Lapbelt injuries and the seatbelt syndrome in pediatric spinal cord injury

Pediatric motor vehicle crashes injuries: A systematic review for forensic evaluation

Children involved in car crashes can experience either direct trauma or inertial injuries resulting from interactions with external objects, such as other vehicles, or with the restraint system. Furthermore, improper use of restraint systems can lead to additional severe injuries. Recent reports from international institutions underscored the persistent prevalence of inadequate restraint systems utilization and this widespread issue increases children's vulnerability and risk of injuries.The aim of this study is to provide a systematic review of the literature on injuries sustained in children involved in road accidents describing and analyzing elements useful for forensic assessment.The literature search was performed using PubMed, Scopus and Web of Science from January 1970 to March 2023. Eligible studies have investigated issues of interest to forensic medicine about traffic accidents involving pediatric passengers. A total of 69 studies satisfied the inclusion criteria and were categorized and analyzed according to the anatomical regions of the body affected (head, neck, thoraco-abdominal, and limb injuries), and the assessment of lesions in reconstruction of the accident was examined and discussed.The review highlights that in motor vehicle accidents involving children, the forensic evaluation of both the cause of death and accident dynamics needs to consider several factors, such as the child's age, the type of restraint system employed, and the specific passenger seat occupied. Considering the complexity of the factors that can be involved in this road accident, it is crucial that there is a comprehensive exchange of information between the judge and the medical expert.

Pediatric chance fracture with seatbelt syndrome: A case report

Key Clinical Message

Prompt recognition and accurate diagnosis of seatbelt-related injuries such as Chance fractures are crucial for pediatric patients. Clinicians should be aware of the unique characteristics of children, including the presence of growth plates, and use advanced imaging techniques such as magnetic resonance imaging to guide appropriate treatment and minimize complications.

Abstract

Seatbelt-related injuries, known as the "seatbelt syndrome," encompass various injuries resulting from automobile accidents, including vertebral fractures, abdominal injuries, and great vessel traumas. Seatbelt signs include bruising or peeling of the anterior chest or abdominal wall, indicating abdominal pressure against the seatbelt. Chance fractures are a type of vertebral fracture characterized by fracture lines through multiple vertebral structures and are often associated with seatbelt injuries in adults. However, the unique features of Chance fractures in pediatric patients, such as the presence of growth plates, require a comprehensive diagnostic approach using advanced imaging techniques, including magnetic resonance imaging (MRI). This case report highlights the complexity of seatbelt-related injuries in children and emphasizes the importance of accurate diagnosis and multidisciplinary management. Understanding these factors can improve clinical knowledge and outcomes in children with seatbelt-related injuries.

Pediatric Spinal Cord Injury: A Review

A spinal cord injury (SCI) can be a devastating condition in children, with profound implications for their overall health and quality of life. In this review, we aim to provide a concise overview of the key aspects associated with SCIs in the pediatric population. Firstly, we discuss the etiology and epidemiology of SCIs in children, highlighting the diverse range of causes. We explore the unique anatomical and physiological characteristics of the developing spinal cord that contribute to the specific challenges faced by pediatric patients. Next, we delve into the clinical presentation and diagnostic methods, emphasizing the importance of prompt and accurate diagnosis to facilitate appropriate interventions. Furthermore, we approach the multidisciplinary management of pediatric SCIs, encompassing acute medical care, surgical interventions, and ongoing supportive therapies. Finally, we explore emerging research as well as innovative therapies in the field, and we emphasize the need for continued advancements in understanding and treating SCIs in children to improve their functional independence and overall quality of life.

Clinical characteristics and treatment of spinal cord injury in children and adolescents

Pediatric and adult spinal cord injuries (SCI) are distinct entities. Children and adolescents with SCI must suffer from lifelong disabilities, which is a heavy burden on patients, their families and the society. There are differences in Chinese and foreign literature reports on the incidence, injury mechanism and prognosis of SCI in children and adolescents. In addition to traumatic injuries such as car accidents and falls, the proportion of sports injuries is increasing. The most common sports injury is the backbend during dance practice. Compared with adults, children and adolescents are considered to have a greater potential for neurological improvement. The pathogenesis and treatment of pediatric SCI remains unclear. The mainstream view is that the mechanism of nerve damage in pediatric SCI include flexion, hyperextension, longitudinal distraction and ischemia. We also discuss the advantages and disadvantages of drugs such as methylprednisolone in the treatment of pediatric SCI and the indications and timing of surgery. In addition, the complications of pediatric SCI are also worthy of attention. New imaging techniques such as diffusion tensor imaging and diffusion tensor tractography may be used for diagnosis and assessment of prognosis. This article reviews the epidemiology, pathogenesis, imaging, clinical characteristics, treatment and complications of SCI in children and adolescents. Although current treatment cannot completely restore neurological function, patient quality of life can be enhanced. Continued developments and advances in the research of SCI may eventually provide a cure for children and adolescents with this kind of injury.

