Background: Percutaneous fixation of proximal humeral fractures (PHF) can lead to rare complications such as intrathoracic wire migration (IWM). Although debatable, its cause involves bone resorption, respiratory motion and negative intrathoracic pressure[1].

Case Report:An asymptomatic 55-year-old man presented to follow-up consultation two weeks after osteosynthesis of PHF due to trauma. Patient was classified as American Society of Anaesthesia Physical Status class II due to his smoking habits. Past medical history was irrelevant. Study image showed IWM through right second intercostal space, traversing right upper lobe and causing discrete contusion of lung parenchyma. Haemothorax, pneumothorax or injury of major vessels were not identified. Multidisciplinary evaluation established that it was safe to remove the wire without the need of open thoracic or guided thoracoscopic surgery.
After adequate monitoring, general anaesthesia was induced. Endotracheal intubation was uneventful and anaesthesia maintained with desflurane. Deltopectoral dissection exposed the wire that was grasped and slowly withdrawn. Ventilatory and haemodynamic parameters were adequate throughout the procedure. Chest X-ray confirmed bilateral lung expansion after surgery. Upon awakening, he was asymptomatic and soon transferred to the ward. On the following day, chest X-ray remained unaltered and patient was discharged.

Discussion: IWM is a known surgical complication, particularly with fixation wires or pins around the shoulder. Pain, dyspnea and hemoptysis may be present but more frequently patients are asymptomatic. Pneumothorax, pericardial tamponade, visceral and great vessel lacerations and intraspinal migration are reported complications following percutaneous PHF fixation. IWM can be reduced by bending the free end of the wire and by removing the material as soon as possible. Surgery to remove intrathoracic wire depends on its location and patient clinical condition. Open thoracic surgery is reserved for instable patients and those with heart or pericardial injury. Anaesthetic management may implicate single lung ventilation, drainage of hypertensive pneumothorax and massive transfusion.

References:[1] Saxena R et al. Migrated Kirschner wire in the posterior mediastinum. Heart Lung Circ. 2014;23(3):e109-10

Learning points: IWM may cause life threatening complications on presentation and during removal surgery. Clinical and radiological follow-up is needed.

11 / Anaesthetic management of intrathoracic wire migration: study of a case