RIB FRACTURES Rib fractures secondary to thoracic trauma are far less common in children than in the adult population They may occur from either a direct blow to the rib or compression of the chest in an anterior–posterior direction In a direct blow to the rib, the rib will fracture inward and may puncture the pleural cavity, causing a pneumothorax, or lacerate a blood vessel resulting in a hemothorax Compression of the chest wall can cause the lateral portions of the ribs to fracture outward Intrathoracic injury is seen less commonly with this type of fracture In one study, rib fractures occurred in 32% of all children admitted with thoracic trauma, with motor vehicle collisions accounting for the largest proportion of injuries Single rib fractures did not correlate with the severity of injury, but as the number of fractures increased, so did the likelihood of multisystem and intrathoracic injuries While studies have shown that first rib fractures are only predictive of intrathoracic injury in the presence of other concerning symptoms, a higher index of suspicion for intrathoracic injury is necessary in the presence of a first rib fracture due to force required to injure this rib in its protected location The pediatric patient with a rib fracture may splint and hypoventilate secondary to pain Physical examination may reveal point tenderness and crepitus if a pneumothorax is present If the patient is stable, then management should focus on relief of pain, monitoring the respiratory status, and further evaluation for underlying injury Wrapping or binding the chest wall is contraindicated because these measures may impair ventilatory function Opiates may be required but should be used with caution because they may also cause respiratory depression For patients requiring admission to the hospital, epidural analgesia or intercostal nerve blocks may be helpful Patients with multiple rib fractures should be admitted to the hospital for pain control, pulmonary physiotherapy, and observation for worsening respiratory status Younger children may require admission to rule out child abuse Prognosis for isolated rib fractures is excellent, with most healing within weeks without any permanent disability RIB FRACTURES AND CHILD ABUSE Rib fractures in young children are highly associated with child abuse In one study, the positive predictive value of a rib fracture for nonaccidental trauma was 95% in children less than years old; this number increased to 100% when there was no obvious accidental mechanism provided by the caretaker Additionally, posterior rib fractures or fractures at multiple stages of healing in infants and