Abdominal injuries associated with thoraco-lumbar fractures after motor vehicle collision

A meta-analysis of the incidence of intra-abdominal injuries associated with thoracic or lumbar flexion-distraction injuries

BACKGROUND

Intra-abdominal injuries (IAIs) are often associated with thoracic or lumbar flexion distraction injuries (TLFDIs) or Chance fractures. The incidence ranges from 10 to 50 % in previous literature.

AIM

To synthesize data about the incidence of IAIs associated with TLFDIs.

METHODS

We searched PubMed, WOS, and Cochrane databases for all studies reporting the incidence of IAIs associated with TL FDIs. The primary outcome was the overall pooled incidence of IAIs, surgical intervention, and specific organ injuries. A subgroup analysis was done for studies that included adults, pediatrics, and mixed populations. We assessed the methodological quality of the included studies using the Newcastle-Ottawa Scale. We used A random effects model to calculate pooled incidence rates and heterogeneity. This systematic analysis followed PRISMA guidelines.

RESULTS

A total of eight retrospective studies with 652 patients met the inclusion criteria. The pooled incidence of overall IAIs associated with TLFDIs was 36.2 % (95 % CI: 32.2 % %-57.2 %), with high heterogeneity (I² = 90.71 %, p = 0.0001). The incidence of surgical interventions was 29.03 % (95 % CI: 22.0 %-48.3 %), with high heterogeneity (I² = 92.3 %, p < 0.0001). Small bowel injuries occurred in 19.17 % of cases, large bowel injuries in 10.92 %, liver injuries in 7.6 %, splenic injuries in 7.2 %, kidney injuries in 5.36 %, and pancreatic injuries in 3.7 %. Pediatric populations showed significantly higher rates of IAAs (55.8 % vs. 23.03 %) and surgical intervention (45.5 % vs.10.6 %) than adults.

CONCLUSION

The pooled incidence of IAAs associated with TL FDIs is 36.2 %, and surgical intervention is 29.03 %. Small bowels, large bowels, liver, and splenic injuries were the most frequent injuries. These rates are probably overestimated due to the retrospective design of studies and the variability in the definition of TLFDIs. Therefore, prospective, well-designed studies are needed to estimate the true incidence of IAAs associated with TLFDIs accurately.

Epidemiology of pediatric thoracolumbar spinal fractures and associated injuries: a single-center experience

OBJECTIVE

This retrospective study aimed to investigate the epidemiology of pediatric patients with thoracolumbar spinal fractures and the characteristics of associated injuries.

METHODS

Sixty-one patients under 18 years old with thoracolumbar spinal fractures were included in the study. Patients were divided into two groups: ≤ 8 years (Group 1) (n = 13) and > 8 years (Group 2) (n = 43). Patients were analyzed for age, gender, fracture type, fracture level, etiology, and associated injuries.

RESULTS

The mean age was 158.7 (± 53.1) months, and the male/female ratio was 1.26. The most common fracture etiology was motor vehicle accidents (39.4%) and falls from height (18%). There was no correlation between the fracture type, the number of fractured vertebrae, and age. The most common associated injury was orthopedic injuries (34.3%). In Group 2, associated injuries developed more frequently in the presence of a major fracture, whereas in Group 1, associated injuries could occur even in isolated minor fractures. In Group 1, intrathoracic injuries associated with fractures (36.4%) were significantly higher than in Group 2 (4.2%). Surgical intervention was required in 9.8% of patients.

CONCLUSION

Although thoracolumbar spinal fractures are rare in children, they are essential because preventable accidents essentially cause them and can have devastating consequences. There are significant differences in epidemiologic and clinical features between age groups. In this study, we have shown that even minor thoracolumbar vertebral fractures may be accompanied by associated injuries in children under 8 years of age. In contrast, major fractures are more frequently related to other organ injuries in older children. This may be because more severe trauma is required for a fracture of the thoracolumbar spine, which is more flexible and elastic in young children compared to adolescents. Our study has provided current and essential results regarding the etiology of pediatric thoracolumbar spine fractures. More multicenter studies are needed to understand the characteristics of thoracolumbar fractures in pediatric patients.

Thoracolumbar Injury Classification and Severity Scale Can Help Identify Intra-Abdominal Injury in Children Injured in an MVC

Background: Motor vehicle crashes (MVC) cause variable injury to the thoracolumbar (TL) region of children secondary to rapid deceleration from seatbelts. This mechanism can also predispose a child to intraabdominal injury (IAI), which necessitates early diagnosis to limit morbidity and mortality. While the maximum extent of TL spine injury can be appreciated shortly after presentation, the severity of IAI may not be appreciated until days later. It is hypothesized that a measure of TL-injury severity will identify patients at risk of concomitant IAI. Methods: Retrospective chart review identified 72 children with MVC-related TL spine injuries from 2007-2020. Patients were grouped based on the presence of IAI and TL spine injury (N=33) compared to isolated TL spine injury (no IAI, N=39). TL spine injury severity was classified according to the Thoracolumbar Injury Classification and Severity Scale (TLICS). Results: Demographics were similar in both groups. Children with concomitant IAI had primarily lumbar spine injuries, while injuries without associated IAI were more broadly distributed throughout the thoracolumbar spine. Children without concomitant IAI were more likely to sustain compression fractures (n=31, 79%), while children with IAI had more distraction injuries (n=24, 73%). TL injuries associated with IAI were significantly more severe than isolated TL injuries (median TLICS=7 [range: 1-9] vs. 1 [range: 1-10], p<0.001). As hypothesized, increasing TLICS is associated with an increased risk of concomitant IAI, such that for every point increase in TLICS, the risk of IAI increases 49% (OR: 1.492, [95% CI 1.254-1.817], AROC 0.795). Conclusions: Given the association between severe spine injury and IAI, this study examines the utility of TLICS score at presentation to establish an index of suspicion for concomitant IAI. While other clinical signs may be suggestive of the presence of IAI, our study may provide clinicians with another data point suggestive of spine injury severity in their diagnostic toolbox to optimally manage pediatric patients after MVC. Level of Evidence: III, Retrospective Cohort Study Key Concepts•Pediatric patients are at risk for sustaining seatbelt syndrome (intraabdominal injury (IAI) associated with spinal column injury) after motor vehicle collisions when restraints are used improperly.•Occult IAIs may not be readily diagnosed with initial trauma workup and require a high index of suspicion to avoid delay in diagnosis and potential morbidity and mortality.•IAI is more frequently associated with spine fractures located in the lumbar spine.•IAI is associated with more severe spine injury (represented by Thoracolumbar Injury Classification and Severity Scale [TLICS] score >5).

