Continuing Education Activity

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 stretched over the bone, making it more prone to laceration. This activity illustrates the evaluation and treatment of scalp lacerations and reviews the interprofessional team's role in managing affected patients.

Objectives:

• Explain the anatomical features that make the evaluation/management of scalp lacerations unique compared to the evaluation/management of lacerations involving other body regions.
• Review the management considerations for scalp lacerations.
• Summarize potential complications of scalp lacerations.
• Outline some interprofessional team strategies for improving care coordination and communication to enhance outcomes for patients with scalp lacerations.

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 lies on stretched skin tissue that lies on the bone that makes it more prone to be lacerated.

Clinicians must have a clear understanding of these differences and their effect on evaluating and managing 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 occurs 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 evaluating 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, the 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 removing foreign bodies, if present, and achieving hemostasis. The bleeding can usually be stopped by applying direct pressure with or without 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 and 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 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

• Bite wound
• Complex laceration.
• Cut wound by a sharp object
• Intracranial injury
• Retained foreign body
• 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. The 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 a proper follow-up to remove 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 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 5]