{"paper_id":"320249d5-e8d3-4f22-b214-8ccf0f5cca7f","body_text":"Cervicothoracic Impalement Injury Caused by a Steel Bar: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Cervicothoracic Impalement Injury Caused by a Steel Bar: A Case Report Peng Zuo, Ziqing Shen, Zihan Cui, Guocai Mao, Liangbin Pan, Jun Zhao This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8353628/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 13 You are reading this latest preprint version Abstract 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. Cervicothoracic trauma Impalement injury Penetrating thoracic injury Pulmonary repair Chest wall reconstruction Thoracic surgery Multidisciplinary management Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Cervicothoracic impalement injuries represent one of the most complex and life-threatening emergencies in thoracic surgery【1–3】. These injuries often involve simultaneous damage to the airway, lung parenchyma, chest wall, and mediastinal vessels, leading to rapid hemodynamic compromise. Rapid diagnosis, proper imaging assessment, and coordinated surgical management are essential for survival【4】. Although isolated thoracic penetrating trauma is relatively common, trans-cervicothoracic impalement by rigid metallic bars remains exceedingly rare. Preoperative CPB standby is a crucial precaution when the trajectory of the foreign body approaches major vascular structures【5】. Here, we report a rare case of cervicothoracic impalement injury caused by a steel bar, successfully managed through emergency thoracic surgery with multidisciplinary collaboration and preoperative CPB standby. Case Presentation A 55-year-old female construction worker was accidentally impaled by a steel bar that entered the right side of the neck and extended obliquely into the thoracic cavity, with the distal tip reaching the T11 vertebral level. On arrival at a regional hospital the patient complained of severe chest pain, chest tightness, dyspnea, and progressive hypoxemia. Initial resuscitation measures (oxygen supplementation, intravenous access and fluids, analgesia, wound stabilization) were instituted, and urgent transfer to The First Affiliated Hospital of Soochow University was arranged. Contrast-enhanced computed tomography (CT) performed on arrival demonstrated the steel bar traversing from the right cervical region (approximately C5 level) obliquely into the left thoracic cavity and terminating at the T11 vertebral body. The bar penetrated the left pulmonary field from apex to base, with left-sided fractures of ribs 1–10, hemopneumothorax, marked mediastinal and subcutaneous emphysema, and an L1 compression fracture. These imaging findings clearly delineated the impalement trajectory and the extent of thoracic structural disruption (Fig. 1 A–C). No definitive active contrast extravasation suggestive of arterial transection was evident on CT, but the trajectory lay in close relation to the aortic arch and left pulmonary artery. Given the trajectory and risk of uncontrolled intrathoracic hemorrhage, a multidisciplinary conference involving thoracic surgery, cardiac surgery, anesthesiology, and critical care was convened. The consensus plan included immediate operative exploration with the cardiac surgery team placing a standby cardiopulmonary bypass (CPB) circuit (vascular access and priming prepared) to permit emergent extracorporeal support if catastrophic bleeding occurred during foreign-body extraction. Under general anesthesia and with standard hemodynamic monitoring, the patient was placed in the right lateral decubitus position. A combined cervical incision (for neck exposure) and a left anterolateral thoracotomy through the 4th intercostal space were performed to provide concurrent access to the cervical and thoracic components of the impalement tract. On thoracic entry, the pleural cavity contained mixed blood and air, and approximately 1,500 mL of hemothorax was evacuated. The steel bar was visually identified traversing the left upper lobe and extending posteriorly toward the base, with multiple pulmonary lacerations and disruption of intercostal vessels along the rib fracture sites (intraoperative views shown in Fig. 2 A–B). Surgical strategy prioritized controlled hemostasis and preservation of lung parenchyma. The operative sequence was as follows: ( 1 ) proximal and distal exposure of potential vascular structures (identification and retraction/protection of the aortic arch and left pulmonary artery), ( 2 ) temporary tamponade and selective ligation of bleeding intercostal vessels, ( 3 ) careful soft-tissue dissection around the foreign body while maintaining the bar in situ until vascular control was secured, and ( 4 ) slow, controlled extraction of the steel bar under direct