Clavicle Kirschner Wire Migration into Left Lung: A Case Report

Foreign Glass Bodies in Pleura and Pancreas: Systematic Review for Entry Hypotheses and Treatment Options in an Unresolved Case

BACKGROUND

Foreign bodies within the pleura and pancreas are infrequent, and the approaches to their treatment still a subject of debate. There is limited knowledge particularly regarding glass foreign bodies.

METHODS

We present a case involving large glass splinters in the pleura and pancreas, with an unknown entry point. In addition, a systematic review was conducted to explore entry hypotheses and management options.

RESULTS

In addition to our case, our review uncovered eight incidents of intrapleural glass, and another eight cases of glass in other intrathoracic areas. The fragments entered the body through impalement (81%), migrated through the diaphragm after impalement (6%), or caused transesophageal perforation (19%) following ingestion. Eight instances of glass inside the abdominal cavity were documented, with seven resulting from impalement injuries and one from transintestinal migration. There were no recorded instances of glass being discovered within the pancreas. Among the 41 nonglass intrapancreatic foreign bodies found, sewing needles (34%) and fish bones (46%) were the most common; following ingestion, they had migrated through either a transgastric or transduodenal perforation. In all these cases, how the foreign bodies were introduced was often poorly recalled by the patient. Many nonglass foreign bodies tend to become encapsulated by fibrous tissue, rendering them inert, though this is less common with glass. Glass has been reported to migrate through various tissues and cavities, sometimes with a significant delay spanning even decades. There are cases of intrapleural migration of glass causing hemothorax, pneumothorax, and heart and major blood vessels injury. For intrapleural glass fragment management, thoracoscopy proved to be effective in 5 reported cases, in addition to our patient. Most intrapancreatic nonglass foreign bodies tend to trigger pancreatitis and abscess formation, necessitating management ranging from laparoscopic procedures to subtotal pancreatectomy. There have been only four documented cases of intrapancreatic needles that remained asymptomatic with conservative management. There is no direct guidance from the existing literature regarding management of intrapancreatic glass foreign bodies. Consequently, our patient is under observation with regular follow-ups and has remained asymptomatic for the past 2 years.

CONCLUSIONS

Glass foreign bodies in the pleura are rare, and our report of an intrapancreatic glass fragment is the first of its kind. Impalement is the most likely method of introduction. As glass has significant migration and an ensuing complication potential, preventive removal of intrapleural loose glass should be considered. However, intrapancreatic glass fragment management remains uncertain.

Intrathoracic Needle Migration from the Mediastinum into the Thoracic Cavity

Intrathoracic needles are rarely used in clinical practice. They can migrate within the body, injure large blood vessels and other organs, and cause severe complications. We report an interesting case of intrathoracic needle removal using video-assisted thoracoscopic surgery. The needle was inserted under the left clavicle, penetrated the mediastinum, and migrated into the right thoracic cavity. Although pneumothorax developed during the disease course, no severe complications were observed. This rare case illustrates the course of needle migration from the mediastinum into the thoracic cavity. Prompt imaging and surgical removal of foreign bodies are necessary in cases of intrathoracic foreign bodies.

Clinical Outcome after Clavicular Hook Plate Fixation for Displaced Medial-End Clavicle Fractures

Background

Surgery of the medial end of the clavicle remains a challenge for orthopedic surgeons. Moreover, there is no standard surgical procedure for treating displaced fractures or dislocation of the medial clavicle. Thus, the present study aimed to evaluate the safety and efficacy of using a hook plate for treating medial-end clavicular fractures and present functional outcomes.

Methods

We retrospectively investigated 18 patients who underwent surgery with a hook plate from July 2016 to December 2021. There were 14 men and 4 women with a mean age of 57.4 years. Fracture union was assessed at follow-up by computed tomography (CT). Other outcome parameters were complications, including implant failure, infection, nonunion, osteolysis of sternal manubrium, and migration of the hook portion. Range of motion (ROM), visual analog scale (VAS), Quick Disabilities of the Arm, Shoulder and Hand (Quick DASH), and American Shoulder and Elbow Society (ASES) scores were evaluated 6 months postoperatively and at the last follow-up.

