A 57-year-old previously homeless male with a history of trauma from a bicycle crash originally presented to our level 1 trauma center for the evaluation of back and flank pain and a "click" in his chest. He was found to have an acute fracture of the left seventh rib and chronic nonunion of left eighth through twelfth ribs [Figure 1 and Table 1]. He underwent elective rib plating for symptom management in addition to evacuation of hemothorax and pulmonary decortication for fibrothorax and trapped lung. The seventh through tenth ribs were plated with a bicortical locking rib fixation system, and a 28 Blake chest tube was placed [Figure 2]. At least three bicortical locking screws were placed proximal and distal to the fracture locations. He tolerated the procedure well and had significant improvement in his symptoms on follow-up. He denied any residual pain or clicking of the ribs and could finally get a good night's sleep. An improvement in his symptoms greatly improved his quality of life so that he was able to obtain a job, was able to rent an apartment, and was no longer homeless.
Three months later, he was riding his bicycle when he was again hit by a motor vehicle. In addition to numerous devastating injuries including a significant traumatic brain injury (TBI) prompting admission to our ICU, he was found to have flail chest with lateral and posterolateral rib fractures of the first through tenth ribs and periprosthetic fractures of the seventh through tenth ribs [Figure 3 and Table 1]. The rib plating hardware was completely intact, except for a single displaced screw from the seventh rib plate [Figure 4]. He was also found to have a hemothorax, for which a chest tube was placed. Notably, there was increased difficulty of the chest tube placement due to the prior pulmonary decortication and rib plating. His new rib fractures were treated nonoperatively due to his poor clinical status from his TBI. Unfortunately, he expired from his injuries.