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Cas lâm sàng cấp cứu nhi khoa 2019

Case 54



Veena Ramaiah

Question

A 3-year-old presents with blood in underwear and a laceration in her genitourinary area. Patient told her mom that she was playing with her 7- and 5-year-old brothers and they were sliding down a pole (a rod from a window shade) they had set up from the bed to the floor. There were hard plastic blocks on the ground near the end of the pole. Mom thinks her daughter slid onto the hard blocks causing the laceration.The patient is able to tolerate an exam in the supine frog-leg position. On exam, there is a perineal laceration that seems to extend up to the distal posterior vaginal wall. There is bleeding from the laceration but not from the inside of the vagina as far as you can tell

Is this a plausible explanation? What is your next step? How would you manage this laceration?

Answer

Genital lacerations are indicative of trauma to the genital area. It is plausible that this occurred from the child straddling an object forcefully—either impaling herself on the rod or falling forcefully on a hard object as it is primarily an external injury.

The concern of sexual abuse always exists with any genital injury. In order to increase the reliability of the history, the child should be interviewed separate from the caretakers, if verbal, to ask the events of the history.

This child was interviewed and reported getting hurt when she slid down the rod and fell. During a screening of sexual abuse history, she denied anyone hurting her or touching her.

Medically, an exam under sedation was arranged to ensure no intravaginal laceration, no extension into the rectum, and to repair the laceration.

In general, straddle injuries in females result in external injury. Most children fall forward so injury is often seen to the anterior structures such as the clitoris, the labia majora, and the fold between the labia majora and minora. Girls can also fall directly onto their perineum as in this case. Again the injury is primarily external and does not involve the hymenal tissue or the more internal structures.

Injuries from sexual abuse or assault are very uncommon overall—80%–90% of exams are normal—however, when they are present, they usually involve  the  posterior  rim  of  the  hymen  (4 o’clock–8 o’clock) or the posterior fourchette.

Keywords: child abuse mimickers, genitourinary, blunt trauma

Bibliography

Adams JA, Kellogg ND, Farst KJ, Harper NS, Palusci VJ, Frasier LD, Levitt CJ, Shapiro RA, Moles RL,

Starling SP. Updated guidelines for the medical assessment and care of children who may have been sexually abused. J Pediatr Adolesc Gynecol April 2016;29(2):81–7.

Saxena AK, Steiner M, Höllwarth ME. Straddle injuries in female children and adolescents: 10-year.


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