How should I manage a scalp laceration in a 7‑year‑old child after a fall, including evaluation for intracranial injury and wound closure?

Management of Scalp Laceration in a 7-Year-Old After Ground-Level Fall

Use the validated PECARN criteria to risk-stratify this child and determine whether CT imaging is needed before proceeding with wound closure. 1

Initial Risk Stratification Using PECARN Criteria

For a 7-year-old child (≥2 years age group), systematically assess the following to categorize risk:

Very Low Risk (No CT needed) 1

The child can safely forgo CT imaging if ALL of the following are present:

• Glasgow Coma Scale (GCS) of 15
• Normal mental status
• No signs of basilar skull fracture (hemotympanum, Battle's sign, raccoon eyes, CSF otorrhea/rhinorrhea)
• No loss of consciousness
• No vomiting
• No severe mechanism of injury
• No severe headache

Risk of clinically important traumatic brain injury: <0.05% 1

Intermediate Risk (Consider CT vs. Observation) 1

If the child has GCS 15 and normal mental status but ANY of:

• History of loss of consciousness
• Vomiting
• Severe mechanism of injury (high-impact fall, motor vehicle collision)
• Severe headache

Risk of clinically important injury: approximately 0.8% 1

For intermediate-risk patients, CT may be considered over observation when: 2

• Parental preference for definitive imaging
• Multiple risk factors present
• Worsening symptoms during observation
• Difficulty with reliable observation

High Risk (CT Strongly Recommended) 1

Immediate non-contrast head CT is indicated if ANY of:

• GCS of 14 or less
• Other signs of altered mental status
• Signs of basilar skull fracture

Risk of clinically important traumatic brain injury: approximately 4.3% 1

Critical Pitfalls to Avoid

Do not rely on skull radiographs—they miss up to 50% of intracranial injuries and provide no information about brain parenchyma. 1 Even when skull fractures are present, 50% of intracranial injuries occur without fracture. 1

Do not assume a simple scalp laceration excludes intracranial injury. In one prospective study, 59% of children with intracranial injury had normal mental status and no focal abnormalities. 3 Scalp lacerations, contusions, and hematomas are NOT significantly associated with intracranial injury presence or absence. 3

Maintain heightened vigilance for non-accidental trauma. If the mechanism does not match the injury pattern or there are unexplained findings, consider abuse and do not apply standard PECARN criteria—these children require imaging regardless of clinical presentation. 4, 2

Imaging Protocol (When Indicated)

If CT is warranted: 4, 2

• Perform non-contrast CT head using dedicated pediatric-specific, reduced-dose protocols following ALARA principles
• Tailor scan parameters to patient size
• Request multiplanar and 3D reconstructions to increase sensitivity for fractures and small hemorrhages
• Do not use IV contrast initially—it may obscure subtle hemorrhages

Observation Strategy (For Intermediate-Risk Patients)

Every additional hour of emergency department observation decreases CT utilization without delaying diagnosis of significant traumatic brain injury. 4, 2 During observation, watch for:

• Clinical deterioration (warrants immediate CT)
• Persistent or worsening vomiting
• Increasing drowsiness
• Development of focal neurologic signs
• Worsening headache

Wound Closure Approach

Once intracranial injury has been appropriately ruled out based on risk stratification:

Scalp lacerations heal well due to excellent vascular supply and can be closed primarily in most cases. Standard wound management principles apply:

• Irrigate thoroughly to remove debris
• Explore the wound to ensure no foreign bodies or deeper structural injury
• Close in layers if deep (galea, then skin)
• Hair apposition techniques or staples are effective for scalp wounds
• Ensure tetanus prophylaxis is current

Do not palpate for skull fractures through the laceration as the sole means of assessment—palpable skull fracture is a high-risk criterion requiring CT, but absence of palpable fracture does not exclude intracranial injury. 1

Discharge Instructions (If No Imaging Abnormalities)

Provide written and verbal instructions at 6th-7th grade reading level including: 5

• Return immediately for: persistent vomiting, increasing drowsiness, seizure activity, worsening headache, behavior changes, unsteady movements, unequal pupils
• Expected symptom course and recovery timeline
• Wound care instructions
• Clear follow-up plan