Seat Belt Injuries: Radiologic Findings and Clinical Correlation1 Curtis
W. Hayes,
William
MD
F. Conway,
James
W.
Lynn
Walsh,
MD
S. Gervin,
The
seat
belt
MD
syndrome
associated
juries
PhD
MD
Coppage,
Alfred
MD,
consists
with
use
of skeletal,
of two-
and
soft-tissue,
three-point
and restraints
visceral
in-
in patients
accidents. Skin abrasions of the neck, chest, and abdomen-the classic seat belt sign-indicate internal injury in 30% of cases. Neck abrasions are associated with injuries to the carotid artery, larynx, and cervical spine; chest abrasions, with fractures of the sternum, ribs, and clavicles and injuries to the heart and thoracic aorta; and abdominal abrasions, with mesenteric tears, bowel perforation and hematoma, Chance fractures, and injuries to the abdominal aorta. The seat belt sign should prompt a diligent search for related involved
in motor
vehicle
injuries.
U INTRODUCTION Lap-type seat belts
became
standard
equipment
in automobiles
in the United
States
The three-point variety of seat belt (combined lap and shoulder belt) became standard in the auto industry in i 973 Theoretically, seat belts protect the wearer during a collision in three ways: They (a) prevent ejection from the auto, in i 964
.
.
(b)
allow
and
(C)
a more
reduce
controlled
deceleration
the severity
of impact
during
between
the
initial
phase
the wearer
of the
There is no doubt that the use of seat belts, especially the three-point lowers morbidity and mortality associated with motor vehicle accidents. performed by Volvo, a Swedish car manufacturer, in 1 967 demonstrated
Index
terms:
Neck,
injuries.
Abdomen. 27.491
RadloGraphics I
From
Medical mond, tember RSNA.
the
1991; Departments
College VA 23298. 18. Address 1991
injuries, Pelvis,
70.4
1
injuries,
#{149}
#{149} Arteries,
injuries.
56.4
1
Bones,
#{149}
collision,
and the car interior.
injuries.
40.4
1
variety, A study that,
Fractures,
#{149}
40.4
1
80.41
1 1 :23-36 of Radiology
ofVirginia/Virginia Received July reprint
26,
requests
(C.W.H.,
W.F.C.,
Commonwealth 1990; revision to
J.W.W., University, requested
L.C.) 12th August
and
General
Surgery,
Trauma
and Marshall Sts. Box 615, 29 and received September
Division MCV Station, 17; accepted
(A.S.G.), Rich. Sep-
C.W.H.
23
Table 1 Patterns
Seen
of Injuries
In Motor
Location Face,
head,
Vehicle
Accidents
Unrestrained
Two-Point
Fractures
and neck
Abdomen
.
Liver and spleen lacerations and rupture
.
Three-Point
Restraint
Injuries to the carotid artery, larynx Hollow viscus injuries (mesenteric tears, perforations), abdominal wall disruptions Fractures of the clavicles, ribs, lumbar spine (Chance), and sternum
.
Hollow viscus injuries (mesenteric tears, perforations) abdominal wall disruptions Lumbar spine fractures (Chance) ,
Chest,
when
Fractures of the thoracolumbar spine, pelvis, and extremities
spine
only
lap belts
were
used,
fatal
very severe cases. Injuries caused by lap belts include mesentenic tears and perforations of the small bowel and colon. Proposed mecha-
injuries
occurred throughout the speeds, as low as 12 mph point restraints, no deaths less than 60 mph.
entire range of (1). With threeoccurred at speeds
The bowel
injury-a small wearing a lap
nisms
due
first seat belt-related injury in a trooper
belt-was described by Kulowski and Rost (2) in 1 956. A pattern of injuries distinctly different from those seen in unrestrained oc-
cupants belt
has since
wearers.
been
recognized
in seat
Braunstein (3) were the first to use the term seat belt syndrome in describing the pattern of abdominal and skeletal injuries related to seat belt use. In this article, we review the common and unusual features of seat belt injuries, their radiologic appearance, and clinical and
operative
Garrett
Restraint
and
correlations.
for
these
to rapid
injuries
are
deceleration
shearing
against
forces
the small
area of the lap belt and increased intraluminal pressure secondary to compression a bowel loop between the seat belt and spine, which produces “blowouts” (5).
the spine, istic nor
distractive
horizontal and posterior
forces
fractures elements
cause
of In
character-
involving of the
the antelumbar
spine. Soft-tissue injuries attributed to lap belts include various abrasions (seat belt sign) and rupture des and penitoneum.
of the abdominal These three
wall injuries-
mus-
hollow viscus injury, flexion-distraction fractunes of the lumbar spine, and abdominal wall disruptions-are the classic seat belt injuries.
