CASE: We present a complex case of a 56-year-old man with multiple left-sided rib pathology including nonunion, rib heterotopic ossification (HO) forming a rib-to-rib synostosis, and rib malunion. After a major forequarter trauma and failed conservative management, followed by scapula reconstruction and rib recontouring, the surgical resection of the rib synostosis, reconstruction of a rib nonunion, and contouring of rib malunions are described. The patient was followed up clinically for 1 year after the final procedure and demonstrated marked improvement in functional outcome. CONCLUSION: In the setting of complex forequarter malunion and nonunion, resolution of painful rib nonunion and synostosis can be effectively managed with HO resection and rib reconstruction.