Burr Hole. A right temporal bone burr hole is being performed in the emergency department due to rapid decompensation from extra-axial bleeding and clinical signs of uncal herniation. (Photo contributor: Kevin J. Knoop, MS, MD.)
The scalp is the soft tissue that covers the cranial vault. Scalp lacerations are common in the emergency department (ED), and most are managed without complications with simple suturing or stapling of the soft tissues under local anesthetic. If admitted, it is usually due to severe injuries associated with the trauma that caused the laceration. Infrequently, bleeding from the scalp’s copious blood supply requires resuscitation and transfusion from acute blood loss. Most delayed complications from scalp wounds occur secondary to infection from gross contamination, retained foreign bodies, bite wounds (including human), or retained hematoma. Infection is rare given the excellent blood supply, and antibiotics are generally not required.
The scalp consists of five layers:
S – Skin
C – Connective tissue
A – Aponeurosis and muscle (Galea)
L – Loose areolar tissue
P – Pericranium (periosteum)
Layers of the Scalp. Skin, connective tissue, aponeurosis, loose areolar tissue, and pericranium make up the layers of the scalp.
The 1st three layers are bound together, allowing them to move over the 4th. Thus, when lacerated, separation most commonly occurs at the loose areolar layer. Most bleeding comes from the superficial temporal artery and the occipital artery, in the aponeurosis and muscular layer.
Management and Disposition
Scalp laceration closure should not hinder trauma resuscitation unless bleeding is uncontrollable and contributing to patient instability. Primary closure is preferred in most cases, as delayed closure of the wound increases the risk of infection and scarring.
Closure options include surgical staples, hair apposition, and suturing. Staples are the preferred closure method in lacerations through the dermis in which bleeding is controlled as they are fast, inexpensive, and have few complications. They achieve similar cosmetic results compared to sutures. When choosing simple interrupted sutures (large wound, significant bleeding, short-haired patient), choose a blue proline suture or similar that stands out from the patient’s hair color and leave long tails when cutting. Hair apposition is more time consuming than the other choices but is a good option for straight wounds under 10 cm in length.
Diagnostic imaging is not necessary for minor isolated scalp lacerations. Bony defect or suspicion for brain injury should prompt a head computed tomography (CT) scan. Concern for foreign body should prompt plain films if radiopaque or ultrasound if not radiopaque.