Case

A patient is transported into Shock Trauma with a knitting needle impaling their neck, anterior to posterior, at a position one inch lateral to the sternoclavicular joint and one inch superior to the upper margin of the clavicle.

Question 1/2 - What structures are at risk?

Click on your selected option(s) below  (correct = 4,  over-thinking = 5+)

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Incorrect. The position lateral to the sternoclavicular joint in a straight anterior to posterior line puts the needle tract too lateral to impact the trachea itself.

Correct! The thyroid gland is a U shape spanning from the midline to each side just below the level of the cricoid cartilage and just superior to the clavicle. Depending on the gland size in how laterally it extends, the gland could be impacted from a needle entry lateral to the trachea.   

Incorrect. This muscle spans from the hyoid bone to the thyroid cartilage, as such it is in the upper region of the neck while the described needle is only 1 inch from the clavicle.  

Correct! The sternocleidomastoid muscle originates from the sternum and clavicular head, angling laterally and posteriorly to attach to the mastoid process (just posterior to the earlobe). If you palpate your neck, the 1 inch lateral to the sternoclavicular joint and 1 inch superior to the clavicle is right in line with the starting trajectory of the sternocleidomastoid muscle.

Correct! The common carotid artery ascends in the neck just lateral to the trachea and would be in the risk area for this needle penetration.

Incorrect. The common carotid artery bifurcates into the internal and external carotid arteries at approximately the level of the laryngeal prominence. Thus, this bifurcation and the resulting internal/external branches are too superior to be at risk from the needle penetration tract.

Incorrect. The common carotid artery bifurcates into the internal and external carotid arteries at approximately the level of the laryngeal prominence. Thus, this bifurcation and the resulting internal/external branches are too superior to be at risk from the needle penetration tract.

Correct! The phrenic nerve arises from levels C3,4,5 and travels inferiorly on the anterior surface of the anterior scalene muscle. The course of the nerve is sufficiently close to the needle trajectory to be of concern. Though the nerve is small and the needle is small, so it would be an unlucky event for the knitting needle to pierce the phrenic nerve.