Goals:

• Enhance Technical Proficiency with Thoracic Exposures

• Promote Critical Decision-Making with Rib Plating Patient Selection

• Foster the Integration of Technology with Surgical Practice

Objectives:

• PGY1-2s

  1. Chest tube insertion and CLR Irrigation

     • Residents will demonstrate safe and accurate chest tube placement, adhering to anatomical landmarks and procedural best practices. They will also practice thoracic irrigation with the CLR thoracic irrigation system. 

  2. Saw Bone Rib Plating (RibFix Titan Systems)

     • Residents will perform rib fixation on Saw Bone models with internal and external plating systems to gain an understanding of the systems and mechanics. 

  3. Cadaveric AR/VR Surgical Planning (Immersive Touch) 

     • Residents will gain an understanding of internal thoracic bony anatomy as it relates to surface landmarks with advanced AR/VR systems that can be used for surgical planning as well.

• PGY3-4s

  1. Cadaveric Rib Plating (RibFix Advantage and RibFix Titan systems)

     • Residents will perform rib fixation on cadaveric models with internal and external plating systems to gain an understanding of the systems and mechanics. 

  2. Sternotomy and Sternal Closure (Wires and SternaLock EZ, Sternalock Blu, and Sternalock XP)

     • Residents will practice midline sternotomies and execute sternal closures using both traditional wiring techniques and plate fixation, ensuring secure and stable repairs.

  3. Sternal Re-Entry

     • Residents will practice how to emergently re-enter the chest that has been closed with sternal plates. 

  4. Thoracotomy and Thoracic Closure (If cadaveric specimens and time allows) 

     • Residents will perform thoracotomies with emphasis on proper incision placement, tissue handling, and subsequent thoracic closure techniques.

Scenario #1:

A 45-year-old male was the unrestrained driver in a high-speed motor vehicle collision. EMS had to extricate the patient and the stearing wheel was bent. He presented with severe chest pain as his only complaint. He is protecting his airway. He has blunted breath sounds bilaterally, crepitus over the right chest with paradoxical motion of his right lateral chest and saturations at 90% despite 15L O2 on a non-rebreather mask. He has good distal pulses with a blood pressure of 145/90 and a heart rate of 110 bpm without ectopy. There are no other signs of trauma. Initial chest x-ray demonstrates multiple rib fractures bilaterally including left 4-7 non-displaced anterolateral rib fractures and right 3-9 displaced anterolateral rib fractures with 4-8 broken posteriorly with minimal displacement. He has a hemopneumothorax on the right and a pneumothorax on the left. 

Scenario #2:

A 32-year-old male is brought to the emergency department by ambulance after sustaining a gunshot wound to the left anterior chest during an altercation. On arrival, he is visibly pale and diaphoretic. His vital signs are: blood pressure is 85/55 mmHg, heart rate 135 beats per minute, and respiratory rate 28 breaths per minute. He is protecting his airway but has tracheal deviation to the right. On auscultation, breath sounds are diminished on the left side, and there is evidence of subcutaneous emphysema. Chest examination reveals a 2-cm gunshot wound just below the left nipple. 1 unit of whole blood increases the blood pressure to 95/60, but his heart rate stays at 135 bpm. eFAST demonstrates a left pneumothorax with a large associated pleural effusion, no pericardial effusion, and no intraabdominal fluid. 

Scenario #3:

A 28-year-old female presents to the emergency department following a stab wound to the precordial region sustained during an altercation at a local gas station. Upon arrival, she is confused and in significant distress. Her initial vital signs reveal a blood pressure of 80/50 mmHg, a heart rate of 130 beats per minute, and a respiratory rate of 26 breaths per minute. Physical examination shows a 1.5-cm stab wound located just inferior to the left nipple, with surrounding ecchymosis. Cardiac auscultation reveals distant heart sounds, and there is evidence of jugular venous distension. A focused assessment with sonography for trauma (FAST) reveals a pericardial effusion with signs of tamponade physiology. 

