Open Access

The risk of pediatric bicycle handlebar injury compared with non-handlebar injury: a retrospective multicenter study in Osaka, Japan

  • Tomoya Hirose1Email author,
  • Hiroshi Ogura1,
  • Takeyuki Kiguchi2,
  • Yasuaki Mizushima3,
  • Futoshi Kimbara4,
  • Junya Shimazaki5,
  • Shigeru Shiono6,
  • Hitoshi Yamamura7,
  • Akinori Wakai8,
  • Ryosuke Takegawa1,
  • Hisatake Matsumoto1,
  • Mitsuo Ohnishi1 and
  • Takeshi Shimazu1
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine201523:66

https://doi.org/10.1186/s13049-015-0146-7

Received: 13 March 2015

Accepted: 25 August 2015

Published: 17 September 2015

Abstract

Background

Bicycle accidents are one of the major causes of unintentional traumatic injury in childhood. The purpose of this study was to examine characteristics and risks of handlebar injury in childhood.

Methods

We conducted a more than 5-year retrospective survey of patients under 15 years of age with bicycle-related injuries admitted to eight urban tertiary emergency centers in Osaka, Japan. Patients were divided into the direct-impact handlebar injury (HI) group and the non-handlebar injury (NHI) group.

Results

The HI group included 18 patients and the NHI group included 308 patients. Median Injury Severity Score (ISS) in the HI group was 9. Injury sites included the chest, 2 (chest bruise, 1; tracheal injury, 1) and abdomen, 16 (hepatic injury, 6; pancreatic injury, 2; duodenal injury, 1; splenic injury, 1; small intestinal injury, 1; retroperitoneal hemorrhage, 1; renal injury, 1; abdominal wall musculature injury, 2; bladder injury, 1; and perineal laceration, 1). There were no significant differences in age, sex, ISS, and prognosis between the two groups. However, significant differences were seen in the abdominal median Abbreviated Injury Scale (AIS) score, which was higher in the HI group (3 vs 0, p < 0.01), and in the head median AIS score, which was higher in the NHI group (0 vs 2, p < 0.01). As mechanisms of injury, falling while riding a bicycle occurred significantly more frequently in the HI group (17 [94.4 %] vs 65 [21.1 %], p < 0.01). Direct transportation from the scene of the accident occurred significantly more often in the NHI group (5 [27.8 %] vs 255 [82.8 %], p < 0.01), whereas transfer from another hospital occurred significantly more frequently in the HI group (11 [61.1 %] vs 45 [14.6 %], p < 0.01).

Conclusions

Handlebar injuries in children have significant potential to cause severe damage to visceral organs, especially those in the abdomen.

Background

Bicycle accidents are one of the major causes of unintentional traumatic injury in childhood; the number of incidents in children under 15 years of age was 26,245 in 2011 in Japan [1]. Children riding bicycles have a higher risk of accidents compared with adults because children have fewer rules and engage in more risky behavior than adults [1]. Helmet use in children has been promoted for the prevention of head injury from bicycle accidents [2, 3]. However, the risk of injuries from direct impact with handlebars has not generally been recognized among children [4, 5]. Therefore, the purpose of this study was to examine the characteristics and risks of childhood handlebar injury compared with non-handlebar injury in Japan.

Methods

Patients and setting

This study was a more than 5-year retrospective survey of patients under 15 years of age with bicycle-related injuries admitted to eight urban tertiary emergency centers in the Osaka area of Japan and was approved by the Ethics Committee of the Osaka University Graduate School of Medicine. We chose the pediatric bicycle injury patients admitted to each institution and collected patient information from their medical records. We identified cases of bicycle-related injury retrospectively by checking the medical records of all trauma patients under 15 years of age. The period for which each hospital had patients enrolled ranged from 5 years (2008–2012) to 12 years (2000–2012). Patients were divided into the direct-impact handlebar injury (HI) group and the non-handlebar injury (NHI) group. Patients with a medical record description of “handlebar injury” or “skin bruise to the body from a handlebar injury” were assigned to the HI group. A typical skin bruise from the handlebar injury is shown in Fig. 1. Patients with other non-handlebar-impact bicycle-related injuries, such as falling while riding a bicycle or collision with vehicles, were assigned to the NHI group. We assessed age, sex, Injury Severity Score (ISS), prognosis, mechanisms of injury, Abbreviated Injury Scale (AIS) score, AIS score of 3 or greater, Glasgow Coma Scale (GCS) on hospital arrival, treatment, medical transport method, and time from accident to arrival at our emergency centers in each patient and compared these variables between the two groups. The AIS score was determined retrospectively for this study, and the GCS on hospital arrival was prospectively given in the records.
Fig. 1