Results

The mean operation time was 43.8 minutes (range, 35-50 minutes) and the mean follow-up was 22.8 months (range, 12-42 months). Bone union was confirmed in all cases. The mean union time was 6.2 months (range, 6-7 months). Implant removal was performed routinely according to the clinical course in 17 cases. The mean implant removal time was 10.0 months (range, 6-14 months). Clinical and functional outcomes measured at the last follow-up were significantly improved compared to those at 6 months postoperatively (p < 0.05). Regarding complications, there were 6 cases (33.3%) of osteolysis of the sternal manubrium. Although the anteroposterior length of the manubrium and hook depth showed significant differences between the non-osteolysis group and the osteolysis group (p = 0.024), ROM, VAS, Quick DASH, and ASES scores were not significantly different between the two groups (all p > 0.05).

Conclusions

Clavicle hook plating can be a safe and effective method that can be easily applied with good outcomes if it is used with appropriate surgical planning and technique for medial-end clavicle fracture. CT scans are useful for preoperative planning and postoperative evaluation of bone union or complications.

Successful uniportal thoracoscopic removal of a new generation implantable loop recorder accidentally migrated into the left pleural cavity and concomitant re-implantation: A case report

INTRODUCTION

With the spread of the use of implantable loop recorders (ILRs) by cardiologists for outpatient cardiac monitoring, intrathoracic migration represents a rare but possible complication occurring after the placement of these devices. Very few cases of ILRs intrathoracic migration into the pleural cavity have been reported, followed in even fewer cases by surgical removal of the devices, but in none re-implantation was performed.

PRESENTATION OF CASE

We report the first case of a patient with a new generation ILR accidentally migrated into the postero-inferior costophrenic recess of the left pleural cavity, successfully removed by uniportal video-assisted thoracic surgery (VATS) and submitted to re-implantation of a new ILR in the same operating session.

DISCUSSION

To reduce the risk of ILRs intrathoracic displacement, the insertion technique must be performed in the most suitable part of the chest wall, with the correct incision and angle of penetration, by an expert operator. When migrated into the pleural cavity, surgical removal should be performed to avoid the onset of early and late complications. A mini-invasive surgical approach by uniportal VATS could be considered as the first choice, ensuring a favourable patient outcome. Re-implantation of a new ILR can be safely performed in the same operating session.

CONCLUSION

In case of intrathoracic migration of ILRs, early removal by mini-invasive approach is recommended as well as concomitant re-implantation. Beyond periodic monitoring of ILRs by cardiologists, strict radiological follow-up with chest X-ray is advisable after implantation, in order to early identify any abnormalities and correctly manage them.

[Effectiveness analysis of Endobutton plate combined with high-strength suture Nice knot fixation in the treatment of distal clavicle fractures]

OBJECTIVE

To investigate the effectiveness of Endobutton plate coracoclavicular fixation combined with fracture site high-strength suture Nice knot cerclage fixation in the treatment of distal clavicle fracture with coracoclavicular ligament injury.

METHODS

The clinical data of 33 cases of distal clavicular fracture with coracoclavicular ligament injury treated by Endobutton coracoclavicular plate fixation between January 2017 and December 2020 were analyzed retrospectively. According to the fixation methods of fracture site, they were divided into two groups: the high-strength suture Nice knot fixation group (study group, 16 cases) and the transacromial Kirschner wire fixation group (control group, 17 cases). There was no significant difference between the two groups in common data such as age, gender, injury side, cause of injury, Craig type, combined injury, time from injury to operation, and preoperative visual analogue scale (VAS) score and Constant-Murley score ( P>0.05). Postoperative fracture healing and complications were observed, and the increase rate of coracoclavicular space on the affected side was calculated at last follow-up. VAS score was used to evaluate shoulder pain before operation, at 1 week, 1 month, 3 months after operation, and at last follow-up. The shoulder function was evaluated according to Constant-Murley shoulder score before operation, at 1 month, 3 months after operation, and at last follow-up.

RESULTS

The operations were successfully completed in both groups without severe complications such as vascular nerve injury and coracoid fracture. In the control group, 1 case (5.9%) had slight pin tract infection and 1 case (5.9%) had Kirschner wire displacement; there was no obvious complication in the study group. The patients in both groups were followed up 9-36 months (mean, 22.9 months). The fracture healing time of the study group and the control group were (12.56±0.73) weeks and (13.59±0.87) weeks, respectively, and the difference was significant ( t=-3.661, P=0.001). At last follow-up, the increase rates of coracoclavicular space on the affected side of the study group and the control group were 8.88%±1.19% and 8.55%±1.07%, respectively, showing no significant difference ( t=0.837, P=0.409). The postoperative VAS score and Constant-Murley score of the two groups significantly improved when compared with those before operation, and the two scores gradually improved with the extension of time after operation ( P<0.05). Except that the VAS score at 1 week and 1 month after operation and the Constant-Murley score at 1 month after operation in the study group were significantly better than those in the control group ( P<0.05), there was no significant difference between the two groups at other time points after operation ( P>0.05).

