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Cardiac arrhythmia caused by a kirschner wire inside the heart
C A R D I A C A R R H Y T H M I A C A U S E D BY A K I R S C H N E R INSIDE THE HEART
WIRE
A n unusual c o m p l i c a t i o n o f finger o s t e o s y n t h e s i s T. A. T. H A A P A N I E M I and U. S. H E R M A N S S O N
From the Departments of Plastic Surgery, Hand Surgery and Burns and Cardiothoracic Surgery, Faculty of Health Sciences, Linkb'ping University, Link6ping, Sweden
A 45-year-old woman with no previous history of cardiac disease woke up one morning with an irregular heartbeat and fatigue. An electrocardiogram showed atrial fibrillation and plain chest radiographs revealed the presence of a metallic pin at the position of the heart. A 24 mm-long metallic pin was removed by open thoracic surgery from within the right ventricle of the heart. Postoperative examination of the pin showed it to be one of the 0.8 mm Kirschner wires that had been used for finger osteosynthesis in her left hand 31 months previously.
Journal of Hand Surgery (British and European Volume, 1997) 22B: 3:402-404 the right ventricle. The pin could not be left in position because of its effect on the heart rhythm and the risk of penetration and cardiac tamponade. Acute thoracic surgery was performed and the pin (Fig 2) was removed from within the right ventricle where it was lodged among the trabeculae without any sign of penetration of the cardiac muscle. Thirty-one months previously the patient had injured her left hand in an accident with a circular saw. She suffered severe lacerations of the thumb, index and middle fingers, which were treated elsewhere by suturing of extensor tendons and two palmar digital nerves and revascularization of the index finger. Osteosynthesis was performed with two Kirschner wires in each of the three digits. In the index finger this was done as an arthrodesis of the damaged MCPjoint (Fig 3). Kirschner wires with diameters 0.8 mm and 1.0 mm were used. After 2 months the Kirschner wires were removed from the thumb and the middle finger as the wires interfered with the mobilization of the IP and PIP joints. She regained, however, only 10 to 15° of painful movement in these joints.
CASE REPORT A 45-year-old woman, without previous cardiac problems, woke up one morning with irregular heartbeat and fatigue. An ECG showed a supraventricular arrhythmia. She was immediately referred to the local hospital where investigation included a plain chest radiograph which revealed the presence of a metallic pin at the position of the heart (Fig 1). The patient was transferred to the department of cardiothoracic surgery at the Link6ping Heart Centre. CT imaging of the thorax indicated the position of the pin to be in the outer muscular wall of
Fig 2 Fig 1
Plain chest radiograph showing a metallic pin at the position of the heart. 402
Peroperative photograph of the metallic pin just removed from the right ventricle. Postoperative measurements with vernier calipers showed it to be 24.40 _+0.05 ram, i.e. slightly shorter than indicated by the metallic ruler in the photograph.
403
KIRSCHNER WIRE IN HEART
ments and the fact that both ends of that pin had been cut confirm that this was the pin removed from the heart (Fig 3). DISCUSSION
Fig 3
Postoperative radiographs after the operation on the left hand 31 months before finding the metallic pin in the heart. Examination of the removed pin showed it to be the shorter of the two Kirschner wires used in the arthrodesis of the index MCP joint (indicated by a black arrow in the AP view).
