Accepted Manuscript Rope Swing Injuries Resulting in Vulvar Trauma Holly R. Hoefgen , M.D. Diane F. Merritt , M.D. PII:
S1083-3188(14)00216-2
DOI:
10.1016/j.jpag.2014.05.009
Reference:
PEDADO 1724
To appear in:
Journal of Pediatric and Adolescent Gynecology
Received Date: 6 February 2014 Revised Date:
20 May 2014
Accepted Date: 22 May 2014
Please cite this article as: Hoefgen HR, Merritt DF, Rope Swing Injuries Resulting in Vulvar Trauma, Journal of Pediatric and Adolescent Gynecology (2014), doi: 10.1016/j.jpag.2014.05.009. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1 TITLE PAGE ROPE SWING INJURIES RESULTING IN VULVAR TRAUMA
Diane F. Merritt, M.D. Washington University School of Medicine in Saint Louis, Missouri
RI PT
Holly R. Hoefgen, M.D.
Department of Obstetrics and Gynecology, Division of Pediatric and Adolescent Gynecology
SC
No Financial Support
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Corresponding Author – Diane F. Merritt, M.D. Department of Obstetrics and Gynecology 660 South Euclid Avenue, Mail code 8064 Saint Louis, Missouri, 63110 Phone number (314-362-4211) Fax Number (314-747-1481) Email: [email protected]
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Disclaimers: Abbot Pharmaceutical (Research Support), DebioPharm (Research Support) – Unrelated to current manuscript
ACCEPTED MANUSCRIPT 2 STRUCTURED ABSTRACT AND KEY WORDS ROPE SWING INJURIES RESULTING IN VULVAR TRAUMA
SC
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River tree rope swings (RTRS) are popular for recreation along inland lakes and rivers, but not without hazard. In a comprehensive review of injuries related to rope swings, genital injuries accounted for nearly three percent. We describe significant genital injuries, with laceration and avulsion of the labia and a large vulvar hematoma in two young women as a consequence of rope swing use. Visitors to inland waterways need to be cognizant of the hazards of rope swings and health care professionals should consider this mechanism of injury when confronted with vulvar trauma.
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KEY WORDS: "Genitalia, Female/injuries", ("Vulva"[MeSH]) AND "Hematoma"[MeSH]), “Rope Swing”
ACCEPTED MANUSCRIPT 3 CASE REPORT INTRODUCTION Pediatric genital injuries represents 0.6% of overall pediatric injuries and this number continues
RI PT
to rise with nearly 57% of these cases attributed to girls. Forty-three percent of these injuries occur as lacerations, with 42.2% occurring as contusions/abrasions.1 Perineal injuries represent 0.2% of all injuries to girls under the age of 15, and are often due to accidental trauma.2 While
SC
many of these accidents are minor, severe injuries require medical assessment and expert repair. The medical provider should always inquire if there was an eyewitness to corroborate the event,
M AN U
and seek to determine if the history of the injury fits the clinical findings. Sexual assault should be considered in cases of genital trauma, and medical providers should clarify the mechanism of the injury. Accidental genital injuries often occur when the individual is dressed in light clothing, and falls upon an object. A different mechanism of injury will be described in this report of two
TE D
cases that occurred as a result of using a rope swing.
River tree rope swings (RTRS) are popular for recreation along inland lakes and rivers, but not without hazard. Rope swings are usually suspended from trees that lean over the water’s edge.
EP
Ropes may be made from natural fibers (hemp, cotton) or synthetic materials (nylon, polyester, polypropylene) and may be twisted, braided or plaited. These ropes are also often fashioned with
AC C
a tag line to pull the rope back and/or a series of knots tied in the main rope for handgrips, foot placement or climbing.3
In a review of injuries related to river tree rope swings, the most common reported injuries were finger fracture, lower extremity trauma, and head and neck trauma. Genital injuries accounted for 2.7% of those in this report, representing two labia minora lacerations in which the severity was
ACCEPTED MANUSCRIPT 4 not described.3 In our series, we present two adolescent females who sustained vulvar trauma as a consequence of rope swinging.
