1. Trauma Anatomic Regions
Elizabeth Gwinn MD
2014, updated 11/2015

2. Zones of the Neck

3. Zones of the Neck
Anterior neck = above the clavicles, up to the TMJ and anterior to the posterior border of the SCM
I = clavicles/sternum to cricoid cartilage
II = cricoid cartilage to angle of mandible
III = above angle of mandible to base of skull

4. Zones of the Neck – WTA algorithm

5. Penetrating neck trauma workup
Zone I
CTA arch and neck
EGD and esophagram
Consider bronchoscopy
Zone II
CTA neck
Consider bronchoscopy/nasopharyngeal scope
Zone III
CTA neck and soft tissues
Good visual inspection of oropharynx

6. Anterior Cardiac Box

7. Anterior Cardiac Box
Superior = angle of Louis (sternomanubrial junction)
Lateral = mid clavicular/nipple line
Inferior = line drawn across the costal margin at the level of the mid clavicular line

8. Anterior cardiac box workup
CXR
Echo
Fluid  pericardial window
Suboptimal view  CT scan if stable or pericardial window

9. Posterior Box

10. Posterior Box Superior – top of scapula Lateral - medial to scapula
Inferior - above costal margins

11. Posterior box workup Gunshot injuries Stab wounds CXR CT arch
EGD and esophagram
Consider bronchoscopy
Stab wounds
If CXR is completely normal  repeat CXR in 6 hours
If PTX or effusion  chest tube
If mediastinal air, consider esophageal injury
If mediastinal widening, consider aortic injury

12. Thoracoabdomen

13. Thoracoabdomen Superior margin Inferior – inferior costal margin
Anterior – nipples
Posterior – tip of scapula
Inferior – inferior costal margin

14. Thoracoabdominal trauma algorithm – Mattox, Kenneth, Moore Trauma 7th Edition

15. Penetrating thoracoabdomen trauma workup
CXR
DPL
Positive if > 10,000 RBC
If DPL cannot be done/won’t be done  diagnostic laparoscopy/laparotomy

16. Anterior Abdomen

17. Anterior Abdomen Superior – costal margins Lateral – mid axillary line
Inferior – inguinal ligament

18. Penetrating anterior abdomen trauma workup
Indications for operation
Hemodynamic instability
Pathway of the bullet
Evisceration
Retained stabbing implement
Gross blood per orifice
Peritonitis
Pneumperitoneum
Positive DPL
GSW >10,000 RBC
Anterior abd stab wound > 100,000 RBC
Thoracoabdomen or black/flank stab wound > 10,000
Gunshot wounds
All GSW that penetrating the peritoneal cavity require an operation
Tangential GSW can be worked up with either DPL (positive > 10,000 RBC) or diagnostic laparoscopy
Anterior abdomen stab wounds
Only 50% penetrate the peritoneal cavity and of these, only 50% will have an injury that requires repair
DPL is positive if >100,000 RBC for anterior abd stab wounds

19. Back and Flank

20. Back and Flank Anterior – mid axillary lines Superior – tip of scapula
Inferior – iliac crest
RETROPERITONEUM

21. Back and flank penetrating trauma workup
Triple contrast (oral, rectal and IV) CT scan
Positive triple contrast is a violation of the retroperitoneal fat plane +/- organ injury, contrast extravasation

22. Triple Contrast CT - Negative

23. Triple Contrast CT - Positive

24. Pelvis

25. Pelvis - blunt
Pelvic fractures – if identified on xray will need CT pelvis
Anterior pelvic fracture – RUG and cystogram

26. Pelvis - penetrating
Bones, abdominal viscera and pelvic outflow tracts at risk
Workup should include
Iliac vessels - CTA pelvic vessels
Extra-peritoneal rectum - Rigid proctosigmoidoscopy
Urethra and bladder - Retrograde urethrogram and cystogram
Females – vaginal exam, consider injury to uterus

27. Case 1

28. Case 2

29. Case 3