Abdominal Ecchymosis

An elderly obese female presents to the office with lower abdominal ecchymosis (Figure). She was in a motor vehicle accident the week before. She was evaluated in the emergency department then discharged home, with an uneventful course thereafter.

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What is the most likely diagnosis?

A. Hemophilia

B. Seat belt sign

C. Cullen sign

D. Grey Turner sign

E. Patterned contusion

F. D and E

G. B and E

Answer and discussion>>

Answer: G.  B. Seat belt sign and E. Patterned contusion

In 1962, Garrett and Braunstein described a phenomenon known as “seat belt syndrome.” Patients presented with linear ecchymosis on the abdominal wall (seat belt sign) and associated abdominal organ, lumbar spine, and intestinal injuries. It occurred in lap-belt restrained patients who had been in motor vehicle accidents.¹ The sign is an example of a “patterned contusion,” a forensic term for bruises that follow the pattern of a traumatizing object in contact with the skin. With the introduction of the three-point seat belt in the 1970s, fatalities from road traffic accidents fell by 60%. But a pattern emerged that was related to skin abrasions of the neck, chest and abdomen, and increased risk of internal injuries. This included the original seatbelt syndrome plus chest, sternum, and rib injuries caused by seat belts in high energy impact accidents.²

Although the use of seat belts in automobile accidents reduces the length of hospital stay, severity of injury, and number of surgeries, physicians need to be aware of the complications the restraints can cause.³  Visible seat belt abrasions on a patient’s body correlate with a four-fold increased likelihood of chest trauma and eight-fold increased likelihood of intra-abdominal injury.⁴  Bruising of the abdominal wall is caused by the fulcrum-like action of the seat belt against abdominal muscles and visceral injuries are caused by compression between the seat belt and vertebral column.⁵ Intestinal ischemia is typically a result of mesenteric tears from the force of impact.⁶ Abdominal wall ecchymosis, or seat belt sign, is associated with abdominal injury in 65% of patients compared to 8% when ecchymosis is absent.⁷ Of note, patients with seat belt sign but no abdominal tenderness or symptoms appear to be at low risk for internal injuries.⁸

Proper diagnosis early on is exceedingly important because of the morbidity and mortality linked to these injuries.^9,10 Shearing forces on the lower abdomen from rapid deceleration and restraint cause intestinal perforations, mesenteric tears, and fractures of the sternum, ribs, and even clavicle.^3,11 Thoracic injury with aortic transection or injuries to major neck vessels also are seen.¹² Chest and abdominal X-rays and CAT scan with contrast are recommended, depending on the clinical condition. In cases where the suspicion is high, patients can be monitored with CAT scans every 8 hours.¹³ Indications for laparotomy include positive abdominal signs (ie, peritonitis, increasing pain, and distension), hemodynamic instability, and positive diagnostic imaging.⁹ Delays in diagnosis and treatment can lead to sepsis, peritonitis, abscess formation, longer hospital stay, and increased rates of acute respiratory distress syndrome.¹⁴

Treatment for seat belt syndrome depends on the organs injured as well as the extent of injuries. Management ranges from conservative to surgical, with hollow organ injuries requiring surgical interventions; vascular and parenchymal injuries can be surgically or conservatively managed. Prognosis varies with type of organ injured and degree of damage.¹⁵ In conclusion, a high index of suspicion and low threshold for diagnostic evaluation as well as surgical exploration is recommended to properly care for patients who present with seat belt sign.

References:

1.       Garrett, J.W. and P.W. Braunstein, The seat belt syndrome. J Trauma, 1962. 2: p. 220-38.

2.       Biswas, S., et al., Abdominal injury patterns in patients with seatbelt signs requiring laparotomy. J Emerg Trauma Shock, 2014. 7(4): p. 295-300.

3.       Abu-Zidan, F.M., et al., Effects of seat belt usage on injury pattern and outcome of vehicle occupants after road traffic collisions: prospective study. World J Surg, 2012. 36(2): p. 255-9.

4.       Velmahos, G.C., R. Tatevossian, and D. Demetriades, The "seat belt mark" sign: a call for increased vigilance among physicians treating victims of motor vehicle accidents. Am Surg, 1999. 65(2): p. 181-5.

5.       Williams, R.D. and F.T. Sargent, The mechanism of intestinal injury in trauma. J Trauma, 1963. 3: p. 288-94.

6.       Aiken, D.W., Intestinal perforation and facial fractures in an automobile accident victim wearing a seat belt. J La State Med Soc, 1963. 115: p. 235-6.

7.       Chandler, C.F., J.S. Lane, and K.S. Waxman, Seatbelt sign following blunt trauma is associated with increased incidence of abdominal injury. Am Surg, 1997. 63(10): p. 885-8.

8.       Sokolove, P.E., N. Kuppermann, and J.F. Holmes, Association between the "seat belt sign" and intra-abdominal injury in children with blunt torso trauma. Acad Emerg Med, 2005. 12(9): p. 808-13.

9.       Zheng, Y.X., et al., Diagnosis and management of colonic injuries following blunt trauma. World J Gastroenterol, 2007. 13(4): p. 633-6.

10.     Khan, I., et al., Mechanisms of injury and CT findings in bowel and mesenteric trauma. Clin Radiol, 2014. 69(6): p. 639-47.

11.     Slavin, R.E. and A.P. Borzotta, The seromuscular tear and other intestinal lesions in the seatbelt syndrome: a clinical and pathologic study of 29 cases. Am J Forensic Med Pathol, 2002. 23(3): p. 214-22.

12.     Rozycki, G.S., et al., A prospective study for the detection of vascular injury in adult and pediatric patients with cervicothoracic seat belt signs. J Trauma, 2002. 52(4): p. 618-23; discussion 623-4.

13.     Brofman, N., et al., Evaluation of bowel and mesenteric blunt trauma with multidetector CT. Radiographics, 2006. 26(4): p. 1119-31.

14.     McStay, C., et al., Hollow viscus injury. J Emerg Med, 2009. 37(3): p. 293-9.

15.     Torba, M., et al., Seat belt syndrome, a new pattern of injury in developing countries. Case report and review of literature*. G Chir, 2014. 35(7-8): p. 177-80.