Straddle injuries occur when a child straddles an object as he or she falls, striking the urogenital area with the force of his or her body weight. Injury is caused by the compression of soft tissues against the bony margins of the pelvic outlet . Straddle injuries are common in children and occur most often during bicycle riding, falls, and playing on monkey bars . (See "Prevention of falls in children".)
The differentiation of straddle injuries from sexual abuse and the treatment for specific types of injury are presented here. The physical examination of the perineum is reviewed separately. (See "The pediatric physical examination: The perineum" and "Gynecologic examination of the newborn and child".)
DIFFERENTIATING STRADDLE INJURY FROM SEXUAL ABUSE
A careful history and physical examination should be performed in children with straddle injuries. The history must correlate with the physical findings to confirm nonsexual trauma . Examination of the child with a straddle injury may be difficult because of anxiety and pain. Pain may be controlled with the application of 2 percent lidocaine jelly to the affected area with a gauze pad. Sedation may be necessary to complete the examination or if sutures are indicated . (See "Procedural sedation in children outside of the operating room".)
Straddle injuries typically are unilateral and superficial [1,5]. They involve the anterior portion of the genitalia in both boys and girls. Most straddle injuries in girls involve the mons, clitoral hood, and the labia minora anterior or lateral to the hymen . Straddle injury to the hymen or posterior fourchette is less common and should raise concern for sexual abuse . As an example, a laceration to the hymenal area that extends from 3 o'clock to 9 o'clock is consistent with a penetration injury and must be explored further . The examiner must have an understanding of normal hymenal variants if he or she is to identify abnormal hymenal findings caused by trauma [9-11]. (See "Gynecologic examination of the newborn and child", section on 'Evaluation of the hymen'.)
Straddle injuries are classified as penetrating or nonpenetrating. Nonpenetrating injuries typically cause minor trauma to the external genitalia: superficial lacerations of the scrotum or penis in boys and lacerations or abrasions of the labia in girls. Perianal and testicular trauma rarely result from nonpenetrating injuries. Penetrating injuries are more serious and extensive (eg, vaginal-peritoneal perforation, rectal injury) and more often indicative of sexual assault [12,13].