The interpretation of urogenital findings in children with straddle injuries

The Interpretation

of Urogenital Findings Straddle Injuries

in Children

With

By M. Denise Dowd, Laura Fitzmaurice, Jane F. Knapp, and David Mooney Kansas

City, Missouri

0 Because urogenital trauma frequently raises the question of sexual abuse, it is important to be able to relate the mechanism of injury to expected examination findings. This study was undertaken to characterize the trauma that results from straddling and correlate such injuries with the history, examination, and patient characteristics. The charts of 100 patients examined in an urban pediatric emergency department were reviewed; their conditions met the criteria of straddle injury-a blow to the perineum as a result of falling or striking a surface or an object with the force of one’s own body weight. Ages ranged from 9 to 187 months (mean, 77.9; median, 67.2); 72% were female. Most injuries were minor lacerations and abrasions of the genitalia. Eleven percent had injury to the posterior fourchette. Hymenal and vaginal injuries were primarily caused by penetrating mechanisms. Five patients who presented with a history of straddling subsequently received the diagnosis of sexual assault based on disclosure by the patient or a witness and inconsistency of physical findings. There were no urethral or perianal injuries resulting from nonpenetrating straddle mechanisms. Straddle injuries include a variety of mostly minor urogenital injuries. Perianal, hymenal. or vaginal trauma suggests a penetrating mechanism, either unintentional or from sexual assault. An investigation for sexual assault should be initiated in the following cases: infants younger than 9 months of age; perianal, hymenal, or vaginal injury; extensive or severe injury; concurrent nonurogenital injuries; and whenever there is lack of correlation between history and physical findings. Copyright o 1994 by W.B. 98unders Comp8ny

the question of sexual abuse. With the dramatic increase in the number of reported cases of sexually abused children, health care providers are frequently asked if physical evidence supports the diagnosis of sexual misconduct. A corollary is: can the given physical findings be explained by unintentional trauma such as a straddling mechanism? These questions often cannot be definitively answered on the basis of examination alone because data on what constitutes “normal” prepubescent genital anatomy are lacking. There have been many studies that characterize the physical findings of prepubescent genitalia who are victims of sexual assau1t.s To date few studies have documented the physical findings of nonabused children.Y.“’ This study was undertaken to determine which physical findings occur in children who sustain straddle injury and to characterize these findings in relation to epidemiologic variables, history, and outcome. MATERIALS AND METHODS Data were retrospectively Codes,

collected

by a single reviewer

Children’s

Mercy Hospital,

Straddle

injury; urogenital

trauma;

sexual

were

TRADDLE

injuries in children are a common in the emergency department (ED). They occur when a child, during bicycle riding or climbing, falls and straddles an object thereby striking and injuring the urogenital area. This mechanism compresses the soft tissues against the bony margins of the pelvic outlet, thereby causing injury. Although common, little more than anecdotal information exists on straddle injuries, and to date no review has been undertaken. In a review of all types of urogenital trauma in females, straddle mechanisms were the cause of injury for seven of 33 patients admitted to a surgical service.’ Other case reports have documented injuries caused by somewhat unusual straddling-type mechanisms: break dancing,? riding banana-seat bicycles,” and go-cart injuries.” Straddle mechanisms are often mentioned in the urology literature as a cause of traumatic disruption of the urethra in male patients.5.’ Urogenital trauma can, and frequently does, raise JournalofPediafr/c Surgery, Vol 29, No

1

(January), 1994: pp 7-10

ED

reviewed.

Patients

injury and a history of straddling.

included

if they

had

tertiary

7, IYYI were

a diagnosis

Straddle

as a result of

of the

for descriptive

at our urban pediatric

urogenital

ICD9

charts

17. 1087 and November

defined as a blow to the perineum

S type of trauma treated

from

Kansas City, Missouri.

analysis. Charts of patients treated care facility between October

INDEX WORDS: abuse.

using the appropriate

(M.D.D.)

of

injury was

falling or

striking a

surface or an object with the force of one’s own body weight. All ages were eligible for inclusion in the study. Charts were reviewed for details

of patient

examination. tic

tests and

instructions. recorded

gender,

age. race, time of injury,

time of

mechanism of injury, ED discharge diagnosis, diagnosresults, Urogenital

in detail.

therapeutic

intervention,

and perianal

including

severity, and size. Pertinent

examination

exact location

and

discharge

findings were

and type of injury,

negative findings were also recorded:

these included (where possible) hymenal size and description. nonurogenital also

reviewed

examination for

any

Patients were excluded

findings were

suggestion

of

recorded.

suspected

Charts sexual

Any were

abuse.