U
PATIERNS
OF INJURY
Unrestrained
vehicle the
face,
occupants
accidents head,
involved
usually neck,
and
sustain
in motor
injuries
extremities
to
second-
aiy to collision with the interior of the car, for example, the windshield, dashboard, and
With three-point frequently involve
restraints, the thoracic
nibs,
clavicles.
sternum,
injuries such blowouts,
erations
and
contusions
usually
only
injuries-rupture
the
and
with lap belts. Cervical spine injuries, carotid and subclavian vascular injuries, and Iaryngeal trauma have been attributed to the
liver
spleen,
or lacerations
of
in particular-outnurn-
in unrestrained
restraints or lap belts by preventing ejection injuries are decreased
oc-
monly
crossing reduce from except
inthe in
U
Hayes
et al
severe, high-speed abdominal injuries of the lumbar spine
occur
id organ
found
with
shoulder
three-point
collisions. Ho!also occur. are less cornrestraints
than
strap.
Table 1 summarizes the patterns of injuries found in restrained and unrestrained victims of motor vehicle accidents. The following sections nies and
RadioGraphics
Catastrophic
as aortic transection, and massive lung lac-
with very low-viscus Fractures
Two-point juries largely auto. Crush
U
most the
steering wheel. In moderate and severe collisions, devastating abdominal and thoracic injuries related to crushing forces are cornmon. According tojordan and Beall (4), so!-
ber hollow viscus injuries cupants by two to one.
24
and
thoracic ventricular
injuries cage:
elaborate on specific seat their radiologic findings.
Volume
11
belt
inju-
Number
1
2.
1.
Figures 1-3. (1) Abdominal seat belt sign. A large anterior abdominal wall abrasion extends from flank to flank in a victim of a high-speed motor vehicle accident. (2) Thoracic seat belt sign. Diagonal abrasions (arrows) extend from the right shoulder to the left side of the chest in the patient, who was seated on the passenger side of the auto. (3) Neck seat belt sign. Diagonal abrasions are present along the course of the shoulder strap.
-
-
...-
3.
U
OF INJURIES
TYPES
. Skin A linear
Abrasions abrasion across
jury, or, including
the
lower
abrasion
extending
across
the
chest from a three-point restraint (Fig 2) is often associated with underlying rib fractunes, clavicular fracture, or sternal fracture. In severe collisions, aortic transection or ventricular rupture should be considered, although these injuries are, in our experience, less common in patients who wore seat belts than in unrestrained occupants in comparable accidents. A diagonal neck abrasion on the side of the shoulder strap (Fig 3) may be associated with vascular injury, tracheal or laryngeal in-
January
1991
cervical process
spine fractures.
injury,
abdomen
extending from flank to flank is the classic seat belt sign (Fig i) . Although this finding is not an incontrovertible sign of significant internal injuries, we have found that they are present in approximately 30% of the patients with a seat belt sign.
A diagonal
occasionally, transverse
.
Skeletal
Fractures
Injuries of the
common seat wore two-point point restraints. quently different
thoracolumbar
spine
belt injuries in patients and, to a lesser extent, The pattern from that
of injury of fractures
tamed by unrestrained victims, explained by the three-column
are
who threeis fresus-
and can concept
be of the structure of the spine by Denis (6) According to this theory, the anterior column is formed by the anterior longitudinal ligament, anterior annulus fibrosus, and anterior .
part umn
of the vertebral body. The is formed by the posterior
ligament, posterior
middle collongitudinal
posterior annulus fibrosus, wall of the vertebral body.
