CME REVIEW ARTICLE
Seatbelt Syndrome in Children
Matthew Arthur Szadkowski, MD and Robert G. Bolte, MD
Abstract: The seatbelt syndrome describes an injury pattern infrequently
seen in restrained passengers in motor vehicle collisions. It occurs when
sudden deceleration forces coupled with compression of the lap belt around
the abdomen causes abdominal wall bruising, intra-abdominal injuries, and
spinal fractures. Infrequent and improper use of appropriate belt restraints
in children has led to high risks for injury in this population.
We describe a case of the seatbelt syndrome with the uncommon finding of
an associated posttraumatic intestinal obstruction. We also review the
literature on the prevalence, risk factors, and types of injuries sustained
by children with the seatbelt syndrome as well as discuss the indications for
laboratory studies, abdominal imaging, surgical intervention, and further
observation. Current recommendations for child seatbelt use and its
effectiveness in preventing injury are also reviewed.
Key Words: abdominal trauma, lap belt injury, seatbelt injury,
seatbelt syndrome, motor vehicle collision
(Pediatr Emer Care 2017;33: 120–127)
TARGET AUDIENCE
This article is intended for health care providers who care for
children and adolescents in an acute-based care setting. Specialists
including emergency medicine physicians, pediatric emergency
medicine physicians, and pediatric trauma surgeons will find this
information particularly useful.
LEARNING OBJECTIVES
After completion of this article, the reader should be able to:
1. Identify the signs and symptoms concerning for intra-
abdominal injury (IAI) in pediatric patients involved in motor
vehicle collisions (MVCs).
2. Describe the common intra-abdominal and spinal injuries
sustained by pediatric patients involved in restrained MVCs.
3. Describe the indications for urgent surgical intervention versus
observation in pediatric patients with a seatbelt sign.
S ince the advent of commercial automobiles in the early 20th
century, safety-minded individuals have continuously attempted
to make transportation by car less dangerous. In the early 1960s, the
seatbelt made its first appearance in automobiles in the United
States. Its effectiveness in preventing the ejection and serious bodily
harm of passengers involved in MVCs quickly became evident. Its
incorporation as a standard design feature was made mandatory by
Clinical Professor (Bolte) and Clinical Assistant Professor (Szadkowski), Divi-
sion of Pediatric Emergency Medicine, Department of Pediatrics, University of
Utah School of Medicine, Salt Lake City, UT.
The authors and staff in a position to control the content of this CME activity
and their spouses/life partners (if any) have disclosed that they have no
financial relationships with, or financial interest in, any commercial
organizations pertaining to this educational activity.
Reprints: Matthew Szadkowski, MD, 295 Chipeta Way, PO Box 581289, Salt
Lake City, UT 84158 (e‐mail: matthew.szadkowski@hsc.utah.edu).
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0749-5161
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Federal Motor Vehicle Safety Standards in 1968.1 However, despite
overall effectiveness in reducing serious injury, it was noted that the
use of restraints was at times associated with a new pattern of ab-
dominal and spinal injury.