Mapping of Orthopaedic Fractures for Optimal Surgical Guidance

Orthopaedic fractures may be difficult to treat surgically if accurate information on the fracture propagation and its exit points are not known. Even with two-dimensional (2D) radiographic images, it is difficult to be completely certain of the exact location of the fracture site, the fracture propagation pattern and the exit points of the fracture. Three-dimensional (3D) computerised tomographic models are better in providing surgeons with the extent of bone fractures, but they may still not be sufficient to allow surgeons to plan open reduction and internal fixation (ORIF) surgery.Fracture patterns and fracture maps are developed to be visual tools in 2D and 3D. These tools can be developed using fractured bones either before or after fracture reduction. Aside from being beneficial to surgeons during pre-surgical planning, these maps aid bioengineers who design fracture fixation plates and implants for these fractures, as well as represent fracture classifications.Fracture maps can be either created ex silico or in silico. Ex silico models are created using 3D printed bone models, onto which fracture patterns are marked. In silico fracture models are created by tracing the fracture lines from a fractured bone to a healthy bone template on a computer. The points of interest in both of these representations are the path of fracture propagation on the bone's surface and exit zones, which eventually determine the surgeon's choice of plate and fracture reduction. Both ex silico and in silico fracture maps are used for pre-surgical planning by the surgeons where they can plan the best way to reduce the fracture as well as template various implants in a low-risk environment before performing the surgery.Recently, fracture maps have been further digitised into heat maps. These heat maps provide visual representations of critical regions of fractures propagating through the bone and identify the weaker zones in the bone structure. These heat maps can allow engineers to develop optimal surgical plates to fix an array of fracture patterns propagating through the bone. Correlation of fractured regions with the mechanisms of injury, age, gender, etc. may improve fracture predictability in the future and optimise the intervention, along with making sure that surgeons do not miss fractures of the bone that may otherwise be hidden from plain sight.

Pattern and In-Hospital Mortality of Thoracoabdominal Injuries Associated with Motor Vehicle Accident-Related Spinal Injury: A Retrospective Single-Center Study

BACKGROUND

Motor vehicle accident (MVA) is a global health hazard that results in spinal, thoracic, and abdominal injuries. Detailed studies on the association between MVA-related traumatic spinal injury (TSI) and thoracoabdominal injuries are lacking. This study aims to elucidate the prevalence, pattern of association between these injuries, and related outcomes in terms of in-hospital mortality.

METHODS

This is a retrospective single-center study of MVA-related TSI with thoracoabdominal associated injuries. Descriptive analysis was performed for gender, age, spinal injury level, thoracoabdominal injury region, admission day, hospital stay duration, and discharge category. The association between TSI and thoracoabdominal injury was analyzed, and the chi-square test was used to test the significance of differences. A statistically significant difference was considered at P values less than 0.05.

RESULTS

The cohort had a mean age of 33.6 ± 17.7 years with predominantly more males (85.1%). Thoracoabdominal injuries were present in 10.5% of MVA-related TSIs, and 9.2% of victims died during their hospital stay. There is a significant (P=0.045) association between the level of the spinal and the region of thoracoabdominal injuries. The presence of TSI-associated thoracic injury significantly (P=0.041) correlated with increased in-hospital mortality more than abdominal injury.

CONCLUSION

Thoracoabdominal injuries concomitant with MVA-related TSI cause considerable mortality. A pattern of association exists between the level of spinal and region of thoracoabdominal injury. Knowledge of this pattern is helpful in the routine practice of trauma health partitioners.

How to deliver an effective primary survey report for the trauma CT: A radiological and surgical perspective

Whole body contrast-enhanced multidetector CT (WB-CE MDCT) is integral to the assessment of the severely injured patient with stable haemodynamic parameters or in those who respond to resuscitation with blood products. WB-CE MDCT is able to identify the number and severity of injuries sustained by the patient and enable time critical intervention.

In this narrative review article we discuss how communication within the trauma team, including the radiologists and appropriate clinicians is crucial in optimizing the effectiveness of WB-CE MDCT. We review the time critical imaging findings and their clinical relevance, which should be included in a succinct CT primary survey report.

We also discuss the process through which the effectiveness of the trauma report may be maximised and how non technical factors including teamwork may be optimised to facilitate decision making in this high pressure environment.

Predictive Model for Operative Intervention after Blunt Abdominal Trauma in Children with Equivocal CT Findings: A Pilot Study

BACKGROUND

To study the clinical and radiologic factors predicting the need for surgical intervention after blunt abdominal trauma (BAT) in children with equivocal computed tomography (CT) scan findings.

METHODS

We performed a retrospective review of the trauma database at our level I pediatric trauma center between 2011 and 2019. We selected patients with BAT and equivocal findings for surgical intervention on CT scan. We studied five factors: abdominal wall bruising (AWB), abdominal pain/tenderness (APT), thoracolumbar fracture, the presence of free fluid (FF), and the presence of solid organ injury, all previously reported in the literature to predict the need for operative intervention. We used t-test, the Kruskal-Wallis test and logistic regression to study the association of these factors with the need for operation in our pediatric cohort.

RESULTS

Of 3044 blunt trauma patients, 288 had abdominal CT scans with 61 patients demonstrating equivocal findings. Operation was performed for 12 patients (19.7%) confirming surgically correctable traumatic injuries. The need for surgical intervention was significantly associated with the age of the patients (P = 0.03), the presence of APT (P = 0.001), AWB (P = 0.01), and FF (P = 0.04). The presence of thoracolumbar fracture and solid organ injury were not significantly associated with the need for operation. For the subset of 37 patients who were injured in a motor vehicle crash, five (13.5%) required surgical intervention, which was significantly associated with the presence of AWB (P = 0.04), APT (P = 0.01), and FF (P = 0.03). A predictive model that used these factors produced a receiver operating characteristic curve of 0.86.

CONCLUSIONS

In cases of equivocal abdominal CT scan findings to evaluate BAT in children, the presence of abdominal wall tenderness, AWB, or FF may be significant factors predicting more accurately the need for operative intervention. A predictive model using the combination of clinical and image findings might determine with more certainty, the need for surgical intervention in children with BAT and equivocal CT findings. Validation on a larger multi-institutional data set should be done.

Traumatic fractures in adults: missed diagnosis on plain radiographs in the Emergency Department

Radiography remains the imaging standard for fracture detection after trauma. The radiographic diagnosis of most fractures and dislocations poses little difficulty to radiologists: however, occasionally these injuries are quite subtle or even impossible to detect on radiographs. Missed diagnoses of fracture potentially have important consequences for patients, clinicians, and radiologists. Radiologists play a pivot role in the diagnostic assessment of the trauma patients: emergency radiologists who are more practiced at seeking out and discerning traumatic fractures can provide an invaluable service to their clinical colleagues by ensuring that patients do not endure delayed diagnoses. This is a narrative review article aims to highlight the spectrum of fractures in adults potentially missed on plain radiographs, the causes of error in diagnosis of fractures in the emergency setting and the key elements to reduce misdiagnosis of fractures.

