You are on page 1of 6

CME REVIEW ARTICLE

Seatbelt Syndrome in Children


Matthew Arthur Szadkowski, MD and Robert G. Bolte, MD

Federal Motor Vehicle Safety Standards in 1968.1 However, despite


Abstract: The seatbelt syndrome describes an injury pattern infrequently overall effectiveness in reducing serious injury, it was noted that the
seen in restrained passengers in motor vehicle collisions. It occurs when use of restraints was at times associated with a new pattern of ab-
sudden deceleration forces coupled with compression of the lap belt around dominal and spinal injury.
the abdomen causes abdominal wall bruising, intra-abdominal injuries, and In 1962, Garrett became the first clinician to describe the
spinal fractures. Infrequent and improper use of appropriate belt restraints now-classic triad of abdominal wall bruising, internal abdominal
in children has led to high risks for injury in this population. injury, and spinal fractures as “the seatbelt syndrome.”2 This in-
We describe a case of the seatbelt syndrome with the uncommon finding of jury occurs when rapid deceleration forces sustained during an
an associated posttraumatic intestinal obstruction. We also review the MVC cause hyperflexion of the torso and consequent compres-
literature on the prevalence, risk factors, and types of injuries sustained sion of the abdomen around the lap belt. The belt acts as a fulcrum
by children with the seatbelt syndrome as well as discuss the indications for for the abdominal wall, causing impingement of the bowel against
laboratory studies, abdominal imaging, surgical intervention, and further the vertebral column and distraction of the supporting structures
observation. Current recommendations for child seatbelt use and its of the vertebral bodies.3,4 Because rear seatbelts became more
effectiveness in preventing injury are also reviewed. commonplace in automobiles in the 1970s, their use by children
Key Words: abdominal trauma, lap belt injury, seatbelt injury, increased dramatically. The first studies describing the types of inju-
seatbelt syndrome, motor vehicle collision ries sustained by restrained children appeared shortly thereafter.5–7
Children who used seatbelts were found to have less massive
(Pediatr Emer Care 2017;33: 120–127)
head, thoracic, and extremity trauma compared with those that did
not use restraints, although IAI became more commonplace.5–7
The hallmark sign of the seatbelt syndrome is abdominal wall ec-
TARGET AUDIENCE chymosis in the distribution of a lap belt.1 However, it is not un-
This article is intended for health care providers who care for common for children with serious IAI to have absent or
children and adolescents in an acute-based care setting. Specialists equivocal physical examination findings.8 Missed diagnosis of in-
including emergency medicine physicians, pediatric emergency testinal perforation or spinal injuries can have significant conse-
medicine physicians, and pediatric trauma surgeons will find this quences. Understanding this injury pattern and its associated
information particularly useful. risk factors will facilitate identifying those patients at greatest risk
and guide appropriate management. Significant injuries to the
head, face, cervical spine, and chest occur in children involved
LEARNING OBJECTIVES in MVCs.9,10 Because these injuries do not constitute the classic
After completion of this article, the reader should be able to: seatbelt syndrome, they will not be reviewed in detail here, al-
though a recent case series and literature review discusses
1. Identify the signs and symptoms concerning for intra- this further.11
abdominal injury (IAI) in pediatric patients involved in motor Improper belt placement secondary to child positioning or
vehicle collisions (MVCs). neglecting to use a recommended booster seat contributes greatly
2. Describe the common intra-abdominal and spinal injuries to preventable seatbelt injuries.12 Because seatbelts were designed
sustained by pediatric patients involved in restrained MVCs. based on an adult's pelvic anatomy, the underdeveloped iliac crests
3. Describe the indications for urgent surgical intervention versus of a child's pelvis do not properly support the anchoring points for
observation in pediatric patients with a seatbelt sign. a lap belt.13 Abdominal injury during an MVC, therefore, typi-
cally occurs when the seatbelt is either improperly resting high