RI PT
CASES
Patient 1 is a 13 yo female who was transported by helicopter to the emergency department (ED) after sustaining extensive genital injuries when she slid down a rope swing. The pediatric
SC
gynecology service was called and an examination under anesthesia (EUA) was expedited due to the extent of patient’s injury and blood loss. The EUA demonstrated a laceration lateral to the
M AN U
clitoral hood extending to the pubic symphysis, through the left labia majora, avulsing the labia minora, and through the rectal mucosa and anal sphincter into the perirectal space (Figure 1a). The injury totaled 15 cm in length with a depth of 7 cm. The pediatric surgery service was consulted to assist in evaluation of her rectal injury. A sigmoidoscopic examination confirmed
TE D
the limits of the laceration as described. Once it was determined that no further rectal involvement other than the mucosal and sphincter tear were apparent, the decision was made for closure of the rectal laceration and rectal sphincter similar to repair of an obstetrical fourth
EP
degree laceration. The rectal mucosa was, therefore, closed in two layers of 3-0 Vicryl (polyglactin) on a tapered needle in a continuous (nonlocking) manner. The perirectal fascia was
AC C
identified and repaired as a separate layer with a continuous, non-locking 3-0 Vicryl. The two severed ends of the external anal sphincter muscle were identified and grasped with Allis clamps. The repair consisted of an end-to-end plication of the disrupted external anal sphincter and its capsule using four figure-of-eight 2-0 Vicryl sutures on a tapered needle. A Peña muscle stimulator was utilized to confirm the integrity of the anal sphincter repair. The perivaginal laceration was bleeding significantly, despite continued compression during the
ACCEPTED MANUSCRIPT 5 anorectal repair. Interrupted Vicryl 2-0 sutures were placed to control the bleeding and to approximate the tissue closing the dead space. The laceration which extended from above the clitoris on the left side down to the anus was then closed in layers with interrupted sutures of 2-0
RI PT
Vicryl. The decision to utilize interrupted sutures was due to concerns for bleeding and
hematoma formation. The skin was then closed with interrupted vertical mattress sutures of 2-0 Vicryl. The avulsed labia minora was also reapproximated with 3-0 and 4-0 Vicryl in layers and
SC
closed with interrupted sutures. A rectovaginal exam was then performed and good sphincter tone and mucosal repair was confirmed. Minimal bleeding was appreciated at the end of their
M AN U
repair (Figure 1b). Upon arrival to the ED, several hours after the injury, the patient’s hemoglobin was 10.6 g/dl and had fallen to 6.4 g/dl by the morning of post-operative day one. The patient and her family elected to forego a blood transfusion as she was minimally orthostatic. Postoperatively, she had a fever of 39.4° C that resolved with pulmonary toilette.
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Blood and urine cultures were negative and her hemoglobin stabilized at 6.5 g/dl. She was discharged home on post-operative day 2 with pain medication, iron supplementation and strict instructions on perineal hygiene which included two to three times daily plain warm water sitz
EP
baths, use of pericare bottle after voiding for hygiene purposes, and the need to wipe from front to back. In addition, patient was counseled on limitation in activities with stress placed on
AC C
vaginal rest and avoidance of straddle activities (such as cycling). At her postoperative visits, performed at 4 and 8 weeks, the patient was healing well and reported fecal continence (Figure 2a). One year after her surgical repair, the patient’s vulvo-vaginal and rectal area was well healed (Figure 2b) and she remained continent, but noted difficulty and pain with defecation and tampon insertion. She had never had any sexual activity. A clinical rectal examination by gastroenterology noted a small “ridge” to left side of the rectum, but an otherwise normal
ACCEPTED MANUSCRIPT 6 examination. She underwent physical therapy to assist with pelvic floor dysfunction, was began on Miralax for constipation and noted resolution of her pain symptoms She remains virginal and declines tampons use at this time.
