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Straddle injuries in children: Evaluation and management

Straddle injuries in children: Evaluation and management
Literature review current through: Jan 2024.
This topic last updated: Oct 23, 2023.

INTRODUCTION — The evaluation and treatment of straddle injuries in children are presented here. The physical examination of the perineum in children, scrotal trauma in children and adolescents, blunt and penetrating genitourinary trauma, and lower genital tract trauma in females are discussed separately:

(See "The pediatric physical examination: The perineum" and "Gynecologic examination of the newborn and child".)

(See "Scrotal trauma in children and adolescents".)

(See "Blunt genitourinary trauma: Initial evaluation and management" and "Penetrating trauma of the upper and lower genitourinary tract: Initial evaluation and management".)

(See "Evaluation and management of female lower genital tract trauma".)

ETIOLOGY AND CLASSIFICATION — Straddle injuries are common in prepubertal children and occur most often during bicycle riding, falls, and playing on monkey bars [1-3]. Straddle injuries usually occur when a child straddles an object as they fall, 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 [4]. Unintentional blunt straddle injuries typically are unilateral and cause limited contusions or superficial lacerations to the anterior portion of the genitalia in males and females [4-6]. Less commonly, children may be impaled by sticks, playground equipment, fence posts, or other similar objects during the fall and sustain a penetrating injury to the genitalia or perineum. These injuries often require surgical repair [6,7].

Straddle injuries are classified as penetrating or blunt.

Blunt – Blunt injuries typically cause minor trauma to the external genitalia such as mild scrotal or vulvar hematomas or superficial lacerations or abrasions of the scrotum or penis in males and of the labia in females. Serious vaginal, perianal, and testicular trauma rarely result from blunt injuries. (See "Scrotal trauma in children and adolescents", section on 'Blunt scrotal trauma'.)

Penetrating – Penetrating injuries are more likely to be serious and extensive than blunt injuries (eg, vaginal-peritoneal perforation, scrotal perforation with testicular injury, urethral disruption, and rectal injury) and more often indicate sexual assault [7,8]. (See "Scrotal trauma in children and adolescents", section on 'Penetrating trauma'.)

EVALUATION — Unintentional straddle injuries are typically confined to the genitalia and perineum. However, patients with findings of multiple trauma should undergo a primary survey and treatment of life-threatening injuries. Evaluation for genital or perineal injuries is then addressed during the secondary survey. (See "Trauma management: Approach to the unstable child", section on 'Initial approach'.)

The clinician should perform a careful history and physical examination in all children with straddle injuries and obtain a urine specimen. Evaluation should identify patients whose injuries warrant special imaging studies, specialty referral, and findings that suggest child abuse. (See 'Indications for specialty referral or consultation' below and 'Findings suggesting child abuse' below and 'Ancillary studies' below.)

History — The history should identify when and how the straddle injury occurred and what object caused the injury. Commonly described mechanisms include falls onto bicycle frames, playground equipment (eg, monkey bars), fences, edges of bathtubs, and furniture [1,2,5]. The child may be impaled on a variety of objects during these falls [7]. Straddle injuries sustained during motor vehicle collisions are less common but may cause significant trauma to the genitalia and perineum and are more often associated with a pelvic fracture [7].

The clinician should ask if the patient has been able to urinate since the injury and if hematuria is present. Typical features also include pain and swelling. In patients who report bleeding, the suspected source and amount should be determined. In males, a history of nausea or vomiting suggests testicular injury. (See "Scrotal trauma in children and adolescents", section on 'History'.)

A history that does not match the severity of physical findings in children with genital injuries should raise concern for physical or sexual abuse. (See "Physical child abuse: Diagnostic evaluation and management", section on 'History' and "Evaluation of sexual abuse in children and adolescents", section on 'History'.)

