Automobile accident occupant injuries

COLLECTIVE REVIEW

Automobile Accident Occupant Injuries

J. K. Sims, MD* Roy J. Ebisut

Randolph K. M. Wong$ Livingston M. F. Wong, MD§

Honolulu, Hawaii

Sims JK, Ebisu RJ, Wong RK, Wong LM: Automobile accident occupant injuries. JACEP 5:796-808, October 1976. accidents, automobi le; seat belts; injuries, seat belt.

INTRODUCTION

Since the invent ion of the "horse- less carriage," the number and types of death and disabil i ty among the occupants of vehicles involved in automobile accidents have been significant. By 1966, the numbers had be- come so a la rming as to resul t in the publicat ion of Accidental Death and Disability: the Neglected Disease of Modern Society2 The impact of this article was enhanced by Farr ington 's "Death in a Ditch. ''2 The implication of bo th was t h a t too m a n y automobile accident victims were dying or were suffering disabl ing morbidity t h a t could h a v e b e e n a v e r t e d by prompt in jury recognition and emergency medical care intervent ion.

This article reviews the spectrum of injuries seen among the retained

occupants of automobiles involved in a cc iden t s in order to f a c i l i t a t e prompt recognit ion of actual and po- ten t ia l injur ies by emergency medical personnel. While gross t raumat ic deformi t ies are eas i ly recognized, often superf ic ia l cu taneous disrup- tions are the only clues to significant under ly ing pathology.

INJURY CATEGORIES

An au tomobi le accident v ic t im's po t en t i a l in ju r i e s are more eas i ly verified, or ruled out, when the information derived from examina t ion and subsequent studies is combined with accurate documentat ion of the damage to the interior of the car and the c i r cums tances of the accident. Accurate eva lua t ion for pa t i en t injur ies requires knowledge of a) the loca t ion of the p a t i e n t in the au-

Supported in part by a grant from the Department of Health, Education, and Welfare under the Emergency Medical Services System Act of 1973 (Public Law 93-154). This article reflects only the opinion of the authors and should not be construed as the opinion of the Depart- ment of Health, Education, and Welfare, the State of Hawaii, the Hawaii Medical Association, the Emergency Medical Services Program of Hawaii, the City and the County of Honolulu, the University of Hawaii School of Medicine, or the Ambu-

lance Department of the City and County of Honolulu.

From the Emergency Medical Services Program of the Hawaii Medical As- sociation,*§ Honolulu; Universi ty of Hawaii School of Medicinet$ and Ambu- lance Departmentt$ of the City and County of Honolulu•

Address for reprints: J. K. Sims, MD, Emergency Medical Services Program, Hawaii, 1301 Punchbowl Street, Hon- olulu, Hawaii 96813.

Page 796 Volume 5 Number 10

tomobile prior to impact, 3,4 b) the de- formations of automobile inter ior fixtures; 5 c) the pa t ien t position in rela- t ion to deformed fixtures, s and d) ex- t e r i o r or i n t e r n a l factors , s This eva lua t ion yields an enormous spec- t r um of possible t raumat ic injuries to occupants of automobiles involved in collisions so the following simplified in ju ry categories (Table 1) will be used for s u b s e q u e n t review: windshield, s t e e r i ng wheel , dashboard, seat belt, whiplash, and miscellaneous fixtures (eg, inter ior automobile fixtures).

Windshield Injuries

Many types of windshield glass in- j u r i e s have been repor ted (Figure 1).s,5, 7-23 and include facial lacerations, facial avulsions, facial nerve lacerat ions, 7-s parot id duct injury, 8 facial bone fractures,~,7-9,11-14, 23 facial (and scalp) contusions and abrasions,a,s,9,19, 21 sku l l f ractures , 11,18 concussion,3, H glass f ragment impac- t ion into brain, 11 tooth avuls ion or dislocation,S,s4 2 corneal/conjuctival abrasions, s eye penetra t ion, TM other eye damage ,~ -~3 , 2s l a c r i m a l ap- para tus injury, s neck or neck vessel l a ce r a t i ons , ~a cerv ica l sp ine frac- t u re /d i s loca t ion or cervica l spinal cord injury,~48 t r u n k (thoracoabdom- ina l ) l ace ra t ions , ~2 and ext remi ty lacerations. 2~

W i n d s h i e l d glass i n j u r i e s occur when the au tomobi le occupant impacts with the windshield (particu-

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Table 2 STEERING WHEEL INJURIES

Facial contusions/lacerations Mandible and facial bone fractures Skull fractures Ports-medulla brainstem rupture Basilar artery rupture Subarachnoid hemorrhage Subdural hematomas Tooth Ioss/avulsion/fract u re Carotid artery injury Acute tracheoesophageal fistula Laryngeal trauma Laryngotracheal injury/rupture Retropharyngeal hematomas Retroesophageal swelling Vocal cord paralysis Cervical spine fractures Anterior chest wall hematoma/contusions Flail chest Rib fractures Hemothorax Pneumothorax Sternum fractures Myocardial contusions Cardiac rupture Cardiac tamponade Aortic tear~dissection~transection~rupture Lung lacerations/contusions Pulmonary artery/vein disruption

Intrapul monary hematomas Pericardial sac rupture/laceration Coronary vessel injury Cardiac interventricular/interatrial septal rupture

or laceration Cardiac chordae tendineae damage Cardiac valve damage Traumatic asphyxia Internal mammary vessel disruption Mediastinal disruption Thoracic vertebral fractures Ruptured diaphragm Liver laceration/fracture/contusion Ruptured spleen .. Ruptured duodenum Pancreatic contusion/transection Mesentery root disruption Abdominal viscus herniation into thoracic cavity Bowel i nju ries (hematomas/tears) Gastric rupture Colon hematomas Kidney fracture/contusion Spleen subcapsular hematoma Inferior vena cava disruption Peritoneal hemorrhage Gallbladder rupture Urinary bladder rupture

windshie ld f rame deformity, the dis- t r ibu t ion of b roken windsh ie ld glass s c a t t e r , t h e o c c u p a n t ' s o r i g i n a l (pre impact) posit ion, the occupant 's f inal (postimpact) position, occupant seat bel t type, occupant seat bel t use, and correctness of seat bel t applica- tion. Glass f ragments can be detected on x- ray for cer ta in types of glass in brain, 1~ lung, 28 and soft t issues. 29

Steering Wheel Injuries

Numerous in jur ies have occurred when an a u t o m o b i l e occupan t im- pacted wi th the s teer ing wheel (Ta- ble 2).3'5'8'12'14-16'18'19'21' 25'30-40 I t

appea r s t h a t any p a r t of the body t h a t f o r c e f u l l y c o l l i d e s w i t h t he s t e e r i n g whee l ( s t ee r ing whee l inju r ies gene ra l ly refer to injur ies in- d u c e d by t h e hub,~2,Ig, 21 spokes , h a n d r i n g or r im, 5 or horn~9,2~, ~) can be contused, lacera ted, ruptured , or f ractured, inc luding unde r ly ing t issues and organs. Automobi le dr ivers t ha t are un re s t r a ined by seat bel ts upon impac t (Figure 2) are qui te li- a b l e to i n c u r s t e e r i n g w h e e l injur ies , 3,54s,31 a l though unres t r a ined f r o n t s e a t p a s s e n g e r s h a v e been