CONCLUSION

For oblique fracture or combined with butterfly fracture in the distal clavicle fracture with coracoclavicular ligament injury, the fracture site high-strength suture Nice knot fixation is a good supplement to the Endobutton plate coracoclavicular fixation. It can stabilize the fracture end, reduce the complications of Kirschner wire fixation, and is more conducive to fracture healing. The effectiveness is satisfactory.

Intracardic migration of Kirschner wire from the right sternoclavicular joint: a case report

Background

Migration of wires and pins within the heart is an uncommon complication. Intracardic migration of Kirschner wire can cause several complications.

Case presentation

A 55-year-old male patient was admitted to the emergency service with dyspnea, stabbing chest pain. The patient’s medical history showed that he had undergone a fixation operation using Kirschner wire and plate for treatment of the right sternoclavicular joint dislocation about 5 months prior. Chest computerized tomography revealed a metallic foreign body locating in the pericardium between the aorta and the right ventricle. There were not any serious complications occurred before operation due to the timely detection of potential risks. Removal of the wire was performed via median sternotomy under general anesthesia without cardiopulmonary bypass. The symptoms of dyspnea and chest pain were relieved after surgery, and the patient recovered without any complications.

Conclusion

The Kirschner wire should be used judiciously in amphiarthrosis in orthopedic surgery for the risk of breakage and migration. The possibility of intracardiac migration of wire should be considered when chest symptoms presenting after surgery with the Kirschner wire. Migrated wires must be removed immediately to prevent serious complications. Regular follow-up and early removal of fixation wires are recommended to prevent migration of wires.

Two reconstruction plates provide superior stability of displaced midshaft clavicle fractures in comparison to single plating - A biomechanical study

BACKGROUND

Displaced midshaft fractures are the most common surgically treated clavicle fractures. However, they are associated with high complication rates following plating due to fixation failure in terms of plate breakage, screw breakage and/or screw loosening. The aim of this study was to compare the biomechanical competence of three different plating techniques for fixation of displaced midshaft clavicle fractures.

METHODS

Displaced midshaft fractures type 2B according to the Robinson classification were simulated by standardized osteotomy gap in 18 synthetic clavicles, assigned to three groups (n = 6) for plating with either superiorly placed Dynamic Compression Plate (width/thickness 11.0/4.0 mm), locked Superior Anterior Clavicle Locking Compression Plate (width/thickness 10.2/2.0 mm), or two non-locked Reconstruction Plates placed superiorly and anteriorly (width/thickness 10.0/2.8 mm). Each specimen was cyclically tested at 3 Hz under craniocaudal cantilever bending, superimposed with torsion around the shaft axis over 720'000 cycles or until failure occurred. The latter was defined by plate breakage, screw breakage or screw loosening.

FINDINGS

Initial construct stiffness (N/mm) and cycles to failure in group Reconstruction Plates (22.30 ± 4.07; 712'778 ± 17'691) were significantly higher compared with both groups Compression Plate (12.53 ± 2.09; 348'541 ± 212'941) and Locking Plate (4.19 ± 0.46; 19'536 ± 3'586), p ≤ 0.019. In addition, these two outcomes were significantly higher in group Compression Plate versus Locking Plate, p ≤ 0.029.

INTERPRETATION

Double plating of unstable midshaft clavicle fractures with reconstruction plates seems to provide superior fixation stability under dynamic loading, when compared to single compression or locked plating, whereas the latter is associated with inferior performance.

Migration of K-wire into the cavum pleura after the reduction of acromioclavicular dislocation, a case report and review of literature

INTRODUCTION

The use of K-wire (Kirschner wire) in acromioclavicular dislocation was the first trans-articular fixation technique to be described.

PRESENTATION OF CASE

A 40-years-old man was presented to the emergency room (ER) with shortness of breath. He had a history of acromioclavicular dislocation two years ago, which had been treated using two K-wires and tension band wiring. The plain x-ray revealed left side pneumothorax with K-wire migrated into the left hemithorax. CT scan showed that K-wire migrated into the posterior cavum pleura. A chest tube was then inserted, and the removal of K-wire was performed using thoracoscopic assisted surgery followed by the removal of the remaining K-wire in the left shoulder. Three days post-surgery, the chest tube was removed, and the patient was discharged from the hospital.