Physical examination — The clinician should perform a complete physical examination to determine any associated injuries. In most patients with unintentional straddle injuries, isolated trauma to the genitalia and perineum is the sole finding. Patients with findings that suggest multiple trauma should undergo appropriate evaluation. (See "Trauma management: Approach to the unstable child", section on 'Initial approach'.)

Analgesia — The goal of the examination is to obtain information without further traumatizing the child. Younger patients may be less distressed if they are examined while sitting in the caretaker’s lap.

Examination of the child with a straddle injury may be difficult because of anxiety and pain. Mild to moderate pain may be controlled with the application of a cold pack as tolerated or viscous lidocaine jelly (maximum dose 4 mg/kg [0.2 mL/kg of 2% viscous lidocaine]) to the affected area with a gauze pad. More severe pain may require opioid analgesia (eg, fentanyl intravenously or intranasally) and/or sedation to obtain a complete examination. Sedation for examination may also be appropriate if laceration repair is anticipated [9]. (See "Procedural sedation in children: Approach" and "Procedural sedation in children: Selection of medications", section on 'Sedation for painful procedures'.)

Genital examination

Females — Examination of the vulva and perineum can be done with the child lying supine with the legs in a "frog-leg" or "butterfly" position and in a "knee-chest" position for visualization of the vagina (figure 1). The labia, clitoris, urethra, hymen, vaginal orifice, perineum, and rectum are examined. It is essential that the examining physician be familiar with normal variants of the external female genitalia (figure 2). (See "Gynecologic examination of the newborn and child", section on 'History and physical examination'.)

Most straddle injuries in females involve the mons, clitoral hood, and the labia minora and are located anterior or lateral to the hymen [10]. Vulvar hematomas and superficial vulvar lacerations in these regions are typical findings. Findings at examination that support unintentional injury include single or stellate lacerations and/or bruising that is consistent with the history. (See 'Females' below.)

Findings of serious injury include:

Injury to the hymen and/or posterior fourchette – The examiner must differentiate normal hymenal variants (figure 3 and figure 4) from abnormal hymenal findings. Trauma to the hymen or posterior fourchette is uncommonly seen with unintentional straddle injuries 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. Bleeding that occurs after a hymenal injury is often minimal and in itself requires no treatment. However, such injuries may indicate vaginal penetration and possible vaginal injury and warrant assessment for deep tears into the perineum or rectum and vaginal perforation. A detailed examination under sedation or anesthesia by a surgeon with pediatric gynecologic expertise is warranted to exclude injuries of the upper vagina and intrapelvic viscera in patients with deep vaginal tears. (See "Gynecologic examination of the newborn and child", section on 'Evaluation of the hymen' and "Evaluation of sexual abuse in children and adolescents", section on 'Female genitalia' and 'Females' below.)

Vaginal bleeding – Vaginal bleeding is also an important finding that must be differentiated from pooling of blood from vulvar lacerations. Gentle irrigation with normal saline can often clarify the source of bleeding. Patients with vaginal bleeding warrant prompt consultation with a surgeon with pediatric gynecologic expertise for an examination which may require sedation or anesthesia. Bleeding of vaginal origin is unlikely if the hymen is intact and a source of bleeding on the external genitalia exists [11]. (See 'Indications for specialty referral or consultation' below.)

Vaginal bleeding is also an important finding that must be differentiated from pooling of blood from vulvar lacerations. Gentle irrigation with normal saline can often clarify the source of bleeding. Patients with vaginal bleeding warrant prompt consultation with a surgeon with pediatric gynecologic expertise for an examination which may require sedation or anesthesia. Bleeding of vaginal origin is unlikely if the hymen is intact and a source of bleeding on the external genitalia exists [11]. (See 'Indications for specialty referral or consultation' below.)

Perineal lacerations or tears – The perineum is the supportive layer of tissue between the introitus and the rectum. This area may sustain a significant portion of the force exerted during penetrating trauma. Perineal lacerations or tears may only involve the perineal skin or my extend into deeper tissues including the perineal body, rectal sphincter, and rectal mucosa. (See "Evaluation and management of female lower genital tract trauma", section on 'Perineum'.)