TE R,.G WHEELf C'SPINE FRAC..TURES I ~ FACIAL I MANDIBULAR

~ . ~ SUBDUg AL tF..l~k'~!k II ~ FRACTURES/DISLOCATION

-- ~ NECK CONTUSION i::~EUIV',QTHC)~ AY, "~

LUNG LI~,C.E~ATIQN "/ //*~'-~--~'~ J ~" ~ , | | ~ FRACTURED STERNUI~

FRACTURED RIBS / / # ~ " , I I

. . . . . . . . . . . \ - l / . • I I I /CARDIAC- RUPTURE ,E,'\U.HUt<\ ' / /AORTIC TRANSECTiOI

--";.,,OK.. \ ¢ON.US,O. • J ~ ' ~ / / I ~ DIAPHPA&Pk ~UPTUi~i

LIVER, GALLB LA, I)b ER ,DU C:,DE NA, L RU pl:. I ' ~ - - . ~ / N ~ . . . ~ " / \ I "

I E BOWEL iNTURIES

RUPTURE

Fig . 2. The "ring of injuries" and steering wheel hub injuries seen upon tran~' lating the steering wheel rim and hub up-and-down and left-to-right as it woulJ impact on the driver.

p r o p e l l e d in to t h e s t e e r i n g w h e e l u p o n i m p a c t a n d s u s t a i n e d injuries.S, ~ Lap-type sea t bel ts wi thout

c r o s s - c h e s t (or s h o u l d e r harneSS} s t r aps 41 s t i l l a l low d r ive r steeri~t wheel in jur ies to occur since collision

October 1976 J ~ l

Table 3 DASHBOARD INJURIES

Concussion Traumatic carotid-cavernous fistula Skull fractures Head injury Facial lacerations Facial bone fractures Mandible fractures Tooth loss Carotid artery crush injury Subcutaneous emphysema Laryngotrac heal i nju ry/fractu re/ruptu re Cervical spine fractures/fracture-dislocations/dislo-

cations "Fatal chest injuries"* Rib fractures Flail chest Lung lacerations Heart lacerations Aortic lacerations Pneumomediastinum Esophageal swelling Liver lacerations Spleen laceration/rupture Pancreatitis Duodenal rupture Paraplegia

* Quotations indicate unspecified types of injuries were reported.

Pelvic fractures Hi p fractu re-dislocations Hip dislocation Acetabulum fractures Femoral head fracture Femoral neck fracture Greater trochanter fracture Femoral shaft fractures Supracondylar femur fractures "Lower extremity injuries"*

"Knee injury" "Knee fractures" Knee abrasions Knee lacerations Patellar fractures Knee cruciate ligament tears Knee medial collateral ligament tears Knee lateral collateral ligament tears Proximal tibia fractures Proximal fibular fracture Legabrasions "Upper extremity injury" Shoulder fractures Humerus fractures Forearm fractures Wrist fracture

impac t forces cause the l ap -be l t ed d r ive r to be f lexed fo rward at the hips and the chest , neck, head, or a rms can coll ide wi th the s t ee r ing wheel.23, 37 Energy-absorb ing or col- lapsible s teer ing column assemblies , 5 d i sh - shaped s t ee r ing wheels , 7 torso r e s t r a i n t s y s t e m s (ie, s h o u l d e r - ha rnes s or cross-chest , l ap -be l t re- s t ra in ts ) proper ly worn, a re increas- ing surv iva l from s teer ing wheel injuries.5, 7

I n c r e a s e d s u r v i v a l is also be ing helped by the prompt recognit ion of po ten t ia l l e tha l injuries.~5,~9, 42 Un- fortunately, innocuous-appearing skin contusions may provide the only major clues to severe under ly ing steering wheel t r auma , a9 In a survey of ao r t i c r u p t u r e s , n i n e cases ou t of 88 casual t ies wi th complete thoracic r u p t u r e d e m o n s t r a t e d no s k i n or t h o r a c i c cage les ions .~9, 43 A o r t i c t r a n s e c t i o n mechanisms~5,s~, s9 include b lun t chest hor izonta l /ver t ica l decelerat ion, m a r k e d chest compression, t r ac t ion (indirect, on the aorta), p r e s s u r e , a n d " shove l ing" lh , ~ (ie, when the dr iver slips under the d a s h ,

~ ] ~ P October 1976

the thorax moves aga ins t the steering wheel caus ing aort ic compression b e t w e e n the s t e r n u m a n d t h e thoracic ve r t eb ra l column - - aort ic s h e a r i n g results15,31). Aor t i c in t i - ma /med ia /adven t i t i a l tears are seen not only at the junc t ion between the r e l a t ive ly fixed descending aor ta and the mob i l e ao r t i c a rch (ie, a t t he l i g a m e n t u m a r t e r i o s u m level ) b u t also in the ascending aorta, descend- i n g a o r t a , a n d t h e a r ch of t h e aorta.S1, 39 These tears are not a lways complete15,21,31,39, 42 and d e l a y e d rup tu re can occur. 3s Prompt recogni- t ion and surgical in te rven t ion have al lowed su rv iva l of aort ic t ea r and t ransec t ion victims. 1~ ,as,42

The s teer ing wheel, wi th i ts prom- inen t r im, can cause a potent ia l r ing of in ju r i e s from forehead to pelvis a n d from r igh t ax i l l a ry l ine to left ax i l l a ry l ine (or f lank to flank). 3~ In assess ing the driver , then, i t is help- ful to know the degree of s t e e r i n g wheel column of deformity,~, ~2,23,3~ the dr iver ' s f inal (postimpact) posi- t ion, sea t bel t use, (eg, fas tened or not, seat bel t fai lure, f i rmly secured

or loose, lap be l t or lap be l t w i th torso r e s t r a i n t ) and assoc ia ted automobile in te r io r f ixture deformities. For o ther occupants, pa r t i cu l a r ly for those in the front seat, the above in- format ion in addi t ion to pre- impact posi t ion would appear desirable.25, 27 Wi thou t this information, there may be difficulty in d i f ferent ia t ing steering wheel in jur ies from those caused by the windsh ie ld , s ea t be l t s , 44 or dashboard.

Dashboard Injuries

The dashboard has been impl ica ted in many occupant injuries dur ing automobi le acc iden ts (Table 3).s,7-9, - 12,14-18,23,25,31j32,37~40,45-53 For our

purposes, the impl ica ted "dashboard" wil l include the t rue dashboard, the glove c o m p a r t m e n t (or glove box), t he d a s h b o a r d i n s t r u m e n t pane l s , dashboard-mounted radios, the fascia ( E u r o p e a n d e s i g n a t i o n ) , d a s h - m o u n t e d h e a t e r s , and d a s h b o a r d - mounted ai r condit ioners.

