OPEN HEAD WOUNDS

If the patient has more serious wounds elsewhere, his head wound can usually wait 12 or 18 hours. Before you operate, study the control of bleeding in Section 63.9.

X–RAYS If a patient has anything more than the most trivial wound, X–ray the vault of his skull.

THEATRE Unless a patient’s wound is very superficial, take him to the theatre, because it may be deeper than it looks. Torrential bleeding can occur, so you may need the full facilities of the theatre in a hurry. Examine his wound on a tipping table, not in a chair. He may bleed severely, or become shocked.

ANAESTHESIA Do a ring block of the scalp as described in A 6.6.

WOUND TOILET Shave the patient’s whole scalp, and clean it with detergent. Be prepared to use several razor blades, because any grit in his scalp will blunt them. Protect his wound meanwhile with a sterile swab or towel.

If his wound is clean–cut, and its edges are healthy and bleeding, don’t excise them.

If it is dirty and ragged, as in C, Fig. 63-19 excise the skin edges all round it in one clean sweep right down to his pericranium. Take care not to cut away more scalp than is necessary, or there will be so much bare skull that his wound will be difficult to close.

Put in a self retaining retractor, and explore his wound cautiously with your gloved finger. This is safer and provides more information than a metal probe. Remove all debris and dead tissue, and syringe it out with saline.

If you feel any sharp bony edges, expose the surface of his skull widely, and goto Section 63.7.

Figure 63.13: CLOSING A SCALP WOUND WITH FLAPS. Try to bring the skin edges together without too much tension, or the patient’s scalp may necrose. Follow the methods for flaps in Section 57.11. With the kind permission of Hugh Dudley.

STITCHING A wound which only cuts a patient’s skin does not gape, but one which cuts his galea gapes widely. Close it with big square vertical mattress sutures of stout monofilament, as in Fig. 63-14. Put them through his skin and his galea. Unless you catch the skin edges in the suture, they will dive inwards, and you will not know if you have closed his wound properly or not. Put most of the sutures in place before you start to tie them.

LOSS OF SCALP Try to bring the skin edges together without too much tension, or his scalp may necrose. Follow the methods for flaps in Section 57.11. Don’t leave bare bone exposed, or it will slough.

(1) If there is comparatively little loss of scalp, you may be able to free it from his pericranium round the wound, so as to mobilize it over the subgaleal space. Mobilize his scalp in the layer between his galea and his pericranium, as in Fig. 63-12.

(2) You may be able to elongate the ends of the wound in a long curved ’S’. Move the skin at the edges of these flaps, so that it closes the incisions, as in Fig. 63-13.

(3) You may be able to cut the flaps shown in Fig. 63-13, or Fig. 63-15. Cut them big. If possible, design them round one of the arteries supplying his scalp. If there is a dog ear at the end of the flap, disregard it, or close it with a small incision at right angles to the main one, as in Fig. 57-16.

Figure 63.14: AN EASY WAY OF CLOSING SCALP WOUNDS. If you don’t catch the edges of the scalp like this, they will dive inwards. Kindly contributed by Peter Bewes.

DIFFICULTIES WI TH OPEN HEAD WOUNDS

If BLOOD COLLECTS UNDER A PATIENT’S GALEA, don’t drain the swelling, or you may infect it. The haematoma will subside spontaneously, just as a cephalhaematoma does in a newborn child.

If he has a head wound, you have NO X-RAYS and you don’t know if he has a penetrating wound involving his dura or not, explore and toilet his wound. If you are in doubt, do a burr hole close beside it, insert the nibblers, and work towards the fracture.

If you CANNOT CLOSE A SCALP WOUND even with flaps, don’t leave the bare bone of the outer table of his skull at the bottom of the wound, for it will take months to granulate over. (1) See again if you can cover the bone with any of the flaps in Fig. 63-15. If necessary, graft the area from which you mobilized the flap. (2) If his exposed skull is covered by epicranium, graft it immediately (57.2). (3) If his epicranium has been stripped off, so that bare bone is exposed, gouge away the outer cortex of his skull. The exposed area of bone will granulate rapidly, and you will soon be able to graft it.

If a patient’s SCALP HAS BEEN PARTLY TORN OFF and hangs loose from his head, transfuse him, trim his scalp, wash it with an antiseptic, such as hydrogen peroxide, and suture it back. Its excellent blood supply, which caused it to bleed so much, will probably keep it alive, provided it is attached to his head by a reasonably broad base. If any exposed skull is still covered by pericranium, graft it immediately. If his pericranium has been removed, gouge the surface of his skull, let it granulate and graft it, as above.