Seat Belt Injuries: Radiologic Findings and Clinical Correlation1 Curtis

W. Hayes,

William

MD

F. Conway,

James

W.

Lynn

Walsh,

MD

S. Gervin,

The

seat

belt

MD

syndrome

associated

juries

PhD

MD

Coppage,

Alfred

MD,

consists

with

use

of skeletal,

of two-

and

soft-tissue,

three-point

and restraints

visceral

in-

in patients

accidents. Skin abrasions of the neck, chest, and abdomen-the classic seat belt sign-indicate internal injury in 30% of cases. Neck abrasions are associated with injuries to the carotid artery, larynx, and cervical spine; chest abrasions, with fractures of the sternum, ribs, and clavicles and injuries to the heart and thoracic aorta; and abdominal abrasions, with mesenteric tears, bowel perforation and hematoma, Chance fractures, and injuries to the abdominal aorta. The seat belt sign should prompt a diligent search for related involved

in motor

vehicle

injuries.

U INTRODUCTION Lap-type seat belts

became

standard

equipment

in automobiles

in the United

States

The three-point variety of seat belt (combined lap and shoulder belt) became standard in the auto industry in i 973 Theoretically, seat belts protect the wearer during a collision in three ways: They (a) prevent ejection from the auto, in i 964

.

.

(b)

allow

and

(C)

a more

reduce

controlled

deceleration

the severity

of impact

during

between

the

initial

phase

the wearer

of the

There is no doubt that the use of seat belts, especially the three-point lowers morbidity and mortality associated with motor vehicle accidents. performed by Volvo, a Swedish car manufacturer, in 1 967 demonstrated

Index

terms:

Neck,

injuries.

Abdomen. 27.491

RadloGraphics I

From

Medical mond, tember RSNA.

the

1991; Departments

College VA 23298. 18. Address 1991

injuries, Pelvis,

70.4

1

injuries,

#{149}

#{149} Arteries,

injuries.

56.4

1

Bones,

#{149}

collision,

and the car interior.

injuries.

40.4

1

variety, A study that,

Fractures,

#{149}

40.4

1

80.41

1 1 :23-36 of Radiology

ofVirginia/Virginia Received July reprint

26,

requests

(C.W.H.,

W.F.C.,

Commonwealth 1990; revision to

J.W.W., University, requested

L.C.) 12th August

and

General

Surgery,

Trauma

and Marshall Sts. Box 615, 29 and received September

Division MCV Station, 17; accepted

(A.S.G.), Rich. Sep-

C.W.H.

23

Table 1 Patterns

Seen

of Injuries

In Motor

Location Face,

head,

Vehicle

Accidents

Unrestrained

Two-Point

Fractures

and neck

Abdomen

.

Liver and spleen lacerations and rupture

.

Three-Point

Restraint

Injuries to the carotid artery, larynx Hollow viscus injuries (mesenteric tears, perforations), abdominal wall disruptions Fractures of the clavicles, ribs, lumbar spine (Chance), and sternum

.

Hollow viscus injuries (mesenteric tears, perforations) abdominal wall disruptions Lumbar spine fractures (Chance) ,

Chest,

when

Fractures of the thoracolumbar spine, pelvis, and extremities

spine

only

lap belts

were

used,

fatal

very severe cases. Injuries caused by lap belts include mesentenic tears and perforations of the small bowel and colon. Proposed mecha-

injuries

occurred throughout the speeds, as low as 12 mph point restraints, no deaths less than 60 mph.

entire range of (1). With threeoccurred at speeds

The bowel

injury-a small wearing a lap

nisms

due

first seat belt-related injury in a trooper

belt-was described by Kulowski and Rost (2) in 1 956. A pattern of injuries distinctly different from those seen in unrestrained oc-

cupants belt

has since

wearers.

been

recognized

in seat

Braunstein (3) were the first to use the term seat belt syndrome in describing the pattern of abdominal and skeletal injuries related to seat belt use. In this article, we review the common and unusual features of seat belt injuries, their radiologic appearance, and clinical and

operative

Garrett

Restraint

and

correlations.

for

these

to rapid

injuries

are

deceleration

shearing

against

forces

the small

area of the lap belt and increased intraluminal pressure secondary to compression a bowel loop between the seat belt and spine, which produces “blowouts” (5).

the spine, istic nor

distractive

horizontal and posterior

forces

fractures elements

cause

of In

character-

involving of the

the antelumbar

spine. Soft-tissue injuries attributed to lap belts include various abrasions (seat belt sign) and rupture des and penitoneum.

of the abdominal These three

wall injuries-

mus-

hollow viscus injury, flexion-distraction fractunes of the lumbar spine, and abdominal wall disruptions-are the classic seat belt injuries.