RETURN TO WORK AFTER SPINAL FRACTURE SURGERY: AN ANALYSIS OF PREDICTIVE FACTORS

ABSTRACT Objective: To retrospectively evaluate factors that influence the return to work of patients of economically active age submitted to surgery due to spinal fractures. Methods: Patients aged between 18 and 65 years that underwent surgery after spinal fracture from 2012 to 2014 were selected. Through a specific questionnaire and review of the medical records, we identified factors that may have influenced the labor return of these patients. Results: Initially, 114 patients were allocated. After applying the inclusion criteria, 51 patients remained. Age, schooling, time to sit on the bed, and residual pain were the factors that influenced all outcomes. Other variables such as ISS (Injury Severity Score), segment of spine, number of affected vertebrae, associated lesions, and previous employment regimen had no influence. Conclusions: The rate of return to work after being submitted to surgery due to a fracture of the spine is related to age, schooling, residual pain, length of hospital stay, and the time the patient takes to be able to sit alone postoperatively. Physiotherapy positively influences the patient’s self-assessment regarding the ability to perform basic tasks. These variables can be used to identify a possible difficulty in the reallocation of these patients in the labor market.

Post-traumatic pancreatico-dural fistula: Case report and management challenges

Pancreatic injury can occur following high-energy blunt trauma to the torso. Although several types of pancreatic fistulas have been described in literature, we report to our knowledge, the first case of a pancreatico-dural fistula of traumatic origin.

A 20-year-old male sustained a severe blow to the thoraco-abdominal region in the setting of a motorcycle accident. A total body scan revealed an AAST (American Association for the Surgery of Trauma) grade 4 splenic injury. A laparotomy with splenectomy and abdominal packing was performed. This was later followed by thoracolumbar instrumentation for posterior fixation of a T11–T12 transdiscal type C fracture with anterior subluxation of T11, according to the AO classification. Subsequent management was complicated by the persistence of a pseudomeningocele despite multiple surgical drainage procedures and a concomitant increase in retroperitoneal fluid collections. High levels of amylase and lipase in the pseudomeningocele fluid confirmed the presence of a pancreatico-dural fistula, due to a Wirsung duct rupture.

This case report illiustrates the challenges in the management of this rare condition.

Small bowel entrapment and ureteropelvic junction disruption associated with L3 Chance fracture-dislocation

Paediatric Chance fracture are rare lesions but often associated with abdominal injuries. We herein present the case of a seven years old patient who sustained an entrapment of small bowel and an ureteropelvic disruption associated with a Chance fracture and spine dislocation following a traffic accident. Initial X-rays and computed tomographic (CT) scan showed a Chance fracture with dislocation of L3 vertebra, with an incarceration of a small bowel loop in the spinal canal and a complete section of the left lumbar ureter. Paraplegia was noticed on the initial neurological examination. A posterior L2-L4 osteosynthesis was performed firstly. In a second time she underwent a sus umbilical laparotomy to release the incarcerated jejunum loop in the spinal canal. An end-to-end anastomosis was performed on a JJ probe to suture the left injured ureter. One month after the traumatism, she started to complain of severe headaches related to a leakage of cerebrospinalis fluid. Three months after the traumatism there was a clear regression of the leakage. One year after the trauma, an anterior intervertebral fusion was done. At final follow-up, no neurologic recovery was noticed. In case of Chance fracture, all physicians should think about abdominal injuries even if the patient is asymptomatic. Initial abdominal CT scan and magnetic resonance imaging provide in such case crucial info for management of the spine and the associated lesions.

The Seatbelt Syndrome-Do We Have a Chance?: A Report of 3 Cases With Review of Literature

The seatbelt syndrome represents an injury pattern seen after motor vehicle accidents. It is secondary to either the misplacement of seatbelts over the abdomen or the misuse of the restraint systems. This syndrome is infrequent in the pediatric population and occurs mostly in school-aged children because recommended lap-shoulder belts and booster seats are often not used in this age group, so that the seatbelt lies over the abdomen. Sudden deceleration bends the child around the lap belt causing injuries to the viscera, head, and spine (Chance fracture), often associated with paraplegia. Because not all patients have an abdominal seatbelt sign, this syndrome can easily not be recognized with potentially life-threatening consequences.We report on 3 patients with the seatbelt syndrome and review the literature regarding prevalence, diagnosis, treatment, and prognosis of the different injuries and discuss the diagnostic challenges of intestinal lesions and their management.Following this accident pattern, in hemodynamically stable patients with a normal abdominal computed tomography scan, close surveillance is warranted to rule out intestinal lesions manifesting with progressive peritoneal irritation. In hemodynamically unstable patients, or if there is evidence of free air on the computed tomography scan, emergency abdominal exploration is required.

Errors in imaging patients in the emergency setting

Emergency and trauma care produces a "perfect storm" for radiological errors: uncooperative patients, inadequate histories, time-critical decisions, concurrent tasks and often junior personnel working after hours in busy emergency departments. The main cause of diagnostic errors in the emergency department is the failure to correctly interpret radiographs, and the majority of diagnoses missed on radiographs are fractures. Missed diagnoses potentially have important consequences for patients, clinicians and radiologists. Radiologists play a pivotal role in the diagnostic assessment of polytrauma patients and of patients with non-traumatic craniothoracoabdominal emergencies, and key elements to reduce errors in the emergency setting are knowledge, experience and the correct application of imaging protocols. This article aims to highlight the definition and classification of errors in radiology, the causes of errors in emergency radiology and the spectrum of diagnostic errors in radiography, ultrasonography and CT in the emergency setting.

Spine trauma in very young children: a retrospective study of 206 patients presenting to a level 1 pediatric trauma center

BACKGROUND

The immature spine has anatomic and biomechanical properties that differ from the adult spine and result in unique characteristics of pediatric spinal trauma. Although distinct patterns of spinal injury have been identified in children younger than 10 years of age, little research has explored the differing characteristics of spinal trauma within this age group, particularly in the very young. The purpose of this study is to identify differences in the epidemiology and characteristics of spinal trauma between children under the age of 4 years and those between 4 and 9 years of age.

METHODS

A review of all patients treated for spinal injury at a single large level I pediatric trauma center between 2003 and 2011 was conducted. Demographic data, injury mechanism, neurologic status, and details of any associated injuries were compiled. Radiographic studies were used to determine injury location and fracture classification. The patient population was divided into 2 groups: the infantile/toddler (IT) group (ages 0 to 3 y) and the young (Y) group (ages 4 to 9 y). Data were compared between these groups using the χ2 test and the Student t test to identify differences in injury characteristics.

RESULTS

A total of 206 patients were identified. Fifty-seven patients were between 0 and 3 years of age and 149 were between 4 and 9 years old. Although motor vehicle collision was the most common cause of injury in both the groups, nonaccidental trauma was responsible for 19% of spine trauma among patients aged 0 to 3 years. Cervical spine injuries were much more common in the youngest patients (P<0.05) with injuries primarily in the upper cervical spine. Children in the IT group were more likely to sustain ligamentous injuries, whereas Y patients had more compression fractures (P<0.05). Neurologic injury was common in both the groups with IT patients more often presenting with complete loss of function or hemiplegia and Y patients sustaining more spinal cord injuries (P<0.05). IT patients had a 25% mortality rate, which was significantly higher than that of the Y group (P=0.005).

CONCLUSIONS

This study shows many significant differences in characteristics of spinal injury in infants/toddlers when compared with older children. These differences can help guide diagnostic evaluation and initial management, as well as future prevention efforts.

LEVEL OF EVIDENCE

Level III.

