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HAS THE SAFETY-BELT REPLACED THE HANGMAN'S NOOSE?
1341 HAS THE SAFETY-BELT REPLACED THE HANGMAN’S NOOSE?
SIR,-British pathologists studying the remains of executed criminals found that the forceful hyperextension of the cervical spine fractured the pedicles of C2, tore the intervertebral ligaments, and sheared the C2-C3 disc. These types of lesion are found in about 10% of cases of upper cervical spine trauma. Between 1970 and 1984, 38 patients were admitted to our neurosurgical service with fractures of the pedicles of C219 during the eleven-year period 1970-81, then 5 cases in 1982,6 in 1983, and 8 in 1984. 35 of these patients (92%) sustained their injuries in car accidents, three-quarters of which were frontal collisions. 28 of these 35 patients (80%) were wearing safety belts, but had had no head rest. The remaining 7 were not wearing safety belts. These numbers indicate that the wearing of safety belts without head rests lends itself to this type of injury. 1,2
The presence after an accident of a bruise or burn on the left side of the driver’s neck or jaw or on a front-seat passenger’s right side (vice versa in Britain) may be related to general head pain. This pain appears to be asymmetric; the body of the jaw is painful on one side, while the temporomandibular joint and temporal muscle are painful on the other. In one case the victim had chipped teeth; the belt restraint had forced the mandible upwards and sideways. We have in this way explained the severity oftemporomandibular joint damage and asymmetric head symptoms in some puzzling cases where no blow to the head or jaw had occurred. Those who assess and treat neck and spinal damage should realise that the shoulder-lap belt may cause torquing of neck and spine and that this can happen in a whiplash incident even though hyperextension of the neck or spine is limited. 4433 West 10th
Avenue, Vancouver, British Columbia,
R. H. ROYDHOUSE
Canada V6R 2H8 1. Huelke
DF, Compton CP. Facial injuries in automobile crashes J Oral Maxillofac Surg 1983, 41: 241-44.
2. 3.
Pye G, Waters EA. Effect of seat belt legislation on injuries in road traffic accidents in Nottingham. Br Med J 1984; 228: 756-57. Roydhouse RH. Whiplash and temporomandibular dysfunction. Lancet 1973; i:
1394-95. 4. Brooke RI, Stenn PG. Post injury myofacial pain dysfunction syndrome: its etiology and prognosis. Oral Surg 1978; 45: 846-50. 5. Swartz G, Zeidler F, Brinkmann B. Gewebever anderungen der insasskleidung durch einwirkung des sicherheitsgurts beim 50 km/h-frontalaufprale. Z Rechtsmed 1984; 92: 291-306. 6. Maurisse M, Lejeune G. Traumatisme et ceinture de securité. Acta Chir Belg 1984; 84:
186-91.
Comparison of forces acting on a body in hanging and impact in vehicle with a safety belt but no head rest.
on
frontal
In a frontal impact, the body is held down in the seat by the safety belt, while the head is thrown violently backwards, thus hyperextending the cervical spine, and causing the same type of injury as hanging (figure). The protection against physical injury provided by safety belts is so widely recognised that many countries now require them by law; should head rests on car seats be required by law also? 17 T F. LESOIN C. E. THOMAS Neurosurgery Service B, G. LOZES Hôpital B, L. VILLETTE CHR de Lille, 59037 Lille, France M. JOMIN .-.
1. Williams TG.
Hangman’s fracture. J Bone Joint Surg 1975; 57: 82-88. J, Colnet G, Pionchon H. Fractures bioediculaires de C2 et ceintures securité. Neurochirurgie 1984; 30: 183-87. Roy-Camille R, De Lacaffiniere JY, Saillant G. Traumatismes du rachis cervical superieur C1-C2. Masson, Paris: 1973
2. Chabannes 3
TORQUING OF NECK AND JAW DUE TO BELT RESTRAINT IN WHIPLASH-TYPE ACCIDENTS
SIR,-The use of seat belts has reduced the number and severity of facial injuries in motor vehicle accidents but the proportion of facial or jaw injuries may have increased. 1,2 Symptoms from trauma to the soft tissues of the spine and neck and temporomandibular joint symptoms due to sudden acceleration-deceleration events ("whiplash" injuries) persist as a considerable medical and dental4 problem. I raised this point in 19723and Brooke and Stenn4 supported this view. Recovery time will be prolonged if the diagnosis is missed. Car seat belts usually have a diagonal shoulder-restraining component. This restricts movement of the upper torso but for convenience it usually has an extension system (eg, inertia reel) that locks only if the extension is above a certain speed, as in a sudden forward movement during deceleration or in reflex bending during sharp acceleration. The rapid imposition of restraint by the diagonal belt in a vehicle occupant who is thrown forward can lead to a burn on the side of the neck or to bruising. These and other accident victims.
injuries5,6
may be
seen on
AVAILABILITY OF MINI PEAK FLOW METERS FOR THE MANAGEMENT OF SEVERE ASTHMA
SIR,-In 1982 the British Thoracic Association (BTA) published a large retrospective analysis of asthma. deaths, confirming2-4 that death in most cases (77/90, 86%) was potentially preventable.