Seatbelt use and risk of major injuries sustained by vehicle occupants during motor-vehicle crashes: a systematic review and meta-analysis of cohort studies

Background

In 2004, a World Health Report on road safety called for enforcement of measures such as seatbelt use, effective at minimizing morbidity and mortality caused by road traffic accidents. However, injuries caused by seatbelt use have also been described. Over a decade after publication of the World Health Report on road safety, this study sought to investigate the relationship between seatbelt use and major injuries in belted compared to unbelted passengers.

Methods

Cohort studies published in English language from 2005 to 2018 were retrieved from seven databases. Critical appraisal of studies was carried out using the Scottish Intercollegiate Guidelines Network (SIGN) checklist. Pooled risk of major injuries was assessed using the random effects meta-analytic model. Heterogeneity was quantified using I-squared and Tau-squared statistics. Funnel plots and Egger’s test were used to investigate publication bias. This review is registered in PROSPERO (CRD42015020309).

Results

Eleven studies, all carried out in developed countries were included. Overall, the risk of any major injury was significantly lower in belted passengers compared to unbelted passengers (RR 0.47; 95%CI, 0.29 to 0.80; I² = 99.7; P = 0.000). When analysed by crash types, belt use significantly reduced the risk of any injury (RR 0.35; 95%CI, 0.24 to 0.52). Seatbelt use reduces the risk of facial injuries (RR = 0.56, 95% CI = 0.37 to 0.84), abdominal injuries (RR = 0.87; 95% CI = 0.78 to 0.98) and, spinal injuries (RR = 0.56, 95% CI = 0.37 to 0.84). However, we found no statistically significant difference in risk of head injuries (RR = 0.49; 95% CI = 0.22 to 1.08), neck injuries (RR = 0.69: 95%CI 0.07 to 6.44), thoracic injuries (RR 0.96, 95%CI, 0.74 to 1.24), upper limb injuries (RR = 1.05, 95%CI 0.83 to 1.34) and lower limb injuries (RR = 0.77, 95%CI 0.58 to 1.04) between belted and non-belted passengers.

Conclusion

In sum, the risk of most major road traffic injuries is lower in seatbelt users. Findings were inconclusive regarding seatbelt use and susceptibility to thoracic, head and neck injuries during road traffic accidents. Awareness should be raised about the dangers of inadequate seatbelt use. Future research should aim to assess the effects of seatbelt use on major injuries by crash type.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6280-1) contains supplementary material, which is available to authorized users.

Continuous hemoglobin monitoring in pediatric trauma patients with solid organ injury

BACKGROUND/PURPOSE

Hemoglobin monitoring is required in pediatric trauma patients with solid organ injury. We hypothesized that noninvasive hemodynamic monitoring (NIHM) represents an effective, safe alternative to laboratory hemoglobin (LabHb) monitoring in clinically stable patients.

METHODS

A retrospective cohort study was conducted regarding pediatric trauma patients (<18 years old) with blunt solid organ injury over six consecutive months. Continuous NIHM was initiated at the time of admission, and LabHb measurements were obtained per institutional guidelines. Measurements were correlated within two hours of assessment and patient outcomes were analyzed.

RESULTS

Twenty-one patients met inclusion criteria and had evaluable data. Blunt trauma was the exclusive mechanism of injury, and mean injury severity score was 16.6 for the cohort. Bland Altman analysis showed an average deviation of 0.80 g/dL between NIHM and LabHb values for all data pairs. Measurement trends were highly correlated in patients with stable hemoglobin levels and those requiring blood transfusion.