Radiographs indicated osteoarthrosis in both joints and this was confirmed at surgery 10 months after the accident when both joints were fused and extensor tendon tenolysis was performed. Fixation of both arthrodeses was done with Kirschner wires, 0.89 mm in diameter (nominally 0.035 inches), using two wires in the thumb IP joint and three wires in the middle finger PIP joint. Apart from these two operations on her left hand, the patient had not had any other operations before finding the Kirschner wire inside her heart. A thorough examination of the medical records reveals that there was no record of the removal of the shorter of the two pins in the index finger MCP joint. The last record of it was a radiograph 18 months after the primary operation. That pin, however, was missing in radiographs of the left hand taken shortly after heart surgery. Precision measure-
Kirschner (1909) wrote on the use of steel wires as part of a device for traction treatment of fractures. Stainless steel pins have been consistently used in fracture treatment since the 1930s (Mooney, 1975). In surgery of the hand they are commonly used for osteosynthesis, usually with diameters from about 0.7 to 1.2 mm, sometimes up to 2 mm. Since there are no patents involved several companies supply these pins to national and international markets. Migration of metallic pins used for fixation to the heart or to the major vascular structures in the thorax is a well documented complication of bone and joint surgery in the shoulder region (Lyons and Rockwood, 1990). In their excellent review of the subject, Lyons and Rockwood report references to four pins that migrated to the heart, two to the subclavian artery, six to the ascending aorta and five to the pulmonary artery. Our own search of the literature, for references to such pins that migrated from osteosynthesis in any anatomical location, has yielded another 12 cases in 11 articles either in the non-English literature or published after their review was written (Ahmadi et al, 1976; Bartek et al, 1975; Chou et al, 1994; Daus et al, 1993; Janssens de Varebeke and Van Osselaer, 1993; Liu et al, 1993; McCardel et al, 1989; Serdiuk, 1974; Smolle-Juettner et al, 1992; Stupachenko, 1981; Tubbax et al, 1989). In one of these 29 cases migration of a metallic pin from the pelvis is described (McCardel et al, 1989) while all the others have occured after pin fixation in the shoulder region, most frequently from the clavicle and the sternoclavicular joint. Lyons and Rockwood suggest that such serious complications due to pin migration from the sternoclavicular joint might have been under-reported because of the sensitive and litigious nature of the problem. Such serious complications have not been reported after Kirschner wire fixation in more distal areas, away from the thorax and large veins. A Kirschner wire is, however, reported to have migrated from the hand to the elbow (Kjeldsen and Tordrup, 1993). Our search of the literature has not revealed any report on Kischner wire migration from the hand to the heart or to the major vascular structures of the thorax. After consideration of the data available we conclude that the metallic pin extracted from the heart is the shorter one of the two 0.8 mm Kirschner wires used for fixation in the primary arthrodesis of the left index MCP joint 31 months previously. The pin had undoubtedly entered the venous circulation, but the time and place of entry will remain unknown. We believe this to be a very unusual complication of surgery of the hand but it does once again raise the question of whether to leave or remove pins used for osteosynthesis once bone healing has been achieved.
404
Acknowledgements We thank AnnaLena Ramer for help with scrutinizing medical records, Annika Malmstr6m and Bertil Jansson for Hungarian and Russian translations and Lars Adolfsson for a critical review of the manuscript. We also thank Staffan Hammerby for help with equipment-specific measurements at the department of diagnostic radiology and Inge Nilsson at the University Hospital precision-tool instrument laboratory for providing facilities for precision measurements.
References Ahmadi A, Zebe H, Roth E, Storch HH, Schmitz W (1976). Iatrogene Fremdk6rper im Herzen [Iatrogenic foreign bodies in heart (author's transl)]. Thoraxchirurgie, 24:213-218. Bartek I, Arvay A, Medgyes A (1975). Kirschner-dr6t okozta szivtamponhd [Cardiac tamponade caused by Kirschner wire]. Orvosi Hetilap (Budapest), 116: 3064-3067. Chou NS, Wu MH, Chan CS, Lai WW, Lin MY (1994). Intrathoracic migration of Kirschner wires. Journal of the Formosan Medical Association, 93: 974 976. Daus GE Draez D Jr, Newton BBJ, Kober R (1993). Migration of a Kirschner wire from the sternum to the right ventricle. A case report. American Journal of Sports Medicine, 21:321 322. Janssens de Varebeke B, Van Osselaer G (1993). Migration of Kirschner's pin from the right sternoclavicular joint resulting in perforation of the pulmonary artery main trunk, Acta Chirnrgica Belgica, 93: 287-291. Kirschner M (1909). Ueber Nagelextension. Beitrage zur Klinischen Chirnrgie, 64: 266-279. Kjeldsen SR, Tordrup PJ (1993). Migration af Kirschner-tr~d fra h~md till albue [Migration of a Kirschner wire from the hand to the elbow[. Ugeskrift for Lteger (Copenhagen), 155:3930-3931. Liu H-P, Chang C-H, Lin PJ et al (1993). Pulmonary artery perforation after Kirschner wire migration: case report and a review of the literature. Journal of Trauma, 34:154-156.
