Lateral implosion injury: a multidisciplinary management approach

Introduction

Background

High-energy shoulder girdle injuries can often occur in combination with chest wall injuries, including rib, peristernal and sternum fractures. The shoulder girdle consists of the scapula, clavicle, and proximal humerus as well as glenohumeral (GH), acromioclavicular (AC), and manubrioclavicular (MC) joints (1-3). When the scapula is injured, it often acts as a projectile into the chest wall, causing underlying rib fractures (4). The term forequarter lateral implosion injury is used to describe any constellation of lesions involving rib and peristernal fractures or dislocations and an ipsilateral shoulder girdle injury (Figure 1).

Figure 1 Illustration of the constellation of injuries that make up a lateral implosion injury. The vector of the shoulder girdle projectile is highlighted by the red arrow. Ipsilateral rib fractures are highlighted in red and contralateral rib fractures are highlighted in pink. Common scapula and proximal humerus fractures are highlighted in yellow and purple, respectively. Acromioclavicular joint dislocation, sternoclavicular joint dislocation, and clavicle fractures are highlighted in green.

The clavicle and scapula link the axial and appendicular skeletons, with many ligamentous and muscular attachments and insertions. The scapula and its muscles cover a majority of the posterior thoracic wall, with the serratus anterior and pectoralis minor covering the anterolateral region. The AC joint provides vertical as well as anterior-posterior stability to the shoulder (5). The MC joint normally consists of highly stable ligaments that require high-energy mechanisms to disrupt it (6). MC joint instability is associated with functional limitations and generally shows improved patient-reported outcomes with reconstruction (7). Not only do the AC and MC joints provide stability, but their associated ligamentous complexes allow for tremendous, coordinated motion (8). Complex upper extremity and torso function requires all these structures to coordinate their efforts due to their shared musculature, and disruptions can lead to instability, deformity, pain, and dysfunction (5,9).

Rationale and knowledge gap

A majority of isolated rib fractures and scapula fractures can be treated conservatively with high rates of healing. However, the subset of patients with lateral implosion injury represents a higher energy, more severe combination of injuries. The deforming muscular forces from the scapula onto the chest wall, in the setting of rib fractures or flail chest, logically impair the healing process through distraction and instability (10). Fractured ribs are also subject to continued displacement and motion through normal breathing biomechanics. Nonoperative management of flail chest has been associated with high rates of in-hospital complications and mechanical ventilatory requirements (11-13). Current literature suggests operative management improves hospital course and functional outcomes (11,13-15). If left untreated, possible outcomes include symptomatic nonunion, malunion, and painful costal cartilage lesions.

Untreated displaced rib fractures can lead to symptomatic nonunion, malunion, or intercostal nerve pain (16-21). In a case described by Brown et al., a patient sustaining multiple rib fractures failed conservative treatment, leading to rib malunion and unremitting intercostal nerve pain, which was successfully treated with surgical decompression (21). Symptomatic malunion and nonunion may be treated successfully with osteotomy and reconstructive procedures (22).

This is the first use of the term lateral implosion injury in literature. While each system has been studied on its own, reports on chest wall and shoulder girdle injuries combined are limited and do not focus on function or quality of life (23-27). Reports do not always consider the shoulder girdle as a whole, isolating the scapula or clavicle (14,23,24,27). Outcomes are mainly focused on in hospital morbidity and mortality (23,26,27). Some studies have supported good functional outcomes in combined rib and scapula fractures (17). While each aspect of the shoulder girdle has been well investigated in literature and studies on surgical stabilization of rib fractures (SSRF) are rising, this report proposes an injury pattern of rib fractures combined with an injury to any aspect of the shoulder girdle, as upper extremity and torso function are closely related.

Objective

These injuries are not well studied in combination with rib fractures, as thoracic injuries are commonly treated by general trauma and thoracic surgeons while shoulder girdle injuries are treated by orthopaedic surgeons. The purpose of this review is to provide a current understanding of lateral implosion injuries from an orthopaedic perspective, to allow for appropriate referral or interdisciplinary collaboration.

