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