Scalp Laceration


Article Author:
Abdulaziz Almulhim


Article Editor:
Mohammed Madadin


Editors In Chief:
Brian Downs
Ziad Katrib


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
5/4/2019 4:38:14 PM

Introduction

A laceration is a pattern of injury in which blunt forces result in a tear in the skin and underlying tissues. Lacerations in the scalp are different from lacerations in other parts of the face and body due to differences in the anatomy and blood supply. The scalp is lying on stretched skin tissue that lies on the bone that makes it more prone to be lacerated.

It's essential that clinicians have a clear understanding of these differences and their effect on the evaluation and management of these types of injuries.

Etiology

Lacerations typically result from blunt trauma causing a tear in the skin and underlying tissue. Examples of cases in which scalp laceration occur range from injuries caused by fall, hammer blows or bottles to severe blast-related trauma in warzones. Knowing the etiology and mechanism of the injury is vital in the evaluation of patients with scalp laceration to anticipate and look for associated injuries and their possible complications.[1][2]

Epidemiology

A study conducted in US emergency departments looking at the frequency and trends of lacerations between 1992 and 2002 found that lacerations represent 8% of cases encountered in emergency departments, with 28% of these lacerations being in the face. Roughly two-thirds of the patients presenting with lacerations were male. Facial lacerations were more common in children. However, even though the number of patients visiting emergency departments has gradually increased over this period, visits for lacerations have declined over the same period.[3]

Pathophysiology

The scalp consists of five layers, summarized by the mnemonic SCALP:

S - Skin

C - SubCutaneous tissue

A - Aponeurosis and muscle (musculoaponeurotic layer ML).

L - Loose areolar tissue and subgaleal fascia

P - Pericranium/Periosteum.

In lacerations, separation most commonly occurs at the loose areolar tissue layer. The musculoaponeurotic layer contains the superficial temporal artery as the muscles require copious blood supply for function. Understanding the layers of the scalp and the blood supply is essential to successfully stopping bleeding from lacerations, which can be substantial in many cases.[1][4]

History and Physical

History

Clinicians should inquire about causative trauma, the age of the wound, the presence of a foreign body, and symptoms of head trauma. They also need to assess the risk of wound contamination (e.g., bite wounds are at high risk). Further, the clinician should collect information on conditions and habits that may affect wound healing adversely such as diabetes mellitus, history of keloids, steroid use, drug or alcohol abuse. Other important factors needed from history include allergies to local anesthetics and tetanus immunization status. 

Examination

The wound should undergo proper assessment for length, depth, shape, contamination or foreign bodies, and skin loss.[5] Proper evaluation requires the removal of foreign bodies and achieving hemostasis. Sometimes, removal of scalp hair is necessary. 

Careful examination of the head and looking for signs of associated injuries such as skull fractures and intracranial injury is essential as they may require immediate intervention to prevent significant morbidity.

Evaluation

Diagnostic imaging is not necessary in all cases of scalp lacerations. However, there are some indications[6][7]:

  • Bony defects on examination or signs of traumatic brain injury warrant CT imaging to look for intracranial injury
  • Patients with clinical findings suggestive of foreign body presence warrant imaging (radiography for radiopaque material such as glass, rocks, and metals and ultrasonography for nonradiopaque materials)

Treatment / Management

The first thing requiring attention in scalp lacerations is the removal of foreign bodies, if present, and achieving hemostasis. The bleeding can usually be stopped by applying direct pressure with or without the use of local lidocaine with epinephrine. If hemostasis is unachievable with these measures, the edges of the scalp are everted using hemostats or skin hooks before prompt suturing of the wound. Controlling bleeding is important as lacerations can result in significant blood loss.[4][8]

Primary closure of the laceration is preferred in most cases, as delayed closure of the wound increases the risk of infection & scarring. Lacerations that are older than 24 hours with an increased risk of infection (e.g., vascular insufficiency, contamination, foreign bodies) may warrant delayed primary closure 4 to 5 days after cleansing and debriding the wound. Primary closure of wounds that look inflamed (warm, swollen, pussy, and red) is contraindicated.[9]

It is crucial the laceration closure does not hinder definitive care and evaluation of more urgent injuries with which it is associated, such as intracranial injury.[10]

Options for closure include surgical staples, hair apposition, and suturing.