S ince the advent of commercial automobiles in the early 20th


century, safety-minded individuals have continuously attempted
to make transportation by car less dangerous. In the early 1960s, the
across the abdominal wall or from slippage of the belt above the
anterior superior iliac crests and onto the abdominal wall.14
Increasing awareness of lap belt injuries led to the progres-
seatbelt made its first appearance in automobiles in the United sive regulations in the 1970s that required all new cars sold in
States. Its effectiveness in preventing the ejection and serious bodily the United States to have 3-point belts in outboard seating posi-
harm of passengers involved in MVCs quickly became evident. Its tions.15 Since September 1, 2007, these requirements were ex-
incorporation as a standard design feature was made mandatory by tended to include the center rear seat.16
We report a clinical presentation of seatbelt syndrome and
discuss its prevalence, diagnosis, and management by reviewing
Clinical Professor (Bolte) and Clinical Assistant Professor (Szadkowski), Divi- the current literature.
sion of Pediatric Emergency Medicine, Department of Pediatrics, University of
Utah School of Medicine, Salt Lake City, UT.
The authors and staff in a position to control the content of this CME activity
and their spouses/life partners (if any) have disclosed that they have no
CASE
financial relationships with, or financial interest in, any commercial A 14-year-old previously healthy girl was involved in a high-
organizations pertaining to this educational activity. speed head-on MVC. She was restrained with a lap belt in the rear
Reprints: Matthew Szadkowski, MD, 295 Chipeta Way, PO Box 581289, Salt
Lake City, UT 84158 (e‐mail: matthew.szadkowski@hsc.utah.edu).
center seat. She sustained positive loss of consciousness. At the
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. scene, she had findings of diffuse abdominal pain and blood
ISSN: 0749-5161 oozing from her left ear canal. Upon arrival in the emergency

120 www.pec-online.com Pediatric Emergency Care • Volume 33, Number 2, February 2017

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.


Pediatric Emergency Care • Volume 33, Number 2, February 2017 Seatbelt Syndrome in Children

department (ED), she had mid lumbar tenderness without step-


offs, a seatbelt sight across her abdomen with diffuse abdominal
tenderness to palpation, and an intact neurological examination.
Comprehensive computerized tomography (CT) scans were per-
formed and showed a left mandibular fracture, soft tissue injury
to the left external auditory canal, hemoperitoneum, and a grade
2 liver laceration. Spinal injuries noted on CT included a fracture
through the bilateral pedicles, facets, lamina, and transverse pro-
cesses of L3 (Figs. 1, 2) as well as a spinous process fracture of
L2. Hemoglobin level was 12 g/dL. Kidney, pancreatic, and liver
function studies were notable for lipase (60 mmol/L) and amylase
(116 mmol/L) levels. She did not require any surgical intervention
and was admitted for medical stabilization. She was eventually
discharged home 5 days later with a lumbar brace.
Eleven days after her initial injury, she developed progressive
diffuse abdominal pain, new fevers up to 38.8°C, and several ep-
isodes of vomiting, one of which was bilious. She presented to the
ED, and an abdominal x-ray showed findings concerning for ileus
versus partial small bowel obstruction. Laboratory studies includ-
ing a complete blood cell count, complete metabolic profile, and
lipase were reassuring. She was admitted to the surgical service, FIGURE 2. Axial CT of the lumbar spine showing a fracture through
and an abdominal CTwith intravenous (IV) contrast showed inter- the pedicles of L3.
val reduction in abdominal ascites and no signs of bowel obstruc-
tion. Her diet was advanced, she became afebrile, and she had no
further vomiting, so she was discharged home 2 days later.
One week later, she presented again to the ED with continued
nausea, decreased appetite, 2 episodes of nonbilious vomiting,
and abdominal distention. An abdominal x-ray showed multiple
dilated loops of small bowel, suggesting small bowel obstruction.
An upper gastrointestinal (GI) tract with small bowel follow-
through confirmed a high-grade partial small bowel obstruction
distal to the ligament of Treitz. She was taken for an exploratory
laparotomy, which revealed multiple dense mesenteric adhesions
thought to be consistent with prior direct bowel injury in this area.
An 18-in segment of jejunum was not salvageable and was
resected. The patient recovered uneventfully and was discharged
home several days later.