Why we started bolting the chest back together

• For most of the 20th century, flail chest was treated by "internal pneumatic stabilization" (e.g. intubate, ventilate, and let the paradoxically moving segment splint itself against positive pressure while it healed). Fixation existed (Judet struts, K-wires, medullary nails were reported across Europe and Asia from the 1950s) but was sporadic and unstudied. Despite the new era of data starting in the early 2000s, the literature is still trying to answer the question of, "who do we operate on and when."

The chronological story of surgical stabilization of rib fractures (SSRF)

• Tanaka et al. (Journal of Trauma, 2002): Thirty-seven ventilated flail-chest patients who couldn't wean by day 5 were randomized to Judet strut fixation versus continued pneumatic stabilization. Surgery dropped d the pneumonia rate (22% vs 90%), shortened ventilator days and ICU stay, reduced tracheostomy, and produced better pain, spirometry, and return-to-work at one year.

• Granetzny et al. (Interactive CardioVascular and Thoracic Surgery, 2005): Forty flail patients randomized to wire/K-wire fixation within 24–36 hours versus external strapping. Fixation shortened ventilator days, ICU and hospital stay, cut pneumonia, restored chest-wall stability (85% vs 50%), and improved 2-month spirometry. 

• Nirula et al. (mid-2000s US cohort): A prospective strut-fixation series against historical controls. Total ventilator days weren't significantly different, but post-fixation ventilator days were shorter (2.9 vs 9.4).

• EAST 2012 (Simon et al., Journal of Trauma and Acute Care Surgery). The first EAST guideline noted that no RCT had compared SSRF to modern nonoperative care (epidural + physiotherapy), and that ~90% of surveyed trauma surgeons wouldn't adopt SSRF without better data.

• Marasco et al. (Journal of the American College of Surgeons, 2013): Forty-six ventilator-dependent flail patients randomized to resorbable-plate fixation versus best-practice ventilation. Shorter ICU stay (285 vs 359 hours), far less post-extubation noninvasive ventilation (3 vs 50 hours), and cost savings. There were no differences in 3-month spirometry or 6-month quality of life. The benefit was acute and physiologic, not necessarily long-term.

• Leinicke et al. (Annals of Surgery, 2013) and the meta-analyses: Pooling the flail literature (9 studies, 538 patients) yielded roughly 4–6 fewer ventilator days, 3–4 fewer ICU days, and (for the first time) a mortality signal (RR 0.44) plus large reductions in pneumonia and tracheostomy. The 2015 Cochrane review (Cataneo et al.) confirmed the direction of effect while flagging tiny samples as a limitation.

• Pieracci et al. (Journal of Trauma and Acute Care Surgery, 2016): A crossover controlled evaluation (nonop in 2013, op in 2014, 70 patients) expanded criteria beyond flail to include severely displaced patterns and failure of medical management. Operative patients had 76% lower odds of respiratory failure and 82% lower odds of tracheostomy, with zero mortality in both arms.

• EAST 2017 (Kasotakis et al.): Meta-analysis of ~986 flail patients gave a conditional recommendation for SSRF in flail chest (mortality OR 0.30, pneumonia OR 0.24, tracheostomy OR 0.24) but explicitly could make no recommendation for non-flail fractures.

• Pieracci et al. (2018). A 4-center analysis of 551 SSRF patients showed each additional pre-op hospital day raised the odds of pneumonia by 31%, prolonged ventilation by 27%, and tracheostomy by 26%, and made the operation technically harder. The "fix early" doctrine (within ~72 hours) dates from here.

• CWIS NONFLAIL trial (Pieracci et al., Journal of Trauma and Acute Care Surgery, 2020): The first dedicated non-flail trial: 110 non-ventilated patients with ≥3 severely displaced ipsilateral fractures plus pulmonary derangements. SSRF within 72 hours improved 2-week pain (numeric pain score 2.9 vs 4.5), reduced pleural-space complications (0% vs 10.2%), and improved respiratory disability. This is the study people cite when they operate on the non-flail-but-miserable patient, but this is slightly countered by the following two studies:

• Marasco et al. (2022) and Meyer et al. (Annals of Surgery, 2023): Two RCTs in broader non-ventilator-dependent populations failed to show acute benefit. Meyer's single-center RCT (84 patients, severe chest-wall injury without clinical flail) found SSRF produced a longer hospital stay (14.5 vs 9.9 days), greater opioid exposure, and worse early quality-of-life scores that only equalized by 3–6 months. Lesson: in unselected non-flail injury, plating can hurt the acute course.