Staples are generally the preferred closure method in lacerations through the dermis in which bleeding is under control as they are fast, cheap, and have few to complications. They also achieve similar cosmetic results when compared to sutures.[11][12]

Straight, small wounds (under 10cm) can be repaired using modified hair apposition, if there is adequate bleeding controlled and the patient has hair that is at least 1cm in length. Even though this method is relatively time-consuming when compared to surgical staples, it is less painful and does not necessitate staple removal, and usually results in good cosmetic results with few complications.[13][14][15]

Simple interrupted sutures may be used for closure if the wound was profusely bleeding and could not attain adequate hemorrhage control without suturing. It is also a valid option if staples are unavailable and hair apposition isn't applicable (e.g., large wound, short-haired patient).[16]

Differential Diagnosis

  • Complex laceration.
  • Cut wound by a sharp object
  • Intracranial injury
  • Retained foreign body
  • Bite wound
  • Skull fracture

Prognosis

Most scalp lacerations unassociated with other traumatic injuries have a good prognosis with little to no long-lasting sequelae and excellent cosmetic results.[11] Wound infections are relatively uncommon due to the excellent blood supply to the scalp area. Risk of bleeding is significant but generally is controllable fairly easily. Factors that may cause poor outcomes include associated facial trauma, chronic conditions that may impair healing (e.g., diabetes, vascular insufficiency), and contaminated wounds with retained foreign bodies.

Complications

  • Bleeding: due to the excellent blood supply to the scalp, lacerations may result in profuse bleeding that may even lead to hemorrhagic shock if not managed promptly[1]
  • Infection: contaminated wounds, bite wounds, and retained foreign bodies pose a higher risk of wound infection
  • Scarring: poor healing outcomes may be related to delayed intervention or patient-related factors such as chronic medical conditions, social habits (smoking, alcohol,) and history of keloids

Deterrence and Patient Education

Scalp lacerations are traumatic injuries. It is essential to instruct patients to stay away or at least be careful when performing high-risk activities, especially given that injuries to the head and face can be severe with long-lasting morbidity.

After wound closure, it is essential to educate patients on how to deal with staples or sutures if they have them, and schedule proper follow up for the removal of these sutures/staples. General instructions on keeping the wound clean and preventing contamination are also essential to avoid unnecessary and preventable infections of the injury.

Enhancing Healthcare Team Outcomes

Even though scalp lacerations are for the most part uncomplicated and can be managed by the emergency team with little to no issues, thoroughly evaluating for injuries that may be associated with facial trauma is essential as many require prompt management that requires the involvement of other healthcare specialties such as plastic surgery and neurosurgery. Being vigilant and not hesitating to ask for help when appropriate is essential in these cases as head injuries can cause significant harm to the patients if not dealt with in a timely and professional manner. The ED nurse or the emergency department physician should inquire about tetanus status. In most cases, antibiotics are not necessary if the wound is clean. However, the patient should be seen in the clinic to ensure that healing is going on as planned.

Scalp lacerations are best addressed through an interprofessional team approach, including physicians, specialists when necessary, nursing staff, (including dermatology specialty-trained nurses), and in the event of infection, pharmacists. Communication among the various disciplines of the health care team will bring about optimal patient care and outcomes. [Level V]


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Scalp Laceration - Questions

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Profuse bleeding is most likely when which layer of scalp is injured?



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A 17-year-old male presents to the emergency department with an injury to the scalp. The wound looks like a laceration with bridging tissue present. Which of the following is the most likely cause of this laceration?



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A 17-year-old man presented to the emergency department a few hours after a fall. He is stable. On physical examination, the provider discovered a scalp laceration which is clean with minimum bleeding, and no foreign body is present. Which one of the following is the best approach to this patient?



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A 17-year-old male rugby player comes to an emergency department with a history of scalp laceration. He ran into a player while striking his head to the helmet of the other player. On physical examination, there were no signs of concussion. He was well oriented in time, place, and person, and his Glasgow coma scale was 15/15. He had minor bruises on the face and a 6 cm laceration on the scalp. The scalp laceration was stitched with an absorbable suture after proper sterilization of the wound. Which appropriate advice should be given to the patient before discharging him from the emergency department?



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A 65-year-old man presents with a small clean scalp laceration. On physical examination, there is no inflammation or contamination of the wound. The wound is only 4 cm in length. After thoroughly cleaning the skin with iodine or chlorhexidine, a local anesthetic is injected subcutaneously. Then a chromic catgut 2/0 is used to stitch the scalp laceration, and a seven-day course of antibiotic medication is prescribed before discharge from the emergency department. The patient is concerned about the prognosis of his injury. Which one of the following is a sequela of the treatment?



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A 40-year-old man fell from his bicycle after a collision in the road. He was injured in his head. In the emergency department, the patient was hemodynamically stable, and he only suffered localized pain. X-rays showed a skull fracture, and a computed tomography scan was not available. He was transferred to a tertiary hospital to be seen by a neurosurgery team. On arrival, his blood pressure was low, and the head bandage was soaked with blood. Which is the first step to be taken for this patient?



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The 2-year-old male is involved in a car accident and sustained a 13 cm scalp laceration. On physical examination, the wound is contaminated with a degloving type injury. X-ray of the head did not show any fracture of the skull. Lab reports show hemoglobin of 9.0 mg/dl, hematocrit of 30%, and white cell count of 4,600 cells/microliter. Which of the following is an appropriate step to close the wound?



