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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.