What is the appropriate management for a 6-year-old child with a straddle injury?

Management of Straddle Injury in a 6-Year-Old Child

Establish prompt urinary drainage and carefully assess for urethral injury, genital trauma, and associated injuries, while maintaining a high index of suspicion for occult serious pathology that may not be immediately apparent.

Immediate Assessment Priorities

Urethral and Genitourinary Evaluation

• Assess for signs of urethral injury immediately: blood at the urethral meatus, inability to void, perineal/scrotal hematoma (butterfly pattern), or suprapubic tenderness indicating bladder distension 1.
• Examine for genital lacerations, abrasions, or contusions, which are the most common findings in pediatric straddle injuries 2.
• Document any penile ecchymosis or swelling, as these may indicate more severe injury even in blunt trauma to a non-erect penis 3.

Critical Red Flags Requiring Urgent Intervention

• Blood at the meatus or inability to void mandates immediate urological consultation for consideration of retrograde urethrogram to stage the injury 1.
• Perianal, hymenal, or vaginal trauma in a straddle injury suggests a penetrating mechanism and warrants investigation for either unintentional penetrating trauma or potential sexual assault 2.
• Extensive or severe injury, concurrent non-urogenital injuries, or lack of correlation between history and physical findings should trigger investigation for non-accidental trauma 2.

Urinary Drainage Management

If urethral injury is confirmed or strongly suspected, establish urinary drainage promptly via suprapubic tube (SPT) or per-urethral catheter (PR) in less severe cases 1.

Key Decision Points for Drainage Method

• SPT is preferred for complete disruptions or when urological expertise/endoscopic equipment is unavailable 1.
• PR catheter placement may be attempted in less severe cases with urological expertise available 1.
• Immediate operative repair or debridement is contraindicated due to the indistinct nature of the injury border in crush injuries 1.

Critical Pitfall to Avoid

The AUA guidelines explicitly state that immediate surgical intervention to repair or debride the injured urethra should not be performed in straddle injuries, as the extent of tissue damage evolves over the first 24-48 hours 1.

Associated Injury Screening

Musculoskeletal Assessment

• Examine for pelvic tenderness or instability, as pelvic fractures can occur with straddle mechanisms and are associated with significant morbidity 4.
• In children 6 years and younger, assess for proximal tibial fractures if the mechanism involved collision with larger individuals or objects 1.
• Obtain knee radiographs (AP and lateral views) if the child has difficulty walking or point tenderness over bony structures 5.

Head and Neck Evaluation

• Assess for any neck pain, torticollis, or limitation of neck movement, as occult cervical spine injuries can occur from falls even without reported direct head/neck trauma 6.
• Children age 6-7 years are at particularly high risk for occult neck injuries from falls or collisions 6.
• Any neck symptoms warrant immediate emergency department evaluation with MRI cervical spine if red flags are present 6.

Abdominal and Rectal Assessment

• Palpate the abdomen for tenderness, distension, or peritoneal signs, as intra-abdominal injuries can occur with significant straddle mechanisms 7.
• Perform careful perianal inspection, as anal sphincter or rectal injuries, though rare in blunt straddle trauma, can occur and require surgical intervention 7.

Imaging Strategy

When to Image the Genitourinary System

• Retrograde urethrogram is the gold standard for staging suspected urethral injury before any catheter manipulation 1, 3.
• Ultrasound of the scrotum/perineum may identify testicular injury or dislocation, which can occur even with seemingly minor external trauma 4.
• MRI pelvis without contrast should be considered if physical examination worsens or if there is concern for corporal injury despite initial negative findings 3.

When to Image Other Systems

• Plain radiographs of the pelvis are indicated if there is pelvic tenderness or mechanism suggests significant force 4.
• CT head without contrast is mandatory if there are any signs of head trauma, altered mental status, or delayed facial/periorbital swelling 8.

Specific Management Based on Injury Pattern

Confirmed Urethral Injury

• Establish urinary drainage as described above 1.
• Arrange urological follow-up for surveillance with uroflowmetry, retrograde urethrogram, and/or cystoscopy, as stricture formation after straddle injury is very high 1.
• Monitor for complications for at least one year, as most strictures develop within this timeframe 1.

Isolated Genital Soft Tissue Injury

• Most minor lacerations and abrasions can be managed conservatively with local wound care 2.
• Lacerations requiring repair should be closed primarily with absorbable suture under appropriate anesthesia 2.
• Any posterior fourchette injury in females warrants careful documentation and consideration of mechanism, as only 11% of true straddle injuries involve this area 2.

No Obvious Urethral or Genital Injury

• Ensure the child can void spontaneously before discharge 1.
• Provide analgesia with acetaminophen and/or NSAIDs if no contraindications 6.
• Arrange follow-up within 3-5 days to reassess when acute inflammation has subsided 5.

Discharge Instructions and Red Flags

Return Immediately If:

• Unable to urinate or decreased urine output 1.
• Increasing pain, swelling, or bruising of the genitals 2.
• Fever develops, suggesting infection or missed intra-abdominal injury 6.
• Any neck pain, stiffness, or neurological symptoms appear 6.
• Severe headache, vomiting, or altered mental status develops 8.
• Abdominal pain or distension occurs 7.

Follow-Up Surveillance

• All patients with urethral injury require long-term urological follow-up with uroflowmetry and imaging to detect stricture formation 1.
• Re-evaluate musculoskeletal injuries in 3-5 days if managed conservatively 5.
• Screen for psychological trauma, as injured children and families should be evaluated for stress reactions related to injury 1.

Special Considerations for Non-Accidental Trauma

High-Risk Scenarios Requiring Investigation

• Infants younger than 9 months with any genital injury 2.
• Perianal, hymenal, or vaginal injury from reported straddle mechanism 2.
• Extensive or severe injury disproportionate to reported mechanism 2.
• Concurrent non-urogenital injuries suggesting multiple trauma 2.
• Any inconsistency between history and physical findings 2.

The AAP recommends that all healthcare providers be alert to signs of potential abuse when evaluating injured children and report concerns to appropriate authorities 1.