CONCLUSIONS

NIHM demonstrated clinically acceptable accuracy when following hemoglobin trends in the defined pediatric trauma patient population. Slight variances between NIHM and LabHb values were occasionally noted, but did not affect clinical management. Continuous NIHM represents a potentially valuable adjunct to traditional laboratory hemoglobin monitoring.

LEVEL OF EVIDENCE RATING

IV.

Epidemiology of Pediatric Traumatic and Acquired Nontraumatic Spinal Cord Injury in Ireland

Objective: To examine the epidemiology of pediatric traumatic (TSCI) and acquired nontraumatic spinal cord injury (NTSCI) in Ireland. There are few studies reporting pediatric TSCI incidence and fewer of pediatric NTSCI incidence, although there are several case reports. As there is a single specialist rehabilitation facility for these children, complete population-level data can be obtained. Method: Retrospective review of prospectively gathered data in the Patient Administration System of the National Rehabilitation Hospital of patients age 15 years or younger at the time of SCI onset. Information was retrieved on gender, age, etiology, level of injury/AIS. Population denominator was census results from 1996, 2002, 2006, and 2011, rolled forward. Results: Since 2000, 22 children have sustained TSCI and 26 have sustained NTSCI. Median (IQR) age at TSCI onset was 6.3 (4.4) years, and at NTSCI onset it was 7.3 (8.1) years. Most common TSCI etiology was transportation (n = 10; 45.5%), followed by surgical complications (n = 8; 36.4%); most common injury type was complete paraplegia (n = 12; 54.5%) followed by incomplete paraplegia (n = 5; 22.7%). Most common NTSCI etiology was transverse myelitis (n = 11; 42.3%) followed by vascular (n = 5; 20%); most common injury type was incomplete paraplegia (n = 17; 65.4%) followed by incomplete tetraplegia (n = 6; 24%). Incidence of TSCI ranged from 0 to 3.1 per million per year; incidence of NTSCI ranged from 0 to 6.5 per million per year. Conclusion: Incidence of SCI in Ireland seems similar to or slightly lower than other developed countries. Injury patterns are also similar, considering variations in reporting methods.

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.

Abdominal injury patterns in patients with seatbelt signs requiring laparotomy

Aims:

We analyzed our series of patients with seatbelt signs (bruising) that underwent laparotomy in order to correlate injury pattern with clinical course and outcome.

Materials and Methods:

Retrospective analysis of patients with seatbelt signs presenting to the level 1 Trauma Unit between 2005 and 2010 was performed. We evaluated the nature of injuries during laparotomy associated with seatbelt signs and their treatment and complications.

Results:

There were 41 patients, 25 (61%) male, with a median age of 26 years. Median injury severity score (ISS) was 25 (range 6–66) and overall mortality was 10% (four patients). Patients were classified into three groups according to time from injury to surgery. Median time to surgery for the immediate group (n = 12) was 1.05 h, early group (n = 22) was 2.7 h, and delayed group (n = 7) was 19.5 h. Patients in the immediate group tended to have solid organ injuries; whereas, patients in the delayed group had bowel injury. Patients with solid organ injuries were found to be more seriously injured and had higher mortality (P < 0.01) and morbidity compared with patients with the “classic” bowel injury pattern associated with a typical seatbelt sign.

Conclusion:

Our data suggest that there is a cohort of patients with seatbelt injury who have solid organ injury requiring urgent intervention. Solid organ injuries associated with malpositioned seatbelts lying higher on the abdomen tend to result in hemodynamic instability necessitating immediate surgery. They have more postoperative complications and a greater mortality. Seatbelt signs should be accurately documented after any car crash.

Dilemma of Blunt Bowel Injury: What are the Factors Affecting Early Diagnosis and Outcomes

