A 71-year-old immunocompetent Caucasian male patient presented to the emergency department via ambulance a few hours after a fall from a height of 3 meters. After a primary survey, a computed tomography (CT) imaging revealed clavicle fracture, serial rib fractures associated with pulmonary contusion and hemopneumothorax on the left side, and non-displaced serial rib fractures on the right side.
He underwent surgery with surgical stabilization with plates of the clavicle and the ribs on the left side and was discharged home on the 19th postoperative day (POD).
Three months later, he presented with a painful swelling on his right chest wall without a history of new trauma or surgery on that side. Physical examination showed a large solitary swelling over the seventh/eighth rib, 3 x 5 cm in dimension. The lesion was soft, tender, fluctuating with defined margins, and not attached to underlying structures.
In order to determine the cause of the swelling, we performed an ultrasonography and a CT Scan that showed a capsulated fluid collection (Figure 1). A diagnostic thoracoscopy showed no abnormal intrathoracic findings (Figure 2), and therefore, an open incision of the collection was performed. Intraoperatively, we confirmed the presence of an encapsulated abscess with purulent secretion coming out from a hole in the 7th rib (Figure 3).
After partial resection of the affected rib and tissue sampling for histological and microbiological examination, a negative pressure dressing was applied (Wound V.A.C. Therapy; KCI, San Antonio, Texas).
Histopathologic examination revealed extensive granulocyte infiltrates. The presence of Candida albicans was detected in the resected tissue but not in blood cultures (in absence of specific treatment). Dressing changes were scheduled every 3 days until a clean granulating wound without any residual sign of infection was obtained. Two weeks after the initial debridement of the infected tissue, the defect measured approximately 10 x 6 cm and was about 4 cm deep. After confirming the presence and course of a sizeable perforator originating from the superior epigastric artery in the proximity of the wound by means of a CT angiography and handheld doppler, a perforator-based superior epigastric artery perforator (SEAP) propeller flap was planned (Figure 4). After its harvest, most of the flap (about 70% of its surface) was deepithelialized and buried to adequately fill the dead space, while the distal tip of the flap served as a monitor to check its perfusion postoperatively (Figures 5 and 6).
The postoperative course was thereafter uneventful, and the patient could be discharged 7 days after the wound closure. On the day of discharge, the wound was healing without any swelling or tenderness of the affected area. At 21 days follow-up, all the wounds were healed, and the patient was allowed to return to all normal activities without any restrictions. Further surgery to remove the monitor skin island under local anesthesia was offered for cosmetic reasons, but the operation was postponed due to the COVID-19 outbreak.
He was treated with fluconazole for 6 months. After a 9-month follow-up, we found no evidence of infection or abnormal wound healing (Figure 7).