migration of a broken kirschner pin into thoracic spinal canal 4 years following internal fixation...

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Eur J Orthop Surg Traumatol (2010) 20:493–495 DOI 10.1007/s00590-010-0592-x 123 UP-TO DATE REVIEW AND CASE REPORT Migration of a broken Kirschner pin into thoracic spinal canal 4 years following internal Wxation of a clavicle fracture Shu-Qing Wang · You-Shui Gao · Jiong Mei · Ming Ni · Jia-Qi Wang · Zhi-Li Zeng Received: 25 November 2009 / Accepted: 5 January 2010 / Published online: 27 January 2010 © Springer-Verlag 2010 Abstract Fractures of the clavicle are common injuries and some of them need open reduction and internal Wxation. As one of economical and practical implants, Kirschner pins (K-pins) are widely employed to treat clavicle frac- tures through percutaneous Wxation in minimal invasion. However, as one of rare and severe complications, K-pins migrations to ascending aorta, thorax, spine and neck have been published previously. Here, a case of migration of a broken K-pin to thoracic spinal canal 4 years following internal Wxation of a clavicle fracture is reported, and con- cerning attention in clinical practice is discussed. Keywords Clavicle fractures · Kirschner pin · Migration · Complication · Breakage Introduction Fractures of the clavicle are common injuries and represent about 2.6–5% of all fractures on the whole [1]. Fortunately, the majority of these fractures could come to union by con- servative treatment; however, some displaced fractures result in nonunion and malunion with a poor shoulder func- tion non-operatively [2]. Osteosynthesis with the method of open reduction and internal Wxation (ORIF) probably improves the prognosis of clavicle fractures, and used implants include cable, Kirschner pin (K-pin), and various plate systems [3]. Because K-pin Wxation is quite economi- cal and practical, meanwhile, percutaneous Wxation and minimal invasion could be achieved, it has been widely employed for osteosynthesis. Nevertheless, the populariza- tion of K-pin could not eliminate its inherent Xaws and neg- ative reports emerge one after another thereafter. As one of rare and severe complications, K-pin migrations to ascending aorta, thorax, spine and neck have been published previously [410]. Here, a case of K-pins migration to thoracic spinal canal 4 years following internal Wxation of clavicular frac- ture is reported. The patient has been informed that the data concerning this case would be submitted for publication. Case report A 28-year-old female patient was encountered in a car acci- dent and suVered distal clavicle and humeral fractures in left simultaneously. These closed fractures were displaced and unstable. On the prerequisite of good general condi- tions, the clavicle fracture was reduced manually and Wxed with K-pins and band through limited incision, meanwhile, humeral fracture was stabilized with a locked intramedul- lary nail under brachial plexus anesthesia. The aVected limb was protected with a shoulder sling in the Wrst 2 weeks after operation and functional exercise of the shoulder was set out gradually. After this patient was discharged with a sat- isfactory consequence, she was followed up regularly at the outpatient department. However, the following plan was dis- continued in the third month. The implants including K-pins, wires and intramedullary nail were supposed to be taken out after the union of humeral fracture; however, the supposition was spoiled undoubtedly. S.-Q. Wang · J. Mei (&) · M. Ni · J.-Q. Wang · Z.-L. Zeng Department of Orthopaedics, Tongji Hospital, Tongji University, 389 Xincun Road, 200065 Shanghai, China e-mail: [email protected]; [email protected] Y.-S. Gao Department of Orthopaedics, Shanghai Sixth People’s Hospital, Shanghai Jiao Tong University School of Medicine, 200233 Shanghai, China

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Page 1: Migration of a broken Kirschner pin into thoracic spinal canal 4 years following internal fixation of a clavicle fracture

Eur J Orthop Surg Traumatol (2010) 20:493–495

DOI 10.1007/s00590-010-0592-x

UP-TO DATE REVIEW AND CASE REPORT

Migration of a broken Kirschner pin into thoracic spinal canal 4 years following internal Wxation of a clavicle fracture

Shu-Qing Wang · You-Shui Gao · Jiong Mei · Ming Ni · Jia-Qi Wang · Zhi-Li Zeng

Received: 25 November 2009 / Accepted: 5 January 2010 / Published online: 27 January 2010© Springer-Verlag 2010

Abstract Fractures of the clavicle are common injuriesand some of them need open reduction and internal Wxation.As one of economical and practical implants, Kirschnerpins (K-pins) are widely employed to treat clavicle frac-tures through percutaneous Wxation in minimal invasion.However, as one of rare and severe complications, K-pinsmigrations to ascending aorta, thorax, spine and neck havebeen published previously. Here, a case of migration of abroken K-pin to thoracic spinal canal 4 years followinginternal Wxation of a clavicle fracture is reported, and con-cerning attention in clinical practice is discussed.

