Impalement at Zone I of Neck Causing Traumatic Subclavian Arterial Compression Injury

Abstract

Neck is vulnerable to external trauma, which can involve key structures such as blood vessels, trachea, esophagus, and other endocrine and nervous system organs because it is not protected by skeleton. This crowding of vital structures at a potentially small place mandates that neck injuries should be investigated and managed properly. Vascular injuries can not only cause potentially lifethreatening hemorrhage but also need profound surgical expertise in management. The mortality from penetrating neck injuries ranges from 2 per cent to 10 per cent.1 We present a case of a 14-year-old male who was riding his bicycle and lost balance and accidently got impaled by a tree branch on the left side of the neck in the supraclavicular fossa (Zone I). We successfully performed open surgical exploration of the left subclavian area and clavicular fossa, and compression injury over the distal left subclavian artery due to this impaled object was treated. A previously healthy 14-year-old male was riding his bicycle at about 30 miles/hour and lost balance and accidently got impaled by a tree branch on the left side of the neck in the supraclavicular fossa. He reported temporary loss of consciousness. He was taken to a hospital nearby the site of the accident. The patient was hemodynamically stable, and there was a visible penetrating wound of size 3 cm at the left side of the neck in Zone I with some bleeding. He was taken to the operating room for wound exploration by the surgeon; however, before the procedure, it was discovered that the pulses in the left upper extremity were not palpable. Immediate CT angiogram of the neck and chest was performed, which revealed abrupt cutoff at the 3rd part of the subclavian artery with no distal flow. He was transferred intubated from the OR to our hospital for further management. On admittance, the patient’s physical examination revealed patent airways, respiratory rate was 20/minute, the trachea was in the midline, and there were no jugular venous turgor and neck wound as described earlier. Bilateral air entry was equal. The patient was hemodynamically stable, the skin was warm and dry, and blood pressure was 120/90 mmHg, with a HR of 100 minutes. He underwent a focused assessment with sonography for trauma, which showed no sign of abnormal bleeding. Pupils were bilaterally isochoric and reactive to light. There was no subcutaneous crepitation. The abdomen was flat, with physiologic respiration-associated mobility. The pelvis was stable. Palpable distal pulses were present in all but the left upper extremity. His neurological function could not be assessed properly because he was intubated and sedated. Capillary refill was less than 0.2 seconds. However, he had biphasic Doppler signal in left brachial, radial, and ulnar arteries. The patient underwent whole body trauma CT scan. The CT head showed no signs of traumatic brain injury. CT angiogram of the thorax and left upper extremity from an outside hospital revealed abrupt cutoff at the 3rd part of the subclavian artery with no distal flow. There was a radio-dense impaled foreign body visualized at the site of sudden cutoff (Fig. 1). The abdominal scans did not show any sign of visceral trauma. We decided to take the patient to the operating room. Trauma surgery worked in conjunction with vascular surgery and we performed a left infraclavicular incision for distal left subclavian artery exploration. Subclavian artery and vein were exposed by left infraclavicular incision, incising clavipectoral fascia and dividing the fibers of the pectoralis major and subclavius muscle. Both the vessels were isolated, and proximal control was obtained. A 5-cm-long wooden piece, which broke from the tree branch and remained in, was found compressing the distal left subclavian artery. This was retrieved, and immediate strong radial pulses were appreciated (Fig. 2). No vessel injury or pseudoaneurysm was noted. The wound was closed in layers with a small Penrose drain after thorough washing, and the patient Address correspondence and reprint requests to Shekhar Gogna, M.D., Department of Surgery, Westchester Medical Center, New York Medical College, 100 Woods Road, Taylor Pavilion, Office Suite #353 Valhalla, NY 10595. E-mail: Shekhar.gogna@ wmchealth.org