PREVALENCE OF SEATBELT SYNDROME


The largest population-based study to date used data from the
Partners for Child Passenger Safety project, an ongoing crash sur-
veillance system, to describe the prevalence of injuries sustained
by children using seatbelts in MVCs. In the study, the prevalence
of seatbelt sign in restrained children in MVCs was 1.3%, while
the prevalence of serious IAI was 0.21%.17 The only prospective
multicenter study of restrained children in MVCs noted the preva-
lence of seatbelt signs and IAIs to be 16% and 6.7%, respectively.18
The significantly increased prevalence rates in this study are likely
due to selection bias because it only included patients presenting
to an ED after an MVC.
Children presenting with a seatbelt sign have approximately
9% to 21% risk of solid organ injury and 11% to 25% risk of GI
injury.18,19 Given the well-documented lack of appropriate booster
seat use as well as misuse of 3-point belts, the group at highest
risk for seatbelt syndrome appears to be children between the
ages of 4 to 9.9,12,20–22 Notably, very few infants who are prop-
erly restrained in child safety seats are found to have serious
abdominal injuries.9,23
Studies in both adults and children have shown a marked de-
crease in the risk for abdominal injuries when using 3-point belts
in place of 2-point belts.13,24 Children involved with MVCs using
FIGURE 1. Sagittal CT of the lumbar spine showing a nondisplaced booster seats with seatbelts have up to a 45% decrease in bodily
fracture through the posterior margin of the L3 vertebral body injury compared with similarly aged children using seatbelts
and pedicle. alone.24 A smaller case series of 98 children involved in MVCs

© 2017 Wolters Kluwer Health, Inc. All rights reserved. www.pec-online.com 121

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.


Szadkowski and Bolte Pediatric Emergency Care • Volume 33, Number 2, February 2017

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.

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.


Pediatric Emergency Care • Volume 33, Number 2, February 2017 Seatbelt Syndrome in Children