Blood at the urethral meatus, gross hematuria in the absence of adjacent bleeding, or periurethral laceration – Urethral injury is unusual in females but may present with blood at the meatus, gross hematuria in the absence of adjacent bleeding, or signs of pelvic fracture, such as pain on palpation or rocking of the pelvis. Pelvic injuries can also cause vaginal lacerations and bleeding. Obstruction of the urethra and difficulty voiding may also occur in patients with large vulvar hematomas. (See "Blunt genitourinary trauma: Initial evaluation and management", section on 'History, examination, and approach to testing' and 'Ability to void' below.)

Males — The penis and scrotum should be inspected with the child lying supine and, if able, standing. Visualization of the anus, perineum, and posterior portion of the scrotum may be accomplished in the "knee-chest" position. Transillumination of the scrotum should be performed, especially in patients with significant scrotal swelling. Examination of the scrotum in males is discussed in greater detail separately. (See "Scrotal trauma in children and adolescents", section on 'Physical examination'.)

Straddle injuries in males commonly result in mild scrotal swelling and bruising. Isolated rectal injury is concerning for sexual abuse. (See "Evaluation of sexual abuse in children and adolescents", section on 'Physical examination'.)

The following findings are concerning for serious trauma (see "Scrotal trauma in children and adolescents", section on 'Physical examination'):

Moderate to severe scrotal or testicular swelling

Scrotal or testicular tenderness on palpation

Testicle not palpated or visualized by transillumination in the hemiscrotum

Unilateral absence of the cremasteric reflex (testicular retraction when the ipsilateral thigh is gently stroked)

Blood at the urethral meatus or gross hematuria

Marked ecchymosis and swelling of the penis or perineum

Laceration to the ventral penis or extending into the corporal bodies (figure 5)

Patterned skin bruises, mouth injuries, or anal trauma suggesting child abuse

Findings suggesting child abuse — The following clinical findings in children with straddle injuries should prompt evaluation for sexual abuse and involvement of an experienced child protection team (eg, social worker, nurse, physician with more extensive experience in the management of child sexual abuse) and/or referral to a child sexual abuse center, if available [4,8,9,12] (see "Evaluation of sexual abuse in children and adolescents"):

Infant younger than nine months

Perianal, rectal, vaginal, penile, scrotal, or hymenal injury that is extensive, severe, or does not correlate with a history of a straddle injury (eg, hymenal or posterior fourchette tear in females or rectal tears in males) (see 'Genital examination' above)

Presence of non-urogenital trauma (eg, patterned bruising or burns) that suggests physical abuse (see "Physical child abuse: Diagnostic evaluation and management", section on 'Physical examination')

Abnormal genital and/or perianal lesions or secretions that suggest a sexually transmitted infection (see "Evaluation of sexual abuse in children and adolescents", section on 'Suspicious findings')

In many parts of the world, a mandatory report to appropriate governmental authorities is also required. (See "Child abuse: Social and medicolegal issues", section on 'Reporting suspected abuse'.)

Ability to void — Because of the potential for urethral damage as a complication of straddle injuries, the clinician should ensure that all patients can urinate. Many children with straddle injuries are apprehensive and may refuse to void initially. If physical findings indicate that the bladder is not overdistended and that the likelihood of an injury requiring sedation or operative care is low, the clinician may encourage voiding by administering acetaminophen orally, local measures to reduce pain (eg, <4 mg/kg topical lidocaine [eg, 0.2 mL/kg of 2% viscous lidocaine]) applied to superficial lacerations, or an ice pack as tolerated.

Ancillary studies — In most children with straddle injuries, the history and physical examination is sufficient to exclude serious injury and no ancillary studies are needed.

