Surgical Stabilization of Rib Fractures in Geriatric Trauma Patients: A National Trauma Data Bank Review

ABSTRACT

Background

Rib fractures are common and increase mortality in older adult patients. Early surgical stabilization of rib fractures (SSRF), < 72 h from admission, has been shown to improve outcomes in younger patients. We hypothesize that patients ≥ 65 years requiring SSRF will have improved outcomes with early SSRF.

Methods

This was a retrospective cohort analysis of patients ≥ 65 years between 1/1/2018 and 12/31/2022 who underwent SSRF and were captured in the National Trauma Data Bank. Patients who died within 24 h were excluded. Demographic and injury characteristics, comorbidities, hospital events and discharge dispositions were captured. Study groups were early (< 72 h) versus late SSRF. Primary outcomes were hospital length of stay (HLOS), intensive care unit LOS (ILOS), duration of mechanical ventilation (DMV), and mortality. With early SSRF as the reference group, multivariable analysis was conducted.

Results

Five thousand one hundred twenty‐nine patients met inclusion criteria. Three thousand seventy (59.8%) underwent early SSRF and 2059 (40.1%) underwent late SSRF. Early SSRF was associated with shorter HLOS (9 vs. 14 days), ILOS (6 vs. 9 days), and DMV (5 vs. 9 days) (all p < 0.001). There was no difference in mortality (4.7% vs. 5.3%, p = 0.23). Early fixation was associated with fewer complications including unplanned intubation (6.6% vs. 13.5%), tracheostomy (1.9% vs. 5.3%), acute respiratory distress syndrome (0.9% vs. 1.7%), and pneumonia (0.2% vs. 0.7%) (all p < 0.001). On multivariable analysis, HLOS, ILOS, and DMV increased with late fixation (all p < 0.001).

Conclusion

Early SSRF is associated with improved outcomes and fewer complications in older adult patients with rib fractures. Further study will guide treatment protocols for the growing population of older adult trauma patients.

Summary

• Key points

  • ○
    Early SSRF was associated with shorter hospital and ICU lengths of stay and duration of mechanical ventilation.
  • ○
    Unplanned intubation, return to the operating room, and ICU admission occurred less frequently in the early SSRF group.
  • ○
    The timing of SSRF had more impact on patient outcomes than the severity of chest wall injury.
• Why does this paper matter?

  • ○
    Current guidelines, including those from the Eastern Association for the Surgery of Trauma (EAST) and the Chest Wall Injury Society (CWIS), recommend performing the surgical stabilization of rib fractures (SSRF) within 72 h of admission for all trauma patients.
  • ○
    This study investigated how the timing of surgical intervention impacted patient outcomes specifically in patients ≥ 65 years of age, finding that early SSRF significantly improves most outcomes, contributing to the limited literature on this practice in the geriatric population.

Early surgical stabilization of rib fractures (< 72 h from admission) was associated with improved outcomes in older adult trauma patients, including reduced lengths of stay in the hospital and intensive care unit, duration of mechanical ventilation, rates of infection, thromboembolic events, and need for additional procedures.

1. Introduction

The American College of Surgeons (ACS) defines older adult trauma patients as those 65 and older [1]. Rib fractures are a common and costly injury in the United States (US) and are present in 10% of all trauma patients [2]. Falls, especially low‐velocity falls from standing, are the most common cause of rib fractures in older adults [1], and have an annual incidence of 14 million in the US [3]. Inpatient admissions for rib fractures cost $469 million in 2016, with the majority of patients being 65 and older [4]. Older adults with rib fractures in the absence of severe concomitant injuries have a 20% three‐month readmission rate, which may further contribute to cost and mortality burden [5].

Rib fractures in older patients pose greater challenges than in their younger counterparts [6, 7]. Increased incidences of osteopenia and osteoporosis place older patients at a greater risk for fractures from low energy mechanisms and recovery may be complicated by increased frailty and burden of comorbidities [8, 9]. These factors contribute to a mortality rate 10% higher than in younger cohorts [10, 11]. Complications from rib fractures may require additional procedures, which carry their own risks [12, 13, 14]. Optimizing treatment of rib fractures in this vulnerable population is critical in reducing morbidity and mortality.

