With the use of seatbelts comes a unique injury profile that has been called "the seatbelt syndrome." The classically described "seatbelt sign" has become a pattern of injury, describing potential underlying damage. As a clinician, clues to the underlying damage follow a thorough physical examination including the removal of all clothing to locate abrasions and bruises to the skin that potentially follow a seatbelt pattern. Delayed presentation of an intra-abdominal injury in the setting of a seatbelt sign has been well documented; however, the question is how long to observe these patients. We present the case of a 17-year-old woman involved in a motor vehicle collision who presented to the emergency department (ED) hemodynamically stable with a lower abdominal wall seatbelt sign. Her initial imaging revealed only an abdominal wall contusion. She was admitted for observation. Approximately 12 h later she started developing abdominal pain, and by 14 h abdominal distention, with repeat imaging showing free fluid and free air. She was taken to the operating room for an exploratory laparotomy and was ultimately discharged back home on day 7.