Rib fixation still helps: Surgical stabilization of rib fractures in traumatic brain injury, a TQIP Study

BACKGROUND: Surgical stabilization of rib fractures (SSRF) has been associated with lower odds of mortality and reduced pulmonary morbidity in patients with chest trauma, but its role in patients with concomitant traumatic brain injury (TBI) remains controversial. We hypothesized that TBI phenotype modifies the association between SSRF and clinical outcomes. METHODS: We conducted a retrospective study using the TQIP (2017–2023) database. Adults 18 years or above with head and thoracic AIS ≥3 and ≥3 rib fractures were included. TBI phenotypes (focal, diffuse, mixed, concussion-only) were classified using ICD-10 codes. The primary outcome was in-hospital mortality. Secondary outcomes were pulmonary composite complications, ventilator days, and tracheostomy. Firth’s penalized regression with SSRF × TBI phenotype interaction assessed effect modification, adjusting for age, sex, race, ISS, Glasgow Coma Scale, shock index, and flail chest. RESULTS: Of 73,965 patients, 80.4% had focal TBI, 12.5% mixed, 4.6% concussion-only, and 2.5% diffuse TBI. Overall, 3.3% underwent SSRF, and 12.8% died. TBI phenotype significantly modified the SSRF-mortality association (interaction p =0.011). SSRF was associated with lower odds of mortality in focal TBI [odds ratio (OR): 0.262, 95% CI: 0.206–0.328, p <0.001]. The diffuse TBI interaction term was statistically significant (OR: 0.220, 95% CI: 0.044–0.691, p =0.007), corresponding to a phenotype-specific OR of 0.058. Mixed TBI (interaction OR: 0.628, p =0.109) and concussion-only (interaction OR: 0.590, p =0.338) did not reach significance. SSRF showed no significant association with pulmonary complications (OR: 1.23, p =0.073) or ventilator days (B=−0.15, p =0.19), with no phenotype interaction for either outcome. SSRF was associated with increased tracheostomy (OR: 2.50, 95% CI: 2.05–3.05, p <0.001) without phenotype interaction. CONCLUSIONS: TBI phenotype significantly modified the association between SSRF and in-hospital mortality. SSRF was associated with lower adjusted odds of mortality in focal and diffuse TBI phenotypes, suggesting that TBI should not categorically preclude SSRF candidacy. These findings support phenotype-based patient selection for SSRF, favoring intervention even in the presence of TBI. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.