Hayes
et al
U
and The pos-
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25
a. Figure
b. 4.
terolateral suspected distraction
tenor bony
Thoracolumbar junction flexion-distraction injury. compression of the superior end plate of L- 1 (large due to splaying of spinous processes (small arrows). of posterior elements (arrow).
column elements
is formed and the
by the posterior
posterior ligamentous
complex. A flexion force on an unrestrained occupant has a fulcrum centered at the middie column, or posterior half of the vertebral body. This produces compression of the antenor forces,
vertebral distraction
Moderate cally
forces
stable,
cases.
body
and, with more severe of the posterior elements.
produce
simple,
compression
Severe
forces
neurologi-
fractures
produce
in these
flexion-distrac-
compression
important elements,
They occur most often at the junction (Fig 4) The anterior .
may
is the which
fully. Restrained
be mild
or moderate.
More
disruption of the posterior must be searched for care-
occupants,
especially
those
wearing lap belts, show characteristic horizontal fractures, frequently at L-2 or L-3. These
fractures
were
first
Chance (7) in 1948. Several these injuries were reported
26
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U
Hayes
et al
reported
by
variations by Smith
(8) in i969. These may involve a single vertebral level (body and posterior dcments) two levels, purely soft-tissue disrupKaufer
,
iion, jury
or a combination. The mechanism is the shifting of the fulcrum of the
to the anterior
abdominal
wall,
seat
producing
distraction
belt,
thus
three
columns
nor)
of the
(anterior, spine.
These
caused
of inforce
by the on all
middle,
and
fractures
show
postelittle
or no anterior compression of the involved vertebral body (Fig 5) Neurologic deficits are infrequent. In some cases, distractive forces produce purely ligamentous disruption at the involved level, leading to a lumbar subluxa.
tion injuries and fracture dislocations due to failure of all three columns; such injuries are unstable and commonly associated with neu-
rologic deficits. thoracolumbar
(a) Anteroposterior radiograph shows anarrow). Injury to posterior elements may be (b) Lateral radiographic findings confirm
of and
tion/dislocation jury.
This
or “Chance injury
usually
equivalent”
involves
in-
disruption
of the soft-tissue components of the postenior and middle columns of the spine (postenior ligamentous complex, posterior longitudinal ligament, and posterior annulus fibrosus). Radiographic findings of this unstable injury may be subtle: mild widening of the posterior aspect of the affected disk space,
widened
facet
processes.
On
latter
abnormality
sign”
(Fig
6).
joints, the
and
splaying
of spinous
anteroposterior
produces Chance
view,
the
fractures
Volume
“empty and
11
their
Number
the
hole hg-
1
6a. Figures
5, 6.
(5) Chance
fracture
6b. of L-2. (a) Anteroposterior
radiograph shows characteristic splaying of the spinous processes (double arrow), with fractures extending through both transverse processes and pedicles (curved arrows) . (b) Lateral radiograph shows the fracture extending through the posteroinferior corner of L-2 (arrow), into the L2-3 disk space. (6) Ligamentous Chance injury at L3-4. (a) Anteropostenor radiograph shows mild widening of the involved disk space (large arrows) and an ‘empty hole sign” (small arrows), denoting splaying of the spinous processes. (b) Lateral radiograph more clearly shows splaying of the spinous processes (double arrow) and widening of the facet joints (curved arrow). ‘
January
1991
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Figure 7. Rib fractures, three-point restraint pattern. (a) Posteroanterior radiograph shows the diagonal course of the shoulder strap. (b) Diagonal seat belt sign (arrowheads) is seen in the same patient. (c) Oblique radiograph shows fracture of the right first rib (arrow). (d) Anteroposterior radiograph shows fractures of the left fourth through ninth ribs (arrows). The sternum was also fractured, but there was no aortic or cardiac injury.
28
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Hayes
et al
Volume
11
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1
tunes
tend
to align
along
the
course
of the
di-
agonal strap (Fig 7) The frequency of severe flail chest with multiple fractures is said to be decreased with seat belt usage, however (i 0) Arndt (1 1) has also described fractures of the transverse processes of C-7 or T- 1 associated with usage of shoulder harnesses. .
.
