Interactive Cardiovascular and Thoracic Surgery 2:210-211(2003)
© 2003 European Association of Cardio-Thoracic Surgery
Case report - Thoracic general |
Intrathoracic migration of Steinman wire
Alpay Sarper*,
Mustafa Ürgüden,
Levent Dertsiz and
Abid Demircan
Department of Thoracic Surgery, Medical Faculty of Akdeniz University, Antalya, Turkey
* Corresponding author. Akdeniz Üniversitesi Tip Fak., Gögüs Cerrahisi Anabilim Dali, 07070 Antalya, Turkey. Tel.: +90-242-227-4343x21120; fax: +90-242-227-8844
sarper{at}med.akdeniz.edu.tr
Received December 27, 2002;
received in revised form February 24, 2003;
accepted February 26, 2003
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Abstract
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We report two cases of intrathoracic migration of Steinman wire used for the treatment of the fracture and shoulder dislocation. The migrations were symptomatic with back pain in our cases. The treatment involved removing of the pin via thoracotomy. The postoperative course was uneventful. Intrathoracic migration of Steinman wires should be expected in fixation of the shoulder problems. To avoid this complication, threaded pins have to be used in surgery of the shoulder region.
Key Words: Intrathoracic migration; Steinman wire; Removal of pin via thoracotomy; Catastrophic cardiovascular event
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1. Introduction
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Wires are widely used in the surgical management of fractures in orthopedic surgery [1]. Some of these metallic fixation devices have a tendency to migrate, and serious complications are not rare [2–8]. We report that two cases had intrathoracic migration of smooth Steinman wires.
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2. Case reports
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2.1. Patient 1
A 46-year-old man had an operation for a fracture of the right scapula. After the open reduction, Steinman wire was used for fixation. The patient was discharged on the sixth postoperative day. No abnormality was found in the follow-up radiography. After a vigorous muscular activity at the fourth month, the patient applied with back pain. Chest roentgenogram revealed that the wire migrated to the right lung (Fig. 1). There was no pneumothorax nor hemothorax. A right thoracotomy was carried out. The wire whose sharp tip contacted with parietal pleura was in the right upper lung. After the wire was removed, the patient's postoperative course was unremarkable.
2.2. Patient 2
A 55-year-old woman was admitted to the emergency department of another hospital for a former reduced right shoulder dislocation. The dislocation was treated by open reduction and fixation with a Steinman wire. The patient was discharged on the seventh postoperative day. Two weeks later, the roentgenogram indicated that the positions of the wire and the shoulder were appropriate. One month after the operation, she was admitted to the hospital with intense back pain. Chest X-ray showed that the wire had migrated into the right thoracic cavity. A thoracic computed tomography scan showed that the wire was in the right upper lobe and the tip of it was seen near the eighth dorsal spine (Fig. 2). There was no evidence of a pneumothorax or hemothorax. The patient was taken to the operating room for the right exploratory thoracotomy. The wire was found to be piercing the right lung parenchyma and the pleura adjacent to the eighth costovertebral joint, but did not enter to the vertebral canal. The wire was carefully pulled out. The patient was discharged on the sixth postoperative day after an uneventful postoperative period.
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3. Discussion
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Utilization of Steinman wires for bone and joint fixation is potentially complicated by migration of the wire from the fixation site over in time. However, a review of the literature disclosed few reports of this complication. When it occurs it can be dangerous. In the literature, there have been some case reports concerning remarkable migration of wires from the shoulder region, for example, to the spinal canal, to the trachea, to the spleen, into the pulmonary artery, into the ascending aorta, into the heart, into the mediastinum, into the lung and to the subclavian artery [2–8].
Various theories have been proposed to explain this migration, including muscular activity as in our patient, regional resorption of bone, and the great freedom of motion of the shoulder. This last one might also be responsible for the breakage of the wires. The migration to the thorax seems to be favored by respiratory excursions, negative intrathoracic pressure, and gravitational forces [9].
Migration may be asymptomatic and discovered on follow-up roentgenogram. Our patients complained of severe back pain. This pain was connected with the irritation of the parietal pleura and vertebral body. Sarwal et al. [2] reported that a subarachnoid-pleural fistula was caused by Kirschner wire. Damage to almost all cervical or thoracic organs with serious complications is possible; several fatal complications have been reported. All of the deaths mentioned in the literature were caused by catastrophic cardiovascular events [4].
Reviewed reports confirm that smooth Steinman wires should be considered very hazardous. If wires absolutely need to be used, terminally threaded pins have to be used and bent. The patients should be followed up both clinically and radiographically until all the wires are removed. Once migration of a pin is recognized, immediate surgical removal should be carried out.
doi:10.1016/S1569-9293(03)00047-1
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References
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Abstract
1. Introduction