Keywords Clavicle fractures · Kirschner pin · Migration · Complication · Breakage

Introduction

Fractures of the clavicle are common injuries and representabout 2.6–5% of all fractures on the whole [1]. Fortunately,the majority of these fractures could come to union by con-servative treatment; however, some displaced fracturesresult in nonunion and malunion with a poor shoulder func-tion non-operatively [2]. Osteosynthesis with the method ofopen reduction and internal Wxation (ORIF) probably

improves the prognosis of clavicle fractures, and usedimplants include cable, Kirschner pin (K-pin), and variousplate systems [3]. Because K-pin Wxation is quite economi-cal and practical, meanwhile, percutaneous Wxation andminimal invasion could be achieved, it has been widelyemployed for osteosynthesis. Nevertheless, the populariza-tion of K-pin could not eliminate its inherent Xaws and neg-ative reports emerge one after another thereafter. As one ofrare and severe complications, K-pin migrations to ascendingaorta, thorax, spine and neck have been published previously[4–10]. Here, a case of K-pins migration to thoracic spinalcanal 4 years following internal Wxation of clavicular frac-ture is reported. The patient has been informed that the dataconcerning this case would be submitted for publication.

Case report

A 28-year-old female patient was encountered in a car acci-dent and suVered distal clavicle and humeral fractures inleft simultaneously. These closed fractures were displacedand unstable. On the prerequisite of good general condi-tions, the clavicle fracture was reduced manually and Wxedwith K-pins and band through limited incision, meanwhile,humeral fracture was stabilized with a locked intramedul-lary nail under brachial plexus anesthesia. The aVected limbwas protected with a shoulder sling in the Wrst 2 weeks afteroperation and functional exercise of the shoulder was setout gradually. After this patient was discharged with a sat-isfactory consequence, she was followed up regularly at theoutpatient department. However, the following plan was dis-continued in the third month. The implants including K-pins,wires and intramedullary nail were supposed to be takenout after the union of humeral fracture; however, thesupposition was spoiled undoubtedly.

S.-Q. Wang · J. Mei (&) · M. Ni · J.-Q. Wang · Z.-L. ZengDepartment of Orthopaedics, Tongji Hospital, Tongji University, 389 Xincun Road, 200065 Shanghai, Chinae-mail: [email protected]; [email protected]

Y.-S. GaoDepartment of Orthopaedics, Shanghai Sixth People’s Hospital, Shanghai Jiao Tong University School of Medicine, 200233 Shanghai, China

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Page 2: Migration of a broken Kirschner pin into thoracic spinal canal 4 years following internal fixation of a clavicle fracture

494 Eur J Orthop Surg Traumatol (2010) 20:493–495

Four years later, she came to our orthopedic departmentservice for slight paresthesia on the left leg. Due to her frac-tures history, radiological examination of the left clavicleand humerus was involved in the primary advice. An X-rayplain Wlm of the left shoulder showed the breakage andmigration of a K-pin (Fig. 1), and further CT scanningrevealed the intra-thoracic spinal migration of one brokenK-pin at the left intervertebral foramen of T1/T2 and the pinceased on the right edge of spinal canal of T2 (Fig. 2a, b).On physical examination, the patient only complained amild hypoesthesia on the lateral leg in left and with all otherresults negative. The patient was informed to be hospital-ized for further treatment, and the migrated K-pin was sup-posed to be taken out and following eVect would beobserved.

An incision over the left clavicle was employed throughwhich wire and K-pins were pulled out carefully underXuoroscopic control. Postoperative X-ray check conWrmedthat implants about the clavicle had been removed and noremnants existed (Fig. 3). Two weeks later, her paresthesiadisappeared magically and sensory function was symmetri-cally Wne in legs. The patient conformed to the followingplan and no other complaint was found.

Discussion

As a rare complication, the breakage and migration of Kirs-chner pins has been reported scarcely in the literature.Although this kind of movement of orthopedic implantdoes exist in many anatomical sites, it is relatively commonat clavicles when K-pins are used. In spite of many attemptsto explain the peculiar phenomenon, an exact reason for K-pinmigration remains unclear. It is speculated that several

factors might contribute to the special migration, such asmuscle action, respiratory movements, capillary attraction,electrolysis, regional bone resorption, gravitational forcesand the great range of motion of the upper extremity [7]. Inthe circumstances of K-pin rupture and joints with a greaterrange of motion, the probability of K-pin migrationincreases accordingly.

