Due to the elasticity of the chest wall, rib fractures indicate exposure to significant traumatic force. Providers should have high suspicion for additional underlying injuries. First rib fractures are concerning for additional injuries and fractures given the amount of force required to break this rib and its proximity to the mediastinum, subclavian vessels, and brachial plexus, as well as the head and cervical spine. Furthermore, each added rib fracture has a near-linear relationship with mortality rate. Unlike adults, there is no inflection point, even at seven or more ribs. ^,

Rib fractures in children under 3 years of age are suspicious for child physical abuse and may be the only indicator of ongoing abuse in as many as 30% of patients. A systematic review of children under 18 years old found that rib fractures from cardiopulmonary resuscitation are exceedingly rare (3 of 923 children) and all were anterior. Current guidelines recommend automatic physical abuse screening for all children under 3 years of age who present with rib fractures.

Chest x-rays are frequent adjuncts to the secondary survey during the initial evaluation of the chest and can quickly identify the presence of pneumothorax, hemothorax, or significant bony trauma. Practice patterns regarding the use of cross-sectional imaging vary between centers. Multiple retrospective studies have found that while computed tomography (CT) scans will frequently pick up additional thoracic injuries compared with chest x-rays alone, the patient is exposed to a greater radiation dose that is highly unlikely to affect their clinical management. Thus, screening CT scans are not recommended in the setting of a normal mediastinum on chest x-ray (even with a first rib fracture). ^, A blunt cardiac injury workup (ECG initially, with an echocardiogram for an abnormal ECG or other clinical indications) should be performed in any child with a sternal fracture or significant sternal bruising, as this bone does not fully ossify until young adulthood, and a fracture indicates exposure to significant anterior-posterior forces on the mediastinum.

Since immobilization of the thoracic cavity is not achievable, rib fractures often take longer to heal than other fractures, and effective pain control will often require a multidisciplinary approach to optimize patient outcomes. The addition of local or regional analgesia can lead to effective pain relief while minimizing opiate exposure.

Flail chest is a rare injury that is the result of multiple ribs with multiple fractures and leads to paradoxical inward motion of the flail segment during inspiration. The management of a flail segment is often complicated by underlying pulmonary injury, particularly in younger patients. Thus, respiratory failure results from both inadequate mechanical support and gas exchange. Attention to pulmonary hygiene strategies with breathing exercises and chest physiotherapy are all needed to prevent further respiratory compromise and complications including pneumonia, ongoing respiratory failure, and prolonged intubation. In patients with an appropriate mental status, noninvasive positive pressure ventilation modes such as continuous positive airway pressure can be considered if ongoing hypoxia is due to inadequate respiratory effort. Similarly, adequate multimodal pain control must be provided to facilitate adequate oxygenation and ventilation.

Operative rib fixation and fixation of the flail segment have been shown to decrease morbidity and ventilator dependence in adults. However, there are no current recommendations regarding surgical rib fixation in the pediatric population. Current literature has been limited to case reports in children who present with significant chest wall deformity, severe dyspnea, or inability to wean from the ventilator. Optimal management of pediatric flail chest injuries and the role of operative fixation are areas of potential future investigation.

An open pneumothorax is a sucking chest wound resulting from a full-thickness defect in the chest wall. It is typically seen after penetrating trauma to the chest ( Fig. 14.1 ). This can be seen with blunt injury mechanisms such as blast injuries or impalement on a larger object. Air is entrained into the thoracic cavity during the negative pressure inhalation phase, resulting in air trapping and ultimately leading to lung collapse and mediastinal shift. Such injuries can be temporarily mitigated in the prehospital setting by placing an occlusive dressing on three sides. This inhibits the entrainment of air by collapsing the dressing over the wound during inhalation while still allowing the accumulated air a means of egress. Once the patient has been appropriately stabilized, a thoracostomy tube should be placed to evacuate any ongoing pneumothorax or hemothorax and a fully occlusive dressing can be applied. Reapproximation and closure of the wound may be required depending on the defect size.

Open pneumothorax (sucking chest wound) in a child who was impaled by a door handle along his right lateral chest wall.

