Prevalence of intra-abdominal injury among patients with seatbelt signs, a systematic review and meta-analysis.

INTRODUCTION: The advancement of seat belts have been essential to reducing morbidity and mortality related to motor vehicle collisions (MVCs). The "seat belt sign" (SBS) is an important physical exam finding that has guided management for decades. This study, comprising a systematic review and random-effects meta-analysis, asses the current literature for the likelihood of the SBS relating to intra-abdominal injury and surgical intervention. METHODS: PubMed and Scopus databases were searched from their beginnings through August 4, 2023 for eligible studies. Outcomes included the prevalence of intra-abdominal injury and need for surgical intervention. Cochrane's Risk of Bias (RoB) tool and the Newcastle-Ottawa Scale (NOS) were applied to assess risk of bias and study quality; Q-statistics and I2 values were used to assess for heterogeneity. RESULTS: The search yielded nine observational studies involving 3050 patients, 1937 (63.5%) of which had a positive SBS. The pooled prevalence of any intra-abdominal injury was 0.42, (95% CI 0.28-0.58, I2 = 96%) The presence of a SBS was significantly associated with increased odds of intra-abdominal injury (OR 3.62, 95% CI 1.12-11.6, P = 0.03; I2 = 89%), and an increased likelihood of surgical intervention (OR 7.34, 95% CI 2.03-26.54, P < 0.001; I2 = 29%). The measurement for any intra-abdominal injury was associated with high heterogeneity, I2 = 89%. CONCLUSION: This meta-analysis suggests that the presence of a SBS was associated with a statistically significant higher likelihood of intra-abdominal injury and need for surgical intervention. The study had high heterogeneity, likely due to the technological advancements over the course of this study, including seat belt design and diagnostic imaging sensitivity. Further studies with more recent data are needed to confirm these results.

Massive haemothorax and haemorrhagic shock due to cervical vascular injury caused by a seat belt.

A woman in her 50s was transported to our hospital after experiencing a road traffic crash that led to a massive haemothorax and haemorrhagic shock due to a cervical vascular injury caused by the seat belt. Contrast-enhanced CT of the chest showed extravascular leakage of the contrast medium from the vicinity of the right subclavicular area and fluid accumulation in the thoracic cavity. The patient was intubated, and a thoracic drainage catheter was placed. She underwent angiography and embolisation of the right costocervical trunk, right thyrocervical trunk and right suprascapular artery using a gelatine sponge and 25% N-butylcyanoacrylate-Lipiodol. She was extubated on the second day after stabilisation of the respiratory and circulatory status. In cases where the bleeding vessel is known and an emergency thoracotomy can serve as a backup, embolisation by interventional radiology should be considered the initial treatment approach.

Seat belt syndrome with caecal perforation and Chance fracture in an adolescent.

Seat belt syndrome describes a combination of injuries a person restrained by a seat belt may have after a high-velocity motor vehicle crash. A seat belt-shaped bruise may be present across the torso. A Chance fracture is a horizontal vertebral fracture, resulting from spinal hyperflexion, and in disruption of the three columns of the vertebral bodies. Its association with intra-abdominal injury is rare in children. A male, in early adolescence, was involved in a high-energy car crash. A total-body CT scan highlighted lacerations of the anterolateral abdominal wall and an acute L4 Chance fracture. Another CT scan performed because of clinical deterioration, showed cecal perforation, caused by a mesenteric tear and non-displaced fracture of the left sacral ala. He underwent a right hemicolectomy with ileocolic anastomosis and protective ileostomy and was immobilised in a body jacket orthosis for 3 months. The ileostomy was closed 3 months later. At 2-year follow-up, he is well.

[Blunt abdominal trauma in children and adolescents: treatment concepts in the acute phase]. / Stumpfes Bauchtrauma bei Kindern und Jugendlichen: Behandlungskonzepte in der Akutphase.