RI PT
Patient 2 is a 15 yo female who slid down a knotted rope swing sustaining a vulvar trauma and bleeding. Her medical care was delayed due to a one and a half hour transit from the rural site of injury to her home, followed by a short commute to the emergency department. Upon
SC
evaluation she was noted to have a moderate to severe swelling of the left labia minora with a 1.5 cm and 0.5 cm lacerations. She was able to void and was discharged with instructions to apply
M AN U
ice, take sitz baths and utilize Percocet for pain control. Five days later, she was evaluated by her pediatrician due to vaginal bleeding and pain and was referred back to the emergency department for evaluation of orthostatic symptoms. The patient was noted to have a 6 cm X 2 cm hematoma of the left labia that was spontaneously draining through a 2 cm open area in her inner
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labia minora. An examination revealed that there was no extension of the hematoma into the peri-vaginal tissues. After intravenous fluid hydration, her vitals signs stabilized, and she was discharged home on pain medication. A week later, the patient was evaluated in the gynecology
EP
clinic where light compression of the hematoma resulted in release of a large amount of clotted blood and pain relief. . The patient was instructed to continue genital hygiene care. Two weeks
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later, her pain and hematoma had resolved, and the previous site of drainage was healing. DISCUSSION
The intended recreational use of the river rope swing is to elevate the thrill-seeker out over the body of water then the person is to release the rope and fall into the water below. Use of rope swings may be associated with personal risk. Foreseeable risks include including poor rope quality (frayed, torn and retied), variable water depth of the river or lake, underwater hazards
ACCEPTED MANUSCRIPT 7 (rocks or tree trunks), surrounding laceration hazards (nails, branches, broken bottles), and homemade attempts at steps and launch pads which may not be stable, and landings resulting in head and neck and extremity trauma.3 Our two patients sustained their vulvar injuries because
RI PT
they slid down the rope swing prior to releasing their grip. The first patient sustained significant perineal and anal injuries. Current surgical literature would support use of a diverting colostomy in addition to repairs of the rectum and anal sphincter in her operative management, because
SC
contamination in the presence of devitalized tissue and unprepped bowel can cause a delay in healing and infectious complications leading to breakdown of the primary repair and
M AN U
incontinence.4,5 From a gynecologic standpoint, this patient’s anorectal injuries resembled a fourth degree laceration following birth trauma. Because of our experience in primary repair of fourth degree lacerations sustained in childbirth, we were comfortable with primary repair of the rectal and anal sphincter injuries. This primary repair was successful both functionally and
TE D
cosmetically. The second patient presented to the emergency department two times with a large vulvar hematoma and was managed conservatively. Active management and drainage of vulvar hematomas may result in rapid recovery and less pain for victims of these injuries.6,7
EP
SUMMARY AND CONCLUSIONS
RTRS injuries are usually due to an intentional plunge with unintended consequences.3 In each
AC C
of our cases, the subjects (clad in bathing suits) had wrapped their legs around the rope and the injuries occurred as they slid down the rope and over the knots intended as handgrips or foot grips. The mechanism of injury occurred as the uneven rope surface abraded or cut into the soft tissues of the perineum as the girls continued to slide. We describe a significant laceration and avulsion of the labia in the first patient, and a large vulvar hematoma as a consequence for our second patient as she forcefully slid with the weight of her body onto a large knot. Both
ACCEPTED MANUSCRIPT 8 adolescents were transported over 100 miles to attain medical attention, a common complicating factor in these injuries. Visitors to inland waterways need to be cognizant of the hazards of rope swings and health care professionals and ED staff should become aware of this mechanism of
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SC
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injury when evaluating patients with vulvar trauma.
