A 3-year-old female came to clinic for a pre-operative visit for pressure-equalizing tubes and a tonsillectomy and adenoidectomy. The patient was new to the practice and during the past medical history, the mother said that the patient had a previous surgery because she had jumped from a couch onto a chair when she was 2.5 years old. She had sustained a straddle injury that needed surgery “to fix her muscles down there” but had no problems since that time. She had no other emergency room visits or hospitalizations. The past medical history revealed multiple ear and throat infections. She also had a history of some snoring. The family history was negative for any bleeding, surgery or anesthesia problems including malignant hyperthermia. The review of systems was negative.
The pertinent physical exam revealed normal vital signs and growth parameters. HEENT showed scared, dull tympanic membranes with fluid behind them bilaterally. Her tonsils were 3+ bilaterally with a relatively large tongue. She had shoddy anterior cervical adenopathy. The rest of her examination was normal except for a small hymenal cleft at 7 o’clock. The diagnosis of a child with a physical examination consistent with chronic ear and throat infections was made with an ASA class III airway. The patient’s clinical course was that she underwent surgery without any complications and had significant improvement in the number of infections over the next year. The pediatrician later reviewed straddle injuries and their treatment.
Presurgical evaluations are very important for any patient particularly if a patient does not have a medical home or consistent health care providers. They also are particularly important for patients with chronic or complicated medical conditions and therefore pediatric health care providers are often asked to assist their dental and surgical colleagues in pre-operative evaluations.
An overview of the elements of a preanesthesia evaluation can be found here, including the American Society of Anesthesiologists (ASA) airway classification. A careful history for any problems with anesthesia should always be asked and documented, especially for any difficulties with waking up from anesthesia, fever or muscle problems. These could indicate possible malignant hyperthermia and an overview of its symptomatology and emergency treatment can be found here.
Straddle injuries are a common form of unintentional female genital trauma. In one study of 105 patients, straddle injuries (81.9%) were the most common and fortunately most of these did not require surgery. Straddle injury trauma occurs because of direct trauma with compression of the vulvar tissues by an object (e.g. falling onto monkey bars, bicycle handle bar or center bar, etc.) or by forceful abduction of the legs and compression (e.g. falls onto a chair or other furniture, breakdancing injury). The trauma is usually non-penetrating, but penetrating trauma can also occur, (e.g. fall onto a piece of furniture and small toy that is co-located).
The most common straddle injuries are abrasions, bruising and lacerations. Hematomas can occur because of extravasation of blood into the loose tissue of the labia, clitoris, mons or vagina. Small lacerations often heal by themselves and do not need specific approximation of the tissues. Large lacerations, those that extend into the muscle or those where the exact extent of the injuries need to be further evaluated, probably will need surgical repair. Patients with vulvar hematomas that do not distort the normal anatomy and the patient is able to void spontaneously usually can be treated conservatively, with ice packs and pain control. If the anatomy is distorted, or there are voiding problems, then further evaluation and treatment are needed. Voiding usually can be treated with a Foley catheter until the swelling resolves. A large hematoma that distorts the anatomy may exert enough pressure to cause pressure necrosis and therefore the hematoma may need to be incised, drained and debrided.
Perianal, hymenal and vaginal trauma often suggests a penetrating injury which may be unintentional or could be associated with sexual abuse. Therefore, patients presenting with these injuries should have sexual abuse considered as part of the management.
Questions for Further Discussion
1. What are some indications for genital examination under general anesthesia?
2. Who are your local consultants for genital trauma?
- Disease: Straddle Injuries | Vulvar Disorders
- Symptom/Presentation: Health Maintenance and Disease Prevention | Trauma
- Specialty: Anesthesia | Child Abuse and Neglect | Emergency Medicine | Obstetrics / Gynecology | Surgery
- Age: Preschooler
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Vulvar Disorders
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Heppenstall-Heger A, McConnell G, Ticson L, Guerra L, Lister J, Zaragoza T. Healing patterns in anogenital injuries: a longitudinal study of injuries associated with sexual abuse, accidental injuries, or genital surgery in the preadolescent child. Pediatrics. 2003 Oct;112(4):829-37.
Dowd MD, Fitzmaurice L, Knapp JF, Mooney D. The interpretation of urogenital findings in children with straddle injuries. J Pediatr Surg. 1994 Jan;29(1):7-10.
Merritt DF. Genital trauma in the pediatric and adolescent female. Obstet Gynecol Clin North Am. 2009 Mar;36(1):85-98.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
4. Patient management plans are developed and carried out.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
19. The health professional works effectively with others as a member or leader of a health care team or other professional group.
25. Quality patient care and assisting patients in dealing with system complexities is advocated.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital