Accepted Manuscript

The London Sign (Patterned Bruising of Blunt Abdominal

Trauma)

V. Raveenthiran

PII: S0022-3468(18)30196-9
DOI: doi:10.1016/j.jpedsurg.2018.03.013
Reference: YJPSU 58621
To appear in:
Received date: 2 March 2018
Accepted date: 8 March 2018

Please cite this article as: V. Raveenthiran , The London Sign (Patterned Bruising of
Blunt Abdominal Trauma). The address for the corresponding author was captured as
affiliation for all authors. Please check if appropriate. Yjpsu(2018), doi:10.1016/
j.jpedsurg.2018.03.013

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Images in Clinical Medicine

The London Sign

(Patterned Bruising of Blunt Abdominal Trauma)

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V. Raveenthiran., M.Ch, FRCS, FACS

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Professor of Pediatric Surgery
SRM Medical College

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Chennai, India.

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Address for correspondence
V. Raveenthiran
200. Fifth Street, Viduthalai Nagar
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Sunnambu Kolathur
Chennai, PIN code 600117
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India
Email: vrthiran@gmail.com
Mobile Phone: 91-94433-10182
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Abstract
Patterned bruising of abdominal wall in blunt trauma is called London sign. It indicates that the

impacting force is sharp and severe enough to cause visceral injury. Despite its practical

significance this sign is seldom described in textbooks and there are no journal articles about it.

This communication is intended to draw the attention of pediatric surgeons to this useful clinical

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sign.

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Keywords
London sign; Blunt abdominal injury; trauma diagnosis; pancreatic laceration.

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TEXT

An 11-year-old boy was seen in Emergency Room for abdominal discomfort and bilious

vomiting. Two days before he had sustained blunt injury due to fall from bicycle. Physical

examination revealed nothing abnormal except for a trivial-looking circular bruising in the

epigastrium (Figure 1). It corresponds to the shape and size of the bicycle handle bar. Such

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patterned bruising of abdominal wall is called the ‘London sign’. The sign implies that the

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impact is sharp and severe enough to cause visceral injury. Epigastric blows are notorious to

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cause pancreatico-duodenal injury as these organs get crushed between the impacting object and

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the vertebral bone.

Ultrasonography and upper gastrointestinal contrast study did not reveal anything
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abnormal except for scanty amount for free fluid in the peritoneal cavity. Although screening
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images were negative, contrast enhanced computed tomography was ordered because of the

London sign which is a sure indicator of visceral injury. CT scan picked up partial rupture of the
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pancreatic body without disruption of its major duct (Grade 2 pancreatic injury) (Figure 2). He
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was managed non-operatively with antibiotics, nil per oral, parenteral nutrition support and anti-

secretory drugs (ranitidine and octreotide). Serum amylase which was 575 U/l at admission came
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down to 64 U/l on the 10th day. At discharge, he tolerated oral feeds and was pain free. At 6
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months follow-up he is well.

Discussion

Presence of the London sign, even in a trivial-looking injury, necessitates hospital

admission and detailed investigation. The sign is named after Dr. Peter London (1922-2015),

emergency physician of Birmingham.(1) He, first described that patterned bruising of abdomen is

always associated with serious internal injuries.(2) Typical shape and size of bruising in
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conformity with that of objects transmitting the impacting force should alert the surgeon. A

variety of patterns such as tyre marks, shirt buttons, knuckles of hand, wrist watch have been

described under the London’s sign. Despite its rich clinical relevance, it is seldom mentioned in

textbooks and there are no references to it journal articles. Although Hamilton Bailey’s

Demonstration of physical signs in clinical surgery mentioned the sign in its earlier editions,

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subsequent editions have omitted it.(3,4) Despite recent advances in medical imaging, this sign has

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not lost its relevance. For example, focused assessment with sonography in trauma (FAST) is

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now the norm in the evaluation of blunt abdominal injuries.(5) However, in our case the visceral

injury missed by FAST was picked up by pursued imaging efforts prompted by the London sign.

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Legends to illustrations

Figure 1: Clinical photograph showing circular bruising of epigastrium (the London sign)

which corresponds to the end-on shape and size of bicycle handlebar.

Figure 2: Contrast enhanced computed tomogram showing fracture of the pancreatic

parenchyma (arrow) without any disruption of its major duct.

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References

1. London PS. Practical Guide to the Care of the Injured. Harcourt Brace/Churchill

Livingstone 1967

2. The Royal College of Surgeons of England. Biography of Peter Stanford London.

Available from {http://livesonline.rcseng.ac.uk/biogs/E006792b.htm} [Accessed on 23

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February 2018]

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3. Clain A (ed). Abdominal and pelvic injuries. In: Hamilton Bailey’s Demonstration of

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physical signs in clinical surgery (17th edn). Bristol, IOP publishing 1986. pp 331-341.

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4. Lumley JSP, D’Cruz AK, Hoballah JJ, Scott-Conner CEH (ed). Hamilton Bailey’s

Demonstrations of Physical Signs in Clinical Surgery (19th edn). New York, CRC Press.
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2016.

5. Richards JR, McGahan JP. Focused Assessment with Sonography in Trauma (FAST) in
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2017: What Radiologists Can Learn. Radiology 2017; 283: 30-48.

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Figure 1
Figure 2