visualization to minimize secondary tearing. The bar was removed without the need to initiate CPB. Pulmonary lacerations were managed by conservative debridement and layered repair: membranous defects were approximated first, followed by interrupted 4 − 0 Prolene figure-of-eight sutures placed to achieve airtight closure. Reinforcement sutures and fibrin sealant were applied as necessary. Intercostal vascular bleeding was controlled with ligatures and electrocautery. Fractured ribs with unstable segments were reduced and stabilized where feasible. The chest wall soft-tissue defect, resulting from muscular disruption and loss of continuity, was reconstructed using a rotational pectoralis major musculocutaneous flap to restore coverage and prevent paradoxical chest wall motion. Hemostasis was confirmed, pleural lavage performed, and two large-bore chest drains were placed (apical and basal). The total operative time was approximately eight hours. Estimated intraoperative blood loss was 1,500 mL. The patient was transferred to the intensive care unit (ICU) intubated and sedated for postoperative ventilatory support and close hemodynamic monitoring. Postoperative management included mechanical ventilation, broad-spectrum intravenous antibiotics, aggressive chest physiotherapy, nutritional support, and targeted analgesia. The patient’s oxygenation and hemodynamics improved steadily. A follow-up chest CT on postoperative day 3 showed full re-expansion of the left lung without residual pneumothorax or uncontrolled collection (Fig. 3 A–D). Bronchoscopic toilet was performed for evacuation of retained secretions and to confirm airway patency. The patient was successfully extubated on postoperative day 5. During the ward stay, the chest wall incision and flap demonstrated progressive healing with good contour and mobility; outpatient photographs showed satisfactory cosmetic result and preserved chest wall function (Fig. 4 A). The patient was discharged in stable condition with outpatient follow-up arranged. Discussion Cervicothoracic impalement injuries are extremely rare but often fatal due to the involvement of vital mediastinal structures【1,4】. Most reported cases emphasize the importance of maintaining the impaling object in situ during transfer to prevent uncontrolled hemorrhage【6】. In this case, the success relied on rapid preoperative imaging, availability of standby CPB, and a multidisciplinary surgical approach led by the thoracic surgery team. The combined cervical and anterolateral thoracotomy provided sufficient exposure to control both cervical and thoracic components of injury【3,5】. Pulmonary lacerations and chest wall defects were effectively repaired using standard thoracic reconstructive techniques. Previous studies similarly reported successful outcomes using timely thoracic exploration and careful hemostasis in impalement cases involving the lung and great vessels【7–9】. This case underscores that prompt decision-making, intraoperative coordination, and surgical expertise remain central to managing complex cervicothoracic impalement trauma. Conclusion The successful management of cervicothoracic impalement injuries depends on rapid evaluation, effective multidisciplinary coordination, and precise thoracic surgical intervention. The integration of preoperative CPB standby and meticulous intraoperative control under thoracic surgical leadership is vital for preventing catastrophic outcomes and promoting full recovery. Declarations Conflict of Interest Statement The authors declare no conflicts of interest. Ethical Approval Written informed consent for publication of this case and images was obtained from the patient. Consent for publication Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Availability of data and materials All data generated or analyzed during this study are included in this published article. Competing interests The authors declare that they have no competing interests. Funding This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Author contributions Peng Zuo: Data collection, manuscript drafting Ziqing Shen: Imaging analysis, manuscript revision Zihan Cui: Literature review, case data verification Guocai Mao: Clinical data management, perioperative support Jun Zhao: Surgical management, critical revision Liangbin Pan: Study supervision, final approval of the manuscript Acknowledgements Not applicable. References Zhao W, Chu M, Ma L, et al. Penetrating chest trauma caused by a falling metallic bar: a case report. J Thorac Dis. 2023;15(7):4027–32. Kim KT, Seo PW. A case of severe thoracoabdominal impalement by a steel bar. Korean J Thorac Cardiovasc Surg. 2016;49(6):481–4. Malla G, Basnet B, Vohra R, et al. Thoraco-abdominal impalement injury: a case report. BMC Emerg Med. 2014;14:7. Ukwuani SI, Umar A, Ismail S, et al. Thoracic impalement injury by the barrel of a locally fabricated gun in 2 patients: case report. Pan Afr Med J. 2022;42:155. Akçam TI, Ergonul AG, Ozdil A, Cakan A, Çağırıcı U. Rebar impalement injury throughout bilateral hemithorax and pericardium. Open J Thorac Surg. 2015;5:31–4. Smeltz AM, Bhatia M, Arora H, Long J, Kumar PA. Anesthesia for resection and reconstruction of the trachea and carina. J Cardiothorac Vasc Anesth. 