Reduced invasive and muscle-sparing operative approaches to the posterolateral chest wall provide an excellent accessibility for the operative stabilization!

Minimized approaches to the posterolateral chest wall
  • A. Langenbach
  • Pascal Oppel
  • Sina Grupp
  • Sebastian Krinner
  • Milena Pachowsky
  • Thomas Buder
  • Melanie Schulz-Drost
  • Friedrich F. Hennig
  • Stefan Schulz-Drost
Original Article



Stabilizing techniques for flail chest injuries are described through wide surgical approaches to the chest wall, especially in the most affected posterior and lateral regions. Severe morbidity due to these invasive approaches needs to be considered due to dissection of the scapular guiding muscles and the risk of injuries to neurovascular bundles. This study discusses possibilities for minimized approaches to the posterior and lateral regions.


Ten fresh-frozen cadavers in lateral decubitus position were observed on both sides. Each surgical arm was kept mobile during the procedure. Approaches were performed following a standard protocol with muscle-sparing incisions starting with 5 cm in length and extending to 10 and 15 cm. The accessible surface comparing the extensions was measured. Visible ribs were counted. In a next step, MatrixRib® Plates were fixed to those ribs to prove the feasibility of rib stabilization through limited approaches.


Combinations of the posterior and lateral minimized approaches allow surgical fixation of 6–9 and 7–11 ribs through 5 and 10 cm incisions, respectively. In the case of an extreme expansion of a rib fracture series, an access extension can be made to 15 cm to be able to adequately supply the entire hemithorax using two approaches.


Extensive invasive surgical approaches to the thoracic wall can be replaced by reduced invasive and muscle-sparing access combinations. A free-moving positioning of the arm and an accurate preoperative plan for minimizing approaches are essential. Minimally invasive plate techniques are very helpful adjuncts.


Flail chest Rib fracture Locked plate osteosynthesis Chest wall stabilization Surgical approach MIPO 



Anterior–posterior direction


Cranial–caudal direction




Square centimeter


Flail chest


Left side






Minimally invasive plate osteosynthesis




Pi = 3.14159265359


Right side


Standard deviation



Prior presentation of this study. Parts of this study were previously presented as a poster presentation by the first author AL at the German Congress for Orthopedics and Trauma Surgery in October 2015 (DKOU 2015, Berlin, Germany) and at the 16th European Congress for Trauma and Emergency Surgery in May 2015 (ECTES, Amsterdam, The Netherlands) in an oral talk by the senior author SSD. The surgical technique had been recently shown by the senior author during a webcast of the AO Foundation with a large number of international participants (AOTrauma Webcast: “Rib Fracture Osteosynthesis—Approaches and Management in the Different Sectors of the Chest Wall”, June 7 / 8, 2017, AMTS Muttenz, Switzerland; main presenter: Stefan Schulz-Drost).

Compliance with ethical standards

Conflict of interest

The senior author has a consultant agreement with DePuySynthes and he is an advisory member of the AO TK Thoracic Surgery Expert Group (THEG). The other authors are not involved in any conflict of interest.


No funds were received in connection to this study.


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2017

Authors and Affiliations

  • A. Langenbach
    • 1
  • Pascal Oppel
    • 1
  • Sina Grupp
    • 1
  • Sebastian Krinner
    • 1
  • Milena Pachowsky
    • 1
  • Thomas Buder
    • 2
  • Melanie Schulz-Drost
    • 4
  • Friedrich F. Hennig
    • 1
  • Stefan Schulz-Drost
    • 1
    • 3
  1. 1.Department of Trauma and Orthopedic SurgeryUniversity Hospital ErlangenErlangenGermany
  2. 2.Institute of Anatomy IUniversity of ErlangenErlangenGermany
  3. 3.Department of Trauma and Orthopedic SurgeryBG Hospital Unfallkrankenhaus Berlin gGmbHBerlinGermany
  4. 4.Department of ControllingGerman Military HospitalBerlinGermany

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