Anatomy:
The galea is a dense white layer that covers the periosteum of the skull. It serves as an insertion point for the frontalis and occipitalis muscles
Five layers of the scalp
· SCALP
o Skin
o Dense Connective tissue
o Aponeurosis (galea)
o Loose connective tissue
o Periosteum
Dense connective tissue layer is richly vascularized. The tight adhesion of these vessels to the connective tissue inhibits effective vasoconstriction, hence the large amount of bleeding in scalp lacerations.
The loose connective tissue layer = the DANGER ZONE when lacerated. This layer contains the emissary veins, which connect with the intracranial venous sinuses. Lacerations at this layer are high risk for spreading infection to the meninges!
Approach:
· Examine the wound, clear of debris, and assess the depth of the wound.
o Superficial wounds generally don’t gape
o Deep wounds gape widely due to laceration of aponeurosis, and the tension from the frontalis muscle and occipitalis muscle pull the wound open in opposite directions
· Hair removal unnecessary unless it interferes with actual closure or knot tying. No increased risk of infection if you do not remove the hair. Shaving head increases risk for infection!
· Obtain hemostasis with pressure and lidocaine with epinephrine.
· If the galea is lacerated more than 0.5 cm it should be repaired with 3-0 or 4-0 absorbable sutures. to prevent a serious cosmetic deformity from developing.
· Skin can be repaired using staples; interrupted, mattress, or running sutures, such as 3-0 or 4-0 nylon sutures; or the hair apposition technique. Removal of sutures or staples in 14 days.
· Antibiotics - With open skull fractures (blunt or penetrating), should give antibiotics: Ceftriaxone 2 grams q12hr + vancomycin for 24 hours.
Complications:
· Asymmetric contraction of the frontalis muscle
· Osteomyelitis, brain abscess - Failure to repair can also allow bacteria to get to the loose connective tissue layer more easily between the galea and periosteum, leading to increased risk of infection
· Subgaleal hematoma
References:
https://sjrhem.ca/rcp-scalp-lacerations-you-can-leave-your-hat-on/
http://pemsource.org/2019/01/01/question-trauma-10/
https://aneskey.com/special-anatomic-sites/
https://www.aafp.org/afp/2017/0515/p628.html
Tintinallis Emergency Medicine a Comprehensive Study Guide 8th Edition