Delayed traumatic diaphragm hernia after thoracolumbar fracture in a patient with ankylosing spondylitis

Traumatic diaphragm hernia can occur in rare cases and generally accompanies thoracic or abdominal injuries. When suffering from ankylosing spondylitis, a small force can develop into vertebral fracture and an adjacent structural injury, and lead to diaphragm hernia without accompanying concomitant thoracoabdominal injury. A high level of suspicion may be a most reliable diagnostic tool in the detection of a diaphragm injury, and we need to keep in mind a possibility in a patient with ankylosing spondylitis and a thoracolumbar fracture, even in the case of minor trauma.

Association between the seat belt sign and intra-abdominal injuries in children with blunt torso trauma in motor vehicle collisions

OBJECTIVES

The objective was to determine the association between the abdominal seat belt sign and intra-abdominal injuries (IAIs) in children presenting to emergency departments with blunt torso trauma after motor vehicle collisions (MVCs).

METHODS

This was a planned subgroup analysis of prospective data from a multicenter cohort study of children with blunt torso trauma after MVCs. Patient history and physical examination findings were documented before abdominal computed tomography (CT) or laparotomy. Seat belt sign was defined as a continuous area of erythema, ecchymosis, or abrasion across the abdomen secondary to a seat belt restraint. The relative risk (RR) of IAI with 95% confidence intervals (CIs) was calculated for children with seat belt signs compared to those without. The risk of IAI in those patients with seat belt sign who were without abdominal pain or tenderness, and with Glasgow Coma Scale (GCS) scores of 14 or 15, was also calculated.

RESULTS

A total of 3,740 children with seat belt sign documentation after blunt torso trauma in MVCs were enrolled; 585 (16%) had seat belt signs. Among the 1,864 children undergoing definitive abdominal testing (CT, laparotomy/laparoscopy, or autopsy), IAIs were more common in patients with seat belt signs than those without (19% vs. 12%; RR = 1.6, 95% CI = 1.3 to 2.1). This difference was primarily due to a greater risk of gastrointestinal injuries (hollow viscous or associated mesentery) in those with seat belt signs (11% vs. 1%; RR = 9.4, 95% CI = 5.4 to 16.4). IAI was diagnosed in 11 of 194 patients (5.7%; 95% CI = 2.9% to 9.9%) with seat belt signs who did not have initial complaints of abdominal pain or tenderness and had GCS scores of 14 or 15.

CONCLUSIONS

Patients with seat belt signs after MVCs are at greater risk of IAI than those without seat belt signs, predominately due to gastrointestinal injuries. Although IAIs are less common in alert patients with seat belt signs who do not have initial complaints of abdominal pain or tenderness, the risk of IAI is sufficient that additional evaluation such as observation, laboratory studies, and potentially abdominal CT scanning is generally necessary.

Lumbar vertebral fractures in children: four cases and review of the literature

BACKGROUND

Vertebral fractures and severe injuries to the spine cord in children are rare and account for a small proportion of all childhood injuries. Pediatric vertebral and spinal cord injuries have unique characteristics depending on their age. Young children sustain upper cervical spine injuries, which are more serious injuries and have a higher mortality rate. Older children have lower spine injuries and thoracoabdominal injuries.

OBJECTIVES

This study aimed to present the epidemiology and potential complications from lumbar spine fractures.

CASES

There were 4 cases of older children who sustained lumbar vertebral fractures.

CONCLUSIONS

Fractures of the lumbar spine in children, although relatively rare, are important to understand. Patterns of injury with vertebral and spinal cord injuries in children vary from those of adults. The biologic differences of children make differences in fracture patterns and alter the management necessary for successful treatment. Errors in management can have adverse effects on these injuries.

Chance fractures in the pediatric population

OBJECT

The pediatric Chance fracture (PCF) is an uncommon injury, but it has been increasingly reported. Knowledge is limited to few case reports and short series. To understand the various aspects of this injury, the authors reviewed the current literature.

METHODS

A literature search was conducted using the PubMed and Ovid online databases and relevant key words. All articles that were in English and provided information regarding PCF as a sole or part of the objective were retrieved.

RESULTS

Seventy-three articles were found to fulfill the inclusion criteria. Relevant information about PCF collected from these articles included: 1) mode of trauma, 2) associated injuries, 3) radiological classification, and 4) treatment.

CONCLUSIONS

Chance fractures in children are potentially devastating injuries largely caused by motor vehicle collisions, and these fractures may be more common than previously thought. Concomitant intraabdominal injuries are common and should be suspected, particularly when a seat belt sign is observed. Blunt abdominal aortic injuries are rarely associated, but should be evaluated for and treated appropriately. Magnetic resonance imaging is best for defining ligamentous injury, which aids in defining the pattern of injury, facilitating appropriate treatment regimens.

Blunt abdominal aortic disruption (BAAD) in shear fracture of the adult thoraco-lumbar spine: case report and literature review

To present a rare case of association of abdominal aorta rupture and flexion-distraction fracture of thoracolumbar spine and to review the literature on this condition. In non-penetrating abdominal traumatic injuries with flexion-distraction fractures of the thoracolumbar spine, rupture of the abdominal aorta is an extremely rare occurrence but its outcome is potentially lethal. This association of skeletal and vascular lesions mainly affects young patients and involves the thoraco-lumbar junction and the portion of the aorta that lies in front of it. The authors analyze the pertinent literature and describe a case, operated in two sittings, of a traumatic lesion of the aorta attributable to a fracture of L1, focusing on mechanism of damage, diagnosis and surgical treatment. At 2-year follow-up examination, there were no neurological deficits. A review of the pertinent literature has shown that mortality can be reduced by a meticulous clinical and radiological work-up for a correct diagnosis followed by surgical repair of any damaged vessels. The possibility of performing a rapid diagnosis by means of total-body CT-scan plus CT-angiography allows repair of vascular damage, stabilization of the patient's hemodynamic conditions and, subsequently, surgical treatment of the vertebral fracture.

Diaphragmatic avulsion with chance fracture: a rare association in the seat belt syndrome

Traumatic diaphragmatic injuries are uncommon in children. Chance fractures are typical in adults who had motor vehicle accidents but infrequent in children. The seat belt syndrome is characterized by a spectrum of injuries caused by the compression of the abdomen by the seat belt. It can affect the abdominal wall, hollow or solid organs, and the spine, but the association between diaphragmatic rupture and Chance fracture is extremely rare. We describe the case of a child who was involved in a car accident and who presented with multiple traumas; liver and lung injuries were first detected, and the patient was managed accordingly. During the hospital stay, a right diaphragmatic avulsion and a Chance fracture, which were initially missed, were diagnosed and treated successfully. The relevance of this case lies in the low incidence of the diaphragmatic rupture and the Chance fracture in children along with their exceptional association and in the diagnosis, which might be especially difficult in the acute setting.

