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