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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