Perioperative ultrasonography in surgical stabilization of rib fractures: A single-center retrospective analysis of its utility in surgical planning and post-discharge follow-up

Abstract

Background

Surgical stabilization of rib fractures (SSRF) improves outcomes in severe chest trauma. computed tomography is the gold standard for diagnosis, but real-time intraoperative localization remains a challenge. This observational study aimed to describe our single-center evaluation with perioperative ultrasonography for intraoperative localization of displaced rib fractures during SSRF.

Methods

We retrospectively analyzed 16 patients with three or more displaced rib fractures who underwent SSRF between January 2020 and December 2025. All patients underwent ultrasonography in the operating room immediately prior to incision using a 4.4 MHz convex array transducer for fracture marking and incision planning. A standardized perioperative protocol was applied to all study participants to evaluate the feasibility of fracture localization. Post-discharge ultrasonography was performed as part of routine outpatient evaluation.

Results

The mean postoperative hospital stay was 5.5 days. Associated thoracic injuries included pneumothorax (n=6), hemothorax (n=6), pulmonary contusion (n=2), traumatic pneumatocele (n=1) and hemopneumothorax (n=1). Perioperative ultrasonography enabled identification of displaced fracture sites and facilitated skin marking prior to incision. In all patients, cortical disruption was visualized as a step-off or discontinuity of the hyperechoic rib line using the convex probe. Postoperative complications were limited to two cases of superficial skin infection (12.5%). During follow-up, ultrasonography identified two cases (12.5%) of small, asymptomatic pleural effusions, which were subsequently confirmed by chest radiography.

Conclusion

Perioperative ultrasonography appears to be a feasible adjunct for intraoperative localization of displaced rib fractures during surgical stabilization. Even with a lower-frequency convex probe, displaced fracture segments were identifiable. Larger prospective and comparative studies are required to determine its impact on operative metrics and clinical outcomes.

Rib fractures are the most frequent outcome of blunt chest trauma. Surgical stabilization of rib fractures (SSRF) has emerged as a treatment option for patients with multiple displaced fractures or flail chest, showing benefits in selected populations.^{[1, 2, 3]} Preoperative imaging, typically computed tomography (CT), is essential or diagnosis and surgical planning. However, CT scans provide static images and cannot assist in real-time intraoperative localization once patient positioning is altered. Ultrasonography (USG) offers portability, real-time imaging, and the ability to dynamically correlate imaging findings with the surgical field.^{[4, 5]}

USG’s accuracy in detecting rib fractures has been described in the literature.^{[4, 5]} Furthermore, USG is widely used in thoracic practice for the identification of pleural effusion and pneumothorax.^{[6, 7]}

While prior reports, such as the work by Martin et al.,^[8] have established the utility of intraoperative USG using high-frequency linear probes, there is limited data on the effectiveness of lower-frequency convex transducers in this setting.

The aim of the present observational study was to retrospectively describe our institutional evaluation using perioperative USG for intraoperative localization of displaced rib fractures during SSRF, particularly in a setting where a high-frequency linear probe was not available.

Methods

Study Design and Patient Selection

We retrospectively analyzed 16 patients who underwent SSRF at the Department of Thoracic Surgery, Alanya, Antalya, Türkiye. Between January 2020 and December 2025, a total of 523 patients were treated for rib fractures at our institution. Among these, patients who underwent SSRF were evaluated for inclusion. Patients were included if they had three or more displaced rib fractures requiring surgical fixation. Sixteen patients met these criteria and were included in the final analysis. All patients underwent standard preoperative evaluation, including thoracic CT to characterize fracture morphology and assess associated intrathoracic injuries.

This study was designed as a retrospective observational clinical research. Prior to the retrospective analysis and consolidation of the anonymized patient data, formal ethical approval was obtained from the Alanya Alaaddin Keykubat University Non-Interventional Clinical Research Ethics Committee on February 11, 2026 (decision no: 03-03). Following the ethical approval, patient data were retrieved from the hospital’s digital database using specific International Classification of Diseases-10 and surgical procedure codes. Due to the targeted nature of the cohort (n=16), data consolidation and retrospective analysis were performed promptly. The study was conducted in strict accordance with the ethical principles of the Declaration of Helsinki. Informed consent was obtained from all patients included in the study.

