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We present an unusual case of a young male with a penetrating neck injury (PNI) due to a work-related injury. A metallic foreign body traversed from entry at surgical Zone 2 to Zone 1 in the neck and resulted in a transection of the left thyrocervical trunk at the origin with the left subclavian artery. Computed Tomographic Angiography (CTA) of the aortic arch and major branch vessels demonstrated haemorrhage anterior to the left subclavian artery and left thyrocervical trunk. We describe some of the diagnostic and operative challenges which may occur in these rare and life-threatening injuries. We have also reviewed some of the recent key literature on this topic and have collated the recommendations of the review. In recent years, there has been a movement away from selective "zone-based" mandatory surgical exploration for Zone 2 injuries, as well as invasive and time-consuming investigations (such as digital subtraction angiography, contrast oesophageal swallow and bronchoscopy) for Zone 1 and 3 injuries due to the high number of negative surgical procedures and investigations. We demonstrate there is now an evidence-based algorithm which demonstrates that a "no zone" approach to the management of these patients is safe and effective. This requires an initial physical examination looking for the presence or absence of "hard", "soft" or "no" physical signs in these patients, and then deciding on subsequent management which would include immediate surgery, CTA of the aortic arch and branches (and subsequent surgical or other management) or observation only. Our aim in describing this case it to highlight that there is now good evidence-based guidance for the safe and effective management of patients with this infrequent but potentially fatal injury.
RESUMO
OBJECTIVE: To define the clinical syndrome of functional popliteal entrapment comparing pre and post surgical clinical outcomes with pre and post-operative provocative ultrasonic investigations. Further, to suggest a management pathway to differentiate chronic exertional compartment syndromes and concomitant venous popliteal compression. METHODS: In 32 claudicant sportspersons, 55 limbs were characterised pre-surgery clinically, with provocative testing including hopping, and following a series of non-invasive tests. The clinical findings, ankle brachial indices (ABI) and duplex outcomes were compared pre-operatively, at 3 months post-operatively (n = 52) and in the long term i.e. 16 months (n = 17). RESULTS: At 3 months, all 55 limbs had clinical follow up. 52 of the 55 limbs had follow up with ultrasound with provocative manoeuvres. The ABIs normalised in 46 (88%). There were 40 of 52 (76%) that became asymptomatic post surgery with a normal scan. There were 4 of 52 (8%) who were clinically asymptomatic but with residual obstruction on duplex and who were able to resume their usual lifestyle. There were 4 (8%) that had abnormal findings both on post-operative scan and clinically. Re-operation on 2 limbs corrected the duplex findings and the symptoms. There were 4 (8%) limbs that had normal duplexes but continued with symptoms albeit varied from the presenting symptoms. In the longer term, a further 2 became symptomatic at 2.8 years requiring a further successful intervention. (Concomitant popliteal venous obstruction was present in 5 limbs (10%) on standing.) CONCLUSIONS: In the claudicating sportsperson, where there are no well characterised specific anatomical abnormalities, the syndrome can be characterised by provocative clinical (particularly hopping) and non-invasive tests. A positive clinical outcome with surgery can be predicted by abnormal pre-surgical ultrasonic investigations and confirmed later by a similar normal post surgical study. Concomitant venous compression may occur while standing with both syndromes related to muscle hypertrophy.
