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These are associated with high-performance car accidents and falls from heights. As the victim decelerates, the viscera continue to move forwards at the terminal velocity. This tears the blood vessels and visceral vascular pedicles from the points of attachment.

Traction injury of the neck can occur with skeletal traction for displaced fractures of the cervical spine. Many structures can be injured in unguarded or inappropriately applied traction. Posterior inferior cerebellar artery ischaemia due to compression of the vertebral artery has been reported.18 Zimmerman et al.19 have stated that traction is more likely to injure the vertebral arteries than hyperextension or rotations.

Arterial injuries can produce dramatic haemorrhage and are difficult to control. However, on other occasions, even a puncture caused by a bullet can self-seal and will then produce delayed disorders. In the neck, acute thrombosis or secondary compression can all produce intracranial ischaemic lesions and the signs and symptoms of these disorders must be carefully noted. The delayed effects are slow to develop but are potentially dangerous. Carefully selected patients can be observed pending arteriography. But such an observation must necessarily be frequent, such as every 15 min or at the most every hour. If such a frequent and regular monitoring of penetrating trauma of the neck is not possible due to staff shortages or due to lack of resources, then there is little justification of expectant management and an operative management is mandatory.

The internal jugular vein (IJV) is the major vein of the neck, transmitting ipsilateral intracranial blood towards the heart. It receives numerous tributaries, and most of these are fairly large vessels (Fig. 19.1). Because it is deeply situated, an injury to the IJV nearly always implies additional injuries to other important structures such as to the carotid artery, the vagus nerve and the viscera of the neck (the oesophagus, trachea, thyroid, larynx).

Most thyroid injuries result from criminal stabs or from fragmented glass injuries in a car accident. Gunshot wounds are usually fatal. Attempted suicide and accidental falls resulting in thyroid cartilage injuries constitute a very small number. Iatrogenic injuries to the thyroid can occur during surgery and irradiation of the neck. Radiation damage to the thyroid can result in two major thyroid disorders: Hypothyroidism occurring after treatment of toxicosis with radioiodine47 Thyroid cancer. This is an independent side-effect of childhood irradiation. The incidence is within 20-100 cases per rad per million population. Similarly, parathyroid adenomas with abundant fibrosis can occur after therapeutic irradiations48

Subclavian triangle injuries caused by a stab or gunshot wound may disrupt major branches of this artery (Fig. 17.1). Arterial bleeding is deeply located and is always associated with additional injuries. The lower roots of the brachial plexus are in the vicinity and these are easily injured. Bleeding is usually profuse, but can be controlled temporarily by extrinsic compression. Simple proximal ligation is not sufficient because the vessels contributing to thyroid and scapular anastomoses will result in retrograde bleeding. Both ends of the thyrocervical trunk therefore, need to be ligated (Fig. 17.1). It is most unusual for this kind of an arterial injury to occur in isolation and therefore it is essential to assess the integrity of the adjacent structures as well.

Not all arterial injuries are fully manifest on initial presentation clinically. Initial damage may be minor enough not to result in disruptive lacerations. Such examples are seen in shotgun injuries of the neck. One or two pellets may partially bruise the arterial wall. With the passage of time, the force of pulsatility may aggravate this damage and the wall may eventually rupture, producing haemorrhage, dissection or an aneurysm.

External injuries to the oesophagus from penetrating trauma are rare. Of the overall injuries to the oesophagus approximately 60% occur in the cervical portion and many of these are associated with concomitant injuries to the regional structures such as the trachea, larynx, the great vessels and the regional nerves.75

The incidence of isolated neck injuries is extremely difficult to evaluate because these are very rare. When these do occur they are often fatal. Neck injuries usually occur with multiple or craniofacial injuries.

Vascular injuries are easily detected if shock, massive bleeding or an expanding haematoma are evident. However, in the early stages, these features may not be present and the injury may remain occult for a while. A high index of suspicion is required for proper management of neck injuries, especially when penetrating trauma has caused the injury. All palpable head and neck pulses should be examined and bilaterally compared. The possibility of unilateral partial vessel injury must be kept in mind when these pulses appear equal.29