Chest wall injuries in children
- Howard Kadish, MD, MBA
Howard Kadish, MD, MBA
- Professor of Pediatrics
- Division Chief, Pediatric Emergency Medicine
- University of Utah School of Medicine
- Section Editor
- Richard G Bachur, MD
Richard G Bachur, MD
- Section Editor — Pediatric Trauma
- Professor of Pediatrics and Emergency Medicine
- Harvard Medical School
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
Chest wall injuries in children are significant primarily because they often occur as the result forceful mechanisms that also cause serious associated injuries. Because the thoracic cage of a child is more elastic and flexible than that of an adult, less of the force of impact is absorbed by the chest wall and proportionally more force is transmitted to intrathoracic organs. Intrathoracic injury (such as pulmonary contusion) often occurs without visible damage to the chest wall.
This topic will review the epidemiology, injury types, evaluation, and management of chest wall injuries in children. Included in chest wall injuries are rib fractures, flail chest, and sternal and scapular fractures. Thoracic trauma, intrathoracic injuries, and pulmonary contusion in children, as well as thoracic trauma and rib fractures in adults, are discussed separately. (See "Initial evaluation and stabilization of children with thoracic trauma" and "Overview of intrathoracic injuries in children" and "Pulmonary contusion in children" and "Initial evaluation and management of blunt thoracic trauma in adults" and "Initial evaluation and management of rib fractures".)
Chest wall injuries in children typically occur as the result of blunt thoracic trauma. Rib fractures constitute the vast majority of these injuries. In a prospective series describing 80 children with thoracic injuries following blunt torso trauma, 28 had rib fractures, and one had a fractured sternum . (See 'Rib fractures' below.)
In reports describing children with thoracic injuries evaluated in pediatric trauma centers, most patients were injured as passengers or pedestrians in motor vehicle crashes [1-3]. Among infants and young children, however, rib fractures occur most commonly as the result of inflicted injury. (See "Orthopedic aspects of child abuse", section on 'Rib fractures'.)
Mortality for children with chest wall injuries is usually the result of associated injuries, particularly head injury. In several retrospective series describing children with thoracic trauma, 4 to 14 percent of deaths occurred because of thoracic injuries alone. Mortality rates for children with chest and head injuries ranged from 28 to 37 percent [2,4,5]. The presence and number of rib fractures is positively correlated with mortality. As an example, in one observational study of over 19,000 children with rib fractures, mortality increased from 2 percent for no rib fractures to 6 percent for one fracture and 8 percent for seven fractures . The presence of any rib fracture compared to no fracture remained strongly associated with increased mortality even after adjustment for injury severity.
- Holmes JF, Sokolove PE, Brant WE, Kuppermann N. A clinical decision rule for identifying children with thoracic injuries after blunt torso trauma. Ann Emerg Med 2002; 39:492.
- Peclet MH, Newman KD, Eichelberger MR, et al. Thoracic trauma in children: an indicator of increased mortality. J Pediatr Surg 1990; 25:961.
- Schweich P, Fleisher G. Rib fractures in children. Pediatr Emerg Care 1985; 1:187.
- Cooper A, Barlow B, DiScala C, String D. Mortality and truncal injury: the pediatric perspective. J Pediatr Surg 1994; 29:33.
- Black TL, Snyder CL, Miller JP, et al. Significance of chest trauma in children. South Med J 1996; 89:494.
- Rosenberg G, Bryant AK, Davis KA, Schuster KM. No breakpoint for mortality in pediatric rib fractures. J Trauma Acute Care Surg 2016; 80:427.
- Sartorelli KH, Vane DW. The diagnosis and management of children with blunt injury of the chest. Semin Pediatr Surg 2004; 13:98.
- Garcia VF, Gotschall CS, Eichelberger MR, Bowman LM. Rib fractures in children: a marker of severe trauma. J Trauma 1990; 30:695.
- Kessel B, Dagan J, Swaid F, et al. Rib fractures: comparison of associated injuries between pediatric and adult population. Am J Surg 2014; 208:831.
- Kadish, H. Thoracic trauma. In: Textbook of Pediatric Emergency Medicine, 5th ed, Fleisher, GR, Ludwig, S, Henretig, FM (Eds), Lippincott, Williams and Wilkins, Philadelphia 2006. p.1433.
- Al-Hassani A, Abdulrahman H, Afifi I, et al. Rib fracture patterns predict thoracic chest wall and abdominal solid organ injury. Am Surg 2010; 76:888.
- Logan PM. Is there an association between fractures of the cervical spine and first- and second-rib fractures? Can Assoc Radiol J 1999; 50:41.
- Harris GJ, Soper RT. Pediatric first rib fractures. J Trauma 1990; 30:343.
- Ozel SK, Kazez A. Horner syndrome due to first rib fracture after major thoracic trauma. J Pediatr Surg 2005; 40:e17.
