Anatomy of the ribs. There are 12 ribs on each side. All 12 connect posteriorly with the vertebrae of the spine. Ribs 1–7 connect anteriorly directly to the sternum, while ribs 8–10 attach to the superior costal cartilages. Ribs 11 and 12 are floating ribs with no anterior attachment. The intercostal vein, artery, and nerve run in the costal groove, which is located along the inferior border of each rib.

Anterior chest wall

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  Pectoralis major muscle: The origin is the anterior surface of the medial half of the clavicle and the anterior surface of the sternum. It inserts into the upper humerus. The blood supply is the pectoral branch of the thoracoacromial trunk.

  
  
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  Pectoralis minor muscle: The origin of the muscle is on the third through fifth ribs near their cartilages. It inserts into the coracoid process of the scapula.

Lateral chest wall

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  Serratus anterior muscle: The origin is the lateral part of the first 8–9 ribs. It inserts into the medial aspect of the scapula.

Posterior chest wall

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  Latissimus dorsi muscle: The origin is the spinous processes of the lower thoracic spine and posterior iliac crest. It inserts into the upper portion of the humerus.

  
  
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  Trapezius muscle: The origin of the trapezius muscle is large, from the occipital bone down through the spinous processes of T12. It inserts on the lateral third of the clavicle and the scapula.

  
  
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  Erector spinae muscle: The origin is the spinous processes of T9–T12 vertebrae and the medial slope of the iliac crest.

  
  
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  Access to fractures underlying the scapula is obtained through the “auscultatory triangle” between the superior edge of the latissimus dorsi, the lateral border of the trapezius, and the inferomedial border of scapula.

The goal of operative rib fixation is to stabilize the chest wall to improve the mechanics of breathing and reduce pain. The procedure should be considered in selected cases with large flail segments, especially in patients who are difficult to wean off the ventilator.

Early fixation within the first few days of hospitalization is considered optimal.

Operative rib fixation for flail chest may shorten duration of mechanical ventilation, ICU length of stay, hospital length of stay, incidence of pneumonia, and need for tracheostomy.

During operative fixation, rib fractures that are significantly displaced should be fixated. The nondisplaced, less severe side of a flail can often be left alone if the chest wall is stable. Ribs 1–3 rarely require fixation, since they are both more stable and more difficult to access.

Video-assisted thoracoscopy (VATS) is often utilized concurrently to facilitate evacuation of residual hemothorax, ensure full inflation of the lung, and inspect the diaphragm, although some prefer to simply enter the pleural space for open irrigation. In all cases, a chest tube is left for pleural decompression at an alternative site.

Preoperative bronchoscopy can ensure clearance of secretions and facilitate bacterial testing. If positive for bacteria, antibiotics should be administered to prevent infection of the hardware to be inserted.

A high-resolution chest CT with three-dimensional reconstruction should be obtained for preoperative planning. This allows an assessment of the degree of displacement of the various fractures and planned approach.

There are many different fixation systems, and most use metal plates with locking screws. Titanium plating with cortical screws (single plate or U-type plate) or absorbable plates are the most commonly used commercial devices by trauma surgeons. Each system has a different system of rib fixation, and the instructions should be read carefully. The system used for this chapter utilizes 2.3 mm × 7 mm drill-free locking screws for unicortical fixation of titanium rib plates.