The elasticity and flexibility of a child’s thoracic cage make chest wall injuries
less common than internal thoracic injuries such as a pulmonary contusion. When
chest wall injuries do occur, the patient is at increased risk for intrathoracic
injuries. Included in chest wall injuries are rib, sternal, and scapular fractures, as
well as flail chest. Goals of treatment should include appropriate evaluation of the
extent of injury and presence of underlying intrathoracic injury. Interventions for
chest wall injuries are mostly supportive, consisting of pain control to prevent
splinting and encouragement of ambulation to prevent hypoventilation.
CLINICAL PEARLS AND PITFALLS
Chest wall injuries are less common in children than adults due to
increased elasticity and compliance of the chest wall, and therefore
their presence often indicates coincident intrathoracic injury.
Most isolated chest wall injuries can be managed as an outpatient with
adequate analgesia to prevent splinting and hypoventilation.
Posterior rib fractures, rib fractures in infants and toddlers, fractures of
different ages, and the absence of a clear mechanism of injury are all
highly concerning for child abuse and should prompt further evaluation.

FIGURE 115.9 Algorithm for the evaluation and diagnosis of traumatic rupture of the thoracic
aorta.


RIB FRACTURES
Rib fractures secondary to thoracic trauma are far less common in children than
in the adult population. They may occur from either a direct blow to the rib or
compression of the chest in an anterior–posterior direction. In a direct blow to the
rib, the rib will fracture inward and may puncture the pleural cavity, causing a
pneumothorax, or lacerate a blood vessel resulting in a hemothorax. Compression
of the chest wall can cause the lateral portions of the ribs to fracture outward.
Intrathoracic injury is seen less commonly with this type of fracture.
In one study, rib fractures occurred in 32% of all children admitted with

thoracic trauma, with motor vehicle collisions accounting for the largest
proportion of injuries. Single rib fractures did not correlate with the severity of
injury, but as the number of fractures increased, so did the likelihood of
multisystem and intrathoracic injuries. While studies have shown that first rib
fractures are only predictive of intrathoracic injury in the presence of other
concerning symptoms, a higher index of suspicion for intrathoracic injury is
necessary in the presence of a first rib fracture due to force required to injure this
rib in its protected location.
The pediatric patient with a rib fracture may splint and hypoventilate secondary
to pain. Physical examination may reveal point tenderness and crepitus if a
pneumothorax is present. If the patient is stable, then management should focus
on relief of pain, monitoring the respiratory status, and further evaluation for
underlying injury. Wrapping or binding the chest wall is contraindicated because
these measures may impair ventilatory function. Opiates may be required but
should be used with caution because they may also cause respiratory depression.
For patients requiring admission to the hospital, epidural analgesia or intercostal
nerve blocks may be helpful.
Patients with multiple rib fractures should be admitted to the hospital for pain
control, pulmonary physiotherapy, and observation for worsening respiratory
status. Younger children may require admission to rule out child abuse. Prognosis
for isolated rib fractures is excellent, with most healing within 6 weeks without
any permanent disability.

RIB FRACTURES AND CHILD ABUSE
Rib fractures in young children are highly associated with child abuse. In one
study, the positive predictive value of a rib fracture for nonaccidental trauma was
95% in children less than 3 years old; this number increased to 100% when there
was no obvious accidental mechanism provided by the caretaker. Additionally,
posterior rib fractures or fractures at multiple stages of healing in infants and



toddlers are considered pathognomonic for abuse. Significant chest wall trauma
in a young child should always lead the examiner to consider child abuse. If no
clear mechanism of injury is presented, further diagnostic studies, such as a
skeletal survey are often appropriate. Consultation with a child abuse specialist,
where available, may help guide appropriate testing and management.

FLAIL CHEST
Fracturing segments of two or more ribs on the same side may result in that
particular chest wall segment losing continuity with the thoracic cage, causing a
flail chest ( Fig. 115.10 ). Flail chest most commonly results from direct impact to
the ribs, and is very uncommon in children, owing to the marked compliance of
the chest wall. When a flail chest does occur, it is usually associated with an
intrathoracic injury, most often pulmonary contusion, because of the force
involved.
The goal of treatment should be to stabilize the involved portion of the thoracic
cage. At the scene, the patient can be placed with the injured side down, thus
improving tidal volume and ventilation. Any patient with respiratory distress
should be intubated and managed with positive pressure ventilation. This serves
two purposes. First, the patient’s airway is well protected. Second, the positive
pressure provides optimal lung expansion and splinting of the injured segment.
However, the high pressures necessary to inflate the underlying contused lung can
cause a pneumothorax; therefore, care must be taken when delivering positive
pressure to the injured child. If the patient does not require intubation, aggressive
pulmonary physiotherapy, along with pain control, is the treatment of choice.


FIGURE 115.10 Pathophysiologic consequence of flail chest with paradoxical motion.
(Reprinted with permission from Fleisher GR, Ludwig S, Henretig FM. Textbook of Pediatric
Emergency Medicine . 3rd ed. Baltimore, MD: Lippincott Williams & Wilkins, Fig. 101.4 .)


STERNAL, SCAPULAR, AND MEDIAL CLAVICLE
FRACTURES
Sternal and scapular fractures are uncommon in children. When diagnosed, a
thorough evaluation for other thoracic injuries is recommended because of the
significant force required to fracture these bones. Fortunately, only rarely are
associated vascular or brachial plexus injuries detected.
Displaced fractures of the proximal one-third of the clavicle (or
sternoclavicular dislocations in older children), while uncommon, may lead to
mediastinal injury from the posteriorly displaced fragment. Patients may present
with neurovascular impairment of the extremity, dysphagia, hoarseness, dyspnea,
or even signs of circulatory compromise. Visualization of the fracture itself may
be difficult on plain films of the sternum or clavicle. If a proximal clavicle
fracture or dislocation is found or highly suspected on CXR, CT angiography of
the chest should be performed to better characterize the injury and assess for
involvement of the great vessels. Treatment will depend on the extent of the
injury, but coordination between orthopedic and general or thoracic surgeons is
usually necessary to ensure adequate evaluation of all possible injuries and
maximize likelihood of a successful outcome (see Chapter 111 Musculoskeletal
Trauma ).

PENETRATING TRAUMA AND ED THORACOTOMY
Goals of Treatment