Patients with the following injuries warrant additional studies:

Urethral disruption – Patients with blood at the meatus, gross hematuria, possible laceration extending into the urethra, marked periurethral or perineal swelling, or persistent inability to void despite marked bladder distension warrant retrograde urethrography. These patients should not undergo bladder catheterization. The technique for performing a retrograde urethrogram is discussed separately. (See "Blunt genitourinary trauma: Initial evaluation and management", section on 'Retrograde urethrogram'.)

Moderate to severe scrotal swelling or pain or abnormal testicular examination – Males with marked abnormality of the scrotum or testicles should undergo ultrasound of the scrotum with Doppler flow. (See "Scrotal trauma in children and adolescents", section on 'Ancillary studies'.)

Deep vaginal and vulvar lacerations – Deep vaginal and vulvar lacerations, especially those that extend into the posterior cul de sac (pouch of Douglas) or into the rectum can cause serious hemorrhage and hemodynamic instability [13]. These patients should have serial hematocrits measured every 30 minutes until bleeding is controlled and should have blood sent for type and crossmatch.

In children with serious multiple trauma, laboratory studies and imaging should be obtained according to the mechanism of injury and physical findings as described separately. (See "Trauma management: Approach to the unstable child", section on 'Laboratory studies'.)

INDICATIONS FOR SPECIALTY REFERRAL OR CONSULTATION — Children with the following injuries warrant prompt evaluation by the appropriate surgical subspecialist:

Vaginal bleeding, extensive vulvar lacerations (eg, >3 cm), or large hymenal tears (surgeon with pediatric gynecologic expertise)

Findings of large testicular or scrotal hematoma, testicular rupture, traumatic testicular torsion, testicular dislocation, scrotal avulsion, or hematocele (blood in the tunica vaginalis) (figure 6) (surgeon with pediatric urologic expertise)

Scrotal lacerations through the dartos layer (figure 7) (surgeon with pediatric urologic expertise)

Signs of urethral disruption such as blood at the meatus, gross hematuria, possible laceration extending into the urethra, marked periurethral or perineal swelling, or persistent inability to void despite marked bladder distension (surgeon with pediatric urologic or urogynecologic expertise)

INITIAL MANAGEMENT

Females — The initial management of straddle injuries in girls is determined by physical examination findings as follows (algorithm 1):

Vaginal bleeding – Patients with vaginal bleeding require examination under anesthesia by a surgeon with pediatric gynecologic expertise. Most vaginal injuries occur as the result of penetrating trauma. The injury typically occurs when an object penetrates the vagina through the hymenal opening, creating a laceration or tear of the hymenal ring [6]. An object that pierces the perineum also may cause direct vaginal injury. These wounds warrant tetanus prophylaxis, as needed (table 1).

Many vaginal lacerations are superficial and limited to the mucosal and submucosal tissues. The child may not complain of pain, and usually little blood loss occurs unless a major vessel is torn. Lacerations confined to the vaginal mucosa are repaired with the child under general anesthesia with fine suture material placed deep into the wound to approximate the tissues and obtain hemostasis. (See "Evaluation and management of female lower genital tract trauma", section on 'Superficial lacerations'.)

Deep lacerations and those that extend beyond the vagina either through the posterior cul de sac (pouch of Douglas) or into the rectum can cause significant hemorrhage that may require fluid resuscitation and blood administration. Thus, type and cross-matched blood should be available during operative repair. Lacerations that extend through the upper vagina may have associated injuries to a variety of structures including major blood vessels above the pelvic floor (eg, the ovarian, internal iliac, and external iliac vessels), the uterus, fallopian tubes, sigmoid colon, or small bowel. Patients suspected of these injuries warrant laparoscopy or exploratory laparotomy. (See "Evaluation and management of female lower genital tract trauma", section on 'Deep lacerations' and "Evaluation and management of female lower genital tract trauma", section on 'Extension beyond the vagina'.)