Fatal accidents due to blunt force trauma are the leading cause of death in children and adolescents [1]. Abdominal trauma is the third most common cause of death after traumatic brain injury and thoracic injuries [2]. Abdominal injury is seen in approximately 2-5% of children involved in accidents [3]. Blunt abdominal injuries are common sequelae of traffic accidents (for example as seat belt injury), falls, and sports accidents. Penetrating abdominal injuries are rare in central Europe. Spleen, liver, and kidney lacerations are the most common injuries after blunt abdominal trauma [4]. In most situations, nonoperative management (NOM) has become the gold standard with the surgeon leading the multidisciplinary treatment [5].

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.

Seat belt injuries and external markings at autopsy in cases of lethal vehicle crashes.

A study was undertaken to determine what injuries are associated with the wearing of seat belts and if the presence of cutaneous seat belt markings observed on victims of lethal vehicle crashes increased the likelihood of underlying injury. Autopsy reports from the files at Forensic Science South Australia were reviewed for all fatal motor vehicle crashes from January 2014 to December 2018. A total of 173 cases were included for analysis with 127 occupants wearing seat belts at the time of impact (73.4%) (age range = 18-93; mean = 45 M:F = 81:46). Of these, only 38 had external seat belt markings (29.9%) (age range = 19-83; mean = 49 M:F = 20:18). Logistic regression modelling showed that occupants who were wearing seat belts were more likely to experience closed head injury without skull fractures in addition to mesenteric and gastrointestinal injury. Increasing body mass index increased the incidence of seat belt markings (p < 0.01) and markings were more likely to be found in the presence of bilateral pelvic fractures. Thus, external seat belt markings were observed in only a minority of seatbelt wearers, and more often in individuals with higher BMIs and with bilateral pelvic fractures (possibly associated with greater momentum and impact force).

Excluding Hollow Viscus Injury for Abdominal Seat Belt Sign Using Computed Tomography.

Importance: Abdominal seat belt sign (SBS) has historically entailed admission and observation because of the diagnostic limitations of computed tomography (CT) imaging and high rates of hollow viscus injury (HVI). Recent single-institution, observational studies have questioned the utility of this practice. Objective: To evaluate whether a negative CT scan can safely predict the absence of HVI in the setting of an abdominal SBS. Design, Setting, and Participants: This prospective, observational cohort study was conducted in 9 level I trauma centers between August 2020 and October 2021 and included adult trauma patients with abdominal SBS. Exposures: Inclusion in the study required abdominal CT as part of the initial trauma evaluation and before any surgical intervention, if performed. Results of CT scans were considered positive if they revealed any of the following: abdominal wall soft tissue contusion, free fluid, bowel wall thickening, mesenteric stranding, mesenteric hematoma, bowel dilation, pneumatosis, or pneumoperitoneum. Main Outcomes and Measures: Presence of HVI diagnosed at the time of operative intervention. Results: A total of 754 patients with abdominal SBS had an HVI prevalence of 9.2% (n = 69), with only 1 patient with HVI (0.1%) having a negative CT (ie, none of the 8 a priori CT findings). On bivariate analysis comparing patients with and without HVI, there were significant associations between each of the individual CT scan findings and the presence of HVI. The strongest association was found with the presence of free fluid, with a more than 40-fold increase in the likelihood of HVI (odds ratio [OR], 42.68; 95% CI, 20.48-88.94; P < .001). The presence of free fluid also served as the most effective binary classifier for presence of HVI (area under the receiver operator characteristic curve [AUC], 0.87; 95% CI, 0.83-0.91). There was also an association between a negative CT scan and the absence of HVI (OR, 41.09; 95% CI, 9.01-727.69; P < .001; AUC, 0.68; 95% CI, 0.66-0.70). Conclusions and Relevance: The prevalence of HVI among patients with an abdominal SBS and negative findings on CT is extremely low, if not zero. The practice of admitting and observing all patients with abdominal SBS should be reconsidered when a high-quality CT scan is negative, which may lead to significant resource and cost savings.

A radiographic and physical analysis of factors affecting seat belt position in sitting car seat.

