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 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