In this review, one RCT comparing surgical rib fixation with conservative treatment in 50 adult polytrauma patients was included. The study findings revealed that there were no significant differences in in-hospital mortality, the requirement for mechanical ventilation, and the length of hospital stay when comparing surgical rib fixation with conservative treatment. However, when assessing the length of stay in the ICU, surgical rib fixation appeared to have a favorable impact, leading to a reduction in ICU duration compared to conservative treatment.

A 2016 systematic review, which does not focus on polytrauma patients, similarly concluded that mortality rates did not differ between the intervention groups (operative vs. non-operative management of flail chest) [1]. This review as well as the review performed by Cataneo et al. also revealed a positive effect of surgical rib fracture fixation and surgical intervention for flail chest on pneumonia rate, duration of mechanical ventilation, duration of ICU, hospital stay and tracheostomy rate [1, 5]. In contrast, a retrospective analysis of the German Trauma Registry database, which examined polytrauma patients from 2008 to 2017 using a matched pairs analysis involving 395 pairs, suggested a reduction in mortality, but an extended duration of mechanical ventilation, ICU stay, and overall hospital stay after surgical stabilization [12]. These seemingly contradictory findings may be attributed to differences in patient populations, the extent and severity of associated injuries, and variations in surgical timing and techniques.

With regard to critically ill trauma patients, a prospective, controlled evaluation of surgical stabilization of rib fractures (SSRF) showed improved outcomes [13]. Particularly with regards to respiratory failure, tracheostomy, and duration of ventilation, the group who underwent surgery demonstrated superior outcomes when compared to the non-operative group. Furthermore, two retrospective cohort studies focused on osteosynthetic treatment in polytrauma patients. These studies revealed that patients who underwent surgery experienced a prolonged need for ventilation and extended hospital or intensive care stays with different advantages observed in individual treatment parameters (e.g. overall survival, incidence of pneumonia). Notably, factors such as the timing of surgical treatment and the extent of pulmonary contusions were considered prognostic parameters [4, 14]. This underscores the importance of individualized treatment strategies and highlights how nuanced factors can substantially influence outcomes.Additionally, no high-quality recent studies focus specifically on polytrauma patients, highlighting a critical gap in the literature. This patient population is particularly complex, as polytrauma often involves severe injuries to multiple organ systems, dynamic physiological derangements, and complications such as pulmonary contusions, hemorrhagic shock, and acute respiratory distress syndrome (ARDS). These factors make the management of bony thorax injuries in polytrauma patients uniquely challenging and necessitate evidence tailored to their specific needs. Current findings derived from isolated thoracic injury cohorts cannot simply be extrapolated to polytrauma patients, given their fundamentally different clinical trajectories and outcomes. In summary, numerous studies show no or limited comparability due to differences in reported parameters and divergent inclusion and exclusion criteria.

It is important to recognize the limitations of this systematic review. The search period of this systematic review was 2 years ago, necessitating a search update. Further, we focused only on systematic reviews including RCTs. However, the limited availability of RCTs results in a restricted relevance of these findings into today’s clinical practice. The low level of certainty into the evidence, stemming from some concerns regarding the risk of bias within the included study and imprecision of the results, further diminishes the robustness of the conclusions. Given these considerations, this systematic review highlights the urgent need for additional high-quality RCTs specifically addressing polytrauma patients. Evidence is urgently required not only to clarify the comparative effectiveness of surgical versus conservative treatment but also to guide critical clinical decisions in a population where missteps can have profound implications for survival and quality of life. Understanding the specific needs and challenges associated with polytrauma patients is essential to optimize their management and improve outcomes in this highly vulnerable population.