Penile zipper injury

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23.17 Penile zipper injury

Background

The most common cause of penile entrapment is an unintentional zipper injury. Most commonly seen in boys aged 2–6 years, this injury occurs while the child is zipping up his pants. In addition to being painful, this condition is a tremendously anxiety-inducing injury for the child.

The patient usually presents for medical attention only after failed attempts at self-extrication. There are two patterns of entrapment for the often-macerated and oedematous soft tissue. First, the movable zipper head may ‘catch onto’ the external genitalia tissue. Second, the interlocking teeth along the zipper path may entrap some soft tissue. In order to disassemble a zipper, one must understand its anatomy. Specifically, a thin median bar is the only structure separating the two tracks on the zipper-sliding device, interlocking them.

Indications

Soft-tissue entrapment in a zipper.

Contraindications

Equipment

Bone or wire cutters.

Local anaesthesia (1% lidocaine without adrenaline (epinephrine), syringe, 30-gauge needle).

Preparation and positioning

Carefully position the patient supine or semisupine in the caregiver’s lap, being careful not to jostle the pants or zipper.

In a child whom you anticipate is going to be too agitated or fearful of the procedure, consider procedural sedation.

Procedure

Soak the exposed external genitalia in mineral oil for 10 minutes to lubricate the contact points. Occasionally, this manoeuvre alone will allow the zipper to easily retract so that the tissue is freed.

Anaesthetise the entrapped tissue using 1% lidocaine without adrenaline (epinephrine).

For the external genitalia entrapped in the zipper sliding device, use the bone or wire cutter to break the thin median bar that separates the two sliding tracks. The front and back plates will fall apart, releasing the entrapped skin (Fig. 23.17.1).

For the external genitalia entrapped in the interlocking teeth, cut the zipper just inferiorly to the entrapment site. The two interlocking rows of teeth will, with gentle manipulation, slowly separate from one another and release the skin.

Provide supportive wound care to the injury site using warm soaks and apply a dressing. In severe soft tissue injuries, however, suture repair and/or debridement of the wound may be necessary under the guidance of a consulting urologist.

Fig. 23.17.1 Diagram of zipper separation after cutting median bar.

Complications

The primary complication in penile zipper removal is pain. This occurs most commonly during the positioning and preparation of the patient. Gentle manipulation and positioning are essential for this procedure.

Tips

• Cutting off the pant legs (and possibly even the rest of the pants around the zipper) can provide significant pain relief.

• Because pain is a significant fear in these patients, a compromise between local anaesthesia and procedural sedation is a regional block. A dorsal penile block will anaesthetise the entire penis.

Further reading

Kanegaye J.T., Shonfeld N. Penile zipper entrapment: A simple and less threatening approach using mineral oil. Paediatr Emerg Care. 1993;9(2):90-91.

Lundquist S.T., Stack L.B. Diseases of the foreskin, penis, and urethra. Emerg Med Clin N Am. 2001;19(3):529-546.

Nolan J.F., et al. Acute management of the zipper-entrapped penis. J Emerg Med. 1990;8(3):305-307.

Woodward G.A. Penile zipper injuries. In: Dieckmann R.A., et al, editors. Paediatric emergency and critical care procedures. St Louis, MO: Mosby; 1997:425-426.

Wyatt J.P., Scobie W.G. The management of penile zip entrapment in children. Injury. 1994;25(1):59-60.

Related

Textbook of Paediatric Emergency Medicine