A 5-year-old girl was brought to her pediatrician after a "fall" 30 minutes before her arrival. The injury occurred in her home; she fell while straddling the back of a chair as she reached for something on a table. Her grandmother, who was serving as the child's foster parent, and an unrelated witness provided the initial history. The child independently confirmed the story provided by the adults.
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The patient was well known to the pediatrician and was in foster care because of sexual abuse.
The child had signs of active bleeding on her clothing when she presented to the office. There was also evidence of bleeding on the labia majora. An approximately 1-cm in diameter bruise was seen on the labia majora. A 2-cm crush injury with splitting of the skin between the labia minora and labia majora was visualized with gentle traction. The injury did not need to be sutured. There were no other injuries (the posterior fourchette, fossa navicularis, hymen, and anus were normal).
Are these findings the result of abuse or trauma caused by an accidental fall?
(Answer and discussion on next page.)
Answer: Trauma From a Straddle Injury
In this case, straddle injury is the most straightforward diagnosis. The caregivers sought early medical care for the child; fresh blood was present on the patient's clothing. Also reassuring was the fact that the genital injury was predominantly external and unilateral--the classic characteristics of a straddle injury, not abuse.
The history verification by 3 sources (the grandmother, child, and an unrelated witness) is also reassuring. The only troubling element in this scenario was that the child was in foster care because of sexual abuse. The social history was considered by the pediatrician but was overshadowed by the factors mentioned above.
By definition, a straddle injury involves a fall onto or striking of an object with the force of one's weight. The injury pattern is caused from compression of the pelvic tissues by the underlying bony structures. The physical description of the injury depends on the type of fall and/or object that is involved.1 The typical injury is more anterior and unilateral and involves the external genitalia more often than internal structures. There would be more extensive internal injury if impalement had occurred.
In almost every case of straddle injury, there is usually an acute and "dramatic" history of the event. The most common chief complaint for females is bleeding followed by pain and bruising. Similar injuries occur in males but only half as frequently as in females.1 In males, the most common presenting complaint is pain and scrotal trauma.2
In one study, the incidence of straddle injuries was found to be 2 in 1000 children younger than age 12 who presented to an emergency department.2 Dowd and coworkers3 looked at the mechanisms of straddle injury. They found that 25% were related to bicycle injuries and 21% to falls on furniture. Another 30% were related to falls while climbing on objects, including playground equipment.
In an effort to differentiate innocent injuries from inflicted injuries, Greaney and Ryan4 proposed using the scoring system shown in the Table.
Jones and Bass1 describe recommendations for treatment of the more complex perineal injuries that require surgical intervention. The literature is devoid of treatment strategies for simple straddle injuries, however. The patient in this case was treated with daily sitz baths and topical antibiotic cream.
The history and physical examination remain the most important elements in differentiating straddle injuries from abuse. The presence of any history or physical findings that prompt one to include child abuse in the differential may mean that the genital complaint is not just a straddle injury. By using the algorithm proposed by Greaney and Ryan, one could, perhaps, answer the abuse/mimic question. If any doubt remains, however, the clinician is obligated to report possible child abuse. *