U

PATIERNS

OF INJURY

Unrestrained

vehicle the

face,

occupants

accidents head,

involved

usually neck,

and

sustain

in motor

injuries

extremities

to

second-

aiy to collision with the interior of the car, for example, the windshield, dashboard, and

With three-point frequently involve

restraints, the thoracic

nibs,

clavicles.

sternum,

injuries such blowouts,

erations

and

contusions

usually

only

injuries-rupture

the

and

with lap belts. Cervical spine injuries, carotid and subclavian vascular injuries, and Iaryngeal trauma have been attributed to the

liver

spleen,

or lacerations

of

in particular-outnurn-

in unrestrained

restraints or lap belts by preventing ejection injuries are decreased

oc-

monly

crossing reduce from except

inthe in

U

Hayes

et al

severe, high-speed abdominal injuries of the lumbar spine

occur

id organ

found

with

shoulder

three-point

collisions. Ho!also occur. are less cornrestraints

than

strap.

Table 1 summarizes the patterns of injuries found in restrained and unrestrained victims of motor vehicle accidents. The following sections nies and

RadioGraphics

Catastrophic

as aortic transection, and massive lung lac-

with very low-viscus Fractures

Two-point juries largely auto. Crush

U

most the

steering wheel. In moderate and severe collisions, devastating abdominal and thoracic injuries related to crushing forces are cornmon. According tojordan and Beall (4), so!-

ber hollow viscus injuries cupants by two to one.

24

and

thoracic ventricular

injuries cage:

elaborate on specific seat their radiologic findings.

Volume

11

belt

inju-

Number

1

2.

1.

Figures 1-3. (1) Abdominal seat belt sign. A large anterior abdominal wall abrasion extends from flank to flank in a victim of a high-speed motor vehicle accident. (2) Thoracic seat belt sign. Diagonal abrasions (arrows) extend from the right shoulder to the left side of the chest in the patient, who was seated on the passenger side of the auto. (3) Neck seat belt sign. Diagonal abrasions are present along the course of the shoulder strap.

-

-

...-

3.

U

OF INJURIES

TYPES

. Skin A linear

Abrasions abrasion across

jury, or, including

the

lower

abrasion

extending

across

the

chest from a three-point restraint (Fig 2) is often associated with underlying rib fractunes, clavicular fracture, or sternal fracture. In severe collisions, aortic transection or ventricular rupture should be considered, although these injuries are, in our experience, less common in patients who wore seat belts than in unrestrained occupants in comparable accidents. A diagonal neck abrasion on the side of the shoulder strap (Fig 3) may be associated with vascular injury, tracheal or laryngeal in-

January

1991

cervical process

spine fractures.

injury,

abdomen

extending from flank to flank is the classic seat belt sign (Fig i) . Although this finding is not an incontrovertible sign of significant internal injuries, we have found that they are present in approximately 30% of the patients with a seat belt sign.

A diagonal

occasionally, transverse

.

Skeletal

Fractures

Injuries of the

common seat wore two-point point restraints. quently different

thoracolumbar

spine

belt injuries in patients and, to a lesser extent, The pattern from that

of injury of fractures

tamed by unrestrained victims, explained by the three-column

are

who threeis fresus-

and can concept

be of the structure of the spine by Denis (6) According to this theory, the anterior column is formed by the anterior longitudinal ligament, anterior annulus fibrosus, and anterior .

part umn

of the vertebral body. The is formed by the posterior

ligament, posterior

middle collongitudinal

posterior annulus fibrosus, wall of the vertebral body.

Hayes

et al

U

and The pos-

RadioGrapbics

U

25

a. Figure

b. 4.

terolateral suspected distraction

tenor bony

Thoracolumbar junction flexion-distraction injury. compression of the superior end plate of L- 1 (large due to splaying of spinous processes (small arrows). of posterior elements (arrow).

column elements

is formed and the

by the posterior

posterior ligamentous

complex. A flexion force on an unrestrained occupant has a fulcrum centered at the middie column, or posterior half of the vertebral body. This produces compression of the antenor forces,

vertebral distraction

Moderate cally

forces

stable,

cases.

body

and, with more severe of the posterior elements.

produce

simple,

compression

Severe

forces

neurologi-

fractures

produce

in these

flexion-distrac-

compression

important elements,

They occur most often at the junction (Fig 4) The anterior .

may

is the which

fully. Restrained

be mild

or moderate.

