SPINE Volume 24, Number 11, pp 11511155 1999, Lippincott Williams & Wilkins, Inc.

Seat Belt Fracture With Late Development of an Enterocolic Fistula in a Child

A Case Report
Merv Letts, MD, FRCSC, Darin Davidson, Philip Fleuriau-Chateau, MD, and Shirley Chou, MD, FRCSC
Abdominal contusions often occur over the area where the seat belt is strapped across the torso, leaving an ecchymotic band of skin now known as the seat belt sign. The seat belt sign is often a predictor of intraabdominal trauma. It has been shown that 63% of adults and up to 78% of children with Chance fractures may have intestinal disruption14 (Table 1). The small bowel was involved in 59% of injuries in 27 reported cases in the literature (Table 2).4,7,9,10 12,15 Despite the frequency with which intra-abdominal injuries occur with seat belt fractures, a delay in diagnosis is common because of minimal initial abdominal symptoms. This lack of detectable abdominal symptoms occurs because of the presence of a retroperitoneal hematoma and tenderness over the spine and abdomen, which makes the assessment of the abdomen difcult.9,10,12 Neurologic injury is uncommon in older children and adults; however, the rate of paraplegia has been reported to be as high as 30% in young children, adding to the attenuation of abdominal signs and symptoms.12 As there has been no documentation in the English medical literature of delayed enterocolic stula in association with Chance fractures in motor vehicle accidents, the authors of this report therefore describe the case of a 9-year-old child who sustained a Chance fracture and delayed enterocolic stula secondary to a motor vehicle accident. The authors wish to increase awareness of the possibility of orthopedic surgeons encountering this late complication in association with exion distraction injuries of the spine, as well as emphasize the chronic nature of the abdominal symptoms, which may mimic those of the cast syndrome. Case Report
This 9-year-old boy was a passenger in the right back seat in a high-velocity, head-on motor vehicle accident. He was wearing only a lap belt at the time of the collision. The childs 12-year-old brother died at the scene of the accident, his mother died 2 days later as a result of her injuries, and his sister sustained a fractured right tibia and fractured right radius and ulna. The child was brought to the Emergency room at the Childrens Hospital of Eastern Ontario, with a heart rate of 108 beats per minute, blood pressure of 121/80, respiratory rate of 28, and a Glasgow Coma Score of 15. The abdomen was rigid and diffusely tender, and there were no bowel sounds. Examination revealed a retroperitoneal hematoma and uid in the abdomen. The child was awake, alert, and cooperative, and was admitted to the Intensive Care Unit. Musculoskeletal ex1151

Study Design. A case report of a 9-year-old boy treated at a pediatric trauma center for a exion extension spiral fracture with late development of an enterocolic stula subsequent to a high-velocity motor vehicle accident. Objectives. To increase the awareness of possible delayed bowel complications associated with exion distraction injuries of the spine in children. Summary of Background Data. Flexion distraction fractures of the spine in children wearing lap seat belts, so-called Chance fractures, are an increasingly common result of high-velocity collisions. This type of fracture, referred to as a seat-belt fracture, is often associated with duodenal or jejunal tears. Although such intra-abdominal injuries are common in such fractures secondary to this type of trauma, the occurrence of an enterocolic stula has never been reported. Methods. A review of all pediatric Chance fractures managed at the Childrens Hospital of Eastern Ontario, as well as a literature review of all reported series of exion distraction injuries to the spine in chlidren, were performed. Results. The subtle and prolonged symptomatology of this lesion and its similarity to a cast syndrome is emphasized. Conclusion. Because the orthopedic surgeon is usually the primary care-giver for children with this type of seatbelt trauma, an appreciation of the possibility of a delayed onset enterocolic stula with its symptomatology is essential to avoid prolonged morbidity. [Key words: Chance fracture, enterocolic stula, exion distraction fracture, seat belt fracture] Spine 1999;24:11511155

Child occupants of motor vehicles are vulnerable to hyperexion extension trauma to their spines when the vehicle is involved in a high-velocity collision. Although the use of seat belts has reduced the frequency of fatalities, they have resulted in the occurrence of spinal seat belt fractures, particularly in children.1 Most seat belts of the current over the shoulder design do not t the child properly and thus really only function as a lap-type restraint. Approximately 11% of belted children sustain exion distraction fractures of the spine or the so-called Chance fracture in motor vehicle accidents.2,4,8,10 The fracture occurs secondary to hyperexion of the body over the seat belt during rapid deceleration at the moment of collision impact.
From the Divisions of Pediatric Orthopaedics and General Surgery, Childrens Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada. Acknowledgment date: July 14, 1998. Acceptance date: September 14, 1998. Device status category: 1.