The characteristic subcutaneous hemorrhage along the seat belt in motor vehicle accidents is called the seat belt sign (SBS). The risk of organ injuries is especially high when abdominal SBS is located above the anterior superior iliac spine (ASIS). The purpose of this study analyzed the physical and radiographic factors of healthy volunteers sit on car seat that affect initial position of abdominal seat belt, namely "lap belt", related to the seat belt injury. This study was examined prospectively relation between physical characteristics of one hundred healthy volunteers and lap belt position sitting the car seat. Physical findings were clarified age, sex, height, body mass index (BMI), and waist circumference. Radiographical findings were measured lumber lordosis (LL), sacral slope (SS), and initial lap belt position by marking with lead tape for the center and ASIS of the lap belt installed on the driver's car seat. In the lateral X-ray image, we measured the horizontal distance (X-value) and vertical distance (Z-value) from the ASIS to the central marker. The lap belt angle was determined to measure the angle between the horizontal line and the straight line connecting the upper edges of the markers. Statistical analysis of the relationships between physical characteristics and radiological findings was performed. X-value and Z-value were positively correlated with body weight, BMI, and waist circumference, while the lap belt angle was negatively correlated with body weight, BMI, and waist circumference. The relationship between physical characteristics and the initial position of seat belt was analyzed. Since the lap belt is positioned higher than the ASIS in occupants with a high BMI, it is likely to cause seat belt injury. This analysis can help to develop safer seat belts and to enlighten car occupants.

The Impact of Seatbelt Use on Trauma Outcomes in Adult Motor Vehicle Collision Patients With Rib Fractures: A National ACS-TQP-PUF Database Analysis.

BACKGROUND: Motor vehicle collisions (MVCs) are a leading cause of morbidity and mortality. However, there is limited evidence examining the effects seatbelt use has on MVC-related injuries and outcomes in patients with rib fractures. We aim to assess how seatbelt use affects associated injuries and outcomes in adult MVC patients with ≥2 rib fractures. METHODS: This retrospective study utilized the American College of Surgeons (ACS) Trauma Quality Programs (TQP) Participant Use File (PUF) Database. Drivers/passengers who sustained ≥2 rib fractures following an MVC and had an AIS ≤2 for extra-thoracic body regions were analyzed. Patients were then subdivided by presence of flail chest into two cohorts, which were subdivided according to injury severity score (ISS) and seatbelt use. Logistic and linear regression was used to assess the impact of seatbelt use on outcomes. RESULTS: Among both low and intermediate ISS classifications, restrained patients in the non-flail chest cohort had decreased incidence of pneumothorax, pulmonary contusion, and liver injury (P < 0.001). After adjusting for confounders, restrained patients (versus unrestrained) had decreased odds of pneumothorax (aOR = 0.91, P = <0.001) and acute respiratory distress syndrome (aOR=0.65, P = 0.02), while having increased odds of splenic laceration (aOR = 1.18, P = 0.003) (intermediate ISS group). Compared to unrestrained patients, restrained non-flail chest patients had a significantly decreased hospital length of stay (LOS) and intensive care unit LOS (P < 0.05). CONCLUSIONS: Seatbelt use may be protective against serious injuries in patients with ≥2 rib fractures, resulting in improved outcomes. Education programs should be developed to bolster seatbelt compliance.

Vertebral artery transection: an unusual lethal seat belt injury.

An 89-year-old man involved in a vehicle crash was found at autopsy to have a linear seat belt mark on the right side of his neck associated with extensive injuries of the right paraspinal muscles with fracture-dislocation and separation of cervical vertebrae 5 and 6. There was also fracture of the right facet joint between cervical vertebrae 5 and 6 and laceration of the right vertebral artery. Death was due to a cervical seat belt injury with spinal fracture and laceration of the right vertebral artery. The presence of extensive injuries to the right paraspinal muscles and cervical vertebra 5-6 fact joint beneath the seat belt mark would be in keeping with trauma due to the belt webbing, rather than mere hyperextension/flexion of the cervical spine. This report demonstrates a rare form of seat belt injury, transection of the vertebral artery, and suggests that the finding of seat belt markings on the lateral aspect of the neck should prompt examination for this type of lethal vascular injury at autopsy.

