SUMMER FUN AND STRADDLE INJURIES

Summer Fun

AND STRADDLE INJURIES

PATRICIA MARAN, MD, FACOG

As the snow drops begin to open, and the crocus tips peek through the soil, I start to hear children playing outside. I am lucky to live in a neighborhood where kids still venture outside. As a former teacher and sports coach turned gynecologist, I am slightly more apprehensive watching kids begin to play this year. Two years of Covid restrictions have deconditioned us all.

Let me explain. A common reason for me to get called to the ER during spring and summer months is to fix straddle injuries: think little children slamming down on their privates. Jungle gyms, backyard balance beams, rope swings, water parks, and bicycles all keep me busy on warm sunny evenings. Just as academic and social skills have been altered for our children so too have fundamental movement skills. Our children are two years taller and heavier, unaccustomed to these bodies, and potentially delayed in learning kinesthetic skills such as skipping, climbing, jumping, peddling, and swimming.

STRADDLE INJURIES

Typical injuries resulting when a child slips or missteps and falls, splitting the legs and causing damage to the genital region. Often these injuries can be categorized as laceration, abrasion, bruise, or trauma. Below I will discuss categories of injuries and preventative suggestions.

Balance changes as children grow; their center of gravity moves during growth spurts. Learning basic activities becomes more difficult the further we are from the ground, making balance beams and jungle gyms my nemesis. Lack of estrogen in prepubescent girls prevents the labia from having any cushion or padding so when they fall, the proximity of bone to skin makes pelvic injuries bleed like facial injuries. I have had a challenging time putting “lady parts” back together after these falls because unlike obstetric injuries of adult women, there is no “extra” skin or folds or fat to help with the repair. Ultimately, while children heal quickly with no marked cosmetic or structural defects, it is exceptionally difficult to keep an elementary child from “playing” for a week during postoperative recovery.

Rule 1: Wear shorts that cover the entire underwear and inner thigh. Don’t play in sundresses and bathing suits without board or bike shorts.

Rule 2: Avoid biking with flip flops; the feet easily slip off the pedals, and bike cross bars have the potential to make mincemeat of the genitalia. Bikes have been difficult to buy for supply chain deficits, so children are often using older siblings’/neighbors’ bikes increasing susceptibility to injury. Helmets, footwear, and proper shorts are likely the most important safety features for little ones.

If your child has injured themselves and you find blood in their groin or on underwear and garments, regardless of how long ago this might have happened, please get this assessed. It’s infinitely easier to fix these genital cuts sooner rather than later. Remember oftentimes children will show doctors and nurses before they might show parents, so encourage them to be honest with health care providers.

GENITAL HEMATOMAS

A purple bruise, possibly expanding, found in the genital region likely after a fall, kick, sports injury or “rough-housing.”

If skin is protected and there are no visible cuts, please make sure the child has no labial or scrotal swelling forming. It’s easy to diagnose: the child will start walking as if they just got off a horse, complaining about underwear pulling or sitting at the dinner table crookedly. Boys may remain curled up in a fetal position if there has been a hematoma that may compromise or constrict the scrotal sac. Older children may be hesitant for anyone to “look down there.” To identify an issue, have them walk over you as you are lying on the floor. Even older children tend to be willing to do this. If anything looks bruised and swollen or you are not able to distinguish distinct anatomy, it’s time to seek help. Have the child sit on a cool pack or damp, cool towels, or have your older child self-administer a wrapped ice pack between the legs. If old enough, have the child use a marker to identify the affected area. Pack the pelvis with covered ice packs and get to the doctor – especially for boys with scrotal injuries and girls with labial hematomas. With no natural place for the body to stop internal bleeding under the skin, a great deal of blood can be lost very quickly in this region.