ACCEPTED MANUSCRIPT 9 ILLUSTRATIONS Photographs
Figure 2
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A) Post-Operative, Patient 1, 4 weeks B) Post-Operative, Patient 1, 15 months
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Figure 1 A) Pre-Operative evaluation, Patient 1, with extensive trauma to the left labia majora extending to pubic symphysis, deep perineal injury and extension through the rectal mucosa and anal sphincter into the perirectal space. B) Post-Operative Repair, Patient 1, Multilayer closure
ACCEPTED MANUSCRIPT 10 REFERENCES
1
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Casey J, Bjurlin M, Cheng E: Pediatric Genital Injury: An Analysis of the National Electronic Injury Surveillance System. Urology 2013; 82(5): 1125-1131
2
Spitzer R, Kives S, Cacia N, et al: Retrospective Review of Unintentional Female Genital Trauma at a Pediatric Referral Center. Pediatr Emerg Care 2008; 24(12): 831-835
3
SC
Sorey WH, Cassidy L, Crout L, et al: River Tree Rope Swing Injuries. South Med J 2008; 101(7): 699-702 4
M AN U
Vincent M, Abel C, Duncan N: Penetrating anorectal injuries in Jamaican children. Pediatr Surg Int. (2012) Doi: 10.1007/s00383-012-3176-5
5
Hashish A: Perineal trauma in children: a standardized management approach. Ann Ped Surg 2011; 7: 55-60
6
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Merritt DF: Genital Trauma in Children and Adolescents. Clin Obstet Gynecol 2008; 51(2): 237–248 7
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EP
Merritt DF: Genital Trauma in Prepubertal Girls and Adolescents. Curr Opin Obstet Gynecol 2011; 23(5): 307-314
FIGURE 1
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SC
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ACCEPTED MANUSCRIPT
A
B
A) Pre-Operative evaluation, Patient 1, with extensive trauma to the left labia majora extending to pubic symphysis, deep perineal injury and extension through the rectal mucosa and anal sphincter into the perirectal space. B) Post-Operative Repair, Patient 1, Multilayer closure
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ACCEPTED MANUSCRIPT
A) Four weeks post-operative
B) 15 months post-operative
FIGURE 2
S1083-3188(14)00216-2
DOI:
10.1016/j.jpag.2014.05.009
Reference:
PEDADO 1724
To appear in:
Journal of Pediatric and Adolescent Gynecology
Received Date: 6 February 2014 Revised Date:
20 May 2014
Accepted Date: 22 May 2014
Please cite this article as: Hoefgen HR, Merritt DF, Rope Swing Injuries Resulting in Vulvar Trauma, Journal of Pediatric and Adolescent Gynecology (2014), doi: 10.1016/j.jpag.2014.05.009. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1 TITLE PAGE ROPE SWING INJURIES RESULTING IN VULVAR TRAUMA
Diane F. Merritt, M.D. Washington University School of Medicine in Saint Louis, Missouri
RI PT
Holly R. Hoefgen, M.D.
Department of Obstetrics and Gynecology, Division of Pediatric and Adolescent Gynecology
SC
No Financial Support
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EP
TE D
Corresponding Author – Diane F. Merritt, M.D. Department of Obstetrics and Gynecology 660 South Euclid Avenue, Mail code 8064 Saint Louis, Missouri, 63110 Phone number (314-362-4211) Fax Number (314-747-1481) Email: [email protected]
M AN U
Disclaimers: Abbot Pharmaceutical (Research Support), DebioPharm (Research Support) – Unrelated to current manuscript
ACCEPTED MANUSCRIPT 2 STRUCTURED ABSTRACT AND KEY WORDS ROPE SWING INJURIES RESULTING IN VULVAR TRAUMA
SC
RI PT
River tree rope swings (RTRS) are popular for recreation along inland lakes and rivers, but not without hazard. In a comprehensive review of injuries related to rope swings, genital injuries accounted for nearly three percent. We describe significant genital injuries, with laceration and avulsion of the labia and a large vulvar hematoma in two young women as a consequence of rope swing use. Visitors to inland waterways need to be cognizant of the hazards of rope swings and health care professionals should consider this mechanism of injury when confronted with vulvar trauma.