Traumatic asphyxia or Perte’s syndrome occurs when a large compressive force on the chest wall coincides with a Valsalva maneuver, resulting in the obstruction of venous return at the level of the superior vena cava (SVC). The sudden increase in pressure is transmitted upstream through a valveless venous system and ruptures smaller venules and capillaries. The resulting petechiae are found in the distribution of the SVC and are most prominent in the conjunctiva and oral mucosa ( Fig. 14.2 ). These petechiae will often become more visible several hours after the initial insult and can be accompanied by significant facial edema and cyanosis. Other symptoms of traumatic asphyxia include confusion and an altered sensorium with temporary or permanent changes to the auditory or visual systems such as tinnitus, hearing loss, pupillary defects, exophthalmos, vision changes, or even blindness. Although treatment of traumatic asphyxia is primarily supportive, children may not be able to adequately express their symptoms; thus, a thorough neurologic, ophthalmic, and otologic exam is needed to identify any deficits and determine if there are any potential treatment options. ^,

This young child was involved in a motor vehicle accident and developed traumatic asphyxia with the development of petechial hemorrhages on the face and upper chest.

Photograph courtesy Dr. David Notrica.

Pulmonary contusions are one of the most common thoracic injuries in children and can occur with blunt or penetrating injuries. They often occur even without rib fractures and can be seen on the initial screening chest x-ray as hazy areas over the lung field. These radiographic findings correlate with areas of lung consolidation from injury. Clinically, pulmonary contusions lead to hypoxia and hypercarbia due to decreased gas exchange in the injured area. While it can be difficult to differentiate a contusion from an effusion or hemothorax on a supine film, comparing it to an upright chest x-ray may clarify the findings. Chest CTs will identify additional contusions that were not found on initial x-rays; however, when only seen on CT, these injuries do not appear to add to patient morbidity or mortality.

Contusions found on chest x-ray often indicate that a larger volume of lung parenchyma has been injured, and these children will typically require a higher degree of support due to ongoing hypoxia. Treatment of lung contusions is mainly supportive, emphasizing adequate pulmonary hygiene, pain control, supplemental oxygen support, and preventing fluid overload. Large pulmonary contusions ( Fig. 14.3 ) tend to evolve over several days with worsening hypoxia due to interstitial edema within the lung parenchyma and surrounding tissues. These patients are at risk of developing acute respiratory distress syndrome, which can increase the mortality rate to as high as 60%. Severe hypoxia that cannot be adequately supported despite intubation and lung protective ventilator strategies may require extracorporeal membranous oxygenation (ECMO) support.

CT coronal slice showing extensive pulmonary contusions with concomitant pneumatocele development.

Pulmonary lacerations are tears in the pulmonary parenchyma, typically from a nearby fracture. This can lead to an ongoing air leak and resulting pneumothorax. If chest tube insertion and subsequent complete lung reexpansion do not adequately address the ongoing leak, then the laceration is unlikely to seal on its own. In this case, pulmonary lacerations can typically be addressed surgically by either oversewing the injured area or with a stapled wedge resection of the injured parenchyma. Repairs should be tested by placing them under water and having the anesthesiologist perform a Valsalva maneuver while looking for the escape of air bubbles.

When pulmonary lacerations occur in association with increased intrabronchial pressure (such as positive pressure ventilation), a bronchopulmonary venous fistula can form, putting the patient at risk for an air embolism. Sudden changes in neurological or cardiovascular status can occur if the air embolism travels to the coronary or cerebral vessels. Once an air embolism is recognized or suspected as the cause, immediate steps must be taken to both stabilize the patient and prevent further air emboli. This may require placement of a thoracostomy tube to allow air leaking out of the parenchyma a lower resistance path out of the thoracic cavity. If placement of a tube fails to rectify the situation, then an emergency thoracotomy to gain control of the lung hilum and address the pulmonary/venous interface is needed.

Pneumothoraces occur when air is trapped inside the pleural cavity but outside the lung ( Fig. 14.4 ). Most commonly, this is from a pulmonary laceration with resulting air leak. Other causes of pneumothorax include penetration of the chest wall and proximal airway disruption. Pneumothoraces should be suspected on the primary survey when there are diminished breath sounds unilaterally and can be distinguished from a hemothorax on chest radiographs. As most trauma chest x-rays are taken in the supine position, a pneumothorax may not always be in the apical location ( Fig. 14.4A ). A new or worsened pneumothorax can occur with improper placement of an endotracheal tube with contralateral lung consolidation ( Fig. 14.4B ).

Several various locations for pneumothorax ( white arrowheads ). (A) CXR showing subpulmonic pneumothorax in a child after a motor vehicle accident. (B) CXR with an endotracheal tube placed into the right mainstem bronchus with right pneumothorax (note the deep sulcus) and left lung consolidation and whiteout.

