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Ann Thorac Surg 2009;88:653-654. doi:10.1016/j.athoracsur.2008.12.093
© 2009 The Society of Thoracic Surgeons
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Case Reports

Migration of a Kirschner Wire From the Clavicle Into the Intrathoracic Trachea

Mitsuo Nakayama, MD, PhD*, Masatoshi Gika, MD, PhD, Hiroki Fukuda, MD, Takeshi Yamahata, MD, Kohei Aoki, MD, Syugo Shiba, MD, Keisuke Eguchi, MD, PhD

Department of General Thoracic Surgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan

Accepted for publication December 30, 2008.

* Address correspondence to Dr Nakayama, 1981 Kamoda-Tujido, Kawagoe, Saitama, 350-8550, Japan (Email: 30mnaka{at}saitama-med.ac.jp).


   Abstract
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 Abstract
Introduction
 Comment
 References
 
We report a 70-year-old man who had a rare complication related to the insertion of Kirschner wires for fixation of a right clavicle fracture. Eight months after the placement of the Kirschner wires, he presented with cough and hemosputum. Chest roentgenograms, chest computed tomographic scans, and bronchoscopy revealed that one of the Kirschner wires had migrated through the lung and into the intrathoracic trachea. Immediate thoracotomy was performed to remove the wire. His postoperative course was uneventful.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
Orthopedic metallic pins and wires are frequently used for the fixation of fractures and dislocations. It is well known that these devices sometimes migrate. The shoulder girdle is one of the areas where pins and wires are commonly used, and migration of such devices to the pleural cavity has been reported several times. Although a number of precautionary measures have recently been recommended, reports about this complication continue to accumulate. We report a case in which a Kirschner wire (K-wire) migrated from a right clavicle fracture site into the intrathoracic trachea.

A 70-year-old man was admitted to our hospital with complaints of chest pain, cough, and hemosputum. The right chest pain had begun 2 months prior to admission, and the cough with hemosputum had developed after that. The patient reported a history of pneumoconiosis. Eight months earlier, he had been involved in a traffic accident in which the distal end of his right clavicle was fractured. At that time he underwent open reduction and internal fixation with three K-wires. For 4 weeks after fixation, serial shoulder roentgenograms confirmed satisfactory reduction and the K-wires were in a good position. The patient was then transferred to another hospital for rehabilitation, he was unavailable for follow-up, and he did not have the wires removed.

With the present admission, a chest roentgenogram indicated that one of the K-wires had migrated through the lung and into the mediastinum. The chest computed tomographic scan demonstrated that the migrated wire penetrated the right side of the trachea, and that the tip of the wire reached the left side of the trachea, adjacent to the aortic arch (Fig 1). Surgical removal of the K-wire was immediately planned. Bronchoscopy, which was performed just before intratracheal intubation for general anesthesia, revealed a metallic wire piercing the intrathoracic trachea (Fig 2). The tip of the wire was poking into the opposite side of the tracheal wall, causing a granulation of the tracheal mucosa. A right anterolateral thoracotomy was commenced to remove the wire. After adhesiotomy between the lung and the mediastinal pleura, the K-wire was seen covered with thin fibrous tissue and granulation. The wire was grasped at the point of the tracheal wall penetration to prevent the tip from moving into the aorta, and then the distal end of the wire buried in the lung was exposed and the wire was pulled out in a retrograde manner. The wire penetration point on the trachea was closed with sutures. During the same operation, the remaining K-wires and soft wire were removed from the clavicle. His postoperative course was uneventful.


Figure 1
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  		Fig 1. The computed tomographic multi-planar reconstruction showing a migrated wire locating in the lung, penetrating the right side of the trachea, and medially reaching the left side of the trachea.

 

Figure 2
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  		Fig 2. Bronchoscopy revealing a metallic wire piercing the intrathoracic trachea and forming a granulation of the tracheal mucosa.

