Surgical management of complex non-union in chest wall instability: focus on posterior rib fractures, parasternal cartilage rupture, and costal margin injury

Abstract Non-union of the chest wall is an underrecognized but functionally significant complication of thoracic trauma, particularly when involving posterior ribs, parasternal cartilage, and the costal margin. Complex instability patterns can result in persistent pain, mechanical dysfunction, and impaired respiration. We describe two patients with symptomatic chest wall non-union. Case 1 was a 62-year-old man with posterior non-union of the seventh and eighth ribs and a secondary costal margin rupture with intercostal hernia. He underwent combined posterior rib plating and costal margin reconstruction, nerve-sparing fibre-tape sutures, and double-layer mesh. Case 2 was a 25-year-old man with a radiographically occult rupture and pseudarthrosis of the third parasternal costal cartilage. He was treated with trans-costosternal osteosynthesis and local bone grafting. These cases illustrate that dynamic and multimodal imaging are often required to diagnose non-unions, and that contemporary plating and mesh techniques can restore stability, relieve pain, and permit early mobilization.