Occult pneumothoraces only visible on cross-sectional imaging will rarely require intervention. Selective CT use is instead reserved for evaluating potential vascular injuries in the setting of an abnormal mediastinal silhouette on initial chest x-ray. ^{, ,} Ultrasound is a highly sensitive screening tool for pneumothorax and hemothorax in adult trauma as the pleural fields can be quickly evaluated as part of an extended FAST (Focused Abdominal Sonogram for Trauma) (eFAST [Extended Focused Abdominal Sonogram for Trauma]) exam. However, like most ultrasound techniques, its utility is hampered by operator skill, and current data suggest that lung ultrasound at a single point on the anterior chest is not as sensitive as a screening chest x-ray in children.

In general, close observation of an occult pneumothorax is safe, even in intubated patients. The Occult Pneumothoraces in Critical Care trial found that observation was relatively safe in adult trauma patients who were not expected to be intubated more than 4 days. While approximately 25% of patients needed chest tube placement, only 6% of these were emergent. However, the failure rate increased to 40% in patients who required ventilatory support for more than 4 days. Current Western Trauma Association (WTA) guidelines state that pneumothoraces <20% can be observed with repeat imaging in 6 hours in asymptomatic, hemodynamically normal patients. One may consider chest tube placement in an intubated patient if they would otherwise be unable to receive an emergent chest tube such as before air transport or in severe chronic lung disease.

Traumatic pneumatoceles can occur after severe blunt force trauma causing alveolar rupture or barotrauma from aggressive positive pressure ventilatory settings or bag-valve masking ( Fig. 14.3 ). This pathology may develop early in the postinjury course over several days and may not be evident on initial chest x-ray. While they can be quite large, in general, these lesions will resolve spontaneously over the course of several weeks to months without any intervention. ^,

A simple pneumothorax is treated with a thoracostomy tube or catheter. The choice between a pigtail catheter or standard chest tube depends on the size and location and whether there is a concomitant hemothorax. In an asymptomatic patient, it may not require treatment at all. Some people advocate for supplemental oxygen at a fractional inspiration of 100% to create a nitrogen gradient and attempt to “washout” the nitrogen in the trapped air. This treatment modality will typically require a follow-up x-ray the following day to evaluate the response. Because its effects are indirect, it should not be considered a primary treatment for an acutely symptomatic patient.

Tension pneumothorax is a life-threatening condition that requires immediate intervention as the associated mediastinal shift leads to compression and obstruction of venous return to the heart and results in cardiovascular collapse ( Fig. 14.5 ). Patients will often present with worsening hypoxia and tachypnea despite increasing supplemental oxygen. Rapid drainage of the chest to remove the trapped air is required to prevent this consequence and can be done with a needle thoracostomy in the second intercostal space in the midclavicular line. (Note that this is different than the recommended fourth or fifth intercostal space in the midaxillary line recommended for adults in ATLS.)

A left tension pneumothorax is seen in this child following a motor vehicle accident. Note the mediastinum is pushed to the patient’s right, and the left diaphragm is markedly depressed.

Injury to any vessels of the chest wall, intrathoracic vessels, pleura, or even the pulmonary parenchyma can result in a hemothorax ( Fig. 14.6 ). The amount of blood that can be present varies widely, but it is estimated that each hemithorax can hold up to 40% of a child’s blood volume. Unfortunately, it is hard to estimate blood loss on screening chest x-ray and CT scans. A chest tube should be placed if the volume of blood is clinically symptomatic to allow for lung reexpansion and a better estimation of whether there is ongoing hemorrhage. Upon tube placement the immediate return of 15 mL/kg of blood or ongoing drainage of 3–4 mL/kg/h are both indications for operative exploration and hemorrhage control.

A left hemothorax has developed in a teenager after a gunshot wound to the left chest.

Previously, it was thought that large-bore chest tubes were necessary for adequate drainage of a hemothorax. However, in a multicenter randomized controlled trial in adults, a 14F percutaneous catheter was found to perform similarly to a large-bore 28–32F catheter with decreased pain associated with having a smaller catheter in place. A small retrospective single-center review comparing pigtail catheters with large-bore chest tubes in children similarly demonstrated no difference in clinical outcomes. Therefore, larger chest tubes should only rarely be needed to achieve adequate drainage. Continued presence of a pleural effusion on chest radiograph after 48 hours is considered a retained hemothorax. Retained hemothorax is a risk factor for infection and may lead to fibrothorax with restriction of full lung expansion.