from the final analysis if any suspicion of

From the Section of Emergmq Medicine und Depurtment of Surgey. Children’s Mercy Hospital, und the University of Missouri School of Medicine, Kansub Ciy, Mf? Dute accepted: Junuaryv2, 1993. Presented ut The Fourth National Co+-ence on Pediatnc Trauma. Indianapolis. Indiana, September 23. 1992. Address reprint requests to M. Denise Dowd, MD, Depatiment 011 Pediatrics, Universityof Washington, RD-20, Seattle. WA 98195. Copyright r 1994 by W B. Saunderrv Compaq> 0022.346Nf9412901-0002$03.00l0 7

a

DOWD ET AL

Table 1. Mechanisms of Straddle Injury Mechanism

Five of the patients (all girls) who initially presented with a history of straddling were eventually given the diagnosis of suspected sexual abuse, based on disclosure by the patient and a full social service evaluation. Their cases are summarized in Table 2.

”

Fall from a bicycle

25

Fall on furniture

23

Fall on miscellaneous object (no climbing)

11

Fall while climbing (other than on furniture)

11

Playground equipment

10

Fall on the back of a shoe or ice skate Ran into an object

Physical Findings: Females

4 3

Other

13

during chart review. If the patient taken to the operating room for examination under anesthesia, examination and any related surgical repair was recorded. examinations were performed by medical or surgical residents the patient in the supine position. sexual abuse was noted

was this ED with

RESULTS

One hundred charts that met the above definition of straddle injury were reviewed. Seventy-two percent of the patients were female. The age range was 9 to 187 months (.75 to 15.6 years); mean, 77.9 (6.5 years); median, 67.2 (5.6 years). Fifty-one percent were between 2 and 6 years of age. Straddle injuries were more common in the warmer months; 36% occurred in June, July, or August. Forty-seven percent of children were black, 46% were white, and 7% were Hispanic. The most common mechanism was a fall on the crossbar of a bicycle, which accounted for 25% of all injuries (Table 1). Falls while climbing on an object other than furniture comprised 21% of all injuries. This included 10 patients who sustained a straddle injury while climbing on playground equipment. Three girls had straddle injuries involving an unintentional penetrating mechanism: a fall onto the handle of a plunger, impalement on a sharp fence post while climbing, and a fall on the steering column of a bicycle after the handlebars came off while riding. The presenting complaint varied with the patient’s gender. For males, pain was the most common presenting complaint; 12 of 28 boys (42.9%) complained of pain. In females, bleeding was most common; 49 of 72 girls (68.1%) presented with this complaint. Twelve patients had no symptoms at the time of presentation (7 boys, 5 girls).

The examination findings of the other 67 girls who sustained true straddle injury (without historical, social, or physical evidence of sexual abuse) are summarized in Table 3. The most common injury was a minor laceration or abrasion of the labia majora or minora (n = 53, 79%); 11 (16%) had injury to the posterior fourchette, 9 of which were minor lacerations. There were 5 hematomas of the vulvar area. Injury of the vagina was noted for 7 patients, and injury of the hymen for 2 patients. Of these, 3 patients had penetrating-type mechanisms; their injuries included a 5-mm hymenal and vaginal tear, with laceration of posterior fourchette (plunger injury); tear of the posterior vaginal wall through to the sigmoid colon (impalement on a fence post); abrasions of the labia minora; and posterior vaginal wall tear extending to the posterior fourchette (steering column of bicycle). Of the girls who sustained nonpenetratingmechanism injury, there was a case of “minor bruising” of both the vagina and hymen in a girl who had fallen on the crossbar of a bicycle and also a case of a “perivaginal” laceration in a girl who fell and straddled a curb. In addition, it was noted that 2 patients had vaginal bleeding, the source of which was not documented. Of these 67 girls, 15 (22.5%) were admitted to the hospital, 10 (15%) of whom required surgical repair. Physical Findings: Males

Physical examination findings are summarized in Table 4. The most common injury was scrotal trauma, which accounted for 16 of 28 (57%) of the injuries in boys. The majority were lacerations (n = ll), 9 of which required repair. Penile trauma was the next most common injury (12 of 28 boys; 43%). Most often this involved a laceration or ecchymosis. Three penile lacerations required repair. Overall, repair of a genital laceration was required for 10 boys; 2 underwent

Table 2. Patients Who Were Victims of Sexual Assault: n = 5 (100% Female) Age (yr)

GenitourinaryFindings

PresentingHistory

Circumferential ecchymosis, legs

4.5

Fell on a piece of wood paneling

Hymenal tear

9

Fell on a log

Large hymen, posterior fourchette ecchymosis

4

Jumped off a slide

Large labial laceration*

4.5

Fell off a porch (3 ft)

Intraperitoneal-vaginal

5

Fell on a headboard

Ecchymotic labia and perianal area

*Required surgical repair.

