Injuries happen. Big injuries and small injuries occur at rates that continually hone and refine our skills and, potentially, deplete our stores of ketamine. We have covered a wide variety of injuries in the past from head to finger and from neck to knee. Certainly, every body part deserves specific attention, but there is one region that garners particular attention from patients, parents, and providers alike: genital trauma. Let us take a moment to review a common cause of genital trauma, the Straddle Injury.

Straddle Injury: Basics

• Straddle injury occurs when a child strikes the perineal area on an object with the force generated by the weight of his/her body.
• Soft tissues become crushed between the object and the bony pelvis.
• Common mechanisms (moments where Gravity wins once again): [Sinclair, 2011]
  • Bicycle’s center bar
  • Playground equipment (ex, rungs of ladder, balance beam)
  • Side of bath tub
  • Across furniture (ex, arm of chair or couch)
  • Edge of pool
• Straddle injuries affect both sexes (obviously, Gravity doesn’t discriminate)
  • Girls are more likely to have bleeding, although injuries to the hymen and vagina are rare.
  • Boys usually present with pain rather than bleeding and are at greater risk for urethral injury.

Straddle Injury: Evaluation

• The patient age/weight are important considerations [Sinclair, 2011]
  • Older/larger children may have more mass and generate more force.
  • Toddlers and preschool-aged kids most often have non-penetrating injuries to the anterior and exterior perineum and/or genitalia.
• This was a trauma and mechanism matters.
  • Evaluate for other traumatic injuries!
  • The object struck and the manner it was struck may increase or decrease the concern for possible penetrating trauma.
    • ~5% have penetrating injuries. [Spitzer, 2008]
    • While rare, if concern for penetrating injury, must consider injuries that extend above the pelvic floor as well.
  • Identification of the anatomy is imperative.
    • This seems straight forward, but some injuries may distort landmarks with hematoma formation, bruising, and/or lacerations.
    • In girls, it is important to be able to identify and ascertain whether there is injury to:
      • Labia major/minor
      • Urethra
      • Clitoris
      • Hymen
      • Vagina
      • Rectum
    • In boys, it is equally important to evaluate the penis, scrotum, and testicles.

Straddle Injury: Don’t be Cruel

• Obviously this is a sensitive region and needs to be examined with great care.
  • Involve child life early (if you don’t have child life, get child life!).
  • Try to limit the number of examinations.
    • This is not the case to have the student see, then the resident see, then the attending see… then the consultant.
    • Coordinate examinations and if the history warrants it, consult Gynecology early to join you for the examination.
  • Examine the genitals and perineum last.
    • Helps to ensure you don’t overlook other injuries.
    • Helps to develop trust between providers and patient/family.
  • Assess need for sedation early and consider multiple approaches.
    • Will oral or intranasal midazolam be all that is required?
    • Will nitrous be useful?
    • Do you anticipate more significant injuries that may need repair – will ketamine be preferable?
    • Some children will require Gynecology to take them to the OR for evaluation and possible repair.

Straddle Injury: Basic Therapy

• Most bleeding can be stopped with gentle, constant pressure.
• Topical anesthetic may help.
• Clean the region gently with warm water.
• Most lacerations will heal without primary closure. [Sinclair, 2011]
• Ensure child is able to urinate!
• Sitz baths at home may assist with keeping region clean and help with discomfort that occurs during urination.
• Follow-up for uncomplicated injuries is still reasonable to occur within 2-4 days.

Straddle Injury: When to Call for Help

• Most minor lacerations do not require repair.
• There are occasions, however, when Gynecology / Urology needs to be involved: [Sinclair, 2011]
  • Unable to urinate / Concern for injury to the urerthra
    • Injury angles toward the anterior vaginal wall (higher incidence of urethra injury)
  • Hymen is injured
    • Hymenal injuries indicate the potential for deeper injury.
  • Anatomy is too distorted to identify structures or is misaligned

Moral of the Morsel

• Straddle injuries will occur, so be prepared for them.
• Don’t be cruel!
  • Limit examinations
  • Use analgesia and/or sedation
• Most minor injuries will heal well without intervention
• Urine is Gold! – Make sure the child can pee.
• Know when to call for help!

References