Photographs of a patient who sustained a handlebar injury. a A typical skin bruise (within circle) from a handlebar injury was suggestive of damage to the abdominal organs. b, c We diagnosed the patient as having injury to the abdominal wall musculature (b, arrow) and duodenum (c, arrow). Surgical treatment was required to repair these injuries

Statistical analysis

Continuous variables are presented as the median and interquartile range (IQR). The Wilcoxon rank-sum test and Fisher’s exact test were used to compare two patient groups. A p value of < 0.05 was considered significant. All statistical analyses were performed using JMP 9.0.2 (SAS Institute Inc., Cary, NC, USA).

Results

Patient characteristics are shown in Table 1. The HI group included 18 patients, and the NHI group included 308 patients. In the HI group, the prognosis was good in all patients. Injury sites were as follows: chest, 2 (chest bruise, 1; tracheal injury, 1); abdomen, 16 (hepatic injury, 6; pancreatic injury, 2; duodenal injury, 1; splenic injury, 1; small intestinal injury, 1; retroperitoneal hemorrhage, 1; renal injury, 1; abdominal wall musculature injury, 2; bladder injury, 1; and perineal laceration, 1) (Table 2, Fig. 1). Therapeutic interventions were performed in 9 patients and included emergency surgery or emergency transcatheter arterial embolization (TAE) in 6 and elective surgery or elective TAE in 3 patients. The other 9 patients were followed with close observation (Tables 1 and 2). There were no significant differences in age, sex, ISS, and prognosis between the two groups (Table 1).
Table 1

Patient characteristics

 

Handlebar impact group

Non-handlebar impact group

p value

Number

18

308

 

Age (IQR)

9 (7–13)

11 (7–14)

0.288

Male (%)

14 (77.8)

209 (67.9)

0.446

Injury Severity Score (IQR)

9 (4–10)

9 (5–17)

0.252

ICU stay (days) (IQR)

5.5 (2–7)

2 (0–4)

0.004

Hospital stay (days) (IQR)

10.5 (6.75–30.5)

5 (2–14)

0.016

GCS on arrival (IQR)

15 (15–15)

15 (13–15)

0.005

Shock on arrival (%)

1 (5.6)

10 (3.2)

0.470

Survivors (%)

18 (100)

297 (96.4)

1.000

Treatment (%)

 Emergency surgery/TAE

6 (33.3)

75 (24.4)

0.4043

 Elective surgery/TAE

3 (16.7)

20 (6.5)

0.1245

 Conservative treatment

9 (50 %)

215 (69.8)

0.1134

IQR Interquartile range, ICU Intensive care unit, GCS Glasgow Coma scale, TAE Transcatheter arterial embolization

Table 2

Characteristics of patients in the handlebar impact group

Age

Sex

Injuries

ISS

Time from injury to final hospital

Treatment

9

M

Renal injury

16

5 h

Emergency TAE

12

M

Hepatic injury

10

26 min

Emergency TAE

15

M

Splenic injury

17

15 min

Emergency TAE

5

M

Pancreatic injury

9

48 h

Emergency surgery

14

M

Duodenal injury, abdominal wall musculature

10

210 min

Emergency surgery

9

F

Small intestinal injury

10

3 h

Emergency surgery

13

M

Bladder rupture, abdominal wall musculature

17

3 h

Elective surgery

14

M

Pancreatic injury

5

12 h

Elective surgery

7

M

Hepatic injury

9

6 h

Elective TAE

6

F

Perineal laceration

2

3 h

Conservative treatment (suture only)