Methods

This paper is a clinical practice review of lateral implosion injuries. A literature search was performed for shoulder girdle, scapula, acromion, coracoid, clavicle, and rib fractures, AC joint, and superior shoulder suspensory complex (SSSC) disruptions. Articles related to epidemiology, etiology, treatment, and outcomes were included. Systematic reviews, randomized controlled trials, cohort studies and book chapters were included.

Mechanism of injury

Lateral implosion injuries are usually the result of high-energy mechanisms of injury, with the scapula serving as a projectile and force vector into the thorax. Anteriorly, the clavicle acts as a gatekeeper of the thorax, with injury to the clavicle associated with rib fractures and other thoracic injuries (23,28). Patients with concomitant rib fractures and ipsilateral clavicle fractures have been associated with a higher rate of clavicle fracture displacement (29,30). Likewise, injury to the scapula is also associated with rib fractures and thoracic injuries (31-33). The scapula lies in close relation to posterior ribs 1–7 (24,34), and operatively indicated patients are most likely to have ipsilateral scapular fractures on ribs 3–6 bordering the scapula (4). Patients with scapula injuries in motor vehicle crashes were 8.8 times more likely to have flail chest injuries (31). High-energy injuries to the rib cage can lead to serious thoracic injuries such as pneumothorax, hemothorax, and even solid organ injury, which are associated with increased mortality (32,35,36).

Chest wall injuries are prevalent following injuries to the shoulder girdle. Between 20–61% of patients with clavicle fractures have associated rib fractures (25,28,29,37). At least 22% of patients with both scapula and clavicle fractures have associated rib fractures (29). As many as 48–71% of scapula fractures have associated rib fractures (26,31,38,39) (Figure 2). In patients with concomitant vertebral fractures, the respective neurosurgery or orthopaedic spine service should be consulted. Clearance or considerations in positioning may be discussed.

Figure 2 3D reconstruction of a lateral implosion injury with red arrows pointing at the shoulder girdle injury and yellow arrows directed at the ipsilateral rib fractures. 3D, three dimensional.

It is important to consider the possibility of costal cartilage lesions during the acute lateral implosion injury and follow-up period. Costal cartilage lesions can occur due to the high-energy mechanism in the acute setting but are difficult to diagnose on computed tomography (CT) and 3-dimensional (3D) CT. A segmentation technique has been developed to highlight cartilage through radiodensity-based color (40). It is also possible for chondral lesions to occur later in the follow-up period, especially in cases of rib nonunion due to rib instability.

Radiographic imaging

Patients with lateral implosion injuries often present to the emergency department as trauma activations. Chest X-ray asymmetry can indicate pathology to the shoulder girdle and chest wall, providing direction for more advanced imaging (Figure 3). While CT is the preferred method for rib fracture identification, it has been reported that CT incorrectly identifies rib fracture numbers and location up to 43% of the time (41,42). This reality is due to the reliance on 2-dimensional (2D) reconstructions. 3DCT reconstructions should be requested whenever rib fracture instability patterns are suspected by scout chest X-rays and physical examination. These images will also help in the discussion with orthopaedic colleagues who must be vigilant to restore stability to the shoulder girdle and a proper functional relationship to the scapulothoracic relationship.

Figure 3 Chest X-ray of a patient with a lateral implosion injury, red arrows point at shoulder girdle injuries and yellow arrows point at the rib fractures. Note the asymmetry and loss of the contour of the left chest wall.

In a 3D mapping study by Thomas et al., a curved planar reformatting (CPR) fracture mapping technique in operative scapula injuries with concomitant rib fractures identified a majority of rib fractures bordering the ipsilateral injured scapular body in posterior ribs 2–7. Flail chest injuries associated with scapula fractures were most likely to occur ipsilaterally on ribs 3–6 at the vertebral scapular border (4) (Figure 4).

Figure 4 An unfurled subscapular flail map created from chest CT DICOM data showing the locations of 47 flail segments from 46 patients with concomitant operatively treated scapula fracture. Each yellow zone represents the location of a flail segment, and the segments were overlaid to signify a location with a high frequency of flail chest (4). Copyright permissions obtained from Wolters Kluwer Health, Inc. CT, computed tomography; DICOM, Digital Imaging and Communications in Medicine.