In 1962, Garrett became the first clinician to describe the
now-classic triad of abdominal wall bruising, internal abdominal
injury, and spinal fractures as “the seatbelt syndrome.”2 This in-
jury occurs when rapid deceleration forces sustained during an
MVC cause hyperflexion of the torso and consequent compres-
sion of the abdomen around the lap belt. The belt acts as a fulcrum
for the abdominal wall, causing impingement of the bowel against
the vertebral column and distraction of the supporting structures
of the vertebral bodies.3,4 Because rear seatbelts became more
commonplace in automobiles in the 1970s, their use by children
increased dramatically. The first studies describing the types of inju-
ries sustained by restrained children appeared shortly thereafter.5–7
Children who used seatbelts were found to have less massive
head, thoracic, and extremity trauma compared with those that did
not use restraints, although IAI became more commonplace.5–7
The hallmark sign of the seatbelt syndrome is abdominal wall ec-
chymosis in the distribution of a lap belt.1 However, it is not un-
common for children with serious IAI to have absent or
equivocal physical examination findings.8 Missed diagnosis of in-
testinal perforation or spinal injuries can have significant conse-
quences. Understanding this injury pattern and its associated
risk factors will facilitate identifying those patients at greatest risk
and guide appropriate management. Significant injuries to the
head, face, cervical spine, and chest occur in children involved
in MVCs.9,10 Because these injuries do not constitute the classic
seatbelt syndrome, they will not be reviewed in detail here, al-
though a recent case series and literature review discusses
this further.11
Improper belt placement secondary to child positioning or
neglecting to use a recommended booster seat contributes greatly
to preventable seatbelt injuries.12 Because seatbelts were designed
based on an adult's pelvic anatomy, the underdeveloped iliac crests
of a child's pelvis do not properly support the anchoring points for
a lap belt.13 Abdominal injury during an MVC, therefore, typi-
cally occurs when the seatbelt is either improperly resting high
across the abdominal wall or from slippage of the belt above the
anterior superior iliac crests and onto the abdominal wall.14
Increasing awareness of lap belt injuries led to the progres-
sive regulations in the 1970s that required all new cars sold in
the United States to have 3-point belts in outboard seating posi-
tions.15 Since September 1, 2007, these requirements were ex-
tended to include the center rear seat.16
We report a clinical presentation of seatbelt syndrome and
discuss its prevalence, diagnosis, and management by reviewing
the current literature.
CASE
A 14-year-old previously healthy girl was involved in a high-
speed head-on MVC. She was restrained with a lap belt in the rear
center seat. She sustained positive loss of consciousness. At the
scene, she had findings of diffuse abdominal pain and blood
oozing from her left ear canal. Upon arrival in the emergency
Pediatric Emergency Care • Volume 33, Number 2, February 2017
Pediatric Emergency Care • Volume 33, Number 2, February 2017
department (ED), she had mid lumbar tenderness without step-
offs, a seatbelt sight across her abdomen with diffuse abdominal
tenderness to palpation, and an intact neurological examination.
Comprehensive computerized tomography (CT) scans were per-
formed and showed a left mandibular fracture, soft tissue injury
to the left external auditory canal, hemoperitoneum, and a grade
2 liver laceration. Spinal injuries noted on CT included a fracture
through the bilateral pedicles, facets, lamina, and transverse pro-
cesses of L3 (Figs. 1, 2) as well as a spinous process fracture of
L2. Hemoglobin level was 12 g/dL. Kidney, pancreatic, and liver
function studies were notable for lipase (60 mmol/L) and amylase
(116 mmol/L) levels. She did not require any surgical intervention
and was admitted for medical stabilization. She was eventually
discharged home 5 days later with a lumbar brace.
Eleven days after her initial injury, she developed progressive
diffuse abdominal pain, new fevers up to 38.8°C, and several ep-
isodes of vomiting, one of which was bilious. She presented to the
ED, and an abdominal x-ray showed findings concerning for ileus
versus partial small bowel obstruction. Laboratory studies includ-
ing a complete blood cell count, complete metabolic profile, and
lipase were reassuring. She was admitted to the surgical service,
and an abdominal CTwith intravenous (IV) contrast showed inter-
val reduction in abdominal ascites and no signs of bowel obstruc-
tion. Her diet was advanced, she became afebrile, and she had no
further vomiting, so she was discharged home 2 days later.
FIGURE 1. Sagittal CT of the lumbar spine showing a nondisplaced
fracture through the posterior margin of the L3 vertebral body
and pedicle.
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Seatbelt Syndrome in Children
FIGURE 2. Axial CT of the lumbar spine showing a fracture through
the pedicles of L3.
One week later, she presented again to the ED with continued
nausea, decreased appetite, 2 episodes of nonbilious vomiting,
and abdominal distention. An abdominal x-ray showed multiple
dilated loops of small bowel, suggesting small bowel obstruction.
An upper gastrointestinal (GI) tract with small bowel follow-
through confirmed a high-grade partial small bowel obstruction
distal to the ligament of Treitz. She was taken for an exploratory
laparotomy, which revealed multiple dense mesenteric adhesions
thought to be consistent with prior direct bowel injury in this area.
An 18-in segment of jejunum was not salvageable and was
resected. The patient recovered uneventfully and was discharged
home several days later.