Surgical stabilization of rib fractures (SSRF) has emerged as an effective intervention for select trauma patients with severe chest wall injuries. The Eastern Association for the Surgery of Trauma (EAST) and the Chest Wall Injury Society (CWIS) provide guidelines for SSRF in patients with traumatic flail chest injuries [2, 15]. Indications in the CWIS guidelines additionally include non‐flail unstable fracture patterns, failure to wean from a ventilator, and ≥ 3 ipsilateral rib fractures with ≥ 2 pulmonary physiologic derangements [15]. Studies have suggested SSRF may be associated with improved outcomes for other indications such as chest wall deformation causing ≥ 30% hemithorax volume loss, severe pain, respiratory failure, concomitant sternal or clavicular fractures, or if the rib fractures cause further penetrating trauma; however, there is insufficient evidence for these as formal indications [16, 17].

Overall, SSRF has been associated with reduced mortality, intensive care length of stay (ILOS), hospital length of stay (HLOS), pneumonia, and need for tracheostomy compared to non‐operative management and has been shown to be cost‐effective [18, 19, 20, 21]. Quality of life surveys demonstrate that SSRF may reduce opioid consumption and likelihood of lasting disability [22, 23]. The timing of this intervention is also important; studies have shown significant improvement in patient outcomes with early SSRF, defined as being performed within 72 h of admission [18, 24, 25].

As our population grows older, and the utilization of SSRF for management of rib fractures increases [26], the development of clear practice guidelines for older patients with rib fractures becomes a necessary component of minimizing the cost burden on the US healthcare system. Currently, the EAST guidelines make only conditional recommendations for SSRF in patients with flail chest after blunt trauma, and were unable to make a recommendation for non‐flail pattern rib fractures due to lack of clinical trials and small sample sizes [2]. Pieracci et al. made a Grade D recommendation for early SSRF based on level 5 evidence and lack of available literature [27]. There is an even greater paucity of literature regarding the older adult population, which is particularly vulnerable for injury and complications as previously noted. Of these studies, most focused on operative versus non‐operative management [23, 28]. Early fixation was associated with improved outcomes including hospital and intensive care unit (ICU) length of stay, as well as shorter duration of mechanical ventilation and rates of VAP, in a single study with a small sample size performed via secondary analysis of a prior trial [18]. Recently released ACS Best Practice Guidelines do not comment on timing of SSRF for older patients [1] Our study aims to address this knowledge gap by contributing to the existing pool of literature and with a larger sample size.

In our study, we aim to determine whether early SSRF (< 72 h) is associated with improved outcomes in older adult patients. We hypothesize that early SSRF is associated with decreased HLOS, ILOS, duration of mechanical ventilation (DMV), and mortality.

2. Methods

2.1. Study Design

This is a retrospective cohort analysis performed using data from the National Trauma Data Bank (NTDB) for patients admitted to NTDB‐participating trauma centers between January 1 2018 and December 31 2022. The NTDB is the largest national repository of trauma registry data in the United States, which contains de‐identified information submitted by participating trauma centers to support research and quality improvement initiatives. This study is compliant with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [29] (see Supporting Information) and was determined exempt from review by the local Institutional Review Board. Patients were included if they were ≥ 65 years of age and underwent SSRF, as documented by specific International Classification of Disease 10th Revision (ICD‐10) procedure codes (see Supporting Information). Patients < 65 years of age or those who died within 24 h of admission were excluded.

Patient demographics, comorbidities, injury characteristics, in‐hospital complications, and discharge dispositions were captured. Demographic data included age, sex, and body mass index (BMI). Comorbidities included chronic obstructive pulmonary disease (COPD), diabetes, smoking, and functional dependent status. Injury characteristics included injury severity score (ISS), abbreviated injury scores (AIS), admission heart rate (HR), systolic blood pressure (SBP), Glasgow Coma Scale (GCS), and presence of flail chest. Primary outcomes included HLOS, ILOS, DMV, and mortality. Secondary outcomes included in‐hospital complications and discharge disposition. Hospital complications included acute respiratory distress syndrome (ARDS), surgical site infection (SSI), deep vein thrombosis (DVT), myocardial infarction (MI), pulmonary embolism (PE), ventilator‐acquired pneumonia (VAP), sepsis, unplanned intubation, unplanned return to the operating room (OR), unplanned ICU admission, and need for tracheostomy. Discharge dispositions captured included home, skilled nursing facility (SNF), rehabilitation facility, or “other.”

