CA1&2

SCALP & SKULL & FACE

(Snell, Page 537)
Fractures of the Skull
Fractures of the skull are common in the adult but much less so in the young child. In the infant
skull, the bones are more resilient than in the adult skull, and they are separated by fibrous
sutural ligaments. In the adult, the inner table of the skull is particularly brittle. Moreover, the
sutural ligaments begin to ossify during middle age. The type of fracture that occurs in the skull
depends on the age of the patient, the severity of the blow, and the area of skull receiving the
trauma. The adult skull may be likened to an egg-shell in that it possesses a certain limited
resilience beyond which it splinters. A severe, localized blow produces a local indentation, often
accompanied by splintering of the bone. Blows to the vault often result in a series of linear
fractures, which radiate out through the thin areas of bone. The petrous parts of the temporal
bones and the occipital crests strongly reinforce the base of the skull and tend to deflect linear
fractures. In the young child, the skull may be likened to a table-tennis ball in that a localized
blow produces a depression without splintering. This common type of circumscribed lesion is
referred to as a “pond” fracture.

(Snell, Page 538-539)

Clinical Features of the Neonatal Skull
Fontanelles
Palpation of the fontanelles enables the physician to determine the progress of growth in the
surrounding bones, the degree of hydration of the baby (e.g., if the fontanelles are depressed
below the surface, the baby is dehydrated), and the state of the intracranial pressure (a bulging
fontanelle indicates raised intracranial pressure). Samples of cerebrospinal fluid can be obtained
by passing a long needle obliquely through the anterior fontanelle into the subarachnoid space or
even into the lateral ventricle. Clinically, it is usually not possible to palpate the anterior
fontanelle after 18 months, because the frontal and parietal bones have enlarged to close the gap.

(Snell, Page 543-544)

Intracranial Hemorrhage
Intracranial hemorrhage may result from trauma or cerebral vascular lesions. Four varieties are
considered here: extradural, subdural, subarachnoid, and cerebral.

Extradural hemorrhage results from injuries to the meningeal arteries or veins. The most
common artery to be damaged is the anterior division of the middle meningeal artery. A
comparatively minor blow to the side of the head, resulting in fracture of the skull in the region of
the anteroinferior portion of the parietal bone, may sever the artery. The arterial or venous
injury is especially liable to occur if the artery and vein enter a bony canal in this region. Bleeding
occurs and strips up the meningeal layer of dura from the internal surface of the skull. The
intracranial pressure rises, and the enlarging blood clot exerts local pressure on the underlying
motor area in the precentral gyrus. Blood may also pass outward through the fracture line to
form a soft swelling under the temporalis muscle. To stop the hemorrhage, the torn artery or vein
must be ligated or plugged. The burr hole through the skull wall should be placed about 1 to 1.5
in. (2.5 to 4 cm) above the midpoint of the zygomatic arch.

Subdural hemorrhage results from tearing of the superior cerebral veins at their point of
entrance into the superior sagittal sinus. The cause is usually a blow on the front or the back of
the head, causing excessive anteroposterior displacement of the brain within the skull. This
condition, which is much more common than middle meningeal hemorrhage, can be produced by
a sudden minor blow. Once the vein is torn, blood under low pressure begins to accumulate in
the potential space between the dura and the arachnoid. In about half the cases, the condition is
bilateral. Acute and chronic forms of the clinical condition occur, depending on the speed of
accumulation of fluid in the subdural space. For example, if the patient starts to vomit, the venous
pressure will rise as a result of a rise in the intrathoracic pressure. Under these circumstances,
the subdural blood clot will increase rapidly in size and produce acute symptoms. In the chronic
form, over a course of several months, the small blood clot will attract fluid by osmosis so that a
hemorrhagic cyst is formed, which gradually expands and produces pressure symptoms. In both
forms, the blood clot must be removed through burr holes in the skull.
Subarachnoid hemorrhage results from leakage or rupture of a congenital aneurysm on the circle
of Willis or, less commonly, from an angioma. The symptoms, which are sudden in onset, include
severe headache, stiffness of the neck, and loss of consciousness. The diagnosis is established by
withdrawing heavily blood-stained cerebrospinal fluid through a lumbar puncture
(spinal tap).

Cerebral hemorrhage is generally caused by rupture of the thin-walled lenticulostriate artery, a

branch of the middle cerebral artery. The hemorrhage involves the vital corticobulbar and
corticospinal fibers in the internal capsule and produces hemiplegia on the opposite side of the
body. The patient immediately loses consciousness, and the paralysis is evident when
consciousness is regained.

