The management of patients with blunt or penetrating neck injuries
can be challenging. Seemingly minor injuries can quickly become
life threatening. Missed injuries and delayed diagnosis can result
in morbidity and mortality. Although ultimate management goals are
the same, each mechanism of injury has its own special considerations.
There is a paucity of data regarding the epidemiology of blunt
and penetrating neck trauma. The demographics are expected to mirror
those of other trauma victims, particularly in urban settings, with
a predominance of young men in the 21- to 30-year-old age group.
Penetrating neck trauma is associated with a high incidence of simultaneous
injuries to other systems. Multiple injuries occur approximately
half of the time.1 Serious injuries following blunt
trauma are less common and are probably underreported because many
are not initially recognized.
The neck contains a high concentration of vascular, aerodigestive,
and spinal structures in a relatively confined space. Other structures
in the neck susceptible to injury are the thyroid and parathyroid
glands, the lower cranial nerves, the brachial plexus, and the thoracic
duct. Many of these structures are in close proximity to the skin
and therefore are vulnerable to injury. Only the spinal cord has
There are several anatomic classifications of the neck. Traditionally, anatomists
have defined the neck in terms of anterior and posterior triangles,
as divided by the sternocleidomastoid muscle (Figure
257-1). The anterior triangle is bounded by the midline of
the neck, the lower border of the mandible, and the anterior border
of the sternocleidomastoid muscle. Within this anterior triangle
are most major vascular and aerodigestive structures: carotid artery,
internal jugular vein, vagus nerve, thyroid gland, larynx, trachea,
and esophagus. The boundaries of the posterior triangle are the
middle third of the clavicle, the anterior border of the trapezius
muscle, and the posterior border of the sternocleidomastoid muscle.
The posterior triangle has few vital structures, except at its base,
where the subclavian artery and brachial plexus are located.
An alternative anatomic classification divides the neck into
three zones (Figure 257-2). This classification
was established to guide the clinician in the diagnostic and therapeutic
management of penetrating injuries. Various authors have defined
the zones differently. The most widely used classification is that
of Roon and Christensen.2 By their definition, zone
I extends from the clavicles to the cricoid cartilage. Zone I includes the
vertebral and proximal carotid arteries, major thoracic vessels,
superior mediastinum, lungs, esophagus, trachea, thoracic duct,
and spinal cord. Zone II extends from the inferior margin of the
cricoid cartilage cephalad to the angle of the mandible. Injuries
in zone II may involve the carotid and vertebral arteries, jugular
veins, esophagus, trachea, larynx, and spinal cord. Zone III is
located between the ...