Scalp Laceration


Anatomy

  • Anterior border: supraorbital ridges
  • Posterior border: external occipital protuberances
  • Lateral borders: temporalis fascia
  • Five ANATOMIC layers (SCALP mnemonic)
    • The skin (S)
    • The superficial fascia [connective tissue] (C)
    • The galea aponeurotica (A)
    • Loose subaponeurotic areolar connective tissue (L)
    • The periosteum (P)
  • Three SURGICALLY distinct layers
    • Outer layer
      • Skin
      • Superficial fascia
      • Galea
    • Middle layer
      • Loose connective tissue
    • Lower layer
      • Periosteum

Pathophysiology

  • Vascular supply is rich
    • Wounds can bleed profusely
    • Vessels tend to remain patent
      • Fibrous SQ fascia prevents retraction
    • Patients CAN exsanguinate from a scalp laceration
  • Subgaleal connective tissue vessels drain into cranial venous sinuses
    • Scalp infection can cause
      • Meningitis
      • Brain abscess
      • Osteomyelitis
  • Stellate lacerations are common
    • Blunt trauma is usual injury mechanism
    • Superficial fascia is inelastic, adheres firmly to skin

 

Evaluation

  • Assess pt completely first
    • ABCs
    • Neuro exam
    • Imaging if needed
      • CT scan
      • Plain films
  • Examine scalp carefully
    • Small lacerations may be missed
    • Wounds may be hidden/ held closed by bloody, matted hair
  • ALWAYS inspect and palpate scalp lacerations
    • Make sure you see the base of the laceration
    • Look for underlying skull fracture
      • If skull fracture - DO NOT close
      • Neurosurgery consult
        • May need operative management
    • Look for debris
      • Can be several centimeters from the laceration
        • Shear injuries disrupt a lot of tissue
  • Check CBC and coagulative factors if wound is large or heavily bleeding

 

Treatment

(Note: while the forehead is technically part of the scalp, forehead lacerations should be treated as facial injuries)

  1. Control bleeding:
    • Local anesthetics with epinephrine
    • Wide (1/2 " or larger) Penrose drain around scalp
      • TIGHT!
      • Go from forehead to occiput
    • If patient needs resuscitation
      • Raney scalp clips can be applied
        • Radiolucent
        • Remove clip later when repairing wound
  2. Anesthetize the wound
    • Scalp block 
  3. Clean the wound gently but thoroughly
    • Irrigate copiously!
      • It's worth the mess
      • High-pressure irrigation is best
  4. Debride conservatively!
    • Remove obviously devitalized tissue
    • Remember - big defects are hard to close
  5. Clip hair far enough away that sutures won't get caught
    • Embedded hairs slow healing
    • EXCEPTION: the forehead hairline
      • Useful landmark for alignment
  6. Closure
    • You DO NOT have to close the periosteum
    • AVOID SQ deep sutures
    • GAPING wounds indicate the galea is disrupted
      • Galea MUST be closed
        • Muscles will pull wound edges apart
        • Sub-galeal hematoma may form
        • Greater chance of infection
        • LOUSY result
      • Close laceration with 3-0 vs. 4.0 nylon/ polypropylene
      • Close in ONE layer
        • Interrupted or vertical mattress sutures
    • NON-GAPING wounds
      • Can be closed with 4-0 vs. 5-0 non-absorbable suture
      • Staples may also be used 
    • Avulsions
      • Even large avulsions can survive
        • Excellent blood supply
      • If attached by tissue bridge: re-attach avulsed area
      • If completely detached
        • Treat as any other amputation
        • Surgery may re-implant with good results
  7. Tetanus if needed

 

Disposition

  1. Most simple lacerations with minor head trauma can be discharged home
    • Head injury precautions
    • Good wound care instructions
      • Patients can rinse hair in 24 hrs
    • Antibiotics NOT routinely needed
    • If continued oozing of blood
      • Elastic bandage compression dressing
      • Gauze pads to direct pressure locally
  2. For more significant lacerations/ trauma
    • Disposition depends on associated injuries
  3. Sutures to be removed in 7-10 days