Hematomas of the vaginal wall may occur if bleeding vessels are not ligated before repair of the overlying vaginal mucosa. These hematomas may be managed with observation and analgesia if active bleeding stops and they are not enlarging; the blood clot eventually will resorb and the swelling subside. However, if the bleeding continues, the repaired laceration should be opened, the blood clot evacuated, and the bleeding points ligated. Packing the vagina may also be useful to promote tamponade of bleeding. (See "Evaluation and management of female lower genital tract trauma", section on 'Vagina'.)

Deep external laceration, urethral or rectal injury or laceration, or retained foreign body – Complicated lacerations of the vulva or perineum, suspected urethral injuries, or retained foreign bodies that are difficult to remove require consultation with the appropriate surgical specialist for further evaluation and repair. Patients with these injuries should receive tetanus prophylaxis, as needed (table 1).

Vulvar lacerations – Skin suturing is not needed for most vulvar lacerations caused by straddle injuries. Small vulvar lacerations (eg, ≤3 cm) without active bleeding should be treated with a topical antibiotic ointment and covered with a clean protective pad that is replaced after toileting. Perineal sutures, if necessary for hemostasis or cosmesis, should be placed with the child under procedural sedation or general anesthesia to decrease additional trauma for the child [11]. Tetanus prophylaxis is indicated, as needed (table 1). (See "Evaluation and management of female lower genital tract trauma", section on 'Vulva'.)

Vulvar hematomas – Most vulvar hematomas will resolve spontaneously. Small to moderate hematomas usually can be controlled by limitation of activity and local measures. Treatment with ice is recommended during the first 12 to 24 hours after injury to reduce edema. Warm tub baths or sitz baths two to three times per day may then be instituted. Tub baths keep the wound clean and may facilitate voiding in girls with mild urinary retention [11].

Large hematomas typically are managed with ice packs, bladder drainage, and analgesia. Sitz baths also may be used to remove secretions and contaminants. Pressure necrosis of the swollen external genitalia may be prevented by having the patient rest primarily on her side or back and use an air-filled rubber or foam "doughnut" when sitting. The ability to urinate should be assessed because large hematomas may obstruct the urethra. In patients with persistent urinary retention or a rapidly expanding vulvar hematoma, placement of a Foley catheter for bladder drainage may become necessary. Urinary retention that persists after the swelling subsides may indicate urethral avulsion [14].

Surgical drainage of vulvar hematomas is usually avoided because the small vessels that are involved in hematoma formation are difficult to identify. In addition, surgical disruption of the skin facilitates introduction of bacteria and may predispose the child to abscess formation. Hematomas associated with hemodynamic instability or that continue to increase in size warrant surgical treatment to evacuate the clot and to cauterize or ligate bleeding sites. (See "Evaluation and management of female lower genital tract trauma", section on 'Vulva'.)

Males — The physical examination guides initial management of straddle injuries in boys as follows (algorithm 2):

Blood at the meatus, gross hematuria, marked periurethral or perineal swelling, or persistently unable to void – Findings that suggest urethral disruption warrant retrograde urethrography and prompt consultation with a surgeon with pediatric urologic expertise. The diagnosis is confirmed by contrast extravasation on retrograde urethrogram. The diagnosis and management of urethral injury is discussed in greater detail separately. (See "Blunt genitourinary trauma: Initial evaluation and management", section on 'Primary evaluation and management' and "Blunt genitourinary trauma: Initial evaluation and management", section on 'Disposition and definitive management'.)

Penetrating injury to the scrotum – Patients with penetrating injury through the dartos layer of the scrotum should receive intravenous antibiotics, tetanus prophylaxis as needed (table 1), and consultation by a surgeon with pediatric urologic expertise. Lacerations superficial to the dartos should receive local wound care and closure with absorbable sutures (eg, 4-0 or 5-0 fast-absorbing gut or plain gut). Prophylaxis with oral antibiotics is also suggested. Management of scrotal wounds, including antibiotic prophylaxis, is discussed separately. (See "Scrotal trauma in children and adolescents", section on 'Management' and "Scrotal trauma in children and adolescents", section on 'Penetrating trauma' and "Scrotal trauma in children and adolescents", section on 'Antibiotic prophylaxis for scrotal wounds'.)