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Table 1. Incidence of Abdominal Injuries Associated With Reported Chance Fractures in Children
Study Glassman et al4 Total No. of Chance Fractures 12 Type of Injury Pancreatitis Small bowel perforation Colonic rupture Duodenal stula Small bowel volvulus Transected jejunum Pancreatitis Subphrenic abscess Ruptured gallbladder and spleen Liver laceration Small bowel infarction Ileus Jejunal transection Jejunal perforation Small bowel infarction Ileus Jejunal perforation Transected ileum Perforation of ileum Obstructive jejunal herniation No. of Cases 1 3 2 1 2 1 1 1 1 1 1 3 1 1 1 1 2 1 1 1 Incidence of Abdominal Injury 50% (1 child had multiple abdominal injuries)

Hardacre et al7 LeGay et al9

2 7

100% 71% (2 children had multiple abdominal injuries)

Reid et al10 Rodger et al11 Rumball and Jarvis12 Wang et al15

7 1 10 1

43% 100% 40% 100%

amination revealed spinal tenderness over the midlumbar area, with a palpable gap at the third and forth lumbar vertebral interspace, and lumbar swelling. Seat belt abrasions were noted bilaterally over the iliac crests. The child was neurovascularly intact. Radiographs demonstrated multiple pulmonary contusions, a right pulmonary effusion, and a widened interspinous process space at L3L4 (Figure 1). Computerized tomography revealed a pedicle fracture of the third lumbar vertebra (Figure 2), a clear spinal canal, free uid in the abdomen, no liver or spleen lacerations, a right psoas hematoma, and no free air in the chest or abdomen. The child was treated with bed rest for a Chance fracture of L3 and L4 vertebrae with an associated abdominal contusion. After 8 days, the abdomen was soft and nontender, and bowel sounds were present. An upper gastrointestinal series with small bowel follow-through was performed at this time, and results were normal. There was no extravasation of the contrast material and no evidence of obstruction. The abdomen was cleared by general surgery, and a hyperextension body cast was applied. After casting, radiographs demonstrated good reduction, with no residual kyphosis at the fracture site (Figure 3). The child was discharged ambulatory and asymptomatic to be observed in the Orthopaedic clinic. One month after injury, radiographs demonstrated early healing of the fracture, and the cast was changed. At this time the child began reporting vague abdominal discomfort, intermittent vomiting, and diarrhea. As there was some concern the child might be developing a cast syndrome, the cast again was changed to one with a large abdominal window, and the symptoms seemed to improve. The cast was changed to a thoracolumbar sacral orthosis after the patient had been in a cast for 2 months. His abdominal symptoms, which had never subsided completely, again appeared to improve with the less constrictive orthosis. However, over the next 6 weeks he began to lose weight, and his intermittent vomiting and diarrhea appeared to be increasing. He was reassessed by the pediatric general surgery service, and another upper gastrointestinal barium series was obtained. The barium was held up in a dilated loop of jejunum in the pelvis, and eventually emptied directly into the

sigmoid colon, thus conrming the presence of an enterocolic stula (Figure 4). Treatment consisted of laparotomy with a segmental small-bowel resection and closure of the stula. The child responded well to this surgical intervention. Two months later, his intestinal function was normal, and he was symptomfree. The spinal fracture healed satisfactorily with no kyphotic deformity. As of 18 months after injury, the child was asymptomatic and had returned to all activities.