GENITAL ABRASIONS

Cuts, scrapes, falls and bug bites naturally occur as part of summer. Summer campfires or beach bonfires are frequented by mosquitoes, especially in the Mid-Atlantic waterways. A simple cut from scratching compromises the skin barrier. On a child’s leg it is easy to use Neosporin or anti-itch cream but when close to the genitals, cracked skin can become an infection requiring antibiotics or further evaluation. Our skin naturally has bacterial organisms, the most common of which are staph and strep bacteria. While generally harmless, if the skin is compromised, these bacteria can penetrate the surface, wall off, and become abscesses, especially in children who are still toilet training. E. coli from our stool very easily can be transmitted to the site of skin abrasions. Certain local isolated infections can be managed at home, but somehow genital abrasions always seem to blossom into unwanted persistent infections. Soak the area in warm water and use a drawing salve or a touch of salt in the bathwater. If the area is getting warmer, larger, redder, and more painful, please get to a practitioner to see if antibiotics are indicated. Rule 3: Wear bug spray or use a morsel to press and combine with oil/vaseline an herb combination of rosemary and cedar, catnip, lavender, or mint to protect the skin. Most of the time, if you are walking on wilderness trails, these sources of bug repellent are all around you.

Rule 4: Wear clothes that cover the legs and arms especially at sunup, sundown, or near murky stagnant water sources. Near the ocean, protect yourself during low tide. Remember, children have a higher metabolism, emit more levels of carbon dioxide, and tend to attract biting insects more readily than adults.

GENITAL TRAUMA

Fun activities can bring unforeseen consequences and injuries even unexpectedly from water fountains, water parks, water skiing, and rope swings.

Rule 5: Wear appropriate clothes.

Rule 6: Whether you have teenagers who wish to sunbathe or little children who can’t help but squeal with delight when they feel water poured, splashed, and blown on them, please play safely. Don’t assume anyone has checked for insecure and unsafe settings. Be cognizant of your own strength, balance, endurance, and surroundings if you are teaching a young one.

Rule 7: Don’t let little girls who might be potty training and going commando stand or squat directly over water jets found at most water parks and town pools.

Fountain play and genital tears: Especially if other children are standing on up-spouts, the pressure from the fountain can blow into the vaginal opening of young children, and subsequently cause tears and trauma to the upper vagina. Not only are these hard to diagnose, but these tears to the vagina can also track upward and water can cause a shear effect thus penetrating through to the abdominal cavity. While these are rare injuries, they are troublesome and potentially dangerous when they occur.

Water skiing for older teens or adult women can result in a similar traumatic injury. If a female has had a hysterectomy or has entered menopause, the tissue of the vagina is less sturdy than it had been. The sheer pressure that occurs as one is pulled through the water to stand on the ski, can cause penetrating water. Typically, women will report a popping sensation or a sense of acute, sudden onset vaginal pain with unexplained bleeding.

Rule 9: Please don’t rope swing.While incredibly fun, swinging on a thick rope, jumping into running river rapids, when your hands are wet, can lead to big trouble. First, it is hard to catch a grip of the rope, especially if you are heavier than you used to be with either less upper body strength or more weight in the hips. Second, when you slip or fail to time a release, you will likely slip down the rope and can tear the skin around the clitoris and labia minora. Third, most rope swings I have used are not the cleanest of devices. Even simple small cuts from a rope can leave rope splinters, abrasions, lacerations, and hematomas or a combination of all of these. Locations for these activities are in scenic, hard to reach places requiring some form of hiking in or out. Swimming towards land as this happens can be difficult; walking after one of these ropeburn injuries can exacerbate risks for infection, and often there is a delay in care, making these injuries challenging to fix and exceptionally painful to withstand.

Rule 10: What you burn today, won’t feel good tomorrow. Seriously, skin cancer including melanoma of the glutes and inner groin are developing more frequently than one might expect. First, these areas burned during our youth are not often examined and evaluated as adults. Second, late diagnosis of skin cancer in the urologists’ and gynecologists’ domain are common. Third, these areas are very vascular, close to the inguinal blood vessel and lymphatic supply and have an easy pathway to metastasize. We may not be able to prevent it for ourselves or our older teens since the sun exposure has already occurred, but for our little ones, SPF clothing and fuller sun coverage protects from all the above summer injuries mentioned.

May our kids play every day, and may we have fun chasing them.

Be well, be safe, and have a great spring and summer.