Pediatric chance fracture with seatbelt syndrome: A case report.

Key Clinical Message: Prompt recognition and accurate diagnosis of seatbelt-related injuries such as Chance fractures are crucial for pediatric patients. Clinicians should be aware of the unique characteristics of children, including the presence of growth plates, and use advanced imaging techniques such as magnetic resonance imaging to guide appropriate treatment and minimize complications. Abstract: Seatbelt-related injuries, known as the "seatbelt syndrome," encompass various injuries resulting from automobile accidents, including vertebral fractures, abdominal injuries, and great vessel traumas. Seatbelt signs include bruising or peeling of the anterior chest or abdominal wall, indicating abdominal pressure against the seatbelt. Chance fractures are a type of vertebral fracture characterized by fracture lines through multiple vertebral structures and are often associated with seatbelt injuries in adults. However, the unique features of Chance fractures in pediatric patients, such as the presence of growth plates, require a comprehensive diagnostic approach using advanced imaging techniques, including magnetic resonance imaging (MRI). This case report highlights the complexity of seatbelt-related injuries in children and emphasizes the importance of accurate diagnosis and multidisciplinary management. Understanding these factors can improve clinical knowledge and outcomes in children with seatbelt-related injuries.

Influence of operative timing on perioperative outcomes of patients with the seatbelt sign.

Background: The seatbelt sign (SBS) is a pattern of bruising/contusions on the chest and abdominal wall following motor vehicle collisions. The aim of this analysis is to investigate the influence of time to surgery following identification of the SBS on perioperative outcomes. Methods: A retrospective review of the Trauma Quality Improvement Program database from 2017 to 2019 was performed. Patients included in this retrospective analysis were involved in motor vehicle collisions, experienced blunt abdominal trauma, presented with skin abrasions/contusions in the SBS distribution, were hemodynamically stable, and underwent laparotomy. Demographics, vital signs, injury severity score, Glasgow coma scale, preoperative CT scans (P-CT), and time from presentation to surgery were recorded. Time from presentation to surgery was subdivided by data quartiles as immediate (<1.3 h), early (1.3-4 h), and delayed (>4 h). The influence of operative timing on postoperative mortality, hospital length of stay (LOS), intensive care unit (ICU) LOS, and ventilator days was assessed in multivariate analyses. Results: A total of 1523 patients were included; 280 underwent immediate, 610 early, and 633 delayed surgery. Patients undergoing surgery in the early and delayed groups who received P-CT scans had shorter mean times to operation (4.52 h vs 5.24 h, p < 0.01). In multivariate analysis, patients who underwent delayed surgery stayed in the hospital 2.5 days longer (p < 0.001), spent 2.8 additional days in the ICU (p < 0.001), and spent 3.75 additional days on a ventilator (p < 0.001) than patients who received early surgery. Within the early and delayed surgical groups, P-CT was associated with lower mortality (OR 0.46 95 % CI 0.24-0.88, p < 0.01) in multivariate analysis. Conclusions: Early surgical intervention was associated with improved patient outcomes by reducing hospital and ICU LOS and ventilator days. Conducting P-CT reduced the time to surgery and mortality. Utilization of P-CT for screening hemodynamically stable patients with the SBS upon admission may expedite identification of the potential need for surgical management of abdominal injury.

Aortic Injury From High-Speed Deceleration Against a Lap Belt in a 10-year-Old.

Traumatic aortic injuries in children and adolescents are rare, and even more rare are blunt traumatic injury to the abdominal aorta in this population. Therefore, there are few reports discussing the presentation and repair of such injuries, especially within the pediatric population. We report the successful repair of traumatic abdominal aortic transection in a 10-year-old female after a high speed MVC. She arrived in extremis with a seatbelt sign and was taken emergently for damage control laparotomy with subsequent postoperative CT findings of aortic transection/dissection at L3 with active extravasation. She immediately underwent open thrombectomy of the bilateral iliac arteries, and repair of her aortic injury with a 12 × 7 mm Hemashield interposition graft extending just distal to the IMA and 1 cm proximal to the aortic bifurcation. There are little data regarding long-term outcomes of pediatric patients undergoing different aortic repair techniques, and further research is needed.

Body mass index influence on lap belt position and abdominal injury in frontal motor vehicle crashes.

