Rapid Responses to:

CLINICAL REVIEW: Jimmy P H Lam, Graeme J Eunson, Fraser D Munro, and John D Orr Lesson of the week: Delayed presentation of handlebar injuries in children BMJ 2001; 322: 1288-1289 [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

Closed duodenal injury - one more for the road

David Bass   (26 May 2001)

Closed duodenal injury - one more for the road 26 May 2001
David Bass, Head: medico-legal services, Western Cape Provincial Government Cape Town, South Africa Send response to journal: Re: Closed duodenal injury - one more for the road	This is an excellent topic to highlight as lesson of the week. Surgical injuries to the upper abdomen are a relatively rare manifestation of childhood injury as a whole, and few doctors will diagnose them with the necessary speed, purely on a basis of their personal experience. So well done to the authors for reminding us all to pracctice good old- fashioned medicine, to carefully and frequently examine - and re-examine - the paediatric abdomen after blunt trauma, and not to rely too heavily on imaging. I would like to mention one other intra-abdominal damage caused by handlebar injury, not highlighted in this paper. The first and third parts of the duodenum may be crushed between the handlebar and the lumbar spine causing rupture of the subserosal blood vessels, and resulting in a slowly expanding intramural haematoma (Voss 1994). The child may be relatively free of symptoms until the haematoma causes complete obstruction of the duodenal lumen, and, as a result, the diagnosis is often delayed. Important clues to the diagnosis include the history of upper abdominal trauma, persistent vomiting, and air-fluid levels in both the stomach and duodenum (the so-called "double bubble")on plain erect abdominal film. If doubt still exists, contrast study of the upper gastro- intestinal tract will show partial-to-complete obstruction of the duodenum, with the "stacked coins" or "coiled spring" apperance caused by oedematous mucosal folds proximal and distal to the point of maximum obstruction. Perhaps the most important reason to confirm this specific diagnosis is that, as an isolated injury, duodenal haematoma does not require laparotomy. Patients can be successfully managed with free naso-gatric drainage and parenteral nutrition. Duodenal patency should return within 10-14 days. Clinical deterioration at any stage, or failure to resolve on this conservative regime should raise suspicion of a mis-diagnosis or other concommitant injury. Being an endemic problem in South Africa, road traffic injury was the commonest cause of duodenal haematoma in our small series of nine cases. However, biycle injury certainly predominated in a larger series from North America (Jewett 1988) where, as is likely in the UK, a greater proportion of children own and ride bicycles, and motor vehicles are driven without somewhat more restraint than they are in my beloved country. Finally, to my knowledge, there is no relationship between myself, and Dr J Bass, first author of the ninth reference cited in this review. References: 1. Voss M, Bass DH. Traumatic duodenal haematoma in children. Injury 1994; 25: 227-230 2. Jewett TC, Caldarola V, Karp M et al. Intramural haematoma of the duodenum. Arch Surg 1988; 123: 54