Surgical rib fixation in pediatric patients: Following the adult trend or a different story?

Abstract

For many years, non-operative management has been an established standard of care for rib fractures. In adults, surgical stabilization of rib fractures (SSRF) has become an increasingly accepted alternative, with growing evidence supporting its benefits. In contrast, the role of SSRF in pediatric trauma remains poorly defined. This study presents the largest known cohort of pediatric SSRF patients to describe their characteristics and assess whether pediatric practice mirrors adult trends. A retrospective review of pediatric patients (<18 years) with rib fractures was conducted using the TQIP database (2017-2023). Patients were stratified by treatment (SSRF vs. non-operative). Demographic, injury, surgical, and outcome characteristics were compared. Adult SSRF patients during the same period were included for secondary analysis. Among 28,465 pediatric rib fractures, 87 (0.31%) underwent SSRF. Pediatric SSRF rates remained stable over time (0.16%-0.39%; p = 0.17), while adult SSRF use increased (1.5%-2.37%; p = 0.0027). Pediatric SSRF patients were older (14.6 vs. 13.0 years; p < 0.001), more likely to present with flail chest (25.3% vs. 1.2%, p < 0.001), and had higher ISS (25.9 vs. 20.3; p < 0.001) compared to non-SSRF pediatric patients. Compared to adults, pediatric SSRF patients underwent less extensive fixation but had more open thoracic injuries (14.9% vs. 2.3%; p < 0.001). Among pediatric SSRF patients, 50.6% had a same-day major thoracic/open-chest procedure. Pediatric SSRF patients had zero mortality, compared to 7.3% in non-operative pediatric patients (p = 0.009) and 2.7% in adults (p = 0.123). SSRF in pediatric patients remains rare, while adult SSRF is increasing in incidence. Our data suggest it is being used in highly selected pediatric cases, largely confined to older children and those presenting with severe or complex thoracic injuries such as flail chest or open fractures. Further research is needed to clarify pediatric-specific indications and determine which injury patterns may be appropriate for SSRF.