While fibrinolytic therapy is acceptable first-line therapy for the treatment of empyema and parapneumonic effusions, ^, it has not been well studied in children for traumatic retained hemothorax. Current Eastern Association for the Surgery of Trauma guidelines for adults recommend video-assisted thoracoscopic surgery (VATS) within 4 days of injury to drain a retained hemothorax. Fibrinolytic therapy is reserved for patients who are not surgical candidates for VATS or have loculated fluid collections present more than a week after injury.

Chylothorax is an uncommon posttraumatic injury due to damage to lymphatic vessels. Since many injured children have diminished enteral intake, chyle flow may be reduced, and it may take several days for the chest tube output to develop the characteristic milky liquid output. There are many anatomic variations in the lymphatic channels that can make identification of the injury difficult. ^, Furthermore, lymphatic vessels themselves are typically clear and difficult to identify amidst disrupted tissue planes. Chyle is typically rich in amino acids, fats, vitamins, electrolytes, and lymphocytes, and an ongoing leak can lead to malnutrition and lymphopenia.

A medium-chain triglyceride diet and avoidance of fats are used to decrease the throughput of the leak management of chylothorax with or without a somatostatin analog. In extreme cases of refractory high-volume output, enteral nutrition can be stopped, and parenteral nutrition is initiated. If noninterventional treatment fails, lymphatic angiography and embolization of the injured lymphatic vessel can be attempted. In the event surgical intervention is needed, preoperative administration of various substances (cream, high-fat meal, methylene blue) or intraoperative use of ICG (indocyanine green) dye can aid in the identification of the source of the leak. If no leak can be identified, supradiaphragmatic ligation of the thoracic duct can be performed via a thoracotomy or a VATS approach.

Diaphragmatic injuries are rare and can be easily missed on initial evaluation. Injuries are more commonly seen on the left as the right diaphragm is protected by the liver. Symptoms mirror those of diaphragmatic irritation including referred shoulder pain, dyspnea, cough, hiccup, and abdominal pain. In blunt trauma, a rapid increase in intraabdominal pressure leads to diaphragm injury and can allow the herniation of intraabdominal contents, usually the bowel ( Fig. 14.7 ). Diminished breath sounds and the presence of bowel sounds in the chest indicate the herniation of bowel through the diaphragm. This can be confirmed by imaging. Rarely, bilateral diaphragmatic injuries can occur ( Fig. 14.8 ).

This child was involved in a motor vehicle accident, and this radiograph was obtained. Note the abnormal contour to the left hemidiaphragm, and the stomach with the nasogastric tube is herniated into the left chest (A). The patient’s operative findings are noted in (B). Note complete avulsion of the left hemidiaphragm with the lung being readily visible through the diaphragmatic defect.

Bilateral diaphragmatic rupture after blunt abdominal trauma seen during an open diaphragmatic repair. The hemostats have been placed on the lower rim of the diaphragmatic rupture.

In patients with penetrating trauma, diaphragmatic injuries can be very subtle depending on the depth and trajectory of the penetrating object. Any penetrating wound below the nipple line, in the upper abdominal quadrants, or in the epigastrium should be evaluated for diaphragmatic injury. This is particularly true if there are injuries on both sides of the diaphragm. Penetrating trauma typically creates small holes in the diaphragm that are easily missed, making immediate herniation rare.

Although herniation may sometimes be seen on chest radiograph, cross-sectional imaging is more sensitive and can identify subtle signs of diaphragmatic injury. However, it is important to emphasize that negative imaging does not exclude diaphragmatic injury. Because failure to recognize a diaphragmatic injury can lead to the entrapment of intraabdominal contents with development of organ ischemia and intestinal obstruction, diagnostic laparoscopy or thoracoscopy should be performed if clinical suspicion remains high ( Fig. 14.9 ).

This teenage patient was initially admitted to another hospital after a motor vehicle accident and was noted to have acute diaphragmatic rupture at a referring facility. (A) Note the rightward shift of the tracheal and the entire mediastinum shifted into the right chest with large gaseous lucencies in the left chest and complete loss of the left heart border. (B) A CT scan was performed at the outlying hospital; the coronal slice here shows the spleen, stomach, and bowel in the left chest. The diaphragmatic defect here is measured as 9 cm. (C) The sagittal slice shown here better delineates some gas-filled colonic loops along with some fluid filled small bowel loops in the left chest. (D) This defect was able to be closed thoracoscopically, and the spleen and colon are visualized traversing the defect here. (E) The diaphragmatic defect is completely visualized after all the abdominal contents are reduced. (F and G) The defect is closed with interrupted pledgeted suture and comes together without tension. (H) A postoperative chest x-ray shows complete reduction of abdominal contents and restoration of the left hemidiaphragm.

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