2020;34:1902–13. Gonzalez-Rivas D, et al. Uniportal fully robotic-assisted sleeve resections: surgical technique and experience of 30 cases. Ann Cardiothorac Surg. 2023;12:9–22. Fujino T, et al. A new approach to left sleeve pneumonectomy: complete VATS left pneumonectomy followed by right thoracotomy for carinal reconstruction. Surg Case Rep. 2018;4:91. Okuda K, Nakanishi R. The non-intubated anesthesia for airway surgery. J Thorac Dis. 2016;8:336–42. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 03 Apr, 2026 Reviews received at journal 02 Apr, 2026 Reviewers agreed at journal 02 Apr, 2026 Reviewers agreed at journal 02 Apr, 2026 Reviewers agreed at journal 02 Apr, 2026 Reviewers agreed at journal 02 Apr, 2026 Reviews received at journal 07 Feb, 2026 Reviewers agreed at journal 07 Feb, 2026 Reviewers agreed at journal 05 Feb, 2026 Reviewers invited by journal 04 Feb, 2026 Editor assigned by journal 28 Dec, 2025 Submission checks completed at journal 28 Dec, 2025 First submitted to journal 13 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-8353628\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Case Report\",\"associatedPublications\":[],\"authors\":[{\"id\":586213941,\"identity\":\"c2f2ed5d-fbbc-42ba-890e-c0caec904d1b\",\"order_by\":0,\"name\":\"Peng Zuo\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"The First Affiliated Hospital of Soochow University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Peng\",\"middleName\":\"\",\"lastName\":\"Zuo\",\"suffix\":\"\"},{\"id\":586213942,\"identity\":\"401ac53e-0d0d-415b-8b61-0a84457c4410\",\"order_by\":1,\"name\":\"Ziqing Shen\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"The First Affiliated Hospital of Soochow University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Ziqing\",\"middleName\":\"\",\"lastName\":\"Shen\",\"suffix\":\"\"},{\"id\":586213943,\"identity\":\"c08bc1f1-84fc-4886-b056-0b4bd0fdc031\",\"order_by\":2,\"name\":\"Zihan Cui\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"The First Affiliated Hospital of Soochow University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Zihan\",\"middleName\":\"\",\"lastName\":\"Cui\",\"suffix\":\"\"},{\"id\":586213944,\"identity\":\"b54b58c1-74e5-47c7-a806-64ea210f5153\",\"order_by\":3,\"name\":\"Guocai Mao\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"The First Affiliated Hospital of Soochow University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Guocai\",\"middleName\":\"\",\"lastName\":\"Mao\",\"suffix\":\"\"},{\"id\":586213945,\"identity\":\"e1d73065-014a-4457-adea-6d0b977c1d00\",\"order_by\":4,\"name\":\"Liangbin Pan\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1ElEQVRIiWNgGAWjYBACNvkHiQ8SeGzk+OUPHyBOCx9DwmODDzJpxpIz2BKI0yLHkPhMcobN4cQNN3gMiHQYw+E0aZ4cZsYNt3s+3njDYCen20BIC2NbsjXPGTZmyTtnN1vOYUg2NjtASAszT+Jt3h4eNr4DudukeRgOJG4jqIWN/4M07z8JoOKcZ0Rq4WFIkpzBYyAhcCOHjUgtEgzJBh94Egwke44ZW84xIMIv8jMYQFH5v76fvfnhjTcVdnIEtaAACWKjBlkLqTpGwSgYBaNgRAAAp+ZAYZB2VqoAAAAASUVORK5CYII=\",\"orcid\":\"\",\"institution\":\"The First Affiliated Hospital of Soochow University\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Liangbin\",\"middleName\":\"\",\"lastName\":\"Pan\",\"suffix\":\"\"},{\"id\":586213946,\"identity\":\"7134ae9a-3e0a-4813-b177-5f6bf1528428\",\"order_by\":5,\"name\":\"Jun Zhao\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"The First Affiliated Hospital of Soochow University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Jun\",\"middleName\":\"\",\"lastName\":\"Zhao\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2025-12-13 15:08:30\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-8353628/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-8353628/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":102212033,\"identity\":\"8a8efa5d-8183-45a2-80ae-6327fee592ef\",\"added_by\":\"auto\",\"created_at\":\"2026-02-09 12:31:47\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":1098046,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003ePreoperative evaluation. \\u003cbr\\u003e\\nA–C: Preoperative CT images showing the steel bar penetrating from the right neck into the thoracic cavity, accompanied by rib fractures and lung lacerations.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"figure1AC.