Blunt bowel and mesenteric injury (BBMI) is frequently a difficult diagnosis at initial presentation. We aimed to study the predictors for early diagnosis and outcomes in patients with BBMI. Data were collected retrospectively from the database registry between January 2008 and December 2011 in the only Level I trauma unit in Qatar. Patients with BBMI were divided into Group A (surgically treated within 8 hours) and Group B (treated after 8 hours). Data were analyzed and χ2, Student's t test, and multivariate regression analysis were performed appropriately. Among 984 patients admitted with blunt abdominal trauma (BAT), 11 per cent had BBMI with mean age of 35 ± 9.5 years. Polytrauma and isolated bowel injury were identified in 53 and 42 per cent, respectively. Mean Injury Severity Score (ISS) was higher in Group A in comparison to Group B (18 ± 11 vs 13 ± 8; P = 0.02). Presence of pain and seatbelt sign ( P = 0.02) were evident in Group B. Hypotension ( P = 0.004) and hypothermia ( P = 0.01) were prominent in Group A. The rate of positive Focused Assessment Sonography for Trauma was greater in Group A ( P = 0.001). Among operative findings, bowel perforation was more frequent in Group B ( P = 0.04), whereas mesenteric full-thickness hematoma was significantly higher in Group A. Pelvic fracture was more frequent finding in Group A ( P = 0.005). The overall mortality rate was 15.6 per cent. In patients with BAT, the presence of abdominal pain, hypotension, ISS greater than 16, hypothermia, pelvic fracture, and mesenteric hematoma might help in early diagnosis of BBMI. Moreover, base deficit and mean ISS were independent predictors of mortality. Delayed operative interventions greater than 8 hours increased morbidity rate but had no significant impact on mortality.

A comparison of injuries, crashes, and outcomes for pediatric rear occupants in traffic motor vehicle collisions

BACKGROUND

This study was initiated was initiated to describe pediatric rear-occupant motor vehicle collision (MVC) injuries, including injury patterns and outcomes as well as characteristics associated with severe injury to the head and abdomen.

METHODS

A retrospective cohort of severely injured (Injury Severity Score [ISS] > 12) pediatric (age <18 years) patients involved in a traffic MVC as a rear occupant and treated at one of two Ontario trauma centers (2001-2010) was studied was studied. Demographic, injury, crash and outcome data were obtained from the trauma registries. Data were statistically compared by two pediatric age groups: children (0-8 years; requiring a child or booster seat) versus adolescents (9-17 years; requiring a lap-shoulder belt).

RESULTS

There were 36 children (34%) and 70 adolescents (66%) severely injured as rear occupants in MVCs. Despite similar ISS (p = 0.716) and mortality rates (p = 0.680) between age groups, there were significant differences in injury patterns and risk factors. Children were more likely to have severe head injuries (78% vs. 39%, p < 0.001) associated with a lack of an age-appropriate child restraints (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.1-10.8; p = 0.029), middle seating (OR, 6.2; 95% CI, 1.5-26.1; p = 0.013), and side-impact crashes (p = 0.007). Adolescents were more likely to have severe abdominal injuries (23% vs. 6%, p < 0.001) associated with the use of lap-shoulder belts (OR, 3.8; 95% CI, 1.1-13.3; p = 0.034), single-vehicle MVCs (p = 0.007), and vehicle extrications (p = 0.035).

CONCLUSION

While safer than the front seat for children, additional study is needed on the restraint systems and the potential for injury to pediatric rear occupants in an MVC. Our data suggest that pediatric age groups differ in injuries, risk factors, and MVC impacts. Recommendations for improved protection of child occupants and preferred seating positions are required.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

Optimizing the rear seat environment for older children, adults, and infants

OBJECTIVE

Our recent rear seat safety research found that more-forward and higher lap belt anchorage locations and much shorter and stiffer seat cushions can improve the protection of older children from 6 to 12 years old who are using the vehicle belt without a booster. The objective of this study was to investigate whether the optimal rear seat restraint systems for adults and infants are consistent with those for older children.

METHODS

We conducted sensitivity analyses and design optimizations for adults and for infants in a rear-facing child restraint system (CRS) using a set of MADYMO models, an automated simulation framework, and occupant belt-fit and posture prediction models from our previous studies. A series of 12 sled tests was also used to validate the computational models.

RESULTS

The optimal belt anchorage locations and the seat cushion length for older children, adults, and rear-facing CRS-seated infants conflict with each other. In particular, more-forward lap belt anchorage locations that prevent submarining for older children would reduce the protection to both adults and CRS-seated infants, although the protection is still acceptable based on regulated injury criteria. A shorter seat cushion could provide optimal protection to older children and adults but would significantly increase the CRS rotation.

CONCLUSIONS

The findings of this study suggested that adaptive/adjustable restraint systems are necessary to simultaneously improve the rear seat occupant protection for all age groups. Supplemental materials are available for this article. Go to the publisher's online edition of Traffic Injury Prevention to view the supplemental file.