2.2. Statistical Methods

Patients were stratified into two study groups: those who underwent early fixation (< 72 h from admission) and those who underwent late fixation (≥ 72 h). Descriptive statistics were performed comparing the groups. Continuous variables that were normally distributed were compared via independent t‐test. Non‐parametric variables were compared using Mann‐Whitney U, and these data elements were reported using medians and interquartile ranges (IQR). Chi squared was used for categorical variables and reported as frequencies and percentages. Due to disproportionate numbers of patients that underwent early fixation, a weighted analysis was performed to control for demographics, injury characteristics, admission vital signs, comorbidities, and presence of flail chest. Inverse propensity matching, which gives heavier weight to underrepresented groups within the data, was used to create a logistic model in SPSS using SSRF ≥ 72 h as the outcome. Predicted probabilities derived from this model were used to calculate the weighting. The formula 1 − (1 − predicted probability) was used for those undergoing early fixation, while the reciprocal of the predicted probability was used for those in the late fixation group. Pairwise deletion was used to account for missing data.

Multivariable analysis was performed using early fixation as the reference. Independent variables were selected based on their clinical relevance and use in prior studies from the literature review. Statistical expertise was employed to determine which were appropriate for inclusion in the models, considering factors such as sufficient frequency of occurrence and elimination of collinearity to ensure validity of the models. Linear regression modeled factors contributing to HLOS, ILOS, and DMV. Logistic regression modeled factors contributing to mortality. Statistical analysis was performed with SPSS 27 (Armonk, NY) and SAS (Cary, NC). Significance levels were set at 0.05 for univariate and 0.001 for multivariable analyses, respectively.

3. Results

3.1. Univariate Analysis

There were 5129 patients who met inclusion criteria. Of them, 3070 (59.8%) underwent early fixation and 2059 (40.1%) underwent late fixation. There was no difference in age (73.4 vs. 73.1 years, p = 0.10) or sex (66.5% vs. 68.4%, p = 0.16) between the groups. Patients undergoing early fixation arrived with lower BMI (28.3 vs. 29.1, p < 0.001), lower ISS (17 vs. 19, p < 0.001), lower HR (86 vs. 89 bpm, p < 0.001), and higher GCS (14.4 vs. 13.9, p < 0.001) and SBP (139 mmHg vs. 135 mmHg, p < 0.001) on admission. There was no difference in prevalence of flail chest (39.2% vs. 38.3%, p = 0.50), AIS chest > 3 (1.9% vs. 2.1%, p = 0.67), and comorbidities between the two study groups. Patient characteristics are delineated in Table 1.

TABLE 1.

Demographic and clinical characteristic comparison of early vs. late SSRF patients.

	Unweighted data			Propensity weighted data
	Early SSRF	Late SSRF	p	Early SSRF	Late SSRF	p
	n (%)	n (%)		n (%)	n (%)
All patients	3070 (59.9)	2059 (40.1)		5010 (50.0)	5007 (50.0)
Male sex	2040 (66.5)	1404 (68.4)	0.16	3381 (67.5)	3376 (67.4)	0.95
AIS chest > 3	59 (1.9)	43 (2.1)	0.67	99 (2.0)	99 (2.0)	1.00
Flail chest	1204 (39.2)	788 (38.3)	0.50	1942 (38.8)	1938 (38.7)	0.95
COPD	402 (13.1)	282 (13.7)	0.50	669 (13.4)	667 (13.3)	0.96
Diabetes	705 (23.0)	507 (24.6)	0.17	1183 (23.6)	1182 (23.6)	0.95
Functional dependent status	241 (7.9)	189 (9.2)	0.09	418 (8.3)	418 (8.3)	0.96
Smoking	392 (12.8)	291 (14.1)	0.16	671 (13.4)	672 (13.4)	0.97

	Mean (SD)	Mean (SD)	p	Mean (SD)	Mean (SD)	p
Age (years)	73.4 (6)	73.1 (6)	0.10	73.2 (6)	73.2 (6)	0.94
BMI	28.3 (6)	29.1 (6)	< 0.001	28.7 (6)	28.7 (6)	0.97
SBP	139 (29)	135 (30)	< 0.001	137 (29)	137 (30)	0.95
Heart rate	86 (18)	89 (20)	< 0.001	87 (19)	87 (20)	0.99
GCS	14.4 (2)	13.9 (3)	< 0.001	14.4 (2)	14.0 (3)	< 0.001
ISS	17 (8)	19 (10)	< 0.001	17 (8)	19 (10)	< 0.001

Note: Bold text indicates significance.

