Handlebar injury in children: Are we ignoring the signs?

• Diagnosis of handlebar injuries with intra-abdominal injury is often delayed; radiologic tests can be initially unremarkable. A handlebar tattoo or other signs of abdominal bruising may be the only initial sign of a concealed injury.
• Abdominal bruising is an important physical finding. Its association with intestinal injury requires an aggressive diagnostic approach including serial physical examination, assessment of vital signs and urine output for 24 h.
• A CT scan is the best radiologic test for identifying intra-abdominal injury from a handlebar impact. It's warranted in cases of persistent abdominal pain, worsening vital signs and altered laboratory analysis.

The diagnosis of blunt intestinal injury in children is difficult and often delayed. We describe two cases of delayed diagnosis of intestinal injury following handlebar injury with abdominal wall tattooing. We review the literature to try and determine the usefulness of handlebar tattooing characteristics as a clinical sign for underlying small bowel injury in order to reduce delayed treatment. We propose a management algorithm for patients with handlebar tattooing.