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A 16-year-old girl comes to an emergency department with a scalp laceration. She fell off from the stairs with her head striking one of the footsteps. On physical examination, she is conscious, well oriented in time, place, and person with a Glasgow coma scale (GCS) score of 15/15. She is hemodynamically stable with a heart rate of 88 bpm and blood pressure of 120/82 mmHg but has a 7 cm long laceration in the scalp. Which one of the following is the best choice to close the wound?



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A 17-year-old male falls off of his bicycle, and his head hits the pavement on the way down. He denies seeking medical help from the fear of getting stitches and puts pressure on the scalp wound to stop bleeding with a dirty cloth. His father brings him to an emergency department after two days. On examination, he is conscious, alert, and oriented with Glasgow coma scale of 15/15. He is hemodynamically stable with a heart rate of 84 bpm and blood pressure of 124/82 mmHg but has a 5 cm long tear in his scalp. Which of the following additional findings is a contraindication for primary closure of the wound?



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A 43-year old male is involved in a motor vehicle accident and is brought to the emergency department. He injured his head after hitting the windshield and breaking it. There are no bony defects on examination but he has a deep 12 cm long wound on the top of his head. His blood pressure is 110/60 mmHg and pulse is 99 bpm. His respiration is normal at 16 bpm. Fluid resuscitation is initiated. Which of the following imaging modalities is most suitable for this patient?



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Scalp Laceration - References

References

Fitzpatrick MO,Seex K, Scalp lacerations demand careful attention before interhospital transfer of head injured patients. Journal of accident     [PubMed]
Arne BC, Management of scalp hemorrhage and lacerations. Journal of special operations medicine : a peer reviewed journal for SOF medical professionals. 2012 Spring;     [PubMed]
Singer AJ,Thode HC Jr,Hollander JE, National trends in ED lacerations between 1992 and 2002. The American journal of emergency medicine. 2006 Mar;     [PubMed]
Turnage B,Maull KI, Scalp laceration: an obvious 'occult' cause of shock. Southern medical journal. 2000 Mar;     [PubMed]
Lee RH,Gamble WB,Robertson B,Manson PN, The MCFONTZL classification system for soft-tissue injuries to the face. Plastic and reconstructive surgery. 1999 Apr;     [PubMed]
Fowler TR,Crellin SJ,Greenberg MR, Detecting foreign bodies in a head laceration. Case reports in emergency medicine. 2015;     [PubMed]
Hamrah H,Mehrvarz S,Mirghassemi AM, The Frequency of Brain CT-Scan Findings in Patients with Scalp Lacerations Following Mild Traumatic Brain Injury; A Cross-Sectional Study. Bulletin of emergency and trauma. 2018 Jan;     [PubMed]
Saigal K,Winokur RS,Finden S,Taub D,Pribitkin E, Use of three-dimensional computerized tomography reconstruction in complex facial trauma. Facial plastic surgery : FPS. 2005 Aug;     [PubMed]
Hollander JE,Singer AJ, Laceration management. Annals of emergency medicine. 1999 Sep;     [PubMed]
Lemos MJ,Clark DE, Scalp lacerations resulting in hemorrhagic shock: case reports and recommended management. The Journal of emergency medicine. 1988 Sep-Oct;     [PubMed]
Kanegaye JT,Vance CW,Chan L,Schonfeld N, Comparison of skin stapling devices and standard sutures for pediatric scalp lacerations: a randomized study of cost and time benefits. The Journal of pediatrics. 1997 May;     [PubMed]
Khan AN,Dayan PS,Miller S,Rosen M,Rubin DH, Cosmetic outcome of scalp wound closure with staples in the pediatric emergency department: a prospective, randomized trial. Pediatric emergency care. 2002 Jun;     [PubMed]
Hock MO,Ooi SB,Saw SM,Lim SH, A randomized controlled trial comparing the hair apposition technique with tissue glue to standard suturing in scalp lacerations (HAT study). Annals of emergency medicine. 2002 Jul;     [PubMed]
Ong ME,Chan YH,Teo J,Saroja S,Yap S,Ang PH,Lim SH, Hair apposition technique for scalp laceration repair: a randomized controlled trial comparing physicians and nurses (HAT 2 study). The American journal of emergency medicine. 2008 May;     [PubMed]
Karaduman S,Yürüktümen A,Güryay SM,Bengi F,Fowler JR Jr, Modified hair apposition technique as the primary closure method for scalp lacerations. The American journal of emergency medicine. 2009 Nov;     [PubMed]
Aderriotis D,Sàndor GK, Outcomes of irradiated polyglactin 910 Vicryl Rapide fast-absorbing suture in oral and scalp wounds. Journal (Canadian Dental Association). 1999 Jun;     [PubMed]

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