Figure 4 Abdominal CT scan with intravenous contrast on day 1 (A) which was normal and on day 3 (B) which showed free intraperitoneal air (arrow) and left pleural effusion. Figure 5 Rectal perforation at the rectosigmoid junction (arrow heads). The perforation was below the

pelvic rim (arrow). Discussion Injury of the colon and rectum following blunt trauma is rare and its early diagnosis is difficult [3]. Restrained patients of MVCs with seatbelt sign have more incidence of intestinal injury than others [4]. 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 MG-132 of blunt abdominal trauma in haemodynamically stable patients [7]. Finding bloody stool or blood per rectal examination mandates proctosygmoidscopy [3]. Some rectal injuries can be detected after contrast enema [8]. There is no reliable diagnostic test that can completely exclude intestinal injury in blunt abdominal trauma when find more immediately

done after trauma [9]. 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 [7]. Clinical suspicion and serial physical examinations are essential in detecting such injuries. The presence Liproxstatin1 of an associated lumbar vertebral fracture makes the clinical abdominal assessment difficult and unreliable [10]. Repeated CT scan after 8 hours in suspected cases may help in early diagnosis of bowel perforation [7].

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 [2]. It is difficult to explain how Phosphoglycerate kinase 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 [14].