Better late than never? Efficacy of late surgical stabilization of acute rib fractures as compared to nonoperative management.

BACKGROUND: Surgical stabilization of rib fractures (SSRF) for severe chest wall injury has increased, with research showing improved outcomes compared with nonoperative management. Ideally, SSRF is performed within 3 days of injury. We hypothesize that late SSRF (days 5 to 14 post-injury) provides benefit over nonoperative treatment in patients with severe chest trauma. METHODS: We analyzed a prospectively collected database (2016 to 2024) from an urban level I trauma center, including patients with ≥3 severely displaced rib fractures. Propensity score matching (PSM, 1:2) was used to compare patients undergoing late SSRF (days 5 to 14 post-injury) to those hospitalized ≥5 days who did not receive SSRF. Outcomes measured were daily morphine milligram equivalents (MME), epidural use, opioid prescription at discharge, hospital length of stay (LOS), ICU-free days, ventilator-free days (VFD), pneumonia, tracheostomy, and mortality. RESULTS: Among 364 SSRF patients, 28 (8%) underwent late SSRF; these patients were matched to 56 No-SSRF patients. Both groups had similar demographics. SSRF patients had lower injury severity score (ISS) (17 vs. 26) but higher RibScore (3.5 vs. 3.0). Late-SSRF patients had significantly lower maximum daily MME post-day 5 (60 mg vs. 148 mg, P=0.045) and nonsignificantly lower median MME (56 mg vs. 67 mg, P=0.47) than No-SSRF patients. There were nonsignificant differences in use of epidurals (8% vs. 33%, P=0.22) and discharge with opioids (75% vs. 87%, P=0.38). Late SSRF was associated with more ICU-free days (6.5 vs. 3.5, P=0.02), shorter hospital LOS (9.0 vs. 16.5 d, P=0.008), and reduced pneumonia incidence (0% vs. 33%, P=0.03). Nonsignificant differences in tracheostomies, VFD, and mortality between the study groups. CONCLUSIONS: Late SSRF is associated with improved in-hospital outcomes. Although early intervention remains ideal, late SSRF may provide clinical benefits in selected patients. (J Trauma Acute Care Surg. 2026;00: 000-000 Copyright © 2026 Wolters Kluwer Health, LLC. All rights reserved. LEVEL OF EVIDENCE: Level III, retrospective review.