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EP
TE D
M AN U
KEY WORDS: "Genitalia, Female/injuries", ("Vulva"[MeSH]) AND "Hematoma"[MeSH]), “Rope Swing”
ACCEPTED MANUSCRIPT 3 CASE REPORT INTRODUCTION Pediatric genital injuries represents 0.6% of overall pediatric injuries and this number continues
RI PT
to rise with nearly 57% of these cases attributed to girls. Forty-three percent of these injuries occur as lacerations, with 42.2% occurring as contusions/abrasions.1 Perineal injuries represent 0.2% of all injuries to girls under the age of 15, and are often due to accidental trauma.2 While
SC
many of these accidents are minor, severe injuries require medical assessment and expert repair. The medical provider should always inquire if there was an eyewitness to corroborate the event,
M AN U
and seek to determine if the history of the injury fits the clinical findings. Sexual assault should be considered in cases of genital trauma, and medical providers should clarify the mechanism of the injury. Accidental genital injuries often occur when the individual is dressed in light clothing, and falls upon an object. A different mechanism of injury will be described in this report of two
TE D
cases that occurred as a result of using a rope swing.
River tree rope swings (RTRS) are popular for recreation along inland lakes and rivers, but not without hazard. Rope swings are usually suspended from trees that lean over the water’s edge.
EP
Ropes may be made from natural fibers (hemp, cotton) or synthetic materials (nylon, polyester, polypropylene) and may be twisted, braided or plaited. These ropes are also often fashioned with
AC C
a tag line to pull the rope back and/or a series of knots tied in the main rope for handgrips, foot placement or climbing.3
In a review of injuries related to river tree rope swings, the most common reported injuries were finger fracture, lower extremity trauma, and head and neck trauma. Genital injuries accounted for 2.7% of those in this report, representing two labia minora lacerations in which the severity was
ACCEPTED MANUSCRIPT 4 not described.3 In our series, we present two adolescent females who sustained vulvar trauma as a consequence of rope swinging.
RI PT
CASES
Patient 1 is a 13 yo female who was transported by helicopter to the emergency department (ED) after sustaining extensive genital injuries when she slid down a rope swing. The pediatric
SC
gynecology service was called and an examination under anesthesia (EUA) was expedited due to the extent of patient’s injury and blood loss. The EUA demonstrated a laceration lateral to the
M AN U
clitoral hood extending to the pubic symphysis, through the left labia majora, avulsing the labia minora, and through the rectal mucosa and anal sphincter into the perirectal space (Figure 1a). The injury totaled 15 cm in length with a depth of 7 cm. The pediatric surgery service was consulted to assist in evaluation of her rectal injury. A sigmoidoscopic examination confirmed
TE D
the limits of the laceration as described. Once it was determined that no further rectal involvement other than the mucosal and sphincter tear were apparent, the decision was made for closure of the rectal laceration and rectal sphincter similar to repair of an obstetrical fourth
EP
degree laceration. The rectal mucosa was, therefore, closed in two layers of 3-0 Vicryl (polyglactin) on a tapered needle in a continuous (nonlocking) manner. The perirectal fascia was
AC C
identified and repaired as a separate layer with a continuous, non-locking 3-0 Vicryl. The two severed ends of the external anal sphincter muscle were identified and grasped with Allis clamps. The repair consisted of an end-to-end plication of the disrupted external anal sphincter and its capsule using four figure-of-eight 2-0 Vicryl sutures on a tapered needle. A Peña muscle stimulator was utilized to confirm the integrity of the anal sphincter repair. The perivaginal laceration was bleeding significantly, despite continued compression during the
ACCEPTED MANUSCRIPT 5 anorectal repair. Interrupted Vicryl 2-0 sutures were placed to control the bleeding and to approximate the tissue closing the dead space. The laceration which extended from above the clitoris on the left side down to the anus was then closed in layers with interrupted sutures of 2-0
RI PT
Vicryl. The decision to utilize interrupted sutures was due to concerns for bleeding and
hematoma formation. The skin was then closed with interrupted vertical mattress sutures of 2-0 Vicryl. The avulsed labia minora was also reapproximated with 3-0 and 4-0 Vicryl in layers and
SC
closed with interrupted sutures. A rectovaginal exam was then performed and good sphincter tone and mucosal repair was confirmed. Minimal bleeding was appreciated at the end of their
M AN U
repair (Figure 1b). Upon arrival to the ED, several hours after the injury, the patient’s hemoglobin was 10.6 g/dl and had fallen to 6.4 g/dl by the morning of post-operative day one. The patient and her family elected to forego a blood transfusion as she was minimally orthostatic. Postoperatively, she had a fever of 39.4° C that resolved with pulmonary toilette.
