Intrathoracic migration of a Kirschner wire in a patient with osteoporosis: a case report

Introduction

Most cases of acromioclavicular joint instability can be treated conservatively, including rest, exercise modification, nonsteroidal anti-inflammatory drugs, and corticosteroid injections (1). Physical therapy and proprioceptive training help strengthen the muscles around the shoulder and improve the joint’s positional awareness, thereby reducing the risk of further dislocations.

Surgery is typically considered for patients who experience severe, persistent symptoms despite conservative treatment. The literature offers several surgical procedures for the treatment of recurrent shoulder dislocation. These methods generally focus on restoring stability to the shoulder joint and preventing further dislocations.

One minimally invasive technique involves closed reduction and percutaneous joint pinning. This procedure is generally safe, with low complication rates and good long-term functional results (2). The most frequently reported complication is infection, because the skin barrier has been disrupted during the operation (3). Deep tissue infection and osteomyelitis may occur in only 4% of cases (4). Neurological complications are less common, such as nerve injuries. Ulnar nerve palsy caused by the pin following percutaneous fixation of the supracondylar fracture of the humerus was published quickly (5). Some case reports about neurapraxia affecting the superficial branch of the radial nerve (6). Nerve recovery took approximately 6 weeks after wire removal (7). In contrast, migration of these pins is rare but can lead to a potentially life-threatening condition. The prevalence of Kirschner wire (K-wire) migration after fixation surgery is estimated to be between 5.8–54% (8). The side on which migration occurs depends on the location of the primary reconstruction; the most common complications arise after sternoclavicular fracture stabilization, followed by fractures of the clavicle, acromioclavicular joint, and proximal humerus (9). A few case reports in the literature document intrathoracic migration to the mediastinum (10), the trachea (11), the pericardium (12), the lung (13), and the great vessels (14). The wires can migrate elsewhere, such as the spleen (15) and spinal canal (16).

We report a case of K-wire migration from the right glenohumeral joint into the right thoracic cavity. The patient has a medical history of osteoporosis, which may have contributed to the migration. This case underscores the importance of selecting the appropriate therapy based on the patient’s history, and we discuss strategies for preventing migration in such complex cases. We present this article in accordance with the CARE reporting checklist (available at https://shc.amegroups.com/article/view/10.21037/shc-2025-5/rc).

Case presentation

We report a 66-year-old woman with a medical history of hypertension and depression. Also, she was diagnosed with osteoporosis in April of 2023. During the dual-energy X-ray absorptiometry (DEXA) test, severe osteoporosis was diagnosed based on a T-score of −2.8. In addition to appropriate lifestyle advice, she received daily 2,000 IU D3 and 3,000 IU calcium, and denosumab injections every 6 months to reduce the risk of fracture.

In June of 2023, the patient presented to the emergency ambulance, following a slip and fall, and she suffered a dislocation of the right shoulder (Figure 1). A successful repositioning was performed under brief anesthesia, and the patient was discharged home with a Gillchrist bandage.

Figure 1 Right shoulder sprain.

A week later, she reported again at the regional trauma center due to a crack in her right shoulder. Imaging studies repeatedly confirmed right shoulder dislocation. Given that the shoulder dislocated again within a short period of time despite conservative therapy, the traumatologist decided on a surgical solution. Under anesthesia, following shoulder reduction, the humeral head was pinned to the scapula with a 85-mm K-wire. The patient was discharged home the day after surgery. No differences were found during a 1-week follow-up.

Three weeks later, they planned to remove the wire, but imaging revealed it had migrated from its original position. The patient reported no significant complaints, aside from mild exertional dyspnoea. There were no differences in the laboratory results, and no signs of anaemia were detected. A computed tomography scan confirmed the wire’s migration into the right thoracic cavity (Figure 2).

Figure 2 Summation CT scan (A) and the CT images showed that the wire had penetrated the chest cavity at the 3^rd intercostal space (B), traversed the right upper lobe (C), and stopped at the level of the 4^th thoracic vertebra (D). CT, computed tomography.

The patient was transferred to our hospital in stable condition. An axillary thoracotomy was performed, revealing approximately 100 mL of blood in the thoracic cavity (Figure 3). The wire had penetrated the chest cavity at the third intercostal space, traversed the right upper lobe, and stopped next to the azygos vein at the level of the fourth thoracic vertebra. After carefully extracting the wire (Figure 4), we did not detect any air leakage or excessive bleeding. The postoperative recovery was uneventful; by the third day, we removed the chest drain, and the patient was discharged on the sixth day without symptoms.

Figure 3 Axillary thoracotomy.

Figure 4 The removed pin.

At the 1-month follow-up, the patient was well, and the chest X-ray showed a normal postoperative status (Figure 5). However, it is essential to note that the long-term implications of K-wire migration can include chronic pain, nerve damage, or even the need for additional surgeries. The patient has had regular pulmonary check-ups in the last 3 years, every 3 months at the regional pulmonary care centre, and has not had any respiratory complaints since then. Control imaging studies of the right shoulder did not confirm recurrent dislocation. With physiotherapy, the range of motion of the right shoulder is almost the same as that of the contralateral shoulder.

Figure 5 Chest X-ray image from 1-month follow-up.

All procedures performed in this study were in accordance with the ethical standards of the institutional ethics committee (approval No. 36/2025-EB) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

Based on the available data, the above complication can occur with any pin, whether plain, twisted, bent-ended, or straight. Regarding the above case studies, the exact cause of K-wire migration remains unclear; however, factors such as shoulder movement and the integrity of wire placement are likely significant (17). But there is only limited data on how the patient’s bone structure or other underlying diseases can affect migration.