Seatbelt: a double-edged sword

Intra-abdominal vascular injury due to blunt trauma is unusual in children. Due to its rarity, detailed reports dealing with its management are scarce in paediatric literature. Diagnosis of these injuries is challenging, and a high degree of awareness is necessary for rapid identification and treatment of these injuries. We report the case of a child with seatbelt sign and mesenteric vein injury due to blunt trauma to the abdomen during a motor vehicle accident where the seatbelt was incorrectly placed. She also sustained cervical vertebral injury. The pattern of injuries in children in these situations may differ from that found in adults. While seatbelts have undoubtedly saved many lives, awareness about correct placement of these restraints is extremely necessary.

Pediatric Chance fractures: a multicenter perspective

BACKGROUND

Chance fractures or flexion-distraction injuries of the spine are uncommon in children. Previous reports have been limited to isolated case reports or very small retrospective series. This is the largest series reported in the English literature.

METHODS

This was a multicenter retrospective review of pediatric Chance fractures treated at 3 large level-1 pediatric trauma centers. We analyzed the demographics, causes, circumstances, treatment, complications, and clinical outcome of 35 patients younger than 18 years old with a Chance fracture. We hypothesize that surgical treatment provides the best results.

RESULTS

There were 20 females and 15 males, with an average age of 9 years (range, 1.6 to 17 y). The most common level of injury was at L2 and L3 (20/35). Fifteen children (43%) had a neurological deficit at the time of injury and only 8 fully recovered. One patient deceased before formal orthopaedic treatment. Patients were treated at the discretion of the surgeon and the surgically treated group (20/34) had greater initial kyphotic deformity (22 degrees) than those treated nonoperatively (14/34; 11.4 degrees) and less posttreatment residual kyphotic deformity (3.5 vs. 20 degrees, respectively). The complication rate related to treatment was 26% (9/34) and most complications in the nonoperative group were related to progression of kyphosis whereas in the surgical group most complications are related to discomfort over the hardware (4 patients). Fifteen children (43%) had neurological deficit at presentation, 7 did not fully recover, for an incidence of permanent neurologic deficit of 10% among restrained patients versus 42% for unrestrained patients. Twenty-one patients (62%) had a good final clinical outcome defined by no chronic pain or neurologic deficit, this represented 45% good outcome in the nonoperative group compared with 84% in the operative group (NS).

CONCLUSIONS

In this multicenter retrospective study, surgical treatment of Chance fractures in children seems to produce better clinical outcome, the appropriate use of restraints reduce the incidence of definitive neurologic deficit.

LEVEL OF EVIDENCE

Level 3, comparative study.

Spinal cord injuries in children and adolescents

This chapter provides an overview of spinal cord injuries (SCI) in children and adolescents, including epidemiology, medical and musculoskeletal complications, rehabilitation and psychosocial aspects. Males are more commonly affected than females during adolescence; however, as the age at injury decreases, the preponderance of males becomes less marked, and by 3 years of age the number of females with SCIs equals that of males. The neurologic level and degree of completeness varies with age; among children injured prior to 12 years of age approximately two-thirds are paraplegic and approximately two-thirds have complete lesions. Among adolescents, approximately 50% have paraplegia and 55% have complete lesions. Management of pediatric-onset SCI should be family centered and developmentally based, responsive to the dynamic changes that occur during growth and development. Distinctive anatomical and physiological features of children and adolescents, along with growth and development, are responsible for unique manifestations and complications of pediatric SCI. SCI without radiological abnormalities (SCIWORA), birth injuries, lap-belt injuries, upper cervical injuries, and the delayed onset of neurological deficits are relatively unique to pediatric SCI. Children who sustain their SCI before puberty experience a higher incidence of musculoskeletal complications, such as scoliosis and hip dislocation.

Development and validation of a modified Hybrid-III six-year-old dummy model for simulating submarining in motor-vehicle crashes

In motor-vehicle crashes, young school-aged children restrained by vehicle seat belt systems often suffer from abdominal injuries due to submarining. However, the current anthropomorphic test device, so-called "crash dummy", is not adequate for proper simulation of submarining. In this study, a modified Hybrid-III six-year-old dummy model capable of simulating and predicting submarining was developed using MADYMO (TNO Automotive Safety Solutions). The model incorporated improved pelvis and abdomen geometry and properties previously tested in a modified physical dummy. The model was calibrated and validated against four sled tests under two test conditions with and without submarining using a multi-objective optimization method. A sensitivity analysis using this validated child dummy model showed that dummy knee excursion, torso rotation angle, and the difference between head and knee excursions were good predictors for submarining status. It was also shown that restraint system design variables, such as lap belt angle, D-ring height, and seat coefficient of friction (COF), may have opposite effects on head and abdomen injury risks; therefore child dummies and dummy models capable of simulating submarining are crucial for future restraint system design optimization for young school-aged children.