TE D
Blood and urine cultures were negative and her hemoglobin stabilized at 6.5 g/dl. She was discharged home on post-operative day 2 with pain medication, iron supplementation and strict instructions on perineal hygiene which included two to three times daily plain warm water sitz
EP
baths, use of pericare bottle after voiding for hygiene purposes, and the need to wipe from front to back. In addition, patient was counseled on limitation in activities with stress placed on
AC C
vaginal rest and avoidance of straddle activities (such as cycling). At her postoperative visits, performed at 4 and 8 weeks, the patient was healing well and reported fecal continence (Figure 2a). One year after her surgical repair, the patient’s vulvo-vaginal and rectal area was well healed (Figure 2b) and she remained continent, but noted difficulty and pain with defecation and tampon insertion. She had never had any sexual activity. A clinical rectal examination by gastroenterology noted a small “ridge” to left side of the rectum, but an otherwise normal
ACCEPTED MANUSCRIPT 6 examination. She underwent physical therapy to assist with pelvic floor dysfunction, was began on Miralax for constipation and noted resolution of her pain symptoms She remains virginal and declines tampons use at this time.
RI PT
Patient 2 is a 15 yo female who slid down a knotted rope swing sustaining a vulvar trauma and bleeding. Her medical care was delayed due to a one and a half hour transit from the rural site of injury to her home, followed by a short commute to the emergency department. Upon
SC
evaluation she was noted to have a moderate to severe swelling of the left labia minora with a 1.5 cm and 0.5 cm lacerations. She was able to void and was discharged with instructions to apply
M AN U
ice, take sitz baths and utilize Percocet for pain control. Five days later, she was evaluated by her pediatrician due to vaginal bleeding and pain and was referred back to the emergency department for evaluation of orthostatic symptoms. The patient was noted to have a 6 cm X 2 cm hematoma of the left labia that was spontaneously draining through a 2 cm open area in her inner
TE D
labia minora. An examination revealed that there was no extension of the hematoma into the peri-vaginal tissues. After intravenous fluid hydration, her vitals signs stabilized, and she was discharged home on pain medication. A week later, the patient was evaluated in the gynecology
EP
clinic where light compression of the hematoma resulted in release of a large amount of clotted blood and pain relief. . The patient was instructed to continue genital hygiene care. Two weeks
AC C
later, her pain and hematoma had resolved, and the previous site of drainage was healing. DISCUSSION
The intended recreational use of the river rope swing is to elevate the thrill-seeker out over the body of water then the person is to release the rope and fall into the water below. Use of rope swings may be associated with personal risk. Foreseeable risks include including poor rope quality (frayed, torn and retied), variable water depth of the river or lake, underwater hazards
ACCEPTED MANUSCRIPT 7 (rocks or tree trunks), surrounding laceration hazards (nails, branches, broken bottles), and homemade attempts at steps and launch pads which may not be stable, and landings resulting in head and neck and extremity trauma.3 Our two patients sustained their vulvar injuries because
RI PT
they slid down the rope swing prior to releasing their grip. The first patient sustained significant perineal and anal injuries. Current surgical literature would support use of a diverting colostomy in addition to repairs of the rectum and anal sphincter in her operative management, because
SC
contamination in the presence of devitalized tissue and unprepped bowel can cause a delay in healing and infectious complications leading to breakdown of the primary repair and
