Traumatic small bowel perforation: handlebar injury

Case contributed by Dr Ian Bickle

Presentation

Fall from bicycle. Body hit the handlebars. Abdominal pain. No distension.

Patient Data

Age: 35 years
Gender: Male
X-ray

Plain films at a peripheral hospital

Chest x-ray:  supine

The lungs are clear.

No subdiaphragmatic gas.

Abdominal x-ray

No bowel obstruction.  No free gas.

Large volume pneumoperitoneum.

Several small foci of gas, together with mesenteric fluid and stranding at the left upper abdomen. There is potential discontinuity of the colonic splenic flexure. Thickening of the jejunum.

Moderate free fluid in pelvis.

Two small splenic lacerations on the inferolateral aspect.

The remainder of the solid organs are normal.

Photo

Intra-operative image

Large perforation of the jejenum 40cm from the DJ flexure.

Case Discussion

The commonest site of traumatic small bowel perforation is the jejunum (near the ligament of Trietz / DJ flexure), as in this case. However, It is often the case that this cannot be identified on CT. In fact, the larger the pneumoperitoneum the harder it often is to localized the site of a perforation.

This is one of the classical mechanisms of injury for a jejunal perforation. Blunt abdominal injury from hitting the handle bars after a fall from a bicycle. It is more typically observed in children.

The intra-operative images show the site of the injury, although the site is difficult if not impossible to identify on the CT.

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Case information

rID: 58713
Published: 4th Mar 2018
Last edited: 14th Aug 2019
Tag: ripas2
Inclusion in quiz mode: Included
Institution: Rotherham Foundation Hospital Trust