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8353628/v1/4bfc2d4af011c33644129144.png\"},{\"id\":102212036,\"identity\":\"10f2d37e-6e20-4a91-a39b-85a6427a8f7c\",\"added_by\":\"auto\",\"created_at\":\"2026-02-09 12:31:48\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":1554738,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eIntraoperative findings.\\u003cbr\\u003e\\nA–B: Intraoperative photographs showing thoracoscopic exploration and open thoracotomy exposure of the impalement tract. (Images demonstrate the foreign body in situ, pulmonary lacerations, and intercostal vessel injury prior to controlled extraction.)\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"figure2AB.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8353628/v1/a6dce15210e2986b1f715ffb.png\"},{\"id\":102212035,\"identity\":\"9e602bf1-41b5-42bf-b58b-00aae7205b46\",\"added_by\":\"auto\",\"created_at\":\"2026-02-09 12:31:48\",\"extension\":\"png\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":1322527,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003ePostoperative imaging.\\u003cbr\\u003e\\nA–D: Extracted steel bar (photograph), postoperative CT scans and chest X-rays confirming full lung re-expansion and absence of residual large pleural collections.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"figure3AD.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8353628/v1/7f4cbeb776241732cd2905e7.png\"},{\"id\":102212034,\"identity\":\"2bc87b44-7ca9-48c0-8bb7-2b0a0328e946\",\"added_by\":\"auto\",\"created_at\":\"2026-02-09 12:31:47\",\"extension\":\"png\",\"order_by\":4,\"title\":\"Figure 4\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":2683546,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eRecovery and outcome.\\u003cbr\\u003e\\nA: Postoperative clinical photograph showing chest wall wound healing and satisfactory contour following rotational musculocutaneous flap reconstruction.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"figure4A.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8353628/v1/46a47adddb3660ebac75fa89.png\"},{\"id\":102212064,\"identity\":\"c198165e-b80a-42c3-b079-4d8a7ddb3247\",\"added_by\":\"auto\",\"created_at\":\"2026-02-09 12:31:55\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":6903871,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8353628/v1/c866d7a0-608f-4e68-b706-5b7cf516e06e.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Cervicothoracic Impalement Injury Caused by a Steel Bar: A Case Report\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eCervicothoracic impalement injuries represent one of the most complex and life-threatening emergencies in thoracic surgery【1\\u0026ndash;3】. These injuries often involve simultaneous damage to the airway, lung parenchyma, chest wall, and mediastinal vessels, leading to rapid hemodynamic compromise. Rapid diagnosis, proper imaging assessment, and coordinated surgical management are essential for survival【4】.\\u003c/p\\u003e \\u003cp\\u003eAlthough isolated thoracic penetrating trauma is relatively common, trans-cervicothoracic impalement by rigid metallic bars remains exceedingly rare. Preoperative CPB standby is a crucial precaution when the trajectory of the foreign body approaches major vascular structures【5】.\\u003c/p\\u003e \\u003cp\\u003eHere, we report a rare case of cervicothoracic impalement injury caused by a steel bar, successfully managed through emergency thoracic surgery with multidisciplinary collaboration and preoperative CPB standby.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e\"},{\"header\":\"Case Presentation\",\"content\":\"\\u003cp\\u003eA 55-year-old female construction worker was accidentally impaled by a steel bar that entered the right side of the neck and extended obliquely into the thoracic cavity, with the distal tip reaching the T11 vertebral level. On arrival at a regional hospital the patient complained of severe chest pain, chest tightness, dyspnea, and progressive hypoxemia. Initial resuscitation measures (oxygen supplementation, intravenous access and fluids, analgesia, wound stabilization) were instituted, and urgent transfer to The First Affiliated Hospital of Soochow University was arranged.\\u003c/p\\u003e \\u003cp\\u003eContrast-enhanced computed tomography (CT) performed on arrival demonstrated the steel bar traversing from the right cervical region (approximately C5 level) obliquely into the left thoracic cavity and terminating at the T11 vertebral body. The bar penetrated the left pulmonary field from apex to base, with left-sided fractures of ribs 1\\u0026ndash;10, hemopneumothorax, marked mediastinal and subcutaneous emphysema, and an L1 compression fracture. These imaging findings clearly delineated the impalement trajectory and the extent of thoracic structural disruption (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003eA\\u0026ndash;C). No definitive active contrast extravasation suggestive of arterial transection was evident on CT, but the trajectory lay in close relation to the aortic arch and left pulmonary artery.