(Snell, Page 578)

Clinical Significance of the Scalp Structure
It is important to realize that the skin, the subcutaneous tissue, and the epicranial aponeurosis
are closely united to one another and are separated from the periosteum by loose areolar tissue.
The skin of the scalp possesses numerous sebaceous glands, the ducts of which are prone to
infection and damage by combs.For this reason, sebaceous cysts of the scalp are common.

Lacerations of the Scalp

The scalp has a profuse blood supply to nourish the hair follicles. Even a small laceration of the
scalp can cause severe blood loss.It is often difficult to stop the bleeding of a scalp wound
because the arterial walls are attached to fibrous septa in the subcutaneous tissue and are unable
to contract or retract to allow blood clotting to take place. Local pressure applied to the scalp is
the only satisfactory method of stopping the bleeding (see below). In automobile accidents, it is
common for large areas of the scalp to be cut off the head as a person is projected forward
through the windshield. Because of the profuse blood supply, it is often possible to replace large
areas of scalp that are only hanging to the skull by a narrow pedicle. Suture them in place, and
necrosis will not occur.
The tension of the epicranial aponeurosis, produced by the tone of the occipitofrontalis muscles,
is important in all deep wounds of the scalp. If the aponeurosis has been divided, the wound will
gape open. For satisfactory healing to take place, the opening in the aponeurosis must be closed
with sutures. Often, a wound caused by a blunt object such as a base- ball bat closely resembles
an incised wound. This is because the scalp is split against the unyielding skull, and the pull of the
occipitofrontalis muscles causes a gaping wound. This anatomic fact may be of considerable
forensic importance.

Life-Threatening Scalp Hemorrhage

Anatomically, it is useful to remember in an emergency that all the superficial arteries supplying
the scalp ascend from the face and the neck. Thus, in an emergency situation, encircle the head
just above the ears and eyebrows with a tie, shoelaces, or even a piece of string and tie it tight.
Then, insert a pen, pencil, or stick into the loop and rotate it so that the tourniquet exerts
pressure on the arteries.

Scalp Infections
Infections of the scalp tend to remain localized and are usually painful because of the abundant
fibrous tissue in the subcutaneous layer. Occasionally, an infection of the scalp spreads by the
emissary veins, which are valveless, to the skull bones, causing osteomyelitis. Infected blood in
the diploic veins may travel by the emissary veins farther into the venous sinuses and produce
venous sinus thrombosis. Blood or pus may collect in the potential space beneath the epicranial
aponeurosis. It tends to spread over the skull, being limited in front by the orbital margin, behind
by the nuchal lines, and laterally by the temporal lines. On the other hand, subperiosteal blood or
pus is limited to one bone because of the attachment of the periosteum to the sutural ligaments.

(Snell, Page 580)

Sensory Innervation and Trigeminal Neuralgia
The facial skin receives its sensory nerve supply from the three divisions of the trigeminal nerve.
Remember that a small area of skin over the angle of the jaw is supplied by the great auricular
nerve (C2 and 3). Trigeminal neuralgia is a relatively common condition in which the patient
experiences excruciating pain in the distribution of the mandibular or maxillary division, with
the ophthalmic division usually escaping. A physician should be able to map out accurately on a
patient’s face the distribution of each of the divisions of the trigeminal nerve.

(Snell, Page 581)

Facial Infections and Cavernous Sinus Thrombosis
The area of facial skin bounded by the nose, the eye, and the upper lip is a potentially dangerous
zone to have an infection. For example, a boil in this region can cause thrombosis of the facial
vein, with spread of organisms through the inferior ophthalmic veins to the cavernous sinus. The
resulting cavernous sinus thrombosis may be fatal unless adequately treated with antibiotics.

(Snell, Page 582)

Facial Muscle Paralysis
The facial muscles are innervated by the facial nerve. Damage to the facial nerve in the internal
acoustic meatus (by a tumor), in the middle ear (by infection or operation), in the facial nerve
canal (perineuritis, Bell’s palsy), or in the parotid gland (by a tumor) or caused by lacerations of
the face will cause distortion of the face, with drooping of the lower eyelid, and the angle of the
mouth will sag on the affected side. This is essentially a lower motor neuron lesion. An upper
motor neuron lesion (involvement of the pyramidal tracts) will leave the upper part of the face
normal because the neurons supplying this part of the face receive corticobulbar fibers from both
cerebral cortices.

CA3&4
NECK
Visibility of the External Jugular Vein
The external jugular vein is less obvious in children and women because their subcutaneous
tissue tends to be thicker than the tissue of men. In obese individuals, the vein may be difficult to
identify even when they are asked to hold their breath, which impedes the venous return to the
right side of the heart and distends the vein. The superficial veins of the neck tend to be enlarged
and often tortuous in professional singers because of prolonged periods of raised intrathoracic
pressure.