ConcurrentInjuries

laceration*

Facial ecchymosis

9

STRADDLE INJURIES

Table 3. Summary of Examination Findings: n = 67 Female Patients ExaminationFindings

No. of Patients

Laceration

Labia majora Labia minora Posterior fourchette

InjurySite

Eccyhmosis

Swelling

Abrasion

Tenderness

27

9

6

9

6

1

5

26

19

2

1

6

1

3

11

9

Hematoma

Erythema

2 1

1

1

Vagina

7

3*

Periurethral area

7

4

1

Mons

7

2

1

Perineum

5

Clitoris

3

Hymen

2

Bleeding

2

2

3 3 2

2 1

2 1

Perianal area

NOTE. Two patients had normal examination findings. *Includes one intraperitoneal-vaginal

tear.

repair of both a penile and a scrotal laceration. The majority (8 of 10) were minor injuries, with simple repairs performed in the ED. In none of the boys was sexual abuse a documented concern of either the parent or the examiner. History of injury and findings of the physical examination correlated well. No anal or perianal injuries were noted. DISCUSSION

Straddle injuries, as defined in this study, can be divided, by mechanism, into two groups: penetrating and nonpenetrating. Physical examination findings differed between the groups. With nonpenetrating mechanisms, minor trauma to the external genitalia was most common. In boys this commonly included superficial lacerations of the scrotum or penis; in girls this involved lacerations or abrasions of the labia. Minor injuries to the posterior fourchette were documented with a history of nonpenetrating straddle injury. There were no perianal injuries in girls or boys who experienced nonpenetrating trauma. Children with penetrating injuries, both unintentional and sexual assault, had injuries that were characteristically different from those of the nonpenetrating group. These included more serious and extensive injuries such as vaginal-peritoneal perforation, which was seen in two cases: a rape and an impalement on a fence post. Hymenal and vaginal

injuries were more common and more serious in this group. Injuries to the posterior fourchette occurred in no greater frequency than in the nonpenetrating trauma group. In the five cases of sexual assault there are aspects of each that indicate the injury may not have been from a typical straddle mechanism. These included severe or extensive injury that did not correlate well with the history, other nongenital injury (facial bruising and bruises around the legs), and a large hymenal diameter. Five girls had falsified histories and were eventually found to be victims of sexual abuse. In a review of cases of sexual abuse in children, 57 of 300 patients presented with a complaint other than suspected sexual abuse. l1 Two presented with straddle injury. An important limitation of this retrospective study is the possibility that patients who experienced sexual abuse may have been missed. Comments regarding the frequency of hymen or vaginal injury in unintentional trauma can be found in the literature, although they are anecdotal.” Our findings were consistent with these reports in that hymen and vaginal injuries were rare in nonpenetrating straddle injury, l3 but occurred with some frequency in girls who had a history of unintentional or intentional penetrating injury. Because this is a retrospective study, accurately identifying the “clock” position of hymenal injury was not possible. Injury to the posterior fourchette occurred with some fre-

Table 4. Summary of Examination Findings: n = 28 Male Patients ExamtnattonFindings

No. of Patrents

Laceration

Ecchymosis

Swelling

Scrotum

16

11

1

4

Penis Pubis

12 2

6

4

3

InjurySite

lnguinal area

1

Perineum

1

Urethra

1

Abrasion

Tenderness

Hematoma

Erythema

2

1

1

2

2

1

1

Bleeding

1

1

NOTE. One patient had normal examination findings,

1

1 1

10

DOWD ET AL

quency in our group of nonpenetrating straddle injuries. Interestingly, trauma to this area is mentioned most commonly in studies of sexually abused children.14 Straddle injuries did not occur in the first 9 months of life (ie, in the child who does not yet walk). The age peak between 2 and 6 years is understandable given the developmental stages during these years. Children who climb and/or ride bicycles are at risk for straddle injury. In the evaluation of straddle injury, there are several indicators that should initiate further investigation for sexual abuse. These “red flags” are summarized in Table 5.

Table 5. Indications for Sexual Abuse Evaluation Infant younger

than 9 months of age

Perianal, vaginal, or hymenal

injury without

history of penetrating

trauma Extensive or severe trauma Presence of nonurogenital Lack of correlation

trauma

between

history and physical findings

Prospective study is needed to characterize physical examination findings in unintentional urogenital trauma and compare these with normal anatomic findings and those seen in cases of sexual abuse. Data should be collected in a longitudinal fashion to evaluate the changes that occur during healing.

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Wynne JM: Injuries to the genitalia in female children. S Afr J 57:47-50, 1980 Gearhart JP, Lowe FC: Genitourinary injuries secondary to dancing in children and adolescents. Pediatrics 77:922-924, LeRoy

JB: Banana-seat

hematuria.

N Engl J Med 282311,

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