Statistical Analysis

Descriptive statistics were used to summarize the clinical data. Categorical variables are presented as frequencies and percentages (n, %), while continuous variables are reported as means on the distribution. Given the feasibility-oriented and descriptive nature of this preliminary study, no comparative statistical tests were performed.

Perioperative USG protocol

In this study, the term “perioperative” specifically refers to the intraoperative period on the surgical table, encompassing the real-time USG localization and marking performed immediately prior to the skin incision.

Perioperative USG was systematically performed in the operating room after induction of general anesthesia and final surgical positioning, but prior to sterile preparation and draping. The cart-based Siemens ACUSON NX3 USG system equipped with a 4.4 MHz convex array transducer was used. Although high-frequency linear probes are generally preferred for superficial cortical imaging, the convex probe was used in this series due to equipment availability.^[8] The transducer was applied longitudinally and transversely over the rib segments previously identified on CT, allowing correlation between radiologic findings and real-time sonographic anatomy. All ultrasonographic assessments were performed by a single, experienced thoracic surgeon who is proficient in thoracic point-of-care ultrasonography (POCUS). This ensured a standardized approach to fracture localization and complication surveillance, minimizing operator-dependent variability.

On ultrasonographic examination, the normal rib cortex was visualized as a continuous hyperechoic linear structure with posterior acoustic shadowing. Fractures were identified by characteristic findings including cortical discontinuity, step-off deformity, displacement of fracture fragments, focal interruption of the hyperechoic line (Figure 1). In patients with markedly displaced fractures, the separation between fragments and angular deformity were clearly appreciable despite the lower-frequency of the convex probe. To ensure methodological consistency, a standardized scanning protocol was applied to all participants, involving pre-incision marking and structured outpatient POCUS assessments.

Figure 1.

Ultrasonographic visualization of a displaced rib fracture. Longitudinal ultrasonographic view of the fractured rib segment. The arrows indicate the proximal and distal hyperechoic cortical ends of the rib fracture. The arrowhead points to the area of significant displacement (step-off deformity).

Surface marking and incision planning

Following sonographic confirmation of the displaced fracture segment, the exact cutaneous projection of the maximal cortical disruption was identified and marked using a sterile surgical marker. Care was taken to ensure that the marking corresponded to the point of greatest displacement or step-off as visualized on USG. Each relevant segment of fractures was individually assessed, and the incision was planned to provide optimal access to all targeted fixation sites through a single exposure whenever feasible.

Surgical technique

All procedures were performed under general anesthesia with single-lumen endotracheal intubation. Patients were positioned in the lateral decubitus position according to fracture location.

The skin incision was then centered over the USG-guided marking, with orientation tailored to the rib trajectory and intercostal space anatomy. Incision length was determined intraoperatively based on fracture configuration and the anticipated need for plate placement, with the aim of providing adequate visualization while avoiding unnecessary soft tissue dissection. This approach allowed direct alignment between the marked fracture site and the surgical field under operative positioning conditions, facilitating efficient exposure of the rib surface prior to reduction and fixation.

A muscle-sparing approach was preferred in all cases. After incision centered over the marked site, soft tissue dissection was carefully carried down to the rib surface while preserving surrounding musculature whenever possible. The periosteum was exposed, and fracture ends were identified (Figure 2). Anatomic reduction was achieved using reduction forceps when necessary. Pre-contoured titanium locking plates were then adapted to the rib curvature and secured with bicortical locking screws placed on either side of the fracture line to ensure stable fixation (Figure 3). Plate length and screw number were selected according to fracture pattern and rib anatomy. In this series, an average of 3.6 ribs were stabilized per patient. Hemostasis was meticulously achieved, and a chest tube was placed when indicated. Wound closure was performed in anatomical layers. All patients were transferred to the recovery unit with standard postoperative monitoring protocols.

Figure 2.

