Biomechanics of chest wall injury: implications for surgical stabilization and failure prevention

Chest wall injury impairs ventilation not only through pain, but also through loss of thoracic cage stability and disruption of regional mechanics. As surgical stabilization of rib fractures continues to expand, variability in operative technique and construct design remains, while recurring complication patterns suggest that mismatch between fixation constructs and physiologic loading may represent an underrecognized and potentially preventable cause of failure. Drawing on clinical guidelines, experimental biomechanics, advanced imaging, and contemporary finite-element modeling, this review synthesizes the mechanical behavior of the thoracic cage across the ribs, costochondral junctions, and sternum, and translates these principles into surgical planning. We propose a mechanics-based framework that links specific instability patterns to functional impairment and informs construct selection, including operative approach, plate and screw strategy, bone quality considerations, and management of sternal and costal cartilage involvement. In addition, we summarize common modes of fixation failure and discuss practical strategies to reduce their occurrence.