Straddle injuries


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    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

  • Background to condition:  

    • Though most injuries are minor, genital injuries in children often cause great anxiety because of the location and concern for future gynaecological and sexual development. 
    • The unestrogenised pre-pubertal genital tissues are friable (with excellent blood flow) and lack distensibility and therefore, even minor trauma can cause injury and bleeding which may appear extensive. 
    • Though urogenital trauma frequently raises the question of sexual abuse 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 should include:

    • Mechanism of injury
    • Timing and setting of injury
    • First aid provided
    • Ability to pass urine and faeces
    • Other injuries
    • Witnesses

    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 Victoria Forensic Paediatric Medical Service (VFPMS) on 1300 66 11 42 for advice prior to performing your examination.

    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 clockface can often be used to describe the location of the injury (see diagram below). 

     Straddle Inj

    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? 

    Acute management:  

    General principles of care 

    If suspicious of non-accidental injury contact the Victoria Forensic Paediatric Medical Service (VFPMS) on 1300 66 11 42 for advice/assessment. 

    • 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

    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 service


    Discharge requirements:

    • Minor injury and able to pass urine 

    Consider consultation with local paediatric or gynaecology team: 

    • Children with non-minor injuries 

    When to consider transfer to tertiary centre: 

    • Child requiring care beyond the comfort level of the hospital 

      For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

    Parent information sheet: link to handout 

      Information specific to RCH

    Discuss non-minor injuries with Gynaecology fellow/registrar on-call