The External Jugular Vein as a Venous Manometer

The external jugular vein serves as a useful venous manometer. Normally, when the patient is
lying at a horizontal angle of 30°, the level of the blood in the external jugular veins reaches about
one third of the way up the neck. As the patient sits up, the blood level falls until it is no longer
visible behind the clavicle.

External Jugular Vein Catheterization

The external jugular vein can be used for catheterization, but the presence of valves or tortuosity
may make the passage of the catheter difficult. Because the right external jugular vein is in the
most direct line with the superior vena cava, it is the one most commonly used (Fig. 11.54). The
vein is catheterized about halfway between the level of the cricoid cartilage and the clavicle. The
passage of the catheter should be performed during inspiration when the valves are open.

(Snell, Page 591)

Clinical Identification of the Platysma
The platysma can be seen as a thin sheet of muscle just beneath the skin by having the patient
clench his or her jaws firmly. The muscle extends from the body of the mandible downward over
the clavicle onto the anterior chest wall.

Platysma Tone and Neck Incisions

In lacerations or surgical incisions in the neck, it is very important that the subcutaneous layer
with the platysma be carefully sutured, since the tone of the platysma can pull on the scar tissue,
resulting in broad, unsightly scars.

Platysma Innervation, Mouth Distortion, and Neck Incisions

The platysma muscle is innervated by the cervical branch of the facial nerve. This nerve emerges
from the lower end of the parotid gland and travels forward to the platysma; it then sometimes
crosses the lower border of the mandible to supply the depressor anguli oris muscle (see page
XXX). Skin lacerations over the mandible or upper part of the neck may distort the shape of the
mouth.

Sternocleidomastoid Muscle and Protection from Trauma

The sternocleidomastoid, a strong, thick muscle crossing the side of the neck, protects the
underlying soft structures from blunt trauma. Suicide attempts by cutting one’s throat often fail
because the individual first extends the neck before making several horizontal cuts with a knife.
Extension of the cervical part of the vertebral column and extension of the head at the
atlantooccipital joint cause the carotid sheath with its contained large blood vessels to slide
posteriorly beneath the sternocleidomastoid muscle. To achieve the desired result with the head
and neck fully extended, some individuals have to make several attempts and only succeed when
the larynx and the greater part of the sternocleidomastoid muscles have been severed. The
common sites for the wounds are immediately above and below the hyoid bone.

(Snell, Page 596)

Carotid Sinus Hypersensitivity
In cases of carotid sinus hypersensitivity, pressure on one or both carotid sinuses can cause
excessive slowing of the heart rate, a fall in blood pressure, and cerebral ischemia with fainting.

(Snell, Page 597)

Taking the Carotid Pulse
The bifurcation of the common carotid artery into the internal and external carotid arteries can
be easily palpated just beneath the anterior border of the sternocleidomastoid muscle at the level
of the superior border of the thyroid cartilage. This is a convenient site to take the carotid pulse.

(Snell, 599)
Arteriosclerosis of the Internal Carotid Artery
Extensive arteriosclerosis of the internal carotid artery in the neck can cause visual impairment
or blindness in the eye on the side of the lesion because of insufficient blood flow through the
retinal artery. Motor paralysis and sensory loss may also occur on the opposite side of the body
because of insufficient blood flow through the middle cerebral artery.

(Snell, 600)
Palpation and Compression of the Subclavian Artery in Patients with Upper Limb
Hemorrhage
In severe traumatic accidents to the upper limb involving laceration of the brachial or axillary
arteries, it is important to remember that the hemorrhage can be stopped by exerting strong
pressure downward and backward on the third part of the subclavian artery. The use of a blunt
object to exert the pressure is of great help, and the artery is compressed against the upper
surface of the 1st rib.

(Snell, 601)
Penetrating Wounds of the Internal Jugular Vein
The hemorrhage of low-pressure venous blood into the loose connective tissue beneath the
investing layer of deep cervical fascia may present as a large, slowly expanding hematoma. Air
embolism is a serious complication of a lacerated wall of the internal jugular vein. Because the
wall of this large vein contains little smooth muscle, its injury is not followed by contraction and
retraction (as occurs with arterial injuries). Moreover, the adventitia of the vein wall is attached
to the deep fascia of the carotid sheath, which hinders the collapse of the vein. Blind clamping of
the vein is prohibited because the vagus and hypoglossal nerves are in the vicinity.

