Category Archives: Technique

Technique, Thorax

The “Backward Finochietto” Problem

Resuscitative thoracotomy is a (sometimes) life-saving procedure reserved for trauma patients in extremis. Thankfully, most trauma centers do very few of these a year. However, that makes it one of those “high severity – low frequency” procedures that generate many, many quality improvement problems. Many of these issues are due to operator unfamiliarity or equipment availability.

Today, I’ll highlight a problem that occasionally crops up at trauma centers across the US: the “backward Finochietto.” One of the most essential components of the resuscitative thoracotomy is rapid access to the chest. A large skin incision is typically made, the thoracic wall and intercostal musculature are divided, and the pleural space is entered.

It’s not easy to insinuate your arm between the ribs in an average person. But, of course, there’s a retractor for that! Von Mikulicz presented the first rib spreader at a German surgical society meeting in 1904.  Various versions of this instrument were devised over the next three decades to make it easier and faster to use.

The Finochietto retractor was introduced in 1936 and boasted several enhancements. It used a rack-and-pinion system to make it easier for the surgeon to spread the chest wall and to make it unlikely to close on its own. The turning lever was hinged so it could be flattened and placed out of the surgical field. The blades had fenestrations so that chest wall tissue could protrude into them, preventing it from slipping when opened. It remains a workhorse instrument for us today and is found in most instrument packs for resuscitative thoracotomy.

But there is a potential problem. Some Finochietto retractors consist of only two pieces: a blade with the linear gear teeth (the rack) and another blade that fits onto it with the turning handle (the pinion). See the image below:

Looks great, right? However, there is one downside. The retractor parts that hook into the soft tissue are of a fixed depth. What if your patient has a more generous body habitus? Placing multiple sets of this retractor in the thoracotomy pack is impractical.

The solution is to allow detachable blades of various sizes. Here’s a modern-day example:

The good news is that the retractor tips are interchangeable. The bad news is that they are sometimes interchangeable with the wrong arm of the retractor! Hence the “backward Finochietto” problem. It’s impossible to use the retractors with the blades on the wrong side, and it takes time the trauma professional does not have to figure out how to snap them off and switch them around.

So what’s the solution? This is clearly an instrument reprocessing quality issue. These instruments are expensive, so your hospital may not be eager to purchase new ones specifically for the trauma bay. It all boils down to foolproofing it in as many ways as possible.  Here are some tips:

  • Provide an educational session for all of the reprocessing techs. Unfortunately, this effect will wear off as staff turnover occurs.
  • Post a photograph of a properly assembled retractor for the techs to use when processing the tray.
  • Use colored instrument marking tape on each piece of the instrument. For example, a green tape strip should be placed on both the retractor’s rack arm and the left blade. Use red tape for the pinion arm and the right blade. All the tech needs to do now is match the colors while assembling the retractor.

Bottom line: This problem is more common than you may think. Ask one of your old-timer trauma surgeons, and I’ll bet they can tell you some stories. But it is easily avoided with a little creativity and some tape! Be sure to do it now so it doesn’t pop up in the heat of a resuscitative thoracotomy.

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Technique, Thorax

How Good Is The Erector Spinae Plane Block?

In my last post, I shared a video outlining the technique for providing an erector spinae plane block (ESPB). Today, I’ll review the most recent analysis of this procedure’s efficacy and safety.

As outlined previously, the ESPB targets the plane between the fascial layers of the thorax, providing analgesia in patients with rib fractures. The technique for use in trauma is relatively new, was first described in 2016, and studies on its effectiveness are finally beginning to accumulate. The most recent and comprehensive was recently published in the Clinical Journal of Pain by a group from Taiwan.

The authors performed a comprehensive search of papers published through 2025. They included only prospective studies comparing pain relief from fascial plane blocks (both ESPB and serratus anterior plane block (SAPB))  with epidural analgesia or no block. They identified only nine papers that included 600 patients, but only 5 used ESPB.