Laceration of the penis – Penile lacerations that extend into the urethra or corporal bodies or are located on the ventral surface (figure 5) warrant evaluation with retrograde urethrography and prompt repair by a surgeon with pediatric urologic expertise [15]. Superficial lacerations can be repaired using procedural sedation, as needed, local anesthetic, and absorbable suture (eg, 4-0 or 5-0 fast absorbing gut or plain gut). Tetanus prophylaxis should also be provided, as needed (table 1).

Moderate to severe pain or swelling of the scrotum or testicle or abnormal testicular examination – Patients with these findings should undergo scrotal ultrasound with Doppler flow. Prompt consultation with a surgeon with pediatric urologic expertise should be obtained for patients with testicular torsion, dislocation, or avulsion; testicular rupture or fracture; hematocele; or scrotal hematoma with testicular compression. (See "Scrotal trauma in children and adolescents", section on 'Indications for subspecialty consultation or referral' and "Scrotal trauma in children and adolescents", section on 'Management'.)

Mild scrotal hematoma – Patients with mild scrotal swelling and an otherwise normal examination may be managed with limitation of activities (avoid contact sports or vigorous exercise), cold therapy with intermittent use of an ice pack as tolerated, supportive underwear (briefs instead of boxers), and nonsteroidal anti-inflammatory medications (eg, ibuprofen) or acetaminophen for pain. (See "Scrotal trauma in children and adolescents", section on 'Blunt scrotal trauma'.)

DEFINITIVE MANAGEMENT AND OUTCOMES — Definitive management and outcomes of serious straddle injuries requiring surgical specialty care are discussed separately:

(See "Overview of traumatic lower genitourinary tract injury".)

(See "Evaluation and management of female lower genital tract trauma".)

(See "Traumatic injury to the male anterior urethra, scrotum, and penis".)

(See "Scrotal trauma in children and adolescents".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pediatric trauma".)

SUMMARY AND RECOMMENDATIONS

Evaluation – The clinician should perform a careful history and physical examination in all children with straddle injuries. Examination of the child with a straddle injury may be difficult because of anxiety and pain. Mild to moderate pain may be controlled with local measures. More severe pain may require opioid analgesia (eg, fentanyl intravenously or intranasally) and/or sedation to obtain a complete examination. Sedation for examination may also be appropriate if laceration repair is anticipated. (See 'History' above and 'Physical examination' above.)

Findings in females – Most straddle injuries in females involve the mons, clitoral hood, and the labia minora and are located anterior or lateral to the hymen. Vulvar hematomas and superficial vulvar lacerations in these regions are typical findings. Findings at examination that support unintentional injury include single or stellate lacerations and/or bruising that is consistent with the history. Findings of serious injury include (see 'Females' above):

Hymenal or posterior fourchette trauma

Vaginal bleeding

Perineal lacerations or tears

Blood at the urethral meatus, gross hematuria, or periurethral laceration

Findings in males – Straddle injuries in males typically result in mild scrotal swelling and bruising. Concerning findings include (see 'Males' above):

Significant pain or swelling of the testicle or scrotum

An empty hemiscrotum indicating testicular dislocation

Marked ecchymosis and swelling of the penis or perineum

Laceration to the ventral penis

Laceration into the corporal bodies of the penile shaft

Findings suggesting abuse – Genital trauma that poorly correlates with a history of straddle injury, occurs in an infant younger than nine months, is associated with abnormal genital and/or perianal lesions or secretions or other physical findings of abuse (eg, patterned bruising or burns) warrants involvement of an experienced child protection team (eg, social worker, nurse, physician with more extensive experience in the management of child sexual abuse) and/or referral to a child sexual abuse center, if available. In many parts of the world, a mandatory report to appropriate governmental authorities is also required. (See 'Findings suggesting child abuse' above.)