PREVALENCE OF SEATBELT SYNDROME
The largest population-based study to date used data from the
Partners for Child Passenger Safety project, an ongoing crash sur-
veillance system, to describe the prevalence of injuries sustained
by children using seatbelts in MVCs. In the study, the prevalence
of seatbelt sign in restrained children in MVCs was 1.3%, while
the prevalence of serious IAI was 0.21%.17 The only prospective
multicenter study of restrained children in MVCs noted the preva-
lence of seatbelt signs and IAIs to be 16% and 6.7%, respectively.18
The significantly increased prevalence rates in this study are likely
due to selection bias because it only included patients presenting
to an ED after an MVC.
Children presenting with a seatbelt sign have approximately
9% to 21% risk of solid organ injury and 11% to 25% risk of GI
injury.18,19 Given the well-documented lack of appropriate booster
seat use as well as misuse of 3-point belts, the group at highest
risk for seatbelt syndrome appears to be children between the
ages of 4 to 9.9,12,20–22 Notably, very few infants who are prop-
erly restrained in child safety seats are found to have serious
abdominal injuries.9,23
Studies in both adults and children have shown a marked de-
crease in the risk for abdominal injuries when using 3-point belts
in place of 2-point belts.13,24 Children involved with MVCs using
booster seats with seatbelts have up to a 45% decrease in bodily
injury compared with similarly aged children using seatbelts
alone.24 A smaller case series of 98 children involved in MVCs
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Szadkowski and Bolte
showed that children in 3-point belts have no difference in the risk
of injury to the abdomen or chest compared with children using
lap belts alone, although they were 9 times less likely to have lum-
bar spine fractures.23 Some propose that the thinner abdominal
wall of children and their smaller anteroposterior diameter place
them at greater risk of abdominal injury, which may not be
prevented by restraint of the upper torso provided by
shoulder belts.25
ABDOMINAL INJURIES
Current data suggest that the seatbelt sign is associated with a
higher rate of GI injuries while the rate of solid organ injuries
remains unaffected.18,26 Intestinal injuries may include hemato-
mas, perforations, contusions, transections, seromuscular tears,
and devascularization secondary to mesenteric avulsions.27 The
most common site of intestinal injury is the jejunum, followed
by the duodenum, ilium, and cecum.28 Intestinal injuries have
been reported in restrained children in MVCs that occur at speeds
as slow as 13 mph (20 km/h).29 Solid organ injuries typically
involve the spleen, liver, kidneys, and pancreas.18,30 The stomach,
bladder, vena cava, and diaphragm are rarely injured.30–33
Children with seatbelt signs are at a considerably higher risk
of IAI compared with those without seatbelt signs, predominately
because of GI injuries.17,18,26 Data from the largest population-
based study found the positive and negative predictive values of
abdominal wall bruising for significant IAI to be 11.5% and
99.9%, respectively, resulting in a number needed to treat of 8.7.17
Children with seatbelt sign are also 9.5 times more likely to
undergo therapeutic laparotomy compared with those without
seatbelt signs.18 Interestingly, 2 large prospective trials found rates
of solid organ injury to be similar between those with and without
seatbelt signs.18,26
Small bowel injury can be a diagnostic dilemma for the
evaluating physician because serious injuries to the bowel and
mesentery may be present without early physical findings or
symptoms.34 The largest prospective study on this topic to date
found that 5.7% of children with a seatbelt sign but without ab-
dominal pain or tenderness on initial examination still had an
IAI, and 2% of this group required acute surgical interven-
tion.18 A multicenter retrospective review of children with doc-
umented intestinal injury found that patients who had operative
intervention performed more than 24 hours after initial injury
did not have a significant increase in early or late complica-
tions, length of hospitalization, morbidity, or mortality com-
pared with those diagnosed and treated less than 6 hours after
initial injury35 This study suggests that children with question-
able or minimal abdominal findings can safely be observed
with serial examinations.