Seatbelts and road traffic collision injuries

Modification of seatbelts and their legislation played an important role in reducing morbidity and mortality of occupants in road traffic collisions. We aimed to review seatbelt development, its mechanism of action and its effects. Seatbelts reduce injury by preventing the occupant from hitting the interior parts of the vehicle or being ejected from the car. We have made a linear regression correlation between the overall seatbelt compliance and road traffic death rates in 46 high income countries to study the relationship between seatbelt use and mortality. There was a very highly significant negative correlation between the seatbelt compliance and road traffic death rates (R = - 0.77, F = 65.5, p < 0.00001). Seatbelt-related injuries include spinal, abdominal or pelvic injuries. The presence of a seatbelt sign must raise the suspicion of an intra-abdominal injury. These injuries can be reduced if seatbelts were applied correctly. Although seatbelts were recognized as an important safety measure, it still remains underused in many countries. Enforcement of seatbelt usage by law is mandatory so as to reduce the toll of death of road traffic collisions.

Seatbelt Triad: Severe Abdominal Wall Disruption, Hollow Viscus Injury, and Major Vascular Injury

The triad of seatbelt-related severe abdominal wall disruption, hollow viscus injury, and distal abdominal aortic injury after a motor vehicle collision is uncommon. We present a small case series involving those three clinical features with the goal of preventing a future missed diagnosis of the distal abdominal aortic injury in particular.

Predictive indicators for bowel injury in pediatric patients who present with a positive seat belt sign after motor vehicle collision

PURPOSE

Abdominal wall bruising (AWB) is a frequent finding in children wearing seat belts involved in motor vehicle collision (MVC) and is highly suspicious but not indicative of intestinal injury. The aim of this study was to find objective clinical and radiologic predictors for the need of an abdominal exploration in these children.

MATERIALS AND METHODS

A retrospective chart review of children admitted from 1998 and 2008 with AWB after MVC was conducted. Demographics, vital signs, physical examinations, radiologic investigations, associated injuries, management, and outcome were extracted. Univariate and multivariate statistical analyses were done.

RESULTS

Fifty-three children with a median age of 9 years (range, 3-16 years) were included. Forty-four patients (83%) had abdominal pain on arrival, and 25 (47%) had free intraabdominal fluid on ultrasound/scan. Intraabdominal injuries were noted in 29 patients (55%), and the most common were mesenteric or bowel injuries (25%), splenic injuries (13%), and hepatic injuries (8%). Ten patients (19%) needed therapeutic laparotomy, and all were victims from collision involving 2 moving vehicles, had abdominal pain, free intraabdominal fluid, and tachycardia. Five patients (50%) operated on had lumbar fracture compared to only 4 patients (9%) in the nonoperative group. Pulse rate higher than 120 (P = .048), lumbar fracture (P = .008), and free intraabdominal fluid (P <or= .001) were significant predictors for intestinal perforation. Overall survival was 98% with 1 death because of head trauma.

CONCLUSION

Intraabdominal injuries in children with AWB after MVC are frequent. Associated lumbar fracture, the presence of free intraabdominal fluid, and pulse rate higher than 120 are significant predictors of intestinal injuries. An abdominal exploration should be considered in these patients.

Seatbelt syndrome associated with an isolated rectal injury: case report

Seatbelt syndrome is defined as a seatbelt sign associated with a lumbar spine fracture and a bowel perforation. An isolated rectal perforation due to seatbelt syndrome is extremely rare. There is only one case reported in the Danish literature and non in the English literature. A 48-year old front seat restrained passenger was involved in a head-on collision. He had lower abdominal pain and back pain. Seatbelt mark was seen across the lower abdomen. Initial trauma CT scan was normal except for a burst fracture of L5 vertebra which was operated on by internal fixation on the same day. The patient continued to have abdominal pain. A repeated abdominal CT scan on the third day has shown free intraperitoneal air. Laparotomy has revealed a perforation of the proximal part of the rectum below the recto sigmoid junction. Hartmann's procedure was performed. The abdomen was left open. Gradual closure of the abdominal fascia over a period of two weeks was performed. Postoperatively, the patient had temporary urinary retention due to quada equina injury which resolved 10 months after surgery. The presence of a seatbelt sign and a lumbar fracture should raise the possibility of a bowel injury.

Pediatric lumbar Chance fractures in British Columbia: chart review and analysis of the use of shoulder restraints in MVAs

Chance fractures of the skeletally immature spine classically occur in frontal motor vehicle accidents (MVAs) when the occupants are restrained by a lap belt only and undergo traumatic hyperflexion of the torso during the impact. We retrospectively examined all MVA-related Chance fractures at British Columbia's Children's Hospital since 1986, by collecting injury and seat-belt use information from chart data and imaging studies. Twenty-six patients were included in the study, 14 wore a lap belt only, seven wore a three-point restraint properly, and five were reportedly misusing the shoulder portion of a three-point restraint. The subjects ranged in age from 3 to 16 with a mean age of 10.6 years. Eleven of the 26 (42%) patients sustained abdominal viscera injuries, seven of the 26 patients suffered neurologic injury (spinal cord and/or spinal nerve injury) associated with their spinal fracture, with two cases of complete paralysis, and there was a 38% incidence of head injury. Concomitant injuries (i.e. to the head, abdomen and abdominal contents) tended to be mitigated by the presence of a properly worn shoulder restraint. This leads to the conclusion that Chance fractures can be sustained even when the occupant is using a shoulder belt to restrain their torso. The mechanism responsible for this is unknown. This may indicate that Chance fractures can be caused by a lesser degree of torso hyperflexion than previously thought. Alternatively, we also speculate that Chance fractures can occur while the torso is restrained by the shoulder belt if the hips submarine beneath the lap belt and the torso experiences hyperflexion secondary to forward excursion of the pelvis and legs during the collision. Future work is necessary to confirm these mechanisms and to find ways to prevent them. These studies will need to use computational or experimental child surrogates that can sit in a slouched posture and submarine during a collision.

Outcome analysis of chance fractures of the skeletally immature spine

STUDY DESIGN

Observational.

OBJECTIVE

The authors present a detailed description of 25 skeletally immature patients with Chance fractures with a mean follow-up of 6.4 years.

SUMMARY OF BACKGROUND DATA

Since the legislation mandating seat belt usage in Canada was first introduced, the fatality rate of automobile collisions has decreased significantly. However, seat belts do not result in the complete elimination of injury. Fractures of the lumbar spine due to seat belts are well recognized in adolescents and adults but there are few reports in young children.

METHODS

Radiographic images and patient records were analyzed for information on patient demographics and injury details.

RESULTS

Treatment involved either posterior instrumentation (n = 16) or a conservative approach using casting or bracing (n = 9). Concomitant injuries were documented. A deformity index was developed as a simple value to take into account the severity of both anterior loss of vertebral height and posterior distraction.

CONCLUSION

The deformity index was significantly higher in patients with a concomitants abdominal injury and significantly higher in patients managed operatively. Functional outcome scores were completed on 14 of the patients. Patients scored within the reported norms on the SF-36 version 2 but scored poorly on the pain and disability component of the AAOS lumbar specific questionnaire. These outcomes indicate a need for using an injury specific score to accurately quantify disability.

