Straddle Injuries in Female Pediatric Patients: a One Year Review
Straddle Injuries in Female Pediatric Patients: a One Year Review
Shaahin Dadjoo1, Julie C. Hakim MD2, Michelle Peterson1, Paulette I. Abbas MD1, Monica E. Lopez MD1, Mary L. Brandt MD1, Jennifer E. Dietrich MD, MSc2
Texas Children’s Hospital and the Michael E. DeBakey Department of Surgery1 and Departments of Obstetrics and Gynecology2, Baylor College of Medicine, Houston, TX
ABSTRACT:
INTRODUCTION: Straddle injuries consist of blunt and/or penetrating trauma to the urogenital area. The purpose of this study is to identify and evaluate treatment of girls <18 years of age with straddle injuries seen as outpatients.
METHODS: A retrospective review of all patients with straddle injuries seen at our institution in 2014 was performed. Exclusion criteria included males, admission >24 hours, or concern for sexual abuse. Data collected includes age, mechanism of injury, and management.
RESULTS: There were 69 girls who met inclusion criteria. The mean age was 6 (range 2–17). The main cause of injury was falling at home (n= 31), falling on a playground (n= 24), or a bicycle/scooter injury (n= 10). There were no penetrating injuries included. 68% (n=47) of patients were managed solely by an ED physician, and 32% (n=22) were seen by the pediatric gynecology and/or pediatric surgery service. 15/22 of these patients (22%) consult patients required primary repair of their laceration. 9/15 (60%) were treated in the OR and 6/15 (40%) were treated at the bedside. There were no urethral or rectal injuries. The gynecology service prescribed at least 1 topical medication in all patients. Patients treated solely by ED physicians were less likely to receive topical medical therapy than patients treated by the gynecology or surgical services (13/47, 28% vs. 22/22, 100% p<0.0001).
CONCLUSION: Straddle injuries most often occur following a fall at home. Significant pain and/or bleeding may require specialty consultation for a careful exam under anesthesia or conscious sedation. The minority of patients (22% in this series) required surgical repair.
Introduction
The straddle injury is a type of trauma caused by blunt trauma to the urogenital region. The prepubertal female genital tissues are delicate as the underlying capillary beds have yet to be estrogenized and are more friable compared to pubertal females.
[1] Even minor trauma to this region can be a cause of concern to healthcare providers and parents due to the nature of the anatomical, physiological, reproductive, and psychosocial factors related to its treatment and management.[2]
The presentation of straddle injuries varies and can be clinically seen as lacerations, hematomas, abrasions, contusions, bruising, dysuria, bleeding, or pain in the urogenital region following a blunt trauma. According to Landsman et al, perineal injuries account for only 0.2% of all injuries to children younger than 15 years seen in a pediatric emergency room, making the incidence of accidental straddle injuries rare.[3] Non-accidental injuries are most often associated with and raise concern for cases of sexual abuse.[4]
Light trauma to the urogenital region can cause profuse or excessive bleeding in the prepubescent female patient. [5] The common mechanisms for accidental straddle injury have been well discussed in the literature. Children who fall and straddle an object, hitting the urogenital region forcibly may sustain a straddle injury.[6] The mechanism of injury include falls at home onto armchairs or other household furniture, or falls onto other objects such as pool ledges.[7] Straddle injuries have also been associated with falls onto the horizontal handle bars or pedals of bicycles or scooters. Still other common accidents occur from the impact of monkey bars or horizontal metal bars found on a typical children’s playground. Some reports also include motor vehicle accidents as a mechanism for straddle injuries. Most straddle injuries are blunt in nature, however there are case reports of “penetrating” straddle injuries caused from high pressure water jets and injuries sustained at water parks on tube slides.[8]
The best method of examination has been a highly discussed topic in the literature. Often times these young girls have already encountered a potentially great psychological trauma and the stress of a physical exam performed by an anxious physician may lead to further psychological trauma.[9] Thus, it is important that before a physical exam takes place, a clinician has a plan to evaluate these patients sequentially, and methodically, with a calm and atraumatic approach.[10] This includes taking a thorough history. The clinician must validate the background story of the accident with the child and guardian separately for corroboration to determine if a case for sexual abuse exists.[11]
In a straddle injury the potential exists for injuries to the vagina, vulva, or urethra , and when injuries are severe enough, stenosis and fistula formation may occur. Depending on the nature of the injury, future normal reproductive, urologic, and psychosocial development may be compromised if patients are not examined effectively and thoroughly as well.[12] We aim to provide a review of our experience in the management of female pediatric patients with straddle injuries treated as outpatients at our institution. The purpose of our study is to evaluate and identify the type of accidental straddle injuries seen at Texas Children’s Hospital who were treated as outpatients and review their course of management.
Methods
Institutional review board approval was obtained from Baylor College of Medicine to conduct this retrospective study. All female patients, treated for a straddle injury as identified by ICD-9 codes for the following: contusions to the genitals, unspecified open wound of the vagina and vulva, other specified noninflammatory disorders of the vulva and perineum, open wounds of other and unspecified parts of genital organs (external) without mention of complication, open wounds of the vulva without mention of complication, and other injury of external genitals were included. To ensure all cases were captured, CPT codes for, colporrhaphy, suture of injury of vagina (nonobstetrical), pelvic examination under anesthesia (other than local), and colposcopy of the cervix including upper/adjacent vagina were also included in our search. The records retrieved were filtered to include only female gender, 17 years of age and younger, with admission to the hospital lasting less than 24 hours, and with no concern for sexual abuse. Each patient chart was then examined to review and record the patient’s age, the time of admission, the mechanism of injury, the management, and the treatment provided. Statistical significance was defined as P<= .05. Analysis was performed using simple averages or percentages and Fisher’s exact tests when appropriate.
