UMEM Educational Pearls

Category: Trauma

Title: Zone Out! Penetrating neck trauma

Keywords: penetrating neck trauma, zones, hard signs, operative management (PubMed Search)

Posted: 2/5/2023 by Robert Flint, MD
Click here to contact Robert Flint, MD


The classic teaching regarding penetrating neck trauma is violation of the platysma muscle in zones 1 and 3 requires angiography, endoscopy and bronchoscopy.  Injury to zone 2 is an automatic operative evaluation. Now, more anatomic and physiologic signs dictate operative management and those not meeting these hard signs get evaluated with Ct angiography. 


Neck zones and hard vs soft signs available by clicking link


Zone Boundaries Structures
I (lower) Clavicles and sternum to the cricoid cartilage Vascular: subclavian arteries and veins, jugular veins, carotid arteries, vertebral arteryAerodigestive: lungs, trachea, esophagusNeurologic: spinal cord, vagus nerveOther: thoracic duct, thyroid gland
II (middle) Cricoid cartilage to the angle of the mandible Vascular: common/internal/external carotid arteries, vertebral arteries, jugular veinsAerodigestive: trachea, larynx, pharynx, esophagusNeurologic: spinal cord, vagus nerve, recurrent laryngeal nerve
III (upper) Angle of the mandible to the base of the skull Vascular: internal carotid arteries, vertebral arteries, jugular veinsAerodigestive: pharynxNeurologic: spinal cord, CN IX, X, XI, XI, sympathetic chainOther: salivary glands




Hard SignsVascular injury

Severe uncontrolled hemorrhage
Refractory shock/hypotension
Large, expanding, or pulsatile hematoma
Unilateral extremity pulse deficit
Bruit or thrill
Neurologic deficit consistent with strokeMinor bleeding

Soft Signs Vascular

Small, nonexpanding hematoma

Proximity wound

Hard SignsAerodigestive tract injuryAirway compromise
Bubbling through wound
Extensive subcutaneous emphysema
Hoarse voice

Soft Signs

Mild hemoptysis
Mild hematemesis
Mild subcutaneous emphysema