Intestinal injuries due to seat belt without seat belt sign:
Although seat belts save lives after motor vehicle accidents, they may cause different types of injuries such as abdominal wall, intra-abdominal, neck and spine or vascular injuries. Seat belt sign indicates the severity of injuries, and usually the risk of intra-abdominal injuries is high when the seat belt sign exists. Published in the Journal of Surgical Case Reports, the authors present two cases of intra-abdominal injuries caused by seat belts without seat belt sign.

Case 1
A 22-year-old man, a passenger in the right front seat of a vehicle, was wearing a 3-point seatbelt at the time of a head-on collision traffic accident. An abdominal CT scan showed thickening of the small intestine wall. The patient was discharged following 5 h of stable observation in the emergency department.

However, over the following 24 h, he developed a severe abdominal pain and was admitted to the emergency department. On examination, there were clear signs of peritonitis. A secondary CT scan showed free air and extensive free fluid in the abdominal cavity. During the laparotomy, a small bowel perforation 5 mm in diameter, and a large volume of intestinal fluid were detected.

Case 2
A 38-year-old male driver was wearing a 3-point seat belt in head-on traffic accident at a speed of ~80 km/h. On admission, he was conscious, his vital signs were normal and he had a right knee fracture. An abdominal CT scan revealed small splenic hematoma and minimal free fluid intra-abdominally.

He was hospitalized and monitored for 10 h. However, his general condition gradually deteriorated, his abdominal pain increased, hypotension and tachycardia developed. A second CT scan was performed and revealed that intra-abdominal free fluid had increased, and the distal part of the small bowel was ischemic with thickened walls.

During the laparotomy, there was more than 2 l of blood and hematomas, and a 100 cm small bowel mesenteric laceration starting from 10 cm above the ileo-caecal valve. This bowel segment was ischemic but had no perforation. There was also laceration of the sigmoid colon and upper rectum mesocolon.

Lessons learnt:-
- The authors recommend that CT scan is performed for haemodynamically stable patients with abdominal pain after a motor vehicle accident, even if there is no seat belt sign.

- If the CT scan is normal, the patient should be hospitalized and followed closely for up to 24 h.

- A control CT scan should be performed and an explorative laparotomy should be planned if peritonitis signs develop.

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