Belt-induced abdominal injuries in recent frontal impact CIREN cases.

OBJECTIVE: The objective is to report sex-related variation in 3-point belt-related abdominal injuries in Crash Injury Research Engineering Network (CIREN) cases. METHODS: A query of CIREN cases was made for those with the highest ranked Collision Deformation Classification (CDC) to the front plane, a principal direction of force (PDOF) ±20° from 0°, and Abbreviated Injury Scale (AIS) 2+ abdomen injuries attributed to the seat belt. Patterns of injury were categorized as above the crest of the ilium, injuries below the crest of the ilium, and injuries above and below the ilium. This was done in the context of autonomous vehicle occupant kinematics testing results. Twelve 5th and 95th percentile 3-point belt-restrained postmortem human subjects were subjects; test speeds and recline angles varied. Abdomen injuries were anticipated; none were observed. RESULTS: Thirty-five occupants with belt-related abdominal injuries were identified. Seventeen case occupants sustained an injury only within the pelvic contents: 5 women and 12 men. Nine of the 17 were at or above the 81st percentile for height, 13 were between the 62nd and 80th percentile for height, and 4 were less than the 50th percentile for height. CONCLUSIONS: The stature component of the body mass index (BMI) appears to be a plausible candidate for an independent variable that is a contributing factor explaining the incidence of pelvic contents injuries when a 3-point belt-restrained occupant is involved in a frontal impact.

Surgical Management of Pectoralis Major Tears of the Sternal Origin Because of Seat Belt Trauma: A Report of 2 Cases.

CASES: Two patients presented with medial chest pain and deformity after high-speed motor vehicle accidents (MVAs) in which they were restrained drivers. Physical examination revealed retraction of the pectoralis major from the sternum on resisted adduction and internal rotation of the arm. MRI confirmed tears of the pectoralis major from the sternal origin. Both patients underwent delayed surgical repair with excellent results. CONCLUSION: Tears of the pectoralis major at the sternal origin are rare injuries that can result in significant deformity and pain. Surgical repair, even in a delayed fashion, can result in excellent patient outcomes.

Lethal mechanisms in cases of inverted suspension from the lap component of seat belts.

A retrospective review of autopsy files at Forensic Science South Australia in Adelaide, Australia, was undertaken over a five-year period from January 2014 to December 2018 for all motor vehicle crashes with rollovers ending with the vehicle inverted and the occupants suspended by the lap component of their seat belts. There were five cases, all male drivers (aged 18-67 years; Mage = 32 years). Acute neck flexion or head wedging was noted in four cases, with facial petechiae in four and facial congestion in one. Deaths were due to positional asphyxia in four cases, with the combined effects of positional asphyxia and head trauma accounting for the remaining case. Although all drivers had evidence of head impact which may have caused incapacitation, in only one case was this considered severe enough to have contributed to death. A blood alcohol level above the legal limit for driving was detected in two cases, but no other drugs were detected. This series demonstrates another subset of cases of seat belt-associated deaths where suspension upside down by the lap component of a seat belt had occurred after vehicle rollovers. Predisposing factors include incapacitation of the victim and delay in rescue. The postulated lethal mechanism involved respiratory compromise from the weight of abdominal viscera on the diaphragm, as well as upper airway compromise due to kinking of the neck and wedging of the head.

Value of Emergent Neurovascular Imaging for "Seat Belt Injury": A Multi-institutional Study.

