Scalp and Skull Injuries Practice Questions

25 multiple-choice questions on Scalp and skull injuries for paramedic and EMT students, from Chapter 35 (Head and Spine Trauma). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. Scalp lacerations tend to bleed heavily mainly because the scalp:

   1. A. Is very vascular and its vessels constrict poorly
   2. B. Has thin skin that does not support clot formation
   3. C. Is drained by arteries rather than by large veins
   4. D. Lacks platelets in its capillary beds after injury
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   Answer: A. Is very vascular and its vessels constrict poorly

   The scalp has a rich blood supply, and its vessels are held open by the dense connective tissue around them, so they do not retract and constrict. The skin is actually thick, and clotting is normal.

2. In a scalp avulsion, the scalp usually separates from the skull through the layer of:

   1. A. Galea aponeurotica tendon
   2. B. Dense subcutaneous fatty tissue
   3. C. Outer table of the skull
   4. D. Loose areolar connective tissue
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   Answer: D. Loose areolar connective tissue

   Beneath the galea lies a loose areolar layer that lets the scalp slide, and avulsions peel away along this plane. Emissary veins cross it, so infection there can spread inward to the cranial cavity.

3. A 9-year-old fell off a bike and has a 5-cm scalp laceration that is bleeding briskly. The skull beneath feels intact. The best way to control the bleeding is:

   1. A. A tourniquet placed snugly around the forehead
   2. B. Loose gauze so that blood can drain from the wound
   3. C. Firm direct pressure with a bulky sterile dressing
   4. D. Packing the wound with hemostatic gauze to the bone
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   Answer: C. Firm direct pressure with a bulky sterile dressing

   When the skull is intact, firm direct pressure controls nearly all scalp bleeding. A loose dressing lets bleeding continue, which matters in a child, who has little blood volume to spare.

4. A man struck over the left side of the head has a depressed skull fracture, and his right arm and face begin twitching. This most likely reflects:

   1. A. Irritation of the brain beneath it
   2. B. Injury to the right cerebral cortex
   3. C. A cervical cord injury from the blow
   4. D. Low blood sugar from skipping a meal
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   Answer: A. Irritation of the brain beneath it

   A depressed fracture can bruise or irritate the underlying motor cortex, causing focal seizures or weakness on the opposite side of the body. Protect the airway, give a benzodiazepine for ongoing seizure per protocol, avoid pressure on the fracture, and transport to a neurosurgical center. Because each hemisphere controls the opposite side, right-sided twitching points to the left cortex under the fracture, and a cord injury causes weakness or numbness rather than focal twitching of the face and arm. Hypoglycemia should be checked, but the focal pattern fits the injury.

5. A 40-year-old driver has a large scalp laceration that is now controlled. His BP is 78/50 mm Hg and HR is 134 beats/min. You should:

   1. A. Attribute the shock to the scalp blood loss
   2. B. Search for another source of hemorrhage
   3. C. Treat it as neurogenic shock from a head injury
   4. D. Expect the blood pressure to recover on its own
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   Answer: B. Search for another source of hemorrhage

   Scalp bleeding can contribute, but shock in an adult with a head wound should prompt a search for chest, abdominal, pelvic, or long-bone hemorrhage. An isolated head injury rarely causes hypotension in adults until the terminal stage.

6. The most common type of skull fracture is:

   1. A. Depressed
   2. B. Basilar
   3. C. Comminuted open
   4. D. Linear
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   Answer: D. Linear

   About 80% of skull fractures are nondisplaced linear fractures, which usually cannot be seen or felt in the field. Depressed and basilar fractures are less common but more often linked to underlying brain injury.

7. A depressed skull fracture is most likely to result from:

   1. A. A fall onto the buttocks from standing height
   2. B. A broad, low-energy impact on the forehead
   3. C. A blow from a small object with high energy
   4. D. Rapid deceleration without any head impact
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   Answer: C. A blow from a small object with high energy

   Concentrated force from a hammer, bat, or corner drives a fragment of bone inward. A broad, low-energy blow spreads force over a wide area and tends to cause linear fractures or none at all.

8. After a blow to the side of the head, a patient has blood behind the ear, hearing loss on that side, and his face droops on the same side. These findings suggest a fracture of the:

   1. A. Nasal bone
   2. B. Temporal bone
   3. C. Frontal bone
   4. D. Mandible bone
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   Answer: B. Temporal bone

   The temporal bone contains the middle and inner ear and the facial nerve canal, so a temporal (basilar) fracture can cause hearing loss, ear bleeding or CSF leak, Battle sign, and facial nerve palsy. Nasal, frontal, and mandible fractures do not cause this combination.

