Surgical Stabilization of Rib Fractures: Secular Trends in Epidemiology and Treatment

Severe chest trauma is one of the most common causes of death in multiply injured patients and is associated with increased mortality in the elderly (1). In certain cases, early surgical stabilization of rib fractures (SSRF) may be associated with a significant reduction in mortality, pulmonary complications, and length of hospital stay (2). A number of recommendations have already been published, including those by the Chest Wall Injury Society (CWIS) and the World Society of Emergency Surgery (WSES) (3).

Methods

Routine data from the BARMER statutory health insurance fund (nationwide longitudinal claims data of around 8.3 million insured individuals) and data from the reim-bursement.INFO Tool (RI Innovation, Hürth, Germany; a web-based application for analyzing structured hospital quality reports and data from the Federal Statistics Office) were evaluated (Ethics Committee Westphalia-Lippe, 2024–006-f-S). Multiple rib fractures were defined as the fracture of three or more consecutive ribs at two or more sites each and identified by the ICD-10-GM (German Modification) codes S22.41, S22.43, S22.44, and S22.5. SSRF was identified by the OPS (German procedure classification) codes 5–346.5, 5–346.c0, 5–346.c1, 5–346.c2, 5–346.c3, 5–346.d0, 5–346.d1, 5–346.d2, and 5–346.d3. Data sets with appropriate codes for patients aged 15 years or over during the periods 2007 to 2022 (BARMER) and 2006 to 2023 (reimbursement.INFO) were included.

Results

A total of 63 045 cases with multiple rib fractures were identified, including 533 cases treated by SSRF in the BARMER dataset, while the reimbursement.INFO dataset contained 759 782 ICD codes for multiple rib fractures and 19 133 OPS codes for SSRF.

An increase in the incidence rate of multiple rib fractures was evident, predominantly involving older age groups. The BARMER data showed a steady rise in the SSRF incidence rate, whereas the reimbursement.INFO data presents a sharp decrease coinciding with the change in OPS coding for chest wall stabilization in 2019 (Figure 1). In 2022, the proportion of patients with multiple rib fractures who underwent SSRF increased over time from 0.33% to 1.76%. The SSRF rate per fracture demonstrates a bimodal distribution, with peaks among young adults and patients aged between 60 and 70, and no clear temporal trend.

Figure 1

Incidence rate of patients with multiple rib fractures

The majority of coded SSRF procedures were performed in thoracic surgery units, albeit with a falling trend, while the proportion treated in trauma surgery units increased from 1.8% to 13.9% in 2023 (Figure 2). Only a few centers reported high annual SSRF case volumes (six departments with an annual average of more than 20 cases between 2019 and 2023). Departments with an average yearly case volume of less than 20 performed 78% of the SSRF procedures between 2019 and 2023.

Figure 2

Proportion of SSRF codes

The average length of hospital stay was longer after SSRF than without. With respect to length of hospital stay for SSRF, linear regression demonstrates a reduction from 19.9 days with a 95% confidence interval of [15.17; 24.73] in 2007 to 16.15 days [11.42; 20.88] in 2022 and an almost constant length of hospital stay for fractures from 11.5 days [11.16; 11.87] in 2007 to 10.61 days [10.25; 10.97] in 2022. This may be partly due to the concurrent decrease in time between hospital admission and the SSRF procedure. In 2022, however, this interval was still more than an average of five days. Total hospital costs were higher in SSRF cases, although these additional costs decreased markedly over time (data not shown).

Discussion

The data show an increase in incidence rates of multiple rib fractures and SSRF, particularly among higher age cohorts. This could be partly due, on the one hand, to changes in social demographics and, on the other, to improved diagnostics, changes in coding practices, and financial incentives. International studies also reveal a rising trend in incidence rates and age-adjusted incidence rates of rib fractures, irrespective of the sociodemographic index (4). Overall, further increases in incidence rates are to be expected given the current trend.

A few centers witnessed high SSRF case numbers. These are specialized thoracic surgery centers, although a proportion of the procedures likely occurred outside the setting of acute trauma and may have involved stabilization without surgical fixation (e.g., by using mesh). This may account for the discrepancy between the SSRF incidence rate of confirmed trauma cases in the BARMER dataset and the SSRF codes reported in the reimbursement.INFO dataset. It cannot be ruled out that some SSRF codes in the reimbursement.INFO dataset are derived from other operations/clinical conditions involving the chest wall.

The low SSRF case volume in the majority of departments may hinder the development of competency in performing SSRF procedures. At the same time, the rise in the proportion of SSRF codes in trauma and general surgery units paralleled the increase in the SSRF incidence rate in the trauma setting (BARMER data), which would suggest an increasing level of traumatological expertise in SSRF.

The average time between hospital admission and SSRF surgery exceeded five days, which is longer than the recommended maximum of 48 to 72 hours (3). So, in the long term, SSRF could also confer health economic benefits in comparison with conservative management. However, this question cannot be finally established in the present unmatched cohort.

Given that patients with severe chest trauma have often sustained multiple injuries, interdisciplinary care led by trauma and orthopedic surgeons is required (5). Care delivery for patients with severe bony chest injuries could potentially be improved by enhanced inter- and intrahospital collaboration, thereby centralizing expertise, possibly through the use of mobile teams. When combined with benchmarking across centers, this could optimize various treatment-related outcomes.

Michael David Huelskamp, Martial Mboulla Nzomo, Laura Acar, Ursula Marschall, Michael Johannes Raschke, Steffen Rosslenbroich

Conflict of interest statement
MDH acknowledges support from the German Research Foundation (DFG) – 493624047 (Clinician Scientist CareerS Münster).

The other authors declare that no conflict of interest exists.

Manuscript received on June 18, 2025, revised version accepted on November 28, 2025

Translated from the original German by Dr. Grahame Larkin

Cite this as:
Huelskamp MD, Mboulla Nzomo M, Acar L, Marschall U, Raschke MJ, Rosslenbroich S: The surgical stabilization of rib fractures: Secular trends in epidemiology and treatment. Dtsch Arztebl Int 2026; 123: 115–6. DOI: 10.3238/arztebl.m2025.0228

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