526977

research-article2014
CPJXXX10.1177/0009922814526977Clinical PediatricsCherniawsky et al

Article
Clinical Pediatrics

Serious Impact of Handlebar Injuries 2014, Vol. 53(7) 672676

The Author(s) 2014
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DOI: 10.1177/0009922814526977
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Hannah Cherniawsky1,2, Ioana Bratu, MD, MSc1,2,

Tara Rankin, MSc2, and William (Bill) Sevcik, MD1,2

Abstract
Background. Injuries from bicycles is a leading cause of trauma in children. We sought to investigate the epidemiology
of bicycle handlebar injuries. Methods. A retrospective analysis of bicycle trauma treated at our institution was
preformed. Results. A total of 462 children younger than 17 years had bicycle trauma. Abdominal handlebar injuries,
representing 9% of bicycle injuries, contributed to 19% of all internal organ injuries, and 45.4% of solid, 87.5% of
hollow, 66.6% of vascular or lymphatic, and 100% of pancreatic injuries. Handlebar injuries were 10 times more likely
to cause severe injury, yet more than half of the children were misdiagnosed at their initial presentation. Delayed
diagnosis and longer hospital stays were observed in handlebar injuries to the abdomen. Conclusion. Physicians
should be aware of the serious impact of bicycle handlebar injury to the abdomen. The mechanism alone should
raise the suspicion of internal organ injury, and timely imaging and surgical consultation.

Keywords
pediatric trauma, bicycle injury, handlebar injury

Cycling remains a popular pastime for children in
Canada with three quarters of Canadian children partici-
pating in the activity.1,2 In Alberta, bicycle trauma tops
the list of sport and recreational activities injuries, espe-
cially in children who do not wear helmets: They are 3
times more likely to suffer head injury in a crash and are
20 times more likely to die. To mitigate such risk,
Alberta passed a law in May 2002 whereby cyclists
younger than 18 years are required to wear an approved
bicycle helmet. Helmet use has helped reduce the rate of
head injuries by up to 54% in parts of Canada; however,
cycling injuries continue to rank among the highest in
injury severity among children.1,3,4 Even though assess-
ments of fractures, lacerations, and head injuries are
common practice, handlebar induced injuries may be
overlooked initially because of the internal nature of the
injuries with its associated insidious presentation.
Handlebar injuries have been shown to account for
10% of bicycle-related injuries.5,6 Modern bikes allow
handlebars to rotate perpendicularly to the cyclists
body. Striking the handlebars at this angle imparts local-
ized, blunt trauma on the abdomen because of the small
surface area of the handlebars that can cause serious
damage to internal organs from focused distribution of
force.5-9 Patients presenting with severe handlebar inju-
ries often have a trivial history of a minor fall at low
speeds and relatively little external trauma.2,5,8-10
Furthermore, many handlebar injuries lack outward
signs proportional to the severity of the internal damage
and tend to have a delayed presentation that can take up
to 24 hours to become apparent.2,5,7,9,10 As such, severe
handlebar injuries to the abdomen can be overlooked.
Timely management of handlebar-induced trauma is
critical to prevent peritonitis, sepsis, hemorrhages, and
other serious sequelae.7 Physicians must maintain a high
index of suspicion when dealing with patients with a
history of handlebar impact and keenly observe them for
signs that point toward severe abdominal trauma.2,7,10
Our study aims to draw attention to the severity of han-
dlebar injuries to the abdomen and contribute useful
information for physicians in their assessment of patients
and counseling of caregivers.
Methods
After obtaining approval from our Institutional Health
Research Ethics BoardHealth Panel (approval study
number 38558), a retrospective analysis of pediatric
(<17 years) with bicycle trauma treated at our institution
was done using existing complementary databases
(Canadian Hospitals Injury Reporting and Prevention
1
University of Alberta, Edmonton, Alberta, Canada
2
Stollery Childrens Hospital, Edmonton, Alberta, Canada
Corresponding Author:
Ioana Bratu, Stollery Childrens Hospital, 2C3.56 WMC, 8440-112
Street, Edmonton, Alberta, T6G 2B7, Canada.
Email: bratu@ualberta.ca

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Cherniawsky et al 673

Program (CHIRPP) and Alberta Trauma Registry (ATR)