BACKGROUND AND PURPOSE: Screening for blunt cerebrovascular injury in patients after motor vehicle collision (MVC) solely based on the presence of cervical seat belt sign has been debated in the literature without consensus. Our aim was to assess the value of emergent neurovascular imaging in patients after an MVC who present with a seat belt sign through a large-scale multi-institutional study. MATERIALS AND METHODS: The electronic medical records of patients admitted to the emergency department with CTA/MRAs performed with an indication of seat belt injury of the neck were retrospectively reviewed at 5 participating institutions. Logistic regression analysis was used to determine the association among age, sex, and additional trauma-related findings with blunt cerebrovascular injury. RESULTS: Five hundred thirty-five adult and 32 pediatric patients from June 2003 until March 2020 were identified. CTA findings were positive in 12/567 (2.1%) patients for the presence of blunt cerebrovascular injury of the vertebral (n = 8) or internal carotid artery (n = 4) in the setting of acute trauma with the seat belt sign. Nine of 12 patients had symptoms, signs, or risk factors for cervical blunt cerebrovascular injury other than the seat belt sign. The remaining 3 patients (3/567, 0.5%) had Biffl grades I-II vascular injury with no neurologic sequelae. The presence of at least 1 additional traumatic finding or the development of a new neurologic deficit was significantly associated with the presence of blunt cerebrovascular injury among adult patients, with a risk ratio of 11.7 (P = .001). No children had blunt cerebrovascular injury. CONCLUSIONS: The risk of vascular injury in the presence of the cervical seat belt sign is small, and most patients diagnosed with blunt cerebrovascular injury have other associated findings. Therefore, CTA based solely on this sign has limited value (3/567 = a 0.5% positivity rate). We suggest that in the absence of other clinical findings, the seat belt sign does not independently justify neck CTA in patients after trauma.

Pediatric traumatic abdominal wall hernia as a component of the seatbelt syndrome: a case series and review of the literature.

BACKGROUND: Blunt impact-induced traumatic abdominal wall hernia (TAWH) is an uncommon pediatric surgical problem classically associated with handlebar injury but increasingly seen with seatbelt use in motor vehicle collisions (MVC). Herein we describe the largest case series of pediatric TAWH to date and review the literature to establish the unique syndromic characteristics of MVC-associated TAWH. METHODS: In this single-institution series, we discuss four pediatric patients, all with seatbelt-associated TAWH after high-speed MVC characterized by full-thickness disruption of the lateral abdominal wall. We then performed a review of the literature to identify additional pediatric MVC-associated TAWH and define the characteristics of patients who sustained this unique injury. RESULTS: In addition to the four patients in our case series, five additional pediatric patients presenting with TAWH after restrained MVC were identified in the literature. Of these nine patients, eight (89%) presented with an obvious seatbelt sign (bruising/laceration to the abdominal wall). Six (67%) had associated injuries typical of the seatbelt syndrome, including four spinal flexion injuries (44%) and five bowel injuries requiring repair or resection (56%). Overall, 56% of seatbelt-associated TAWH occurred in children with a BMI percentile > 95%. CONCLUSIONS: In this case series and literature review, we note a high rate of seatbelt syndrome injuries in pediatric patients presenting with TAWH after restrained MVC. Suspicion for TAWH should be high in children presenting with a seatbelt sign and should trigger a low threshold for pursuing additional axial imaging. LEVEL OF EVIDENCE: Level IV; case series.

Analysis of Lap Belt Fit to Human Subjects using CT Images.

In vehicle collisions, the lap belt should engage the anterior superior iliac spine (ASIS). In this study, threedimensional (3D) shapes of bones and soft tissues around the pelvis were acquired using a computed tomography (CT) scan of 10 male and 10 female participants wearing a lap belt. Standing, upright sitting, and reclined postures were scanned using an upright CT and a supine CT scan system. In the upright sitting posture, the thigh height was larger with a higher BMI while the ASIS height did not change significantly with BMI. As a result, the height of the ASIS relative to the thigh (ASIS-thigh height) became smaller as the BMI increased. Because the thigh height of females was smaller than that of males, the ASIS-thigh height was larger for females than for males. As the ASIS-thigh height was larger, the overlap of the lap belt with the ASIS increased. Thus, the lap belt overlapped more with the ASIS for the females than for the males. The abdomen outer shape is characterized by the trouser cord formed valley, the torso/thigh junction, and the anterior convexity formed between them depending on the adipose tissues. The abdomen outer shapes changed from the standing, the reclined posture to the upright sitting posture. In the reclined sitting posture, the lap belt is positioned upward and rearward relative to the ASIS, and the overlap of the lap belt with the ASIS was smaller compared to the upright posture.