More

disruption of the posterior must be searched for care-

occupants,

especially

those

wearing lap belts, show characteristic horizontal fractures, frequently at L-2 or L-3. These

fractures

were

first

Chance (7) in 1948. Several these injuries were reported

26

U

RadioGrapbics

U

Hayes

et al

reported

by

variations by Smith

(8) in i969. These may involve a single vertebral level (body and posterior dcments) two levels, purely soft-tissue disrupKaufer

,

iion, jury

or a combination. The mechanism is the shifting of the fulcrum of the

to the anterior

abdominal

wall,

seat

producing

distraction

belt,

thus

three

columns

nor)

of the

(anterior, spine.

These

caused

of inforce

by the on all

middle,

and

fractures

show

postelittle

or no anterior compression of the involved vertebral body (Fig 5) Neurologic deficits are infrequent. In some cases, distractive forces produce purely ligamentous disruption at the involved level, leading to a lumbar subluxa.

tion injuries and fracture dislocations due to failure of all three columns; such injuries are unstable and commonly associated with neu-

rologic deficits. thoracolumbar

(a) Anteroposterior radiograph shows anarrow). Injury to posterior elements may be (b) Lateral radiographic findings confirm

of and

tion/dislocation jury.

This

or “Chance injury

usually

equivalent”

involves

in-

disruption

of the soft-tissue components of the postenior and middle columns of the spine (postenior ligamentous complex, posterior longitudinal ligament, and posterior annulus fibrosus). Radiographic findings of this unstable injury may be subtle: mild widening of the posterior aspect of the affected disk space,

widened

facet

processes.

On

latter

abnormality

sign”

(Fig

6).

joints, the

and

splaying

of spinous

anteroposterior

produces Chance

view,

the

fractures

Volume

“empty and

11

their

Number

the

hole hg-

1

6a. Figures

5, 6.

(5) Chance

fracture

6b. of L-2. (a) Anteroposterior

radiograph shows characteristic splaying of the spinous processes (double arrow), with fractures extending through both transverse processes and pedicles (curved arrows) . (b) Lateral radiograph shows the fracture extending through the posteroinferior corner of L-2 (arrow), into the L2-3 disk space. (6) Ligamentous Chance injury at L3-4. (a) Anteropostenor radiograph shows mild widening of the involved disk space (large arrows) and an ‘empty hole sign” (small arrows), denoting splaying of the spinous processes. (b) Lateral radiograph more clearly shows splaying of the spinous processes (double arrow) and widening of the facet joints (curved arrow). ‘

January

1991

Hayes

et a!

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RadloGrapbics

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27

Figure 7. Rib fractures, three-point restraint pattern. (a) Posteroanterior radiograph shows the diagonal course of the shoulder strap. (b) Diagonal seat belt sign (arrowheads) is seen in the same patient. (c) Oblique radiograph shows fracture of the right first rib (arrow). (d) Anteroposterior radiograph shows fractures of the left fourth through ninth ribs (arrows). The sternum was also fractured, but there was no aortic or cardiac injury.

28

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U

Hayes

et al

Volume

11

Number

1

tunes

tend

to align

along

the

course

of the

di-

agonal strap (Fig 7) The frequency of severe flail chest with multiple fractures is said to be decreased with seat belt usage, however (i 0) Arndt (1 1) has also described fractures of the transverse processes of C-7 or T- 1 associated with usage of shoulder harnesses. .

.

,

Sternal with seat

fractures are belt injuries.

deceleration

force

num strap,

through the accounting

quency

blowouts, extremely

of aortic except severe

fractures

Figure

8

Sternal

fracture.

Lateral

radiograph

demonstrates a slightly depressed fracture of only the anterior cortex of the sternum (arrows) immediately beneath the site of the shoulder strap.

amentous equivalents are frequently seen in children and other back-seat passengers, since two-point restraints are still used in the back seats of most autos. New legislation making back-seat three-point restraints mandatory may decrease the number of such injuries. Anterolateral compression fractures have

been reported der restraints.

in occupants These injuries

wearing occur

shoulat the

thoracolumbar junction and may be due to a roll-out mechanism of combined flexion and rotation about the axis of the shoulder strap (9). Rib fractures are common in all victims of motor vehicle accidents of moderate or se-

vere are

force, used.

