The True‐Blue technique: Enhanced chondral assessment of the chest wall

Summary: Chest wall trauma is rapidly evolving and now represents a multidisciplinary field with incredible growth in research and surgical intervention; however, even with more than 800 publications on chest wall trauma to date, surgical indications are not black and white. Injury patterns need to be better defined and outcome measurements need to evolve for accurate longer term functional assessment of patients if this field of surgery is to move beyond historical indications for operative intervention. This essay will communicate what is known about operative indications in a way that stratifies the need for surgery.

Discussion of Surgical Indications: The Black, White, and Gray

Weatherby

2024

Anatomy of the Ribs, Sternum, and Costal Margin

Haase,

Shaikh

2024

Summary: The ribs, sternum, and costal margin provide a rigid, but flexible chest wall that functions to provide protection to the vital cardiothoracic organs, while also allowing for varying levels of respiration based on physiologic need. The latter function is accomplished through various muscular attachments and rib articulations with both the axial spine posteriorly and the sternum anteriorly. The accessory muscles of inspiration rely on the downward slope and outward curve of each rib, which when contracted move the ribs upward and outward, in turn forcing the sternum anterior and increasing the thoracic volume. Ribs are also classified as true, false, or floating based on their attachment anteriorly to the costal cartilage and sternum. Ribs 1–7 are considered true ribs as their costal cartilage directly articulates with the manubrium and sternum. Ribs 8–10 are considered false ribs because their costal cartilage connects to the cartilage of the immediately superior rib instead of the sternum itself. This complex cartilaginous structure is referred to as the costal margin, which provides attachments for the diaphragm and various abdominal muscles. Although historically thought to be a consistent structure, its variable nature has recently been defined in cadaveric studies. Ribs 11 and 12 are considered floating ribs because they have rudimentary cartilage caps and are not attached to the sternum at all. The sternum comprises the manubrium, body, and xiphoid process. Each component has differing mobility, muscle attachment, and function.

Rib and Sternum Nonunions: Diagnosis and Treatment and Awareness of Other Potential Posttraumatic Pathology

Cole

2024

Summary: As the operative management of acute, chest wall, skeletal injury escalates throughout the world, it has become commonplace for patients with posttraumatic conditions to present with clinical reconstructive challenges as well. In addition, it is becoming clear that rib nonunions are not rare, likely more than 5% of rib fractures. No subspecialty is better equipped to address such painful conditions than orthopaedic surgery. Likewise, there are a plethora of other posttraumatic problems that patients face, from intercostal neuralgia, pleural herniation, rib synostosis, and costal margin and sternal injuries that do not heal properly, which require treatment solutions. This emerging new field of surgery is optimized by an interdisciplinary approach, between general and orthopaedic trauma surgeons, and between thoracic, anesthesia, and rehabilitation specialists. This article emphasizes the workup and operative treatment of painful rib and sternal nonunions, in particular, and familiarizes the orthopaedist with other cold skeletal trauma in general. From the distinctive history and physical examination of the patient with a rib psuedoarthrosis to proper diagnostic studies, the surgeon is led through a principled approach to nonunion surgery, inclusive of autogenous graft harvest to provide both biologic and mechanical variables to bear in the successful treatment of this condition.