An unusual case of a penetrating neck injury (PNI) illustrating the use of a “no zone” approach for the management of this injury and a review of the literature.

A.P. Joseph, A. Newey, A. Glover, W. Mohabbat

Key points of article

Penetrating Neck injury is relatively uncommon. The case involved a young male who had hit a sledgehammer onto an axe head embedded in the stump of a tree. A 5 mm metal fragment had broken off and lodged in the left side of his neck in Zone 2 and then travelled down to lodge in Zone 1. There was a large haematoma over his left neck anterior to the left sternomastoid muscle with a small entry wound and there was no associated crepitus or it was non pulsatile. CXR showed a metallic foreign body at the left root of his neck at the apex of his left lung and superior to the medial border of the left clavicle. A subsequent CT angiogram showed the metallic object in the left base of his neck anterosuperior to the left subclavian artery and anterior to the left thyrocervical trunk. There was active arterial contrast extravasation seen which was thought to be arising from the thyrocervical trunk or left subclavian artery.  Subsequent surgical exploration demonstrated transection of the left thyrocervical trunk which was repaired after balloon occlusion of the left subclavian artery. The patient developed a thrombus in his L brachial artery which was removed. On day 2 he developed neurological symptoms which included headache, diplopia and a right inferior quadrantanopia. He was found to have a local dissection in the left subclavian artery which was treated with anticoagulation for 12 weeks. He made a full recovery from his initial vascular injury and the complications.

Key learning points

1. All patients with penetrating neck injury should be assessed for “hard”, “soft” or “no” signs

2. “Hard” signs = Active bleeding or Shock, Expanding or pulsatile haematoma, Bruit or Thrill, Massive subcutaneous emphysema, Air Bubbling from wound, Massive haemoptysis or haematemesis all require immediate transfer to the OT for surgical exploration

3. “Soft” signs = Venous oozing, Non-expanding or non-pulsatile haematoma, Minor haemoptysis, Dysphonia, Dysphagia, Subcutaneous emphysema all require a CT angiogram of the aortic arch and major branch vessels, then treat depending on findings (as in this case and patient was transferred to the OT for exploration)

4.  “No signs” = observation only


Zones of the neck and relation to major vessels

Zone 1 Sternal notch to cricoid cartilage

Zone 2 Cricoid cartilage to angle of mandible

Zone 3 Angle of mandible to base of skull

Key Vessels –

  • LSUB = left subclavian artery
  • LVA = left vertebral artery
  • TCT = thyrocervical trunk
  • IM = internal mammary artery
  • CCT = costocervical trunk


Coronal MIP CT angiogram demonstrates the metallic foreign body (yellow arrow) located immediately anterior to the thyrocervical trunk. Branches of the thyrocervical trunk (green arrowheads) and active contrast extravasation (red arrow) are shown. Injected intravenous contrast in the left subclavian vein (orange asterisks). 

Dr Anthony Joseph FACEM
Associate Professor University of Sydney
Chair IFEM Trauma Special Interest Group

Key reference
K. Inaba, B.C. Branco, J. Menakar, et al., Evaluation of multidetector computed tomography for penetrating neck injury: a prospective multicentre study, Trauma 72 (1) (2012) 576–584.


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