Treatment of symptomatic intercostal heterotopic ossification after surgical stabilization of rib fractures: report of two cases and review of the literature

Surgical strategy for treating multiple symptomatic rib fracture malunions with bridging heterotopic ossifications: A case report

Rib fractures are common and serious injuries, which can negatively impact long-term quality of life. Here we present a woman in her early twenties who was referred to our trauma surgery outpatient clinic five years after a motor vehicle collision in which she sustained upper extremity injury and multiple displaced rib fractures. The rib fractures were initially managed non-operatively. At the time of the outpatient consultation, she endured persistent severe pain located between the left scapula and the thoracic spine. The pain worsened on repetitive motion and deep respiration. A new chest CT revealed left-sided posterior rib fracture malunions of ribs 4 to 8 with heterotopic ossifications (HO) that formed an osseous bridge between these ribs. Surgical excision of the bridging HO and remodeling of the angulated rib malunions resulted in significant alleviation of symptoms, which allowed her to return to work and other activities. Given the dramatic improvement after surgery, we suggest considering surgical remodeling and excision for rib fracture malunions and associated HO that cause local mechanical symptoms.

Resection of Posttraumatic Rib Synostoses Resolves Pulmonary Insufficiency: A Case Report

CASE

A 30-year-old woman underwent open reduction and internal fixation for multiple segmental rib fractures status post a motor vehicle collision. A year later, the patient presented with extensive intercostal heterotopic ossification associated with multilevel, hemithoracic, rib synostoses compromising her ventilation. The patient subsequently underwent synostoses excision and hardware removal. Pulmonary function tests (PFT), imaging, and patient-reported outcome scores demonstrate resolution of impairment.

CONCLUSION

Resection of multilevel, intercostal, rib synostoses provided an effective treatment for pulmonary restrictive disorder secondary to traumatic rib synostosis. This is the first patient with documentation of prereconstructive and postreconstructive PFTs for chest wall synostosis excision.

Development of Bilateral Heterotopic Ossification After Survival of Life Threatening Purpura Fulminans

Heterotopic ossification has been reported in patients who have undergone traumatic amputations, burn injuries, and total hip arthroplasty; however, the incidence of heterotopic ossification following purpura fulminans has only been reported in one case with unilateral involvement. Here we present a bilateral lower extremity case of heterotopic ossification as sequelae of purpura fulminans. 

A 34-year-old male smoker with a past medical history of stab wounds to the chest and abdomen requiring emergent exploratory laparotomy, diaphragmatic repair, and splenectomy 15 years ago presented to the emergency department with a rapid onset of high fevers, chills and myalgia. He did not receive post-splenectomy prophylactic vaccinations for Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae. The patient presented clinically in septic shock with disseminated intravascular coagulation. The patient was admitted to the Medical Intensive Care Unit and subsequent workup suggested Streptococcus pneumoniae bacteremia. Over the next 48 hours, the patient developed extensive necrosis of the bilateral upper and lower extremities concerning for purpura fulminans. The decision was made to perform a right transradial forearm amputation as well as bilateral transtibial amputations. He tolerated these procedures and was discharged to an inpatient rehabilitation facility. Approximately four months following his bilateral below knee amputations, the patient had difficulty wearing the prosthetics secondary to pain and eventually discontinued use altogether. At home, he continued to ambulate by bearing weight on his knees while wearing kneepads. He continued to report significant tenderness and pain along the bilaterally, below knee amputation stumps. His physical examination was concerning for significant distal bone formation in his bilateral amputation stump sites without evidence of skin breakdown. Intraoperatively, extensive bony formation was found bilaterally within his soleus muscle flaps, concerning for heterotopic ossification. Postoperatively, the patient was refitted for lower extremity prosthetics. 

Similar to burns and trauma, the development of heterotopic ossification in patients with purpura fulminans may be directly related to the inflammatory process and amount of tissue damage. In some cases, heterotopic ossification could be caused from daily living activities, so the timing of diagnostic imaging techniques and clinical intervention is crucial.