flew forward, hitting his lower abdomen on the handlebars as he fell. Immediately after the accident, a bulge was noticeable at the point of impact. There was no loss of consciousness. The pain had remained at the site of impact. There were no other abdominal symptoms and no history of previous abdominal surgery or hernia. His vital signs were normal. Abdominal examination revealed an abrasion in the right upper inguinal region. A swelling in the area of impact was apparent when the patient was asked to cough. The swelling which measured 6 × 4 cm was obvious on standing [Figure 1]. On palpation, the area was tender, and the swelling decreased on gentle pressure, with gurgling sounds. A defect could not be palpated because of tenderness. Other abdominal examinations were normal. The chest and other systems were also normal. A diagnosis of TAWH was made and explained to the patient and his parents. Following resuscitation, an emergency abdominal ultrasound was done which showed normal intra abdominal organs with no significant free fluid or air in the peritoneal cavity. The swelling in the inguinal region was noted to contain loop of bowel. Urea and electrolytes, and blood counts were normal. Since the patient was hemodynamically stable and the diagnosis clinically apparent, he was prepared for emergency local exploration under general anesthesia. Through an upper inguinal incision over the swelling, exploration of the wound revealed a 5-cm linear defect in the internal oblique and transversus abdominis muscles. About 10 cm of small bowel was trapped in the muscle layers of the abdominal wall to lie just beneath the skin. There was no blood within the peritoneal cavity, and inspection of the small bowel, cecum, and right colon revealed no injury.
The bowel was reduced without difficulty. The peritoneal defect was closed with vicryl 2/0, while the defects in transversus abdominis and internal oblique muscles were repaired with Proline 1. Postoperative recovery was uneventful. He was followed up for 2½ years without any complications.
| Discussion|| |
Handlebar hernia is very rare in children, with less than 30 cases reported in the English literature, and none reported from Nigeria.  In these patients, the handlebar provides a small focal point which exerts localized force to the abdomen. This force, being blunt in nature, does not penetrate the abdomen, but because the impact is at a focal point, the energy is dissipated through the abdominal wall. In combination with increased abdominal pressure due to direct impact, this leads to the shearing of muscle and fascia layers.  In the present case, the hernia occurred in the inguinal region, which together with lower abdomen is the commonest site probably because of anatomically weak configuration. Our patient was 14 years old. A recent review of literature indicates a mean age of 9 years with more than two-thirds being males. 
The clinical presentation of the child with handlebar hernia depends on the presence of associated intra-abdominal organs' injury. However, such injuries are rare and occur in 8% of cases.  This may be due to resistance of the hollow viscera to blunt injury, and also because in most cases the point of impact is in areas away from the parenchymatous abdominal organs. Our patient did not have abdominal organs' injury as evidenced by hemodynamic stability and absence of signs of peritonitis.
As shown in our patient, careful examination may reveal an imprint on the abdomen through which the force was channeled. Around the imprint, a tender mass may be palpated that has the characteristics of a hernia including positive cough impulse and reducibility.  Apart from these findings, abdominal examination is usually normal. However, all of the above-mentioned features may be absent, as there are cases of patients in which symptoms appeared 48 h after the accident. In rare cases, the hernia would not be identified until exploratory laparoscopy or laparotomy is done. 
Following abdominal trauma, a hematoma my mimic handlebar hernia, especially when tenderness prevents eliciting the usual features of a hernia. Although usually noticed before the accident by the patient or his family, a pre-existing inguinal hernia should also be considered. In this, as in other reports, abdominal ultrasound was a very useful diagnostic tool. Besides excluding intra-abdominal organs' injury, it also showed herniation of the bowel through the abdominal wall defect.  However, if the patient is unstable, diagnosis is uncertain, or suspicion of visceral injury is high, then computed tomography (CT) imaging is the investigation of choice. 
The treatment of handlebar hernia consists of surgical exploration with closure of the defect. , Similar to other reports, in our patient, the defect was small and localized and closure was achieved with non-absorbable suture. , With larger defects, seen after high-energy impacts, prosthetic materials are often used to achieve closure.  Debate continues as regards to surgical approach to treatment. If there are signs of intra-abdominal organs' injury on presentation; generalized peritonitis, evidence of perforation on CT, or hemodynamic instability, primary surgical intervention should be carried out promptly. , In our patient, there were no positive indicators for intra-abdominal injury, hence the hernia was repaired through a local wound exploration. This is the approach in 80% of reported cases, which provides the best anatomical layered closure with subsequent minimal residual defect and improved long-term cosmesis. , In addition, laparoscopic repair of TAWH is feasible and safe in the pediatric patient and should be considered as an alternative approach with potentially less morbidity than an exploratory laparotomy for handlebar injuries in a stable patient.  Recently, Litton et al. reported a 13-year-old boy with a handlebar hernia, in whom visceral injury was excluded with CT imaging and was planned for delayed repair. On return for elective repair, no hernia was present and a repeat CT imaging 4 months post-injury revealed no defect in the abdominal wall musculature.  Matsuo et al. also describe a 9-year-old boy managed with a compression corset, resulting in the disappearance of the hernia on clinical examination by 3 weeks, and healing of abdominal musculature on CT at 3 months.  However, because the size of the defect is usually small, the risk of strangulation and incarceration is very high, hence surgical repair is favored.
In conclusion, handlebar hernia is an uncommon diagnosis that can easily be missed due to absence of physical signs on presentation. The mechanism of trauma to the abdomen and the recognition of sometimes subtle signs should prompt high suspicion to the presence of a handlebar hernia. When in doubt, additional ultrasound or computed tomography scanning greatly helps to establish the diagnosis. Early recognition and treatment is recommended to prevent incarceration or strangulation.
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