Here are the factoids:

  • Overall, fascial plane blocks in general (both SAPB and ESPB) significantly improved subjective pain scores during the first six hours, but were not after that for patients not receiving an epidural
  • When looking at SAPB alone, pain scores were improved during the first 24 hours; with ESPB alone, they were only improved during the first 6 hours.
  • Both types of plane blocks achieved pain scores similar to epidural analgesia
  • Both blocks decreased in-hospital opioid use, but this was not statistically significant
  • Hypotension occurred significantly less with fascial plane blocks compared to epidural analgesia
  • There was no difference in hospital length of stay with plane blocks compared to standard treatment

Bottom line: What does it all mean? First, there is still too little data to distinguish nuances in outcomes when comparing ESPBs and SAPBs. However, it appears that plane blocks result in less hypotension and so are a bit safer. However, subjective pain scores are only improved during the first 6 hours with ESPB. This suggests that there may be a significant placebo effect for this invasive procedure. Opioid use is the same.

With the exception of the first six hours, ESPB doesn’t look that exciting. It requires special equipment (ultrasound) and a trained provider to perform. It works as well as an epidural, which makes it more useful in patients with contraindications to this modality.

My take is that this may be a promising technique, but it’s still a bit too early to tell. This “large” series included only 600 patients, and fewer than half had the ESPB. So keep studying this procedure to see if it makes sense in the future.

Reference:  Efficacy and Safety of Serratus Anterior Plane Block and Erector Spinae Plane Block for Rib Fracture Pain: A Systematic Review and Meta-analysis. The Clinical Journal of Pain 42(2):e1334, February 2026. | DOI: 10.1097/AJP.0000000000001334

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Technique, Thorax

What Is It: The Erector Spinae Plane Block

Chest trauma is extremely common, and the incidence is rapidly increasing in the elderly population, with the rapid increase in falls. Rib fractures are always a concern, and the most important factor in their management is pain control.

Over the years, numerous modalities have been described, including:

  • Decreasing rib motion using taping or rib belts (highly discouraged due to the incidence of complications)
  • Systemic pain medication (may cause respiratory depression)
  • Epidural analgesia (contraindicated in patients on anticoagulants)
  • Intercostal nerve (rib) blocks (not all ribs accessible)
  • Intrapleural analgesia (not very effective, with unpredictable absorption and spread)
  • Rib fixation procedures
  • Erector spinae plane blocks

In general, we have been moving from more general to very focused pain control. Analgesic usage has predominated, with operative procedures recently becoming more common for select patients.

The new kid on the block now is the erector spinae plane block (ESPB).  It is technically easier to provide relief for rib fractures at most levels. It involves small injections and is relatively simple to perform under ultrasound guidance after proper training.

This video is a good introduction to the general concepts and techniques for the ESPB. Obviously, watching a video will not give you the skills to do this yourself. Work with a trained professional to gain experience with this technique.

YouTube player

In my next post, I’ll review the data on the efficacy and value of this block.

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Practice guidelines, Technique

When To Take The Catheter Out After Bladder Repair

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Bladder injuries are a relatively uncommon finding in abdominal trauma. The most common mechanisms are penetrating injury and blunt force injuries that disrupt the anterior pelvic ring. In most cases, repair of a full-thickness injury is straightforward and can be performed by the trauma surgeon during the abdominal exploration. More complicated injuries near the trigone usually require assistance from our urology colleagues.

But what happens after the repair? How long should the urinary catheter be left? Should a cystogram be performed before removing it? Over time, the interval to catheter removal and the number of patients with pre-pull studies have been shrinking. There is a huge amount of variability in how trauma professionals approach this, making it one of those areas that is ripe for a practice guideline! And unfortunately, there are none.

The group at the Medical College of Wisconsin in Milwaukee performed a retrospective review of their experience over 13 years at their Level I trauma center. All adult patients with non-complex, full-thickness bladder injuries that were repaired were included in the study.

Here are the factoids:

  • Only 86 patients met the inclusion criteria
  • The injuries were intraperitoneal in 43%, extraperitoneal in 31%, and mixed in the remaining 26%
  • Trauma managed 41% of patients, and urology managed 59%
  • Comparing care by trauma surgery vs urology, there were significant differences in catheter duration (median 11 vs 17 days) and use of pre-pull cystogram (77% vs 100%)
  • There was a 4% leak rate in patients treated by each group (1 vs 2)

The authors concluded that the variation in management between urology and trauma resulted in similar leak and complication rates and suggested that a standard practice should be developed.