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.

Molecular Mechanisms Underlying Cell Death in Spinal Networks in Relation to Locomotor Activity After Acute Injury in vitro

Understanding the pathophysiological changes triggered by an acute spinal cord injury is a primary goal to prevent and treat chronic disability with a mechanism-based approach. After the primary phase of rapid cell death at the injury site, secondary damage occurs via autodestruction of unscathed tissue through complex cell-death mechanisms that comprise caspase-dependent and caspase-independent pathways. To devise novel neuroprotective strategies to restore locomotion, it is, therefore, necessary to focus on the death mechanisms of neurons and glia within spinal locomotor networks. To this end, the availability of in vitro preparations of the rodent spinal cord capable of expressing locomotor-like oscillatory patterns recorded electrophysiologically from motoneuron pools offers the novel opportunity to correlate locomotor network function with molecular and histological changes long after an acute experimental lesion. Distinct forms of damage to the in vitro spinal cord, namely excitotoxic stimulation or severe metabolic perturbation (with oxidative stress, hypoxia/aglycemia), can be applied with differential outcome in terms of cell types and functional loss. In either case, cell death is a delayed phenomenon developing over several hours. Neurons are more vulnerable to excitotoxicity and more resistant to metabolic perturbation, while the opposite holds true for glia. Neurons mainly die because of hyperactivation of poly(ADP-ribose) polymerase-1 (PARP-1) with subsequent DNA damage and mitochondrial energy collapse. Conversely, glial cells die predominantly by apoptosis. It is likely that early neuroprotection against acute spinal injury may require tailor-made drugs targeted to specific cell-death processes of certain cell types within the locomotor circuitry. Furthermore, comparison of network size and function before and after graded injury provides an estimate of the minimal network membership to express the locomotor program.

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.

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.

Kainate-mediated excitotoxicity induces neuronal death in the rat spinal cord in vitro via a PARP-1 dependent cell death pathway (Parthanatos)

Kainate is an effective excitotoxic agent to lesion spinal cord networks, thus providing an interesting model for investigating basic mechanisms of spinal cord injury. The present study aimed at revealing the type and timecourse of cell death in rat neonatal spinal cord preparations in vitro exposed to 1 h excitotoxic insult with kainate. Substantial numbers of neurons rather than glia showed pyknosis (albeit without necrosis and with minimal apoptosis occurrence) already apparent on kainate washout and peaking 12 h later with dissimilar spinal topography. Neurons appeared to suffer chiefly through a process involving anucleolytic pyknosis mediated by strong activation of poly(ADP-ribose)polymerase-1 (PARP-1) that generated poly ADP-ribose and led to nuclear translocation of the apoptotic inducing factor (AIF) with DNA damage. This process had the hallmarks of parthanatos-type neuronal death. The PARP-1 inhibitor 6-5(H)-phenathridione applied immediately after kainate washout significantly prevented pyknosis in a dose-dependent fashion and inhibited PARP-1-dependent nuclear AIF translocation. Conversely, the caspase-3 inhibitor II was ineffective against neuronal damage. Our results suggest that excitotoxicity of spinal networks was mainly directed to neurons and mediated by PARP-1 death pathways, indicating this mechanism as a potential target for neuroprotection to limit the acute damage to the local circuitry.

