(1535) Conservative Management of Empyema Formation After Rib Plating

Introduction: Rib plating is recommended for patients with multiple rib fractures or flail chest. This surgical approach has been shown to improve quality of life and reduce complications during the healing process. Although fixation has been implemented for decades, little is known about the variety of secondary complications that may arise and their treatment modalities. We report on the successful conservative management with antibiotics and tissue-type plasminogen activator (TPA) and dornase of a patient with empyema following rib fixation in the surgical intensive care unit.

Description: A 32 year old male with history of alcohol use disorder was brought to the emergency department trauma bay after a motor vehicle accident. The patient was agitated with complaints of right chest pain and difficulty breathing. Imaging showed a right hemopneumothorax and 4th-9th rib fractures with displacement. A right-sided chest tube was placed. The patient was admitted to the surgical intensive care unit (SICU). On hospital day 2 he became tachycardic, tachypneic, hypoxic and required oropharyngeal intubation and mechanical ventilation. Computed tomography (CT) was obtained and showed persistent right hemopneumothorax with increased airspace consolidation in the right lower lung. The patient was taken to the operating room for video-assisted thoracoscopic surgery. The patient’s 5th and 6th ribs were plated using titanium alloy plates and screws. The patient was successful extubated post operatively. In the next few days the patient became tachycardic, febrile with increasing leukocytosis. CT Chest showed a right anterior loculated empyema. A right pigtail was placed. The patient was given intra pleural administration of TPA and Dornase for the loculated empyema. A repeat CT Chest demonstrated significant improvement in the empyema with evidence of abscess resolution.

Discussion: Empyema is an extremely rare complication of rib fracture fixation and the literature on it is scarce. Many still debate the benefits of nonsurgical versus surgical treatments for patients with flail chest or multiple rib fractures. Our clinical findings contribute to the growing information on rib fixation. This case provides clinicians with an improved understanding of possible complications and successful conservative management.