Database as well as medical chart review by comparing
epidemiology, injury, and outcomes from February 2012
through July 2013.
CHIRPP is an injury and poisoning surveillance sys-
tem presently operating in the emergency departments
of all 11 pediatric and 4 general hospitals across
Canada.11,12 The CHIRPP system, which has been in
operation since 1990, runs on an Oracle platform and
currently contains about 2.2 million records (injury
events). When an injured or accompanying person (par-
ent or caregiver) presents to a CHIRPP site, they are
asked by hospital staff to complete one side of a CHIRPP
data collection form. The hospital staff complete the
reverse side of the form with clinical data. Information
Figure 1. According to mechanism of bicycle trauma,
collected includes activity at the time of injury, activity participants were divided into 2 groups: those injured
leading to the injury, the direct cause of the injury, con- by handlebar and non-handlebar. The handlebar group
tributing factors, time and place of the injury event, the was further divided into handlebar versus abdomen and
patients age and sex, up to 3 injuries (body part and handlebar versus other.
nature of injury) and the treatment received in the emer-
gency department. Narrative fields provide information
laboratory and radiologic investigations and results at the
to further refine the coding and identify rare events and
initial and definitive visits were recorded.
consumer products. All collected data are reviewed by
All patients with bicycle injuries were then classified
the CHIRPP site coordinator for any missing informa-
in 2 groups: handlebar and non-handlebar injured.
tion. Completed forms are sent to the Public Health
According to the mechanism of injury, the handlebar
Agency of Canada in Ottawa for entry by a trained cod-
group was further subdivided into: handlebar versus
ing team. Although only select hospitals report to
abdomen, and handlebar versus other. The handlebar
CHIRPP, previous work has shown that the data col-
versus abdomen group included only those whose abdo-
lected through the program represent general injury pat-
men made direct contact with the handlebars. All inju-
terns among Canadian youth.13 Previous investigations
ries resulting from handlebar contact to any other region
have also reported on other methodological aspects of
of the body were placed in the handlebar versus other
CHIRPP.14-18
group. Statistical analysis was done using Microsoft
By accessing the complimentary ATR Database, we
Excel using Fischers exact test, with P value <.05 con-
determined the epidemiology, injury, and outcomes for
sidered as significant.
all pediatric bike traumas with severe injuries (deter-
mined as Injury Severity Score (ISS) >12)19 treated at
our institution. The ATR data were further enhanced by
Results
more information provided in the hospital medical chart
in terms of specifics of treatment and outcomes. Of the 462 children injured while riding a bicycle, 71%
Patients injured while fixing, walking a bike, or were male with median age 11 years. In all, 76% of par-
involved in a bicycle collision while not cycling were not ticipants were using an unspecified bicycle, 9% were
included. The involvement of the health care system fol- using a dirt-bike, and 11% were using a BMX bike (4%
lowing the injury was analyzed. This includes the date unknown). Only 55% of participants wore a helmet.
and location of initial health care contact and number of Handlebar impact accounted for 12% of all injuries,
health care visits prior to presentation at our hospital with 75% of these being handlebar versus abdomen
(level 1 pediatric trauma center). Presentation to our insti- (Figure 1). Sixty-eight percent of handlebar versus
tution was defined as either an initial or delayed definitive abdomen injuries occurred from a general fall, 10%
visit. An initial visit was defined as one presenting to or from stunting, 12% from excess speed, and 5% from
being transferred to us with a prompt initial diagnosis. collisions with vehicles. Of significance, 1 out of 4
Delayed definitive visits were defined as those where pre- patients with handlebar injury to the abdomen presented
vious health care contact resulted in a missed/incorrect with damage to internal organs compared with 1 in 100
diagnosis, or a premature discharge from the emergency of non-handlebar injuries. Furthermore, 10.9% of han-
room. The length of time between initial and delayed dlebar and only 1.2% of non-handlebar injuries had
definitive visits, where applicable, was also noted. Vitals, severe injuries with ISS >12.