uncommon, with incidence around 1.5%.61,62 Awareness and dil- CONCLUSIONS


igence on the part of the clinician are required to detect these Appropriate use of child safety seats and booster seats with
critical injuries. 3-point restraints significantly reduce, but does not eliminate,
the risk for intra-abdominal and spinal injuries in pediatric
patients. Early diagnosis of small bowel injury may be difficult
and requires a high index of suspicion to facilitate appropriate di-
DISCUSSION
agnostic testing and consultation. Children presenting with
Although this article focuses on seatbelt-related injury, seatbelt signs are at higher risk of GI injury and need for therapeu-
failure to use or the misuse of restraints poses a much greater risk tic laparotomy than those without seatbelt signs. Current data sug-
for children. Car seat use reduces the risk for death to infants gest that children with a seatbelt sign and abdominal tenderness
(<1 year) by 71%,63 while booster seat use reduces the risk for se- on initial examination are at higher risk for IAI and, therefore,
rious injury by 45% for children aged 4 to 8 years when compared warrant additional evaluation via laboratory studies, CT imaging,
with seatbelt use alone.24 For older children and adolescents, or observation. Those with a seatbelt sign but no abdominal ten-
3-point seatbelt use reduces the risk for death and serious injury derness are at low risk for serious IAI, although further studies
by approximately half.22 Unfortunately, booster seat use among are needed before definitive guidelines regarding the time of ob-
4- to 7-year-olds was only 46% in 2013.64 Even when car seats servation in these cases can be made.
and booster seats are implemented, improper installation rates
are very high, with an estimated combined rate of misuse
at 46%.65 REFERENCES
The American Academy of Pediatrics has published state-
1. Transportation National Highway Traffic Safety Administration. Title 49 of
specific policy recommendations regarding the use of seat re-
the United States Code, Chapter 301, Motor Vehicle Safety Standard No.
straints. They recommend rear-facing car seats for infants under
208 — Occupant Crash Protection Passenger Cars. Available at: http://www.
2 years of age, forward-facing car seats until 4 years of age or nhtsa.gov/cars/rules/import/FMVSS/#SN208. Accessed December 21, 2015.
the maximum weight of the car seat, booster seats until the child
is 4 ft 9 in and 8 to 12 years of age, and 3-point seatbelts for all 2. Garrett JW, Braunstein PW. The seat belt syndrome. J Trauma. 1962;2:
other children.66 The significantly increased risk for improperly 220–238.
restrained children to suffer serious IAI compared with properly 3. Stylianos S, Harris BH. Seatbelt use and patterns of central nervous system
restrained children emphasizes the need for every child to be injury in children. Pediatr Emerg Care. 1990;6:4–5.
restrained as recommended by the American Academy of 4. Poplin GS, Mcmurry TL, Forman JL, et al. Nature and etiology of
Pediatrics guidelines. hollow-organ abdominal injuries in frontal crashes. Accid Anal Prev. 2015;
Children with seatbelt signs are at a considerably higher risk 78:51–57.
of IAI compared with those without seatbelt signs. The low num- 5. Agran P, Dunkle D, Winn D. Injuries to a sample of seatbelted children
ber needed to treat of 8.7 calculated in the study by Lutz et al17 evaluated and treated in a hospital emergency room. J Trauma. 1987;27:
confirms the importance of evaluating for IAI in every restrained 58–64.
child with abdominal wall bruising after MVC. Children without 6. Gunby P. Lap seat belts useful but can injure children. JAMA. 1981;245:
abdominal bruising have been found to have very low likelihood 2281–2282.
of IAI (0.1%).17 Thus, while the presence of abdominal ecchymo-
7. Braun P, Dion Y. Intestinal stenosis following seat belt injury. J Pediat Surg.
sis signifies a high risk of IAI, the absence of ecchymosis does not
1973;8:549–550.
entirely exclude injury. Owing to the high risk of co-injury to the
spine, children with abdominal bruising should also be main- 8. Tso EL, Beaver BL, Haller JA Jr. Abdominal injuries in restrained
tained in full spine precautions until spinal injury can be ruled pediatric passengers. J Pediatr Surg. 1993;28:
out. If hollow viscous injury is suspected or diagnosed, urgent ex- 915–919.
ploratory laparotomy is indicated. 9. Winston FK, Durbin DR, Kallan MJ, et al. The danger of premature
In children with a seatbelt sign and abdominal pain or tender- graduation to seat belts for young children. Pediatrics. 2000;105:
ness on examination, an abdominal CT scan should be strongly 1179–1183.
considered given the high risk of IAI. The disadvantages of the 10. Rao RD, Berry CA, Yoganandan N, et al. Occupant and crash
use of oral contrast when obtaining abdominal CTs coupled with characteristics in thoracic and lumbar spine injuries resulting
the trivial improvement in specificity for detecting IAI do not jus- from motor vehicle collisions. Spine J. 2014;14:
tify its use over IV contrast.40 Abdominal ultrasound and perito- 2355–2365.
neal lavage are also not recommended because of their lack 11. Eberhardt CS, Zand T, Ceroni D, et al. The seatbelt syndrome—do we have
of specificity. a chance?: a report of 3 cases with review of literature. Pediatr Emerg Care.
The dearth of large prospective trials makes it difficult to cre- 2016;32:318–322.
ate concrete management guidelines for children presenting with a 12. Durbin DR, Chen I, Smith R, et al. Effects of seating position and
seatbelt sign but no initial abdominal tenderness or pain. The find- appropriate restraint use on the risk of injury to children in motor vehicle
ing that approximately 2% of these cases require surgical interven- crashes. Pediatrics. 2005;115:e305–e309.
tion suggests that these patients should be admitted for observation
13. Anderson PA, Rivara FP, Maier RV, et al. The epidemiology of
and have serial abdominal examinations to detect evolving physi- seatbelt-associated injuries. J Trauma. 1991;31:60–67.
cal signs suggestive of IAI.18
Given the extremely high sensitivity of newer CT scanners, 14. Sato TB. Effects of seat belts and injuries resulting from improper use.
discharge home with specific follow-up instructions may be con- J Trauma. 1987;27:754–758.
sidered for children with a seatbelt sign who have a normal ab- 15. State of Michigan. Seat Belt History in the U.S. and Michigan. Available at:
dominal CT scan and no abdominal symptoms.41 If the CT scan https://www.michigan.gov/documents/msp/Seat_belt_timeline_03_web_
is negative for injury but abdominal pain persists, continued ob- 386202_7.pdf. Accessed December 21, 2015.
servation with serial examinations is indicated, although no clear 16. Transportation National Highway Traffic Safety Administration. Federal
guidelines on length of observation currently exist. Motor Vehicle Safety Standards; Occupant Crash Protection. Final Rule.

