6-year-old undergoes rib stabilization surgery

In May 2016, a 6-year-old boy was admitted to the pediatric trauma service at Mayo Clinic's Level I pediatric trauma center in Rochester, Minnesota. He had multiple right-sided rib fractures and a liver laceration — the result of a serious horse riding accident. Although adequately treated with analgesics, the boy continued to complain of severe pain along his right chest wall that night and the following morning.

Unsure what to do for his patient, the surgical resident asked for a consult with Brian D. Kim, M.D., a trauma surgeon at Mayo Clinic's campus in Rochester and a recognized expert in rib fracture stabilization and complex chest wall reconstruction.

"It's unusual for a primarily adult trauma surgeon to be contacted by the pediatric trauma group, but I understood their concern when I saw the X-rays," Dr. Kim says. "The boy had several comminuted, highly displaced rib fractures on the right side. When I examined him, the fractures were tenting the skin out, and he was in an immense amount of pain. Like any child, he was trying to push through it, but the pain was just too intense. He didn't have on a gown because he couldn't stand the slightest touch on his chest."

Pediatric flail chest

Severe rib fractures are rare in pediatric blunt trauma. A child's thorax is much more compliant than an adult's because of the pliability of the cartilage and bony structure. Thus, most of the impact from a traumatic event is transferred to internal structures, with little or no injury to the structure of the chest. Rib fractures in children usually indicate a direct blow and great force. Dr. Kim's patient had been thrown and then stomped by a horse.

There are two potential treatments for flail chest, which is defined as two or more contiguous rib fractures with two or more breaks per rib. One is prolonged positive pressure ventilation; the other is internal rib fracture stabilization using titanium plates and screws.

Although still somewhat controversial, chest wall stabilization has been shown to be highly effective in adults and is associated with fewer ventilator, intensive care unit and hospital days, reduced risk of pneumonia, and faster overall recovery. There is little experience or consensus relative to the procedure in pediatric patients, however, especially in children younger than age 13.

Although no child as young as 6 had undergone rib stabilization, Dr. Kim felt it was the best option for his patient. The sixth, seventh and eighth right ribs were severely comminuted, distracted and displaced, and each had multiple fractures. Without surgical fixation, they would heal in a nonanatomic way that would likely necessitate chest wall reconstruction later in life. What's more, the boy's pain seemed intractable, and rib fracture stabilization is associated with significant pain relief.

After lengthy conversations with the boy's parents, Dr. Kim decided to perform an open reduction and internal fixation of the rib fractures.

The boy tolerated the procedure well and experienced complete pain relief from the rib fractures, although he did have some normal postoperative pain. X-rays showed an excellent technical outcome. He was discharged on day three, and at a one-month follow-up visit was found to have healed well, with no chest deformity.

Three months later, in August 2016, Dr. Kim removed the plates because they could potentially affect the growth of the boy's chest wall. In older patients who are skeletally mature, the plates are usually left in place, just as they are in adults.

Today, the patient — the youngest ever to undergo surgical stabilization of rib fractures following trauma — continues to do well.

Dr. Kim acknowledges that the operation remains controversial, but perhaps also underperformed, for pediatric patients. "He's a rough-and-tumble kid, who is always running and jumping and falling off things and is really built to withstand a lot. But this injury was too severe for him to heal normally. I believe the surgical repair led to the best possible outcome for him," Dr. Kim says. "Further studies about chest wall stabilization in children are definitely needed."