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 — Adult and Pediatric Emergency Medicine
- Senior 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.
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- 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