Combined Abdominal and Spine Injuries after High Energy Flexion-Distraction Trauma

Combined abdominal (AT) and spine (ST) trauma in the multiply traumatized patient (MT) requires optimal clinical management. At the Traumacenter Murnau, Germany all multiply injured patients (injury severity score ≥ 16) are registered in a large prospective database (DGU-Tramaregister). From 1 January 2002 until 31 December 2004, 731 multiply injured patients (ISS ≥ 16) were admitted to the Trauma Center Murnau. In this population, ST was diagnosed in 287 patients (39%), AT was diagnosed in 100 patients (14%), and in 35 patients (5%) a combined ST and AT was observed. The most frequent injury mechanism in patients with a combined ST and AT was high-energy flexion-distraction trauma caused by motor vehicle accident with seat belt fastened passengers, bicycle accident, and fall from great height. In the cohort group of 35 patients, 29 required either abdominal or spinal operation. In 23 patients the AT and in 18 patients the ST necessitated operation. In 14 patients both the AT and ST called for surgery. The AT was predominately treated with splenectomies, resections and suturing of the intestine. The ST resulted in 14 posterior and four postponed anterior stabilizations of the thoracolumbar and four anterior fusions of the cervical spine. Mean age of these patients was 37 years in comparison to 47 years in the control group (MT without combined AT and ST). ISS of patients with combined AT and ST was 38 points compared to 26 points in the control group, and mortality was 7% in the combined group compared to 14% in the control group. The present study documents that damage control principles applied to patients sustaining the complex combination of AT and ST can result in low mortality rates despite the severity of this injury.

Intraabdominal Injury is Common in Blunt Trauma Patients who Sustain Spinal Cord Injury

The evaluation of the abdomen in patients with spinal cord injury (SCI) is challenging for obvious reasons. There are very little data on the incidence and complications of patients who sustain SCI with concomitant intraabdominal injury (IAI). To determine the incidence and outcomes of IAI in blunt trauma patients with SCI, a trauma registry and record review was performed between January 1998 and December 2005. Baseline demographic data, Injury Severity Score, and associated IAI were collected. Two groups were established and outcomes were analyzed based on the presence or absence of IAI. Intraabdominal and hollow viscus injures were found in 15 per cent and 6 per cent, respectively, of 292 patients with blunt SCI. The presence of intraabdominal injury varied according to the level of the SCI: 10 per cent of cervical, 23 per cent of thoracic, and 18 per cent of lumbar SCI. The overall mortality was 16 per cent. The presence of intraabdominal injury was associated with longer intensive care unit length of stay (13 versus 6 days, P < 0.01), hospital length of stay (23 versus 18 days, P < 0.05), higher complication rate (46% versus 33%, P = 0.09), and higher mortality (44% versus 11%, P < 0.01) when compared with patients with SCI without IAI. Intraabdominal injuries are common in blunt SCI. Liberal evaluation with computed tomography is necessary to identify injuries early.

Distribution of Spinal and Associated Injuries in Multiple Trauma Patients

Injury to the spinal column and cord are often part of life-threatening multiple trauma. Epidemiological data could help to establish an evidence-based assessment and therapy of these patients. We present a retrospective chart analysis of 590 multiple traumatized patients admitted within a 4-year-period. Patients suffering from injuries of the spinal column were analysed regarding mechanism and distribution of their injuries to all body regions. Thirty-one percent (n = 183) of polytraumatized patients displayed a spine injury. Distribution analysis showed peaks in the cervical spine and the thoraco-lumbar junction. The risk of relevant associated injuries is mainly influenced from anatomical vicinity to the injured spinal segment. Injuries to the spinal column are frequent in the multiple trauma patients population. Diagnosed injuries to distinct body regions should make the trauma team suspicious of injury to the nearby spinal column. Appropriate treatment includes thorough assessment of all injuries to clarify the damage and carry on special protection of these spinal regions preventing from deterioration.

Ureteropelvic junction disruption and distal ureter injury associated with a Chance fracture following a traffic accident: a case report

A 10-year-old girl sustained a ureteropelvic junction disruption and distal ureter injury associated with the Chance fracture following a traffic accident. She was sitting on the rear seat of a car wearing a lap belt. Extensive small bowel mesenteric trauma was noted. Radiography revealed a left haemothorax with mediastinal shift and an unstable flexion-distraction vertebral fracture at L2 (Chance fracture). Subsequent intravenous pyelography demonstrated proximal extravasation from the right kidney without continuity to the upper and mid ureter, indicating a ureteropelvic junction avulsion or necrosis. Definitive surgery was delayed until day 33 because of urosepsis. Due to extensive small bowel resection, ischaemia of the ureter, and the history of urosepsis, a right subcapsular nephrectomy (rather than ureteral reconstruction) was considered the safest option for minimising further complications. It is important that trauma specialists recognise additional injuries after major trauma. Early use of a multidisciplinary approach is recommended to reduce morbidity and mortality.

The complexity of seat belt injuries including spinal injury in the pediatric population: a case report of a 6-year-old boy and the literature review

We present, along with a literature review, the case report of a 6-year-old boy, involved in a high-speed motor vehicle accident, who sustained a seat belt injury of the lumbar spine. We discuss the clinical presentation of thoracolumbar fractures in children, the sensitivity of clinical examination and radiographic evaluation and the associated abdominal injuries that are commonly present with seat belt spinal injuries. Computerized tomography is limited in the detection of soft tissue spinal fractures because these fractures occur in the plain of the section. Plain lateral x-rays of the lumbar spine and computerized tomographic three-dimensional reconstruction images can be helpful but they cannot evaluate the extent of the soft tissue injury. The magnetic resonance imaging scan is the best diagnostic tool to provide the diagnosis.

Reconstruction of crashes involving injured child occupants: the risk of serious injuries associated with sub-optimal restraint use may be reduced by better controlling occupant kinematics

OBJECTIVE

To determine whether injuries to sub-optimally restrained child occupants in real-world crashes were likely to be preventable by alternative restraint usage practices and to assess the usefulness of crash reconstruction for exploring injury mechanisms in child occupants.

METHODS

Real-world crashes in which child occupants sustained significant injuries were reconstructed on a laboratory crash sled using the Hybrid III family of child dummies. Alternative restraint scenarios and cases in which children were not seriously injured were also simulated to compare dummy kinematics and dynamic responses in optimal restraint configurations.

RESULTS

Restraint misuse was associated with greater motion of the dummy torso and head during crashes, often allowing contact between the child and the vehicle interior, resulting in injury. Poor pre-crash posture for a child inappropriately restrained in an adult belt appeared to worsen the geometry of the sash (shoulder) belt, resulting in a cervical injury due to direct interaction with the belt. Dynamic dummy data did not appear to discriminate between injury and non-injury cases.

CONCLUSIONS

Dummy kinematics suggest that injuries in which inappropriate use and misuse were a factor were less likely if the most appropriate restraint was used correctly. Adequately controlling the head and upper body of the child occupant was seen to prevent undesirable interactions with the vehicle interior and restraint system, which were associated with injury in the real world. Neck forces and moments and injury criteria calculated from these did not predict injury reliably.

