This study showed no significant differences in patient demographics, including age, sex, BMI, smoking history, and other underlying diseases, between the operative and non-operative groups. Motorcycle accidents were the primary cause of multiple rib fractures at the National Taiwan University Hospital (operative group, 44.6%; non-operative group, 44.7%), which may be due to the high rate of motorcycle use in Taiwan [18]. In Taiwan, nearly 60% of all driving fatalities involve motorcycles. The second most common cause of rib fractures was falls.

Patients in the operative group had higher head AIS scores and worse consciousness statuses with lower GCS scores, indicating that this group had clinically more severe injuries and may have needed other surgical interventions in addition to SSRFs, especially clavicle ORIFs. The clavicle is a body part that is usually injured during motorcycle accidents [19]. According to a previous systemic review, clavicle and rib fractures are closely related in patients with poly-trauma, and almost a fifth of all patients with blunt chest trauma sustain both injury types [19].

As Taiwan is a left-driving country, the primary side of rib fractures was the left side. Patients in the operative group had more thoracic complications than those in the non-operative group, including displacements, pleural effusions, and pneumothoraces, indicating that this group had a more critical clinical status. A previous study showed that rib fixation may benefit selected patients with traumatic rib fractures and much more severe clinical conditions, such as those with bilateral rib fractures, multiple displaced rib fractures, flail segments, and concomitant thoracic injuries [20].

The mean time to surgery in our hospital was 4.34 ± 2.97 days, approximately 96 h. A previous retrospective study that included 2,839 patients, of whom 1,520 (53.5%) underwent early surgical stabilization of rib fractures (< 72 h), showed that early surgical stabilization of rib fractures decreased the length of hospital and ICU stay and lowered the rates of unplanned intubations, unplanned ICU admissions, and tracheostomies [21]. In our hospital, the strategy for rib fractures was to observe initially and perform surgical management if the clinical status matched the surgical criteria. In our study, we did not conduct a subgroup analysis between the early and late operations.

In this study, patients in the operative group had longer hospital and ICU stays and higher intubation rates. This finding differs from a previous study that showed a statistical benefit of surgical fixation compared to conservative management of rib fractures in terms of ICU length of stay, mechanical ventilation, mortality, pneumonia, and tracheostomy [6]. This different result may be because of the higher proportion of patients undergoing other surgical interventions, thus extending the recovery period and length of hospital stay. However, in the operative group, the pain scale was much lower at 2 weeks and 3 months after the operation than in the non-operative group, indicating that the patients in the operative group had a significantly better quality of recovery after surgery than the non-operative group. In a previous randomized controlled trial of patients with severe chest trauma, SSRF increased hospital length of stay and did not provide any quality of life benefit for up to 6 months [22]. In our study, surgical intervention showed a better long-term prognosis for these patients.

Between 2017 and 2019, our medical institution conducted a prospective study that compared the long-term outcomes of non-surgical and surgical management of rib fractures in patients with major trauma without head injuries. And showed that surgical management of rib fractures can reduce pain and hospital stay in patients with major trauma [23]. In this study, we retrospectively collected data on all patients with rib fractures diagnosed in our hospital and showed that surgical management could reduce the pain scale and increase the quality of life, even in patients with simultaneous head injuries.

However, this study had some limitations. First, owing to this study’s retrospective design, there may have been bias in collecting and reviewing patient data. Some data may have been obscured, and some may have been lost during follow-up. Second, the pain scale is a subjective method for evaluating clinical outcomes; the lack of objective evaluation may have also introduced some bias. Third, our study did not focus on subgroup analysis or evaluation of the surgical stabilization of rib fractures in patients with non-multiple rib fractures. The final item, the lack of data on the degree of displacement of rib fractures, which may influence the decision-making process for surgical stabilization. Future studies should include this variable to better stratify patients and evaluate outcomes.