D a s h b o a r d i n j u r i e s f r e q u e n t l y occur in unres t r a ined front seat au- t o m o b i l e o c c u p a n t s h , 7 - 9 , 1 2 - 1 5 , 2 3 , 3 ~ , -

Volume. 5 Number 10 Page 799

4v,4s,5o when the driver and/or front sea t pas senger s are propel led forward into the dashboard 13 (ie, the "second collision"S,~7, 23) dur ing fron- tal vehicle impact (ie, the "primary collision"23). Lower e x t r e m i t y injur ies in unres t ra ined passengers are quite common, (Figure 3)5,~,2~, 45-t8 with knee impacts resul t ing in direct local injuriesS,15,24, tS-4s (part icularly f rac tures24, 45-48) as wel l as force t r a n s m i s s i o n up the sha f t of the femur to the hip and pelvis (result ing in fractures and dislocations (Figure 4).5,~5,45,47, 4s P r e - i m p a c t cross- leggedness seemed to genera te hip d i s l oca t i on for severe k n e e - d a s h - board collisions, whereas pre-impact bi la teral hip abduction seemed to result in hip fractures. 4s

P a d d i n g the d a s h b o a r d and increased proper seat belt use are de- creasing many types of dashboard injuries.5,8,12, 48 P rev ious ly , the un- be l t ed d r i v e r would s l ide e i t h e r under or around the steering wheel into the dashboard or windshield," whereas the unres t r a ined front seat p a s s e n g e r was p rope l l ed in to the dash s t ra ight on or obliquely. How- ever, a front seat occupant res t ra ined only by a lap-type seat bel t can be flexed at the hips with the resu l tan t impac t of uppe r body a g a i n s t the dashboard_ 23 Use of l ap- type seat belts alone has actual ly increased the i nc idence of cases of the "padded dash syndrome" of l a ryngot rachea l rupture. In "padded dash syndrome" the lap be l t ed o c c u p a n t is f lexed t r u n k fo rward a t the hips , the h y p e r - e x t e n d e d n e c k a n t e r i o r l y s t r ikes the padded dash forcefully (Figure 5), and this blow rup tu res the larynx or t rachea with min ima l resu l tan t anter ior neck skin disrup- t ion> e In several cases, passengers i n i t i a l l y were def lec ted f rom the windshield down onto the dashboard.

The rear of the front seat is to the rear seat passenger as the dashboard and steering wheel are to front seat occupants, inc luding the spectrum of in jur ies .~5, ~° P o s t e r i o r f r on t sea t padding and rear seat passenger seat bel t buckle-up, with three-poin t or shoulder/waist seat belts, have been advocated to d iminish these types of injuries.445,1e,25

Padding of dashboard or rear of the front seat alone does not completely

'DA SHBOARD KNEE'

S~A, FT o~ SUPRACONbYL~R ._ . - - !.I ) \ " - . "/ -----FRACTURED

,x,~ ";. " - . TIBIA, (3)

/ - -'-FRACTURED FIBULA (3)

Fig. 3. The poorly-restrained or unrestrained automobile occupant's leg slides forward (blackened arrow) and may collide with the dashboard at any o f several points (dotted arrows)_ The numbered white arrows show some o f the counter- forces to the dotted arrows and show injury sites.

'DASHBOARD HIP'

I I

R ~ ' ~ \ FRA, CTURE SJ

PELVIS (ACET/kBULUM ,KWZLUDED) PROXIMAL FEMUR ~ ' ~ - ' - ' ~ NECK OF ~EMUR / / / \ \

~ ~ FEi'~C)RAL i-,Eb, b _J i-, ) \ ' / - ~' ) ~k GR'r'kTER-TIRQCHENTER ~ ' " / \

I

Fig. 4. During an automobile collision, a poorly-restrained or unrestrained occupant may be propelled forward, with direct hip impact with the dashboard or force transmission from the knee up the shaft of the f e m u r to the hip resulting in hip and/or f emur fractures.

protect from in jury in automobile collisions,16, ~3 and dashboard fixtures also present problems. In an example of the latter, an occupant of a colli-

sion vehicle, upon crash impact, in- ha led a r u b b e r g r omme t from the dashboard into his r ight lower lobe bronchus. =s

Page 800 Volume 5 Number 10 October 1976 , , w ~ D

Table 4 INJURIES A S S O C I A T E D WITH SEAT BELTS

Decapitation Medulla oblongata transection Traumatic retinal angiopathy

(Purtscher's disease) Skull fractures Facial bone fractures (indirect) Facial lacerations (indirect) Concussion "Facial injuries" (indirect) Neck lacerations Laryn gotracheal i nj u ry/fractu re/ru ptu re (i ndi rect) Cervical spine fractures Atlanto-occipital joint injury Cervical spine fracture-dislocation Cervical spinal cord transection Cervical spondylosis Strained or stiff neck Common carotid artery rupture Phrenic nerve injury Brachial plexus injury Sternocleidomastoid muscle rupture Internal carotid artery occlusion Hyoid bone fractu re Retropharyngeal hematomas Cervical spine transverse process (C7) fracture Thoracic spine transverse process fractures (T1, T2) Clavicular fractures Sternal fractures Rib fractures Cardiac rupture Shoulder harness pattern subcutaneous hematomas Chest bruising Aortic intima ruptures Ruptured diaphragm Stomach herniation into the thoracic cavity Herniation of colon and small bowel and stomach

into ventral hernia (delayed) Herniation of colon and small bowel into lateral ab-

dominal wall hernia "lntrathoracic and intra-abdominal injuries" "lntra-abdominal injuries" "Bowel perforation" Posterior parietal peritoneal tears Flank hernia (delayed) Colon mesentery tears

Small bowel mesentery tears Sigmoid mesentery tears Sigmoid contusions/tears Colon contusions/tears/lacerations/pu nctures/tran-

sections Small bowel lacerations/punctures/rupture/transec-

tion Bowel ecchymoses/discoloration/laceration Duodenal disruption/rupture/transection "Jejunal injury" "Necrosis of sigmoid" Retroperitoneal hemorrhage Avulsion of omentum Liver contusions/lacerations/rupture Inferior vena cava laceration Spleen ruptu re/laceration Abdominal aorta dissection Renal artery rupture Kidney rupture Renal contusions Hepatic vein avulsion (from inferior vena cava) Pancreatic rupture Lower abdominal (wall) abrasions/contusions/

bruises/hematomas "Seat belt burns" (lap type) Anterior abdominal muscle myolysis Rectus abdominis muscle hematomas Rectus abdominis muscle transection Ventral hernia (delayed development) Umbilical hernia (containing transverse colon and

stomach) Rupture of pregnant uterus Fetal injury/death Placental separation

-Urinary bladder contusions Suprapubic/pubic/inguinal contusions Urethral rupture Pelvic fractures Hip dislocation Lumbar spine fractures Vertebral column compression fractures Lumbar spine subluxation Lumbar spine dislocation Lumbar spine fractu re-dislocation Paraplegia

Seat Belt Injuries

Automobile seat belts, while pre- vent ing or min imiz ing many serious injuries and fatalities,4,12,14,1~,26,27, - 44,47,48,50,54,55 have in themselves been a direct or indirect source of injury to their wearers (Table 4). 7,16,17,23,41,44,-

~,49,52,54-7s There are several different types of seat belts current ly in use, 4~,- 44,s2,~5 and comparat ive retrospect ive h u m a n studies52, 55 and prospect ive animal studies (Savannah baboons - - Papio cyanocephalus) 41 h a v e been conducted to review the injuries char-

J ~ F ) October 1976

acter is t ical ly associated with a given seat belt type.