Despite identification of the "at risk" patient and the BTA’s carefully formulated recommendations, the annual mortality of about 1600 deaths in England and Wales continues unchanged.5 Why have the BTA findings had no impact on asthma deaths? The answer may lie in the need to recognise slowly deteriorating and acute severe
asthma
at an
earlier stage
so
that
treatment can
be
promptly to pre-empt any crisis. The patient’s own perception of breathlessness in asthma is highly variable, despite similar degrees of airway obstruction; many patients fail to appreciate large falls in peak flow.6,7 In the BTA study 67/90 (74%) patients tolerated breathlessness and failed to appreciate how suddenly deterioration can occur. Therefore, the need for and potential advantages of self-monitoring of asthma are recognised.8,9 Miniature Wright and Vitalograph peak flow meters are widely used for self-assessment of asthma. They cost only £ 10 or so and are light but sturdy and small but reliable. However, their availability depends on the patient’s ability to pay or the physician’s access to local financial resources. Surely, these devices should be freely available on the NHS, to be prescribed for the at risk asthma patient at the discretion of his or her physician. The need for these devices for monitoring asthma has been likened to that of the measurement of glycosuria in diabetes;9 here, unfortunately, the analogy ends because urine testing kits can be prescribed on the NHS. started
Department of Medicine, Royal Liverpool Hospital, Liverpool L7 8XP
ALAN J. WILLIAMS SUSAN E. CHURCH
1. British Thoracic Association. Death from asthma in two regions of England Br Med J 1982; 285: 1251-55. 2 Ormerod LP, Stableforth DE. Asthma mortality in Birmingham 1975-7 53 deaths. Br
Med J1980;
280: 687-90.
3. Cochrane GM, Clark TJH. A survey of asthma mortality in patients between ages 35 and 64 in the Greater London Hospitals in 1971. Thorax 1975; 30: 300-05. 4. Fraser PM, Speizer FE, Waters SDM, Doll R, Mann NM. The circumstances preceding death from asthma in young people in 1968-1969. Br J Dis Chest 1971; 65: 71-84. 5. OPCS Asthma mortality statistics for England and Wales, 1979-1983. London: Office of Population Census and Surveys. 6. Rubmfield AR, Pain MCF. Perception of asthma. Lancet 1976, i: 882-84. 7. Editorial Perception of breathlessness in asthma. Lancet 1983; i: 912-13. 8. Stableforth DE. Death from asthma. Thorax 1983, 38: 801-05. 9. Seaton A Asthma: Contrasts in care. Thorax 1978; 33: 1-2.
SIR,-British pathologists studying the remains of executed criminals found that the forceful hyperextension of the cervical spine fractured the pedicles of C2, tore the intervertebral ligaments, and sheared the C2-C3 disc. These types of lesion are found in about 10% of cases of upper cervical spine trauma. Between 1970 and 1984, 38 patients were admitted to our neurosurgical service with fractures of the pedicles of C219 during the eleven-year period 1970-81, then 5 cases in 1982,6 in 1983, and 8 in 1984. 35 of these patients (92%) sustained their injuries in car accidents, three-quarters of which were frontal collisions. 28 of these 35 patients (80%) were wearing safety belts, but had had no head rest. The remaining 7 were not wearing safety belts. These numbers indicate that the wearing of safety belts without head rests lends itself to this type of injury. 1,2
The presence after an accident of a bruise or burn on the left side of the driver’s neck or jaw or on a front-seat passenger’s right side (vice versa in Britain) may be related to general head pain. This pain appears to be asymmetric; the body of the jaw is painful on one side, while the temporomandibular joint and temporal muscle are painful on the other. In one case the victim had chipped teeth; the belt restraint had forced the mandible upwards and sideways. We have in this way explained the severity oftemporomandibular joint damage and asymmetric head symptoms in some puzzling cases where no blow to the head or jaw had occurred. Those who assess and treat neck and spinal damage should realise that the shoulder-lap belt may cause torquing of neck and spine and that this can happen in a whiplash incident even though hyperextension of the neck or spine is limited. 4433 West 10th
Avenue, Vancouver, British Columbia,
R. H. ROYDHOUSE
Canada V6R 2H8 1. Huelke
DF, Compton CP. Facial injuries in automobile crashes J Oral Maxillofac Surg 1983, 41: 241-44.
2. 3.
Pye G, Waters EA. Effect of seat belt legislation on injuries in road traffic accidents in Nottingham. Br Med J 1984; 228: 756-57. Roydhouse RH. Whiplash and temporomandibular dysfunction. Lancet 1973; i:
1394-95. 4. Brooke RI, Stenn PG. Post injury myofacial pain dysfunction syndrome: its etiology and prognosis. Oral Surg 1978; 45: 846-50. 5. Swartz G, Zeidler F, Brinkmann B. Gewebever anderungen der insasskleidung durch einwirkung des sicherheitsgurts beim 50 km/h-frontalaufprale. Z Rechtsmed 1984; 92: 291-306. 6. Maurisse M, Lejeune G. Traumatisme et ceinture de securité. Acta Chir Belg 1984; 84:
186-91.