© 2017 Wolters Kluwer Health, Inc. All rights reserved. www.pec-online.com 123

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.


Szadkowski and Bolte Pediatric Emergency Care • Volume 33, Number 2, February 2017

Available at: http://www.nhtsa.gov/cars/rules/rulings/Anton_FRNov16. 37. Sherck JP, Oakes DD. Intestinal injuries missed by computed tomography.
html. Accessed December 21, 2015. J Trauma. 1990;30:1–5.
17. Lutz N, Nance ML, Kallan MJ, et al. Incidence and clinical significance of 38. Holmes JF, Offerman SR, Chang CH, et al. Performance of
abdominal wall bruising in restrained children involved in motor vehicle helical computed tomography without oral contrast for the detection
crashes. J Pediatr Surg. 2004;39:972–975. of gastrointestinal injuries. Ann Emerg Med. 2004;43:120–128.
18. Borgialli DA, Ellison AM, Ehrlich P, et al. Association between the seat belt 39. Killeen KL, Shanmuganathan K, Poletti PA, et al. Helical computed
sign and intra-abdominal injuries in children with blunt torso trauma in tomography of bowel and mesenteric injuries. J Trauma. 2001;51:
motor vehicle collisions. Acad Emerg Med. 2014;21:1240–1248. 26–36.
19. Paris C, Brindamour M, Ouimet A, et al. Predictive indicators for bowel 40. Ellison AM, Quayle KS, Bonsu B, et al. Use of oral contrast for abdominal
injury in pediatric patients who present with a positive seat belt sign after computed tomography in children with blunt torso trauma. Ann Emerg
motor vehicle collision. J Pediatr Surg. 2010;45:921–924. Med. 2015;66:107–114.e4.
20. Durbin DR, Elliott MR, Winston FK. Belt-positioning booster seats and 41. Kerrey BT, Rogers AJ, Lee LK, et al. A multicenter study of the risk of
reduction in risk of injury among children in vehicle crashes. JAMA. 2003; intra-abdominal injury in children after normal abdominal computed
289:2835–2840. tomography scan results in the emergency department. Ann Emerg Med.
21. Eby DW, Kostyniuk LP. A statewide analysis of child safety seat use and 2013;62:319–326.
misuse in Michigan. Accid Anal Prev. 1999;31:555–566.
42. Cox TD, Kuhn JP. CT scan of bowel trauma in the pediatric patient. Radiol
22. National Highway Traffic Safety Administration. Traffic Safety Facts: Clin North Am. 1996;34:807–818.
2013 Data. Children. Available at: http://www-nrd.nhtsa.dot.gov/Pubs/
43. Cha JY, Kashuk JL, Sarin EL, et al. Diagnostic peritoneal lavage remains a
812154.pdf. Accessed January 2, 2016.
valuable adjunct to modern imaging techniques. J Trauma. 2009;67:
23. Gotschall CS, Better AI, Bulas D, et al. Injuries to Children Restrained in 2- 330–334.
and 3- Point Belts. Annual Proceedings/Association for the Advancement of
44. Jansen JO, Logie JR. Diagnostic peritoneal lavage - an obituary. Br J Surg.
Automotive Medicine. 1998;42:29–43.
2005;92:517–518.
24. Arbogast KB, Jermakian JS, Kallan MJ, et al. Effectiveness of belt
positioning booster seats: an updated assessment. Pediatrics. 2009;124: 45. Rothrock SG, Green SM, Morgan R. Abdominal trauma in infants and
1281–1286. children: prompt identification and early management of serious and
life-threatening injuries. Part I: injury patterns and initial assessment.
25. Newman KD, Bowman LM, Eichelberger MR, et al. The lap belt complex: Pediatr Emerg Care. 2000;16:106–115.
intestinal and lumbar spine injury in children. J Trauma. 1990;30:
1133–1138. 46. Stassen NA, Lukan JK, Carrillo EH, et al. Abdominal seat belt marks in the
era of focused abdominal sonography for trauma. Arch Surg. 2002;137:
26. Sokolove PE, Kuppermann N, Holmes JF. Association between the “seat
718–722.
belt sign” and intra-abdominal injury in children with blunt torso trauma.