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003eGiven the trajectory and risk of uncontrolled intrathoracic hemorrhage, a multidisciplinary conference involving thoracic surgery, cardiac surgery, anesthesiology, and critical care was convened. The consensus plan included immediate operative exploration with the cardiac surgery team placing a standby cardiopulmonary bypass (CPB) circuit (vascular access and priming prepared) to permit emergent extracorporeal support if catastrophic bleeding occurred during foreign-body extraction.\\u003c/p\\u003e \\u003cp\\u003eUnder general anesthesia and with standard hemodynamic monitoring, the patient was placed in the right lateral decubitus position. A combined cervical incision (for neck exposure) and a left anterolateral thoracotomy through the 4th intercostal space were performed to provide concurrent access to the cervical and thoracic components of the impalement tract. On thoracic entry, the pleural cavity contained mixed blood and air, and approximately 1,500 mL of hemothorax was evacuated. The steel bar was visually identified traversing the left upper lobe and extending posteriorly toward the base, with multiple pulmonary lacerations and disruption of intercostal vessels along the rib fracture sites (intraoperative views shown in Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003eA\\u0026ndash;B).\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003eSurgical strategy prioritized controlled hemostasis and preservation of lung parenchyma. The operative sequence was as follows: (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e) proximal and distal exposure of potential vascular structures (identification and retraction/protection of the aortic arch and left pulmonary artery), (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e) temporary tamponade and selective ligation of bleeding intercostal vessels, (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e) careful soft-tissue dissection around the foreign body while maintaining the bar in situ until vascular control was secured, and (\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e) slow, controlled extraction of the steel bar under direct visualization to minimize secondary tearing. The bar was removed without the need to initiate CPB.\\u003c/p\\u003e \\u003cp\\u003ePulmonary lacerations were managed by conservative debridement and layered repair: membranous defects were approximated first, followed by interrupted 4\\u0026thinsp;\\u0026minus;\\u0026thinsp;0 Prolene figure-of-eight sutures placed to achieve airtight closure. Reinforcement sutures and fibrin sealant were applied as necessary. Intercostal vascular bleeding was controlled with ligatures and electrocautery. Fractured ribs with unstable segments were reduced and stabilized where feasible. The chest wall soft-tissue defect, resulting from muscular disruption and loss of continuity, was reconstructed using a rotational pectoralis major musculocutaneous flap to restore coverage and prevent paradoxical chest wall motion. Hemostasis was confirmed, pleural lavage performed, and two large-bore chest drains were placed (apical and basal).\\u003c/p\\u003e \\u003cp\\u003eThe total operative time was approximately eight hours. Estimated intraoperative blood loss was 1,500 mL. The patient was transferred to the intensive care unit (ICU) intubated and sedated for postoperative ventilatory support and close hemodynamic monitoring. Postoperative management included mechanical ventilation, broad-spectrum intravenous antibiotics, aggressive chest physiotherapy, nutritional support, and targeted analgesia. The patient\\u0026rsquo;s oxygenation and hemodynamics improved steadily. A follow-up chest CT on postoperative day 3 showed full re-expansion of the left lung without residual pneumothorax or uncontrolled collection (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003eA\\u0026ndash;D). Bronchoscopic toilet was performed for evacuation of retained secretions and to confirm airway patency. The patient was successfully extubated on postoperative day 5. During the ward stay, the chest wall incision and flap demonstrated progressive healing with good contour and mobility; outpatient photographs showed satisfactory cosmetic result and preserved chest wall function (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003eA). The patient was discharged in stable condition with outpatient follow-up arranged.