Question #368

A patient attends A+E with a bleeding head wound. Which of the following statements is incorrect?

The blood vessels lie in the connective tissue

A sagittal wound would be more easily sutured

The skin can slide easily over the aponeurosis

There are five layers to the scalp

Infection can rapidly spread in the subaponeurotic space

The five layers of the scalp can be remembered easily as:

• S – skin
• C – connective tisse (densely fibrous, it is here that the superficial blood vessels run and are held open by the fibrous connective tissue resulting in significant haemorrhage. Blood supply comes from both internal and external carotid arteries).
• A – aponeurosis
• L – loose connective tissue (movement occurs here, between the periosteum and aponeurosis – this is distinct from most other areas where skin moves easily over its underlying layers).
• P – periosteum. (It is the internal layer of periosteum, within the cranium, that fuses with the dura - not the periosteum of the scalp).

The scalp is under tension from frontalis and occipitalis muscles, a coronal wound will therefore be under greater stress and harder to suture closed.

N.B. Although the internal carotid artery has no branches in the neck, the small supra-orbital and supratrochlear vessels branch from the ophthalmic artery before passing through the supra-orbital foramen and medial angle of the orbit respectively to supply the scalp.

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