3DCT can also be helpful in the interpretation of scapula fractures and manubrioclavicular dislocations (Figures 5,6). Particularly in disciplines outside orthopaedics, it is hard to interpret the severity of displacement or angulation without the aid of this imaging modality.

Figure 5 3D reconstruction of severely fractured and malunited left scapula. 3D, three dimensional.

Figure 6 3D reconstruction superior-inferior view of both an anterior and posterior manubrioclavicular dislocation. (A) Right anterosuperior manubrioclavicular dislocation. (B) Right posterior manubrioclavicular dislocation. Red arrows indicate force vector of manubrioclavicular dislocation. 3D, three dimensional.

Surgical indications

The decision for surgical intervention in lateral implosion injuries requires careful consideration of the associated injuries, and individual factors such as baseline activity and function and comorbidities. An interdisciplinary approach is important in the management of patients with lateral implosion injuries. A coordinated approach with a trauma surgeon can include nerve block, cryoablation, or placement of a chest tube after completion of open reduction and internal fixation (ORIF). Nerve blocks and cryoablation for rib fractures have been shown to provide significant pain relief and reduced hospital length of stay (LOS) (43-45). The principles of ORIF are to restore length, alignment, rotation, and stability, to allow for early mobility (46). The following surgical indications serve as a reference for when to consult orthopaedic surgery for operative management of shoulder girdle injuries. The following indications can be used as a guide for coordinating care alongside General Trauma and Thoracic surgeons who should already be familiar with operative indications for chest wall instability, which are based on rib fracture patterns and respiratory instability (47) (Table 1).

Scapula

Surgical indications for scapular fractures are based on angular deformity and/or displacement (48). Diagnosis of scapula fractures on radiographs is difficult due to overlying musculoskeletal structures or being overlooked, especially in patients with blunt chest trauma (49,50). The current gold standard for evaluation of scapula injuries is 3DCT (49). Well-published surgical indications for scapular fractures include:

• A lateral scapula border offset or “medialization” greater than 20 mm, measured on an anteroposterior view of an X-ray or CT scan of the scapula.
• Glenopolar angle less than 22 degrees, measured on an anteroposterior view of an X-ray or CT scan of the scapula.
• Angular deformity greater than 45 degrees, measured on the Y-view of an X-ray or 3DCT scan of the scapula.
• Intraarticular glenoid fracture with step-off or gap greater than 4 mm, where the fracture fragment comprises more than 25% of the glenoid.

There are other surgical indications that occur because of combination fractures, such as with clavicle and scapula, but the list above serves as a good starting point for discussion with orthopaedic colleagues to plan combined or staged approaches (Figures 7,8).

Figure 7 3D reconstruction and AP X-ray of a left scapula. 3D reconstruction of a preoperative scapula fracture and a postoperative X-ray. 3D, three dimensional; AP, anterior-posterior.

Figure 8 A table of surgical indications for scapula fractures.

Clavicle

Approximately 75% of clavicle fractures occur in the middle one third of the bone, and most of the discussion around indications should be attributed to these variants. One of the common problems with current radiographic practices is that there is inadequate imaging to appreciate clavicle fracture displacement. Ideally, an imaging protocol should include an anteroposterior view of bilateral clavicles and orthogonal views of the shoulder (a caudal and cephalic tilt of 30° is also acceptable and more practical) (Figure 9). The clearest indication is an open fracture, where irrigation, debridement, and stabilization are crucial.

Figure 9 Right displaced midshaft clavicle fracture shown in X-ray injury films. (A) Injury AP X-ray film of a right displaced, midshaft clavicle fracture. (B) Orthogonal X-ray view demonstrating the amount of shortening of the right displaced, midshaft clavicle fracture. (C) Postoperative AP X-ray of right clavicle after open reduction internal fixation. AP, anterior-posterior.

The most commonly cited indication for clavicle surgery was informed by a classic study by McKee et al. in which clavicles with greater than two centimeters of shortening were reconstructed and associated with improved functional outcomes (51). A subsequent classic study, which was a Canadian randomized controlled trial of operative vs. nonoperative management of clavicle fractures, demonstrated improved outcomes for operative treatment of displaced clavicle fractures based on outcome metrics of cosmetics as well as symptoms of pain and dysfunction (52).