THE JOURNAL OF HAND SURGERY VOL. 22B No. 3 JUNE 1997 Lyons FA. Rockwood CAJ (19901. Migration of pins used in operations on the shoulder. Journal of Bone and Joint Surgery, 72A: 1262 1267. McCardel BR. Dahners LE. Renner JB (19891. Kirschner wire migration from the pelvis to the heart and a new method of fixation of articular fracture fragments, acetabular reconstruction. Journal of Orthopaedic Trauma, 3: 257-259. Mooney E Fractures of the shaft of the femur. In: Rockwood CA J, Green D P (Eds): Fractures. Philadelphia, J.B. Lippincott Company, 1975: 1075-1129. Serdiuk AA ( 19741, Ranenie perikarda, nastupivshee posle metalloosteosinteza pereloma kliuchitsy [Injury of the pericardium following metallic osteosynthesis of a fracture of the clavicle]. Vestnik Khirurgii imeni i i Grekova fMoscow), 112:110 111. Smolle-Juettner FM. Hofer PH. Pinter H. Friehs G. Szyskowitz R (19921. Intracardiac malpositioning of a sternoclavicular fixation wire. Journal of Orthopaedic Trauma. 6: 102-105. Stupachenko ON (19811. Migratsiia otlomka metallicheskoi spitsy posle osteosinteza pravoi kliuchitsy [Migration of a fragment of a metal pin after osteosynthesis of the right clavicle]. Ortopedija, Travmatotogija i Protezirovanie IMoscow), 11: 35-36. Tubbax H. Hendzel P, Sergeanl P 119891. Cardiac perforation after Kirschner wire migration. Acta Chirurgica Belglca. 89:309 311.
Received:28 August 1996 Accepted after revision:4 November 1996 12 Haupaniemi MD, Department of Plastic Surgery,Hand Surgeryand Burns, University Hospital, SE-58185Link6ping, Sweden. © 1997The British Societyfor Surgeryof the Hand
WIRE
A n unusual c o m p l i c a t i o n o f finger o s t e o s y n t h e s i s T. A. T. H A A P A N I E M I and U. S. H E R M A N S S O N
From the Departments of Plastic Surgery, Hand Surgery and Burns and Cardiothoracic Surgery, Faculty of Health Sciences, Linkb'ping University, Link6ping, Sweden
A 45-year-old woman with no previous history of cardiac disease woke up one morning with an irregular heartbeat and fatigue. An electrocardiogram showed atrial fibrillation and plain chest radiographs revealed the presence of a metallic pin at the position of the heart. A 24 mm-long metallic pin was removed by open thoracic surgery from within the right ventricle of the heart. Postoperative examination of the pin showed it to be one of the 0.8 mm Kirschner wires that had been used for finger osteosynthesis in her left hand 31 months previously.
Journal of Hand Surgery (British and European Volume, 1997) 22B: 3:402-404 the right ventricle. The pin could not be left in position because of its effect on the heart rhythm and the risk of penetration and cardiac tamponade. Acute thoracic surgery was performed and the pin (Fig 2) was removed from within the right ventricle where it was lodged among the trabeculae without any sign of penetration of the cardiac muscle. Thirty-one months previously the patient had injured her left hand in an accident with a circular saw. She suffered severe lacerations of the thumb, index and middle fingers, which were treated elsewhere by suturing of extensor tendons and two palmar digital nerves and revascularization of the index finger. Osteosynthesis was performed with two Kirschner wires in each of the three digits. In the index finger this was done as an arthrodesis of the damaged MCPjoint (Fig 3). Kirschner wires with diameters 0.8 mm and 1.0 mm were used. After 2 months the Kirschner wires were removed from the thumb and the middle finger as the wires interfered with the mobilization of the IP and PIP joints. She regained, however, only 10 to 15° of painful movement in these joints.
