Straddle Injury

Get CMEStraddle Injury

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!



Spitzer RF1, Kives S, Caccia N, Ornstein M, Goia C, Allen LM. Retrospective review of unintentional female genital trauma at a pediatric referral center. Pediatr Emerg Care. 2008 Dec;24(12):831-5. PMID: 19050662. [PubMed] [Read by QxMD]

Sean M. Fox
Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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  1. My 8 year old daughter slid on a water slide in school. Slide was steep with nothing to hold on the sides, and water in the pool was quite low so she bumped on the pool floor quite hard. She noticed some blood when she changed her swimming costume. It was dark when i saw it.
    Next day again she had bleeding from vagina. Like period. It was red fresh blood. So I took her to the doctor, after examining her she said she cant see any cut or bruse, and since theres no pain so it cant be internal injury and most probably she is having her periods. I was flabbergasted. She’s just 8 years old! With no hair on pubic area or underarm. Her figure is still childish so where does this period come from. Can u pls enlighten me what do u think it is? Could it be internal organ injury? I hope not.

  2. Does this sound like the right thing to do? My 3.5 year old daughter fell on her foot today while walking, and got up, crying in pain, while holding her crotch.

    She screamed that her vagina hurts but was able to sit comfortably and play later.

    However, when I checked her underwear two times today there was minor spotting, a few drops of blood, and she cried from burning/pain while peeing. The last time was four hours after the injury. She can pee and only seems to be in pain when she does, so we are assuming a minor abrasion/bruise but there is no evidence of injury. We will keep an eye on it over night and if it still hurts when she pees tomorrow, will take her to her doctor.

    • Hi, same thing happened to my niece. Could you please share what happened after to your daughter?

    • what did it end up being my daughter has same symptoms after a fall at gym camp she was complaining about her toes when I picked her up and pinky was almost black and blue on part on 2nd day. she didnt complain to anybody but said she let out a yelp and admitted she didnt want to have to stop playing.. i wasnt there because she was at a camp so didnt she how fell went but said it was off high end of balance beam 3-4 feet high..that night when unpacking her bag saw a pen mark size dot on bathingsuit . then next day saw a drop of blood in her urine drip on toilet seat..additionally she wet the bed that night several times and had urgent and frequent urniation with burning/pain while urinating at first but gone away since fall and now increased to blood in urine ? sound same?

  3. For boys, they can still bleed and it still be a minor injury right..? And if so when should the bleeding stop?

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