Intraoperative confirmation of displaced rib fractures. Perioperative view of the surgical field following soft tissue dissection and exposure of the rib surface. The arrows indicate the specific sites of the displaced rib fractures, confirming the accurate localization achieved via preoperative ultrasonographic marking. The anatomic correlation between the sonographic findings and the direct surgical visualization of the cortical step-off is demonstrated.

Figure 3.

Post-reduction stabilization of rib fractures. Intraoperative view following fracture reduction and plate fixation. The arrow indicates the realigned fracture line (anatomic reduction), and the arrowheads denote the titanium locking plates and screws securing the rib segments in place.

Management of Associated Injuries

For all patients, a comprehensive trauma assessment was performed, including thoracic CT and additional imaging studies as clinically indicated. Associated injuries were carefully documented, and treatment strategies were determined through multidisciplinary consultation to ensure coordinated care. Thoracic injuries such as pneumothorax and hemothorax were initially managed with tube thoracostomy when indicated. Adequate lung re-expansion and stabilization of respiratory function were achieved prior to definitive rib fixation. The decision regarding the timing of SSRF was based on hemodynamic stability, respiratory status, and the presence of other injuries requiring urgent intervention. Extrathoracic injuries were managed in collaboration with the relevant specialties. Radius and clavicle fractures underwent open reduction and internal fixation by the orthopedics department. The patient diagnosed with splenic rupture underwent splenectomy performed by the general surgery department, whereas other solid organ injuries without hemodynamic instability were treated conservatively in accordance with institutional trauma protocols. Vertebral and pelvic fractures were assessed by spine and trauma teams and managed non-operatively when stable.

Post-discharge Follow-up

After chest tube removal and achievement of clinical stability, patients were discharged from the hospital (mean postoperative length of stay: 5.5 days). All patients were scheduled for routine outpatient follow-up visits at predetermined intervals. During these visits, thoracic USG was performed as the initial imaging modality to evaluate for residual or newly developed pleural effusion. In accordance with institutional follow-up protocol, control chest radiographs were subsequently obtained (Figure 4). This sequential imaging strategy enabled direct comparison between ultrasonographic findings and conventional radiographic assessment within the same visit. The purpose of this approach was not to replace standard radiographic evaluation, but to assess the concordance of USG findings with routine chest radiography in the postoperative surveillance setting.

Figure 4.

Postoperative chest radiograph of a patient with plates affixed to the right 8^th to 11^th ribs during an outpatient follow-up visit. The image demonstrates successful surgical stabilization of the rib fractures with optimal plate placement and good pulmonary expansion, confirming the absence of significant pleural effusions or pneumothorax at discharge.

Results

Patient Characteristics

The study group included 10 men (62.5%) and 6 women (37.5%). The mean age was 58.2 years. The injury mechanisms were falls (n=7), traffic accidents (n=7), ship accident (n=1), and animal striking (n=1). Flail chest was diagnosed in 3 patients. The mean total hospital stay was 7.0 days, and the mean postoperative hospital stay was 5.5 days.

Associated thoracic injuries included pneumothorax (n=6), hemothorax (n=6), pulmonary contusion (n=2), traumatic pneumatocele (n=1) and hemopneumothorax (n=1). A total of 10 patients (62.5%) received a chest tube prior to SSRF, while two additional patients (12.5%) underwent chest tube placement during the SSRF procedure. One patient with minimal hemothorax was successfully managed conservatively without chest tube insertion.

Extrathoracic injuries included radius fracture (n=3), splenic rupture (n=1), liver laceration (n=1), concussion/head trauma (n=1), vertebra fracture (n=2), pelvis fracture (n=2), clavicle fracture (n=2), and scapula fracture (n=1). The vertebra, pelvis, scapula, and liver laceration were managed conservatively.

Perioperative USG Findings

Perioperative USG successfully identified cortical disruption in all 16 patients. In each case, displaced fracture segments were visualized as a hyperechoic cortical discontinuity or step-off sign (Figure 1).^[9] Furthermore, in the two patients with concomitant hemothorax, USG consistently demonstrated the presence of anechoic fluid collections in the pleural space, reinforcing its diagnostic utility as a dual-purpose imaging tool for both rib fracture assessment and thoracic complication screening (Figure 5).

Figure 5.