[Seat belt syndrome. Acute spinal cord injury due to incorrect use of two-point seat belts]

Traumatic spinal cord injury (SCI) is a rare entity in the pediatric age group. These injuries are mainly caused by road traffic accidents (RTA), especially in children not wearing a seat belt. The use of child safety devices such as seat belt restraints has decreased morbidity and mortality in RTA but their incorrect use can also produce serious injuries that are grouped under the term "seat-belt syndrome". This syndrome associates vertebral and spinal cord injuries, intra-abdominal, cutaneous, and muscle-skeletal lesions. We present three patients with complete spinal cord and intra-abdominal injuries, requiring urgent surgery in two of them. On examination, all three patients had seat belt marks on the lower abdominal region. The three patients can be included in this syndrome and its main cause was the use of a two-point seat belt.

Lapbelt injuries and the seatbelt syndrome in pediatric spinal cord injury

BACKGROUND/OBJECTIVE

Approximately 250,000 patients are presently living with spinal cord injury (SCI) in the United States. Approximately 20% of patients with SCI are less than 20 years old, and 15% are less than 15 years old. The most common cause of pediatric SCI is a motor vehicle collision (MVC; approximately 40%); lapbelt injuries and the seatbelt syndrome are seen more often in children involved in MVCs.

METHODS

A search and analysis of current literature on lapbelt injuries, seatbelt syndrome, and pediatric SCI using PubMed.

RESULTS

Children involved in MVCs who are improperly restrained are at higher risk of sustaining injuries. The risk of significant intra-abdominal injuries is increased almost fourfold in these children. Presence of abdominal wall ecchymosis (AWE) was associated with intra-abdominal injuries in up to 84% of children, with hollow viscus injury being the most common. Likewise, presence of AWE is associated with vertebral fractures, including Chance fractures, in up to 50% of patients. Vertebral fractures were associated with SCI in up to 11%. The presence of AWE in an improperly restrained child should warrant a thorough search for intra-abdominal injuries, vertebral fractures, and SCI.

CONCLUSIONS

Lapbelt injuries and the seatbelt syndrome are often associated with pediatric SCI in improperly restrained children. This injury complex and its associated abdominal injuries are difficult to diagnose unless a high index of suspicion is maintained; delay in diagnosis increases morbidity, and early surgical intervention should be considered.

Chance-Type Fractures of the Thoracolumbar Spine: Imaging Analysis in 53 Patients

OBJECTIVE

Chance-type fractures are subtle unstable injuries that are often associated with intraabdominal injuries. CT-based observations made during routine interpretations revealed involvement of a burst component to this fracture pattern and a clue on the transaxial images to its presence. The purpose of this review was to determine how often these features occurred in a retrospective study of a large sample because these findings influence diagnosis and management.

MATERIALS AND METHODS

A retrospective review of all patients identified from the University of Maryland Shock Trauma Center trauma registry and IDXRad system diagnosed with flexion-distraction injuries of the thoracolumbar spine over an 8-year period was performed. Three trauma radiologists assessed the admission spinal radiographs, CT studies with multiplanar images, and available MRI examinations. Imaging findings were confirmed by consensus. Abdominopelvic CT studies and surgical reports were reviewed for evidence and type of intraabdominal injury. A literature review of previous similar series was performed.

RESULTS

Fifty-three patients were identified for inclusion in the study. Associated intraabdominal injury occurred in 40% and most commonly involved the bowel and mesentery. A close examination of the fracture patterns on CT revealed that a burst-type fracture with posterior cortex buckling or retropulsion was a common finding (48%). Also, serial transaxial CT images often (76%) showed a gradual loss of definition of the pedicles that we refer to as the "dissolving pedicle" sign. The study showed that the horizontally oriented fracture planes through the posterior elements can often be recognized radiographically, but these fractures can be very subtle.

CONCLUSION

Intraabdominal injuries occurred in 40% of flexion-distraction thoracolumbar fractures in our study cohort, which is slightly lower than previously reported. About half of the patients with this injury displayed a burst-type component that could have a significant influence on surgical management. The dissolving pedicle sign can assist in recognition of this often subtle injury on transaxial CT.

Paediatric lap-belt injury: A 7 year experience

OBJECTIVE

To highlight the injuries that result from lap-belt use and make recommendations for prevention, the recent experience of a regional paediatric trauma centre was reviewed.

METHODS

Retrospective review of admissions to Starship Children's Hospital from 1996 to 2003, with significant injury following involvement in a motor vehicle crash, while wearing a lap-belt. Patients were identified from two prospectively collected databases and discharge coding data.

RESULTS

In total, 19 patients were identified over the 7 year period. The morbidity sustained includes 15 patients with hollow viscus injury, 13 laparotomies, 7 spinal fractures, 2 paraplegia and 1 fatality. A total of 11 patients required laparotomy with a median delay of 24 h. Of patients in the present series, 58% were aged less than 8 years and thus were inappropriately restrained.

CONCLUSIONS

Lap-belt use can result in a range of life-threatening injuries or permanent disability in the paediatric population. The incidence of serious lap-belt injury does not appear to be decreasing. Morbidity and mortality could be reduced by the use of three-point restraints, age appropriate restraints and booster seats.

Diagnostic errors in polytrauma: a structured review of the recent literature

Clinically important diagnostic errors are relatively common among polytrauma patients (2-40%). Errors are not random; they are more frequent in the spine and periarticular appendicular skeleton, especially in hemodynamically unstable patients who require resuscitation or operative intervention before completion of secondary or tertiary clinical survey. Misleading history, distracting findings, and misjudgments all contribute to risks of diagnostic errors.

The Clinical Presentation of Pediatric Thoracolumbar Fractures

BACKGROUND

The initial evaluation of suspected pediatric thoracolumbar fractures can be challenging. We aimed to describe the clinical presentation of thoracolumbar fractures in children and adolescents including an evaluation of physical examination sensitivity and specificity, and a description of injury severity and disposition.

METHODS

This was a case control, retrospective study. All patients with radiologically proven fractures (January 1997-June 2001) were studied. Data were collected in a standardized fashion, as part of the trauma registry, and extracted for retrospective analysis, including: patient demographics, clinical acuity, mechanism of injury, injury scores, and length of stay.

RESULTS

There were 96 patients with thoracolumbar fractures (TLF) and 96 control patients (NTLF) enrolled in our study. The groups were significantly different (p < 0.05) regarding several variables including: median age (11 years TLF, 7.5 years NTLF), Revised Trauma Score (7.84 for TLF, 7.55 for NTLF), need for hospital admission (60% TLF, 86% NTLF), PICD admission (23% TLF, 56% NTLF), general surgical procedures (18%TLF, 34% NTLF), Injury Severity Score (8 TLF, 10NTLF). Patients were not different regarding gender, Glasgow Coma Scale, hospital days, or mortality. An abnormal thoracolumbar spine examination was noted in 77 TLF patients and 20 NTLF patients, the sensitivity was 87% (95% CI: 78-93) and the specificity was 75% (95% CI: 65-84). The most common thoracolumbar spine abnormality was tenderness.

CONCLUSIONS

Thoracolumbar spine fractures are more common in older children and adolescents. The physical examination has a sensitivity of 87% in this retrospective analysis. Mortality was low and few patients required operative intervention for a thoracolumbar fracture.