Abbreviations: AIS, abbreviated injury score; BMI, body mass index; COPD, chronic obstructive pulmonary disease; GCS, Glasgow Coma Scale; ISS, injury severity score; SBP, systolic blood pressure.

After propensity weighted analysis, the two study groups were similar in all characteristics aside from GCS (14.4 vs. 14.0, p < 0.001) and ISS (17 vs. 19, p < 0.001). Early fixation was associated with shorter HLOS (9 vs. 14 days, p < 0.001), ILOS (6 vs. 9 days, p < 0.001), and DMV (5 vs. 9 days, p < 0.001), with no difference in mortality (4.7% vs. 5.3%, p = 0.23). Primary outcomes are summarized in Table 2.

TABLE 2.

Univariate analysis of primary outcomes between early vs. late SSRF patients.

	Unweighted data			Propensity weighted data
	Early SSRF	Late SSRF	p	Early SSRF	Late SSRF	p
	Median [IQR]	Median [IQR]		Median [IQR]	Median [IQR]
HLOS, days	9 [6, 13]	14 [10, 21]	< 0.001	9 [6, 14]	14 [10, 20]	< 0.001
ILOS, days	5 [4, 9]	9 [5, 16]	< 0.001	6 [4, 9]	9 [5, 16]	< 0.001
DMV	5 [3, 10]	9 [4, 16]	< 0.001	5 [3, 11]	9 [4, 16]	< 0.001
Mortality (%)	142 (4.6)	109 (5.3)	0.28	238 (4.7)	264 (5.3)	0.23

Note: Bold text indicates significance.

Abbreviations: DMV, duration of mechanical ventilation; HLOS, hospital length of stay; ILOS, intensive care unit length of stay.

Early fixation was associated with lower incidences of unplanned return to the OR (0.2% vs. 0.9%), unplanned ICU admission (6.3% vs. 12.8%), unplanned intubation (6.6% vs. 13.5%), the need for tracheostomy (1.9% vs. 5.3%), the prevalence of ARDS (0.9% vs. 5.7%), VAP (1.9% vs. 3.6%), DVTs (2.2% vs. 3.3%), and the incidence of sepsis (1.5% vs. 2.4%) (all p ≤ 0.001). Patients in the early fixation group were more likely to be discharged home (48.5% vs. 38.2%, p < 0.001). A summary of secondary outcomes can be found in Table 3.

TABLE 3.

Univariate analysis of secondary outcomes between early vs. late SSRF patients.

Outcome	Unweighted data			Propensity weighted data
	Early SSRF	Late SSRF	p	Early SSRF	Late SSRF	p
	n (%)	n (%)		n (%)	n (%)
Discharge disposition			< 0.001			< 0.001
Home	1,440 (49.2)	718 (36.8)		2,313 (48.5)	1,812 (38.2)
Skilled nursing facility (SNF)	673 (23.0)	440 (22.6)		1,109 (23.2)	1,077 (22.7)
Rehab	618 (21.1)	504 (25.8)		1,015 (21.3)	1,200 (25.3)
Other	197 (6.7)	288 (14.8)		335 (7.0)	655 (13.8)
ARDS	26 (0.8)	37 (1.8)	0.002	44 (0.9)	83 (1.7)	< 0.001
Surgical site infection	3 (0.1)	7 (0.3)	0.10	5 (0.1)	16 (0.3)	0.02
DVT	67 (2.2)	70 (3.4)	0.01	111 (2.2)	164 (3.3)	0.001
Myocardial infarction	15 (0.5)	16 (0.8)	0.19	25 (0.5)	8 (0.2)	0.10
Pulmonary embolism	35 (1.1)	37 (1.8)	0.05	58 (1.2)	87 (1.7)	0.01
Unplanned intubation	193 (6.3)	282 (13.7)	< 0.001	331 (6.6)	676 (13.5)	< 0.001
Unplanned return to OR	7 (0.2)	18 (0.9)	0.001	12 (0.2)	45 (0.9)	< 0.001
Unplanned ICU admission	189 (6.2)	189 (9.2)	< 0.001	314 (6.3)	640 (12.8)	0.01
Sepsis	43 (1.4)	50 (2.4)	0.007	74 (1.5)	118 (2.4)	0.001
VAP	52 (1.7)	75 (3.6)	< 0.001	93 (1.9)	178 (3.6)	< 0.001
Tracheostomy	54 (1.8)	120 (5.8)	< 0.001	93 (1.9)	267 (5.3)	< 0.001