8

M

Hepatic injury

2

3 h

Conservative treatment

9

M

Hepatic injury

4

3 h

Conservative treatment

3

M

Hepatic injury

9

75 min

Conservative treatment

13

M

Hepatic injury

4

3 h

Conservative treatment

7

M

Tracheal injury, mediastinal emphysema

10

3 h

Conservative treatment

11

M

Retroperitoneal hematoma

9

15 min

Conservative treatment

10

M

Abdominal bruise

1

191 min

Conservative treatment

7

M

Chest bruise

1

Unknown

Conservative treatment

ISS Injury severity score, TAE Transcatheter arterial embolization

However, significant differences were seen in the abdominal median AIS, which was higher in the HI group compared with NHI group, and in the number of patients with abdominal AIS score of 3 or greater, which was also significantly higher in the HI group. The head median AIS score was significantly higher in the NHI group, and the number of patients with a head AIS score of 3 or greater was also significantly higher in the NHI group (Table 3). The GCS on hospital arrival was significantly lower in the patients in the NHI group (GCS score 15: n = 176, 14: n = 50, 13: n = 17, 12: n = 8, 11: n = 9, 10: n = 4, 9: n = 8, 8: n = 5, 7: n = 7, 6: n = 5, 5: n = 5, 4: n = 4, 3: n = 10) than in those in the HI group (GCS score 15: n = 16, 14: n = 2) (Table 1).
Table 3

Abbreviated Injury Scale (AIS) score and AIS score of ≥3 in the handlebar impact versus non-handlebar impact group

 

Handlebar impact group

Non-handlebar impact group

p value

Number of patients

18

308

 

AIS score (median)

 Head (IQR)

0 (0–0)

2 (0–4)

<0.001

 Face (IQR)

0 (0–0)

0 (0–0)

0.099

 Chest (IQR)

0 (0–0)

0 (0–0)

0.278

 Abdomen (IQR)

3 (1.75–3)

0 (0–0)

<0.001

 Pelvic & extremity (IQR)

0 (0–0)

0 (0–0)

0.025

 Soft tissue (IQR)

1 (0–1)

1 (0–1)

0.171

AIS ≥3 (n)

 Head (%)

0 (0)

130 (42.2)

<0.001

 Face (%)

0 (0)

1 (0.3)

1.000

 Chest (%)

1 (5.6)

42 (13.6)

0.486

 Abdomen (%)

11 (61.1)

19 (6.2)

<0.001

 Pelvic & extremity (%)

0 (0)

27 (8.8)

0.381

 Soft tissue (%)

0 (0)

0 (0)

1.000

IQR Interquartile range

Regarding mechanisms of injury, falling while riding a bicycle occurred significantly more frequently in the HI group, whereas the incidence of collision with vehicles was significantly higher in the NHI group (Table 4). Direct transportation from the scene of the accident to our emergency centers occurred significantly more often in the NHI group, whereas transfer to our emergency centers from another hospital occurred significantly more frequently in the HI group (Table 4). The time from accident to arrival at our emergency centers was significantly longer in the HI group than in the NHI group (Table 4).
Table 4

Mechanism of injury, medical transport method, and time from accident to hospital in the handlebar impact versus non-handlebar impact group

 

Handlebar impact group

Non-handlebar impact group

p value

Number of patients

18

308

 

Mechanism of injury

 Single bicycle accident (%)

18 (100)

76 (24.7)

<0.001

 Fall from bicycle (%)

17 (94.4)

65 (21.1)

<0.001

 Collision with obstacle (%)

1 (5.6)

11 (3.6)

0.500

 Contact accident with car or motorcycle (%)

0 (0)

232 (75.3)

<0.001

Transport

 Ambulance/helicopter (%)

5 (27.8)

255 (82.8)

<0.001

 Walk-in (%)

2 (11.1)

8 (2.6)

0.010

 Hospital transfer (%)

11 (61.1)

45 (14.6)

<0.001

Time to hospital (min)

180 (127.5–255) n = 17

34 (26–50) n = 276

<0.001

Discussion

The numbers of bicycles and associated riders have increased, and bicycle-related injuries have become a major health problem [6]. Bicycle trauma comprises a significant proportion of trauma in children. However, the risk of pediatric bicycle handlebar injury has not been emphasized. In 1997 in the United States, 1.15 per 100,000 subjects 19 years and younger were estimated to have suffered serious abdominal and pelvic organ injury leading to hospitalization that was associated with non-motor-vehicle bicycle handlebar accidents [5]. Winston et al. [7] considered handlebars as hidden spears because impact with handlebars might be accompanied by visceral organ injury through the concentration of an external force applied by the end of the handlebar to a child’s body.

The typical mechanism of pediatric bicycle handlebar injury is a falling accident in which the child loses control of the bicycle, begins to fall, the front wheel turns to the side, and the end of the bicycle handlebar strikes the neck, chest, abdomen, or pelvic area of the rider [7, 8]. We consider that pediatric bicycle handlebar injury can be caused by the immature decision-making ability of the child, the impact caused by sudden braking or collision, and the insufficient muscular power of the child’s body to withstand such impacts. About 90 % of patients with significant intra-abdominal organ injury were reported to have visible skin bruises from handlebar contact [9, 10] such as that shown in Fig. 1a.