M AN U
incontinence.4,5 From a gynecologic standpoint, this patient’s anorectal injuries resembled a fourth degree laceration following birth trauma. Because of our experience in primary repair of fourth degree lacerations sustained in childbirth, we were comfortable with primary repair of the rectal and anal sphincter injuries. This primary repair was successful both functionally and
TE D
cosmetically. The second patient presented to the emergency department two times with a large vulvar hematoma and was managed conservatively. Active management and drainage of vulvar hematomas may result in rapid recovery and less pain for victims of these injuries.6,7
EP
SUMMARY AND CONCLUSIONS
RTRS injuries are usually due to an intentional plunge with unintended consequences.3 In each
AC C
of our cases, the subjects (clad in bathing suits) had wrapped their legs around the rope and the injuries occurred as they slid down the rope and over the knots intended as handgrips or foot grips. The mechanism of injury occurred as the uneven rope surface abraded or cut into the soft tissues of the perineum as the girls continued to slide. We describe a significant laceration and avulsion of the labia in the first patient, and a large vulvar hematoma as a consequence for our second patient as she forcefully slid with the weight of her body onto a large knot. Both
ACCEPTED MANUSCRIPT 8 adolescents were transported over 100 miles to attain medical attention, a common complicating factor in these injuries. Visitors to inland waterways need to be cognizant of the hazards of rope swings and health care professionals and ED staff should become aware of this mechanism of
AC C
EP
TE D
M AN U
SC
RI PT
injury when evaluating patients with vulvar trauma.
ACCEPTED MANUSCRIPT 9 ILLUSTRATIONS Photographs
Figure 2
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A) Post-Operative, Patient 1, 4 weeks B) Post-Operative, Patient 1, 15 months
SC
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Figure 1 A) Pre-Operative evaluation, Patient 1, with extensive trauma to the left labia majora extending to pubic symphysis, deep perineal injury and extension through the rectal mucosa and anal sphincter into the perirectal space. B) Post-Operative Repair, Patient 1, Multilayer closure
ACCEPTED MANUSCRIPT 10 REFERENCES
1
RI PT
Casey J, Bjurlin M, Cheng E: Pediatric Genital Injury: An Analysis of the National Electronic Injury Surveillance System. Urology 2013; 82(5): 1125-1131
2
Spitzer R, Kives S, Cacia N, et al: Retrospective Review of Unintentional Female Genital Trauma at a Pediatric Referral Center. Pediatr Emerg Care 2008; 24(12): 831-835
3
SC
Sorey WH, Cassidy L, Crout L, et al: River Tree Rope Swing Injuries. South Med J 2008; 101(7): 699-702 4
M AN U
Vincent M, Abel C, Duncan N: Penetrating anorectal injuries in Jamaican children. Pediatr Surg Int. (2012) Doi: 10.1007/s00383-012-3176-5
5
Hashish A: Perineal trauma in children: a standardized management approach. Ann Ped Surg 2011; 7: 55-60
6
TE D
Merritt DF: Genital Trauma in Children and Adolescents. Clin Obstet Gynecol 2008; 51(2): 237–248 7
AC C
EP
Merritt DF: Genital Trauma in Prepubertal Girls and Adolescents. Curr Opin Obstet Gynecol 2011; 23(5): 307-314
FIGURE 1
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M AN U
SC
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ACCEPTED MANUSCRIPT
A
B
A) Pre-Operative evaluation, Patient 1, with extensive trauma to the left labia majora extending to pubic symphysis, deep perineal injury and extension through the rectal mucosa and anal sphincter into the perirectal space. B) Post-Operative Repair, Patient 1, Multilayer closure
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ACCEPTED MANUSCRIPT
A) Four weeks post-operative
B) 15 months post-operative
FIGURE 2