The re is a wide spec t rum of inju r i e s a t t r i bu t ed to au tomobi le occupan t r e s t r a i n t systems. This va- r ie ty is more easily understood if different ia t ion by a c t u a l res t ra in t sys- t em is used. Current ly, there are six major types of automobile res t ra in t systems in use (Table 5). 41,44 Since each type of res t ra in t system causes character is t ic injuries,55,~7,s',~l, 67-69 the type of res t ra in t system in which the vic t im is found must be known. 44

A detai led analysis of injuries sus- t a ined by occupants r e s t r a i ned by several seat belt types (although not all) has been performed. ~S

L a p Belts . An extensive range of injur ies has been seen in those re- s t ra ined only with lap belts (Table 6).7 y16 ~17,23 ~37 ~41 ~49 ~51,54 ~56 ~60-70 ~73-75, -

77,78 The indirect injuries seen in association with lap belt use are usually not the resul t of direct t raumat ic impact of the belt with the body, but r a t h e r the r e su l t of the secondary collision of the automobile occupant

Volume 5 Number 10 Page 801

DASHBOARD HEAD ¢ NECK INJURIES ( PADDED I:)ASH SYNDROME ]

Fig. 5. Dashboards cause injuries not only to the knee and hip, but to the head and neck as well, whether or not the dashboard is padded. Laryngotracheal rupture occurs when the restrained occupant is flexed at the hips neck-first into a padded dash - "padded dash syndrome_"

LAP BELT INJURIES

CLkSp. It, Hilt II UII"U~II N t N G

Fig. 6. Injuries directly and/or indirectly caused by the lap-type seat belt (a two-point fixation system) alone, some resulting when the seat belt wearer is forcibly flexed about the belt at the waist ("clasp-knife") or slides under the belt ("submarining").

CROSS CHEST- LAFP~-.,.BELT INJURIES FR/~CTURED tNkNOtlL I= CON~U~i~ON

NEF,~) LkCS~, ~. IONS ~ I , ,1 ] "TOOTH AVUt.Sl0N STRNNED/C;TWF Nrr.C ~, ~ \ ]

Fig. 7. During an automobile collision a wearer o f the cross chest - lap belt restraint system (either a 3- or 4-point f ixation restraint system) may sustain injury either from impacting with the belt webbing directly (eg, torso strap marks) or indirectly (eg, oblique sternal fracture), or f rom unrestrained head/neck motion about a restrained torso (eg, cervical spine fractures).


Table 5 AUTOMOBILE RESTRAINT

SYSTEMS

1, Lap belt,

2, Diagonal belt

3. 3-point or 4-point fixation belt (lap plus diagonal)

4. Lap belt with double shoulder harness

5. Inverted y-yoke harness with inertia reel

6. Air bag (with lap belt)

with the inter ior components of the car. ~ The lap belted occupant, upon the automobile 's p r imary collision, 23 gets forcefully flexed at the hips, and his torso is propelled forward to impact with the car's inter ior fixtures, damage ensu ing (Figures 5 and 6).7, - 12,za,16,~3,37,4s,~z This movement has been referred to as "clasp-knife ''5~ or "jackknife ''48 flexion. This flexion with r e su l t an t second collision injuries has encouraged a shift away from lap belt only res t ra in t systems to the 3- and 4-point f ixat ion r e s t r a i n t sys- terns, ie, lap belt 151us diagonal belt.V, - 16723137,41

In ju r ies to the au tomobi le occupant produced by the seat belt itself have been referred to as '~tertiary collision injuries" from the ter t iary col- l is ion of the occupant with his re- s t ra in t systemA 1 These injuries are the direct injur ies listed in Table 6 (ie, not labeled as indirect) and range from lower abdominal wall lap belt ab ras ions /con tus ions /b ru i ses /hematomas 49,54,61,63,66,67,69,74,77,7s (by map-

ping out belt impact with the abdomen) to the creation of increased intra-abdominal pressure of a magnitude sufficient to rup ture a hemidiaphragm, zv,69,74 with the hern ia t ion of stomach into the thoracic cavity27, 74 External abdominal wall contusions (as well as signs of peri toneal i rr i tat ion) not in- f r e q u e n t l y imply ser ious i n t r a - ab - domina l and/or l u m b a r spine injury.Z7~41~61~63~66,67

Several mechan i sms for m a n y of the abdomina l , pelvic, and l u m b a r spine lap belt injuries have been pro- posed.7,4s,~°,61,64,eS,ST, G9 The abdomina l wall in jur ies reflect the direct

October 1976 J ~ P

Table 6 -~ INJURIES ASSOCIATED WITH LAP BELTS

Facial bone fractures (indirect) Facial lacerations (indirect) "Facial injuries" (indirect) Laryngotracheal injury/fracture/rupture (indirect) Cervical spine fracture (indirect) Rib fractures Diaphragm rupture Stomach and colon and small bowel herniation into

an abdominal ventral hernia (delayed effect) Herniation of stomach into the thoracic cavity (acute) Herniation of colon and small bowel into lateral ab-

dominal wall hernia (delayed effect) "lntra-abdominal injuries" Bowel perforation Posterior parietal peritoneal tears Abdominal flank hernia Colon mesentery tears Sigmoid mesentery tears Sigmoid contusions/tears/lacerations Colon contusions/tears/lacerations/pu nctu res/tran-

sections Small bowel lacerations/punctures/rupture/transec-

tion Bowel ecchymoses/discoloration/laceration Duodenal disruption/rupture/transection "Jejunal injury" Necrosis of sigmoid Retroperitoneal hemorrhage

Liver contusions/lacerations/rupture Inferior vena cava laceration Spleen rupture/lacerations Abdominal aorta dissection Renal contusions Pancreatic rupture Lower abdominal wall abrasions/contusions/bruises/

hematomas Seat belt "burns" (lap type) Anterior abdominal muscle myolysis (acute) Anterior abdominal wall lipolysis Rectus abdominis muscle hematoma Rectus abdominis muscle transection Ventral hernias (delayed development) Rupture of pregnant uterus Fetal injury/death Placenta separation Urinary bladder contusions Suprapubic/pubic/inguinal contusions Pelvic fractures Hip dislocation Lumbar spine fractures Vertebral column compression fractures Lumbar spine subluxation Lumbar spine dislocation Lumbar spine fracture-dislocation Paraplegia

seat belt webbing shear ing action (as a band), made worse if the belt folds or kinks upon itself_44, s7 Abdominal viscera damage has been at t r ibuted to b lun t bel t shea r ing action; 49,6~- 63,G4,7~ compression of viscera between the anterior abdominal wall and the vertebral column;49,66, 67 acute mas- sive development of in t ra-abdominal pressure;~7, 6G torsion; 4s closed bowel loops;49 entrapment;6~;66,67 direct vio- lence; 6~ and increased in t r a -u te r ine pressure.G4, 7~ The lumbar spinal injuries have been a t t r i b u t e d to ex- treme f lexion of the l u m b a r spine over the r e s t r a i n e d hips or abdo- raen6°,~7, 69 (Figure 6), with pat terns for each of the different lumbar in- Juries reviewed elsewhere. 6s Pa t i en t COmplaint of back p a i n s t r o n g l y SUggested ver tebral column disrup- '.ioa and/or lumbar spinal cord dam- ~ge. 6°,67 Lumbar, pelvic, and abdominal injuries a t t r ibuted to a specific, SOmetimes u n r e l i a b l e lap be l t ~echanism tha t allows "submar in- i11g,"17,44 a n d i m p r o p e r lap be l t ~se17y41,44,56,6°163,69,7° have occurred.