Discussion Chance fractures and concomitant intra-abdominal trauma resulting from seat-belt injuries in high-velocity motor vehicle collisions have been well documented in the literature.4,9,10,12 These fractures occur secondary to hyperexion of the spine over the seat belt as a result of rapid deceleration at the moment of impact. The axis of exion of the spine has been reported to be the contact point between the seat belt and either the anterior abdominal wall13 or the anterior spinal column, the latter being more common in young children with small compressible abdomens.3 The mechanism of injury has been Table 2. Frequency of Abdominal Injuries in 27 Reported Abdominal Injuries Associated With Chance Fractures in Children4,7,9 12,15
Type of Injury Duodenal stula Subphrenic abscess Ruptured gallbladder and spleen Liver laceration Obstructive jejunal herniation Pancreatitis Colonic rupture Small bowel infarction Small bowel volvulus Transected jejunum Ileus Small bowel perforation Frequency [no. (%)] 1/27 (4) 1/27 (4) 1/27 (4) 1/27 (4) 1/27 (4) 2/27 (7) 2/27 (7) 2/27 (7) 2/27 (7) 3/27 (11) 4/27 (15) 7/27 (26)

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Figure 1. A, Chance fracture of the fourth lumbar vertebra in a 9-year-old child. B, Note the anterior compression of the body of the fourth lumbar vertebra and the widened disc space between the third and fourth lumbar vertebrae posteriorly indicating possible fracture through the disc and through the body of the fourth lumbar vertebra.

well described. If the axis of exion is between the seat belt and the abdominal wall, body exion over the seat belt during the collision creates a tension moment causing the fracture.13 Alternatively, compression of the vertebral body of the spine occurs, followed by distraction of the posterior elements as the spine exes over the seat belt, and it is this distraction force that causes the fracture either through the pedicle and spinous process or through the disc space itself.6 This is probably the mechanism of fracture in younger children under 12 or 13 years of age. With the marked abdominal compression that occurs as a result of the seat belt, segments of bowel can be severely compressed against the rigid spine, resulting in rupture, laceration, or severe contusion. Younger children are predisposed to seat-belt fractures, because the seat belt was designed for adults and consequently does not t over the pelvis but across the

abdomen, predisposing younger children to abdominal and spinal injury.1,12 The child in this report sustained his injuries while sitting in the back seat of the car and while wearing a lap belt, which, although undoubtedly saved his life, failed to protect him sufciently from spinal and abdominal injuries. The need for better-designed seat belts for the child is self-evident and long overdue. Intra-abdominal injuries are commonly associated with Chance fractures. The majority of these injuries have been reported in young children between 4 and 9 years of age,1 because of the difference in anatomy be-

Figure 2. Computed tomography of the third lumbar vertebra, illustrating pedicle and body fracturing.

Figure 3. Appearance on follow-up examination, 6 months after injury, revealing good healing and no kyphotic deformity.

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Figure 4. Upper gastrointestinal barium series revealing dilated loops of small bowel and an enterocolic stula with emptying of contrast material into the sigmoid colon.

tween children and adults. The increased head to body ratio in young children and a more cephalad center of gravity in children causes increased torque about the seat belt fulcrum during the collision, potentiating the severity of the injury. Also, in young children with weaker abdominal musculature and smaller abdomens, a greater compression force is exerted on the abdominal contents. Any bowel trapped between the belt and the spinal column is at great risk for laceration or perforation, hence the higher incidence of such lesions in children noted in the literature as compared with that reported for adults. In the child reported here, it is conceivable that if a portion of the cecum and a loop of subadjacent ileum were compressed together between the belt and lumbar spine, ischemic necrosis of their respective bowel walls might have occurred. Over the ensuing weeks, the bowel walls probably gradually disrupted, resulting in an everenlarging enterocolic stula causing gastrointestinal symptoms. The presence of the seat belt sign has been a very accurate predictor of intra-abdominal injuries in children.14 Although the child in this study showed the seat belt sign, all initial investigations for bowel disruption were negative. Intra-abdominal injuries frequently have been subject to delayed diagnosis when assessing the abdomen becomes difcult because of tenderness from the vertebral fracture and abdominal contusion.9,10,12 The child in this case report was not diagnosed with an enterocolic stula until 4 months after he sustained his injuries. Likely, he had a small segment of ischemic injury to the small bowel, which did not result in overt perforation, but rather, healed