Internal Jugular Vein Catheterization

The internal jugular vein is remarkably constant in position. It descends through the neck from a
point halfway between the tip of the mastoid process and the angle of the jaw to the
sternoclavicular joint. Above, it is overlapped by the anterior border of the sternocleidomastoid
muscle, and below, it is covered laterally by this muscle. Just above the sternoclavicular joint, the
vein lies beneath a skin depression between the sternal and clavicular heads of the
sternocleidomastoid muscle. In the posterior approach, the tip of the needle and the catheter are
introduced into the vein about two fingerbreadths above the clavicle at the posterior border of
the sternocleidomastoid muscle (Fig. 11.61). In the anterior approach, with the patient’s head
turned to the opposite side, the triangle formed by the sternal and clavicular heads of the
sternocleidomastoid muscle and the medial end of the clavicle are identified. A shallow skin
depression usually overlies the triangle. The needle and catheter are inserted into the vein at the
apex of the triangle in a caudal direction.

(Snell, 602)
Subclavian Vein Thrombosis
Spontaneous thrombosis of the subclavian and/or axillary veins occasionally occurs after
excessive and unaccustomed use of the arm at the shoulder joint. The close relationship of these
veins to the 1st rib and the clavicle and the possibility of repeated minor trauma from these
structures are probably factors in its development. Secondary thrombosis of subclavian and/or
axillary veins is a common complication of an indwelling venous catheter. Rarely, the condition
may follow a radical mastectomy with a block dis- section of the lymph nodes of the axilla.
Persistent pain, heaviness, or edema of the upper limb, especially after exercise, is a complication
of this condition.

Anatomy of Subclavian Vein Catheterization

The subclavian vein is located in the lower anterior corner of the posterior triangle of the neck
(Fig. 11.62), where it lies immediately posterior to the medial third of the clavicle.

Infraclavicular Approach
Since the subclavian vein lies close to the undersurface of the medial third of the clavicle (Fig.
11.62), this is a relatively safe site for catheterization. The vein is slightly more medially placed
on the left side than on the right side.

Anatomy of Procedure
The needle should be inserted through the skin just below the lower border of the clavicle at the
junction of the medial third and outer two thirds, coinciding with the posterior border of the
origin of the clavicular head of the sternocleidomastoid muscle on the upper border of the
clavicle (Fig. 11.62). The needle pierces the following structures:
o Skin
o Superficial fascia
o Pectoralis major muscle (clavicular head)
o Clavipectoral fascia and subclavius muscle
o Wall of subclavian vein

The needle is pointed upward and posteriorly toward the middle

of the suprasternal notch.
Anatomy of Problems
o Hitting the clavicle: The needle may be “walked” along the lower surface of the clavicle
until its posterior edge is reached.
o Hitting the 1st rib: The needle may hit the 1st rib, if the needle is pointed downward and
not upward.
o Hitting the subclavian artery: A pulsatile resistance and bright red blood flow indicate that
the needle has passed posterior to the scalenus anterior muscle and perforated the
subclavian artery.

Anatomy of Complications
o Pneumothorax: The needle may pierce the cervical dome of the pleura, permitting air to
enter the pleural cavity. This complication is more common in children, in whom the
pleural reflection is higher than in adults.
o Hemothorax: The catheter may pierce the posterior wall of the subclavian vein and the
pleura.
o Subclavian artery puncture: The needle pierces the wall of the artery during its insertion.
o Internal thoracic artery injury: Hemorrhage may occur into the superior mediastinum.
o Diaphragmatic paralysis: This occurs when the needle damages the phrenic nerve.
(Snell, Page 605)
Clinical Significance of the Cervical Lymph Nodes
Knowledge of the lymph drainage of an organ or region is of great clinical importance.
Examination of a patient may reveal an enlarged lymph node. It is the physician’s responsibility
to determine the cause and be knowledgeable about the area of the body that drains its lymph
into a particular node. For example, an enlarged submandibular node can be caused by a
pathologic condition in the scalp, the face, the maxillary sinus, or the tongue. An infected tooth of
the upper or lower jaw may be responsible. Often, a physician has to search systematically the
various areas known to drain into a node to discover the cause.

Examination of the Deep Cervical Lymph Nodes

Lymph nodes in the neck should be examined from behind the patient. The examination is made
easier by asking the patient to flex the neck slightly to reduce the tension of the muscles. The
groups of nodes should be examined in a definite order to avoid omitting any. After the
identification of enlarged lymph nodes, possible sites of infection or neoplastic growth should be
examined, including the face, scalp, tongue, mouth, tonsil, and pharynx.

(Snell, 619-620)
Injury to the Brachial Plexus
The roots and trunks of the brachial plexus occupy the anteroinferior angle of the posterior
triangle of the neck. Incomplete lesions can result from stab or bullet wounds, traction, or
pressure injuries. The clinical findings in Erb-Duchenne and Klumpke’s lesions are fully
described on page 429.

(Page 653-654)

CA5
ARM & CUBITAL FOSSA

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