January

regardless With

1991

three-point

of whether restraints,

common in patients It is theorized that

is absorbed

small area of the for the relatively

shoulder low fre-

transections or ventricular in victims of accidents force. We have observed

involving

only

the

of the sternum

immediately

shoulder

(Fig

strap

the

by the ster-

8),

which

anterior

cortex

beneath

the

appears

of

to be

characteristic of this mechanism. Sternal fractures in unrestrained occupants or those with lap belts only (due to impact against the steering wheel or dashboard) are often associated with myocardial contusion. To date, we have been cases of myocardial with sternal fractures straps.

unable to document contusion associated caused by shoulder

Clavicle fractures are commonly ed with use of three-point restraints motor vehicle accidents. .

Soft-Tissue

Transverse

and tears

Visceral

of the

rectus

syndrome. beneath

associatduring

Injuries abdominis

dc and anterior peritoneal tears ing more frequently recognized seat belt mediately

any

These injuries the site of the

mus-

are becomas part of the occur imlap portion

of the seat belt and may be quite subtle radiologically (Fig 9) Computed tomography (CT) may show only abrupt thinning of the .

involved muscle at the level of injury, and this finding may easily be overlooked. This injury is frequently associated with hollow viscus injury (i 2) and may provide a clue to

the gravity

of the

injury.

restraints frac-

Hayes

et a!

U

RadioGraphics

U

29

e.

I.

Figure year-old periorly

9. Abdominal wall disruption. (a-d) CT images demonstrate rectus muscle disruption in a 14victim of a high-speed motor vehicle accident. Images show normal rectus abdominis muscles su(straight arrows in a) virtually absent rectus muscles in the midportion of the abdomen (arrows in b, c) and normal-appearing muscles inferiorly (arrows in d) . Subcutaneous flank hemorrhage was also seen (curved arrow in a). An abdominal seat belt sign was present. (e) Diagram illustrates transverse tears of the rectus abdominis muscles at the site of abdominal abrasions (arrows). (0 Intraoperative view shows an extensive tear of the anterior abdominal wall (arrows). ,

,

30

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RadloGraphics

U

Hayes

et al

Volume

11

Number

1

a.

b. Figure 10. Small bowel perforation. CT scans obtained with oral and intravenous administration of contrast material show unequivocal extraluminal gas (arrows in a) mesenteric thickening (arrow in b) and moderate free fluid in the pelvis (arrow in c). ,

,

a! authors 5 1 patients

c.

dc

accidents)

(1 4- 1 7) In their 1 989 study (37 ofwhom were in motor .

,

Rizzo

et al (1 8) examined

of vehi-

the

The most common significant injuries encountered in restrained patients are mesentenic tears and frank ruptures of the small bowel and colon. Vascular tears occur on the mesenteric side of the bowel, more frequently in the small bowel than in the colon. Perforations nearly always occur on the antimesenteric border. Jejunal and ileal perforations are most common, with large intestine and duodenal ruptures less frequent. In an examination of case reports, Williams and Kirkpatrick (1 3) found a higher rate of hollow viscus injury in patients who wore two- versus three-point restraints. Sixty-three of 82 injuries involved the small bowel; 1 9 involved the colon. Mesenteric tears and bowel perfo-

frequency of the following CT findings: cxtraluminal air, free intraperitoneal fluid, thickened or infiltrated mesentery, and thickened bowel wall (Figs 10, 1 1). Extraluminal air was observed in only nine of 16 cases of perforation (56%) Two cases showed extravasation of orally administered contrast material. In all cases of bowel perforations, there were moderate to large amounts of free intraperitoneal fluid. Thickened bowel wall (75%) and mesentenic infiltration (88%) were also found in most cases of perforation. From this study and others, one may conclude that (a) free gas or extravasated contrast material are relatively specific but insensitive (56%) signs of bowel perforation; (b) the presence of moderate or

rations quency mined

large when tion,

were equally common. of these injuries cannot from this study, however,

The true frebe detersince it rep-

resented an analysis of case reports. The efficacy of CT in the evaluation blunt abdominal trauma and potential

low

viscus

January

injuries

1991

has been

studied

.

amounts of free intraperitoneal fluid, not associated with solid organ lacerashould raise the suspicion of bowel perforation or mesenteric vascular tear; and (c)

of hol-

by sever-

Hayes

et al

U

RadioGraphics

U

31

a localized mesenteric hematoma or the finding of a focal high-attenuation clot adjacent to bowel are helpful in localizing the site of injury. In the above situation, CT and diagnostic penitoneal lavage should be used as complementary diagnostic examinations.