Ultrasonographic evaluation of hemothorax and associated lung changes. Thoracic ultrasonography image of a patient with blunt chest trauma. The black arrow indicates the diaphragm, serving as the anatomical boundary. The white arrow highlights the compressed and atelectatic lower lobe of the lung (liver-like appearance/hepatization). The asterisk (*) denotes the hypoechoic pleural collection consistent with hemothorax. This sonographic view demonstrates the utility of point-of-care ultrasound in identifying associated intrathoracic injuries.

The use of USG-guided marking enabled targeted incisions aligned with the sonographic findings. The USG allowed direct correlation between the fracture location and the planned incision site. No intraoperative complications attributable to USG use were observed.

Post-discharge USG Findings

During outpatient follow-up, thoracic USG identified two small, asymptomatic pleural effusions, corresponding to 12.5% of the total study population (Figure 6). These findings were subsequently confirmed by routine chest radiographs, demonstrating concordance between the two imaging modalities in all evaluated cases.

Figure 6.

Post-discharge ultrasonographic follow-up of minimal pleural effusion. Bedside M-mode ultrasonography during outpatient follow-up revealing a small, asymptomatic pleural

Although routine radiographs remained part of the standard follow-up protocol, the use of USG as the initial imaging modality allowed for early, non-invasive detection of minor pleural collections without reliance on ionizing radiation. The effusions detected were small, did not require therapeutic intervention, and were clinically silent, highlighting the potential role of USG as a sensitive adjunct in postoperative surveillance.

Furthermore, the thoracic USG was systematically used to screen for pulmonary complications; notably, no cases of postoperative pneumonia were identified during the follow-up period. The absence of B-lines, subpleural consolidations, or air bronchograms on ultrasonographic examination confirmed the preservation of parenchymal health in all patients.

Discussion

Clinical Efficacy of POCUS-guided Mapping

This retrospective single-center study describes our clinical evaluation using perioperative USG for intraoperative localization of displaced rib fractures during surgical stabilization. The findings suggest that USG may provide real-time guidance in identifying fracture sites, even when a lower-frequency convex probe is used. We visualized cortical disruption as a step-off in every case, allowing for precise identification of the fracture site prior to incision. Our approach differs from previously described techniques by demonstrating that a 4.4 MHz convex probe—commonly more accessible in general operating theaters—provides sufficient resolution to identify cortical step-offs, even in patients where soft tissue thickness might limit linear probe penetration.^[8]

Although the cohort size (n=16) is relatively small, it reflects a focused group of patients meeting strict surgical criteria for SSRF in a specialized thoracic unit. In the literature, several preliminary reports on SSRF techniques have utilized similar sample sizes to demonstrate clinical feasibility and procedural innovation.^[10] Therefore, we believe our systematic findings provide an important contribution to the evolving field of thoracic POCUS.

While CT remains essential for preoperative planning, it provides only static images and cannot account for patient positioning during surgery. USG offers a dynamic, bedside assessment that may assist in aligning the incision with the underlying fracture.^[5] In our study, USG-guided marking was used to ensure the anatomic alignment of the surgical approach with the sonographically identified fracture site. However, it is important to clarify that this study did not involve direct measurements of operative parameters. Consequently, we do not claim that this technique results in “smaller” or “minimal” incisions compared to conventional methods such as standard CT-guided planning. Our findings should be interpreted as a proof-of-concept demonstrating the technical feasibility of real-time fracture localization, rather than a definitive measure of clinical or metric superiority. The potential impact of this targeted approach on reducing surgical trauma remains a hypothesis to be tested in future prospective, randomized trials.

While intraoperative ultrasound localization for SSRF has been previously described, most notably by Martin et al.,^[8] our findings further validate this approach using a low-frequency convex transducer. This is clinically significant because convex probes provide superior depth penetration in patients with significant subcutaneous edema or higher body mass index, where high-frequency linear probes may lose resolution at the rib level. Furthermore, we expand the perioperative use of USG to include postoperative outpatient surveillance, demonstrating its utility in monitoring for late-onset asymptomatic pleural collections

During post-discharge follow-up, the USG detected two small, asymptomatic pleural effusions, which were confirmed by subsequent chest radiographs. While these findings are limited in number and did not alter clinical management, they highlight the potential of the USG as a supplementary imaging tool for early detection of minor postoperative pleural collections.

