Seatbelt syndrome associated with an isolated rectal injury: case report
© Hefny et al; licensee BioMed Central Ltd. 2010
Received: 8 December 2009
Accepted: 4 February 2010
Published: 4 February 2010
Seatbelt syndrome is defined as a seatbelt sign associated with a lumbar spine fracture and a bowel perforation. An isolated rectal perforation due to seatbelt syndrome is extremely rare. There is only one case reported in the Danish literature and non in the English literature. A 48-year old front seat restrained passenger was involved in a head-on collision. He had lower abdominal pain and back pain. Seatbelt mark was seen across the lower abdomen. Initial trauma CT scan was normal except for a burst fracture of L5 vertebra which was operated on by internal fixation on the same day. The patient continued to have abdominal pain. A repeated abdominal CT scan on the third day has shown free intraperitoneal air. Laparotomy has revealed a perforation of the proximal part of the rectum below the recto sigmoid junction. Hartmann's procedure was performed. The abdomen was left open. Gradual closure of the abdominal fascia over a period of two weeks was performed. Postoperatively, the patient had temporary urinary retention due to quada equina injury which resolved 10 months after surgery. The presence of a seatbelt sign and a lumbar fracture should raise the possibility of a bowel injury.
Despite the decreasing mortality in restrained victims of motor vehicle collisions (MVC), a new type of injury related to seatbelt usage has emerged. Seatbelt sign is the linear ecchymosis of the skin caused by the seatbelt following MVC . Seatbelt syndrome is defined as a seatbelt sign associated with a lumbar spine fracture and a bowel perforation. An isolated rectal perforation due to seatbelt syndrome is extremely rare. There is only one case reported in the Danish literature and non in the English literature .
Injury of the colon and rectum following blunt trauma is rare and its early diagnosis is difficult . Restrained patients of MVCs with seatbelt sign have more incidence of intestinal injury than others . Intestinal injury should be strongly suspected in patients with a seatbelt sign associated with a lumbar fracture (seat belt syndrome) [5, 6]. Computed tomography (CT) has shown to be the diagnostic test of choice for the evaluation of blunt abdominal trauma in haemodynamically stable patients . Finding bloody stool or blood per rectal examination mandates proctosygmoidscopy . Some rectal injuries can be detected after contrast enema .
There is no reliable diagnostic test that can completely exclude intestinal injury in blunt abdominal trauma when immediately done after trauma . In equivocal abdominal examinations, diagnostic peritoneal lavage may help in detecting intestinal perforation, but similarly, it may also miss the injury if it was performed soon after trauma . Clinical suspicion and serial physical examinations are essential in detecting such injuries. The presence of an associated lumbar vertebral fracture makes the clinical abdominal assessment difficult and unreliable . Repeated CT scan after 8 hours in suspected cases may help in early diagnosis of bowel perforation . In our patient, the abdominal CT scan was repeated due to persistent abdominal pain and distension. It has shown free intraperitoneal air. At laparotomy, perforation of the proximal part of the rectum was detected. This is a very rare seatbelt complication . It is difficult to explain how the rupture occurred under the pelvic rim although there was no pelvic fracture in this patient. This injury was not iatrogenic by the pedicle screws as the screws did not penetrate beyond the bodies of the vertebrae as shown by figure 3. Furthermore, the rectal perforation was only in the anterior wall of the rectum while the posterior wall was intact. Pedicle screw internal fixation was indicated because the patient presented with a neurological deficit, unstable fracture and narrowing of the spinal canal of more than 50% [11–13]
The only way we could explain the mechanism of this rectal injury is by sudden increase of the intra luminal pressure of a closed bowel loop by the seatbelt during deceleration. This can result in a bursting injury with perforation [7, 14]. The same mechanism has been proposed for oseopahgeal rupture caused by a seatbelt injury . A distended closed bowel loop is especially susceptible to rupture when its wall is stretched because of the tri-axial stress effect. In contrast, if it was empty, a larger force is required to cause its rupture [15, 16].
In cases of delayed diagnosis of large bowel perforation, Hartmann's procedure is safer and more effective . Delayed diagnosis of intestinal perforation increases the incidence of sepsis and its associated morbidity and mortality [10, 18]. Primary closure of the abdominal fascia is ideal but it was impossible in our patient. The development of abdominal compartment syndrome was a real concern because of the distension and oedema of the inflamed bowel. The abdomen was left open and gradually closed . The technique we have used is cheap, controls fluid and heat loss, does not adhere to the abdominal wall and simplifies re-exploration of the abdomen with decreased mortality . Despite that, the abdominal domain may be lost as the edges may retract with a risk of evisceration if the abdominal wall closure was delayed [19, 20].
The presence of a seatbelt sign and a lumbar fracture should raise the suspicion of a bowel injury. Seatbelt injury can cause rectal perforation. Repeated serial clinical examination is essential to avoid missed bowel perforations.
Written informed consent was obtained from the patient for the publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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