The selection of the appropriate treatment method in each case depends on the patient’s condition, the frequency of dislocations, and any other shoulder injuries. Therefore, a detailed medical examination and specialist consultation, with particular attention to the patient’s history, are essential to develop the most appropriate therapeutic plan.

Risk factors for K-wire migration

K-wire migration is a recognized complication after orthopedic fixation, most commonly in the clavicle, shoulder girdle, elbow, hand, and pelvic region. Several biomechanical and patient-related factors contribute to this phenomenon. Inadequate wire fixation—including insufficient bending of the external wire end, insufficient thread purchase, or the use of smooth wires—significantly increases the risk of gradual loosening and subsequent migration. High mobility of the affected joint (such as the shoulder or sternoclavicular joint) creates repetitive mechanical forces that can drive the wire deeper or allow it to travel along tissue planes (18). Rarely, negative intrathoracic pressure or respiratory motion has been implicated in intrathoracic or mediastinal migration, particularly in upper-extremity fixations (19). Additionally, poor bone quality, such as in osteoporosis, reduces friction and stability in the bone–wire interface, facilitating displacement.

Baghdadi et al. (20) report a case of a 10-year-old girl with osteogenesis imperfecta. One year after surgical fixation of a subtrochanteric femoral fracture, she experienced abdominal discomfort, chest pain, and occasional back pain. An abdominal X-ray showed K-wire migration from the left femoral neck to the right retroperitoneal space. The pin was removed through an oblique subcostal incision, and her symptoms resolved.

Kayalar et al. (21) examined outcomes of percutaneous fixation for proximal humerus fractures, emphasizing that careful patient selection is crucial. Their results showed good functional outcomes in younger patients and in simple two-part fractures, while elderly or osteoporotic patients experienced higher complication rates, such as pin migration and malunion.

In most cases, K-wire migration is asymptomatic. The presence and severity of symptoms can vary based on the location of the migration, ranging from mild dyspnea and chronic chest pain (22) to hemodynamic instability requiring urgent intervention (23). In our patient’s case, no severe symptoms were noted for 3 weeks, and the migration was discovered incidentally. Migration of K-wires into the chest cavity can lead to serious complications such as haemothorax (24), pneumothorax (25), or even life-threatening bleeding (26). Outcomes depend on the migration’s location and the time until the diagnosis. Our patient had not undergone any imaging assessments since the operation, despite her history of osteoporosis. Fortunately, her slow migration likely prevented pneumothorax or severe bleeding.

Preventive techniques, existing clinical management strategies

Several techniques have been described to prevent pin migration, including bending the K-wires into various shapes and covering the exposed ends with materials such as adhesive tape, corks, rubber stoppers, epoxy putty, and plastic balls (27). However, these temporary solutions have several disadvantages, such as patient discomfort, increased pin volume, skin irritation, and a higher infection rate. To prevent such complications, it’s essential to ensure adequate fixation, account for the patient’s movement during healing, and use the appropriate wire length (28).

The duration the device remains implanted has been identified as an essential factor contributing to its potential for migration. Pins are typically removed once imaging confirms that the fracture is stable, which generally occurs 4–6 weeks after they are inserted (29).

An essential step in management is the appropriate radiographic follow-up. Shoulder and clavicle wires require especially close monitoring due to reports of intrathoracic migration. Patients should be instructed to avoid strenuous motion and report pain or reduced wire prominence, as these can signal loosening or migration (30). Suppose migration is detected early and the wire is still accessible. In that case, it should be removed promptly—usually as an outpatient procedure—and alternative fixation used if fracture stability is at risk. If the wire has migrated deeply or toward vital structures (thorax, mediastinum, abdomen, vessels, spine), urgent imaging—typically CT—is required, and removal should be performed by the appropriate specialty team (cardiothoracic, vascular, general, or neurosurgery). Although minimally invasive removal is possible, larger incisions are often needed for patient safety. After removal, patients are monitored for complications such as bleeding, pneumothorax, or infection.

As an alternative to wire fixation, the most commonly used procedures are the arthroscopic Bankart technique (31) and Latarjet technique (32), the open Snyder-Lembert technique (33), or capsular shift and plication (34), which can be performed using an arthroscopic or open approach.

In our case report, the patient’s history of osteoporosis is a risk factor for the percutaneous pinning. The educational value is that the aforementioned preventive device should have been used during the pinning. In addition, given the osteoporosis, migration would have been recognized earlier with closer follow-up. This case report is limited by its single-patient design. Although osteoporosis in the patient’s medical history may have contributed to fixation wire migration, this association remains hypothetical. Other factors, including biomechanical forces or technical aspects of fixation, cannot be excluded. The rarity of this complication limits the generalizability of the findings.

Conclusions

Percutaneous fixation is a valuable minimally invasive option in carefully selected patients with favorable fracture patterns and adequate bone quality. In elderly or osteoporotic patients, however, reduced bone density compromises fixation stability, increasing the risk of implant migration. In such cases, percutaneous techniques should be applied cautiously, and alternative treatment strategies should be considered.

When percutaneous pinning is used, meticulous surgical technique and preventive measures—such as appropriate implant selection, multiplanar fixation, and soft-tissue protection—are essential. Patients must also be informed about postoperative risks and advised to avoid excessive loading or trauma during healing. Routine radiological follow-up is critical after K-wire fixation to detect early signs of migration. Prompt surgical intervention is required if displacement occurs, in order to prevent serious complications.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://shc.amegroups.com/article/view/10.21037/shc-2025-5/rc

Peer Review File: Available at https://shc.amegroups.com/article/view/10.21037/shc-2025-5/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://shc.amegroups.com/article/view/10.21037/shc-2025-5/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional ethics committee (approval No. 36/2025-EB) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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