9. Ecchymosis over the mastoid process behind the ear, known as Battle sign, indicates a fracture involving the:

   1. A. Frontal bone above the orbits
   2. B. Parietal bone at the vertex
   3. C. Temporal bone at the skull base
   4. D. Occipital bone near the inion
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   Answer: C. Temporal bone at the skull base

   The mastoid is part of the temporal bone, and blood from a fracture of the middle cranial fossa collects there. Battle sign is a key finding of basilar skull fracture.

10. Thirty minutes after a fall, a 70-year-old has no raccoon eyes or Battle sign. What is the correct interpretation?

    1. A. A basilar skull fracture is ruled out
    2. B. The fracture is most likely a linear one
    3. C. Their absence lowers the need for transport
    4. D. The signs often take hours to appear
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    Answer: D. The signs often take hours to appear

    Periorbital and mastoid bruising usually develop several hours after injury, so their absence on scene does not exclude a basilar fracture. Relying on them early leads to undertriage.

11. After a head injury, a patient has clear, watery fluid dripping from one nostril that increases when he leans his head forward. This is most suggestive of:

    1. A. A CSF leak from a skull base fracture
    2. B. Mucus from a broken nasal bone
    3. C. Tears draining from an orbital fracture
    4. D. Fluid from a maxillary sinus fracture
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    Answer: A. A CSF leak from a skull base fracture

    Clear, watery nasal drainage that increases with leaning forward after head trauma is typical of CSF rhinorrhea from a fracture of the anterior skull base. Let it drain onto loose gauze, avoid nasal devices, and transport. Nasal and maxillary sinus fractures cause bleeding or bloody mucus rather than a steady clear drip, and tears from an eye injury do not produce a flow that increases when the head is tipped forward.

12. A man with thick hair was struck on the head and is bleeding, but you cannot see a wound. The best way to find the source is to:

    1. A. Wrap the whole head in a pressure bandage
    2. B. Part the hair and feel with gloved hands
    3. C. Look for blood draining from the ears
    4. D. Wait until the bleeding comes to a stop
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    Answer: B. Part the hair and feel with gloved hands

    Hair hides scalp wounds and skull deformities. Systematically part the hair and palpate gently with gloved hands, checking your gloves for blood and feeling for step-offs, before applying direct pressure. A circumferential bandage applied before the wound is found may not press on the bleeding point, blood from the ears suggests a skull base fracture rather than locating the scalp wound, and waiting allows continued blood loss.

13. A 4-month-old with a head injury has an open anterior fontanelle. Compared with an adult, the infant may show signs of rising ICP later because:

    1. A. Their brains are less prone to swelling
    2. B. The infant skull is thicker than an adult's
    3. C. The fontanelle seals as pressure rises
    4. D. The open skull can expand somewhat
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    Answer: D. The open skull can expand somewhat

    Open sutures and fontanelles let the infant skull expand a little, so ICP may rise more slowly and classic signs may appear late; a bulging fontanelle, irritability, vomiting, and poor feeding may be early clues. Young children are, if anything, more prone to diffuse brain swelling, the infant skull is thinner than an adult's, and the fontanelle does not close in response to pressure; it bulges.

14. The main delayed complication of a basilar skull fracture with a CSF leak is:

    1. A. Meningitis
    2. B. Hypocalcemia
    3. C. Pulmonary embolism
    4. D. Diabetes mellitus
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    Answer: A. Meningitis

    A fracture that opens the dura to the sinuses or middle ear gives bacteria a path to the meninges. That is why nothing should be inserted into the nose or ear and why these patients are watched for fever and headache.

15. A 32-year-old with a gunshot wound to the head has exposed brain tissue. Appropriate care of the wound is to:

    1. A. Apply firm pressure to stop the bleeding
    2. B. Push the brain tissue back into the skull
    3. C. Cover it lightly with a sterile dressing
    4. D. Leave the wound open to allow drainage
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    Answer: C. Cover it lightly with a sterile dressing

    Cover the exposed brain loosely to protect it from contamination without compressing it. Direct pressure is the usual reflex for bleeding, but here it can push bone and brain inward and worsen the injury.

16. A 19-year-old has a screwdriver impaled in the side of his skull. He is responsive to pain and breathing adequately. You should:

    1. A. Remove it carefully to allow full assessment of the wound
    2. B. Stabilize the object in place with bulky dressings
    3. C. Shorten it with cutting tools before transport
    4. D. Pull it out only if bleeding becomes severe
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    Answer: B. Stabilize the object in place with bulky dressings

    Impaled objects in the skull are left for surgeons, because removal can cause uncontrolled bleeding and further brain injury. Cutting or moving the object transmits force to the brain.

