Purpose <p>Bicycle handlebar injuries in children can cause severe internal trauma despite a seemingly low-energy mechanism. External signs are unreliable indicators of underlying organ damage, and independent clinical predictors of organ injury have not been systematically evaluated.</p> Methods <p>A retrospective review was performed of patients under 18 years presenting with bicycle handlebar injuries to a tertiary pediatric surgery center (June 2023–December 2025). Firth penalized-likelihood logistic regression was used to identify independent predictors of abdominal organ injury, and diagnostic performance metrics were calculated for key clinical findings.</p> Results <p>Fifty-one patients were included (mean age 10.5 ± 2.7 years; 90.2% male). Seventeen patients (31.4%) sustained organ injuries. Abdominal pain (43.1%) and chest pain (9.8%) were the most common symptoms. On multivariable analysis, abdominal pain was an independent predictor of abdominal organ injury (adjusted OR = 11.00; 95% CI 2.31–52.33; <i>p</i> &lt; 0.001; AUC = 0.78). Chest pain was recorded in 5 patients and accompanied thoracic injury in all of them. The handlebar sign was present in 45.1% but was not a significant predictor overall; however, upper abdominal bruise location was associated with organ injury in 77.8% of cases, whereas no organ injury occurred with lower abdominal bruising. Ten patients (19.6%) required surgery. No mortality was observed.</p> Conclusion <p>Abdominal pain was an independent predictor of abdominal organ injury. Upper abdominal bruise location was associated with a high rate of organ injury and may serve as a localizing sign, and chest pain reflected thoracic injury. These results support a symptom and anatomy-guided triage approach for pediatric handlebar trauma.</p> Level of evidence <p>IV (Retrospective study).</p>