Note: Bold text indicates significance.

Abbreviations: ARDS, acute respiratory distress syndrome; DVT, deep vein thrombosis; VAP, ventilator‐acquired pneumonia.

3.2. Multivariable Analysis

A longer HLOS was associated with late fixation, the presence of flail chest, COPD, diabetes, and higher BMI (all p < 0.001). An increase in ILOS was associated with late fixation, presence of flail chest, COPD, higher BMI, male sex, and increased age (all p ≤ 0.001). DMV remained increased by late fixation and higher BMI (both p < 0.001). Notably, AIS chest > 3 did not contribute to increased HLOS, ILOS, or DMV. A summary of these findings can be found in Table 4.

TABLE 4.

Linear regression for HLOS, ILOS, and DMV.

		Predicted probability	t	p
Prolonged HLOS
Factors increasing risk	Late SSRF	0.36	37.22	< 0.001
	Flail chest	0.07	7.43	< 0.001
	Increased BMI	0.06	6.34	< 0.001
	Higher heart rate	0.15	15.25	< 0.001
	Diabetes	0.05	5.50	< 0.001
	COPD	0.07	7.19	< 0.001
Factors decreasing risk	Higher SBP	‐0.18	−17.99	< 0.001
No effect	AIS chest > 3	0.01	1.10	0.27
	Increased age	0.02	2.38	0.02
	Male sex	0.02	1.70	0.09
	Smoking	0.03	2.88	0.004
	Functional dependent status	0.01	0.57	0.57
Prolonged ILOS
Factors increasing risk	Late SSRF	0.24	22.58	< 0.001
	Flail chest	0.10	9.38	< 0.001
	Increased age	0.04	3.31	0.001
	Male sex	0.04	3.86	< 0.001
	Increased BMI	0.10	8.72	< 0.001
	Higher heart rate	0.15	14.39	< 0.001
	COPD	0.08	7.13	< 0.001
Factors decreasing risk	Higher SBP	‐0.16	−15.25	< 0.001
No effect	AIS chest > 3	0.000	−0.02	0.99
	Smoking	0.02	1.31	0.19
	Diabetes	0.02	2.11	0.04
	Functional dependent status	−0.01	−0.54	0.59
Prolonged DMV
Factors increasing risk	Late SSRF	0.19	12.04	< 0.001
	Increased BMI	0.07	4.08	< 0.001
	Higher heart rate	0.13	8.16	< 0.001
Factors decreasing risk	Higher SBP	−0.12	−7.30	< 0.001
No effect	AIS chest > 3	−0.02	−1.00	0.32
	Flail chest	0.04	2.69	0.01
	Increased age	0.003	0.21	0.84
	Male sex	0.03	2.04	0.04
	Smoking	−0.01	−0.76	0.45
	Diabetes	0.03	2.09	0.04
	COPD	0.04	2.46	0.01
	Functional dependent status	0.001	0.07	0.95

Note: Bold text indicates significance.

Abbreviations: AIS, abbreviated injury score; BMI, body mass index; COPD, chronic obstructive pulmonary disease; DMV, duration of mechanical ventilation; HLOS, hospital length of stay; ILOS, ICU length of stay; SBP, systolic blood pressure.