• WSES/CWIS position paper (Sermonesi et al., World Journal of Emergency Surgery, 2024): Operate on flail chest; consider SSRF for non-flail patients with ≥3 displaced fractures plus pulmonary derangements or failure to wean; fix within 48–72 hours; and TBI and pulmonary contusion are no longer absolute contraindications.

• SOFRIB trial (Ang, Nathens et al., Annals of Surgery, 2026): A 9-center RCT (236 patients, ≥3 displaced fractures with pulmonary compromise) found SSRF did not shorten ICU stay (primary endpoint), and was associated with a longer hospital stay (+3.3 days) and more pneumonia (11.4% vs 3.3%). Yet, SSRF delivered clinically meaningful gains in SF-36 quality of life, pain impact, and a trend toward better return to work. 

The takeaway that now dominates the field: select, don't reflex. The clearest winners remain flail chest with respiratory failure and carefully chosen displaced non-flail patients with physiologic compromise. Indications by pattern.

• Flail chest (≥3 consecutive ribs each broken in ≥2 places): strongest indication in a hemodynamically stable patient.

• Non-flail, ≥3 ipsilateral displaced fractures: consider when severely displaced (≥15 mm override, lung protrusion, or ≥25% hemithorax volume loss) or with pulmonary physiologic derangements/failure to wean.

• Absolute contraindication: hemodynamic instability. TBI and pulmonary contusion are not absolute contraindications anymore.

Which ribs to plate, when, and how

• The ribs with the most biomechanical advantage to plate are ribs 3–10, with 4-9 being the most contributory to respiration. Ribs 1–2 are deep, near the subclavian vessels, contribute little to respiration, and are morbid to expose. Ribs 11–12 float and are generally left alone unless dangerously displaced into critical structures. Within the range, ribs 6–8 deserve the strongest consideration for plating as they drive the most thoracic-volume change and are the easiest to expose without dividing muscle, which can contribute to post operative pain and mobility limitations (WSES-AAST Thoracic Trauma Guidelines, 2025; WSES/CWIS 2024).

• The paradigm of, "fix one break per rib to convert flail to non-flail" is biomechanically inferior. Finite-element modeling (Bauman et al., 2024) shows stabilizing all fracture lines restores ~95% of normalized stability versus ~56% for partial fixation. The WSES/CWIS position is to fix all displaced fractures reachable through the index incision; selective plating is acceptable for minimally displaced or hard-to-access breaks or if the patient deteriorates.

• Timing. Early plating, within 48–72 hours, is a strong recommendation. A large ACS-TQIP analysis found an ~82-hour inflection with less ARDS and ventilator-associated pneumonia when done early; a randomized ≤48h vs >48h comparison favored early fixation on length of stay, ventilator days, and cost.

Approach by fracture zone (WSES/CWIS): <- see the videos in the following section.

• Anterior (ribs 3–6): supine, arm suspended; oblique inframammary incision with a muscle-sparing sub-pectoral flap. Protect the long thoracic, intercostobrachial, and pectoral nerves.

• Lateral/anterolateral/posterolateral: lateral decubitus, arm on an overhead board; vertical axillary incision along the anterior border of latissimus ("line of best fit"). The long thoracic nerve runs superficially on serratus anterior and it should be protected as injury leads to winged scapula.

• Posterior/subscapular: lateral decubitus or prone; parascapular incision through the triangle of auscultation, retract the scapula and push erector spinae medially. VATS-assisted intrathoracic plating is a helpful option for very posterior/subscapular fractures to avoid scapular retraction.

Plate placement and biomechanics: 

• Place plates on the upper two-thirds of the rib to spare the inferior neurovascular bundle; start fixation near the fracture. Anatomically precontoured titanium locking plates are standard. U-plates grip both cortices and resist bending ~79% better in the lab and can be useful in osteoporotic bone. Intrathoracic plating exploits the thicker/denser inner cortex and shows shorter stay and operative time per rib in one prospective series, but extrathoracic plating has more consistent evidence and intrathoracic should be reserved for experienced hands. Bicortical vs monocortical: no clear winner. Bridge-plate comminuted zones; cable cerclage helps in fragmented or thin (<8 mm) bone.

