What is the appropriate evaluation and management for an 11-year-old child with chest pain in the left mammary (mamillary) area following a fall 5 days ago?

Evaluation and Management of Chest Pain in an 11-Year-Old Following a Fall

In an 11-year-old with localized left mammary chest pain 5 days after a fall, the most likely diagnosis is musculoskeletal injury (costochondritis or chest wall contusion), which should be managed conservatively with NSAIDs after excluding serious traumatic injuries through focused physical examination and chest radiography. 1

Initial Clinical Assessment

History Elements to Obtain

• Pain characteristics: Sharp, localized pain that worsens with breathing, movement, or palpation strongly suggests musculoskeletal origin rather than cardiac pathology 1
• Mechanism of injury: Details of the fall including height, surface landed on, and direct impact to chest wall 2
• Red flag symptoms: Absence of exertional component, radiation to left arm/jaw/neck, diaphoresis, dyspnea, syncope, or palpitations makes cardiac etiology extremely unlikely 3, 1
• Timing: Pain persisting 5 days post-trauma is consistent with musculoskeletal injury healing timeline 4

Physical Examination Priorities

• Chest wall palpation: Point tenderness over costochondral junctions or ribs confirms musculoskeletal diagnosis 1
• Respiratory assessment: Evaluate for pneumothorax (unilateral decreased breath sounds, respiratory distress) or pneumomediastinum, which can present with abrupt, continuous pain in older children 5
• Cardiovascular examination: Assess for signs of cardiac contusion (rare but serious), including irregular rhythm, new murmurs, or signs of pericarditis 3
• Skin examination: Look for bruising or abrasions consistent with trauma mechanism 2

Diagnostic Approach

Mandatory Initial Testing

• Chest radiography (2 views): Indicated to exclude rib fractures, pneumothorax, pneumomediastinum, or pulmonary contusion in any child with chest trauma and persistent pain 2
• 12-lead ECG: Only if cardiac symptoms present (exertional pain, syncope, palpitations, family history of sudden cardiac death) or if examination suggests cardiac involvement 3, 1, 6

When Advanced Imaging Is Indicated

Contrast-enhanced chest CT is NOT routinely recommended for isolated chest wall pain after minor trauma 2. However, consider if:

• Clinical suspicion for intrathoracic injury (hemopericardium, cardiac contusion, significant pulmonary contusion) based on mechanism or examination findings 2
• Rib fractures detected on plain films in context requiring assessment for underlying organ injury 2

Important caveat: Routine CT screening for chest injury is explicitly not recommended in pediatric trauma without specific clinical indications 2

Critical Differential Diagnoses to Exclude

Traumatic Injuries

• Rib fractures: More common than recognized; anterior/posterior fractures better detected by CT but plain films adequate for initial assessment 2
• Pneumothorax/pneumomediastinum: Presents with abrupt, continuous pain; requires careful radiographic examination as can be subtle 5
• Cardiac contusion: Rare but life-threatening; suspect if significant blunt force mechanism 2

Non-Traumatic Causes (Less Likely Given History)

• Costochondritis: Most common cause of pediatric chest pain overall (73.6% in one series); characterized by reproducible tenderness 1, 5
• Cardiac arrhythmias: Would present with palpitations, syncope, or exertional symptoms 5
• Anxiety/psychogenic: Common in adolescents but less likely with clear trauma history 4, 5

Management Algorithm

If Examination and Imaging Normal:

1. Reassurance: Explain benign musculoskeletal nature; chest pain in children rarely cardiac (only 1.2-3.8% of cases) 4, 5, 6
2. Conservative treatment: NSAIDs (ibuprofen 10 mg/kg/dose every 6-8 hours) for pain control 1
3. Activity modification: Avoid activities that exacerbate pain until resolved 1
4. Return precautions: Seek immediate care if develops dyspnea, syncope, palpitations, or worsening pain 3, 1

If Rib Fractures Identified:

• Pain management: Adequate analgesia to prevent splinting and atelectasis 2
• Pulmonary hygiene: Incentive spirometry, deep breathing exercises 2
• Follow-up: 2-4 weeks to ensure healing and resolution of symptoms 2

Red Flags Requiring Immediate Escalation:

• Respiratory distress or oxygen desaturation: Suggests pneumothorax or significant pulmonary injury 5
• Hemodynamic instability: May indicate cardiac injury or internal bleeding 2
• New cardiac symptoms: Syncope, severe palpitations, or exertional symptoms require urgent cardiac evaluation 1, 5

Special Consideration: Non-Accidental Trauma

While the history describes an accidental fall, maintain appropriate vigilance: Child abuse should be considered if injuries are inconsistent with the provided history, particularly in younger children 2. However, at age 11 with a clear trauma history and localized findings, this is less concerning than in infants or toddlers where skeletal surveys would be indicated 2.

Common Pitfalls to Avoid

• Over-testing: Extensive cardiac workup (echocardiography, stress testing, Holter monitoring) is unnecessary without cardiac symptoms or examination findings; one study showed potential 20% reduction in unnecessary testing with standardized approach 6
• Assuming cardiac cause: Unlike adults, cardiac etiology accounts for <4% of pediatric chest pain cases 4, 5, 6
• Missing pneumomediastinum: Requires careful radiographic examination; can be subtle but presents with characteristic abrupt, continuous pain 5
• Inadequate pain control: Undertreated pain can lead to splinting and respiratory complications if rib fractures present 2