Computed tomography scans are frequently used to identify
IAI in children presenting with seatbelt signs. In previous decades,
CT imaging has been shown to be insensitive in detecting hollow
viscous injury,28,36,37 although the newer-generation helical CT
scanners can find 76% to 98% of GI injuries.38–41 The presence
of peumoperitoneum, bowel wall thickening, streaking of mesen-
teric fat, or otherwise unexplained peritoneal fluid in the absence
of solid organ injury is useful indicator of bowel injury.28,36,42
With the exception of slightly better specificity, the use of oral
contrast with abdominal CT does not appear to be more adept at
detecting IAI compared with IV contrast.28,40 The use of diagnos-
tic peritoneal lavage has been described as a valuable technique
for identifying IAI, although its use has decreased in recent years
with the advent of improved imaging and focus on nonoperative
care.43–45 Limited data suggest the use of abdominal ultrasound
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Pediatric Emergency Care • Volume 33, Number 2, February 2017
to detect injuries associated with seatbelt signs has shown
inadequate sensitivity.46
To reduce the need for obtaining CT scans, a recent study
sought to derive a clinical prediction rule to identify those children
who are at lowest risk for IAI following blunt trauma requiring
acute intervention.47 This study generated a prediction rule
consisting of 7 patient history and physical examination findings
which had a negative predictive value of 99.9%. A limitation of
this study, in terms of prediction of seatbelt injury, was that only
one third of the population was involved in an MVC. If further
validated, this prediction rule may reduce the need for children
with low-risk criteria to have CT scans performed or be admitted.
Apart from monitoring for the presence of ongoing blood
loss, laboratory testing in the setting of abdominal trauma has
not been shown to be a consistent, reliable indicator of solid or
hollow organ injury.45
Posttraumatic intestinal obstruction is a less commonly seen
complication of MVC-related abdominal trauma and can occur
weeks to months after injury.48 Children will often present with
signs and symptoms consistent with small bowel obstruction. This
injury is thought to occur from a combination of a crush injury to
the bowel wall and ischemia from mesenteric injury. The disrup-
tion in mesenteric blood flow causes bowel wall inflammation
and fibrosis, which can lead from isolated bowel scarring to
full thickness bowel necrosis.48 These findings are not typi-
cally seen on the initial abdominal CT scan following trauma;
therefore, clinicians must maintain a high suspicion for this
condition in children who present with vomiting or signs of in-
testinal obstruction weeks after blunt abdominal trauma (see
Case Study above).48,49
SPINAL INJURIES
Motor vehicle collisions cause approximately 40% of all spi-
nal cord injuries in children.50 Fortunately, spinal injuries are quite
uncommon in restrained children involved in MVCs, occurring in
approximately 0.12% of cases.17 The presence of known IAI in-
creases the risk of vertebral fractures significantly, with reported
incidence of co-injury of 15%.17
The most common type of spinal injury associated with
seatbelt use is a Chance fracture. First described by Chance in
1948,51 this flexion-distraction injury has become synonymous
with lap belt use, constituting approximately 42% to 100% of ver-
tebral fractures seen in restrained MVCs.52 It describes a compres-
sion fracture to the anterior vertebral body as well as a transverse
fracture that extends through the posterior elements of the verte-
bra. Disruption of the posterior ligamentous complex of the spine
may or may not be involved as well.53 Mechanistically, it occurs
when the spine hyperflexes around the fixed anterior axis of the
vertebral column.
Diagnosis of lumbar spinal injuries can be performed using
lateral radiographs and/or CT scanning.45 Treatment is based on
the severity of bony injury and/or ligamentous involvement. The
presence of neurological deficit or spinal canal compromise war-
rants immediate surgical intervention.53 Significantly displaced
fractures or ligamentous injuries generally require surgical fusion,
while isolated bony injuries are treated with a hyperextension
brace or cast.54 Overall, children with Chance fractures tend to
have favorable outcomes with very few persistent neurological
deficits.3,30,53–59 In these case series, 13 (18%) of 72 patients with
Chance fractures had resulting paraplegia.
Although not part of the classic seatbelt syndrome, serious
C-spine injury, generally associated with significant hyperflexion
forces, can occur in restrained children involved in MVCs.60 The
incidence of cervical neck injury in pediatric trauma is relatively
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Pediatric Emergency Care • Volume 33, Number 2, February 2017
uncommon, with incidence around 1.5%.61,62 Awareness and dil-
igence on the part of the clinician are required to detect these
critical injuries.