Bottom line: This is a provocative study, but still falls under the rule “don’t let a single scientific paper change your practice.” It’s small, it’s retrospective, and it essentially examines “how we do it.” 

However, it does extend and add to things we already know. Inaba published a paper in 2013 that showed bladder injuries typically healed within 9 days. A urology group noted that there were no complications in their patients who did not undergo cystography before removing the catheter.

This paper should stimulate two things. First, a carefully designed prospective study should be conducted to determine the timing of catheter removal and the need for a cystogram. And in the meantime, some enterprising centers should craft their own practice guideline that adopts a standard discontinuation time (seven days?) and selective or non-use of pre-pull cystography with safeguards built in to ensure patient safety.

References: 

  1. Investigating the timing of catheter removal after traumatic bladder injury: a single-institution 12-year experience: Trauma Surgery & Acute Care Open 2025;10:e001693.
  2. Prospective evaluation of the utility of routine postoperative cystogram after traumatic bladder injury. J Trauma Acute Care Surg 2013; 75:1019–23.
  3. Clinical Utility of Routine Follow-up Cystography in the Management of Traumatic Bladder Ruptures. Urology 2018; 113:230–4.
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Technique, Thorax

The “Backward Finochietto” Problem

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Resuscitative thoracotomy is a (sometimes) life-saving procedure reserved for trauma patients in extremis. Thankfully, most trauma centers do very few of these a year. However, that makes it one of those “high severity – low frequency” procedures that generate many, many quality improvement problems. Many of these issues are due to operator unfamiliarity or equipment availability.

Today, I’ll highlight a problem that crops up occasionally at various trauma centers across the US: the “backward Finochietto.” One of the most essential components of the resuscitative thoracotomy is rapid access to the chest. A large skin incision is typically made, the thoracic wall and intercostal musculature are divided, and the pleural space is entered.

It’s not easy to insinuate your arm between the ribs in an average person. But, of course, there’s a retractor for that! Von Mikulicz presented the first rib spreader at a German surgical society meeting in 1904.  Various versions of this instrument were devised over the next three decades to make it easier and faster to use.

The Finochietto retractor was introduced in 1936 and boasted several enhancements. It used a rack and pinion system to make it easier for the surgeon to spread the chest wall and made it unlikely to close on its own. The turning lever was hinged so it could flattened and placed out of the surgical field. The blades contained fenestrations so chest wall tissue could protrude into them and keep it from slipping when opened. It remains a workhorse instrument for us today and is found in most instrument packs for resuscitative thoracotomy.

But there is a potential problem. Some Finochietto retractors consist of only two pieces: a blade with the linear gear teeth (the rack) and another blade that fits onto it with the turning handle (the pinion). See the image below:

Looks great, right? However, there is one downside. The retractor parts that hook into the soft tissue are of a fixed depth. What if your patient has a more generous body habitus? Placing multiple sets of this retractor into the thoracotomy pack is not practical.

The solution is to allow detachable blades of various sizes. Here’s a modern-day example:

The good news is that the retractor tips are interchangeable. The bad news is that they are sometimes interchangeable with the wrong arm of the retractor! Hence the “backward Finochietto” problem. It’s impossible to use the retractors with the blades on the wrong side, and it takes time the trauma professional does not have to figure out how to snap them off and switch them around.

So what’s the solution? This is clearly an instrument reprocessing quality issue. These instruments are expensive, so your hospital may not be excited about purchasing new ones just for the trauma bay. It all boils down to foolproofing it in as many ways as possible.  Here are some tips:

  • Provide an educational session for all of the reprocessing techs. Unfortunately, this effect will wear off as staff turnover occurs.
  • Post a photograph of a properly assembled retractor for the techs to use when processing the tray.
  • Use colored instrument marking tape on each piece of the instrument. For example, a green tape strip should be placed on both the rack arm of the retractor and the left blade. Use red tape for the pinion arm and the right blade. All the tech needs to do now is match the colors as they assemble the retractor.

Bottom line: This problem is more common than you may think. Ask one of your old-timer trauma surgeons and I’ll bet they can tell you some stories. But it is easily avoided with a little creativity and some tape! Be sure to do it now so it doesn’t pop up in the heat of a resuscitative thoracotomy .

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