Neck trauma: Clinical

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Neck trauma: Clinical

USMLE® Step 2 questions

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USMLE® Step 2 style questions USMLE

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A 66-year-old woman comes to the Emergency Department because of a decelerating motor vehicle accident that resulted in injury to her neck. Her temperature is 37.1°C (98.8°F), pulse is 90/min, respirations are 20/min, and blood pressure is 130/85 mm Hg. Physical examination shows bilateral loss of pain and temperature sensation in her upper extremities with triceps and biceps reflexes are weak bilaterally and strength 2/5. Lower extremity reflexes are present, with 4/5 muscle strength. Which of the following is a risk factor for the most likely diagnosis?


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The neck is a compact tube packed with many vital structures including blood vessels like the carotid artery and internal jugular vein, nerves like the brachial plexus, parts of the airway like the larynx and trachea, and parts of the digestive tract, such as the pharynx and esophagus. As a result, even seemingly innocuous traumatic injury can be lethal. The cervical spine is the most flexible and mobile part of the vertebral column.

But, that flexibility comes with a price, making the cervical spine the most vulnerable part of the vertebral column to trauma. Now, neck trauma can be classified into penetrating neck injury, like that from a knife stab, and blunt neck injury, like that from a car crash.

Before delving into penetrating neck injuries, it’s crucial to review the anatomy. The neck is anatomically divided into three zones. From bottom to top, zone I, or the lower zone, is from the clavicles to the cricoid cartilage, zone II, or the middle zone, is from the cricoid cartilage to the angle of the mandible, and zone III, or the upper zone, is from the angle of the mandible to the base of the skull. To help you remember the order of the zones, think of going up an elevator, so zones I, II, III from bottom to top. The neck is enveloped by the superficial and deep cervical fascia, and sandwiched between them is the platysma muscle.

Anatomically, the neck can also be described in triangles. The sternocleidomastoid muscle separates the neck into two triangles. The anterior triangle contains most of the major anatomic structures, including the larynx, trachea, pharynx, esophagus and major vascular structures; while the posterior triangle contains muscles, the spinal accessory nerve, and the spinal column.


Neck trauma refers to any type of injury to the neck, which is the area of the body between the head and the shoulders. It is classified into blunt neck trauma (e.g. injuries caused by motor vehicle accidents), and penetrating trauma (e.g. neck stab injuries). It is a penetrating neck injury if the platysma muscle is torn.

The management of blunt neck trauma follows ABCDEs (airway, breathing, circulation, disability, and exposure) sequence. Intubation should be done quickly to clear the airway (if not clear, and the cervical spine immobilized with a cervical collar. Next, reference to clinical decision tools such as the NEXUS or Canadian C-spine rule is necessary to determine if the C-spine is “cleared”, or if CT imaging is necessary to decide surgical vs non-surgical definitive management.

ABCDEs sequence also applies to penetrating neck injury. Securing the airway may require orotracheal intubation, or emergent cricothyrotomy if necessary. Hemorrhage control is done by direct pressure on the wound, and if that doesn't suffice, a Foley catheter is inflated in the wound to occlude it. For hemodynamically unstable individuals, emergency surgery is required. With penetrating neck injuries cervical collars are usually not necessary unless they are associated with a neurological deficit or a suspected concomitant blunt neck injury.


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