Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access
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Case Report

Volume 15, Number 9, September 2024, pages 215-221

Conservative Treatment of Empyema Formation Following Intrathoracic Rib Fixation With Antibiotics and Tissue Plasminogen Activator/Dornase

Figures

Figure 1.
Figure 1. (a) Initial radiographic image of the patient’s chest. Black arrows indicate the pulmonary contusions on the initial radiographic image. (b) Computed tomography scan of the patient’s chest showing subcutaneous air along with a hemopneumothorax. White arrows indicate the rib fracture and the pulmonary contusions.
Figure 2.
Figure 2. Computed tomography of three-dimensional reconstruction of the patient’s rib fractures. White arrows indicate the displaced rib fractures.
Figure 3.
Figure 3. Radiographic image of the right fifth and sixth ribs plated using titanium RibFix bridge implanted intrathoracically along the posterior surface of the ribs. Lateral white arrow indicates the titanium RibFix bridge and the medial white arrow indicates the improved pleural effusion.
Figure 4.
Figure 4. (a) Computed tomography with a loculated anterior right pleural fluid collection suspicious for loculated empyema secondary to infected hardware (indicated by the white arrow). (b) Significant improvement in the loculated empyema after treatment with tissue plasminogen activator (tPA) and DNase (indicated by the white arrow with only small residual effusion on the posterior).

Table

Table 1. Literature Review of Case Reports on Complications Found in Patients With Rib Fracture Fixation
 
StudyAge/genderEtiologyRibs fracturedRepair typeIntrathoracic or extrathoracic rib platingPulmonary complications before RFFPulmonary complications after RFFPostoperative treatments (i.e. explant)LOS (days)
ARDS: acute respiratory distress syndrome; F: female; IV: intravenous; LOS: length of stay; M: male; RFF: rib fracture fixation; tPA: tissue plasminogen activator.
Abidali et al [15]66, MFall from 12 ft ladderRt #3-12
Lt #7-10		Not statedExtrathoracicHemothoraxNoneRegional pain catheters17
Allen et al [16]48, FPedestrian versus carLt #5-10Acute innovations RibLoc U+ systemExtrathoracicEmpyemaPneumonia and bilateral effusionsIV antibiotics42
DeGenova et al [17]39, MAggressive coughingLt #10, 11RibFix Blu systemExtrathoracic reduction and instrumentationNoneNoneIndwelling pain catheter0
DeGenova et al [17]61, FAssaultLt #5, 6RibFix Blu systemExtrathoracic reduction and instrumentationNoneNoneIndwelling pain catheter0
DeGenova et al [17]60, M15 ft fallLt #10, 11RibFix Blu systemExtrathoracic reduction and instrumentationNoneNoneIndwelling pain catheter and narcotics0
Fawzy et al [13]20s, not statedMotorcycle accidentRt #5, 7-9
Lt #2, 3		Not statedExtrathoracicRt pneumothorax, bilateral pulmonary contusions, emphysemaPneumonia, empyemaAntibiotics, pigtail drainage, tPA26
Stefani et al [18]79, FAccidental fallLt #2-8Judet plates and Sanchez-Lloret platesExtrathoracicHemothorax, multiple pulmonary contusionsBilateral pneumoniaMechanical ventilation, non-invasive ventilation90
Whittaker et al [19]32, M4.5 m fall, crushed by boatRt #4-9DePuy Synthes CMF MatrixRIBExtrathoracicBilateral hemopneumothorax, bilateral pulmonary contusionsNoneChest drain, wound drain, ECMO20
Zhou et al [14]61, MFallLt #1-63D printing locking plates, MIPO techniqueExtrathoracicPneumothorax, ARDS, pulmonary contusionsNoneThoracic drainage tubeNot stated