Does cryo work for plating pain?

Intercostal nerve cryoablation reduces opioids and ICU time in retrospective SSRF series, but the randomized evidence is genuinely mixed and the certainty is low and there's a real neuropathic-pain safety signal.

• Adjunct to SSRF (retrospective): A 2026 systematic review/meta-analysis (Ikarine et al., Journal of Surgical Research; 4 cohorts, 479 patients) found INCA + SSRF cut opioid use (~140 MME), ICU stay (~2.8 days), hospital stay (~1.8 days), and post-op intubation (RR 0.47). The GRADE certainty was very low. Supporting single-center series (Fernandez 2022, Marturano 2023, O'Connor 2023, Carmona 2026) echo lower opioids and shorter ICU stays.

• The randomized/negative data: Choi et al. (2021 pilot) found no analgesic difference. Hopper et al. (2026) found no clear opioid reduction in non-ventilated patients, benefit mainly in ventilated patients. Importantly, there were more referrals for intercostal neuralgia (20% vs 4.5%).

• Percutaneous cryoneurolysis for rib fractures (no surgery): one small positive RCT by Finneran (2025) found better inspired volume and far less oxycodone, and one larger negative RCT by Forrester (2026) found no difference in pain or opioids out to 12 months.

• Thoracic surgery RCTs: two recent RCTs (Weksler 2025; Koliakos 2025) showed no benefit and higher neuropathy scores, even though large observational data and a 2026 meta-analysis (Towe et al.) show opioid reduction.

If done, apply the probe to the inferior rib edge, 2–4 cm lateral to the spine to avoid the sympathetic chain. Depending on the device, apply −60 to −70°C for ~1-2 minutes per bundle. Avoid cryo above rib 3 and below the 10th rib (abdominal-wall bulge). 

Standard thoracotomy closure

The classic pericostal suture loops around the ribs (normally with 1 or 2 Vicryl) and can crush the intercostal nerve against the lower rib's inferior edge. A cadaver study showed 70–100% nerve entrapment that could possibly drive post-thoracotomy pain.

The potential fix is intracostal / nerve-sparing closure (Cerfolio, Annals of Thoracic Surgery, 2003): drill small holes through the lower rib and pass the approximating sutures through those holes and over the top of the upper rib, so nothing compresses the nerve. Cerfolio's series showed markedly lower pain at 2 weeks, 1 month, and 3 months, with less burning/shooting (neuropathic) pain. Variants that achieve the same without drilling include the edge-closure and double-edge techniques (Sakakura 2010; El-Hag-Aly 2015), which reduce pain out to 6–12 months. 

Sternal (median sternotomy) closure

Standard wire cerclage: ~1–3 wires through the manubrium and 3–5 through/around the body, twisted to compress the halves. Figure-of-eight wiring reduces longitudinal motion. An RCT of 700 high-risk patients showed lower superficial and deep wound infection, and a large observational series showed far less dehiscence (0.06% vs 0.66%). AATS gives it a Class IIb recommendation.

Rigid plate fixation (RPF): titanium locking plates/screws for true rigid fixation. Raman et al. (2012) showed better CT healing and 6-month union (70% vs 24%). Allen et al. (2017/2018, JTCVS/ATS) showed better healing, sternal union 80% vs 67%, fewer sternal complications (0% vs 5%), less pain, better SF-36, and roughly cost-neutral. A meta-analysis (Tam et al., 2018) found benefit concentrated in high-risk patients (obesity, prior chest radiation, severe COPD, steroids). ERAS Cardiac Guidelines (JAMA Surgery 2019) showed Class IIa evidence for rigid fixation to accelerate healing and reduce wound complications especially in high-risk patients. Plating is contraindicated in osteoporosis/active infection. 