~he worsening of the spectrum of in- hries through submar in ing and im-

~ [ ] ~ October 1976

.J proper lap belt use cause advocation of proper seat belt use. 17,64,66,70

D i a g o n a l Belts. The diagonal re- s t r a i n t be l t is a s ingle s t rap t ha t runs across the wearer 's torso from one shoulder diagonal ly across the chest to t he contrala teral hip41,4~, s2 as two-point fixation (ie, fixed each end) without any lap belt component. This belt was felt to reduce injuries by at least 50% in one report_ 79 How- ever, t r a u m a as severe as decapita- tion52, 57 has been associated wi th diagonal belt use alone, sT,s8 Other injuries associated with diagonal belt use are listed in Table 7Y,~2,54,~,- 57,ss,61,66,ss Possible non-direct injur ies (ie, not caused by th e occupant colliding with the cross-shoulder diagonal belt) found in association with bandolier belt use have been noted about the extremities, ~2,25 but may ac- tua l ly r ep re sen t n o n r e s t r a i n e d ex- t remlty flailing. As with lap seat belts, a loose diagonal belt appeared to con- fer more in jury potential for the wearer than did snug securing. 52

T h r e e - p o i n t (or F o u r - p o i n t ) Fix- a t i o n Lap D i a g o n a l Belts . (Table

8) 41'55'58'59'72 In th is r e s t r a i n t appa r a t u s (Figure 7) the lap bel t is combined with the diagonal belt41, - 44,52,55 and was recommended to minimize secondary collision injuries. 7,- 16,23 The designat ion "shoulder harness" may refer ei ther to this belt or to belts 4 and 5 (Table 5l with reader confusion result ing. The term "shoulder harness" will be used in this review when it appears that three- or four-point fixation lap and diagonal belts were implied. Animal experi- ments, us ing primates, to investigate seat bel t in jur ies 41 indicate lesions that can be expected to be seen in man in the future, al though the extremity injuries ~ reported for seat belt wearers were not shown as a t t r ibutable to the belt_

Lap Belt with Double Shoulder H a r n e s s . There are few reports ~1,55 on injuries associated with this system (Table 9). They do not reveal whether or not extremity injuries 55 were a t t r i bu t ab l e to this r e s t r a in t system.

I n v e r t e d Y-Yoke H a r n e s s w i th Iner t ia R e e l a n d A i r B a g Re-


s t r a i n t . For these two separa te re- s t r a i n t sys tems the re were insuffi- cient medical j ou rna l case reports for review. A n i m a l s tud ies 4' i nd ica t ed t h e s e two sy s t ems to be compara - t ive ly far super ior to al l o thers tested in providing protect ion from injury.

Sea t be l t i n ju r i e s a re commonly associated with mul t ip le injur ies of o ther etio]ogies.7,12,15,17,27,44,51,s2, - S4,hS,Go,o7,69 I t may be difficult to dif- fe rent ia te a seat bel t injury from a s teer ing wheel injury. 44 Seat bel t fail- ure also occurs, appa ren t ly rarely,54, - 57 so the re may be injur ies a t t r i bu tab le to the sea t bel t prior to snap and also to the subsequent secondary collision. Rel iable pa t i en t assessment for seat bel t in jur ies requi res a knowledge of the following:44,54, 61 v ic t im height , weight , and age; au tomobi le make, model, and year; occupant locat ion (pre- and post-collision); in ter ior au- t o m o b i l e f i x t u r e d e f o r m i t i e s ; au- t omob i l e co l l i s ion d e t a i l s (eg, automobile head-on collision at 55 mph w i t h c o n c r e t e b r i d g e a b u t m e n t ) ; crash velocity; t ime of crash; detai ls of r e s t r a in t sys tem for each occupant as applied; degree of r e s t r a in t system snugness; evidence for seat belt fail- ure; o ther possible contr ibutors t ha t can a c c o u n t for s a m e i n j u r y (eg, s teer ing wheel, dashboard).

Sea t be l t s should be r ega rded as providing incomplete (or par t ia l ) pro- tection from injur ies (with less protect ion provided upon belt k ink ing 67) and as p rov id ing much less protec- t ion wi th increas ing automobile col- l is ion speed.'5,27,54,55, eo Marked re- duction in seat belt protect ion is reported at au tomobi le speeds above 30 to 60 mph.15,52, 55 Never the less , occupant r e s t r a in t systems repor tedly s i g n i f i c a n t l y r e d u c e i n j u r y a n d death,475725,27,44,54,95,57-5S ,61,64 ~66 ,-

s7-sg,73 particularly when ejection from the a u t o m o b i l e is possibleS,~5,27, G= and, as such, r e s t r a in t systems were s t rong ly advocated.4715,25,27744,4s , 52- 54~55~58,59161164768

Whiplash

Whiplash refers to the in jur ies of the neck, cervical spine, brain, cra- n ia l nerves , cervical sp ina l nerves, and cervical spinal cord produced by the "violent f l inging of the head on the neck ''s° as genera l ly induced by r e a r - e n d au tomob i l e collisions.S, is-


Table 7 INJURIES ASSOCIATED WITH USE OF DIAGONAL BELTS

Medulla oblongata transection Traumatic retinal angiopathy Skull fracture Concussion Cervical spine fractures (indirect with belt too loose) Cervical spine fractures (direct) ', Atlanto-occipital joint injury Cervical spine dislocation or fracture-dislocation Cervical spinal cord transection Strained or stiff necks Tearing of neck muscles Common carotid artery rupture Sternal fractu re Rib fractures Cardiac rupture Chest bruising Aortic intima ruptures Liver rupture Spleen rupture Kidney rupture Renal artery rupture Hepatic vein disruption Pelvi'c fractures Urethral rupture Umbilical hernia (with transverse colon and stomach as contents)

Table 8 INJURIES ASSOCIATED WITH USE OF LAP-DIAGONAL BELTS

Concussion Mandibular fracture Traumatic retinal angiopathy ("shoulder harness" Tooth avulsion "Slight head injuries" Head lacerations Strained or stiff necks , "Strangulation injuries" ("shoulder harness") Laryngeal fractures ("shoulder harness") Retropharyngeal hematoma ("shoulder harness") Sternocleidomastoid muscle rupture ("shoulder harness") Decapitation ("shoulder harness") Phrenic nerve injury ("shoulder harness") Internal carotid artery occlusion ("shoulder harness") Cervical spondylosis Cervical spine fracture (Cz) Cervical spine fracture (Cz transverse process) Thoracic spine fracture (T1 and T2 transverse processes) Torso contusions (strap marks) "Rib injury" Rib fractures Sternal fractu re Clavicular fracture Splenic rupture Pelvic fracture Humerus fracture-subluxation

53,59,68,80-87 Resul t ing whip lash inju- r ies 5719'21~53'55'59~68 ~72'80-86iss-90 from

these r e a r - e n d and o t h e r t y p e s of au tomob i l e co l l i s ions cover a wide spec t rum (Table 10).