Spine and Spinal Cord Injury in Motor Vehicle Crashes: A Function of Change in Velocity and Energy Dissipation on Impact with Respect to the Direction of Crash

OBJECTIVE

To examine the effect of change in velocity (DeltaV) and energy dissipation (IE) on impact, above and below the test levels for Federal MVC Safety Standards, on the incidence of spine fractures (SF), spinal cord injury (SCI)), SF mortality and the associated injury patterns in Frontal (F) and Lateral (L) MVCs. Comparison of 214 patients with SF or SCI with 938 patients who did not have SF or SCI.

METHODS

1152 MVC adult drivers or front-seat passengers (701 F & 451 L) evaluated at 10 Level I CIREN study Trauma Centers together with vehicle and crash scene engineering reconstruction. Patient seat belt (SB) and/or airbag (AB) use correlated with clinical, or autopsy findings.

RESULTS

The relationship between DeltaV and IE rose exponentially as DeltaV increased. Of the 1152 patients, all with AIS> or =3 injuries, there were 214 patients with spine fractures of AIS > or =2. In FMVCs there were more SF patients with Cervical SF than in LMVCs (68F versus 64 L) and more Thoracic (35F versus 21L) and Lumbar (39F versus 16L) SF. However, the incidence of spinal cord injury was greatest in the Cervical SF (33%), compared with the Thoracic SF (18%), or Lumbar SF (2%). Most important, in FMVCs 49% of SF, 47% of SCI and 71% of the SF deaths (p < 0.05) occurred at > mean of 47.4 kph. In contrast, in LMVCs 51% of SF, 52% of SCI and 67% of the SF deaths occurred at DeltaV > mean of 35.3 kph. However, 80% of all deaths in SCI occurred in Cervical SF cases, in these 74% also had a brain injury. In contrast, the deaths in Thoracic SF were due to combinations of brain (45%), thorax (95%) or associated pelvic fracture injuries (50%). Airbag (AB), or Seat belt (SB) restraints appeared to protect FMVC SF patients from SCI at lower DeltaV, but 84% of Cervical SCI patients at DeltaV > 47 kph had AB protection and in a few cases the AB appeared responsible for the SCI. In contrast, 82% of Lumbar SF patients had SB, but in FMVCs where jackknifing due to backloading occurred, improper SB positioning may have contributed to the SF.

CONCLUSIONS

The implication for SCI in both front seat drivers and passengers in either FMVC or LMVC crashes above their respective DeltaV means is that improved spine fracture protection is necessary at higher DeltaV levels. More effective safety systems to prevent Cervical SCIs should be developed using two-level frontal and side AB & SB+pretensioner devices, which protect against SF at DeltaV both at and 1SD above the FMVC (47 & 72 kph = 30 & 45 mph) and LMVC (35 & 54 kph =22 & 34 mph) means.

The Association between Chance Fractures and Intra-abdominal Injuries Revisited: A Multicenter Review

The association between Chance fractures and intra-abdominal injuries is reported to be as high as 89 per cent. Because prior studies were small series or case reports, we conducted a multicenter review to learn the true association between Chance fractures and intra-abdominal injuries as well as diagnostic trends. Trauma registry data, medical records, and radiology reports from 7 trauma centers were used to characterize 79 trauma patients with Chance fractures. Initial methods of abdominal assessment were computed tomography (CT) scan (79%), clinical examination (16%), and diagnostic peritoneal lavage (DPL) (5%). Twenty-six (33%) patients had intraabdominal injuries of which hollow viscus injuries predominated (22%). Twenty patients (25%) underwent laparotomy. The presence of an abdominal wall contusion and automobile restraint use were highly predictive of intra-abdominal injury and the need for laparotomy. The association between a Chance fracture and intra-abdominal injury is not as high as previously reported. CT scan has become the primary modality to assess the abdominal cavity of patients with Chance fractures, whereas the role of DPL has diminished.

Schockraummanagement bei Verletzungen der Wirbels�ule im Rahmen eines Polytraumas

Injuries to the spine are often part of life-threatening multiple trauma. In this review diagnostics and emergency room management were investigated in order to formulate effective recommendations for the emergency strategy. Clinical trials were systematically collected (MEDLINE, Cochrane, and hand searches) and classified into evidence levels (1 to 5 according to the Oxford system). The patient's history and clinical symptoms have low rates for specificity and positive predictive value, whereas their negative predictive value and sensitivity are high between 90 and 100%, respectively. CT imaging reaches higher rates for sensitivity, specificity, and positive and negative predictive values in comparison to conventional radiographic series. The patient's history should be asked and clinical investigation should be done in any case. Imaging diagnostics preferably as multislice spiral CT should be performed after stabilization of the patient's general condition and before admission to the intensive care unit.

Conus medullaris and cauda equina syndrome as a result of traumatic injuries: management principles

Conus medullaris syndrome (CMS) and cauda equina syndrome (CES) are complex neurological disorders that can be manifested through a variety of symptoms. Patients may present with back pain, unilateral or bilateral leg pain, paresthesias and weakness, perineum or saddle anesthesia, and rectal and/or urinary incontinence or dysfunction. Although patients typically present with acute disc herniations, traumatic injuries at the thoracolumbar junction at the terminal portion of the spinal cord and cauda equina are also common. Unfortunately, a precise understanding of the pathophysiology and optimal treatments, including the best timing of surgery, has yet to be elucidated for either traumatic CES or CMS. In this paper the authors review the current literature on traumatic conus medullaris and cauda equina injuries and available treatment options.

Posterolateral approach in the treatment of unstable vertebral body fractures of the thoracic-lumbar junction with incomplete spinal cord injury in the paediatric age group

OBJECTS

Our retrospective study was carried out to demonstrate the value of, indications for, and results of use of the posterolateral approach (PLA) with decompression and instrumental stabilisation in paediatric patients with unstable vertebral body fractures at the thoracic-lumbar junction.

METHODS

Fourteen patients aged 7-14 years were operated on from 1990 to 2000. All these patients were admitted with unstable vertebral body fractures at the thoracic-lumbar junction with incomplete spinal injuries and were operated on within 24 h after sustaining the trauma: a PLA was used to achieve unilateral or bilateral spinal canal decompression and instrumental stabilisation with the Cotrel-Dubousset instrumentation.

RESULTS

A good neurological recovery was noted in 13 patients (4/13 Frankel D and 9/13 Frankel E) during 1 year of follow-up. The postoperative anterior-posterior diameter of the spinal canal was evaluated by percentile referred to an average value between the measurements at the superior and inferior levels. The radiographic control estimated the vertebral alignment. An important tendency to hyperkyphosis in 1 patient necessitated surgical correction after 1 month in the interests of a good vertebral alignment.

CONCLUSIONS

The PLA makes if possible to define a proper surgical corridor to accomplish all surgical goals in the treatment of spinal fractures in children: decompression, spinal alignment and stabilisation minimising the surgical stress, that are essential in paediatric surgery. It allows early mobilisation and an early start on the rehabilitative treatment, which is very important in children and is difficult to reconcile with bracing and a long period of bed rest as recommended for conservative treatment.