32

U

RadioGraphics

U

Hayes

et al

The relative roles of CT and diagnostic penitoneal lavage in the evaluation of blunt trauma have been examined by a number of authors In cases

and

remain

in which for bowel injury

controversial

(19-25).

there is a high suspicion (seat belt sign or Chance

Volume

11

Number

1

Figure

15.

Intraperitoneal

bladder

rupture.

Cys-

obtained with the patient supine demonstrates intraperitoneal extravasation of contrast material from the bladder, with contrast material clearly outlining the right paracolic gutter and inferior margin of the liver. togram

fractures

of the

spine)

,

judicious

use

of both

tests is warranted. Because small bowel lacerations may initially be asymptomatic and since delay produces significant morbidity, rapid evaluation, with both tests if necessary, is

recommended.

is suspected, to diagnostic important

When

hollow

viscus

CT should be performed peritoneal lavage, since CT signs of intraperitoneal

injury prior the fluid

or free air may be related to the lavage itself (26). The frequency of liver and splenic injuries is reduced with the use of two- and threepoint restraints. Severe forces and crush injuries continue to produce the usual complement of liver lacerations (Fig 1 2) splenic lacerations and ruptures (Fig 1 3) and pancreatic (Fig 14) and renal injuries. Significant injuries may be produced with less severe forces when there is improper positioning of the two- or three-point restraint ,

,

(27,28).

Proper

usage

dictates

that

to obesity, the load of be dissipated over ment, resulting in ment of the shoulder ondary ing”)

,

a passenger-side directly across

slouching, or “submanina sudden deceleration may the abdominal compartvisceral injuries. Placestrap under the arm by

occupant the liver,

produces a force with potentially

devastating effects. Intraperitoneal rupture of a distended bladder may occur due to lap belt pressure during an accident (Fig 1 5) Urethral injury .

has

occasionally

been

reported

as well.

Sev-

eral cases of uterine injury have also been reported (29), including a case in which nipture of a gravid uterus left a 6th-month fetus free in the abdominal cavity. Fortunately, such

reports

are

rare.

Cases of diaphragmatic rupture have been reported in seat belt wearers (30) (Fig 16). The mechanism of the injury may be secondaiy to faulty placement of the belt or sliding of the occupant under the belt in the early stages

of the

impact,

leading

to upward

ab-

dominal pressure from the belt and subsequent herniation of abdominal contents into the thoracic cavity.

the lap

belt be positioned across the anterior iliac spine so that the forces are dissipated through the stable, bony pelvis. If the belt migrates up onto the abdominal wall (sec.

January

1991

Hayes

et a!

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RadloGrapblcs

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33

common carotid angiogram same patient shows extensive ary to laryngeal fracture.

. Vascular Injuries We have seen one case common carotid artery in a motor

three-point tient also

vehicle

(b) CT scan of the of the neck second-

demonstrates a transection (arrow) below the bifurcation. gas in the soft tissues of the anterior and lateral aspects

of transection in a patient

accident

of the involved

while

using

a

seat belt (Fig 1 7a) The same pahad a fracture of the larynx that ne.

cessitated a tracheostomy (Fig 1 7b) Similar cases, as well as injuries to the internal carotid artery, subclavian artery, and superior .

vena cava, have also been reported In the literature (31-35). The force of collision required to produce thoracic aortic tears appears to be greater in restrained occupants than in unrestrained persons.

The

shoulder

strap

more controlled deceleration during the collision, which shearing force on the aorta aortic severe

injuries forces

are (Fig

Seat belt-related dominal

aorta

have

may

allow

relatively i 8) (36).

common

injuries

involving

been

a

of the chest may decrease the somewhat. Still,

reported

with

the ab(37,38).

tient same

also sustained a Chance level. The mechanism

presumably the aorta

fracture of injury

at the was

distraction and compression between the seat belt and spine.

of

U

RadioGrapbics

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Hayes

et a!

-----

-

---

--

---C

proximal descending aorta, with a well-defined flap (arrow) at the lower extent of the injured segment. U

CONCLUSIONS

Given

the

accident, three-point less

34

--.--- --------

I,

We observed one case in which distal abdominal aortic occlusion occurred due to a near-complete transection (Fig 19). This pa-

severe

same

force

of impact

a seat belt wearer type belt) will injuries

than

during

a nonwearer.

