Introduction

The neck is unique in the body in that it has many important visceral structures that are not well protected by bone. The management of patient with a direct injury to the neck is a difficult problem in the emergency department (₁).

In this paper a 10 year old girl is presented with penetrating neck trauma of Zone III, caused by a traffic accident.

Case

A ten year old girl was hit by a car while walking on the street. She fell down and was subjected to a penetrating trauma on her neck which resulted with a device to break and stay in the wound. She was brought to the public hospital emergency by the driver of the car. After physical examination and computer scanning of thorax, she was transferred to our university hospital because of penetrating neck injury for further diagnosis and treatment.

When she was brought to our emergency department she was alert, blood pressure was 90/60 mmHg, pulse rate was 92 per minute, breath rate 26 per minute. On the right frontal region and on her face there were lacerations. And also there was the hole of penetrating device on the right of the jugulum near the head of the clavicle, sized 0.5X0.5 cm. The foreign body was not seen from the outside. There were no other significant findings on the physical examination. In her laboratory studies there were no abnormal findings.

On the chest X-ray, at the left part of the neck foreign body was seen at oblique position. Also on the lateral chest X-ray it was seen on the clavicle and extended on the second costa (Figure 1). On the chest computer tomography, done at the public hospital, the foreign body was seen in the soft tissue of suprasternal region protruding into the head of the clavicula and extended on the second costa (Figure 2).

Figure 1

Figure 1: AP chest X-ray of the patient.

Figure 2

Figure 2: Lateral chest X-ray of the patient.

At the pediatric emergency department the child was stabilized and the emergency physician wanted thoracic surgery consultation. The foreign body was taken off in the surgery room by thoracic surgeons. The foreign body was a pencil. The child was hospitalized for 48 hours at the thoracic surgery department. Postoperative period was uneventful. Chest X-rays were in normal limits and she was discharged.

Figure 3

Figure 3: Thorax tomography of the patient

Discussion

Few emergency situations have more potential for rapid deterioration than penetrating neck trauma (₂). The physician must be concerned with airway patency, control of major hemorrhage and stability of osseous structures and must also be evaluated for other less apparent but potentially lethal injuries (₁).

The neck can be divided into three zones to help guide evaluation of vascular injuries: Zone I, as defined as the area between the clavicle and cricoid cartilage, injuries have highest mortality. Zone II is the area between the cricoid cartilage and angle of the jaw. Up to 80% penetrating injuries included in Zone II but mortality is low with these injuries because of ease of exposure and ability to control bleeding. Zone III consists of the area between the angle of the jaw and the base of the skull. This is the least common area of injury but has high morbidity secondary due to the difficulty of obtaining exposure of the involved structures (₂,₃). In our case the injury was in the Zone III. In Zone III there are more important anatomic structures including distal internal carotid artery, jugular vein, parotid gland, cranial nerves, spinal cord and intracranial structures. Some of authors, advice angiography particularly for Zone I and Zone III routinely (₄,₅,₆). But Meyer reported only 9 positive angiograms in his series of including 113 patients (₇), and also Jurkovich showed only 3-4% usefulness of angiography in his study (₄). We could not perform angiography to our case because of our hospitals possibilities are not suitable to perform angiography overnight.

There are lots of arguments about managing a penetrating neck trauma. For some of the authors physical examination is inadequate in penetrating neck trauma (₈,₉). Some of the centers prefer exploration routinely for the injuries of Zone II, which involve destruction in platysma (₈,₁₀). The exploration of zone I and Zone III can increase the morbidity, for that reason if there is no specific sign, some of the authors recommend the nonoperative treatment of the penetrating neck injuries (₁₁,₁₂). In Canada, because of lower incidence of high-morbidity of Zone I and Zone III injuries and high incidence low kinetic energy trauma with a prediction to Zone II, the surgeon may consider a selective approach where appropriate (₁₁).

In our case there was no indication of neck exploration, for vascular (continued hemorrhage, unstable vital signs, diminished or absent pulses, large or expanding hematoma) airway (difficulty breathing, voice change) visceral (difficulty swallowing, subcutaneous emphysema), coughing, spitting or vomiting of blood) or neurologic reasons (₁,₂). Due to this we did not perform a surgical exploration.

As a result we believe that penetrating neck traumas can pose significant diagnostic and therapeutic challenges for emergency physicians and also physical examination is still a significant factor that can aid in the management of penetrating neck trauma to the surgeon.

Correspondence to

Hakan POYRAZOGLU, MD, Çukurova University, Faculty of Medicine, Cardiovascular Surgery Department, 01330 Adana, Turkey E mail: hpoyrazoglu@yahoo.com