Mortality was increased by the presence of flail chest with an Odds Ratio (OR) of 1.61, p = 0.001, increased age (OR = 1.09), COPD (OR = 1.96), or occurrence of any in‐hospital complication (OR = 5.16) (all p < 0.001). After matching, mortality risk was increased by the presence of flail chest (OR = 1.67), male sex (OR = 1.56), increased age (OR = 1.09), COPD (OR = 1.93), and any hospital event (OR = 5.04) (all p < 0.001). Notably, there was no difference in mortality between the early and late fixation groups (p = 0.38). A summary of the factors contributing to mortality can be found in Table 5.

TABLE 5.

Logistic regression for mortality.

Mortality		Odds ratio (OR)	95% CI	p
Factors increasing risk	Increased age	1.09	1.07–1.11	< 0.001
	Male sex	1.56	1.25–1.93	< 0.001
	Flail chest	1.67	1.38–2.01	< 0.001
	Higher SBP	1.01	1.01–1.02	< 0.001
	COPD	1.93	1.53–2.43	< 0.001
	Any hospital complication	5.04	4.15–6.13	< 0.001
Factors decreasing risk	Higher heart rate	0.99	0.99–0.997	< 0.001
No effect	Late SSRF	0.92	0.76–1.11	0.378
	AIS chest > 3	1.74	1.02–2.98	0.04
	Increased BMI	0.99	0.97–1.01	0.16
	Smoking	0.79	0.57–1.07	0.13
	Diabetes	1.25	1.01–1.55	0.04
	Functional dependent status	1.33	1.00–1.78	0.05

Note: Bold text indicates significance.

Abbreviations: AIS, abbreviated injury score; BMI, body mass index; CI, confidence interval; COPD, chronic obstructive pulmonary disease; SBP, systolic blood pressure.

4. Discussion

Richardson et al. first highlighted increased mortality associated with rib fractures in older patients [30]. Since then, improving outcomes for older patients with rib fractures has been prioritized. Christie et al. demonstrated improved outcomes for older patients who underwent SSRF for three or more rib fractures and recalcitrant pain; however, timing of fixation was not discussed [28]. In younger patients, it is well‐established that earlier fixation portends improved outcomes [2, 22, 24, 25, 31].

Our study demonstrated that early fixation (< 72 h) is associated with reductions in lengths of stay, including both hospital and ICU lengths of stay. We further found early SSRF was associated with decreased incidences of ARDS, PE, VAP, unplanned intubation, and tracheostomy; however, we were not able to demonstrate a difference in mortality. This is in line with Chen Zhu et al. and Christie et al., who also demonstrated improvements in respiratory‐related complications with early fixation, including decreased incidences of unplanned intubation, VAP, tracheostomy, and ARDS [18, 28]. Reduction in risk of unplanned intubation, unplanned admission to the ICU, and unplanned return to the OR additionally decrease the risk of morbidity and mortality in older patients [32, 33, 34, 35, 36]. Older patients are already at increased risk of mortality from traumatic injuries due to higher prevalence of comorbidities which may result in decreased pulmonary reserve and poorer functional status [9, 10, 37].

While injury burden plays a critical role in the timing and feasibility of SSRF, the increased surgical risk in geriatric patients further complicates decisions surrounding the use of surgical fixation in this population. The factors that place older patients at higher risk of both rib fractures and prolonged recovery also put them at higher risk of complications from surgery and anesthesia [38]. Concern for these complications has led to a notable underutilization of SSRF in older patients [39], despite literary consensus that SSRF reduces mortality, HLOS, ILOS, DMV, and infectious complications [16, 18, 19, 20, 21, 24, 25, 28, 40, 41].

Additionally, we found that early SSRF was associated with a reduced frequency of thromboembolic events, perhaps in part because early SSRF reduces pain, encouraging early mobility. This is important both from a patient outcomes and quality standpoint as venous thromboembolism is a benchmark of quality among trauma centers and healthcare institutions. Finally, early SSRF was found to be associated with a significantly higher likelihood of discharge home, which not only serves as a proxy for patients' relative physical abilities on discharge, but is an important quality of life measure, particularly in older patients.

Interestingly, our trial found that early SSRF was associated with decreased HLOS, ILOS, and DMV following propensity‐weighted multivariable analysis, whereas severe chest injury, as defined by AIS chest, was not. This suggests the severity of chest wall injury played a less significant role than the timing of SSRF, and is a remarkable finding that should guide surgeons to advocate for early fixation for appropriately selected older patients with rib fractures.