CASE REPORT A 45-year-old woman, without previous cardiac problems, woke up one morning with irregular heartbeat and fatigue. An ECG showed a supraventricular arrhythmia. She was immediately referred to the local hospital where investigation included a plain chest radiograph which revealed the presence of a metallic pin at the position of the heart (Fig 1). The patient was transferred to the department of cardiothoracic surgery at the Link6ping Heart Centre. CT imaging of the thorax indicated the position of the pin to be in the outer muscular wall of
Fig 2 Fig 1
Plain chest radiograph showing a metallic pin at the position of the heart. 402
Peroperative photograph of the metallic pin just removed from the right ventricle. Postoperative measurements with vernier calipers showed it to be 24.40 _+0.05 ram, i.e. slightly shorter than indicated by the metallic ruler in the photograph.
403
KIRSCHNER WIRE IN HEART
ments and the fact that both ends of that pin had been cut confirm that this was the pin removed from the heart (Fig 3). DISCUSSION
Fig 3
Postoperative radiographs after the operation on the left hand 31 months before finding the metallic pin in the heart. Examination of the removed pin showed it to be the shorter of the two Kirschner wires used in the arthrodesis of the index MCP joint (indicated by a black arrow in the AP view).
Radiographs indicated osteoarthrosis in both joints and this was confirmed at surgery 10 months after the accident when both joints were fused and extensor tendon tenolysis was performed. Fixation of both arthrodeses was done with Kirschner wires, 0.89 mm in diameter (nominally 0.035 inches), using two wires in the thumb IP joint and three wires in the middle finger PIP joint. Apart from these two operations on her left hand, the patient had not had any other operations before finding the Kirschner wire inside her heart. A thorough examination of the medical records reveals that there was no record of the removal of the shorter of the two pins in the index finger MCP joint. The last record of it was a radiograph 18 months after the primary operation. That pin, however, was missing in radiographs of the left hand taken shortly after heart surgery. Precision measure-
Kirschner (1909) wrote on the use of steel wires as part of a device for traction treatment of fractures. Stainless steel pins have been consistently used in fracture treatment since the 1930s (Mooney, 1975). In surgery of the hand they are commonly used for osteosynthesis, usually with diameters from about 0.7 to 1.2 mm, sometimes up to 2 mm. Since there are no patents involved several companies supply these pins to national and international markets. Migration of metallic pins used for fixation to the heart or to the major vascular structures in the thorax is a well documented complication of bone and joint surgery in the shoulder region (Lyons and Rockwood, 1990). In their excellent review of the subject, Lyons and Rockwood report references to four pins that migrated to the heart, two to the subclavian artery, six to the ascending aorta and five to the pulmonary artery. Our own search of the literature, for references to such pins that migrated from osteosynthesis in any anatomical location, has yielded another 12 cases in 11 articles either in the non-English literature or published after their review was written (Ahmadi et al, 1976; Bartek et al, 1975; Chou et al, 1994; Daus et al, 1993; Janssens de Varebeke and Van Osselaer, 1993; Liu et al, 1993; McCardel et al, 1989; Serdiuk, 1974; Smolle-Juettner et al, 1992; Stupachenko, 1981; Tubbax et al, 1989). In one of these 29 cases migration of a metallic pin from the pelvis is described (McCardel et al, 1989) while all the others have occured after pin fixation in the shoulder region, most frequently from the clavicle and the sternoclavicular joint. Lyons and Rockwood suggest that such serious complications due to pin migration from the sternoclavicular joint might have been under-reported because of the sensitive and litigious nature of the problem. Such serious complications have not been reported after Kirschner wire fixation in more distal areas, away from the thorax and large veins. A Kirschner wire is, however, reported to have migrated from the hand to the elbow (Kjeldsen and Tordrup, 1993). Our search of the literature has not revealed any report on Kischner wire migration from the hand to the heart or to the major vascular structures of the thorax. After consideration of the data available we conclude that the metallic pin extracted from the heart is the shorter one of the two 0.8 mm Kirschner wires used for fixation in the primary arthrodesis of the left index MCP joint 31 months previously. The pin had undoubtedly entered the venous circulation, but the time and place of entry will remain unknown. We believe this to be a very unusual complication of surgery of the hand but it does once again raise the question of whether to leave or remove pins used for osteosynthesis once bone healing has been achieved.