The mechanisms for whiplash i~' j u r i e s h a v e been p r o p o s e d in de' tailS°,ST, 91 and eva lua t ed in experl" m e n t a l a n i m a l s t u d i e s (Figure 8) 80 8s Phys io log ica l , pathological,

October 1976 ~

Fig. 8. A mult ipl ici ty of injuries may be included under the general terms of "whiplash injuries." Since some o f these in jur ies are symptomatic , the emergency physician cannot disprove their existence.

and pathophysiological explanat ions have been offered84-ss, 9° for v i r tua l ly all the injur ies and victim symptoms. Weaker neck muscula ture in women reportedly accounts for their greater s u s c e p t i b i l i t y to w h i p l a s h injuries,41,5~,s9, 72 p a r t i c u l a r l y for

Table 9 DOUBLE SHOULDER HARNESS INJURIES

"Head injuries" "Head lacerations" Nasal fractures Mandibular fractures Concussion Stiff and strained necks Thoracic "pulled muscles" Rib fractures

diagonal and diagonal-lap seat belt systems. F ron t seat head supports (ie, "head rests") have been the primary devices advocated to diminish whiplash injuries.S,52, s8

Miscel laneous Interior Fixture Injuries

Numerous automobile inter ior fixtures have been implicated as caus- ing occupant , injuries d u r i n g accidents, and each has been associated with types of injuries. (Table 11).

Rest ra in t systems have been advocated to minimize these miscellaneous secondary collisions with interior t]xtures,4,25, 5°,93 even for rear seat passengers, 4 al though res t ra in t systems ma y increase in ju ry sever i ty when occupant compar tment in t ru- sions are involved. 15

CONCLUSION

From the above review it can be seen t h a t v i r t u a l l y every in t e r io r component of an automobile may be considered a potential source of in- j u r y to the a u t o m o b i l e occupan t s when tha t vehicle is involved in a collision. We hope this review will assist emergency medical personnel in the assessment of the automobile accident victim, whether it be as to history, physical examination, roent- genology, ultrasonography, or labora- tory tests.

ACKNOWLEDGEMENTS

The authors would like to acknowledge the following for their contributions to the preparation of this article: US De- partment of Health, Education and Wel- fare under the EMSS Act; EMS (Hawaii) Secretarial Staff, manuscript typing; Hawaii Medical Library Staff, assistance in li terature search; Thomas Whelan, MD, Professor & Chairman, Department of Surgery, School of Medicine, Univer- sity of Hawaii, Honolulu, Hawaii, manuscript critique.

REFERENCES

1. National Academy of Sciences- National Research Council (NAS-NRC): Accidental Death and Disability: the Neg- lected Disease of the Modern Society. Washington, NAS-NRC, 1966, 38 pp.

2. Farrington JD: Death in a ditch. Bul- letin of the American College of Surgeons 52:121-130, 1967.

3. Weisz GM, Schramek A, Barzilai A:

Table 10 SPECTRUM OF WHIPLASH INJURIES

Cerebral concussion "Brain injury" Retrograde amnesia Amnesia Post-traumatic amnesia Subarachnoid hemorrhage Headache or recurrent headaches Vertigo Tinnitus Ataxia Dysarthria Difficulty concentrating Mood changes or irritability or tension or enhanced

excitability Insomnia Blurred vision or diplopia "CNS damage" Concussion of the medulla Dilated pupils Hornet's syndrome Atlanto-occipital joint injuries

Cervical vertebrae fractures or fracture-dislocations Cervical vertebra spinous process fractures Cervical disc injury/protrusion/rupture Cervical spondylosis Cervical spinal ligamentous tears Cervical nerve root compression/stretching/injury Cervical radiculitis Cervical muscular tears/hemorrhage Neck strains/sprains/spasm/stiffness Loss of cervical lordosis Pyramidal tract (CNS) damage Retropharyngeal edema Sternocleidomastoid muscle swelling/tenderness Neck pain Upper extremity paresthesias Upper extremity sensory decrements Hypertonic reflexes Decreased tendon reflexes Extensor plantar responses Transient loss of abdominal reflexes Vasomotor instability

J ~ P October 1976 Volume 5 Number 10 Page 805

Injury to the driver. J Trauma 14:212- 215, 1974.

4. Markham DE: Anterior dislocation of the hip and diastasis of the contralateral sac ro- i l i ac j o i n t - - t he r e a r - s e a t passenger 's injury? Br J Surg 59:296-298, 1972.

5. Huelke DF: Mechanisms of injury in automobile crashes. Cali f Med 116:23-29, 1972.

6. Walsh WA, Scarpa FJ, Brown RS, et al: Gasoline immersion burn. N Engl J Med 291:830, 1974.

7. Holding BF, Sul l ivan JC: Injuries of the face and jaws. J Med Assoc State Ala 35:521-527, 1966.

8. Spira M, Gerow F J, Hardy SB, et al: Windshield injuries of the face. J Trauma 8:513-526, 1968.

9. Huelke DF, Grabb WC, Dingman RO: Facial injuries due to windshield impacts in automobile accidents. Plast Reconstr Surg 37:324-333, 1966.

10. Schultz RC: The changing character and managemen t of soft t issue windshield injuries. J Trauma 12:24-33, 1972.

11. Rushworth RG: Windscreen injuries of the brain. Med J Aus t 2:80-83, 1969.

12. Gra t tan E: Pat terns , causes, and pre- vention of facial injury in car occupants. Proc R Soc Med 65:913-916, 1972.

13. Patr ick LM: Cadaver windshield impac t r e s e a r c h . P l a s t R e c o n s t r S u r g 37:314-322, 1966.

14. Hueston JT, Cook RM, Langford A: Face fractures in motor accidents. Med J Aus t 1:940-941, 1964.

15. Nage l DA, P r i e s t JR, B u r t o n DS: Motor vehicle accidents: h u m a n causes and i n j u r i e s s u s t a i n e d . Cl in Orthop 92:239-250, 1973.

16_ But ler RM, Moser FH: The padded d a s h synd rome : b l u n t t r a u m a to the larynx and trachea. Larynoscope 78:1172- 1182, 1968.

