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CASE REPORT
Year : 2012  |  Volume : 15  |  Issue : 2  |  Page : 238-240

Case report of traumatic abdominal wall hernia following blunt motorcycle handlebar injury and review of the literature


1 Department of Surgery, College of Medicine, University of Ibadan and University College Hospital, Nigeria
2 Department of Surgery, University College Hospital, Ibadan, Nigeria

Date of Acceptance13-May-2011
Date of Web Publication16-Jun-2012

Correspondence Address:
T O Ogundiran
Department of Surgery, University College Hospital, PMB 5116, Ibadan
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1119-3077.97337

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   Abstract 

A 25-year-old man, riding a motorcycle, rammed into a moving car at a T junction and sustained a blunt lower-right abdominal injury with the handlebar of his motorbike. He developed a swelling at the point of impact for which he presented in hospital 10 days later. Clinical assessment revealed a healthy young man with a soft, nontender reducible swelling over the lateral half of the right inguinal area. A diagnosis of acute traumatic hernia was made. Abdominal ultrasonography revealed a wide-necked defect in the anterior abdominal wall over the right inguinal area with protruding bowel loops beneath an intact skin. He was planned for herniorrhaphy but has defaulted since then.

Keywords: Abdominal wall hernia, handlebar injury, trauma


How to cite this article:
Ogundiran T O, Obamuyide H A, Adesina M A, Ademola A F. Case report of traumatic abdominal wall hernia following blunt motorcycle handlebar injury and review of the literature. Niger J Clin Pract 2012;15:238-40

How to cite this URL:
Ogundiran T O, Obamuyide H A, Adesina M A, Ademola A F. Case report of traumatic abdominal wall hernia following blunt motorcycle handlebar injury and review of the literature. Niger J Clin Pract [serial online] 2012 [cited 2019 Dec 12];15:238-40. Available from: http://www.njcponline.com/text.asp?2012/15/2/238/97337


   Introduction Top


Acute traumatic abdominal wall hernias are extremely rare with fewer than 70 cases reported in the English literature by 2005. [1],[2] Handlebar injury causing abdominal wall hernia is even rarer, only 29 cases were reported from 1939 to 2005. [2] In this report, we present a case of traumatic handlebar abdominal wall hernia in an adult in Ibadan, Nigeria, and review the existing literature on the subject.


   Case Report Top


A 25-year-old male artisan presented at the Accidents and Emergency Department of the University College Hospital, Ibadan, Nigeria in January 2009 with a 10-day history of a lower-right quadrant abdominal swelling. The swelling developed following blunt impact he had with the handlebar of a motorcycle he was riding. He had rammed his motorbike into a car which suddenly crossed his path at an intersection. The swelling was initially painful but the pain gradually resolved. The swelling was reducible and there were no symptoms of intestinal obstruction. He sustained no other injuries. He had no antecedent history of groin swelling and there was no other significant past medical history.

Physical examination revealed a young man with a satisfactory general condition. He had healing bruises over the right iliac fossa. There was a soft reducible non-tender 10cm long swelling with positive cough impulse overlying a palpable fascial defect, 6 cm long over the lateral half of the right inguinal ligament. His bowel sounds were normoactive. Examination of the systems was essentially normal. A clinical diagnosis of traumatic abdominal wall hernia was made. Abdominal ultrasonography revealed a wide-necked defect in the anterior abdominal wall over the right inguinal area with protruding bowel loops beneath the intact skin. He was planned for herniorrhaphy but he has not returned for the treatment since then.


   Discussion Top


Traumatic abdominal wall hernia (TAWH) is postulated to be caused by a force that is sufficient to disrupt the underlying muscles and fascia of the anterior abdominal wall but not the tough and elastic overlying skin. A forceful blow to the abdomen, most commonly due to a handle bar injury or fall from a height has been described as the most common cause of acute TAWH. [3] The abdominal wall defect in handlebar injury is often found in the lower abdomen, with only two cases reported as occurring in the upper abdomen. [2]

However, Samir and Poston were of the opinion that it is highly unlikely that the development of an abdominal wall hernia can be attributable to a single strenuous event. [4] They posited that hernias are related to structural abnormalities in the musculature of the abdominal wall. While discussing the medicolegal implications of traumatic hernias, Schofied concluded that a close relationship between a potential causative event and the development of the hernia must be demonstrated. [5] Smith et al. agreed that there might be sufficient evidence to suggest a causative role for a single strenuous event and suggested criteria that could be useful in the legal setting. [6]

The clinical features of TAWH include a history of blunt trauma to the abdomen, abdominal pain and a bulge of the local soft tissue at the ecchymotic area overlying the defect. Physical examination would reveal the swelling with or without tenderness and a palpable defect depending on the phase of presentation in hospital. An ultrasonography and computed tomography may show subcutaneous bowel loops and the defect. They may also help in differentiating a hernia from a haematoma, define the anatomy of the surrounding abdominal wall and identify other associated injuries. The need for other investigative modalities will depend on other injuries sustained by the patient.