Other key investigations have been published to reveal the risk factors associated with a greater risk of nonunion (53-56), which serve as a guide to choosing surgical candidates. The following should be used as a guide to operating on clavicle fractures and at a minimum, discussing with the patient the pros and cons of surgery. These are risk factors for poor outcomes or increased nonunion.

• More than 1.5 cm of shortening;
• Z-Deformity or comminution;
• Lateral fractures distal to the coracoid;
• Elderly and female.

AC joint

The Rockwood classification is the most widely used system for categorizing AC joint injuries. It considers the AC joint itself, the coracoclavicular ligaments, and the deltoid and trapezius muscles, while also noting the direction of clavicle dislocation relative to the acromion (57). The SSSC, made up of the AC joint, coracoacromial and coracoclavicular ligaments, distal clavicle, acromion and coracoid processes, is an osseoligamentous ring that supports the GH joint. A double disruption of the SSSC is rare and indicates surgical reduction and stabilization (2,58-60).

Surgical reconstruction is indicated for complete disruption of both CC and AC ligaments, or in other words, 100% more distance between coracoid and clavicle on the injured side vs the intact side (61). Rockwood types IV to VI AC dislocations are surgically indicated to prevent chronic dysfunction and pain (3). These three types involve complete tearing of the AC and coracoclavicular ligaments, but they differ in the clavicle displacement. Type IV presents with posterior displacement of the clavicle, type V with clavicle elevation, and type VI with clavicle dislocated inferior to the acromion. In contrast, type III injuries involve complete tearing of the AC ligaments and partial tearing of the CC ligaments, and their management remains controversial (3,57) (Figure 10).

Figure 10 Right-sided acromioclavicular joint dislocation and multiple ipsilateral rib fractures. (A) Preoperative X-rays and 3D reconstruction of acromioclavicular joint dislocation with multiple right-sided rib fractures. Red arrow indicates acromioclavicular joint dislocation; yellow arrows indicate ipsilateral rib fractures. (B) Postoperative X-ray of acromioclavicular internal fixation. 3D, three dimensional.

Manubrioclavicular joint (MCJ)

MCJ dislocations can be categorized as anterior or posterior, with posterior dislocations being less frequent but potentially fatal due to the proximity of vascular structures (62) (Figure 6). This makes it critical to promptly rule them out in the initial management.

If closed reduction attempts fail or if there is confirmed vascular compromise, significant instability, or mediastinal symptoms, surgical intervention may be required.

Surgical fixation options range from medial clavicle resection to reduction and reconstruction using a tendon graft or suture wire, including techniques like the figure-of-8 method and various other approaches or combinations thereof (63) (Figure 11).

Figure 11 Intraoperative photo of a manubrial-clavicular suture repair.

Despite the growing body of literature on operative techniques and management of MCJ injuries, there is no consensus on surgical indications (62). Further studies that propose a surgical algorithm for MCJ pathology are necessary.

In general, vascular or neurologic injury is also indication for surgical exploration and fixation. Finally, surgery must account for patient-specific considerations, such as high-level athletes or workers who need predictable outcomes and accelerated rehabilitation.

Rehabilitation

The senior author keeps surgically fixed patients non-weight bearing and range of motion (ROM) limited to below the plane of the shoulder from postoperative weeks 1–6. It is imperative to allow osseoligamentous structures time to scar in or heal. After 6 weeks, the patient can begin to range above the plane of the shoulder as tolerated and start with 3–5 pounds of resistance. Expectations should be appropriately set for patients, as function may not revert to pre-injury levels due to the severity of the trauma. Emphasis should be placed on diligent rehabilitation to regain maximal ROM and strength. The patient can begin to increase resistance from 8 to 12 weeks, after which all restrictions are lifted.

Outcomes

Lateral implosion injuries, characterized by a combination of rib fractures and ipsilateral shoulder girdle injuries, have not been extensively studied in the literature as a distinct condition. This may be because chest wall fractures are typically managed by general trauma and thoracic surgeons, while shoulder girdle injuries fall under the expertise of orthopaedic specialists. To address this knowledge gap, our group is working on a prognostication study of combined shoulder and chest injury severity as it regards in-hospital morbidity and mortality. Other gaps include the lack of consensus on MCJ surgical indications and surgical techniques, a need for standardized terminology and classifications, and prospective studies on functional outcomes. There are, however, other authors who have given insight into the outcomes of patients who sustain combined injuries.