Volume

the

(especially usually sustain

11

Seat

Number

1

Table 2 Seat Belt Synd rome: Location

Physical

Signs

and

Related

Injuries

of

Abrasion

Affected

Neck

Structures

Injuries to the carotid artery, larynx, cervical spine, transverse process Injuries to the sternum, ribs, clavicle, heart (myocardial contusion) thoracic aorta Injuries to the small and large bowel (mesenteric tears, perforations, hematoma) vertebrae (Chance fractures, especially L-2, L-3), abdominal aorta and branches

Chest

,

Abdomen

,

30% of cases. Chance fractures and their ligamentous equivalents, large and small bowel perforations or mesentenic tears, and abdominal wall disruptions are more common than solid organ injury. Occasional significant vascular injuries also occur. Table 2 summanizes the various injuries associated with different seat belt abrasions. The history of a restrained occupant in a significant motor yehide accident or the presence of the telltale seat belt sign should prompt a diligent search for these related injuries. U

1

.

REFERENCES Bohlin NI. A statistical analysis of 28,000 accident cases with emphasis on occupant restraint. Proceedings of the Eleventh Stapp Car Crash Conference. Soc Automotive Eng Trans

2.

3. 4.

Figure

19. Distal abdominal aortic occlusion following seat belt injury. Anteroposterior abdominal aortogram shows complete occlusion just proximal to the aortic bifurcation. At surgery, complete transection with only intact adventitia was found. A Chance fracture was present at L-4.

belts

prevent

vehicle cupant’s

dashboard, However, juries

perience,

ejection

of the wearer

and decrease impact with

the severity the steering

and other a distinctly

occurs

in seat

the

scat

interior different belt

belt

from of the wheel,

structures. pattern

wearers.

In our

1991

6.

the oc-

7.

of in-

8.

cx-

sign-abdominal,

chest, or neck bruises and abrasions at the site of belt contact-is associated with significant internal injuries in approximately

January

5.

9.

1967;

76:2981-2994.

KulowskiJ,

Rost WB. Intra-abdominal injury from safety belt in auto accident. Arch Sung 1956; 73:970-971. GarrettjW, Braunstein PW. The seat belt syndrome.JTrauma 1962; 2:220-237. Jordan GL, Beall AC. Diagnosis and management of abdominal trauma. Curr Prob Surg 1971 ; November:3-62. WilliamsJS, Lies BA, Hale HW. The automotive safety belt: in saving a life may produce intra-abdominal injuries. J Trauma 1966; 6:303-313. Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine i983; 8: 817-83 1. Chance GQ. Note on the type of flexion fracture ofthe spine. BrJ Radiol 1948; 21:452-453. Smith WS, Kaufer H. Patterns and mechanisms of lumbar injuries associated with lap seat belts.J Bonejoint Surg [Ami 1969; Si: 239-254. Miniaci A, McLaren AC. Anterolateral cornpression fracture of the thoracolumbar

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10.

1 1.

i2

13

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.

14.

1 5.

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a seat

1989;

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belt

injury.

Clin

Orthop

Rd

Res

toneal lavage in blunt abdominal ArchSurg 1989; 124:344-347.

Newman RJ. Chest wall injuries and the seat belt syndrome. Injury I 984 ; 1 6: 1 10113. Arndt RD. Cervical-thoracic transverse pro-

24.

cess

25.

fracture:

further

observation

on

the 15:600-

seatbelt syndrome.J Trauma 1975; 602. Johnstone BR, Waxman BP. Transverse disruption ofthe abdominal wall: a tell-tale sign of seat belt related hollow viscus injury. Aust N ZJ Sung 1987; Williams JS, Kirkpatrick

57:455-460. JR. The

nature

of

seat belt injuries. J Trauma 197 i 1 1:207216. Cook DE, WalshJW, Vick CW, Brewer WH. Upper abdominal trauma: pitfalls in CT diagnosis. Radiology 1986; 159:65-69. DonohueJH, Federle MP, Griffiths

Trumkey

DD.

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injunies.JTrauma Orwig D, Federle blood as evidence the sentinel clot

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SherckJP, Oakes DD. Intestinal missed by computed tomography. 1990;

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la-

Gomez Diagnostic ment of ment.J Keaney

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GA, Alvarez R, Plasencia G, et al. penitoneal lavage in the manageblunt abdominal trauma: a reassessTrauma 1987; 27:1-5. PA, Vahey T, Burney RE, Glazer G. tomography

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