CASE: We present the case of a 57-year-old woman who sustained a comminuted transverse sternal fracture that failed primary open reduction internal fixation (ORIF). The patient underwent staged nonunion reconstruction with a tricortical iliac crest bone graft and mesh plate. With 18 months of a sustained successful outcome, we propose a treatment strategy for a challenging clinical problem. CONCLUSION: When primary ORIF fails, bone healing and resolution of a painful sternal nonunion can be effectively managed with a tricortical iliac crest in-lay autograft and locking mesh plate.