,
Sternal with seat
fractures are belt injuries.
deceleration
force
num strap,
through the accounting
quency
blowouts, extremely
of aortic except severe
fractures
Figure
8
Sternal
fracture.
Lateral
radiograph
demonstrates a slightly depressed fracture of only the anterior cortex of the sternum (arrows) immediately beneath the site of the shoulder strap.
amentous equivalents are frequently seen in children and other back-seat passengers, since two-point restraints are still used in the back seats of most autos. New legislation making back-seat three-point restraints mandatory may decrease the number of such injuries. Anterolateral compression fractures have
been reported der restraints.
in occupants These injuries
wearing occur
shoulat the
thoracolumbar junction and may be due to a roll-out mechanism of combined flexion and rotation about the axis of the shoulder strap (9). Rib fractures are common in all victims of motor vehicle accidents of moderate or se-
vere are
force, used.
January
regardless With
1991
three-point
of whether restraints,
common in patients It is theorized that
is absorbed
small area of the for the relatively
shoulder low fre-
transections or ventricular in victims of accidents force. We have observed
involving
only
the
of the sternum
immediately
shoulder
(Fig
strap
the
by the ster-
8),
which
anterior
cortex
beneath
the
appears
of
to be
characteristic of this mechanism. Sternal fractures in unrestrained occupants or those with lap belts only (due to impact against the steering wheel or dashboard) are often associated with myocardial contusion. To date, we have been cases of myocardial with sternal fractures straps.
unable to document contusion associated caused by shoulder
Clavicle fractures are commonly ed with use of three-point restraints motor vehicle accidents. .
Soft-Tissue
Transverse
and tears
Visceral
of the
rectus
syndrome. beneath
associatduring
Injuries abdominis
dc and anterior peritoneal tears ing more frequently recognized seat belt mediately
any
These injuries the site of the
mus-
are becomas part of the occur imlap portion
of the seat belt and may be quite subtle radiologically (Fig 9) Computed tomography (CT) may show only abrupt thinning of the .
involved muscle at the level of injury, and this finding may easily be overlooked. This injury is frequently associated with hollow viscus injury (i 2) and may provide a clue to
the gravity
of the
injury.
restraints frac-
Hayes
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RadioGraphics
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29
e.
I.
Figure year-old periorly
9. Abdominal wall disruption. (a-d) CT images demonstrate rectus muscle disruption in a 14victim of a high-speed motor vehicle accident. Images show normal rectus abdominis muscles su(straight arrows in a) virtually absent rectus muscles in the midportion of the abdomen (arrows in b, c) and normal-appearing muscles inferiorly (arrows in d) . Subcutaneous flank hemorrhage was also seen (curved arrow in a). An abdominal seat belt sign was present. (e) Diagram illustrates transverse tears of the rectus abdominis muscles at the site of abdominal abrasions (arrows). (0 Intraoperative view shows an extensive tear of the anterior abdominal wall (arrows). ,
,
30
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Hayes
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Volume
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1
a.
b. Figure 10. Small bowel perforation. CT scans obtained with oral and intravenous administration of contrast material show unequivocal extraluminal gas (arrows in a) mesenteric thickening (arrow in b) and moderate free fluid in the pelvis (arrow in c). ,
,
a! authors 5 1 patients
c.
dc
accidents)
(1 4- 1 7) In their 1 989 study (37 ofwhom were in motor .
,
Rizzo
et al (1 8) examined
of vehi-
the
The most common significant injuries encountered in restrained patients are mesentenic tears and frank ruptures of the small bowel and colon. Vascular tears occur on the mesenteric side of the bowel, more frequently in the small bowel than in the colon. Perforations nearly always occur on the antimesenteric border. Jejunal and ileal perforations are most common, with large intestine and duodenal ruptures less frequent. In an examination of case reports, Williams and Kirkpatrick (1 3) found a higher rate of hollow viscus injury in patients who wore two- versus three-point restraints. Sixty-three of 82 injuries involved the small bowel; 1 9 involved the colon. Mesenteric tears and bowel perfo-
frequency of the following CT findings: cxtraluminal air, free intraperitoneal fluid, thickened or infiltrated mesentery, and thickened bowel wall (Figs 10, 1 1). Extraluminal air was observed in only nine of 16 cases of perforation (56%) Two cases showed extravasation of orally administered contrast material. In all cases of bowel perforations, there were moderate to large amounts of free intraperitoneal fluid. Thickened bowel wall (75%) and mesentenic infiltration (88%) were also found in most cases of perforation. From this study and others, one may conclude that (a) free gas or extravasated contrast material are relatively specific but insensitive (56%) signs of bowel perforation; (b) the presence of moderate or
rations quency mined
large when tion,
were equally common. of these injuries cannot from this study, however,
The true frebe detersince it rep-
resented an analysis of case reports. The efficacy of CT in the evaluation blunt abdominal trauma and potential
low
viscus
January
injuries
1991
has been
studied
.
