You have been called to the Emergency Room to review a previously well adult male who has sustained a penetrating injury to the root of the neck.
a) Describe the anatomy of the root of the neck on the left side describing the clinically important
structures that may be injured. (50% marks)
b) Outline the issues specific to management of a penetrating neck injury. (50% marks)
The root of the neck is the junction between the thorax and the neck. It opens into, and is the cervical side of, the superior thoracic aperture, through which pass all structures going from the head to the thorax and vice versa. The root of the neck is bound laterally by the first rib, anteriorly by the manubrium, and posteriorly by the T1 vertebrae.
From anterior to posterior, the major contents are:
Subclavian artery and branches
Subclavian vein and tributaries (EJV)
Recurrent Laryngeal nerve
Dome of pleura
Lymphatics and thoracic duct
Sympathetic chain, stellate ganglion
Requires management at a trauma centre with appropriate expertise. May require multiple speciality input - interventional radiology, ENT, vascular, cardiothoracic.
Urgent surgical exploration required for haemodynamic compromise, expanding or pulsatile haematoma, extensive subcutaneous emphysema, stridor, or neurological deficit with intra op bronchoscopy/ endoscopy/ angiography if available.
If no indication for urgent surgical exploration requires CT angiography (or equivalent) with close
observation in ICU +/- flexible laryngoscopy +/- endoscopy +/- oral contrast swallow study.
Additional Examiners’ Comments:
Most candidates were not aware of the issues and management priorities associated with this type of trauma.
Anatomy is not our strong suite. This question describes injury to Zone 1 of the neck, where all the important stuff seems to be. For an excellent revision of the important issues, the interested trainees are directed to Karim Brohi's 2002 write-up of neck wounds on trauma.org.
Generic approach to management:
Specific concerns in a Zone 1 injury:
Reasons for urgent surgical exploration: