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Straddle injuries

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  • See also

    Acute Scrotal Pain or Swelling

    Key Points 

    1. Most injuries are minor
    2. Consider analgesia +/- procedural sedation early for examination
    3. Although infrequently associated with non-accidental injury, if suspected, consult a senior doctor and consider advice from the forensic paediatric medical service

    Background

    Although most straddle injuries are minor, genital injuries in children often cause great anxiety because of the location and concern for future gynaecological and sexual development. The unoestrogenised pre-pubertal female genital tissues are friable (with excellent blood flow) and lack distensibility. Therefore, even minor trauma can cause injury and bleeding which may appear extensive. 

    Urogenital trauma frequently raises the question of non-accidental injury, however it is uncommonly associated with it. It is important to be able to correlate the history of the injury with physical findings on examination. Thorough documentation and appropriate referral of cases suspicious for abuse is a priority of care.

    Assessment

    History

    • Mechanism of injury
    • Timing and setting of injury
    • First aid provided
    • Inability to pass urine and faeces
    • Other injuries
    • Witnesses
    • Consider if injury is consistent with history, is there a suspicion of non-accidental injury?

    Examination

    General assessment of the child looking for evidence of other injuries.

    Examination should be performed only ONCE, therefore consider early involvement of a senior clinician.  If suspicious of non-accidental injury contact the local forensic paediatric medical service.

    Examination is usually performed in the supine frog-legged position. Explanation and gentle handling of the child is important. Consider analgesia +/- procedural sedation.

    Document a detailed description of the injury. A clock face can often be used to describe the location of the injury (see diagram below).


    Features to consider on examination:

    • Can the posterior or upper limit of the wound be seen? If not, examination under anaesthaesia should be considered.
    • Is there an expanding haematoma?
    • Is there any anal or rectal involvement? 

    Management

    General principles of care

    • If suspicious of non-accidental injury contact the local forensic paediatric medical service
    • Compression of bleeding with a clean dressing pad
    • If there is significant vaginal bleeding in older adolescents, the vagina can be packed with a tampon or gauze
    • Use ice packs to reduce bleeding and swelling (avoid directly overlying the clitoris)
    • Irrigate the area with warm water
    • Review tetanus status

    Severity of Injury

    Treatment

    Follow up / Consultation

    Minor

    Bleeding is minor or has stopped and the child can void spontaneously

    Salt water baths for comfort

    Topical anaesthetic cream or barrier cream to reduce local pain on micturation

    Reduction in strenuous activity for 24 hours to prevent re-injury

    Simple analgesia

    GP

    Non-minor

    Ongoing bleeding, laceration borders not visualised, labia minora tear, unable to void, clinician concern

    Management as above
     
    Consider urethral catheter if unable to void e.g. in the presence of a large vulval hematoma

    Local paediatric team
     
    Local Gynaecology or Surgical service

    Consider consultation with local paediatric team when:

    • Child with non-minor injury 
    • Child unable to pass urine
    • Suspected non-accidental injury for forensic examination

    Consider transfer when:

    Child requiring care beyond the comfort level of the local hospital 

    For emergency advice and paediatric or neonatal ICU transfers information, see Retrieval Services

    Consider discharge when:

    Minor injury and able to pass urine 

    Parent information

    Straddle injuries

    Forensic Paediatric Medical Services

    NSW The Child Protection Helpline 132 111
    Child Protection Units:

    • The Children’s Hospital at Westmead 02 9845 2434 / AH 02 9845 0000
    • Sydney Children’s Hospital, Randwick 02 9382 1412 / AH 02 9382 1111

    Queensland’s Child Protection and Forensic Medical Service
    07 3068 2659 or 07 3068 2660 / AH 07 3068 1111

    Victorian Forensic Paediatric Medical Service (VFPMS) 1300 66 11 42

     

    Last Updated May 2020

  • Reference List

    1. Bond GR, Dowd MD, Landsman I et al. Unintentional Perineal Injury in Prepubescent Girls: A Multicenter, Prospective Report of 56 Girls, Paediatrics 1995 May, 95 (5) 628-631
    2. Dowlut-McElroy T, Higgins J, Williams K et al. Patterns of Treatment of Accidental Genital Trauma in Girls. J Pediatr Adolesc Gynecol 2018 Feb;31(1):19-22
    3. Mendez DR., Straddle injuries in children: Evaluation and management, UpToDate, accessed October 2018
    4. Roland D, Lewis G, Rowlands R et al. Female perineal injuries in children and adolescents presenting to a paediatric emergency department. Emerg Med J 2016;33:73-75
    5. Spitzer RF, Kives S, Caccia N et al. Retrospective review of unintentional female genital trauma at a pediatric referral centre. Pediatr Emerg Care 2008 Dec;24(12):831-5