Ultra-Sling for Unstressed Wound Healing

Shoulder Pain, Fever, and Chills in a Fifty-Three-Year-Old Man (continued)

Answer: Abscess between the subscapularis and posterior portion of the chest wall.

Multiplanar magnetic resonance images of the area about the right shoulder girdle, including T1-weighted images, STIR (short-tau-inversion-recovery) images, and T1-weighted images with fat saturation following intravenous injection of gadolinium, demonstrated a multiloculated fluid collection between the subscapularis muscle and the posterior portion of the chest wall (Figs. 1 and 2). The rotator cuff muscles, including the subscapularis muscle, demonstrated no abnormalities. The walls of the lesion were thickened and irregular, with multiple septations that were enhanced with the gadolinium. There was moderate surrounding edema. The abscess extended inferiorly from the area anterior to the scapula, along the midaxillary and posterior axillary lines, to the level of the diaphragm. The pleura, hilum, and mediastinum of the lung appeared to be normal. Aspiration of fluid from the lesion was not performed before the operation.
The patient was taken to the operating room for urgent open drainage of the abscess on the evening of admission. After induction of general anesthesia, the patient was placed in the lateral decubitus position on a beanbag. Routine preparation and draping were performed. A curvilinear incision was made over the medial border of the scapula and was extended inferiorly. The inferior border of the trapezius muscle was retracted superiorly to expose the lower half of the medial scapular border. Electrocautery was used to release the rhomboid musculature from the medial scapular edge and to expose the underlying space. Upon entrance into the scapulothoracic space, a massive amount of purulent fluid was immediately encountered. Approximately 500 mL of purulent material was evacuated. Intraoperative gram-staining of the specimen yielded gram-positive cocci in clusters.

Multiple areas of loculation were released by gently sweeping an index finger through the area. A moderate degree of necrotic tissue was found to be forming the septations and lining the edges of the abscess and was removed with a rongeur. The space was then irrigated with pulsatile lavage with use of 9 L of saline solution with cefazolin antibiotic (2 g of cefazolin per 3-L bag). Two large Hemovac drains were placed to evacuate fluid from the scapulothoracic space. The rhomboid musculature was reapproximated to the medial scapular border with absorbable PDS (polydioxanone) monofilament suture. Prolene monofilament suture (Ethicon, Somerville, New Jersey) was used for skin closure. A shoulder sling (DonJoy UltraSling; dj Orthopedics, Vista, California) was used postoperatively, with the arm positioned at the side to allow unstressed wound-healing.