- Shweiki E, Klena J, Wood GC, Indeck M. Assessing the true risk of abdominal solid organ injury in hospitalized rib fracture patients. J Trauma 2001; 50:684.
- Borman JB, Aharonson-Daniel L, Savitsky B, et al. Unilateral flail chest is seldom a lethal injury. Emerg Med J 2006; 23:903.
- Nakayama DK, Ramenofsky ML, Rowe MI. Chest injuries in childhood. Ann Surg 1989; 210:770.
- Kwon, Y, Sarwark, JF. Proximal humerus, scapula, and clavicle. In: Fractures in Children, 5th, Beaty, JH, Kasser, JR (Eds), Lippincott, Williams, and Wilkins, Philadelphia 2001. p.751.
- Stanley D, Trowbridge EA, Norris SH. The mechanism of clavicular fracture. A clinical and biomechanical analysis. J Bone Joint Surg Br 1988; 70:461.
- Webb PA, Suchey JM. Epiphyseal union of the anterior iliac crest and medial clavicle in a modern multiracial sample of American males and females. Am J Phys Anthropol 1985; 68:457.
- Waters PM, Bae DS, Kadiyala RK. Short-term outcomes after surgical treatment of traumatic posterior sternoclavicular fracture-dislocations in children and adolescents. J Pediatr Orthop 2003; 23:464.
- Ferguson LP, Wilkinson AG, Beattie TF. Fracture of the sternum in children. Emerg Med J 2003; 20:518.
- DeFriend DE, Franklin K. Isolated sternal fracture--a swing-related injury in two children. Pediatr Radiol 2001; 31:200.
- Hechter S, Huyer D, Manson D. Sternal fractures as a manifestation of abusive injury in children. Pediatr Radiol 2002; 32:902.
- Chiu WC, D'Amelio LF, Hammond JS. Sternal fractures in blunt chest trauma: a practical algorithm for management. Am J Emerg Med 1997; 15:252.
- Sadaba JR, Oswal D, Munsch CM. Management of isolated sternal fractures: determining the risk of blunt cardiac injury. Ann R Coll Surg Engl 2000; 82:162.
- Bowen TR, Miller F. Greenstick fracture of the scapula: a cause of scapular winging. J Orthop Trauma 2006; 20:147.
- Stephens NG, Morgan AS, Corvo P, Bernstein BA. Significance of scapular fracture in the blunt-trauma patient. Ann Emerg Med 1995; 26:439.
- Veysi VT, Mittal R, Agarwal S, et al. Multiple trauma and scapula fractures: so what? J Trauma 2003; 55:1145.
- Weening B, Walton C, Cole PA, et al. Lower mortality in patients with scapular fractures. J Trauma 2005; 59:1477.
- Westcott J, Davis SD, Fleishon H, et al. Rib fractures. American College of Radiology. ACR Appropriateness Criteria. Radiology 2000; 215 Suppl:637. www.acr.org (Accessed on February 20, 2007).
- Section on Radiology, American Academy of Pediatrics. Diagnostic imaging of child abuse. Pediatrics 2009; 123:1430.
- Kelloff J, Hulett R, Spivey M. Acute rib fracture diagnosis in an infant by US: a matter of child protection. Pediatr Radiol 2009; 39:70.
- Ferrera PC, Wheeling HM. Sternoclavicular joint injuries. Am J Emerg Med 2000; 18:58.
- Rankin AP, Comber RE. Management of fifty cases of chest injury with a regimen of epidural bupivacaine and morphine. Anaesth Intensive Care 1984; 12:311.
- Cicala RS, Voeller GR, Fox T, et al. Epidural analgesia in thoracic trauma: effects of lumbar morphine and thoracic bupivacaine on pulmonary function. Crit Care Med 1990; 18:229.
- Karmakar MK, Ho AM. Acute pain management of patients with multiple fractured ribs. J Trauma 2003; 54:615.
- Gunduz M, Unlugenc H, Ozalevli M, et al. A comparative study of continuous positive airway pressure (CPAP) and intermittent positive pressure ventilation (IPPV) in patients with flail chest. Emerg Med J 2005; 22:325.
- Linton DM, Sviri S. Conservative management of flail chest after cardiopulmonary resuscitation by continuous negative extrathoracic pressure. Crit Care Resusc 2006; 8:339.
- Engel C, Krieg JC, Madey SM, et al. Operative chest wall fixation with osteosynthesis plates. J Trauma 2005; 58:181.
- INJURY TYPES
- Rib fractures
- - First rib fractures
- - Lower rib fractures
- Flail chest
- Clavicle fractures
- Sternal fractures
- Scapular fractures
- PRIMARY EVALUATION AND MANAGEMENT
- Initial assessment
- - History
- - Physical examination
- Diagnostic studies
- - Electrocardiogram
- - Imaging
- DEFINITIVE MANAGEMENT
- SUMMARY AND RECOMMENDATIONS