Clinical Implications and Postoperative Utility

​Our finding that USG successfully identified asymptomatic pleural effusions in 12.5% of our cohort during follow-up highlights its role as a practical surveillance tool. Unlike conventional radiography, bedside USG allowed for real-time parenchymal and pleural assessment without ionizing radiation. While USG has broader established roles in guiding regional anesthesia for perioperative pain management, thoracocentesis and chest tube placement, quickly identifying the presence of pneumothorax, early diagnosis and serial follow-up of pulmonary contusion or evaluating diaphragmatic function, sternal fractures and screening for cardiac contusion or tamponade, our study specifically demonstrates its dual-purpose utility in SSRF: Facilitating intraoperative fracture localization and screening for early postoperative complications (Figure 7).^{[11, 12, 13, 14, 15, 16, 17, 18, 19]} This integrated approach may streamline the clinical workflow for rib fracture management, although its superiority over standard imaging protocols remains to be evaluated in larger studies.

Figure 7.

Ultrasonographic evaluation of a sternal fracture. Bedside ultrasonographic assessment showing a sternal fracture. The arrows indicate the displaced cortical ends of the sternal bone, and the arrowhead highlights the fracture line, demonstrating the utility of sonography in identifying sternal disruptions.

Although the retrospective design precluded the measurement of operative time and incision size, the precise anatomic correlation achieved in all cases suggests a potential for surgical optimization. This study has several limitations. First, its retrospective design and small sample size (n=16) limit the generalizability of the findings. Second, the absence of a control group precludes direct comparison between USG-guided localization and conventional surgical planning based solely on CT imaging. Third, objective operative parameters such as incision length, operative time, intraoperative blood loss, and postoperative pain scores were not quantitatively measured; therefore, the impact of perioperative USG on surgical efficiency cannot be determined. Additionally, a convex 4.4 MHz probe was used instead of the standard high-frequency linear transducer, which may limit the applicability of the findings to settings equipped with different USG technology. Finally, as a single-center experience, the results reflect institutional practice patterns and may not be universally reproducible. The absence of a control group and the lack of objective operative metrics are major limitations of this study. Without these comparative data, the measurable benefits of perioperative USG cannot be fully established. However, as a pilot evaluation of perioperative USG in SSRF, it provides foundational data on the use of accessible convex probes. This study serves as a preliminary feasibility report, and we acknowledge that prospective, randomized trials are necessary to provide the objective evidence required to support the routine clinical use of this modality.

Furthermore, our study focused primarily on the technical feasibility of USG-guided localization and did not evaluate functional clinical outcomes. The lack of data regarding postoperative pain scores, longitudinal opioid consumption, pulmonary function tests, and time to mobilization is a significant limitation. While our findings demonstrate that USG is a reliable tool for anatomic localization, its direct impact on patient-centered recovery metrics remains to be established in prospective clinical trials designed to capture these multidimensional data points.

Future prospective trials should utilize a randomized design to compare USG-guided localization against standard CT-based planning, specifically measuring metrics such as incision-to-rib ratios and postoperative pain scores to confirm the clinical superiority of this technique

Perioperative USG may enhance surgical localization and could be considered as a useful adjunct in SSRF. In this single-center retrospective series, perioperative USG was feasible for intraoperative localization of displaced rib fractures during SSRF. Even with a 4.4 MHz convex probe, cortical step-offs were identifiable in markedly displaced fractures. Prospective controlled studies are required to determine its impact on operative parameters and clinical outcomes.

Ethics

Ethics Committee Approval: The study protocol was approved by the Institutional Review Board (IRB) of Alanya Alaaddin Keykubat University (protocol no: 03-03, date: 11.02.2026). This study was conducted in accordance with the principles set forth in the Declaration of Helsinki.

Informed Consent: Retrospective data were used for this study. Institutional Review Board approval was obtained, and where applicable, informed consent was obtained from all individual participants included in the study.