amounts of free intraperitoneal fluid, not associated with solid organ lacerashould raise the suspicion of bowel perforation or mesenteric vascular tear; and (c)
of hol-
by sever-
Hayes
et al
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31
a localized mesenteric hematoma or the finding of a focal high-attenuation clot adjacent to bowel are helpful in localizing the site of injury. In the above situation, CT and diagnostic penitoneal lavage should be used as complementary diagnostic examinations.
32
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Hayes
et al
The relative roles of CT and diagnostic penitoneal lavage in the evaluation of blunt trauma have been examined by a number of authors In cases
and
remain
in which for bowel injury
controversial
(19-25).
there is a high suspicion (seat belt sign or Chance
Volume
11
Number
1
Figure
15.
Intraperitoneal
bladder
rupture.
Cys-
obtained with the patient supine demonstrates intraperitoneal extravasation of contrast material from the bladder, with contrast material clearly outlining the right paracolic gutter and inferior margin of the liver. togram
fractures
of the
spine)
,
judicious
use
of both
tests is warranted. Because small bowel lacerations may initially be asymptomatic and since delay produces significant morbidity, rapid evaluation, with both tests if necessary, is
recommended.
is suspected, to diagnostic important
When
hollow
viscus
CT should be performed peritoneal lavage, since CT signs of intraperitoneal
injury prior the fluid
or free air may be related to the lavage itself (26). The frequency of liver and splenic injuries is reduced with the use of two- and threepoint restraints. Severe forces and crush injuries continue to produce the usual complement of liver lacerations (Fig 1 2) splenic lacerations and ruptures (Fig 1 3) and pancreatic (Fig 14) and renal injuries. Significant injuries may be produced with less severe forces when there is improper positioning of the two- or three-point restraint ,
,
(27,28).
Proper
usage
dictates
that
to obesity, the load of be dissipated over ment, resulting in ment of the shoulder ondary ing”)
,
a passenger-side directly across
slouching, or “submanina sudden deceleration may the abdominal compartvisceral injuries. Placestrap under the arm by
occupant the liver,
produces a force with potentially
devastating effects. Intraperitoneal rupture of a distended bladder may occur due to lap belt pressure during an accident (Fig 1 5) Urethral injury .
has
occasionally
been
reported
as well.
Sev-
eral cases of uterine injury have also been reported (29), including a case in which nipture of a gravid uterus left a 6th-month fetus free in the abdominal cavity. Fortunately, such
reports
are
rare.
Cases of diaphragmatic rupture have been reported in seat belt wearers (30) (Fig 16). The mechanism of the injury may be secondaiy to faulty placement of the belt or sliding of the occupant under the belt in the early stages
of the
impact,
leading
to upward
ab-
dominal pressure from the belt and subsequent herniation of abdominal contents into the thoracic cavity.
the lap
belt be positioned across the anterior iliac spine so that the forces are dissipated through the stable, bony pelvis. If the belt migrates up onto the abdominal wall (sec.
January
1991
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common carotid angiogram same patient shows extensive ary to laryngeal fracture.
. Vascular Injuries We have seen one case common carotid artery in a motor
three-point tient also
vehicle
(b) CT scan of the of the neck second-
demonstrates a transection (arrow) below the bifurcation. gas in the soft tissues of the anterior and lateral aspects
of transection in a patient
accident
of the involved
while
using
a
seat belt (Fig 1 7a) The same pahad a fracture of the larynx that ne.
cessitated a tracheostomy (Fig 1 7b) Similar cases, as well as injuries to the internal carotid artery, subclavian artery, and superior .
vena cava, have also been reported In the literature (31-35). The force of collision required to produce thoracic aortic tears appears to be greater in restrained occupants than in unrestrained persons.
