First rib fractures are associated with a high incidence of thoracic, vascular, abdominal, and central nervous system injuries. Usually reported in the adult population, first rib fractures are infrequently described in the pediatric population. We take this opportunity to describe six pediatric patients who sustained traumatic first rib fractures. Overall, five patients required operative intervention. Two patients sustained major vascular injuries which were detected on physical examination and confirmed by arch aortography. In view of the high percentage of patients with vascular injury, first rib fracture in a pediatric patient should prompt a search for major vascular injury.