This patient appears to have an abrasion in the RUQ, likely sustained when the handlebars made a direct impact. On further questioning, the family saw the handlebars hit directly in the RUQ, with one end hitting her belly and the other hitting the ground. The next step in management is to evaluate for internal injuries. A CBC would provide baseline hemoglobin and hematocrit (H/H) levels, although remember even if there is acute bleeding, the H/H will likely be normal. You should also obtain a liver panel and lipase. While normal values here do not rule out liver or pancreatic injuries, they may be helpful in tracking injury progression with serial levels. In any trauma patient in whom you suspect there may be internal bleeding, consider a blood bank tube to hold or type and screen. UA may be obtained to evaluate for hematuria.
The next question is imaging. The role of the FAST exam is not well defined in children, and in the otherwise stable child may not yield information, although there have been studies investigating serial FAST exams along with serial evaluation with some promise. Ultimately, given the location and mechanism of injury with abdominal pain and an overlying abrasion, a CT scan with IV contrast to evaluate for solid organ injury would be advisable. The most common/classic injuries seen with handlebar injuries include liver and splenic lacerations, pancreatic injuries, duodenal hematoma, and hollow viscous injuries.
Even if the initial imaging and workup is negative, serial abdominal exams over the next twenty four hours would be advisable as trauma protocol CT scanning has poor sensitivity for hollow viscous injuries, and patients should be watched for delayed onset of peritonitis. Your patient had a positive FAST exam, and CT showed a low grade liver laceration with elevated AST/ALT. They did not require operative intervention and were managed conservatively.
Beware the handlebar injury! (see reference 2).
A 29 year old male arrives after falling off of an ATV. He is complaining of left shoulder pain, and appears in moderate distress. The following image was obtained of the shoulder. What injuries are noted (hint: there are at least two)? What else should you be worried about based on the injuries/findings in this XR? What is the next step in the management of this patient?