 

   Comment
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 Abstract
 Introduction
 Comment
References
 
Migration of orthopedic pins and wires around the shoulder girdle into the chest cavity has been a rarely reported but well-known complication since it was first noted by Mazet [1] in 1943, and reports about this complication continue to accumulate [2, 3]. Lyons and Rockwood have reviewed 47 reports documenting the migration of pins and similar devices used in the fixation of bones or joints around the shoulder area into the chest cavity [4]. Eight pins migrated to the lung and 10 to the lung and mediastinum, without vascular involvement. Seventeen pins migrated to a major cardiovascular structure and caused serious complications. Eight cases had fatal outcomes, and all of the deaths were associated with catastrophic cardiovascular events and pericardial tamponade. In 9 patients, the pin was not removed after migration was recognized, and 6 of the 9 patients died suddenly [4]. It is noteworthy that 1 of the 6 patients died 2 days before the planned date of an elective thoracotomy [5]. Therefore, Lyons and Rockwood recommended immediate removal of the pin if follow-up roentgenograms show any migration of it [4]. In the present case, the tip of the K-wire reached to the left side of the tracheal wall, adjacent to the aortic arch. We began the removal operation immediately to prevent sudden death due to bleeding from the aorta.

Although the migration of a shoulder pin to the lung is not a novel occurrence, migration of a K-wire, with penetration of the intrathoracic trachea through the lung, has not been reported. We believe that there are three other reports in the literature of pin migration to the trachea from the shoulder region [6–8]. In all three cases, a pin migrated and penetrated the cervical trachea. In the present case, on the other hand, a K-wire migrated and penetrated the intrathoracic trachea.

Several precautions should be taken if K-wires are to be used for internal fixation of shoulder girdle fractures and dislocation. To prevent potential migration, it is highly recommended to bend the subcutaneous end of each pin into the shape of a walking stick, use restraining devices, carry out close clinical and radiographic follow-up, and withdraw the wires at the end of treatment [4]. In the present case, all three K-wires were bent at the distal end and were secured with a restraining soft wire, but one of the K-wires that was bent insufficiently had migrated. The patient received close clinical and radiographic follow-up for 4 weeks after fixation, but was unavailable for follow-up after that time, and he did not have the wires removed.

This case reminds us that several serious precautions should be taken when orthopedic pins and wires are used for fixation of shoulder girdle fractures and dislocation as follows: (1) The subcutaneous end of each K-wire must be bent sufficiently, and a restraining device should be used in conjunction with it. (2) The patient must receive close clinical and radiographic follow-up until the pins and wires are removed. (3) The wires must be withdrawn when the desired therapeutic effect has been attained. (4) If a wire migrates, it must be removed without delay to prevent sudden and fatal complications.

We, as thoracic surgeons, should not only know this complication and these precautions thoroughly, but also inform orthopedists of this complication, and when possible, assist the coiling of the wire in these cases to prevent the wire migration.


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Mazet Jr R. Migration of Steinmann pin from shoulder region into the lung: report of two cases J Bone Joint Surg Am 1943;25:477-483.
  2. Casey MC, Ernest EM, Jeffrey LJ, et al. Removal of an intrathoracic migrated fixation pin by thoracoscopy Ann Thorac Surg 2001;71:368-370.[Abstract/Free Full Text]
  3. Medved I, Simic O, Bralic M, et al. Chronic heart perforation with 13.5 cm long Kirschner wire without pericardial tamponade: an unusual sequelae after shoulder fracture Ann Thorac Surg 2006;81:1895-1897.[Abstract/Free Full Text]
  4. Lyons FA, Rockwood Jr CA. Migration of pins used in operations on the shoulder J Bone Joint Surg Am 1990;72:1262-1267.[Medline]
  5. Gerlach D, Wemhoner SR, Ogbuihi S. Two cases of pericardial tamponade caused by migration of fractured wires from the sternoclavicular joint Z Rechtsmed 1984;93:53-60.[Medline]
  6. Kremens V, Glauser F. Unusual sequela following pinning of medial clavicular fracture Am J Roentgenol 1956;76:1066-1069.
  7. Foster GT, Chetty KG, Mahutte K, et al. Hemoptysis due to migration of a fractured Kirschner wire Chest 2001;119:1285-1286.[Abstract/Free Full Text]
  8. Taira O, Miura H, Uchida O, et al. A case of Kirschner's wire migrating through the trachea after right clavicular osteosynthesis J J S B 1994;16:88-93.



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This Article
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