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No breakpoint for mortality in pediatric rib fractures.

BACKGROUND: Rib fracture number correlates with mortality in adult trauma patients, sharply rising above six fractured ribs. Because of the pliability of younger ribs, pediatric ribs are believed to require more energy to fracture. We hypothesized this will result in a different rib fracture-associated pediatric mortality rate.

METHODS: We queried the National Trauma Data Bank (American College of Surgeons, Chicago, Illinois) for patients younger than 21 years with and without rib fractures (2002-2009), abstracting the number of rib fractures, diagnoses, procedures, and outcomes. Univariable and multivariable analyses were performed with logistic regression to adjust for age and concomitant injury.

RESULTS: We identified 729,240 pediatric patients, 19,442 with rib fractures. Mortality doubled from 1.79% without rib fracture to 5.81% for one rib fracture and then nearly linearly increased to 8.23% for seven fractures unlike the pattern in adults. This pattern persisted irrespective of the age group evaluated. Ventilator days also increased with increasing number of rib fractures. Adjusted odds of mortality increased up to six rib fractures for all age groups. Penetrating injury, concomitant injury, and hemothorax all predicted mortality on multivariable analysis. More than two rib fractures also predicted chest tube placement (odds ratio [OR], thoracostomy 11.89 (11.37-12.44), thoracotomy 5.89 (5.17-6.84), thoracoscopy (6.28-12.03), laparotomy 2.68 (2.49-2.89).

CONCLUSION: Mortality increased nearly linearly for increasing numbers of pediatric rib fractures without an inflection. Odds of mortality increases with each additional rib fractured in all pediatric age groups.

LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.

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