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674 Clinical Pediatrics 53(7)
Distribution of Injuries by Subgroup
160
Number of Recorded Injuries
140
120
100
80
60
40
20
0 age subgroup were later seen for complications. Two
Injury Type
Figure 2. The most common injuries across the sample
include abrasions, closed upper extremity fractures and
soft tissue injuries of the head, neck, or extremities (CNS=
central nervous system injury). The handlebar versus
abdomen subgroup accounts for only 9% of the sample, yet
is overrepresented in all abdominal injuries.
In the sample at large, the most common injuries
include abrasions (n = 135), closed fractures of upper
extremities (n = 114), and soft tissue injuries of extremi-
ties, head, and neck (n = 118). The handlebar versus
abdomen group accounted for only 9% of the sample but
accounted for the majority of internal visceral injuries:
45.4% of solid, 87.5% of hollow, 66.6% of vascular or
lymphatic and 100% of pancreatic injuries (Figure 2).
Of those with internal organ injuries from handle bar
contact, there was a greater likelihood of presenting with
fever, emesis, signs of peritonitis, and high lipase as
seen in Table 1. Other laboratory results such as white
blood cell count and neutrophil count, and liver enzyme
levels were initially non-specific for injury. Less than
half of the patients with handlebar versus abdomen
mechanism of injury had diagnostic imaging at their ini-
tial visit to investigate abdominal injuries.
More than half of the children with handle bar inju-
ries to the abdomen had delayed definitive diagnosis
(were misdiagnosed and discharged, only to come back
within hours) at their initial visits. The average time
between initial and definitive visits in this group was
18.3 hours. The average hospital stay for those admitted
was 6.75 days.
Interestingly, of those with internal organ injury due
to non-handlebar bicycle trauma, 60% had a delayed
definitive visit because of transfer from a non-level-1
trauma center to our center as a level 1, and none were
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misdiagnosed. (Please note that on average, 60% of all
our pediatric trauma patients are transferred from
another facility to ours.) The average time between ini-
tial and delayed definitive visits was 1.9 hours with an
average hospital stay of 4.6 days for those admitted.
handlebar versus
other
Patients in the handlebar versus abdomen group with
solid organ injuries such as liver/spleen/pancreatic inju-
non handlebar
ries were all managed conservatively with success. The
handlebar versus
3 patients with bowel injuries and one with vascular
abdomen injuries were managed surgically. Three patients from
the handlebar versus abdomen with internal organ dam-
children were admitted for 5 and 7 days for postopera-
tive bowel obstructions from adhesions. One child was
admitted for 14 days for a splenic abscess arising from
their splenic injury.
Discussion
The mechanism of bicycle handlebar impact to the abdo-
men should raise suspicion of potential significant inter-
nal organ injury. Though often subtle at initial
presentation and delayed in definitive diagnosis,2,5,8,10
our findings indicate that a significant proportion of
handlebar injuries to the abdomen have an elevated
injury severity score when compared with non-handle-
bar bicycle injuries. Handlebar to the abdomen cause the
vast majority of internal organ injuries incurred while
cycling.5,7,10 In our study, 1 out of 4 patients with a his-
tory of handle-bar trauma to the abdomen had internal
organ damage to the splee/liver/pancreas/bowel.
In congruence with previous findings, our study sug-
gests that clinical symptoms such as vomiting, peritoni-
tis, or fevers are indicators of internal organ injury after
blunt trauma from bicycle handlebar to the abdomen.6,10
Half of the children with internal injuries from handle-
bar trauma presented with elevated lipase at their initial
visit, while all of the children without any internal inju-
ries had a normal lipase.
Furthermore, the finding that more than half of the
patients with internal organ injuries from handlebar
impact to the abdomen were misdiagnosed initially, and
discharged prematurely, only to return with frank perito-
nitis, reflects the subtle initial presentation, and need for
initial high suspicion based on mechanism of injury and
initial radiological imaging using a computed tomogra-
phy scan for definitive diagnosis.5,6,10 Injuries from han-
dlebar to the abdomen result in longer hospital stay
because of a delay in definitive diagnosis, treatment, and
increased severity of injuries.10
Our study is limited as it is a single center observa-
tional research with a limited time frame. However, our
study points out the severity if there is impact of bicycle
Cherniawsky et al 675

Table 1. Initial Laboratory, Radiologic, and Clinical Investigations of Children With and Without Internal Organ Injury by
Subgroup.

Handlebar vs Abdomen Handlebar vs Abdomen Non-Handlebar Bike

With Internal Organ With No Internal Organ Trauma With Internal
Injury, % Injury, % Organ Injury, %
Emesis 33.3 6.9 20.0
Peritonitis 44.4* 0.0 20.0
Fever 37.8C at any time 33.3* 3.4 20.0
Radiologic test performed 55.5 39.4 100.0
Blood work completed 77.8 18.75* 100.0
Elevated lipase 50.0 0.0 12.5
Delayed definitive visit noted 100.0* 15.6 60.0
Time between initial and delayed 18.3* 15.8 1.9
definitive visit (hours)
Patient misdiagnosed at initial emergency 55.5* 0.0 0.0
room visit
Average hospital stay of those admitted 6.75 3.6 4.6
(days)

*Significantly different.

handlebar to the abdomen. We are not suggesting not
riding a bicycle, but consideration of safety mechanism
to the handlebar may be warranted. Previous studies
have recommended retractable, curved, or padded han-
dlebars to reduce the kinetic energy imparted on the
abdomen.5,8 We also recommend that industry design a
device to prevent handlebars from rotating perpendicu-
lar to the body such as to reduce the direct impact of the
handlebar head-on end (rotating the handlebar is often a
fun bike trick to show off to friends).
Handlebar injuries are serious in nature and can be
life threatening. Their subtle or delayed presentation and
deceptively minor history can cause them to be over-
looked.2,5-8,10 However, a delay in diagnosis and treat-
ment can result in sepsis, hemorrhages, or even death.5
Physicians should have a high index of suspicion when
evaluating a child with a history of handlebar trauma to
the abdomen. The mechanism of handlebar injury to the
abdomen in a child presenting to the emergency room is
by itself an indicator of potential severe injury and
requires serial abdominal exams, laboratory investiga-
tions, and prompt computed tomography of the abdo-
men to rule out hollow viscus or solid organ injuries.
Caregivers should seek health care if emesis, peritonitis,
or fever appears following a handlebar injury.
Modifications to handlebars may reduce the severity and
number of injuries.
Acknowledgments
We would like to thank the Canadian Hospitals Injury
Reporting and Prevention Program and Alberta Trauma
Registry for access to their databases.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) disclosed receipt of the following financial sup-
port for the research, authorship, and/or publication of this
article: This study was supported by a grant from the University
of Alberta Faculty of Medicine and Dentistry (Wynne Rigal
Summer Research Award).
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