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showed that children in 3-point belts have no difference in the risk to detect injuries associated with seatbelt signs has shown
of injury to the abdomen or chest compared with children using inadequate sensitivity.46
lap belts alone, although they were 9 times less likely to have lum- To reduce the need for obtaining CT scans, a recent study
bar spine fractures.23 Some propose that the thinner abdominal sought to derive a clinical prediction rule to identify those children
wall of children and their smaller anteroposterior diameter place who are at lowest risk for IAI following blunt trauma requiring
them at greater risk of abdominal injury, which may not be acute intervention.47 This study generated a prediction rule
prevented by restraint of the upper torso provided by consisting of 7 patient history and physical examination findings
shoulder belts.25 which had a negative predictive value of 99.9%. A limitation of
this study, in terms of prediction of seatbelt injury, was that only
one third of the population was involved in an MVC. If further
validated, this prediction rule may reduce the need for children
ABDOMINAL INJURIES with low-risk criteria to have CT scans performed or be admitted.
Current data suggest that the seatbelt sign is associated with a Apart from monitoring for the presence of ongoing blood
higher rate of GI injuries while the rate of solid organ injuries loss, laboratory testing in the setting of abdominal trauma has
remains unaffected.18,26 Intestinal injuries may include hemato- not been shown to be a consistent, reliable indicator of solid or
mas, perforations, contusions, transections, seromuscular tears, hollow organ injury.45
and devascularization secondary to mesenteric avulsions.27 The Posttraumatic intestinal obstruction is a less commonly seen
most common site of intestinal injury is the jejunum, followed complication of MVC-related abdominal trauma and can occur
by the duodenum, ilium, and cecum.28 Intestinal injuries have weeks to months after injury.48 Children will often present with
been reported in restrained children in MVCs that occur at speeds signs and symptoms consistent with small bowel obstruction. This
as slow as 13 mph (20 km/h).29 Solid organ injuries typically injury is thought to occur from a combination of a crush injury to
involve the spleen, liver, kidneys, and pancreas.18,30 The stomach, the bowel wall and ischemia from mesenteric injury. The disrup-
bladder, vena cava, and diaphragm are rarely injured.30–33 tion in mesenteric blood flow causes bowel wall inflammation
Children with seatbelt signs are at a considerably higher risk and fibrosis, which can lead from isolated bowel scarring to
of IAI compared with those without seatbelt signs, predominately full thickness bowel necrosis.48 These findings are not typi-
because of GI injuries.17,18,26 Data from the largest population- cally seen on the initial abdominal CT scan following trauma;
based study found the positive and negative predictive values of therefore, clinicians must maintain a high suspicion for this
abdominal wall bruising for significant IAI to be 11.5% and condition in children who present with vomiting or signs of in-
99.9%, respectively, resulting in a number needed to treat of 8.7.17 testinal obstruction weeks after blunt abdominal trauma (see
Children with seatbelt sign are also 9.5 times more likely to Case Study above).48,49
undergo therapeutic laparotomy compared with those without
seatbelt signs.18 Interestingly, 2 large prospective trials found rates
of solid organ injury to be similar between those with and without SPINAL INJURIES
seatbelt signs.18,26 Motor vehicle collisions cause approximately 40% of all spi-
Small bowel injury can be a diagnostic dilemma for the nal cord injuries in children.50 Fortunately, spinal injuries are quite
evaluating physician because serious injuries to the bowel and uncommon in restrained children involved in MVCs, occurring in
mesentery may be present without early physical findings or approximately 0.12% of cases.17 The presence of known IAI in-
symptoms.34 The largest prospective study on this topic to date creases the risk of vertebral fractures significantly, with reported
found that 5.7% of children with a seatbelt sign but without ab- incidence of co-injury of 15%.17
dominal pain or tenderness on initial examination still had an The most common type of spinal injury associated with
IAI, and 2% of this group required acute surgical interven- seatbelt use is a Chance fracture. First described by Chance in
tion.18 A multicenter retrospective review of children with doc- 1948,51 this flexion-distraction injury has become synonymous
umented intestinal injury found that patients who had operative with lap belt use, constituting approximately 42% to 100% of ver-
intervention performed more than 24 hours after initial injury tebral fractures seen in restrained MVCs.52 It describes a compres-
did not have a significant increase in early or late complica- sion fracture to the anterior vertebral body as well as a transverse
tions, length of hospitalization, morbidity, or mortality com- fracture that extends through the posterior elements of the verte-
pared with those diagnosed and treated less than 6 hours after bra. Disruption of the posterior ligamentous complex of the spine
initial injury35 This study suggests that children with question- may or may not be involved as well.53 Mechanistically, it occurs
able or minimal abdominal findings can safely be observed when the spine hyperflexes around the fixed anterior axis of the
with serial examinations. vertebral column.
Computed tomography scans are frequently used to identify Diagnosis of lumbar spinal injuries can be performed using
IAI in children presenting with seatbelt signs. In previous decades, lateral radiographs and/or CT scanning.45 Treatment is based on
CT imaging has been shown to be insensitive in detecting hollow the severity of bony injury and/or ligamentous involvement. The
viscous injury,28,36,37 although the newer-generation helical CT presence of neurological deficit or spinal canal compromise war-
scanners can find 76% to 98% of GI injuries.38–41 The presence rants immediate surgical intervention.53 Significantly displaced
of peumoperitoneum, bowel wall thickening, streaking of mesen- fractures or ligamentous injuries generally require surgical fusion,
teric fat, or otherwise unexplained peritoneal fluid in the absence while isolated bony injuries are treated with a hyperextension
of solid organ injury is useful indicator of bowel injury.28,36,42 brace or cast.54 Overall, children with Chance fractures tend to
With the exception of slightly better specificity, the use of oral have favorable outcomes with very few persistent neurological
contrast with abdominal CT does not appear to be more adept at deficits.3,30,53–59 In these case series, 13 (18%) of 72 patients with
detecting IAI compared with IV contrast.28,40 The use of diagnos- Chance fractures had resulting paraplegia.
tic peritoneal lavage has been described as a valuable technique Although not part of the classic seatbelt syndrome, serious
for identifying IAI, although its use has decreased in recent years C-spine injury, generally associated with significant hyperflexion
with the advent of improved imaging and focus on nonoperative forces, can occur in restrained children involved in MVCs.60 The
care.43–45 Limited data suggest the use of abdominal ultrasound incidence of cervical neck injury in pediatric trauma is relatively
122 www.pec-online.com © 2017 Wolters Kluwer Health, Inc. All rights reserved.
© 2017 Wolters Kluwer Health, Inc. All rights reserved. www.pec-online.com 123
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