In children under 2 with scalp bite punctures/avulsion, CT head is often the next step to rule out skull fracture or intracranial penetration.
For scalp bite wounds in children <2 years where deeper injury is hard to assess, head CT is the exam-favored next step to rule out skull fracture/penetration before closure.
An 18-month-old girl is brought in to see you by her parents after she was attacked by a neighbor’s dog and sustained a bite wound to the scalp. On examination, she is awake and crying, with partial avulsion of the scalp and puncture wounds that are not actively bleeding. Her tetanus immunization is up to date
Which of the following is the best NEXT step in the management of this patient's condition?
Answer Options:
This is a young child (<2 years) with a scalp dog bite involving puncture wounds and partial avulsion. In this age group, skull penetration/open or depressed fracture and intracranial injury can be present despite a deceptively limited external exam, because soft tissues and hair obscure assessment and the calvarium is thinner. The management priority is therefore to exclude open/depressed skull fracture or penetrating injury before proceeding with closure or bedside-only wound management.
Contemporary head injury guidance (e.g., NICE Head Injury guideline NG232, 2023) supports urgent CT imaging in children when there is concern for suspected open or depressed skull fracture or penetrating injury. Similarly, ACR Appropriateness Criteria: Head Trauma—Child (2020) supports CT when there is clinical suspicion of skull fracture/penetration. While dog bites aren’t the classic “blunt head injury” population, the same principle applies: if penetration/open fracture is on the table, image first.
After CT excludes intracranial extension or skull fracture, the next steps typically include copious irrigation, selective debridement, consideration of primary closure for cosmetically important facial/scalp wounds when appropriate, antibiotic prophylaxis (commonly amoxicillin-clavulanate), and surgical consultation if deeper injury is present.
| Option | What It Tests / Implies | Why It’s Wrong Here |
|---|---|---|
| irrigation and primary closure of the wounds | Standard dog-bite wound care and cosmesis | Premature before ruling out **open/depressed fracture or intracranial penetration** in a high-risk age/mechanism scenario. |
| computed tomography (CT) of the head | Prioritizing evaluation for skull fracture/penetration | Correct: CT is the best next step when deeper injury can’t be safely excluded on exam in a toddler with puncture/avulsion scalp bite. |
| irrigation and debridement of the wounds | Basic wound care | Necessary eventually, but still secondary to excluding intracranial injury when penetration/fracture is plausible. |
| transcranial ultrasonography | Non-ionizing imaging idea for infants | Not the standard test to evaluate **skull fracture/penetrating intracranial injury** in this setting; CT is faster and definitive for bone/air/foreign body concerns. |
In children **<2 years** with **scalp bite punctures/avulsion**, think **occult skull fracture/penetration**—**CT head before closure** is the exam-safe move.
The stem tempts you into “dog bite = irrigate + antibiotics + close (sometimes)” thinking. Boards often invert the order: when the wound location/mechanism suggests **hidden deep injury** (here, infant scalp punctures/avulsion), the “next step” is **diagnostic confirmation (CT)** before you do the satisfying procedural choices.
A 14-month-old has two small puncture wounds to the parietal scalp after a dog bite. He is consolable, neurologically normal, and the exam is limited by swelling and hair. Next best step?
A 20-month-old is bitten on the scalp. You palpate a step-off with visible bone. Best next step?
A 6-year-old sustains a superficial scalp laceration from a vaccinated family dog. No punctures, no avulsion, normal neuro exam, wound fully visualized to galea without deeper extension. Next step?
A 2-year-old has a dog bite to the scalp. CT is negative for fracture/penetration, and the wound will be closed. Best prophylactic antibiotic?
A toddler is bitten on the scalp by a stray dog that cannot be captured for observation. Tetanus is up to date. Next step regarding rabies?
How would your management differ between (1) a fully visualized superficial scalp laceration in a 7-year-old and (2) puncture scalp wounds with swelling in a 14-month-old—specifically regarding imaging, closure strategy, and consultation?
A1: Exams like ABEM/EM boards expect you to recognize that infants/toddlers have thinner calvaria and less reliable exams, so puncture bites can hide skull fracture/penetration—CT becomes the safer next step.
A2: Not when there’s plausible penetrating injury/open fracture risk. Observation strategies are primarily for low-risk blunt head trauma, not unclear-depth puncture wounds.
A3: While ultrasound may detect some skull fractures in select settings, boards typically consider CT the definitive test when ruling out open/depressed fracture or intracranial injury is essential.
A4: Often yes when the wound is clean/irrigated and there’s no deep-structure involvement; the scalp is highly vascular and tends to heal well—this is commonly tested as “closure can be considered” once deeper injury is excluded.
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