Direct-impact handlebar injuries to the liver, spleen, pancreas, duodenum, intestines, kidney, urethra, abdominal wall, and major vessels have been reported [4, 8]. The rate of handlebar injuries to parenchymatous organs such as the liver, kidney, pancreas, and spleen reportedly ranges from 20 to 37 % [4, 1113], and gastrointestinal perforation has been reported in 9–10 % of children with handlebar injuries [4, 11, 12]. Cevik et al. [10] reported that 85.7 % of children who sustained direct-impact handlebar injuries required operative intervention. In our study, 50.0 % of the children who sustained direct-impact handlebar injuries required operation or TAE intervention (Tables 1 and 2). These are surprisingly high rates, which indicate that children with handlebar injuries should be examined carefully.

Traumatic abdominal wall hernia is a well-known complication of handlebar injuries and is defined as herniation through disrupted musculature and fascia associated with blunt trauma, without skin penetration because of the skin’s elasticity, and with no evidence of prior hernia defect at the site of injury [4, 14, 15]. However, traumatic abdominal wall hernia is rare, so due to a lack of knowledge of this condition, apparent clinical signs associated with this injury might easily be missed [16]. Two of the patients in the present study had injuries to their abdominal wall musculature and required surgical repair (Table 2, Fig. 1). Knowledge of the mechanism of trauma to the abdomen and visible handlebar skin bruises, if they exist, can help the physician to suspect the presence of traumatic abdominal wall trauma.

Falling while riding a bicycle occurred significantly more frequently and GCS on hospital arrival was significantly higher in the HI group compared with the NHI group (Tables 1 and 4). It is possible that the severity of pediatric handlebar injuries is underestimated by parents, witnesses, and the ambulance crew at the scene of an accident. Thus, transfer from another hospital occurred significantly more frequently and the time from accident to patient arrival at our emergency centers was significantly longer in the HI group (Table 4). In our study, one patient with pancreatic injury was not transferred to our center until 48 h after the injury (Table 2). The severity of pediatric bicycle handlebar injury might often be underestimated when based on the mechanism of the accident or the level of consciousness of the patient. We suggest more liberal use of CT scanning in the assessment of severe handlebar injury, at least for those injuries involving the abdomen.

There are some limitations in this study. First, it is a retrospective study. We collected patient information only from patient medical records. Second, study periods are different for each medical institution because medical records must be preserved for at least 5 years in Japan. Third, the medical institutions participating in this research were all urban tertiary emergency centers in Osaka, Japan. In major metropolitan areas of Japan, hospitals are categorized into three levels of emergency care (Primary emergency care: for patients with low-acuity conditions who can be safely discharged home; Secondary emergency care: for patients with moderate-acuity conditions who require admission to a regular inpatient bed; and Tertiary emergency care: for patients with high-acuity conditions who require admission to the ICU). Therefore, the subjects of this study were urban residents, and they had been judged as having severe or suspected severe trauma at the accident scene or initial medical institution before they were transported to our centers. This might lead to the difference in sample size of the HI and NHI groups in the present study. The research data does not cover all pediatric bicycle accidents. More comprehensive research into pediatric bicycle injuries would be desirable in a future study. Fourth, adult patients with handle bar injury were not included in this study. There is little documentation on bicycle handle bar injury in adult patients because of the following possible reasons: i) the abdominal muscles of adults are more well developed than those of children, ii) adults are less inclined to ride bicycles as recklessly as children do, and iii) adults generally can better perceive risks than children can [17].

As a preventive strategy for traumatic handlebar injury in the future, it might be effective to modify the shape of the ends of the handlebars, limit the side-to-side rotation of the front wheel fork assembly, and promote the wearing of an abdominal protector to prevent pediatric handlebar injuries.

Conclusions

It should be emphasized that handlebar injuries in children have a significant potential to cause severe damage to visceral organs, especially those in the abdomen. Such injuries require a high degree of suspicion so that visceral organ damage from handlebar injuries can be detected early and appropriate treatment can be administered.

