Hard signs were highly specific but identified only about half of patients with major injury in penetrating neck trauma, supporting imaging-based selective management, while a composite of clinical signs and haemodynamic status improved sensitivity but left non-trivial residual risk.
Hard signs were specific but insensitive for major injury in penetrating neck trauma.
Hard signs were similarly specific but insensitive for operative or endovascular management.
Outcome frequency rose significantly across three sign categories: no signs, soft signs only, and hard signs.
A composite of 'any sign or haemodynamic instability' achieved high sensitivity for major injury but at the cost of low specificity and residual risk.
Restricting the reference standard to imaging- or operatively-verified patients reduced the negative predictive value of hard signs.
Exploratory multivariable models showed moderate discrimination but offered no decision-curve advantage over hard signs alone at clinically relevant thresholds.
The study findings are described as exploratory and requiring external validation before informing clinical practice.
This research examined how reliably 'hard signs' — serious symptoms like active bleeding, expanding neck hematoma, or airway compromise — can identify major blood vessel or airway injuries in patients with penetrating neck wounds such as stab or gunshot wounds. Studying 310 patients over roughly 12 years at a single hospital, the researchers found that while hard signs were very good at ruling injuries in (high specificity), they missed about half of all major injuries (low sensitivity of around 55%), meaning many seriously injured patients did not show obvious hard signs at first assessment. When the researchers combined hard signs with soft signs and signs of hemodynamic instability (low blood pressure or shock) into a composite rule, they captured about 97% of major injuries — but this came at the cost of flagging many patients who did not actually have serious injuries, and a small but meaningful 6.4% of patients who tested negative by this composite rule still ended up needing surgery or an endovascular procedure. More complex statistical models performed slightly better overall but provided no practical advantage over simply using hard signs in clinical decision-making. This research suggests that relying on hard signs alone to decide who needs immediate surgery for penetrating neck trauma will miss a substantial proportion of seriously injured patients, supporting the use of imaging (such as CT angiography) to evaluate patients who lack obvious hard signs rather than assuming they are safe. The authors caution that these are exploratory, single-centre findings that need to be confirmed in other hospitals and patient populations before changing clinical protocols.
Barrientos M, Zapata C, Toro D, López C. (2026). Diagnostic accuracy and predictive value of hard signs for operative or endovascular management and major injury in penetrating neck trauma: a single-centre retrospective cohort study.. European journal of trauma and emergency surgery : official publication of the European Trauma Society. https://doi.org/10.1007/s00068-026-03343-w