Sternal fracture plating

• Sternal fractures occur in ~3–8% of blunt trauma (classically the belted driver or a flexion-compression mechanism), and >95% are managed nonoperatively. There are no RCTs; the entire evidence base is Level IV case series and database studies, and there is no consensus on selection (Klei et al., International Orthopaedics, 2019; Christian et al., European Journal of Trauma and Emergency Surgery, 2022).

• The most agreed-upon indication in the Mayberry surgeon survey was non-union after ~6 week, and even that only reached 68% agreement. Pragmatic operative triggers (Bauman et al., European Journal of Trauma and Emergency Surgery, 2022) include: pain >5 despite protocolized analgesia by hospital day 2, palpable fracture motion/clicking, respiratory derangement (incentive spirometry <50% predicted or declining), reduced upper-extremity range of motion, gross displacement/overlap, mechanical instability, and sternal fractures accompanying flail chest. Notably, displacement alone is a weak indication because it correlates poorly with symptoms.

How to plate the sternum: 

• Get a CT with 3D reconstruction to characterize the fracture and measure sternal thickness for screw length. Supine, midline anterior incision over the palpable fracture, pectoralis lifted off the sternum bilaterally, subperiosteal exposure with a malleable retractor behind the sternum to protect the mediastinum. A randomized sternotomy-closure trial (Raman et al., Annals of Thoracic Surgery, 2012) supports rigid plating's superior healing over wire. Configure the plate to the pattern: longitudinal plate(s) for transverse body fractures, transverse plating for manubrial/oblique or longitudinal patterns, and H-shaped/custom for complex multifragmentary fractures. Rules of thumb (Bauman): ≥2 cm plate overlap each side, ≥4 bicortical locking screws per side, no screws in the fracture zone, and depth-limited drilling to protect retrosternal structures. For non-unions, debride the pseudarthrosis and add iliac crest bone graft when there's a gap. 

Chest tubes in trauma and irrigation for retained hemothorax

When and how to place a chest tube:

A Western Trauma Association multicenter study validated a ~300 mL threshold above which observation frequently fails (adjusted OR 16 for failure). Drain traumatic pneumothorax >~35 mm on CT or >20% on chest x-ray. Place the tube in the triangle of safety in the 4th–6th intercostal space in the anterior-to-mid axillary line. The triangle of safety is bounded by the lateral border of pectoralis major, anterior border of latissimus dorsi, a line above the nipple, and the axillary apex (JAMA Surgery chest-tube review, Anderson et al., 2022). For pneumothorax, 14 Fr pigtails match 28–32 Fr tubes with less pain (Kulvatunyou). For hemothorax, multiple RCTs and a 2024 meta-analysis (Lyons et al., 1,847 patients) show 14 Fr tubes are similar to 28–32 Fr for failure rate, with better patient comfort and no benefit above ~32 Fr. Practically, use a large bore in the unstable/massive-hemothorax patient. Antibiotic prophylaxis is indicated for penetrating chest trauma and delayed drainage of retained hemothorax, not for routine blunt chest-tube placement (AAST/WSES 2024); if used, a single dose of cefazolin is adequate coverage.

Irrigation to prevent retained hemothorax:

An emerging, high-yield practice. After placement, instill ~1 L of warmed sterile saline and evacuate it (a three-way stopcock helps); WTA suggests ≥1,000 mL, especially for penetrating injury. Evidence is all observational (Level III) but consistent:

• Kugler et al. (propensity-matched, 2017): retained hemothorax 5.6% vs 21.8%.

• Al Tannir et al. (2024): retained hemothorax 10% vs 21%, VATS 6% vs 19%, shorter tube days and stay.

• Lyons et al. meta-analysis (2025, 1,319 patients): failure 10.7% vs 18.2%, shorter tube duration and ICU/hospital stay.
  A swine model suggests a 28 Fr tube irrigates better than 14 Fr and that 3 L adds nothing over 1 L. Adds only ~7–12 minutes. 

Notably, there is no RCT yet. If hemothorax is retained anyway then proceed with early VATS, not a second chest tube (EAST 2011, Level 1). Aim for within 3–7 days. Intrapleural tPA + DNase is a reasonable alternative for poor operative candidates (~87% avoid the OR in a meta-analysis, but longer stays). 