Voiding – Because of the potential for urethral damage as a complication of straddle injuries, the clinician should ensure that all patients can urinate. Many children with straddle injuries are apprehensive and may refuse to void initially. If physical findings indicate that the bladder is not overdistended and that the likelihood of an injury requiring sedation or operative care is low, the clinician may encourage voiding by administering mild analgesia (eg, acetaminophen orally) and use local measures to reduce pain. (See 'Ability to void' above.)

Ancillary studies – In most children with straddle injuries, the history and physical examination is sufficient to exclude serious injury and no ancillary studies are needed. Patients with suspected urethral disruption should undergo retrograde urethrography. Boys with significant scrotal or testicular abnormalities warrant scrotal ultrasound with Doppler flow. Hemodynamically unstable girls with extensive vaginal injury or vulvar lacerations should have serial hematocrits measured and blood sent for type and cross match. (See 'Ancillary studies' above.)

Management – The initial management of straddle injuries in boys and girls and the indications for surgical subspecialty referral are described in the algorithms and above (algorithm 1 and algorithm 2). (See 'Initial management' above and 'Indications for specialty referral or consultation' above.)

  1. Waltzman ML, Shannon M, Bowen AP, Bailey MC. Monkeybar injuries: complications of play. Pediatrics 1999; 103:e58.
  2. Scheidler MG, Schultz BL, Schall L, Ford HR. Mechanisms of blunt perineal injury in female pediatric patients. J Pediatr Surg 2000; 35:1317.
  3. Takei H, Nomura O, Hagiwara Y, Inoue N. The Management of Pediatric Genital Injuries at a Pediatric Emergency Department in Japan. Pediatr Emerg Care 2021; 37:73.
  4. Dowd MD, Fitzmaurice L, Knapp JF, Mooney D. The interpretation of urogenital findings in children with straddle injuries. J Pediatr Surg 1994; 29:7.
  5. Bond GR, Dowd MD, Landsman I, Rimsza M. Unintentional perineal injury in prepubescent girls: a multicenter, prospective report of 56 girls. Pediatrics 1995; 95:628.
  6. Spitzer RF, Kives S, Caccia N, et al. Retrospective review of unintentional female genital trauma at a pediatric referral center. Pediatr Emerg Care 2008; 24:831.
  7. Jones JG, Worthington T. Genital and anal injuries requiring surgical repair in females less than 21 years of age. J Pediatr Adolesc Gynecol 2008; 21:207.
  8. Pokorny SF, Pokorny WJ, Kramer W. Acute genital injury in the prepubertal girl. Am J Obstet Gynecol 1992; 166:1461.
  9. Lynch JM, Gardner MJ, Albanese CT. Blunt urogenital trauma in prepubescent female patients: more than meets the eye! Pediatr Emerg Care 1995; 11:372.
  10. Iqbal CW, Jrebi NY, Zielinski MD, et al. Patterns of accidental genital trauma in young girls and indications for operative management. J Pediatr Surg 2010; 45:930.
  11. Pokorny SF. Genital trauma. Clin Obstet Gynecol 1997; 40:219.
  12. Benjamins LJ. Genital trauma in pediatric and adolescent females. J Pediatr Adolesc Gynecol 2009; 22:129.
  13. Hoefgen HR, Merritt DF. Rope swing injuries resulting in vulvar trauma. J Pediatr Adolesc Gynecol 2015; 28:e13.
  14. Muram D, Levitt CJ, Frasier LD, et al. Genital injuries. J Pediatr Adolesc Gynecol 2003; 16:149.
  15. Tasian GE, Belfer RA. Genitourinary trauma. In: Fleisher and Ludwig's Textbook of Pediatric Emergency Medicine, 7th ed, Shaw KN, Bachur RG (Eds), Wolters Kluwer Lippincott Williams & Wilkins, Philadelphia 2016. p.1160.
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