traumatic arterial occlusion following major or minor blunt trauma , especially in the absence of any other bony injury , is a rare phenomenon . 
motor - scooter handlebar syndrome is one such type of arterial occlusion affecting vascular structures following direct blow by a handlebar of a motorbike or bicycle to the groin .
given their superficial course at this location , femoral vessels are the most common vascular structures affected . in all instances ,
injury to iliac vessels remains exceedingly rare , given its posterior position within the pelvis , representing only 0.4% of vascular injuries . in this case , we highlight a delayed presentation of external iliac artery occlusion secondary to  motor - scooter handlebar syndrome , in a paediatric patient .
pathophysiology and management of vascular injuries in the paediatric population vary significantly compared with the adult population .
additional factors which need to be considered include : smaller vessel size or vessel spasm , higher risk of infection , tendency for re - stenosis and continuing growth .
we review previous paediatric cases of this unusual vascular injury to highlight the pathology and most appropriate management option .
a 15-year - old male presented to the emergency department following a direct blow from his bicycle handlebars to his groin .
his abdominal examination was unremarkable , except for a small abrasion and visible mass in his right groin .
after exclusion of other abdominal or chest injuries , he was discharged on the same day with a diagnosis of right groin haematoma and follow - up in 68 weeks .
his symptoms included pain and paraesthesia in his right buttocks on mobilization > 100 m. he was found to have absent peripheral pulses in his right leg , although it appeared well perfused with a normal capillary refill .
an arterial doppler ultrasound showed a right external iliac artery thrombus occluding the proximal two - thirds of the vessel .
a computed tomography scan of the abdomen and pelvis with intravenous contrast identified complete occlusion of the right external iliac artery 1 cm beyond its origin . however , the common femoral artery and profunda femoris remained patent via collaterals ( fig .  1 ) . 

he underwent a right external iliac thromboendarterectomy with patch repair using a saphenous vein graft .
a suprainguinal incision was initially made in attempt to expose the proximal external iliac artery .
due to its extent , retrieval of the entire thrombus was incomplete and a second groin incision near the junction of the common femoral with external iliac ( at the inguinal ligament level ) was required .
the patient subsequently underwent a proximal and distal thrombectomy , and the arteriotomy was extended between the two incisions identifying an intimal stricture with significant fibrosis ( fig .  2 ) .
an intimal flap was identified in the distal region and tacked down with a 7 - 0 prolene suture .
the long saphenous vein was harvested and the defect closed with patch repair extending from proximal iliac to proximal femoral vessel .
at the initial 2-week follow - up , the vessels remained patent and patient was progressing well .
subsequently , regular biannual follow - up was planned to monitor for any longer - term complications . 

figure  2:occlusion of right external iliac artery 1 cm below its origin ( white arrow ) .
occlusion of right external iliac artery 1 cm below its origin ( white arrow ) .
 motor - scooter handlebar syndrome is an uncommon form of arterial blunt injury following a direct blow by the handlebar of motorbikes or bicycles .
only a handful of paediatric cases have been reported [ 1 , 2 , 47 ] . the common femoral vessel is the most commonly affected vascular structure .
a common site for these injuries is at the inguinal ligament , where the femoral artery is superficial and courses anterior to the superior pubic ramus and femoral head . as such , it is prone to compression between the handlebar and posterior osseous structures .
in addition , it is a relatively immobile structure , tethered by arterial branches , periadventitial connective tissue and the femoral sheath .
they proposed that a circumferential tear of the intima leads to dissection and prolapse of the inner aortic layers , causing complete luminal occlusion .
, patients may remain asymptomatic until a period of growth spurt or they resume more rigorous physical activity .
this can lead to delay in the diagnosis , and a high index of suspicion needs to be maintained to avoid ischaemic complications such as limb length discrepancy [ 8 , 9 ] .
in such instances , it is important to rule out any secondary occlusion of the femoral artery and vein that may predispose to the development of thrombosis within these vessels .
duplex sonography should be carried out to assess flow velocities and waveform characteristics in these patients , and is especially suited to the paediatric population as they have reduced abdominal fat , and there is no radiation .
identified ultrasound , in the right hands , to be highly sensitive ( 100% ) and specific ( 97.5% ) for the detection of arterial injuries when compared with surgical findings .
open arterial thromboendarterectomy with graft or patch repair is the standard of care for such cases in trauma centres .
previously documented cases include patch repair or bypass using saphenous vein , bovine pericardium and synthetic material [ 13 , 5 , 6 ] .
one case was successfully treated with iv heparinzation alone . however , in most injuries , the presence of significant groin haematoma may limit anticoagulation , requiring more urgent operative re - vascularization . in our patient , delayed presentation and presence of significant collaterals meant definitive operative management could be planned as a semi - elective procedure .
the role of endovascular intervention in this paediatric population has previously been documented mainly as a temporizing measure for revascularization [ 4 , 5 ] .
used a nitinol stent in the distal superficial femoral artery of a 13-year - old patient whose arterial and venous calibre at the time of injury were of inappropriate size for reconstruction .
the main disadvantage of endovascular interventions in paediatric patients is the constantly enlarging calibre of the vessel with a fixed stent diameter .
this can predispose to complications such as restenosis , stent fracture , stent dislocation and acute on chronic ischaemia . as a result , future vascular reconstruction may be compromised and in extreme cases , this may progress to significant ischaemia and even limb loss .
we provide an unusual cause of external iliac occlusion secondary to bicycle handlebar injury to the groin .
all patients presenting with groin injury from this mechanism should be carefully investigated with duplex sonography and monitored for risk of vascular injury .
the presence of collaterals , particularly in the paediatric population , can lead to delay in diagnosis .
literature seems to advocate open primary surgery for management of these injuries ; however , endovascular and conservative medical management have also been used successfully .
the latter two were contraindicated in our patient and open surgery was the most appropriate option .
long - term follow - up , beyond the 12-month period , is needed , particularly in relation to known vascular complications including pseudoaneurysms , arteriovenous fistula formation and restenosis .
 arterial occlusion following blunt trauma is an uncommon occurrence . 
 we report an unusual case of delayed external iliac artery occlusion in a young male following blunt abdominal injury . 
 he was successfully treated with thromboendarterectomy and saphenous vein patch repair . 
 there have only been a handful of documented cases occurring in the paediatric population . 
 all patients presenting with groin injury from this mechanism should be carefully investigated and monitored for risk of vascular injury . 