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Table of Contents
LETTER TO EDITOR
Year : 2019  |  Volume : 35  |  Issue : 2  |  Page : 268-269

Kirschner wire in acromoclavicular joint – Should chest X-ray be recommended in preoperative evaluation of the patient?


1 Consultant of Anesthesiology; Interventional Pain Specialist, Kalyan Hospital, Ludhiana, Punjab, India
2 Consultant of Orthopaedics and Spine Surgeon, Kalyan Hospital, Ludhiana, Punjab, India

Date of Web Publication25-Jun-2019

Correspondence Address:
Raman Sikka
256, Parkash Colony, Barewal, Ludhiana, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joacp.JOACP_251_18

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How to cite this article:
Sikka R, Kalyan RS. Kirschner wire in acromoclavicular joint – Should chest X-ray be recommended in preoperative evaluation of the patient?. J Anaesthesiol Clin Pharmacol 2019;35:268-9

How to cite this URL:
Sikka R, Kalyan RS. Kirschner wire in acromoclavicular joint – Should chest X-ray be recommended in preoperative evaluation of the patient?. J Anaesthesiol Clin Pharmacol [serial online] 2019 [cited 2019 Sep 17];35:268-9. Available from: http://www.joacp.org/text.asp?2019/35/2/268/261290



We report a case of a 38-year-old patient posted for surgery of fistula-in-ano. His history was insignificant regarding cardiorespiratory disorders. There was no history of any chronic medical disorder. He was operated for left acromoclavicular joint (AC joint) fracture dislocation 5 years back. His postoperative period was uneventful. Patient being a migrant labourer could not be followed by the operating team. In his preoperative evaluation, his chest X-ray which was incidentally done by the operative team prior to pre-anesthetic checkup, showed a foreign body lying in the right side near second thoracic (D2) vertebral body [Figure 1]. On further evaluation computed tomography (CT) scan showed a metallic needle (28 × 10 mm) in the right trapezius muscle at D2 vertebral body level with small intramuscular hematoma collection with overlying subcutaneous tissue edema. The Kirschner wire (K-wire) was removed under local anaesthesia [Figure 2] and subsequently patient was operated for fistula-in-ano under spinal anesthesia.
Figure 1: Kirschner wire in chest X-ray

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Figure 2: Kirschner wire removed from the trapezius

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K-wire migration can result in mortality by threatening vital organs in some cases.[1],[2],[3] There are different opinions on why wires migrate. In particular, a greater range of motion in the shoulder, negative intrathoracic pressure associated with respiration, gravitational force and muscular activities may cause migration from the upper extremity.[1],[2],[4],[5] Such materials can have a long silent period within the tissue or can cause chronic discharge, infection or chronic pain and may damage neurovascular structure.[2],[4] There are specific guidelines to be followed in such a surgery. The external tips of the K-wire should be bent to prevent migration.[2],[5] Surgical site should be monitored by radiograph at 4 weeks interval and K-wire should be removed immediately if any signs of loosening present.[1],[5] There are case reports in which patient was symptom free but chest X-rays and CT scan indicated that one of the K-wire had migrated to the mediastinum which was removed by median sternotomy.[2] Another case report showed K-wire migrating to the heart and mimicking acute coronary syndrome.[6]

There is no high quality evidence on the effectiveness of routine preoperative chest radiography. Five clinical guidelines make recommendations on the basis of low level evidence and expert opinion. The guidelines concur that routine preoperative chest X-ray in asymptomatic otherwise healthy patient is not indicated. The American College of Physician states that chest X-ray should not be used routinely for predicting risk of postoperative complications. The ASA Task Force did not recommend extremes of age, smoking, stable cardiorespiratory disease as unequivocal indication of chest radiography.[7]

As there are no guidelines recommending preoperative chest X-ray in these patients who may present for surgeries and since they are asymptomatic for any K-wire migration which eventually can cause harm during surgery if migrated to or lying near vital structures, we recommend consideration of a chest X-ray in a long-standing case of AC joint fixation with K-wires.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Regel JP, Pospiech J, Aalders TA, Ruchholtz S. Intraspinal migration of a Kirschner wire 3 months after clavicular fracture fixation. Neurosurg Rev 2002;25:110-2.  Back to cited text no. 1
    
2.
Kumar P, Godbole R, Rees GM, Sarkar P. Intrathoracic migration of a Kirschner wire. J Royal Soc Med 2002;95:198-9.  Back to cited text no. 2
    
3.
Medved I, Simic O, Bralic M. Chronic heart perforation with 13.5 cm long Kirschner wire without pericardial tamponade: an unusual sequelae after shoulder fracture T. Ann Thorac Surg 2006;81:1895-7.  Back to cited text no. 3
    
4.
Ballas R, Bonnel F. Endopelvic migration of a sternoclavicular K-wire. Case report and review of literature. Orthop Traumatol Surg Res 2012;98:118-21.  Back to cited text no. 4
    
5.
Fransen P, Bourgeois S, Rommens J. Kirschner wire migration causing spinal cord injury one year after internal fixation of a clavicle fracture. Acta Orthopaedica Belgica 2007;73:390-2.  Back to cited text no. 5
    
6.
Lenard L, Aradi D, Donauer E. Migrating Kirschner wire in the heart mimics acute coronary syndrome. Eur Heart J 2009;30:754.  Back to cited text no. 6
    
7.
Kumar A, Srivastava U. Role of routine laboratory investigations in pre operative evaluation. JOACP 2011;27:174-9.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2]



 

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