Solberg et al. found that surgical stabilization of flail chest with a concomitant clavicle fracture or dislocation significantly reduced in-hospital complications, pain, and the duration of chest tube and intubation, compared to nonsurgical management (11). Similarly, Chuang et al. reported promising preliminary results using the mirror Judet approach for surgical stabilization of ipsilateral scapula and rib fractures, with acceptable clinical outcomes (13). In contrast, Hoepelman et al. found no significant difference in long-term outcomes and complications between operative and nonoperative treatment of patients with ipsilateral rib and scapula fractures (27). It should be noted, however, that the study hospital had indications in place to treat patients with more severe rib cage injuries and more severe scapula fracture patterns. These limitations resulted in only 28% of the patients in this study meeting criteria to undergo any type of surgical fixation for their fractures. The low sample size of the operative treatment group limits the ability to adequately compare it to the conservative treatment group. Additionally, Langenbach et al. specifically investigated surgical stabilization of costoclavicular injuries in the setting of flail chest injuries and clavicle fractures, and reported positive outcomes, which included complete wound healing and early functional treatment with good clinical results (14).

Early SSRF has been shown to reduce hospital and intensive care unit (ICU) LOS, ventilator time and complications (10,15,64). In a prospective series of 40 patients fixed with muscle-sparing chest wall surgery compared to 38 patients with conventional non-muscle sparing surgery, there were no differences in respiratory muscle strength, physical activity or quality of life. Kasotakis et al. performed a systematic review totaling 986 patients with flail chest and the 334 who underwent SSRF demonstrated lower mortality, shorter ventilation duration, hospital and ICU LOS, and complications including pneumonia and tracheostomy. Of note, there were only three prospective randomized trials and there was inadequate data for pain analysis (64). There is a lack of functional outcome and patient-reported outcome measurement (PROM) data regarding SSRF patients. The current largest series of rib nonunion reconstruction evaluating functional outcomes consists of 25 patients and 51 rib nonunions, in which all patients achieved radiographic union and 89% of patients (n=16/18) were satisfied with surgery, 83% (n=15) reported mild to no pain, and the majority of patients were able to return to work (65).

These studies highlight the potential benefits of surgical intervention in specific presentations of lateral implosion injury and emphasize the need for a comprehensive approach to their management. One of the abiding orthopaedic principles which permeates the culture amongst fracture surgeons is that restoration of anatomy and stability to the skeleton allows for earlier pain control and faster rehabilitation. When these goals are achieved, earlier pain control and faster return to function yield better results. Though this reality is clear to most surgeons, further high-quality evidence is needed in the field to inform both clearer indications and advantages for surgery.

Strengths and limitations

While there are studies regarding patients with concomitant rib fractures and scapula or clavicle fractures (13,24), to our knowledge, there are no reports evaluating the combination of chest wall fractures with shoulder girdle injuries. There are no large, multicenter trials supporting improved functional outcomes and PROMS in patients with surgically fixed concomitant rib and shoulder girdle fractures (13,24). Further studies will serve to validate functional outcomes and PROMs in addition to morbidity and mortality.

Conclusions

In conclusion, forequarter lateral implosion injury is a musculoskeletal and respiratory pathology complex involving shoulder and chest wall fractures and dislocations. Since these two anatomical regions function in concert, it is vital to provide concomitant treatment as indicated. Recognition amongst both thoracic and general surgeons treating the trauma patient of the classic operative indications used by orthopaedic surgeons will provide a stimulus to interdisciplinary care and collaborative treatment plans.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Christopher F. Janowak) for the series “Chest Trauma” published in Current Challenges in Thoracic Surgery. The article has undergone external peer review.

Peer Review File: Available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-20/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-20/coif). The series “Chest Trauma” was commissioned by the editorial office without any funding or sponsorship. P.A.C. received educational grants from KLS Martin and Stryker; consulting fees from Exactech. He serves on the Ad Hoc Committee of Harvard Medical School and is a stockholder of Bonefoam, Inc. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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