Both Chen Zhu et al. and Prins et al. failed to demonstrate a mortality benefit between early and late SSRF, which was corroborated by our study [18, 25]. Yet it is important to note the NTDB only captures in‐hospital mortality and studies which found mortality benefit from SSRF compared to conservative management were performed using post‐discharge mortality [19, 28]. The mortality rate in geriatric patients with unplanned admission to the ICU is nearly 50% [36], and prolonged ILOS and DMV increase 1‐year mortality, are associated with poorer discharge disposition, and often result in permanent disability [32, 42, 43, 44]. Conversely, successful weaning from mechanical ventilation may decrease risk of mortality by 62% [45]. Our study found early SSRF was associated with shorter ILOS, DMV, and reduced rates of unplanned ICU admission, suggesting that a mortality benefit may be observed if post‐discharge mortality data were available.

The lack of differences in comorbidities between the study groups suggests pre‐existing illness burden did not impact the timing of surgical fixation, although frailty was not captured. The similarity between the two study groups in AIS chest > 3 and presence of flail chest suggests the severity of chest wall injury did not play a significant role either. The early fixation group demonstrated statistically higher GCS and improved admission hemodynamics, with lower ISS, which we interpret may represent concomitant injury, as opposed to rib fractures, that dictated surgical timing. We acknowledge that, although these analyses demonstrated statistical significance, the clinical significance is less, although not zero. An ISS of 19 versus 17 in an older adult may portend different outcomes, especially in a frail individual. Furthermore, a GCS of 13.9 versus 14.4, while marginal, may offer differences in outcomes for older patients who are less resistant to the insults of injury, where small differences affect outcomes to a greater degree.

A multimodal and comprehensive approach to risk stratification in surgical planning must be taken for geriatric patients. Guidelines such as the PriME (Perioperative Management of Elderly Patients) recommendations suggest factors such as independence, fall risk, and functional reserve be considered in surgical planning [46]. However, standard measures for assessing these parameters may be confounded by the presence of rib fractures and concomitant injuries. Mobility testing, as well as verbal questionnaires, may not be feasible to perform due to pain and injury burden, or in the setting of mechanical ventilation. Additional research is needed to identify the best objective measures for assessing surgical risk in older adult patients with rib fractures due to confounding pain and high rates of comorbidities. National efforts to improve care for this population may help mitigate some of the factors under consideration. The American College of Surgeons Geriatric Surgical Verification (ACS GSV) is awarded to institutions with age‐friendly postoperative protocols that focus on reduction of postoperative delirium and outcomes such as return to function, while emphasizing goals that are most important to the individual patient [47]. Standardization of clinical practice, surgeon experience, and measures to reduce postoperative complications common to the older adult population will help minimize the impact the factors contributing to risk stratification have on these patients' hospital course and is a key component to consider in future trials.

Our study had several limitations. First, its descriptive and retrospective nature prevents determination of causality. Some survivorship bias exists with patients operated on early, selecting for patients well‐suited for early operative intervention. This is demonstrated via the fact that, despite inverse propensity matching, the late fixation group demonstrated a higher ISS. Thus, healthier, less severely injured patients, who are inherently less complex, were selected for early fixation. The higher SBP and lower HR of the early SSRF group, although marginal, may further support this theory. Further investigation is required for this subset of patients to determine which patient characteristics led to delay of SSRF.

Use of a database such as NTDB comes with several inherent limitations. As the NTDB does not capture the timing of diagnosis, we were unable to determine if pulmonary, thromboembolic, or other complications occurred before or after rib fixation. Thus, the apparent benefit of early fixation may reflect fewer preexisting complications rather than a direct causal effect. The NTDB also lacks several data elements pertinent to this study population. For instance, commonly used frailty indices such as the Charlson Comorbidity Index (CCI) [48] are not recorded. Although many constituent variables of the CCI are available, disease severity and cancer classification data are not, precluding accurate post‐hoc calculation. Additionally, while the NTDB records whether patients returned to the OR, it does not specify the indication, preventing distinction between returns related to pulmonary complications versus those for unrelated procedures. Operational factors such as OR logistical delays or cancellations are also not captured.