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eCervicothoracic impalement injuries are extremely rare but often fatal due to the involvement of vital mediastinal structures【1,4】. Most reported cases emphasize the importance of maintaining the impaling object in situ during transfer to prevent uncontrolled hemorrhage【6】.\\u003c/p\\u003e \\u003cp\\u003eIn this case, the success relied on rapid preoperative imaging, availability of standby CPB, and a multidisciplinary surgical approach led by the thoracic surgery team. The combined cervical and anterolateral thoracotomy provided sufficient exposure to control both cervical and thoracic components of injury【3,5】.\\u003c/p\\u003e \\u003cp\\u003ePulmonary lacerations and chest wall defects were effectively repaired using standard thoracic reconstructive techniques. Previous studies similarly reported successful outcomes using timely thoracic exploration and careful hemostasis in impalement cases involving the lung and great vessels【7\\u0026ndash;9】.\\u003c/p\\u003e \\u003cp\\u003eThis case underscores that prompt decision-making, intraoperative coordination, and surgical expertise remain central to managing complex cervicothoracic impalement trauma.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eThe successful management of cervicothoracic impalement injuries depends on rapid evaluation, effective multidisciplinary coordination, and precise thoracic surgical intervention. The integration of preoperative CPB standby and meticulous intraoperative control under thoracic surgical leadership is vital for preventing catastrophic outcomes and promoting full recovery.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eConflict of Interest Statement\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;The authors declare no conflicts of interest.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEthical Approval\\u003c/strong\\u003e\\u003cbr\\u003e\\u0026nbsp;Written informed consent for publication of this case and images was obtained from the patient.\\u003c/p\\u003e\\n\\n\\u003cp\\u003eConsent for publication\\u003c/p\\u003e\\n\\u003cp\\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images.\\u003c/p\\u003e\\n\\n\\u003cp\\u003eAvailability of data and materials\\u003c/p\\u003e\\n\\u003cp\\u003eAll data generated or analyzed during this study are included in this published article.\\u003c/p\\u003e\\n\\n\\u003cp\\u003eCompeting interests\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare that they have no competing interests.\\u003c/p\\u003e\\n\\n\\u003cp\\u003eFunding\\u003c/p\\u003e\\n\\u003cp\\u003eThis study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\\u003c/p\\u003e\\n\\n\\u003cp\\u003eAuthor contributions\\u003c/p\\u003e\\n\\u003cp\\u003ePeng Zuo: Data collection, manuscript drafting\\u003cbr\\u003e Ziqing Shen: Imaging analysis, manuscript revision\\u003c/p\\u003e\\n\\u003cp\\u003eZihan Cui: Literature review, case data verification\\u003c/p\\u003e\\n\\u003cp\\u003eGuocai Mao: Clinical data management, perioperative support\\u003cbr\\u003e Jun Zhao: Surgical management, critical revision\\u003cbr\\u003e Liangbin Pan: Study supervision, final approval of the manuscript\\u003c/p\\u003e\\n\\n\\u003cp\\u003eAcknowledgements\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eZhao W, Chu M, Ma L, et al. Penetrating chest trauma caused by a falling metallic bar: a case report. J Thorac Dis. 2023;15(7):4027\\u0026ndash;32.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKim KT, Seo PW. A case of severe thoracoabdominal impalement by a steel bar. Korean J Thorac Cardiovasc Surg. 2016;49(6):481\\u0026ndash;4.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMalla G, Basnet B, Vohra R, et al. Thoraco-abdominal impalement injury: a case report. BMC Emerg Med. 2014;14:7.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eUkwuani SI, Umar A, Ismail S, et al. Thoracic impalement injury by the barrel of a locally fabricated gun in 2 patients: case report. Pan Afr Med J. 2022;42:155.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAk\\u0026ccedil;am TI, Ergonul AG, Ozdil A, Cakan A, \\u0026Ccedil;ağırıcı U. Rebar impalement injury throughout bilateral hemithorax and pericardium. Open J Thorac Surg. 2015;5:31\\u0026ndash;4.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSmeltz AM, Bhatia M, Arora H, Long J, Kumar PA. Anesthesia for resection and reconstruction of the trachea and carina. J Cardiothorac Vasc Anesth. 2020;34:1902\\u0026ndash;13.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eGonzalez-Rivas D, et al. Uniportal fully robotic-assisted sleeve resections: surgical technique and experience of 30 cases. Ann Cardiothorac Surg. 2023;12:9\\u0026ndash;22.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eFujino T, et al. A new approach to left sleeve pneumonectomy: complete VATS left pneumonectomy followed by right thoracotomy for carinal reconstruction. Surg Case Rep. 2018;4:91.