A missed scalp laceration causing avoidable sequelae

• Scalp lacerations are common injuries that can be missed in polytrauma.
• A thorough secondary survey is of immense importance to avoid missed injuries.
• Areas missed in the secondary survey due to contraindications should be revisited.
• Examination of wounds requires cleaning and possibly the use of local anaesthetic.
• Missed lesions can have significant sequelae causing increased morbidity.

IntroductionWe present the case of an overlooked scalp laceration in an 81-year-old lady who presented with polytrauma following a fall down stairs. Complications that developed required more extensive treatment compared to what would have sufficed with early identification.Presentation of caseImaging on admission to hospital showed multiple vertebrae and rib fractures as well as a large cranial subcutaneous haematoma with no intracerebral bleed. Before the laceration was identified, the patient developed acute anaemia requiring transfusion. Continued reduction in haemoglobin levels called for a more thorough examination of the scalp. Investigation, following copious irrigation, revealed a large laceration. The presence of infection and necrotic tissue necessitated a general anaesthetic for debridement and closure.DisscussionDiagnostic errors are more common in patients presenting with multiple or severe injuries. Initial management in trauma cases should focus on more evident or life threatening injuries However, it is important that reflections and recommendations are continually made to reduce diagnostic errors, which are higher in polytraumatised patients.Various factors including haemodynamic instability and patient positioning added to the elusive nature of this wound. Adequate examination of lacerations requires thorough cleaning as coagulated blood and other material may obscure findings. This is particularly important in scalp lacerations where the overlying hair can form a barrier that is effective at hiding the wound edges.ConclusionThis case highlights the importance of a thorough secondary survey; an effective examination technique would have avoided the need for extensive treatment to manage the sequelae of the missed scalp laceration.