Declarations

Acknowledgements

This study was supported by a medical research grant on traffic accident from The General Insurance Association of Japan.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine
(2)
Department of Emergency Medicine, Osaka General Medical Center
(3)
Senshu Trauma and Critical Care Center, Rinku General Medical Center
(4)
Senri Critical Care Medical Center, Osaka Saiseikai Senri Hospital
(5)
Emergency and Critical Care Medical Center, Osaka Police Hospital
(6)
Osaka Prefectural Nakakawachi Medical Center of Acute Medicine
(7)
Department of Trauma and Critical Care Medicine, Osaka City University Graduate School of Medicine
(8)
Traumatology and Critical Care Medical Center, National Hospital Organization Osaka National Hospital

References

  1. Wegman F, Zhang F, Dijkstra A. How to make more cycling good for road safety? Accid Anal Prev. 2012;44:19–29.View ArticlePubMedGoogle Scholar
  2. Ekman DS, Ekman R. Twenty-five years of bicycle helmet promotion for children in Skaraborg District, Sweden. Int J Inj Contr Saf Promot. 2012;19:213–7.View ArticlePubMedGoogle Scholar
  3. Berg P, Westerling R. A decrease in both mild and severe bicycle-related head injuries in helmet wearing ages—trend analyses in Sweden. Health Promot Int. 2007;22:191–7.View ArticlePubMedGoogle Scholar
  4. Karaman I, Karaman A, Aslan MK, Erdoğan D, Cavuşoğlu YH, Tütün O. A hidden danger of childhood trauma: bicycle handlebar injuries. Surg Today. 2009;39:572–4.View ArticlePubMedGoogle Scholar
  5. Winston FK, Weiss HB, Nance ML, Vivarelli-O’Neill C, Strotmeyer S, Lawrence BA, et al. Estimates of the incidence and costs associated with handlebar-related injuries in children. Arch Pediatr Adolesc Med. 2002;156:922–8.View ArticlePubMedGoogle Scholar
  6. Corden TE, Tripathy N, Pierce SE, Katcher ML. The role of the health care professional in bicycle safety. WMJ. 2005;104:35–8.PubMedGoogle Scholar
  7. Winston FK, Shaw KN, Kreshak AA, Schwarz DF, Gallagher PR, Cnaan A. Hidden spears: handlebars as injury hazards to children. Pediatrics. 1998;102:596–601.View ArticlePubMedGoogle Scholar
  8. Nadler EP, Potoka DA, Shultz BL, Morrison KE, Ford HR, Gaines BA. The high morbidity associated with handlebar injuries in children. J Trauma. 2005;58:1171–4.View ArticlePubMedGoogle Scholar
  9. Muthucumaru M, Keys C, Kimber C, Ferguson P, Varma P, Cheng W. Trend of severe abdominal injuries from bicycle accidents in children: a preventable condition. J Paediatr Child Health. 2012;48:259–62.View ArticlePubMedGoogle Scholar
  10. Cevik M, Boleken ME, Sogut O, Gökdemir MT, Karakas E. Abdominal injuries related to bicycle accidents in children. Pediatr Surg Int. 2013;29:459–63.View ArticlePubMedGoogle Scholar
  11. Erez I, Lazar L, Gutermacher M, Katz S. Abdominal injuries caused by bicycle handlebars. Eur J Surg. 2001;167:331–3.View ArticlePubMedGoogle Scholar
  12. Sparnon AL, Ford WD. Bicycle handlebar injuries in children. J Pediatr Surg. 1986;21:118–9.View ArticlePubMedGoogle Scholar
  13. Clarnette TD, Beasley SW. Handlebar injuries in children: patterns and prevention. Aust N Z J Surg. 1997;67:338–9.View ArticlePubMedGoogle Scholar
  14. Rathore A, Simpson BJ, Diefenbach KA. Traumatic abdominal wall hernias: an emerging trend in handlebar injuries. J Pediatr Surg. 2012;47:1410–3.View ArticlePubMedGoogle Scholar
  15. Kubota A, Shono J, Yonekura T, Hoki M, Asano S, Hirooka S, et al. Handlebar hernia: case report and review of pediatric cases. Pediatr Surg Int. 1999;15:411–2.View ArticlePubMedGoogle Scholar
  16. van Bemmel AJ, van Marle AG, Schlejen PM, Schmitz RF. Handlebar hernia: a case report and literature review on traumatic abdominal wall hernia in children. Hernia. 2011;15:439–42.PubMed CentralView ArticlePubMedGoogle Scholar
  17. Bohmer JH, Proust AF. Adult bicycle handlebar injury. Am J Emerg Med. 2006;24:624–5.View ArticlePubMedGoogle Scholar

Copyright

© Hirose et al. 2015

Advertisement