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eOkuda K, Nakanishi R. The non-intubated anesthesia for airway surgery. J Thorac Dis. 2016;8:336\\u0026ndash;42.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"journal-of-cardiothoracic-surgery\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"jcts\",\"sideBox\":\"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)\",\"snPcode\":\"13019\",\"submissionUrl\":\"https://submission.nature.com/new-submission/13019/3\",\"title\":\"Journal of Cardiothoracic Surgery\",\"twitterHandle\":\"@BioMedCentral\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC/SO AJ\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Cervicothoracic trauma, Impalement injury, Penetrating thoracic injury, Pulmonary repair, Chest wall reconstruction, Thoracic surgery, Multidisciplinary management\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-8353628/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-8353628/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eBackground\\u003c/h2\\u003e \\u003cp\\u003eCervicothoracic 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.\\u003c/p\\u003e\\u003ch2\\u003eCase Presentation:\\u003c/h2\\u003e \\u003cp\\u003eA 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.\\u0026nbsp;1A\\u0026ndash;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.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003eAn 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.\\u0026nbsp;2A\\u0026ndash;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\\u0026thinsp;\\u0026minus;\\u0026thinsp;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.\\u0026nbsp;3A\\u0026ndash;D). At follow-up the patient demonstrated stable respiratory function and good chest wall healing (Fig.\\u0026nbsp;4A).\\u003c/p\\u003e\\u003ch2\\u003eConclusion\\u003c/h2\\u003e \\u003cp\\u003eThis case highlights the critical role of thoracic surgeons in the management of complex cervicothoracic impalement trauma. Rapid evaluation, precise preoperative planning\\u0026mdash;including the preoperative establishment of standby CPB by the cardiac surgery team\\u0026mdash;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.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Cervicothoracic Impalement Injury Caused by a Steel Bar: A Case Report\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-02-09 12:31:31\",\"doi\":\"10.21203/rs.3.rs-8353628/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2026-04-03T21:30:59+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-04-02T20:56:10+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"68834462728253917687323692837247296905\",\"date\":\"2026-04-02T17:28:46+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"220686003520608541835476191230065761054\",\"date\":\"2026-04-02T16:51:37+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"85331986509399062179417326459496273255\",\"date\":\"2026-04-02T13:29:01+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"39810732247565797097014217085020586503\",\"date\":\"2026-04-02T13:27:58+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-02-07T12:49:42+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"294916161101187746034658987031561888267\",\"date\":\"2026-02-07T08:34:53+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"204535900640950676540148866701907219111\",\"date\":\"2026-02-05T08:52:11+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2026-02-04T11:47:10+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2025-12-29T02:09:20+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2025-12-29T02:08:14+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"Journal of Cardiothoracic Surgery\",\"date\":\"2025-12-13T14:48:31+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"journal-of-cardiothoracic-surgery\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"jcts\",\"sideBox\":\"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)\",\"snPcode\":\"13019\",\"submissionUrl\":\"https://submission.nature.com/new-submission/13019/3\",\"title\":\"Journal of Cardiothoracic Surgery\",\"twitterHandle\":\"@BioMedCentral\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC/SO AJ\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"0b6f1301-1e2c-4c17-a85a-ae6dd240bf0d\",\"owner\":[],\"postedDate\":\"February 9th, 2026\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"in-revision\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-04-03T21:38:44+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-02-09 12:31:31\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-8353628\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-8353628\",\"identity\":\"rs-8353628\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}