A 27-year-old male with no past medical history was the driver and sole occupant of a car which crashed through a fence at 80 kph and hit a lamp post. He was wearing a seatbelt, the airbags did not deploy and despite the significant intrusion into the passenger space, he extricated himself unaided. He was resuscitated according to Advanced Trauma Life Support® principles. The primary survey identified decreased air entry at the base of the right lung and right-sided abdominal and lower chest tenderness. Abrasions were evident over the anterolateral abdominal wall and a large, right-sided abdominal swelling was noted.\nTrauma series computed tomography (CT) scans demonstrated a flail segment between the sixth and eight ribs with disruption of the intercostal muscles and a small right haemothorax (Fig. a). In the abdomen, there was hepatic contusion with an intrinsic liver injury (Fig. b). Blood was noted around the liver with minor active haemorrhage. The right abdominal wall was ruptured—the right rectus abdominis muscle had been torn from its costal attachments to the midpoint. The hepatic flexure of the colon had herniated through the intercostal muscles of the eighth and ninth ribs and was lying adjacent to the fractured ribs (Fig. c). Both small and large bowel had herniated through the abdominal wall lateral to rectus abdominis, but remained covered by external oblique (Fig. d). Herniation of small and large bowel immediately adjacent to the fractured ribs raised the suspicion of occult bowel injury not detected on CT.\nThe operative management was undertaken by both thoracic and abdominal surgeons. The ribs were re-opposed with absorbable polyglycolic acid sutures and a chest drain inserted. At laparotomy, it was noted that the hernia sac contained omentum, the bowel having reduced spontaneously under general anaesthesia. A small rent in the mesentery of the proximal small bowel was noted. The abdominal defect was repaired with a 20 × 30 cm sheet of cross-linked acellular porcine dermal collagen (Permacol™, Covidien, Gosport, Hants, UK) which was sutured to the margins of the fascial defect with interrupted nylon sutures, using a ‘bridge’ technique, with a 5-cm underlay on the left.\nPost-operatively, the patient was managed in the intensive care unit for 24 h. A seroma that developed at the hernia site after 1 week was treated conservatively. Impaired abdominal wall function, particularly reduced mobility, was noted post-operatively. Sitting up from lying down position and hip flexion caused difficulty, but improved with intensive physiotherapy. He was discharged home 9 days after admission.\nSix weeks after discharge, he was well with good mobility. He had a persistent seroma at the hernia site. A repeat CT of the thorax and abdomen at 10 weeks demonstrated no residual defect in the anterior abdominal wall and resolution of the seroma (Fig. ).
An 8-year-old Cameroonian boy with no significant past history was brought to our emergency service following a road traffic accident. On crossing a road, he was knocked down by an oncoming motorbike weighing approximately 125 kg, medium sized, and traveling at moderate speed. The motorbike fell on the boy with the handlebar catching him in the abdomen as its rider lost control. He sustained a lesion to the head with no initial loss of consciousness. On arrival, he complained of pain in his head and a swelling in the left upper quadrant of his abdomen.\nOn examination, he was conscious, with a Glasgow coma score of 15/15, blood pressure of 119/83 mmHg, pulse of 90 beats per minute, respiratory rate of 18 breaths per minute, temperature of 37.3 °C; he was 96 cm tall and weighed 26 kg. There was a 2 cm laceration in the occipital region of his head, and a swelling in his left lumbar region with mild bruising of the overlying skin (Fig. ). The swelling was reducible and disappeared in the supine position. There was no guarding and no rebound tenderness. He had normal bowel sounds on auscultation and the rest of the examination was unremarkable.\nA diagnosis of mild head injury and a handlebar hernia was made. After resuscitation, his scalp laceration was closed with a one point suture and he was programmed for surgery for the handlebar hernia the next day. A surgical exploration of the area showed a 7 cm laceration of his lateral abdominal wall (Fig. ), running from the external oblique aponeurosis through all the muscle layers to his peritoneum with loops of small bowel present in the opening. There was no blood or feces in the area immediately surrounding the lesion. Exploration of the bowel loops closest to the opening did not reveal signs of intra-abdominal injury. The abdominal wall defect was repaired in layers. The abdominal incision was closed in a standard manner. His postoperative period was uneventful. He was discharged on postoperative day 9 and scheduled 2 weeks later for a follow-up visit, but unfortunately was lost to follow-up.