Migrating orthopaedic pin

Abstract

A 43-year-old male presented with a 3-day history of sharp pleuritic chest pain that came on suddenly while driving. For 12 months prior to this, he had similar 'niggling' intermittent pain. He had no other associated symptoms.His past medical history included a motorcycle accident 30 years ago in which he sustained a fracture dislocation of the sternoclavicular joint. This was treated with internal fixation. According to the patient, the pin was supposed to be removed 6 weeks following the initial injury but on admission for pin removal it was noted that the pin had moved and so surgery was cancelled. More recently, the patient suffered a fall resulting in a left occipital and T12/L1 wedge fractures. A chest X-ray ( Fig. 1a) at the time of this fall shows a metal foreign body in the left lateral mid-chest. At the time of the most recent admission, a chest X-ray (Fig. 1b) shows that the foreign body had migrated inferiorly and medially. For further evaluation of his chest pain, a computerized tomography scan was also arranged. This showed a metallic pin between his T12 vertebral body and the left crus of the left hemi-diaphragm with the tip abutting (and pointing directly at) the aorta (Fig. 2). Given the proximity to the aorta and the patient's pleuritic symptoms, it was thought necessary to remove the foreign body.On the basis of the imaging, it was difficult to ascertain preoperatively the exact position of the object. Scatter during the computerized tomography scan distorted the diaphragm and thus we were unable to tell whether or not it was on or in the left diaphragm. Given this, it was decided to first attempt to extract the object thoracoscopically. The neurosurgical team were also made available should a paravertebral dissection to locate the foreign body be required. a b Fig. 1. (a) A chest X-ray taken in 2006 showing the position of the metallic foreign body positioned in the left midthoracic region. (b) Subsequent chest X-ray at presentation in 2011 showing migration of the foreign body to below the left hemidiaphragm. a b Fig. 2. Computerized tomography scan of abdomen (a) horizontal and (b) coronal views showing the position of the metallic pin.