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Ann Thorac Surg 2000;69:1953-1955
© 2000 The Society of Thoracic Surgeons

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Case reports

Intrathoracic migration of Kirschner pins

^a Service de Chirurgie Thoracique, CHU de Nice, Hôpital Pasteur, Nice, France
^b Service de Chirurgie Thoracique, CHU de Toulouse, Hôpital Purpan, Toulouse, France

Address reprint requests to Dr Mouroux, Service de Chirurgie Thoracique, Hôpital Pasteur, 30, Av de la Voie Romaine, BP 69, 06002 Nice Cedex 1, France
e-mail: chir-thoracique{at}chu-nice.fr

	Abstract

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We report two cases of intrathoracic migration of Kirschner pins used for the treatment of sternoclavicular joint dislocation. The migration was asymptomatic in both cases. Treatment involved median sternotomy in one patient and video-assisted thoracoscopy in the other. A favorable outcome was observed in both patients. The reports confirm the potential dangers related to management of sternoclavicular joint dislocation with metallic fixation devices.

	Introduction

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Metallic fixation devices are widely used in the surgical management of fractures of the clavicle and dislocations of sternoclavicular or acromioclavicular joints. It is well known that migration of these devices may occur; however serious complications are extremely rare [1]. We report herein two cases of intrathoracic migration of Kirschner pins.

	Case reports

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Patient 1
A 26-year-old man was involved in a car accident. He sustained a grade III anterior dislocation of left clavicle. Open reduction was carried out; two bent Kirschner pins (Mathys, Etupef, France) secured with a restraining device were employed. The patient was discharged on the 6th postoperative day. In the following three months repeat roentgenogram showed the correct position of both the clavicle and the pins.

At the fourth month when the patient was admitted for removal of the pins, chest roentgenogram revealed that one of the pins was broken and a portion had migrated to the mediastinum (Fig 1). Thoracic computed tomographic (CT) scan confirmed the migration to the anterior mediastinum.

View larger version (109K): [in this window] [in a new window]   Fig 1. Chest roentgenogram showing the mediastinal migration of the broken Kirschner pin.

Patient 2
A 20-year-old man was admitted to the emergency department of another hospital for multiple contusions and a grade III anterior dislocation of the left clavicle following a car accident.

The dislocation was treated by open reduction using two Kirschner pins. The patient was discharged on the 7th postoperative day. Two weeks later, the roentgenogram showed the correct position of the pins. At 1-month follow-up the roentgenogram revealed the migration of a pin to the anterior mediastinum. Right video-assisted thoracoscopy was performed, but the pin could not be identified. "Conversion" to open thoracotomy was carried out, but the wire was not found. The patient was then referred to one of us. A thoracic CT scan showed the presence of the pin anteriorly to the ascending aorta, with one tip in close contact with the aortic wall. Median sternotomy was performed; the pin was easily identified; one tip had entered the wall of the extrapericardial ascending aorta. It was extracted and the lesion repaired with a U-shaped mattress suture. The patient was discharged on the 7th postoperative day after an uneventful postoperative period.

	Comment

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The migration of metallic orthopedic fixation devices is a rare complication of operations on the shoulder. In a review of the literature Lyons and Rockwood were able to find 47 cases reported between 1943 and 1981; in 21 of these cases the migration of the device followed the treatment of a sternoclavicular dislocation [1].

All types of pins (smooth, threaded or bent) have been reported to migrate [1]. Various theories have been proposed to explain this migration, including muscular activity, regional resorption of bone and the great freedom of motion of the shoulder [1]. This last one might also be responsible for the rupture of the devices. The migration to the thorax seems to be favored by respiratory excursions, negative intrathoracic pressure, and gravitational forces [1, 2].

A great variability (1 day to 21 years) in the delay between positioning and migration has been reported [1]. Migration may be asymptomatic and discovered on follow-up roentgenogram; this occurred in our patients. Interestingly in one of them the pin had penetrated the aortic wall without causing bleeding. Damage to almost all cervical or thoracic organs with serious complications is possible [1]; several fatal complications have been reported. All the deaths mentioned in the literature were caused by catastrophic cardiovascular events [1]. It is noteworthy that in one of the fatalities reported in literature, the migration of a pin had been recognized, but the patient died two days before the planned elective thoracotomy [3].

Surgical removal of migrated pins is considered mandatory in both symptomatic and asymptomatic cases [1, 2]. In our experience CT scan revealed useful in preoperative evaluation, especially in deciding upon the operative approach.

Sternotomy [2, 4] or thoracotomy [5] have been used by different authors; sternotomy may be considered more appropriate in emergency conditions or in the presence of a cardiac or an intrapericardial vascular injury [2, 4]. The video-assisted thorascopy seems to be well adapted in this setting. In one patient we were able to remove the pin from the mediastinum by video-assisted thoracoscopy without particular difficulties. In the other patient the video-assisted thoracoscopy performed at another institution failed and open procedures were necessary. This patient underwent unsuccessful thoracotomy and then sternotomy. Similarly, Pate and Wilhite reported a case in which median sternotomy was necessary after an unsuccessful left thoracotomy for a Kirschner wire which had migrated into the pulmonary artery [6].

The use of metallic fixation device should not be considered mandatory in the management of sternoclavicular joint dislocations. On the contrary, in posterior dislocations, close reduction is usually stable and does not require pins [7]. Anterior dislocation often recur following close reduction; however a minimal deformity with no functional impairment is generally the unique sequela [7, 8]; so a nonoperative approach is preferred by many orthopedic surgeons, in order to eliminate the hazards of metallic fixation devices [7, 8].

Our reports confirm that fixation of sternoclavicular joint dislocation by using metallic devices should be considered as a very hazardous procedure. Its use should be restricted as much as possible. Once migration of a pin is recognized, immediate surgical removal should be carried out.

	References

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1. Lyons F.A., Rockwood C.A., Jr Migration of pins used in operations on the shoulder. J Bone Joint Surg 1990;72–A:1262-1267.[Free Full Text]
2. Janssens de Varebeke B., Van Osselaer G. Migration of Kirschner’s pin from the right sternoclavicular joint resulting in perforation of the pulmonary artery main trunk. Acta Chir Belg 1993;93:287-291.[Medline]
3. Gerlach D., Wemhöner S.R., Ogbuihi S. Two cases of pericardial tamponade caused by migration of fractured wires from the sternoclavicular joint. Z Rechtsmed 1984;93:53-60.[Medline]
4. Tubbax H., Hendzel P., Sergeant P. Cardiac perforation after Kirschner wire migration. Acta Chir Belg 1989;89:309-311.[Medline]
5. Nordback I., Markkula H. Migration of Kirschner pin from clavicle into ascending aorta. Acta Chir Scand 1985;151:177-179.[Medline]
6. Pate J.W., Wilhite J.L. Migration of a foreign body from the sternoclavicular joint to the heart. Am Surg 1969;35:448-449.[Medline]
7. Trafton P.G., Hulstyn M.J. Musculoskeletal trauma. In: Morris P.J., Malt R.A., eds. Oxford textbook of surgery. Oxford: Oxford University Press, 1994:2309-2325.
8. De Jong K.P., Sukul D.M. Anterior sternoclavicular dislocation. J Orthop Trauma 1990;4:420-423.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Marcel Dahan Jérôme Mouroux Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Venissac, N. Articles by Mouroux, J. Search for Related Content PubMed PubMed Citation Articles by Venissac, N. Articles by Mouroux, J.