Cervicothoracic Impalement Injury Caused by a Steel Bar: A Case Report

Background Cervicothoracic impalement injuries are extremely rare and carry a high risk of mortality because of potential involvement of major vessels, airway structures, and lung parenchyma. Effective management requires not only rapid assessment and timely transfer but also advanced thoracic surgical techniques to control bleeding, repair pulmonary injuries, and reconstruct the chest wall. Case Presentation: A 55-year-old female construction worker sustained an accidental impalement injury when a steel bar entered through the right side of the neck and extended obliquely into the thoracic cavity, with the distal end reaching the level of the T11 vertebral body. Computed tomography revealed a transfixing laceration through the left lung from apex to base, fractures of the first to tenth ribs on the left side, hemopneumothorax, mediastinal and subcutaneous emphysema, and a compression fracture of the L1 vertebra (Fig. 1A–C). After initial stabilization at a local hospital, the patient was urgently transferred to the Department of Thoracic Surgery, The First Affiliated Hospital of Soochow University. Given the extensive intrathoracic injury and the potential for uncontrollable hemorrhage, the cardiac surgery team preoperatively established a standby cardiopulmonary bypass (CPB) circuit to ensure immediate circulatory support if massive bleeding occurred. Results An emergency multidisciplinary operation was performed under general anesthesia, led by the thoracic surgery team. A combined cervical and left anterolateral thoracotomy was carried out to expose the impalement tract. The steel bar was found to traverse the left upper lobe, causing extensive pulmonary lacerations and multiple intercostal vessel ruptures (intraoperative view in Fig. 2A–B). After careful dissection and isolation of the surrounding great vessels and mediastinal structures, the foreign body was removed under direct visualization to prevent secondary hemorrhage. Multiple lung tears were repaired using interrupted 4 − 0 Prolene sutures in a two-layer fashion to ensure airtight closure. Active bleeding from intercostal vessels and chest wall muscle tears was managed with ligation and electrocautery. Several rib fractures were stabilized, and a rotational pectoralis major musculocutaneous flap was mobilized to reconstruct the chest wall defect. Thorough pleural lavage was performed, and two chest drainage tubes were placed for effective postoperative drainage. The operation lasted approximately eight hours, with an estimated intraoperative blood loss of 1,500 mL. The patient was transferred to the intensive care unit for postoperative ventilatory support, broad-spectrum antibiotics, and nutritional therapy. Postoperative imaging confirmed full lung re-expansion and satisfactory wound healing (Fig. 3A–D). At follow-up the patient demonstrated stable respiratory function and good chest wall healing (Fig. 4A). Conclusion This case highlights the critical role of thoracic surgeons in the management of complex cervicothoracic impalement trauma. Rapid evaluation, precise preoperative planning—including the preoperative establishment of standby CPB by the cardiac surgery team—and meticulous thoracic surgical intervention emphasizing safe foreign body extraction, lung parenchymal repair, and chest wall reconstruction are key to achieving favorable outcomes. Coordinated multidisciplinary collaboration remains essential in transforming a life-threatening injury into a survivable event.