Intraspinal migration of a Kirschner wire as a late complication of acromioclavicular joint repair: a case report
Mankowski et al. Journal of Medical Case Reports
Intraspinal migration of a Kirschner wire as a late complication of acromioclavicular joint repair: a case report
Bartosz Mankowski 0
Tadeusz Polchlopek 0
Marcin Strojny 0
Pawel Grala 0
Krzysztof Slowinski 0
0 Department of Trauma, Burns and Plastic Surgery, Poznan University of Medical Sciences , Poznań , Poland
Background: Penetrating neck trauma involving foreign bodies is a rare event in European countries. Due to its relatively high mortality rate, the correct management strategy must be initiated from the beginning to prevent fatal complications. In the medical literature, there are only a few cases describing foreign bodies penetrating the cervical spine. Because of its rareness, many trauma centers lack the proper routine to adequately manage such injuries. Case presentation: This case report describes a 34-year-old white man of Central European descent with Kirschner wire migration and perforation of his vertebral foramen. He underwent acromioclavicular joint repair surgery 7 years ago, presented with a painful sensation around the area of his left clavicle and left side of his neck after a motorcycle accident. No neurological deficit was detected. Conclusions: In such cases, a thorough radiological evaluation of the spinal cord and the surrounding vasculature is mandatory for a complete understanding of the extent of the injury and determining the proper surgical management. In cases of vertebral artery trauma both an endovascular and an open approach can be contemplated.
Implant migration; K-wire migration; Penetrating neck trauma; Surgical management of neck trauma; Vertebral artery injury
Penetrating neck injuries are uncommon in European
countries. Due to the lack of cases, surgeons have
insufficient experience to properly deal with such problems. The
complexity of neck anatomy makes procedures in this
region very challenging and can easily lead to complications
such as airway compromise, severe hemorrhage, and
peripheral or cranial nerve damage [
]. Injuries caused by
foreign bodies in the neck are uncommon as well, they
usually occur as a result of ingested objects penetrating
the cervical area. In the medical literature, there are only a
few cases describing foreign bodies penetrating the
cervical spine [
]. In addition, injuries to the vertebral
artery caused by a foreign body penetrating the cervical
spine are extremely rare. Vertebral artery injuries are
scarce even in specialized trauma centers . The
incidence of vertebral artery injury varies from 0.5 to 2 % in
all trauma cases [
] and represents less than 1 % of all
vascular injuries [
]. However, the mortality rate of
traumatic vertebral artery injury is reported to be
approximately 8 % [
]. Symptoms of vertebral artery injury
are associated with ischemia of the cerebellum, brain
stem, and the primary visual cortex [
A 34-year-old white man of Central European descent was
admitted to our department after falling off a motorcycle
onto his left shoulder. He had undergone an
acromioclavicular joint repair procedure with the use of two Kirschner
wires (K-wires) and a tension band 7 years ago. The
implants were never removed. His chief complaint was of
painful sensation around the area of his left clavicle and left
side of his neck. No neurological deficit was detected. An
X-ray performed at our department showed two broken
Kwires and a tension band. One of the wires penetrated the
suprascapular soft tissues; the other had migrated toward
his cervical spine (Fig. 1). A computed tomography
angiography revealed that the K-wire penetrated his C6 vertebra
© 2016 Mankowski et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
(Fig. 2a) and was in direct contact with his vertebral artery
without breaching the lumen (Fig. 2b). Furthermore, a
dislocated left clavicle shaft fracture was detected without
injury to the underlying vascular and neural structures. After
proper diagnosis and preparation, he was scheduled for an
elective surgery. During surgery, the position of the K-wire
was located by anterior-posterior fluoroscopy. A skin
incision was made parallel to the lateral wall of his
sternocleidomastoid muscle (SCM) as seen in Fig. 3. His
platysma muscle was then incised and the SCM, with the
cervical vessels, was retracted medially. Further exploration
of the lateral cervical triangle was carried out by careful
blunt and sharp dissection to reach components of the
brachial plexus and to visualize the scalene muscles (Fig. 4).
At this time the K-wire was not palpable and further
dissection between the scalene muscles was necessary.
When the K-wire became visible, the free end was
dissected from the surrounding tissues and removed. No
injury to his brachial plexus was detected and no
bleeding was noted. The remaining wires were removed from
his clavicle and supraclavicular area without
complications through a second incision performed alongside the
clavicle. Fluoroscopy was performed to determine the
location of the remaining implants and to make sure that
no other metal components were overlooked. Through
the same incision the fractured clavicle was reduced and
stabilized using a locking compression plate (LCP)
system as seen in Fig. 5. During the post-surgical evaluation
a paresthesia was noted on his C8 dermatome radiating
to his fourth and fifth finger. However, this resolved
spontaneously within 3 days. He was discharged on the
seventh day with no neurological deficits. The
angiography unit was informed about the operation and
possible intraoperative vertebral artery injury, in the event
endovascular intervention would be needed.