17. In an infant, a bulging anterior fontanelle when the baby is quiet and upright suggests:

    1. A. Dehydration from poor feeding
    2. B. Normal closure of the sutures
    3. C. Low cerebrospinal fluid volume
    4. D. Increased intracranial pressure
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    Answer: D. Increased intracranial pressure

    The open fontanelle reflects pressure inside the skull, so bulging in a calm, upright infant suggests raised ICP. A sunken fontanelle suggests dehydration, the opposite finding.

18. A blow to the temple is especially dangerous because a fracture of the thin temporal bone can tear the:

    1. A. Middle meningeal artery
    2. B. Superior sagittal sinus
    3. C. Internal carotid artery
    4. D. Bridging cortical veins
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    Answer: A. Middle meningeal artery

    The middle meningeal artery runs in a groove on the inner temporal bone, and its laceration causes an epidural hematoma. Bridging veins are the source of subdural hematomas, not epidurals.

19. A 30-year-old intubated after a fall has raccoon eyes and clear fluid from the nose, and his stomach is distended. To decompress the stomach you should insert:

    1. A. A nasogastric tube
    2. B. No gastric tube at all
    3. C. An orogastric tube
    4. D. Manual epigastric pressure
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    Answer: C. An orogastric tube

    With signs of a basilar skull fracture, a nasogastric tube can pass through the fractured cribriform plate into the brain, so the tube goes through the mouth. The nasal route is the habitual choice, which makes it the tempting wrong answer. Leaving the stomach distended raises aspiration risk and limits ventilation, and pressing on the epigastrium can push gastric contents upward without decompressing the stomach.

20. When palpating the skull of a trauma patient, you should:

    1. A. Press firmly to locate areas of instability
    2. B. Avoid touching the head if there is bleeding
    3. C. Feel gently for deformity, step-off, or crepitus
    4. D. Palpate only the areas that the patient says are painful
    Show answer

    Answer: C. Feel gently for deformity, step-off, or crepitus

    Gentle palpation finds depressions, crepitus, and lacerations hidden by hair without moving fragments. Firm pressure risks displacing a depressed fracture into the brain.

21. Brain tissue is often bruised over the base of the skull during deceleration because the inner skull base:

    1. A. Has rough, irregular bony ridges
    2. B. Is lined with thick, firm padding
    3. C. Is filled with air-containing sinuses
    4. D. Moves independently of the vault
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    Answer: A. Has rough, irregular bony ridges

    The floor of the anterior and middle cranial fossae is ridged, so the frontal and temporal lobes are scraped and contused as the brain slides. The sinuses lie outside the cranial cavity and do not contact the brain.

22. A 64-year-old woman tripped and hit her head 2 days ago. Her daughter calls EMS because she now has bruising behind her left ear and a worsening headache. You should suspect:

    1. A. A simple scalp contusion
    2. B. A basilar skull fracture
    3. C. An isolated ear infection
    4. D. A tension-type headache
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    Answer: B. A basilar skull fracture

    Battle sign appearing a day or more after head trauma is classic for a basilar skull fracture, and a new or worsening headache raises concern for intracranial injury. She needs transport for CT.

23. An open skull fracture is defined by:

    1. A. A fracture line wider than 5 mm
    2. B. Bone fragments driven inward into the brain
    3. C. A fracture involving the skull base
    4. D. A break in the scalp over the fracture
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    Answer: D. A break in the scalp over the fracture

    An open fracture communicates with the outside through a scalp wound, creating a route for infection. Depressed fragments define a depressed fracture, which may be open or closed.

24. A 6-month-old has a large, boggy scalp swelling after a fall and is pale with a heart rate of 190 beats/min. The most important concern is:

    1. A. Dehydration from reduced oral intake
    2. B. Hypovolemia from bleeding into the scalp
    3. C. Hypothermia from exposure at the scene
    4. D. Normal agitation after a minor fall
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    Answer: B. Hypovolemia from bleeding into the scalp

    Infants have a small blood volume, and bleeding into the scalp or skull can produce shock that it would not cause in an adult. Pallor and marked tachycardia in this setting call for urgent transport.

25. Which finding most strongly suggests a skull fracture in a patient with a scalp laceration?

    1. A. Bleeding that soaks two dressings
    2. B. A laceration longer than 5 cm
    3. C. Swelling of the surrounding scalp
    4. D. A visible step-off in the bone
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    Answer: D. A visible step-off in the bone

    A palpable or visible step-off reflects displaced bone. Heavy bleeding, wound length, and swelling are expected with scalp wounds and do not indicate a fracture by themselves.