Dynamics of early locomotor network dysfunction following a focal lesion in an in vitro model of spinal injury

It is unclear how a localized spinal cord injury may acutely affect locomotor networks of segments initially spared by the lesion. To investigate the process of secondary damage following spinal injury, we used the in vitro model of the neonatal rat isolated spinal cord with transverse barriers at the low thoracic-upper lumbar region to allow focal application of kainate in hypoxic and aglycemic solution (with reactive oxygen species). The time-course and nature of changes in spinal locomotor networks downstream of the lesion site were investigated over the first 24 h, with electrophysiological recordings monitoring fictive locomotion (alternating oscillations between flexor and extensor motor pools on either side) and correlating any deficit with histological alterations. The toxic solution irreversibly suppressed synaptic transmission within barriers without blocking spinal reflexes outside. This effect was focally associated with extensive white matter damage and ventral gray neuronal loss. Although cell losses were < 10% outside barriers, microglial activation with neuronal phagocytosis was detected. Downstream motor networks still generated locomotor activity 24 h later when stimulated with N-methyl-d-aspartate (NMDA) and serotonin, but not with repeated dorsal root stimuli. In the latter case, cumulative depolarization was recorded from ventral roots at a slower rate of rise, suggesting failure to recruit network premotoneurons. Our data indicate that, within the first 24 h of injury, locomotor networks below the lesion remained morphologically intact and functional when stimulated by NMDA and serotonin. Nevertheless, microglial activation and inability to produce locomotor patterns by dorsal afferent stimuli suggest important challenges to long-term network operation.

Clinical Implications of the Seat Belt Sign in Blunt Trauma

Patients with the seat belt sign (SBS) from motor vehicle crashes (MVCs) are prone to specific regional injury patterns. Investigators at a Level 1 trauma center analyzed the incidence, clinical implications, and spectrum of regional injuries in patients injured in MVC over 2 years. SBS was seen in 11.3 per cent of patients injured in MVCs and 20.5 per cent of patients with known restraint use. Restrained patients were less severely injured with lower injury severity scores (7.62 vs 11.33) and mortality (1.1 vs 5.7%). Patients with SBS had lower mortality rates than patients without SBS (1.4 vs 3.7%). Thoraco-abdominal injuries were present in 47 per cent (34 of 72) of patients with SBS. Compared with patients without SBS, patients had a higher incidence of hollow viscous injuries (HVI) and solid organ trauma (8 and 17% vs 1 and 3%, P < 0.05); splenic trauma was 24-fold higher (9.7 vs 0.4%), liver injuries 3.1-fold higher (6 vs 3%), and rib fractures 2.4-fold higher ( P < 0.05). Children had 2.8-fold higher rates of HVI (18 vs 9%, P < 0.05). SBS is associated with underlying regional injuries in nearly half of patients with a higher prevalence of HVI and solid organ trauma.

Is the "seat belt sign" associated with serious abdominal injuries in pediatric trauma?

BACKGROUND

The "seat belt sign" (SBS) has been reported to be highly associated with intra-abdominal injury. This study defines its predictive value in identifying injuries in a large pediatric trauma population.

METHODS

At a level I pediatric trauma center, we performed a retrospective review of trauma flow sheets for all motor vehicle crash victims (ages, 0-20) requiring trauma team activation during 2005 and 2006. All patients with an abdominal SBS recorded were included in the analysis.

RESULTS

Of 331 patients (mean age, 9.96 years), an SBS was present in 54 (16%) of these children. Abdominal injury was identified by computed tomography scan or intraoperatively in 12 (22%) of these children. Three (6%) children with SBS required operative intervention. Two had a bowel injuries and one had a negative laparoscopy. SBS and abdominal tenderness were reported in 30 (56%) patients; 8 (15%) of whom sustained abdominal injury. Of the 277 (84%) children without SBS, 36 (13%) had abdominal injuries. Four (11%) of these had a positive laparotomy with three having a bowel injuries. The relative risk of an abdominal injury given an SBS was 1.7 (CI 0.96-2.69; p = 0.078). Four (1.4%) children without SBS died of head injuries compared with zero with SBS. The SBS had a sensitivity of 25% and a specificity of 85%.

CONCLUSIONS

The SBS was not significantly associated with abdominal injury in our population. Patients without SBS had a higher Injury Severity Score and accounted for all of the deaths. SBS may not be as predictive of abdominal injury as previously reported.

Post-traumatic Subserosal Small Bowel Herniation Leading to Obstruction in a Child with Acute Spinal Cord Injury

The presentation of small bowel injury from lap belt use varies substantially, ranging from gross hemodynamic instability to insidious physiologic deterioration to simple failure of improvement. Rarely does small bowel injury manifest as an obstruction. This paper describes one such occurrence; in this case, herniation of intact mucosa/submucosa through a serosal tear caused a high-grade small bowel obstruction in a pediatric patient with an acute spinal cord injury and a virgin abdomen.