What is the appropriate treatment for bruising to the neck?

Management of Neck Bruising

The appropriate treatment for neck bruising depends critically on the patient's age and clinical presentation: in infants under 6 months, any neck bruising warrants skeletal survey for occult fractures regardless of trauma history; in penetrating trauma with hard signs (expanding hematoma, hemodynamic instability, active hemorrhage), immediate surgical exploration is required; and in stable patients with soft signs or non-traumatic bruising, CT angiography is the first-line imaging modality. 1, 2, 3

Pediatric Neck Bruising (Non-Traumatic)

Infants Under 6 Months

• Any bruising in infants under 6 months requires skeletal survey (SS), regardless of location or reported trauma history, as this age group has the highest risk of occult fractures from abuse 1
• When high-risk bruising protocols were implemented in emergency departments, 50% of infants under 6 months with bruising were classified as likely or definite abuse cases 4
• Skeletal surveys identified occult fractures in 38% of infants under 6 months who underwent imaging 4

Children 6-24 Months

• Neck bruising in children 6-24 months requires skeletal survey when there is no history of trauma or only a history of rough play/handling 1
• SS is necessary for all children with patterned bruises (showing imprint of an object) on the neck, regardless of any trauma history 1
• SS is mandatory when bruising is attributed to abuse or domestic violence 1

Additional Concerning Features

• Any child under 24 months with neck bruising plus additional injuries (burns, whip marks, frenulum tears) requires immediate skeletal survey 1
• The combination of neck bruising with these findings indicates high likelihood of non-accidental trauma 1

Penetrating Neck Trauma with Bruising

Hard Signs Requiring Immediate Surgical Exploration

Proceed directly to operating room without imaging if any of the following are present: 2, 3

• Expanding hematoma (indicates active bleeding threatening airway or causing exsanguination) 2
• Hemodynamic instability 2, 3
• Active hemorrhage or pulsatile hematoma 2
• Dysphonia (suggests laryngeal or recurrent laryngeal nerve injury) 2
• Hemoptysis (indicates tracheal or major vascular injury) 2
• Weak carotid pulse with neurological deterioration (drowsiness indicates cerebral ischemia requiring immediate intervention) 3
• Air bubbling in wound or massive hematemesis 2

Critical pitfall: Delaying surgical exploration to obtain imaging in patients with hard signs significantly increases mortality 2, 3

Soft Signs Allowing Selective Management

For stable patients with soft signs, obtain CT angiography before deciding on surgical intervention: 2, 5

• Nonpulsatile/nonexpanding hematoma 2
• Dysphagia (may indicate esophageal or pharyngeal injury) 2
• Subcutaneous emphysema 2
• Venous oozing 2

Imaging Protocol for Stable Patients

• CT angiography (CTA) is first-line imaging with sensitivity of 90-100% and specificity of 98.6-100% for vascular injuries 1, 2, 5
• CTA simultaneously identifies extravascular soft-tissue and aerodigestive injuries with 100% sensitivity 1
• Consider CT esophagography in conjunction with CTA for suspected upper digestive tract injuries (sensitivity 100%, specificity 85-91%) 1
• MRI is valuable for evaluating spinal cord injury, disk injury, and ligamentous injury in stable patients 1, 5

Initial Stabilization for Traumatic Neck Bruising

All patients with traumatic neck bruising require: 3

• Airway assessment and securing while maintaining cervical spine immobilization 3
• Large-bore IV access establishment 3
• Fluid resuscitation initiation 3

Management Algorithm Summary

The American College of Radiology recommends a "no-zone" approach focusing on clinical signs rather than anatomic zones for penetrating neck trauma 2

1. Assess for hard signs → If present, immediate surgical exploration 2, 3
2. If stable with soft signs → CTA as first-line imaging 2, 5
3. For pediatric non-traumatic bruising → Age-based skeletal survey protocol 1
4. Consider additional imaging based on specific concerns (esophagography, conventional arteriography for equivocal CTA) 2

Common Pitfalls to Avoid

• Never delay surgical exploration for imaging in patients with hard signs and neurological compromise (drowsiness, weak pulse) as this significantly increases mortality 3
• Do not rely on single trauma history in infants under 6 months - skeletal survey is mandatory regardless of explanation provided 1
• Avoid underestimating neck bruising in young children - it has high association with occult fractures (38% in infants under 6 months) 4
• Do not use ultrasound as primary imaging for penetrating neck trauma due to limitations from overlying soft-tissue injury and limited evaluation of surrounding structures 1