17. Payne DP, ResnicoffSA, States JD, et al: Seat bel t abdomina l wal l muscu la r avulsion. J Trauma 13:262-267, 1973.

18. Voigt GE, Sk~ld G: Ring fractures of the base of the skull. J Trauma 14:494- 505, 1974.

19. Watanabe T: Atlas of Legal Medicine, Lippincott, Philadelphia, 1968, p. 67-68:

20. Polson CJ, Gee D J: The Essentials of Forensic Medicine, Pergamon, New York, 1973, p_ 126.

21. Spitz WU, Fisher RS (eds): Medico- legal Investigations of Death, Charles C Thomas, Springfield, Illinois, 1973, p. 332- 345, 517.

22. Watson J: Soft-tissue aspects of facial fractures. Proc R Soc Med 65:918-920, 1972.

23. N a h u m AM: Facia l t r a u m a in au- t omob i l e col l i s ions . Trans A m A c a d O p h t h a l m o l Oto laryngol 69:396-404, 1965.

Table 11 MISCELLANEOUS INTERIOR FIXTURE INJURIES

Fixture

Knobs

Rear-view mirrors

Sunvisors

Door pillars or door posts (A-pillar, B-pillar windshield frame)

Steering column and supports

Gearshift lever

Front seat headrest

Ignition keys

Rear of the front seat

Front compartment parcel shelf

Side window frame

Door paneling

Emergency brake handle

Door armrests

Type of Injury

Facial injuries Knee perforationsg,24, 33

Facial lacerations Eye Injury Facial bone fractures12,17

Facial lacerations Facial bone fractures 12

Facial injuries Facial lacerations Facial bone fractures Fracture of the mandible " Loss of teeth Fatal head injury Head contusions Skull fractures Cervical spine injury2,9,12,1s,le# 9

Patella fractu res Tibial fractu rest5, 24

Through-and through midfacial impalement

Right hemithoracic impalement92, 9~ with resultant right hemothorax, right atrial puncture, right pulmonary artery puncture, and death

Bilaterial clavicular fractures 94

Knee perforation 24

Facial bone fractures Mandible fractures Laryngotracheal injury Fatal chest injuries Liver lacerations Splenic rupture Interventricular septal tear Anterior hip dislocations Diastasis of contralateral sacroiliac joint

with anterior hip dislocation Upper extremity injuries",14-1s., 23

Open tibial fracture Femur laceration 4e

Facial injuries Facial bone fractures Fractures of the mandibleg# 4

Muscle contusions Joint stiffness Extremity fractures Pelvic bruising Pelvic fracture Clavicular fracture 24

Femoral artery laceration 46

Pelvic bruising Pelvic fractures Rib fractures "Fatal inju ries"24, 33

Page 806 Volume 5 Number 10 October 1976 , ~ ] ~ P

Table 11 (Continued)

Firewall (by encroachment of a collision-deformed front wheel assembly)

Floorboard/Toepan

Automobile roof

Ashtray

Tibia/fibula fractures Ankle fractures Femu,r fractures15, 21,46

Ankle fracture-dislocations Tibia/fibula fractures Open ankle fractures "Fatal injuries" by intrusions into the oc-

cupant compartment and extremity entrapmentS,IS,24,33, 46

Facial lacerations Eye injury Loss of teeth Facial bone fractures Mandibular fracture Skull fractures Fatal head injury (unspecified type) Head and cervical spine injuries

(unspecified types) Cervical odontoid process (C2) fracture is Cervical spine dislocation Brachial plexus avulsion3,12,15,1s,ss

Scalp bruising (infant) 2s

24. Huelke DF: Ext remi ty injuries produced in mo to r veh ic l e col l i s ions . J Frauma 10:189-200, 1970.

25. Chris t ian MS: Non-fatal injuries sustained by back seat passengers. Br IVied J 1:320-322, 1975.

26. Hossack DW: The pa t te rns of injuries received by 500 drivers and passengers killed in road accidents . Med J A u s t 2:193-195, 1972.

27. Tonge JL, O'Reilly MJJ, Davison A, et ah Traffic crash fatalities. Med J Aus t 2'.5-13, 1972.

28. Bishop JM, Gran t AF: Inhala t ion of multiple foreign bodies in a motor-vehicle accident. Med J Aus t 1:955-956, 1968.

29. Whelan GP: The radiopacity of glass in soft tissue. J A C E P 4:401-402, 1975.

30. Lo AM, St iegmann GV: Cardiac rupture secondary to b lun t t rauma. Il l Med J 143:250-252, 1973.

11. Coermann R, Dotzauer G, Lange W, et al: The effects of the des ign of the Steering assembly and the i n s t r u m e n t Panel on injuries (especially aortic rupture) sustained by car drivers in head-on Collision. J Trauma 12:715-724, 1972.

12. Elliot JM, Rogers LF, Wissinger JP, ~t sl: The hangman ' s fracture. Diagnostic l~adiology 104:303-307, 1972.

la. Stephens GL: Steer ing wheel b lun t ~ hdominal t r a u m a . J K y Med Assoc 9:131-139, 1961.

~ ) October 1976

34. Nolan J J , A s h b u r n FS: Tracheoe- .sophageal f istula as an isolated effect of s t e e r i n g whee l injury_ Med A n n D C 29:384-387, 1960.

35. Barnes JP, Diamonon JS: Traumatic rup tu re of the ga l lb ladder due to non- penet ra t ing injury. Texas State Journal of Medicine (Texas Medicine) 59:785-787, 1963.

36. Goffin Y, Heyndrickx G: Traumat ic rupture of the r ight coronary ar tery with 9 hours survival Forensic Sci 4:135-144, 1975.

37. Schneider RC, Livingston KE, Cave AJE, et ah H a n g m a n ' s f rac ture of the cervical spine. J Neurosurg 22:141-154, 1965.

38. Yajko RD, Seydel F, Trimble C: Rup- ture of the stomach from blunt abdominal t rauma. J Trauma 15:177-183, 1975.

39. Lacquet LK, Kuijpers PJ, Van Lent D, et al: Traumat ic rupture of the aortic i s thmus after b lun t chest t rauma, d Car- diovasc Surg 15:537-547, 1974.

40. t l a u m a n RL: Traumat ic pancreat i t is and r e t r o p e r i t o n e a l r u p t u r e of the duodenum. Ohio State Med J 63:802-4, 1967.

41. Snyder RG, Snow CC, Young JW, et al: Pathology of t r a u m a at t r ibuted to re- s t ra in t systems in crash impacts. Aet;osp Med 39:812-829, 1968.

42. C u k i n g n a n RA J r , B r e n n e r WI, Acinapura AJ: Traumat ic aortic transec-

t ion. N Y S ta te J Med 74:2412-2413, 1974.

43. Z e l d e n r u s t J, A a r t s JH: T r a u m a - tische aor ta rupture bij verkeersongeval- len. N e d T i j d s c h r Geneeskd 106:464- 468, 1962.

44. Huelke DF, Snyder RG: Seat belt injuries: the need for accuracy in report ing of cases. J Trauma 15:20-23, 1975.

45. Naclerio EA: Axioms on emergency m a n a g e m e n t of chest injuries. Hospital Medicine 6:6-15, 1969 (March).

46. De Fonseka CP: Fracture of the r ight lower l imb of drivers due to penetra t ion of the front wheel. Br J Surg 56:321-326, 1969_

47. Gra t t an E: Injuries to hip joint in car occupants. Br Med J 1:71-73, 1969.

48. Ritchey SJ, Schonholtz G J, Thompson MS: The dashboard femoral fracture. J Bone Jo in t Surg (Am) 40-A:1347-1358, 1958.