404
Acknowledgements We thank AnnaLena Ramer for help with scrutinizing medical records, Annika Malmstr6m and Bertil Jansson for Hungarian and Russian translations and Lars Adolfsson for a critical review of the manuscript. We also thank Staffan Hammerby for help with equipment-specific measurements at the department of diagnostic radiology and Inge Nilsson at the University Hospital precision-tool instrument laboratory for providing facilities for precision measurements.
References Ahmadi A, Zebe H, Roth E, Storch HH, Schmitz W (1976). Iatrogene Fremdk6rper im Herzen [Iatrogenic foreign bodies in heart (author's transl)]. Thoraxchirurgie, 24:213-218. Bartek I, Arvay A, Medgyes A (1975). Kirschner-dr6t okozta szivtamponhd [Cardiac tamponade caused by Kirschner wire]. Orvosi Hetilap (Budapest), 116: 3064-3067. Chou NS, Wu MH, Chan CS, Lai WW, Lin MY (1994). Intrathoracic migration of Kirschner wires. Journal of the Formosan Medical Association, 93: 974 976. Daus GE Draez D Jr, Newton BBJ, Kober R (1993). Migration of a Kirschner wire from the sternum to the right ventricle. A case report. American Journal of Sports Medicine, 21:321 322. Janssens de Varebeke B, Van Osselaer G (1993). Migration of Kirschner's pin from the right sternoclavicular joint resulting in perforation of the pulmonary artery main trunk, Acta Chirnrgica Belgica, 93: 287-291. Kirschner M (1909). Ueber Nagelextension. Beitrage zur Klinischen Chirnrgie, 64: 266-279. Kjeldsen SR, Tordrup PJ (1993). Migration af Kirschner-tr~d fra h~md till albue [Migration of a Kirschner wire from the hand to the elbow[. Ugeskrift for Lteger (Copenhagen), 155:3930-3931. Liu H-P, Chang C-H, Lin PJ et al (1993). Pulmonary artery perforation after Kirschner wire migration: case report and a review of the literature. Journal of Trauma, 34:154-156.
THE JOURNAL OF HAND SURGERY VOL. 22B No. 3 JUNE 1997 Lyons FA. Rockwood CAJ (19901. Migration of pins used in operations on the shoulder. Journal of Bone and Joint Surgery, 72A: 1262 1267. McCardel BR. Dahners LE. Renner JB (19891. Kirschner wire migration from the pelvis to the heart and a new method of fixation of articular fracture fragments, acetabular reconstruction. Journal of Orthopaedic Trauma, 3: 257-259. Mooney E Fractures of the shaft of the femur. In: Rockwood CA J, Green D P (Eds): Fractures. Philadelphia, J.B. Lippincott Company, 1975: 1075-1129. Serdiuk AA ( 19741, Ranenie perikarda, nastupivshee posle metalloosteosinteza pereloma kliuchitsy [Injury of the pericardium following metallic osteosynthesis of a fracture of the clavicle]. Vestnik Khirurgii imeni i i Grekova fMoscow), 112:110 111. Smolle-Juettner FM. Hofer PH. Pinter H. Friehs G. Szyskowitz R (19921. Intracardiac malpositioning of a sternoclavicular fixation wire. Journal of Orthopaedic Trauma. 6: 102-105. Stupachenko ON (19811. Migratsiia otlomka metallicheskoi spitsy posle osteosinteza pravoi kliuchitsy [Migration of a fragment of a metal pin after osteosynthesis of the right clavicle]. Ortopedija, Travmatotogija i Protezirovanie IMoscow), 11: 35-36. Tubbax H. Hendzel P, Sergeanl P 119891. Cardiac perforation after Kirschner wire migration. Acta Chirurgica Belglca. 89:309 311.
Received:28 August 1996 Accepted after revision:4 November 1996 12 Haupaniemi MD, Department of Plastic Surgery,Hand Surgeryand Burns, University Hospital, SE-58185Link6ping, Sweden. © 1997The British Societyfor Surgeryof the Hand