Integrated surgical management of forequarter lateral implosion injury: Technical considerations and early outcomes

Concomitant ipsilateral fractures of the clavicle, scapula, and ribs, termed forequarter lateral implosion injury, represent a severe but underrecognized injury pattern resulting from high-energy lateral shoulder trauma. While the surgical indications for isolated chest wall and shoulder girdle injuries are well described, guidance on the integrated management of this combined injury complex remains limited. We describe a reproducible multidisciplinary approach for the concurrent surgical fixation of clavicle, scapula, and rib fractures, illustrated through two cases of forequarter lateral implosion injury resulting from high-energy road traffic accidents. Preoperative planning incorporated CT three-dimensional (3D) reconstructions and patient-specific 3D printed models to facilitate pre-operative planning, with a multidisciplinary team involved for incision planning and fixation sequencing. Surgery was performed in a single setting with the patient in the lateral position, utilizing muscle-sparing approaches and a staged fixation strategy to address the clavicle, scapula, and ribs through coordinated exposures. Simultaneous osseous stabilization allowed restoration of the superior shoulder suspensory complex integrity and chest wall mechanics, enabling immediate postoperative shoulder mobilization and aggressive pulmonary rehabilitation. Both patients demonstrated early pain resolution, functional shoulder range of motion, radiographic union, and return to work within months and without major complications. In the setting of combined chest wall and shoulder girdle disruption, the cumulative biomechanical instability may justify a judicious relaxation of traditional surgical thresholds to permit concurrent surgical stabilization to facilitate earlier rehabilitation and recovery. This study characterizes the underrecognized entity of a forequarter lateral implosion injury, highlights practical management considerations, and supports an integrated surgical strategy to optimize functional recovery.