The
shoulder
strap
more controlled deceleration during the collision, which shearing force on the aorta aortic severe
injuries forces
are (Fig
Seat belt-related dominal
aorta
have
may
allow
relatively i 8) (36).
common
injuries
involving
been
a
of the chest may decrease the somewhat. Still,
reported
with
the ab(37,38).
tient same
also sustained a Chance level. The mechanism
presumably the aorta
fracture of injury
at the was
distraction and compression between the seat belt and spine.
of
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-----
-
---
--
---C
proximal descending aorta, with a well-defined flap (arrow) at the lower extent of the injured segment. U
CONCLUSIONS
Given
the
accident, three-point less
34
--.--- --------
I,
We observed one case in which distal abdominal aortic occlusion occurred due to a near-complete transection (Fig 19). This pa-
severe
same
force
of impact
a seat belt wearer type belt) will injuries
than
during
a nonwearer.
Volume
the
(especially usually sustain
11
Seat
Number
1
Table 2 Seat Belt Synd rome: Location
Physical
Signs
and
Related
Injuries
of
Abrasion
Affected
Neck
Structures
Injuries to the carotid artery, larynx, cervical spine, transverse process Injuries to the sternum, ribs, clavicle, heart (myocardial contusion) thoracic aorta Injuries to the small and large bowel (mesenteric tears, perforations, hematoma) vertebrae (Chance fractures, especially L-2, L-3), abdominal aorta and branches
Chest
,
Abdomen
,
30% of cases. Chance fractures and their ligamentous equivalents, large and small bowel perforations or mesentenic tears, and abdominal wall disruptions are more common than solid organ injury. Occasional significant vascular injuries also occur. Table 2 summanizes the various injuries associated with different seat belt abrasions. The history of a restrained occupant in a significant motor yehide accident or the presence of the telltale seat belt sign should prompt a diligent search for these related injuries. U
1
.
REFERENCES Bohlin NI. A statistical analysis of 28,000 accident cases with emphasis on occupant restraint. Proceedings of the Eleventh Stapp Car Crash Conference. Soc Automotive Eng Trans
2.
3. 4.
Figure
19. Distal abdominal aortic occlusion following seat belt injury. Anteroposterior abdominal aortogram shows complete occlusion just proximal to the aortic bifurcation. At surgery, complete transection with only intact adventitia was found. A Chance fracture was present at L-4.
belts
prevent
vehicle cupant’s
dashboard, However, juries
perience,
ejection
of the wearer
and decrease impact with
the severity the steering
and other a distinctly
occurs
in seat
the
scat
interior different belt
belt
from of the wheel,
structures. pattern
wearers.
In our
1991
6.
the oc-
7.
of in-
8.
cx-
sign-abdominal,
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January
5.
9.
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Rost WB. Intra-abdominal injury from safety belt in auto accident. Arch Sung 1956; 73:970-971. GarrettjW, Braunstein PW. The seat belt syndrome.JTrauma 1962; 2:220-237. Jordan GL, Beall AC. Diagnosis and management of abdominal trauma. Curr Prob Surg 1971 ; November:3-62. WilliamsJS, Lies BA, Hale HW. The automotive safety belt: in saving a life may produce intra-abdominal injuries. J Trauma 1966; 6:303-313. Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine i983; 8: 817-83 1. Chance GQ. Note on the type of flexion fracture ofthe spine. BrJ Radiol 1948; 21:452-453. Smith WS, Kaufer H. Patterns and mechanisms of lumbar injuries associated with lap seat belts.J Bonejoint Surg [Ami 1969; Si: 239-254. Miniaci A, McLaren AC. Anterolateral cornpression fracture of the thoracolumbar
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GA, Alvarez R, Plasencia G, et al. penitoneal lavage in the manageblunt abdominal trauma: a reassessTrauma 1987; 27:1-5. PA, Vahey T, Burney RE, Glazer G. tomography
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