London Sign: More than Meets the Eye

Pediatric handlebar injuries are a separate subset of unintentional injuries that need to be treated with a high degree of suspicion. They can be associated with varying underlying injuries which are often underestimated and cannot be predicted based on the external sign alone, thus leading to delayed diagnosis with missed injuries. In case 1, a 7-year-old boy presented a day after falling from his bicycle. Examination revealed a handlebar sign in the hypogastrium with guarding. Laparotomy revealed a jejunal perforation. In case 2, a 13-year-old boy presented with pain abdomen after being rammed by a bicycle handle. Examination revealed a handlebar sign in the lower part of the abdomen. He did not have any signs of peritonitis and was conservatively managed. In case 3, a 13-year-old boy with a history of fall from a bicycle sustained an abdominal handlebar injury. An impression of the handlebar was noted along with periumbilical tenderness and absent bowel sounds. Midline laparotomy revealed a walled-off collection of pus around a grade 3 duodenal laceration in the anterolateral aspect of the third part of the duodenum. In case 4, an 8-year-old boy presented after a fall while driving his bicycle with a handle imprint over the right upper quadrant. As the primary and secondary survey was normal, the child was managed conservatively. Handlebar injuries are apparently minor looking injuries with significant underlying impact on the underlying organs. These injuries must always be evaluated, and a low threshold must be kept for radiological investigations. Such children should be kept under observation for evolving signs of injury despite being seemingly normal.