The fourth case was a 57-year-old man who presented after being pinned between a crane and a wall. He had fractures of the right anterior costochondral cartilage of ribs 1 to 5. These fractures were posteriorly displaced with respect to the sternum. He also had minimally displaced posterior left ribs 1 to 7 fractures, nondisplaced right ribs 3 to 4 fractures, and a displaced right clavicle fracture. He was initially treated nonoperatively and did not require mechanical ventilation during his index hospitalization. He did, however, develop an empyema, which precluded insertion of metal plates at the time of thoracotomy for this empyema. After 1 year, he had persistent pain, particularly with coughing, sneezing, or sudden movement. This pain required chronic narcotic pain medication and precluded his ability to return to work as a construction worker. He also complained of visible deformities on the chest wall, which were palpable and clearly unstable with chest wall motion on examination. CT scanning demonstrated chronic hypertrophic nonunion of the costosternal joints on the right. His presenting complaint was deformity rather than pain, and epidural catheter was not indicated at this time. He was then offered, and underwent, an uncomplicated surgical fixation procedure (Fig 2). He did not require mechanical ventilation in the perioperative period. In follow-up, the patient reported improvement in his respiratory symptoms and resolution of his chest pain and deformity. He had not yet returned to work at the time of his last visit and was then lost to follow-up.