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Background Costal margin rupture (CMR) injuries are under-diagnosed and inconsistently managed, whilst carrying significant symptomatic burden. We hypothesised that the Sheffield Classification system of CMR injuries would relate to injury patterns and management options. Methods Data were collected prospectively between 2006 and 2023 at a Major Trauma Centre in the United Kingdom. CT scans were interrogated and injuries were categorised according to the Sheffield Classification. Clinical, radiologic, management and outcome variables were assessed. Results 54 patients were included in the study. Intercostal hernia (IH) was present in 30 patients and associated with delayed presentation (p = 0.004), expulsive mechanism of injury (i.e. such as occurs with coughing, sneezing, or retching), higher Body Mass Index (p < 0.001), and surgical management (p = 0.02). There was a bimodal distribution of the level of the costal margin rupture, with IH Present and expulsive mechanism injuries occurring predominantly at the 9th costal cartilage, and IH Absent cases and other mechanisms at the 7th costal cartilage (p < 0.001). There were correlations between the costal cartilage being thin at the site of the CMR and the presence of intercostal hernia and expulsive aetiology (p < 0.001). Management was conservative in 23 and surgical in 31 cases. Extrathoracic mesh IH repairs were performed in 3, Double Layer Mesh Repairs in 8, Suture IH repairs in 5, CMR plating in 8, CMR sutures in 2, and associated Surgical Stabilization of Rib Fractures in 11 patients. There was one post-operative death. There were 7 repeat surgical procedures in 5 patients. Conclusions The Sheffield Classification is associated statistically with presentation, related chest wall injury patterns, and type of definitive management. Further collaborative data collection is required to determine the optimal management strategies. Level of Evidence Level III, Observational

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