The lack of post‐discharge follow‐up data is another considerable limitation of the NTDB, limiting analysis of mortality to that which occurred during the index admission. Given that prolonged ILOS is associated with increased 1‐year mortality [32], longer follow‐up is a more appropriate measure of mortality as this may have prevented our ability to see a difference in mortality rate after discharge. Additionally, patients whose discharge status was classified as “Other” encompassed convalescent facilities and non‐medical destinations (law enforcement, against medical advice, etc.), the nuance of which does have important implications for quality of life after hospital discharge as well. In addition to these data‐related limitations, a lack of consistency in clinical practice nationally introduces further potential sources of bias. The complexity of rib fixation surgery, surgeon experience, and institutional practice patterns represent additional sources of variability. Identification of centers with ACS GSV status could mitigate some of these confounders, though this designation is not uniformly adopted and is not captured in the NTDB, and would limit the number and characteristics of centers included, limiting external validity. Institutional criteria for SSRF also vary, with some centers limiting fixation to patients with flail segments. While such heterogeneity may enhance the external validity of findings, it introduces confounding related to local practice and resource availability. Even among well‐resourced academic institutions represented in the NTDB, limited OR access and personnel constraints may delay SSRF.

ICD‐10 codes were used to identify patients who underwent SSRF and those who had flail chest injuries. However, all other clinical data in the NTDB is captured from multiple sources including physician notes, nursing notes, discharge summaries, etc. This variability in data collection methodology is another limitation of the NTDB. Finally, reliance on ICD‐10 coding for identification of SSRF does not distinguish between patients who also underwent adjunctive pain procedures such as nerve blocks, cryoablation, or placement of continuous analgesic catheters. These interventions may influence postoperative outcomes, including HLOS and ILOS, but are not reliably captured in the database.

Further research is warranted to better delineate the clinical impact of early versus delayed SSRF. Prospective, pragmatic randomized controlled trials would allow for the determination of causality, comprehensive capture of relevant data elements, including comorbidities, procedural details (like timing, indication, and technique), and the assessment of the temporal relationship between complications and fixation. Incorporation of post‐discharge follow‐up would also facilitate evaluation of long‐term mortality, patient‐reported outcomes, and quality of life.

This observational study elucidates the correlation between early SSRF and patient outcomes, highlighting an area for future, hypothesis‐testing studies to investigate causality. The STROBE guidelines provide standardization to facilitate this process; however, the aforementioned limitations of the NTDB caused challenges with adherence that may be of particular importance to the older adult population. The deidentified nature of the data available prevented reporting on settings, locations, ACS GSV status, or surgeon experience. The lack of follow‐up data and patient reported outcomes becomes more important when dealing with patients of increased age both as a tool of efficacy and pre‐operative planning.

5. Conclusions

Ultimately, while considering individual patient factors, injury patterns, and resources, we suggest that surgeons advocate for early SSRF, within 72 h of admission, for older adults who are deemed candidates for fixation. Resources should be allocated to allow for these cases, and clinicians and institutions should continue to work to optimize outcomes for geriatric patients who sustain rib fractures.

Author Contributions

Jared Plumb: study concept and design, analysis and interpretation of data, drafting of manuscript, critical revisions of the article, final approval for publication. Gena V. Topper: study concept and design, analysis and interpretation of data, drafting of manuscript, critical revisions of the article, final approval for publication. Jacob Metheny: drafting of manuscript, critical revision of the article, final approval for publication. Patrick Morris: study concept and design, citation management, final approval for publication. T. Hess: study concept and design, critical revision of the article, final approval for publication. Krystal Hunter: study design, statistical analysis, final approval for publication. Malia Voytik: drafting of manuscript, final approval for publication. Connor Magura: analysis and interpretation of data, final approval for publication. Asanthi Ratnasekera: critical revision of the article, final approval for publication. Tanya Egodage: study concept and design, analysis and interpretation of data, project administration and supervision, critical revision of the article, final approval for publication.

Funding

The authors have nothing to report.

Disclosure

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Table S1: STROBE statement—checklist of items that should be included in reports of observational studies.

Plumb J., Topper G. V., Metheny J., et al., “Surgical Stabilization of Rib Fractures in Geriatric Trauma Patients: A National Trauma Data Bank Review,” Journal of the American Geriatrics Society 74, no. 3 (2026): 738–747, 10.1111/jgs.70297.