OBJECTIVE: As obesity rates climb, it is important to study its effects on motor vehicle safety due to differences in restraint interaction and biomechanics. Previous studies have shown that an abdominal seatbelt sign (referred hereafter as seatbelt sign) sustained from motor vehicle crashes (MVCs) is associated with abdominal trauma when located above the anterior superior iliac spine (ASIS). This study investigates whether placement of the lap belt causing a seatbelt sign is associated with abdominal organ injury in occupants with increased body mass index (BMI). We hypothesized that higher BMI would be associated with a higher incidence of superior placement of the lap belt to the ASIS level, and a higher incidence of abdominal organ injury. METHODS: A retrospective data analysis was performed using 230 cases that met inclusion criteria (belted occupant in a frontal collision that sustained at least one abdominal injury) from the Crash Injury Research and Engineering Network (CIREN) database. Computed tomography (CT) scans were rendered to visualize fat stranding to determine the presence of a seatbelt sign. 146 positive seatbelt signs were visualized. ASIS level was measured by adjusting the transverse slice of the CT to the visualized ASIS level, which was used to determine seatbelt sign location as superior, on, or inferior to the ASIS. RESULTS: Obese occupants had a significantly higher incidence of superior belt placement (52%) vs on-ASIS placement (24%) compared to their normal (27% vs 67%) BMI counterparts (p < 0.001). Notable trends included obese occupants with superior placement having less abdominal organ injury incidence than those with on-ASIS belt placement (42% superior placement vs 55% on-ASIS). In non-obese occupants, there was a higher incidence of abdominal organ injury with superior lap belt placement compared to on-ASIS placement counterparts (Normal BMI: 62% vs 41%, Overweight: 57% vs 43%). CONCLUSIONS: In CIREN occupants with abdominal injury, those with obesity are more prone to positioning the lap belt superior to the ASIS, though the impact on abdominal injury incidence remains a key point for continued exploration into how occupant BMI affects crash safety and belt design.

Do signs of abdominal wall injury on computed tomography predict intra-abdominal injury in trauma patients with a seatbelt sign?

BACKGROUND: A seatbelt sign in patients with blunt abdominal injury is associated with both abdominal wall and intra-abdominal injuries. This study aimed to assess the association between signs of abdominal wall injury on computed tomography (CT) and rates of intra-abdominal injury in patients with a blunt abdominal injury and a clinical seatbelt sign. METHODS: This study includes hemodynamically stable trauma patients with blunt abdominal injury and a clinical seatbelt sign who were hospitalized in two regional trauma centers in Israel, during 2014-2019. All data were collected via the medical center's trauma registry in both centers. RESULTS: We identified 123 stable blunt abdominal trauma patients with a seatbelt sign, of which 101 (82.1%) and 22 (17.9%) had a low-grade and high-grade abdominal wall injury according to CT findings, respectively. Laparotomy rates were significantly higher in patients with signs of high-grade abdominal wall injury (p<0.0001). No differences in the timing of laparotomy between low and high-grade injuries were found. CONCLUSIONS: In stable patients with blunt abdominal trauma and a clinical seatbelt sign, the severity of abdominal wall injury, as represented by CT findings, may predict a need for surgical treatment.

The relationship of body mass index, belt placement, and abdominopelvic injuries in motor vehicle crashes: A Crash Injury Research and Engineering Network (CIREN) study.

OBJECTIVE: Obesity has important implications for motor vehicle safety due to altered crash injury responses from increased mass and improper seatbelt placement. Abdominal seatbelt signs (ASBS) above the anterior superior iliac spine (ASIS) in motor vehicle crashes (MVCs) often correlate with abdominopelvic trauma. We investigated the relationship of body mass index (BMI), lap belt placement, and the incidence of abdominopelvic injury using computed tomography (CT) evaluation for subcutaneous ASBS mark and its location relative to the ASIS. METHODS: A retrospective analysis of 235 Crash Injury Research and Engineering Network (CIREN) cases and their associated abdominal injuries was conducted. CT Scans were analyzed to visualize fat stranding. 150 positive ASBS were found and their ASBS mark location was classified as superior, on, or inferior to the ASIS. RESULTS: Obese occupants had a higher incidence rate of belt placement superior to the ASIS, and occupants with normal BMI had a higher incidence of proper belt placement (p < 0.05). Trends of interest developed, notably that non-obese occupants with superior belt placement had increased incidence of internal abdominopelvic organ injury compared to those with proper belt placement (Normal BMI: 53.3% superior vs 39.4% On-ASIS, Overweight: 47.8% superior vs 34.7% On-ASIS). CONCLUSIONS: Utilizing CT scans to confirm ASBS and lap belt placement relative to the ASIS, superior belt placement above the ASIS was associated with elevated BMI and a trend of increasing incidence of internal abdominopelvic organ injury.