Penetrating neck injuries are stressful events for
surgeons. The risk of iatrogenic damage to surrounding
structures is high and makes flawless knowledge of the
neck anatomy mandatory. K-wire migration into the
cervical spine after fixation of a fractured clavicle is rare.
Apart from injury to the vertebral artery, it may cause
damage to the nerve roots, dura mater, and spinal cord. When
such material penetrates the vertebral canal, a wide
laminectomy is required to expose both ends of the K-wire,
followed by dura mater repair and hemostasis [
In the presented case there was a risk of causing
injury to the vertebral artery while removing the
Kwire. Mwipatayi et al. never attempted to repair the
vertebral artery in cases with such an injury. In all
cases the vessel was ligated, clipped or hemostasis
was attained using bone wax .
In general, the vertebral artery can be divided in four
anatomical segments: V1 to V4 [
]. Care must be
taken to account for anatomical variations of these
segments to avoid serious complications by iatrogenic injury
. The first part of vertebral artery (V1) originates from
the subclavian artery and ends by entering the transverse
foramen. In 90 % of cases, its entrance is at the level of
C6, but it can be as high as C3 [
]. The artery is relatively
unprotected during this path and its injury would
require wide surgical exposure and ligation of the
vessel. The V2 segment travels through the C6 to C2
transverse processes and merges into the V3 from the C2
vertebra to its entry point through the dura mater [
Bleeding, due to arterial injury, in these segments should be
stopped using bone wax. However, if performed carelessly,
this may harm the cervical nerve root. The last part of the
vertebral artery (V4) has an entirely intracranial course,
merging with the basilar artery. Occlusion of the vertebral
artery at this point may cause cerebellar ischemia. Other
complications, due to injury to the vertebral artery, are
massive neck hematomas, pseudoaneurysms, dissections or
arteriovenous fistulas [
]. The mortality rate associated with
vertebral artery injury is estimated to be 6.9 % [
from severe and uncontrollable bleeding, most vertebral
artery injuries are asymptomatic. Reid and Weigelt suggested
that neurological deficits accompanying vertebral artery
injury are caused by direct physical damage to the spinal cord
and cervical roots rather than ischemic changes within
these structures [
]. An open neck exploration procedure
is the preferred method for acute and unstable cases with
an uncontrolled hemorrhage and a growing hematoma in
the cervical region [
]. Stable patients, that is, vertebral
dissections, can be treated by endovascular techniques, which
are the recommended procedures compared to an open
surgical intervention. These techniques allow vascular
repair using a minimal invasive approach and have proven
their value in earlier studies [
]. Blunt vertebral artery
injuries can be successfully managed as well using
endovascular techniques including stenting, occlusion or
pseudoaneurysm coil occlusion [
6, 7, 18, 19
]. Lesions that do not
qualify for endovascular treatment are those that are within
2 cm from the origin of the vertebral artery or in the V4
segment close to the posterior inferior cerebral artery
(PICA) . Herrera et al. presented the endovascular
treatment of 18 patients with penetrating injury of the vertebral
artery. In all cases, sacrifice of the artery was a necessity
due to severe hemorrhage. Occlusion was carried out if
patency of the PICA was visualized. The authors did not
observe any neurological complications; the unaffected
vertebral artery seemed to sufficiently supply the contralateral
The presented case can be subdivided into two main
categories of surgical management: open surgery or
endovascular procedures. The open approach was necessary to
safely remove the foreign body and to prevent vertebral
artery injury. If, during surgery, a hemorrhage had
occurred, direct pressure could have been applied to achieve
hemostasis. In case of an uncontrollable bleeding, the
patient would have been moved to the angiography unit
for endovascular occlusion of the vessel.
Vertebral artery injuries are uncommon and rarely caused
by penetrating foreign bodies. The possibility of injury to
the vertebral artery must be evaluated which makes
accurate radiological assessment mandatory. An open surgical
approach is still the recommended management procedure
for the acute setting. Endovascular techniques have proven
their value in penetrating vertebral artery injuries and are
capable of achieving hemostasis in severe hemorrhages.
I experienced no problems with my shoulder joint
following initial surgery to my acromioclavicular joint 7
years ago. After my motorcycle accident, I was taken by
the ambulance to an emergency department where they
said I needed surgery. The surgeon explained in detail
the possible risks and complications that could occur
during surgery. Nonetheless, I agreed to have the surgery
done at a trauma centre in Poznan, Poland. Surgery
went without complications and I was discharged home
3 days after surgery. I have no medical knowledge and I
write the above only to assist in this case report.