BrieXy reviewing these reports related to K-pin migra-tion, we Wnd that terrible complications including lung andheart perforation, Wstulas of the aorta and pulmonary artery,hemothorax and neurological deWcits could be caused. Pri-bán described a patient that showed clinical symptoms ofsevere paraparesis of lower limbs [9]. Similar to our currentcase, spinal cord in the level of C7/T1 was penetrated trans-versally by a K-pin. After emergency operation of K-pinextraction and adjuvant methylprednisolon therapy, thepatient regained some sensory and walking ability whilelosing sexual function permanently. Fortunately, ourpatient regained her sensory function postoperatively andno sequela was found. The migrated K-pin located at pos-terior of T1 level and the penetration was extremely slow;moreover, the broken K-pin was about 7 cm in length andmaintained a relatively stable position to prevent furthermoving and harming.

Fig. 1 Anteroposterior view of the left clavicle showing both K-pinsgoing rupture 4 years post operation, one of which migrating to tho-racic spinal region (T1/T2) and penetrating the vertebra

Fig. 2 CT scanning indicating the broken K-pin moving from theupper left to below right in coronal (a), it penetrating the left interver-tebral foramen, passing the vertebra canal transversely, and restingwith its tip inserting the pedicle of T2 (b)

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Page 3: Migration of a broken Kirschner pin into thoracic spinal canal 4 years following internal fixation of a clavicle fracture

Eur J Orthop Surg Traumatol (2010) 20:493–495 495

It is still unknown why, how and where K-pins migratefor it seems quite impossible to duplicate the same givenindividual conditions to research. However, the rare com-plication of K-pin migration should be carved in orthope-dists’ mind and several measures could be adopted to avoidits occurrence. First, indications of osteosynthesis withK-pins for clavicle fractures should be selected cautiously,for more reliable and eVective implants are available alter-natively now [1, 3]. If K-pins cross the acromion and themotion of acromioclavicular joint is restricted, certainly,stress on pins will cause it easier to rupture, and consequen-tially, it is easier for broken pins to migrate. Second, all

patients should be required to comply with individualfollowing plan and K-pins had better to be taken out afterbone union. Third, special attention should be paid to theK-pins-Wxed fracture history if the patient has musculoskel-etal, respiratory or cardiac complains in the following period.Last, postoperative function recovery should be under ther-apeutist’s guidance. Early immobilization is full of beneWtsbecause K-pins Wxation is not so sturdy and steady, anddrastic activity may lead to re-shifting of bone fragmentsand breakage of pins. Rarity of K-pin migration should notbe neglected until disastrous complications occur.

ConXict of interest statement No beneWts in any form have been orwill be received from a commercial party related directly or indirectlyto the subject of this manuscript.

References

1. Jeray KJ (2007) Acute midshaft clavicular fracture. J Am AcadOrthop Surg 15:239–248

2. McKee MD, Pedersen EM, Jones C, Stephen DJ, Kreder HJ,Schemitsch EH et al (2006) DeWcits following nonoperative treat-ment of displaced midshaft clavicular fractures. J Bone Joint SurgAm 88:35–40

3. Khan LK, Bradnock TJ, Scott C, Robinson M (2009) Fractures ofthe clavicle. J Bone Joint Surg Am 91:447–460

4. Nordback I, Markkula H (1985) Migration of Kirschner pin fromclavicle into ascending aorta. Acta Chir Scand 151:177–179

5. Bedi GS, Gill SS, Singh M, Lone GN (1997) Intrathoracic migra-tion of a Kirschner pin: case report. J Trauma 43:865–866

6. Regel JP, Pospiech J, Aalders TA, Ruchholtz S (2002) Intraspinalmigration of a Kirschner pin 3 months after clavicular fracture Wx-ation. Neurosurg Rev 25:110–112

7. Adbenoor J, Mantoura J, Nahas A (2000) Cervicothoracic pinmigration following open reduction and pinning of a clavicularfracture: a case report. East J Med 5:26–28

8. Fransen P, Bourgeois S, Rommens J (2007) Kirschner wire migra-tion causing spinal cord injury one year after internal Wxation of aclavicle fracture. Acta Orthop Belg 73:390–392

9. Pribán V, Toufar P (2005) A spinal cord injury caused by a migrat-ing Kirschner pin following osteosynthesis of the clavicle: a casereview. Rozhl Chir 84:373–375 Czech

10. Motamedi M, Mortazavi SM, Miresmaseeli SH (2008) Migrationof a broken Kirschner wire from an acromioclavicular joint intothe neck: a case report. Eur J Orthop Surg Traumatol 18:19–21

Fig. 3 Postoperative X-ray examination demonstrating all implantsremoved and no remnants left

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