DISCUSSION
Although this article focuses on seatbelt-related injury,
failure to use or the misuse of restraints poses a much greater risk
for children. Car seat use reduces the risk for death to infants
(<1 year) by 71%,63 while booster seat use reduces the risk for se-
rious injury by 45% for children aged 4 to 8 years when compared
with seatbelt use alone.24 For older children and adolescents,
3-point seatbelt use reduces the risk for death and serious injury
by approximately half.22 Unfortunately, booster seat use among
4- to 7-year-olds was only 46% in 2013.64 Even when car seats
and booster seats are implemented, improper installation rates
are very high, with an estimated combined rate of misuse
at 46%.65
The American Academy of Pediatrics has published state-
specific policy recommendations regarding the use of seat re-
straints. They recommend rear-facing car seats for infants under
2 years of age, forward-facing car seats until 4 years of age or
the maximum weight of the car seat, booster seats until the child
is 4 ft 9 in and 8 to 12 years of age, and 3-point seatbelts for all
other children.66 The significantly increased risk for improperly
restrained children to suffer serious IAI compared with properly
restrained children emphasizes the need for every child to be
restrained as recommended by the American Academy of
Pediatrics guidelines.
Children with seatbelt signs are at a considerably higher risk
of IAI compared with those without seatbelt signs. The low num-
ber needed to treat of 8.7 calculated in the study by Lutz et al17
confirms the importance of evaluating for IAI in every restrained
child with abdominal wall bruising after MVC. Children without
abdominal bruising have been found to have very low likelihood
of IAI (0.1%).17 Thus, while the presence of abdominal ecchymo-
sis signifies a high risk of IAI, the absence of ecchymosis does not
entirely exclude injury. Owing to the high risk of co-injury to the
spine, children with abdominal bruising should also be main-
tained in full spine precautions until spinal injury can be ruled
out. If hollow viscous injury is suspected or diagnosed, urgent ex-
ploratory laparotomy is indicated.
In children with a seatbelt sign and abdominal pain or tender-
ness on examination, an abdominal CT scan should be strongly
considered given the high risk of IAI. The disadvantages of the
use of oral contrast when obtaining abdominal CTs coupled with
the trivial improvement in specificity for detecting IAI do not jus-
tify its use over IV contrast.40 Abdominal ultrasound and perito-
neal lavage are also not recommended because of their lack
of specificity.
The dearth of large prospective trials makes it difficult to cre-
ate concrete management guidelines for children presenting with a
seatbelt sign but no initial abdominal tenderness or pain. The find-
ing that approximately 2% of these cases require surgical interven-
tion suggests that these patients should be admitted for observation
and have serial abdominal examinations to detect evolving physi-
cal signs suggestive of IAI.18
Given the extremely high sensitivity of newer CT scanners,
discharge home with specific follow-up instructions may be con-
sidered for children with a seatbelt sign who have a normal ab-
dominal CT scan and no abdominal symptoms.41 If the CT scan
is negative for injury but abdominal pain persists, continued ob-
servation with serial examinations is indicated, although no clear
guidelines on length of observation currently exist.
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Seatbelt Syndrome in Children
CONCLUSIONS
Appropriate use of child safety seats and booster seats with
3-point restraints significantly reduce, but does not eliminate,
the risk for intra-abdominal and spinal injuries in pediatric
patients. Early diagnosis of small bowel injury may be difficult
and requires a high index of suspicion to facilitate appropriate di-
agnostic testing and consultation. Children presenting with
seatbelt signs are at higher risk of GI injury and need for therapeu-
tic laparotomy than those without seatbelt signs. Current data sug-
gest that children with a seatbelt sign and abdominal tenderness
on initial examination are at higher risk for IAI and, therefore,
warrant additional evaluation via laboratory studies, CT imaging,
or observation. Those with a seatbelt sign but no abdominal ten-
derness are at low risk for serious IAI, although further studies
are needed before definitive guidelines regarding the time of ob-
servation in these cases can be made.
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