Surface landmarks to orient your incisions

Rib counting.

• Sternal angle (Angle of Louis): the palpable manubriosternal ridge is where the 2nd rib/2nd costal cartilage insert (see image below). Count down from here. 

• Inferior angle (tip) of the scapula: ≈ 7th rib and the go-to posterior landmark when supine landmarks are inaccessible (lateral decubitus). Abduct/forward-flex the arm to slide the scapula off the upper ribs.

• Nipple: ≈ 4th–5th intercostal space in men and supine women, but it is unreliable in ~44% of women, where it drifts to the 6th space or below.

• Inframammary fold: closest to the 6th rib (the "sentinel rib"); the fold sits between the 5th and 6th ribs.

Primary resources:

• Chest Anatomy: 

  • Right thoracic anatomy - narrated and Robotic thoracoscopic review of left thoracic anatomy 

  • Mastering Bronchoscopy for Thoracic Surgery: Chapter 2 

• Basics of Thoracic Surgery:

  • The Atrium: Basics of Thoracic Surgery 

  • CTSNet Step-by-Step Series: Posterolateral Thoracotomy 

• Ribs/Chest:

  • Education Resources – Chest Wall Injury Society 

    • SSRF Criteria video - YouTube

    • Inframammary exposure video <- REVIEW THIS PRIOR TO THE LAB

    • Paraspinal exposure video <- REVIEW THIS PRIOR TO THE LAB

    • Subscapular exposure video <- REVIEW THIS PRIOR TO THE LAB

    • Axillary exposure video <- REVIEW THIS PRIOR TO THE LAB

    • Sternal exposure video - YouTube <- REVIEW THIS PRIOR TO THE LAB

    • Keyhole exposure video <- REVIEW THIS PRIOR TO THE LAB

  • EAST Guidelines: Rib Fractures, Open Reduction and Internal Fixation of (UPDATE IN PROCESS) - Practice Management Guideline 

  • Rib Plating:

    • RibFix Advantage: RibFix® Advantage Animation | Zimmer Biomet

      • Minimally invasive demonstration: RibFix Advantage Intrathoracic Rib Fixation - YouTube 

    • RibFix Titan: ribfixtitan_Lateral Extra.mp4 - Google Drive 

• Sternum:

  • Sternotomy: CTSNet Step-by-Step Series: Midline Sternotomy 

  • Sternotomy closure with wires: CTSNet Step-by-Step Series: Sternal Closure Using Stainless Steel Wires 

  • Sternal Wire Closure: DoubleWire Sternal Closure - YouTube 

  • Sternal Plating: SternaLock® Blu Primary Closure System 

Additional resources:

• Open Chest Tube Placement: 

  • Surgeon Shows How to Place a CHEST TUBE | Behind the Knife - Bedside Procedures Episode 1 

• Epicardial Pacing Wire Placement:

  • CTSNet Step-by-Step Series: Pacing Wires 

  • CTSNet Step-by-Step Series: Chest Drains 

• Thoracic irrigation: 

  • How to use the CLR Irrigator 

  • CLR-enabled thoracic irrigation for management of hemothorax 

• PGY1 and PGY2 Residents:

  • Learn about chest wall/rib anatomy and surgical planning with the use of the Immersive Touch AR/VR platform.

  • Practice chest tube placement and thoracic irrigation with the CLR irrigation system and CLR mannequins. 

  • Practice the fundamentals of rib fixation on sawbones. 

  • If time allows, rotate through the cadaveric stations to practice sternotomy and thoracotomy incisions and closures. 

• PGY3/4 Residents:

  • Practice with the RibFix Advantage and RibFix Titan systems on cadaveric models. 

  • Practice sternotomy with a sternal saw or Lebsche knife and practice sternal closure with wires and plates. 

    • Learn about and practice emergency chest access in recently wired or plated patients. 

  • Practice thoracotomy and thoracic closure with sutures. 

  • If time allows, rotate through the CLR and Immersive Touch stations. 

• PGY5 Resident Volunteers: 

  • Participate in stations as needed or rotate as educators throughout the stations.