Written informed consent was obtained from our patient
for the publication of this case report and any
accompanying images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
The authors declare that they have no competing interests.
The patient was admitted under the care of TP and MS. He was operated by
KS and BM. All authors contributed in writing the manuscript, read and
approved the final draft.
Submit your next manuscript to BioMed Central
and we will help you at every step:
1. Van Waes OJ , Cheriex KC , Navsaria PH , van Riet PA , Nicol AJ , Vermeulen J . Management of penetrating neck injuries . Br J Surg . 2012 ; 99 : 149 - 54 .
2. Munera F , Cohn S , Rivas LA . Penetrating injuries of the neck: use of helical computed tomographic angiography . J Trauma . 2005 ; 58 : 413 - 8 .
3. Tallon JM , Ahmed JM , Sealy B. Airway management in penetrating neck trauma at a Canadian tertiary trauma centre . CJEM . 2007 ; 9 : 101 - 4 .
4. Wang Z , Liu Y , Qu Z , Leng J , Fu C , Liu G. Penetrating injury of the spinal cord treated surgically . Orthopedics . 2012 ; 35 : 1136 - 40 .
5. Fransen P , Bourgeois S , Rommens J . Kirschner wire migration causing spinal cord injury one year after internal fixation of a clavicle fracture . Acta Orthop Belg . 2007 ; 73 : 390 - 2 .
6. Mwipatayi BP , Jeffery P , Beningfield SJ , Motale P , Tunnicliffe J , Navsaria PH . Management of extra-cranial vertebral artery injuries . Eur J Vasc Endovasc Surg . 2004 ; 27 : 157 - 62 .
7. Desouza RM , Crocker MJ , Haliasos N , Rennie A , Saxena A . Blunt traumatic vertebral artery injury: a clinical review . Eur Spine J . 2011 ; 20 : 1405 - 16 .
8. Eastman AL , Chason DP , Perez CL , McAnulty AL , Minei JP . Computed tomographic angiography for the diagnosis of blunt cervical vascular injury: is it ready for primetime? J Trauma. 2006 ; 60 : 925 - 9 .
9. Fassett DR , Dailey AT , Vaccaro AR . Vertebral artery injuries associated with cervical spine injuries: a review of the literature . J Spinal Disord Tech . 2008 ; 21 : 252 - 8 .
10. Meier DE , Brink BE , Ery WJ . Vertebral artery trauma . Arch Surg . 1981 ; 116 : 236 - 9 .
11. Biffl WL , Moore EE , Elliott JP , Ray C , Offner PJ , Franciose RJ , et al. The devastating potential of blunt vertebral arterial injuries . Ann Surg . 2000 ; 231 : 672 - 81 .
12. Miller PR , Fabian TC , Bee TK , Timmons S , Chamsuddin A , Finkle R , et al. Blunt cerebrovascular injuries: diagnosis and treatment . J Trauma . 2001 ; 51 : 279 - 85 (discussion 285-6 ).
13. Wada S , Noguchi T , Hashimoto T , Uchida Y , Kawahara K. Successful treatment of a patient withpenetrating injury of the esophagus and brachiocephalic artery due to migration of Kirschner wires . Annals of Thoracic Cardiovascular Surgery . 2005 ; 11 ( 5 ): 313 - 5 .
14. Ulm AJ , Quiroga M , Russo A , Russo VM , Graziano F , Velasquez A , et al. Normal anatomical variations of the V3 segment of the vertebral artery: surgical implications . J Neurosurg Spine . 2010 ; 13 : 451 - 60 .
15. Hong JT , Park D , Lee MJ , Kim SW , An HS . Anatomical variations of the vertebral artery segment in the lower cervical spine . Spine . 2008 ; 33 : 2422 - 6 .
16. Bruneau M et al. Anatomical variations of the V2 segment of the vertebral artery . Oper Neurosurg . 2006 ; 59 : 20 - 3 .
17. Reid JD , Weigelt JA . Forty-three cases of vertebral artery trauma . J Trauma . 1988 ; 28 : 1007 - 12 .
18. Pham MH , Rahme RJ , Arnaout O , Hurley MC , Bernstein RA , Batjer HH , et al. Endovascular stenting of extracranial carotid and vertebral artery dissections: a systematic review of the literature . Neurosurg . 2011 ; 68 : 856 - 66 .
19. Herrera DA , Vargas SA , Dublin AB. Endovascular treatment of traumatic injuries of the vertebral artery . Am J Neuroradiol . 2008 ; 29 : 1585 - 9 .