DISCUSSION

This technique is easy and cheap, but it can cause lethal complications. K-wire can migrate into the area of vital organs, including the liver, heart, neck lung subclavian artery, and aorta.

CONCLUSION

K-Wire should be used cautiously for treating upper extremity injury, especially acromioclavicular dislocation, due to its lethal complications. This method is outdated and should be restricted as much as possible.

Management of clavicle shaft fractures with intramedullary devices: a narrative review

INTRODUCTION

Displaced and shortened clavicle fractures are frequently treated surgically. Although extramedullary fixation using a plate and screws is most commonly used, intramedullary nailing has become increasingly popular over the last decade. Traditional intramedullary nailing is usually associated with a high risk of hardware migration as well as hardware irritation at its entry point. Newer devices, however, seem to mitigate these problems. The aim of this narrative review is to provide an overview of clavicle shaft fractures and treatment with intramedullary nails, in particular the newer, locked devices.

AREAS COVERED

In general, this review covers current literature related to clavicle shaft fractures with a specific focus on the treatment of displaced and shortened fractures with intramedullary nails.

EXPERT OPINION

Clavicle shaft fractures can be effectively treated with an intramedullary nail. The risk of hardware migration when employing the newer, improved designs appears to be minimal. The advantages of using intramedullary fixation include smaller incision sizes as well as the avoidance of routine procedures generally associated with the removal of prominent subcutaneous hardware as per extramedullary fixation.

Single-center experience in the treatment of extremely medial clavicle fractures with vertical fixation of double-plate: A retrospective study

Patients suffering from extremely medial clavicle fractures combined with distinct displacement generally need surgical intervention. Double-plate fixation is a widely applied technique in the treatment of distal radius fracture, which has been reported to fix lateral clavicle fracture as well. This study reveals the effect of double-plate fixation as an innovative procedure in the treatment of extremely medial clavicle fractures for the first time.Nine patients complaint of extremely medial clavicle fracture were enrolled in this research from May 2017 to March 2019. Patients were operated with an open reduction and internal fixation using the double-plate technique. Postoperative x-ray was taken regularly to observe the fracture healing at each visit, and the related complications were also recorded. The rating score systems of Constant Murley score of treated shoulder and contralateral shoulder, ROWE score as well as American Shoulder and Elbow Surgeons (ASES) were evaluated to comment on the postoperative shoulder joint function.All patients achieved postoperative fracture healing with no complications. Only 1 patient complained of slight restriction, 2 patients complained of pain during overhead work, and another patient was found with plate breakage. Meanwhile, the Constant Murley scores of treated and contralateral shoulder were 94.1 and 98.5 points, respectively, indicating the similar shoulder function. Furthermore, the ROWE and ASES scores of the involved shoulder were 96.7 and 96.3 points at average, respectively.It is the first time to introduce the surgical technique of vertical double-plate fixation implied in stable fixation of extremely medial clavicle fractures, which could provide the surgeons with an alternative method for this type of fracture.

Kirschner Wire Temporary Intramedullary Fixation Combined with a Locking Anatomical Plate versus a Reconstruction Plate in the Treatment of Comminuted Clavicular Fractures: A Retrospective Study

We investigate the clinical efficacy of Kirschner wire temporary intramedullary fixation combined with a locking anatomical plate for the treatment of comminuted clavicular fractures. We retrospectively studied 112 patients [80 (71%) men] treated between February 2007 and February 2014. The patients were allocated to treatment with Kirschner wire temporary intramedullary fixation combined with a locking anatomical plate [minimally invasive group (G_M)] or a reconstruction plate [traditional group (G_T)]. The 112 patients were followed up for 12-48 months (mean, 14 months). The operation time was significantly shorter in G_M than in G_T. Intraoperative blood loss was significantly less in G_M than in G_T. The total incision length was significantly shorter and the visual analog scale pain score 24 h after surgery was significantly lower in G_M than in G_T. Fracture healing time was significantly shorter and the complication rate was significantly lower in G_M than in G_T. No significant difference in shoulder function score was observed between groups. We recommend Kirschner wire temporary intramedullary fixation combined with a locking anatomical plate as the treatment of choice for comminuted clavicular fractures because of the shorter operation time, lesser intraoperative blood loss, easier reduction of the operation, quicker fracture healing, and lower postoperative complication rate.