49. Witte CI: Mesentery and bowel injury from au tomot ive sea t belts. A n n Surg 167:486-492, 1968.

50. Kulowski J: Fractures of the shaft of the femur resul t ing from automobile accidents. Journal of the International Col- lege o f Surgeons 42:412-417, 1962.

51. Fletcher BD, Brogden BG: Seat belt f r a c t u r e s of the sp ine and s t e r n u m J A M A 200:167-168, 1967.

52. Lindgren S, Warg E: Seat belts and acc ident p r even t ion . Pract i t ioner 188: 467-473, 1962.

53. Fite JD: Neuro-ophthalmologic syn- dromes in automobile accidents. South Med J 63:567-570, 1970.

54. Garre t t JW, Brauns te in PW: The seat be l t synd rome , J T r a u m a 2:220-237, 1962.

55. Lister RD, Milsom BM: Car seat belts on analysis of the injuries sustained by car occupants. Pract 191:332-340, 1963.

56. Campbell DK: Seat belt injur,]: injury of t he a b d o m i n a l a o r t a . R a d i o l o g y 92:123-124, 1969.

57. Saldeen T: Fatal neck injuries caused by use of diagonal safety belts. J Trauma 7:856-862, 1967.

58_ A r n d t RD: Cervical- thoracic t rans- verse process fracture: fur ther observa- t ions on the s ea t be l t syndrome . J Trauma 15:600-602, 1975.

59. Johnson DH: Case report of cervical spine fracture with lap-shoulder bel t re- s traints . JACEP 3:31-35, 1974.

60. Howland W J, Curry JL, Buffington CB: F u l c r u m f r ac tu r e s of the l u m b a r spine. J A M A 193:140-141, 1965.

61. Will iams JS, Lies BA Jr, Hale HW Jr: The automotive safety belt: in saving a life may produce in t ra -abdomina l injuries. J Trauma 6:303-313, 1966.

62. F i sh J, W r i g h t RH: The sea t bel t syndrome - - does it exist? J Trauma 5: 746-750, 1965.


63. Ger r i t sen R, Frobese AS, Pezzi PJ: Unusual abdominal injuries due to seat belts. Journal of the Albert Einstein Med- ical Center 14:63-66, 1966.

64. Cmsby WM, Snyder RG, Snow CC, et al: Impact injuries in pregnancy. I_ ex- per imental studies. A m J Obstet Gynecol 101:100-108, 1968.

65. Dyer I: Discuss ion . A m J Obstet Gynecol 101:108-109, 1968.

66. MacLeod JH, Nicholson DM: Seat- belt t r auma to the abdomen. Can J Surg 12:202-206, 1969.

67. Ritchie WP, Ersek RA, Bunch WL, et al: Combined visceral and ver tebral in- j u r i e s f rom lap type s ea t bel ts . Surg Gynecol Obstet 131:431-435, 1970.

68. Gissane W: The causes and the pre- vention of neck injuries to car occupants. Ann R Coll Surg Engl 38:161-163, 1966.

69. Smith WS, Kaufer H: Pa t t e rns and mechanisms of lumbar injuries associated with lap seat belts. J Bone Joint Surg (Am) 51-A:239-254, 1969.

70. Cocke WM Jr , Meyer KK: Splenic rupture due to improper placement of automobi l e sa fe ty bel t . J A M A 183:693, 1963.

71. W i l l i a m s RD, S a r g e n t FT: The mechanism of in tes t inal injury in t rauma. J Trauma 3:288-294, 1963.

72. Ebbe t t s J: Seat be l t s and cervical spondylosis. Practitioner 188:802, 1962.

73. Herrero FA, Walton BE, Jurkiewicz MJ: E m e r g e n c y m a n a g e m e n t of facial

fractures following automobile accidents. A m Surg 31:85-89, 1965.

74. Dardik H, Warren A, Dardik I: Dia- phragmatic , visceral, and somatic injuries following rear seat belt t rauma. N Y State J Med 73:577-580, 1973.

75. Rubor i ts FE: Traumat ic rup ture of the p regnan t uterus from "seat belt injury." A m J Obstet Gynecol 90:828-829, 1964.

76. F i s h e r P: In jury produced by seat belts: report of two cases. J Occup Med 7:211-212, 1965.

77. H u r w i t t ES, Si lver CE: "Seat bel t hernia": a vent ra l he rn ia following an automobile crash. J A M A 104:829-831, 1965.

78. LeMi re JR, D a n i e l E, C h a p i n H: In t ra -abdomina l injuries caused by automobile seat belts. J A M A 201:735-737, 1967.

79. B~ckstr~Jm CG: Traffic in ju r ies in south Sweden wi th special reference to medico-legal autopsies of car occupants and value of safety belts. Acta Chir Scand suppl 308, 1963.

80. O m m a y a AK, F a a s F, Ya rne l l P: W h i p l a s h i n j u r y and b r a i n damage . J A M A 204:285-289, 1968.

81. Gay JR, Abbott KH: Common whip- ]ash i n j u r i e s of t h e neck . J A M A 152:1698-1704, 1953.

82. Cameron BM: Whiplash injuries. A m J Nurs 62:72-75, 1962.

83. Nicholson MW: Whiplash: fact, fan- tasy or fakery. Hawaii Med J 33:168-170, 1974.

84. Franke l CJ: Medical-legal aspects ~[ injuries to the neck. J A M A 169:216-223,1 1959.

85. Shapiro SK, Torres F: Bra in injur~ compl i ca t i ng w h i p l a s h in jur ies . Min~ Med 43:473-476, 1960.

86. McGehee FO: Whiplash injury of the cervical spine :-- I. American Journal o[ Orthopedics 1:105-108, 1959.

87. McKeever DC: The mechanics of the so-ca l led w h i p l a s h in ju ry . America~ Journal of Orthopedics 2:3-6, 1960.

88. MacNab I: Accelerat ion injuries 01 the cervical spine. J Bone Joint Surg (Am) 46-A:1797-1799, 1964.

89. Hall RF, Stuck RM, Hall OEK: Whip. lash in jury of the cervical spine - - I I American Journal of Orthopedics 1:109. 111, 1959.

90. Rose DL: The w h i p l a s h ' injury: American Journal of Orthopedics 2:141. 144, 1960.

91. Cameron BM, Cree CMN: A critique of the compression theory of whiplash American Journal of Orthopedics 2:127. 129, 1960.

92. S teward FW: Perfora t ion of middle th i rd of face b) ~ a foreign body: report of a case. J Oral Surg 18:512-513, 1960.

93. Cowen PN: Fata l stab wound by c01. umn gear-change lever. Br Med J 1:236, 1965.

94. F e t t e r m a n LE: D e V a n e FH: Au- tomobile head r e s t r a i n t injury. JAMA 214:1328, 1970.

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Automobile accident occupant injuries