by stulizing with the colon. The orthopedic surgeon should be aware of this late complication, even in the presence of a previously normal upper gastrointestinal study. In response to this diagnostic difculty, it has even been recommended that all patients with Chance fractures have a minilaparotomy at initial examination to ensure an accurate and prompt diagnosis to prevent further morbidity.5 Because there was no initial perforation in this child, even a minilaparotomy would not have revealed any obvious pathology other than contused bowel. Current use of the laparoscope might assist in earlier diagnosis of these more subtle bowel injuries. The symptoms from an enterocolic stula are similar to those of a cast syndrome with persistent vomiting. Because this occurs during the time most young children with Chance fractures are being treated in a cast, misdiagnosis of a cast syndrome may be made. True cast syndrome, however, usually occurs within several days of applying the cast, whereas in this case of enterocolic stula, symptoms of vomiting occurred much later, approximately 3 weeks after the initial cast was applied. The association of diarrhea is also not typical of cast syndrome, and other abdominal trauma, such as enterocolic stula, should be suspected. This case also emphasizes that a normal gastrointestinal series performed shortly after the accident does not necessarily rule out a bowel injury that might progress to an enterocolic stula. Conclusion This case report is the rst documentation of a patient sustaining a Chance fracture with a delayed enterocolic stula. As in other reported cases, the seat belt sign was an accurate predictor of the presence of intra-abdominal trauma in this child. The delayed diagnosis of the abdominal injury in this child occurred because of the gradual development of the enterocolic stula, which appeared to begin developing approximately 1 month after injury and to become fully established 3 to 4 months after the trauma. Orthopedic surgeons should be aware of this rare type of bowel injury and the symptoms it produces, which are similar to those of the cast syndrome. The injuries sustained by this child lend further credence to the recommendations of other studies that better seat belts need to be designed for use by young children, so that the belt ts over the pelvis and hips rather than across the abdomen. References
1. Agran PF, Dunkle DE, Winn DG. Injuries to a sample of seatbelted children evaluated and treated in a hospital emergency room. J Trauma 1987;27:58 64. 2. Chance GQ. Note on a type of exion fracture of the spine. Br J Radiol 1948;21:4323. 3. Denis F. The three column spine and its signicance in the classication of acute thoracolumbar spinal injuries. Spine 1983;8:81731. 4. Glassman SD, Johnson JR, Holt RT. Seatbelt injuries in children. Trauma 1992;33:882 6. 5. Gumley G, Taylor TKF, and Ryan MD. Distraction fractures of the lumbar spine. J Bone Joint Surg [Br] 1982;64:520 5.

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6. Gertzbein SD, Court-Brown CM. Flexion-distraction injuries of the lumbar spine: Mechanisms of injury and classication. Clin Orthop 1988;227: 52 60. 7. Hardacre JM, West KW, Rescorla FR, Vane DW, and Grosfeld JL. Delayed onset of intestinal obstruction in children after unrecognized seat belt injury. J Pediatr Surg 1990;25:9679. 8. Hoffman M, Spence L, Wesson D, Armstrong PF, Williams JI, Filler RM. The Pediatric passenger: Trends in seatbelt use and injury patterns. J Trauma 1987; 24:974 6. 9. Legay DA, Petrie DP, Alexander DI. Flexion distraction injuries of the lumbar spine and associated abdominal trauma. J Trauma 1990;30:436 44. 10. Reid, AB, Letts RM, Black GB. Pediatric chance fractures: Association with intra-abdominal injuries and seatbelt use. J Trauma 1990;30:384 91. 11. Rodger RM, Missiuna P, Ein S. Entrapment of bowel within a spinal fracture. J Pediatr Orthop 1991;11:7835. 12. Rumball K, Jarvis J. Seat-belt injuries of the spine in young children. J Bone Joint Surg [Br] 1992;74:571 4. 13. Smith WS, Kaufer H. Patterns and mechanisms of lumbar belt injuries associated with lap seat belts. J Bone Joint Surg [Am] 1969;51:239 53. 14. Vandersluis R. The seatbelt syndrome. Can Med Assoc J 1987;137:1023 4. 15. Wang SF, Tiu CM, Chou YH, Chang T. Obstructive intestinal herniation due to improper use of a Seat Belt: A case report. Pediatr Radiol 1993;23: 200 1.

Address reprint requests to Dr. M. Letts Department of Surgery Childrens Hospital of Eastern Ontario 401 Smyth Road Ottawa, Ontario Canada K1H 8L1