Multiple rib fractures (MRFs) are common injuries in both young and elderly people. MRFs pose a serious health hazard. Morbidity and mortality rates increase by the number and type of rib fractures. In addition, patients have poor quality of life at long-term follow-up. Although papers on surgical stabilization of rib fractures (SSRF) have been reported sporadically for nearly 100 years, the majority of patients with MRF have been treated nonoperatively. Recently, there have been advances in image examination techniques and surgical materials suitable for SSRF, and studies emphasizing the utility of SSRF have increased. The present study aimed to investigate postoperative short-term outcomes of SSRF. We evaluated 62 cases (66 sides) in a 20-year period. The cases were divided into two periods : 16 cases in the first decade and 46 in the second. In the latter group, SSRF were performed in patients with a significantly wider range of age (p = 0.022). Earlier SSRF (p = 0.028) reduced intraoperative bleeding (p < 0.001) and shortened the duration of postoperative mechanical ventilation (p = 0.042) and chest drain stay (p = 0.004), despite repairing a similar number of ribs (p = 0.839). This study also presents a discussion on the advantages and disadvantages of SSRF based on a review of the literature.

　　Although reports on surgical stabilization of rib fractures (SSRF) have increased in foreign countries, the surgery is not yet widely performed in Japan. The main reason for this situation may be the lack of information on the SSRF method in Japanese literature. We present preoperative planning, operative techniques, and pitfalls of SSRF, through our 81 cases (87 sides) practice with a literature review. In preoperative planning, it is essential to select the ribs requiring osteosynthesis by the location, number and fracture type ; and to design the approach to the ribs intended for minimal incision and muscle-sparing. Volume-rendering CT images as well as traditional scans including 3D reconstruction are advantageous for this planning. Ultrasound examination in the operating room is also beneficial. Rib dislocation on CT is an important finding requiring osteosynthesis. In Japan, a threaded-type plate, a claw-type plate, and an intramedullary splint can be used for treatment. The implants to employ should be chosen depending on the location and type of the fractured ribs. Flexible claw-type plates are especially recommended for stabilizing costochondral fractures. Several pitfalls as well as where to and how to use should be considered. We are devising thoracic and subcutaneous drainage for effective management.

　　Tourniquet has been used to control hemorrhage since antiquity. The tourniquets have had a unique place in military papers : love-hate relationships throughout history with each war having surgeons take opposite stances on their safety and efficacy. It has been called at times ‘an invention of the Evil One', and at other times life-saving although with the caveat of being a ‘last resort'. Following the wars in Afghanistan and Iraq, a great change in attitude towards the use of the tourniquet has happened. Several significant advancements were introduced in combat casualty care in those wars, leading to dramatic increases of survival and limb-saving rates. Among these advances, tourniquet application was the most important factor. A paradigm shift has occurred, as wartime innovations have been translated to civilian emergency medicine. The tourniquet is now applied in civilian-level trauma care widely throughout the world. In Japan, however, prehospital tourniquet application by paramedics or EMTs is still met with resistance, despite guidelines for the application of such treatments in The Educators Handbook of Improving Hemorrhage Control for Response Capabilities against Terrorism in 2018. The purpose of this study was to review the history of the tourniquet from ancient times to the current situation, clarify the significance of the tourniquet, and recognize present issues in Japan.