Acad Emerg Med. 2005;12:808–813. 47. Holmes JF, Lillis K, Monroe D, et al. Identifying children at very low risk of
clinically important blunt abdominal injuries. Ann Emerg Med. 2013;62:
27. Slavin RE, Borzotta AP. The seromuscular tear and other intestinal lesions
107.e2–116.e2.
in the seatbelt syndrome: a clinical and pathologic study of 29 cases. Am J
Forensic Med Pathol. 2002;23:214–222. 48. Lynch JM, Albanese CT, Meza MP, et al. Intestinal stricture following seat
belt injury in children. J Pediatr Surg. 1996;31:1354–1357.
28. Sivit CJ, Taylor GA, Newman KD, et al. Safety-belt injuries in children
with lap-belt ecchymosis: CT findings in 61 patients. AJR Am J 49. Kaban G, Somani RA, Carter J. Delayed presentation of small bowel injury
Roentgenol. 1991;157:111–114. after blunt abdominal trauma: case report. J Trauma. 2004;56:1144–1145.
29. Arbogast KB, Kent RW, Menon RA, et al. Mechanisms of abdominal 50. National Spinal Cord Injury Statistical Center. The 2012 Annual Statistical
organ injury in seat belt-restrained children. J Trauma. 2007;62: Report for the Model Spinal Cord Injury Care Systems. Available at:
1473–1480. https://www.nscisc.uab.edu/PublicDocuments/reports/pdf/2012%
30. Santschi M, Lemoine C, Cyr C. The spectrum of seat belt syndrome 20NSCISC%20Annual%20Statistical%20Report%20Complete%
among Canadian children: results of a two-year population surveillance 20Public%20Version.pdf. Accessed January 5, 2016.
study. Paediatr Child Health. 2008;13:279–283. 51. Chance GQ. Note on a type of flexion fracture of the spine. BrJ Radiol.
31. Decou JM, Abrams RS, Gauderer MW. Seat-belt transection of the 1948;21:452.
pararenal vena cava in a 5-year-old child: survival with caval ligation. 52. Achildi O, Betz RR, Grewal H. Lapbelt injuries and the seatbelt syndrome
J Pediatr Surg. 1999;34:1074–1076. in pediatric spinal cord injury. J Spinal Cord Med. 2007;30(suppl 1):
32. Kimmins MH, Poenaru D, Kamal I. Traumatic gastric transection: a case S21–S24.
report. J Pediatr Surg. 1996;31:757–758. 53. Voss L, Cole PA, D'Amato C. Pediatric chance fractures from lapbelts:
33. Knapp JF, Dowd MD, O'conner T, et al. Case 01-1993: a six-year-old girl unique case report of three in one accident. J Orthop Trauma. 1996;10:
with respiratory distress following involvement in a motor vehicle crash. 421–428.
Pediatr Emerg Care. 1993;9:116–120. 54. Glassman S, Johnson J, Holt R. Seatbelt injuries in children. J Trauma.
34. Saladino RA, Lund DP. Abdominal trauma. In: Fleisher GR, Ludwig S, 1992;33:882–886.
eds. Textbook of Pediatric Emergency Medicine. 6th ed. Philadelphia,
55. Gumley G, Taylor TK, Ryan MD. Distraction fractures of the lumbar spine.
PA: Lippincott Williams & Wilkins; 2010:
J Bone Joint Surg Br. 1982;64:520–525.
1271–1277.
56. Reid AB, Letts RM, Black GB. Pediatric Chance fractures: association
35. Letton RW, Worrell V; APSA Committee on Trauma Blunt Intestinal Injury
with intra-abdominal injuries and seatbelt use. J Trauma. 1990;30:
Study Group. Delay in diagnosis and treatment of blunt intestinal injury
384–391.
does not adversely affect prognosis in the pediatric trauma patient. J Pediatr
Surg. 2010;45:161–165. 57. Santschi M, Echave V, Laflamme S, et al. Seat-belt injuries in
children involved in motor vehicle crashes. Can J Surg. 2005;48:373–376.
36. Bulas DI, Taylor GA, Eichelberger MR. The value of CT in detecting bowel
perforation in children after blunt abdominal trauma. AJR Am J Roentgenol. 58. Shepherd M, Hamill J, Segedin E. Paediatric lap-belt injury: a 7 year
1989;153:561–564. experience. Emerg Med Australas. 2006;18:57–63.