Some classification has been proposed for TAWH. Wood et al. identified three categories based on the size of the rupture and the cause of the injury. First, the lower quadrant abdominal defects and hernias caused by blunt trauma most commonly from a handlebar. The second category consists of larger defect hernias that follow motor vehicular crashes. The third category includes intraabdominal bowel herniation into rents in the retroperitoneum. [7] Lane et al. divided TAWH into two types-low energy injuries following impact on small blunt objects and high energy injuries usually from automobile and pedestrian collisions. [8]

Since TAWH occurs in the setting of trauma, a full trauma protocol should be followed. High-energy injuries that are associated with other abdominal injuries require a midline laparotomy to attend to all the injuries. For low-energy injuries the defect can be repaired through an incision placed over the defect since they are not often associated with other abdominal injuries. In both cases primary repair is advocated and prosthesis is avoided because of a high risk for post operative wound infection. [9] Adequate debridement and solid repair of the fascial planes with nonabsorbable sutures are needed to prevent recurrence. In the series by Laneet al., six patients presented with varying degrees of abdominal tenderness and either abdominal skin ecchymosis or abrasions from a high-energy motor vehicle collision. All had associated injuries requiring open repair. The hernias were closed primarily and three patients developed postoperative wound sepsis. In a retrospective review of 34 patients with TAWH, Nettoet al. questioned early surgery in some cases and suggested that the mechanism of injury should be considered in deciding the need for urgent laparotomy. [10] Moreover, they concluded that occult TAWH discovered by CT may not require urgent repair and that those resulting from motor vehicle collision were more likely to require laparotomy.

In conclusion, we have reported a rare case of TAWH that occurred following a motorcycle handlebar injury in whom diagnosis was made clinically and was confirmed by abdominal wall ultrasonography. One drawback is that the patient has not returned for definitive surgical treatment at which the absence of a preexisting unnoticed inguinal hernia could have been confirmed. We have also reviewed the existing literature on the subject. TAWH resulting from low-energy injuries are not often associated with other abdominal injuries and can be repaired through an incision over the defect. Urgent laparotomy may not be indicated in occult cases that are diagnosed by radiological imaging. TAWH resulting from motor vehicle collision are more likely to require a laparotomy.

 
   References Top

1.Esposito TJ, Fedorak I. Traumatic lumbar hernia: Acase report and literature review. J Trauma 1994;37:123-6.  Back to cited text no. 1
    
2.Chen HY, Sheu MH, Tseng LM. Bicycle handlebar hernia: A rare traumatic abdominal wall hernia. J Chin Med Assoc 2005;68:283-5.  Back to cited text no. 2
    
3.Damschen DD, Landercasper J, Cogbil TH, Stolee RT. Acute traumatic abdominal hernia: Case reports. J Trauma 1994;36:273-6.  Back to cited text no. 3
    
4.Samir P, Poston GJ. It is highly unlikely that the development of an abdominal wall hernia can be attributable to a single strenuous event.  Ann R Coll Surg Engl 2006;88:168-71.  Back to cited text no. 4
    
5.Schofield PF. Inguinal hernia: Medicolegal implications. Ann R Coll Surg Engl 2000;82:109-10.  Back to cited text no. 5
    
6.Smith GD, Crosby DL, Lewis PA. Inguinal hernia and a single strenuous event. Ann R CollSurgEngl1996;78:367-8.  Back to cited text no. 6
    
7.Wood RJ, Ney AL, Bubrick MP. Traumatic abdominal hernia: Acase report and review of the literature. Am Surg1988;54:648-51.  Back to cited text no. 7
    
8.Lane CT, Cohen AJ, Cinat ME. Management of traumatic abdominal wall hernia. AmSurg2003;69:73-6.  Back to cited text no. 8
    
9.Jones BV, Sanchez JA, Vinh D. Acute traumatic abdominal wall hernia. Am J Emerg Med 1989;7:667-8.  Back to cited text no. 9
    
10.Netto FA, Hamilton P, Rizoli SB, Nascimento B Jr, Brenneman FD, Tien H, et al. Traumatic abdominal wall hernia. Epidemiology and clinical implications. J Trauma2006;61:1058-61.  Back to cited text no. 10
    



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