We identified 69 patients who met our inclusion criteria. The mean age was 6 years old with a range of 2 to 17. There were 18 patients who were transferred to Texas Children’s Hospital for further evaluation from an offsite facility. The geosocial locations of the incidents of straddle injuries can be seen in Table 1. The main mechanism of injury was a fall at home with (n=31) nearly 45% of our patients falling into this category. A close second was due to falls at a school playground (n=24) with 35% of patients accounting for these sustained injuries. Lastly, we identified falls from a bicycle or scooter as the third most common mechanism of injury (n=10) accounting for about 15% of our patients’ injuries. Four patients (6%) were classified as “other;” these patients sustained straddle injuries in accidents including one motor vehicle accident and one accidental kick in the groin during dance [DS3] practice.
There were no penetrating injuries in this series. Injuries were most common in the summer months of May and June accounting for 26% of the injuries in a 12 month period. In our group, 68% (n=47) of the patients were managed solely by an emergency department physician, and 32% (n=21) were managed by the gynecology or general surgery services. We found that the labia is the most commonly injured site of the body, followed by the clitoral hood and perineum (Table 2). Many children sustained injuries in more than one anatomical location as well (Table 2.)
Anatomy of Injury
Conservative management was sufficient for a majority of our patients and utilized on 54 girls or 78.3% of our patient group. Conservative management consisted of sitz baths, ice packs, and no physical activity for 2–4 weeks following the accident.
About 1/3 of our patients (22/69) received a consult from the surgery or gynecology service. A consult was most often requested from the emergency department when pain and significant bleeding prevented an adequate examination of the patient. Fifteen patients (22%) received surgical repair of lacerations of the perineum, labia, or vaginal introits. All patients who received a surgical intervention were repaired primarily. Nine of the 15 were treated in the operating room under general anesthesia while six of the 15 were treated at the bedside in the emergency department under conscious sedation[JH4] [DS5] . Three patients received sedation at the bedside that were later transferred to the operating room for repair under general anesthesia. Only one patient that received conscious sedation was managed conservatively. We found that repair took place in the operating room when there was concern for urethral or perianal involvement in the straddle injury. In total, 25 patients in the cohort had suspected urethral damage, however, upon examination there were no urethral or rectal injuries found in this series of patients. Two patients were treated post-operatively with straight Foley catheters to relieve urinary retention and were dismissed the same day once they met discharge criteria. There were no other complications found in this cohort of patients and no patients were readmitted for further management.
In all patients consulted by a physician from the gynecology service, at least 1 medicated cream was prescribed. All patients seen by the gynecology service were treated with the use of at least one of the following: bacitracin, estrogen, or lidocaine. A great majority of the patients examined by pediatric gynecology, 71%, received 2 or more of these medicated creams in combination. The patients treated solely by the emergency room physicians were much less likely to receive a similar topical medical therapy than patients treated by the gynecological or surgical service (13/47, 28% vs 22/22, 100% p<0.0001).
Discussion
The straddle injuries we saw in our series were minor, and in this cohort, only 31.88% received gynecologic or surgical consultation. More so, only 21.74% received a surgical intervention which always consisted of a primary repair. Our study reveals that 42.9% of the surgical management interventions took place at the bedside under conscious sedation and 57.1% were examined under general anesthesia in the operating room due to inadequate examination at the emergency room bedside.
This study shows similar findings to data presented earlier in the literature with regard to the most common mechanisms[13], most common anatomical region injured[14], highest incidence based on time of year[15], and situations where a straddle injury may be sustained[16]. Previous studies suggest that more gynecological or surgical consultation may be required in the management of mild straddle injuries.[17] Our results support the findings of Spitzer et al suggesting that more cases of mild, acute straddle injuries may be managed conservatively in the emergency department without the need or the depletion of consult resources.
We found that the probability of patients being treated with topical medical ointment decreased greatly if a consult was not called by the emergency department physician. We cannot conclusively say if the prescription of medical ointments improved the outcomes or management of these patients who received such medication due to 34/69 or 49% of patients being lost to follow up. We will plan to answer such questions such as the true infection rate and the efficacy of topical medical ointment therapy in a future prospective studies. In addition to this we also plan to develop a management algorithm for emergency care providers providing clear guidelines on when it is best to manage a patient conservatively as discussed here or to call in for a specialty consultation.
The results of this study show that straddle injuries most often occur following a fall at home. The evidence provided in this study shows that injury is most commonly found to the labia and that urethral involvement is often over suspected. Finally, we found that significant pain and/or bleeding may require specialty intervention for further management.
Acknowledgements
Dr. William and Susan Pokorny, Charlene Barclay, Dr. Stephanie M. Cruz, Dr. Patricio Lau, Dr. Yangyang Yu, Dr. Timothy C. Lee, Dr. Alireza Shamshirsaz, Dr. Nisa Dadjoo
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