124 www.pec-online.com © 2017 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.


Pediatric Emergency Care • Volume 33, Number 2, February 2017 Seatbelt Syndrome in Children

59. Louman-gardiner K, Mulpuri K, Perdios A, et al. Pediatric lumbar Chance 63. Durbin DR. Child passenger safety. Pediatrics. 2011;127:788–793.
fractures in British Columbia: chart review and analysis of the use of
64. National Highway Traffic Safety Administration. The 2013 national survey
shoulder restraints in MVAs. Accid Anal Prev. 2008;40:
of the use of booster seats. Available at: http://www-nrd.nhtsa.dot.gov/
1424–1429.
Pubs/812037.pdf. Accessed January 3, 2016.
60. Ernat JJ, Knox JB, Wimberly RL, et al. The effects of restraint type on
65. National Highway Traffic Safety Administration. Traffic Safety
pattern of spine injury in children. J Pediatr Orthop. 2016;36:594–601.
Facts: National Child Restraint Use Special Study. Available at:
61. Platzer P, Jaindl M, Thalhammer G, et al. Cervical spine injuries in pediatric http://www-nrd.nhtsa.dot.gov/Pubs/812157.pdf.
patients. J Trauma. 2007;62:389–396. Accessed January 5, 2016.
62. Patel JC, Tepas JJ, Mollitt DL, et al. Pediatric cervical spine injuries: 66. American Academy of Pediatrics Policy Statement. Child passenger safety.
defining the disease. J Pediatr Surg. 2001;36:373–376. Pediatrics. 2011;127:788–793.

© 2017 Wolters Kluwer Health, Inc. All rights reserved. www.pec-online.com 125

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.