Neck Trauma: Cervical Spine, Seatbelt Sign, and Penetrating Palate Injuries.

Pediatric cervical spine, blunt cerebrovascular, and penetrating palate injuries are rare but potentially life-threatening injuries that demand immediate stabilization and treatment. Balancing the risk of a missed injury with radiation exposure and the need for sedation is critical in evaluating children for these injuries. Unfortunately, effective clinical decision tools used in adult trauma cannot be uniformly applied to children. Careful risk stratification based on history, mechanism and examination is imperative to evaluate these injuries judiciously in the pediatric population. This article presents a review of the most up-to-date literature on pediatric neck trauma.

The use of computed tomography imaging for abdominal seatbelt sign: A single-center, prospective evaluation.

INTRODUCTION: Guidelines surrounding abdominal seat belt sign (SBS) were made prior to the use of modern computed tomography (CT) imaging. We sought to prospectively determine whether a negative CT scan is associated with the absence of hollow viscus injury (HVI), and we hypothesized that trauma patients with an abdominal SBS without CT imaging findings would not have a hollow viscus injury (HVI). METHODS: A prospective cohort of patients with SBS was compiled over one year. Subjects were divided into those with and without HVI. Covariate distributions were summarized by group. Bivariate tests and logistic regression were used to investigate associations between covariates and HVI. RESULTS: Of 220 patients with SBS, the incidence of HVI was 7% (n = 15). Radiographic findings were strongly associated with HVI and no patients with a negative CT scan had HVI. Free fluid was seen in 80% (12) of patients with HVI, whereas it was found in only 11% (23) without injury. A composite variable for negative CT scan was found to be associated with the absence of HVI: (Fisher's exact 1-tailed p, doubled = 0.014). CONCLUSION: In this study, the incidence of HVI with SBS is lower than previously reported, and no patients with negative CT imaging required an operation for HVI-suggesting there is a population of patients with SBS who could be discharged from the emergency room. A prospective multicenter study is needed to confirm these findings.

Motor vehicle collision with seatbelt sign and traumatic abdominal wall hernia should raise suspicion for hollow viscus injury.

Diagnosing hollow viscus injury following motor vehicle collision (MVC) requires a high index of suspicion. Here we present two cases of high velocity MVC, with 3-point restrained occupants, who presented with a seatbelt sign and associated acute traumatic flank herniation. Both patients underwent a computer tomography (CT) scan which did not identify any hollow viscus injuries. Significant injuries were ultimately identified in the operating room (OR). The presence of a seatbelt sign and underlying acute traumatic hernia should prompt a heightened level of suspicion for intra-abdominal injury, particularly hollow viscus. A heightened level of suspision and a lower threshold for operative exploration is suggested to avoid the morbidity and mortality associated with a delayed diagnosis of hollow viscus injury.

Computed tomographic imaging in the pediatric patient with a seatbelt sign: still not good enough.

PURPOSE: Considering the improvements in CT over the past decade, this study aimed to determine whether CT can diagnose HVI in pediatric trauma patients with seatbelt signs (SBS). METHODS: We retrospectively identified pediatric patients with SBS who had abdominopelvic CT performed on initial evaluation over 5 1/2years. Abnormal CT was defined by identification of any intra-abdominal abnormality possibly related to trauma. RESULTS: One hundred twenty patients met inclusion criteria. CT was abnormal in 38/120 (32%) patients: 34 scans had evidence of HVI and 6 showed solid organ injury (SOI). Of the 34 with suspicion for HVI, 15 (44%) had small amounts of isolated pelvic free fluid as the only abnormal CT finding; none required intervention. Ultimately, 16/120 (13%) patients suffered HVI and underwent celiotomy. Three patients initially had a normal CT but required celiotomy for clinical deterioration within 20h of presentation. False negative CT rate was 3.6%. The sensitivity, specificity and accuracy of CT to diagnose significant HVI in the presence of SBS were 81%, 80%, and 80%, respectively. CONCLUSIONS: Despite improvements in CT, pediatric patients with SBS may have HVI not evident on initial CT confirming the need to observation for delayed manifestation of HVI. LEVEL OF EVIDENCE: Level II Study of a Diagnostic Test.