Comparison of forces acting on a body in hanging and impact in vehicle with a safety belt but no head rest.
on
frontal
In a frontal impact, the body is held down in the seat by the safety belt, while the head is thrown violently backwards, thus hyperextending the cervical spine, and causing the same type of injury as hanging (figure). The protection against physical injury provided by safety belts is so widely recognised that many countries now require them by law; should head rests on car seats be required by law also? 17 T F. LESOIN C. E. THOMAS Neurosurgery Service B, G. LOZES Hôpital B, L. VILLETTE CHR de Lille, 59037 Lille, France M. JOMIN .-.
1. Williams TG.
Hangman’s fracture. J Bone Joint Surg 1975; 57: 82-88. J, Colnet G, Pionchon H. Fractures bioediculaires de C2 et ceintures securité. Neurochirurgie 1984; 30: 183-87. Roy-Camille R, De Lacaffiniere JY, Saillant G. Traumatismes du rachis cervical superieur C1-C2. Masson, Paris: 1973
2. Chabannes 3
TORQUING OF NECK AND JAW DUE TO BELT RESTRAINT IN WHIPLASH-TYPE ACCIDENTS
SIR,-The use of seat belts has reduced the number and severity of facial injuries in motor vehicle accidents but the proportion of facial or jaw injuries may have increased. 1,2 Symptoms from trauma to the soft tissues of the spine and neck and temporomandibular joint symptoms due to sudden acceleration-deceleration events ("whiplash" injuries) persist as a considerable medical and dental4 problem. I raised this point in 19723and Brooke and Stenn4 supported this view. Recovery time will be prolonged if the diagnosis is missed. Car seat belts usually have a diagonal shoulder-restraining component. This restricts movement of the upper torso but for convenience it usually has an extension system (eg, inertia reel) that locks only if the extension is above a certain speed, as in a sudden forward movement during deceleration or in reflex bending during sharp acceleration. The rapid imposition of restraint by the diagonal belt in a vehicle occupant who is thrown forward can lead to a burn on the side of the neck or to bruising. These and other accident victims.
injuries5,6
may be
seen on
AVAILABILITY OF MINI PEAK FLOW METERS FOR THE MANAGEMENT OF SEVERE ASTHMA
SIR,-In 1982 the British Thoracic Association (BTA) published a large retrospective analysis of asthma. deaths, confirming2-4 that death in most cases (77/90, 86%) was potentially preventable.
Despite identification of the "at risk" patient and the BTA’s carefully formulated recommendations, the annual mortality of about 1600 deaths in England and Wales continues unchanged.5 Why have the BTA findings had no impact on asthma deaths? The answer may lie in the need to recognise slowly deteriorating and acute severe
asthma
at an
earlier stage
so
that
treatment can
be
promptly to pre-empt any crisis. The patient’s own perception of breathlessness in asthma is highly variable, despite similar degrees of airway obstruction; many patients fail to appreciate large falls in peak flow.6,7 In the BTA study 67/90 (74%) patients tolerated breathlessness and failed to appreciate how suddenly deterioration can occur. Therefore, the need for and potential advantages of self-monitoring of asthma are recognised.8,9 Miniature Wright and Vitalograph peak flow meters are widely used for self-assessment of asthma. They cost only £ 10 or so and are light but sturdy and small but reliable. However, their availability depends on the patient’s ability to pay or the physician’s access to local financial resources. Surely, these devices should be freely available on the NHS, to be prescribed for the at risk asthma patient at the discretion of his or her physician. The need for these devices for monitoring asthma has been likened to that of the measurement of glycosuria in diabetes;9 here, unfortunately, the analogy ends because urine testing kits can be prescribed on the NHS. started
Department of Medicine, Royal Liverpool Hospital, Liverpool L7 8XP
ALAN J. WILLIAMS SUSAN E. CHURCH
1. British Thoracic Association. Death from asthma in two regions of England Br Med J 1982; 285: 1251-55. 2 Ormerod LP, Stableforth DE. Asthma mortality in Birmingham 1975-7 53 deaths. Br
Med J1980;
280: 687-90.
3. Cochrane GM, Clark TJH. A survey of asthma mortality in patients between ages 35 and 64 in the Greater London Hospitals in 1971. Thorax 1975; 30: 300-05. 4. Fraser PM, Speizer FE, Waters SDM, Doll R, Mann NM. The circumstances preceding death from asthma in young people in 1968-1969. Br J Dis Chest 1971; 65: 71-84. 5. OPCS Asthma mortality statistics for England and Wales, 1979-1983. London: Office of Population Census and Surveys. 6. Rubmfield AR, Pain MCF. Perception of asthma. Lancet 1976, i: 882-84. 7. Editorial Perception of breathlessness in asthma. Lancet 1983; i: 912-13. 8. Stableforth DE. Death from asthma. Thorax 1983, 38: 801-05. 9. Seaton A Asthma: Contrasts in care. Thorax 1978; 33: 1-2.