Penetrating neck trauma: stabbing

Case contributed by Dr Dayu Gai

Presentation

This 20 year old male was stabbed in the right side of his neck. A CT neck was performed.

Patient Data

Age: 20 years
Gender: Male
Modality: CT

Wound track extends from a skin defect in the right anterolateral neck, through platysmus and the substance of the sternocleidomastoid muscle, which is thickened and contains clot and gas locules.

The wound tract terminates superficial to the lateral aspect of the mid pole of the right lobe of thyroid, immediately superficial to the distal common carotid artery and internal jugular vein.

Gas locules track along the facial planes deep to the sternocleidomastoid, sternohyoid and sternothyroid muscles.

Conclusion:

  • Penetrating injury of the right anterolateral neck traverses platysmus and the sternocleidomastoid muscle but terminates superficial to the thyroid gland, carotid artery and internal jugular vein, with no evidence of vascular injury.

Case Discussion

Traumatic injury to the neck can be a devastating injury due to the high density of crucial anatomical structures within the neck1.

The neck has traditionally been divided into 3 anatomic zones2. They are as follows:

  • Zone 1 - from the level of the clavicles and sternal notch to the cricoid cartilage
    • Important structures here include the aortic arch, proximal carotid arteries, vertebral arteries, subclavian vessels, innominate vessels, lung apices, oesophagus, trachea, brachial plexus and thoracic duct
  • Zone 2 - from the cricoid cartilage to the angle of the mandible
    • Important structures include the common, internal and external carotid arteries, the jugular veins, larynx, hypopharynx and proximal oesophagus.
  • Zone 3 - from the angle of the mandible to base of skull
    • Important structures include the internal carotid artery, vertebral artery, external carotid artery, jugular veins, prevertebral venous plexus and facial nerve trunk

Assessment of neck injuries has been aided by the use of CT angiography. Types of injury include vascular injury, oesophageal perforation, laryngeal fractures and neurological injury.

Previously, zone 2 injuries penetrating the platysma were thought to require immediate surgical exploration. One current study suggests that thorough clinical examination can prevent unnecessary surgical exploration of zone 2 neck injuries. Clinical criteria which would indicate surgical intervention/exploration include:

  • Exsanguinating haemorrhage
  • Expanding haematoma
  • Shock
  • Airway compromise
  • Massive subcutaneous haematoma

While endovascular techniques have seen increasing use in other traumatic vascular injuries, open surgical repair is considered the gold standard for most vascular neck trauma. One study suggests that patients with stable, intimal, high zone 3 carotid injuries and vertebral artery injuries can be repaired endovascularly. Otherwise, surgical exploration is the intervention of choice.

Case contributed by A/Prof Pramit Phal.

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Case Information

rID: 32006
Case created: 9th Nov 2014
Last edited: 29th Nov 2016
Inclusion in quiz mode: Included

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