A 69-year-old woman was admitted to the emergency department after an accidental fall. She presented with left shoulder pain and functional impairment. Clinical history included essential hypertension and obesity. Traditional X-ray series and computed tomography (CT) scan with three-dimensional reconstruction were performed. Examinations showed a 3-part fracture of the proximal left humerus, accounting to the Neer's classification (AO/ASIF: 11-B2) [Figure and ]. Two days after patient acceptance to our department, fracture was treated by closed reduction and fixation with two retrograde K-wires and one threaded wire, by mean of a modified “en palmière” technique: The first two wires were retrograde nonthreaded bent wires inserted at the deltoid “V” level, while the latter was an anterograde threaded wire percutaneously introduced to fix the great tuberosity [Figure and ]. Two days after surgery, the patient was discharged from the hospital. One month after surgery, the patient came back for routine clinical and radiographic control, to evaluate the fracture healing and eventually plan the wires removal. In that setting, she referred about global well-being and no pain at the shoulder. X-rays demonstrated the intrathoracic migration of the threaded wire used for tuberosity fixation [Figure and ]. A complementary CT scan was immediately performed to better show the spatial relationship between the wire and intrathoracic vital organs. It revealed the device was migrated through the fifth intercostal space to the left lung parenchyma, without the signs of pneumothorax, nor bleeding [Figure and ]. She was extensively interviewed and investigated for any symptom or sign. She only referred about episodic intercostal mild pain that onset 1 week after surgery and was elicited by a cough. Due to low severity of the symptom, it was completely underestimated by the patient. Physical examination, vital parameters, and blood examination resulted normal. The patient was immediately managed by mean of video-assisted thoracoscopic approach to remove the migrated wire from the lung parenchyma. Intraoperatively, a fibrin-coated spot was identified on the lung surface and excised. This allowed the foreign body to be visualized and easily removed []. Neither parenchymal bleeding nor pneumothorax was observed. A chest drain tube was inserted, and antibiotic prophylaxis was administered. The postoperative outcome was free of complications, and the patient was discharged 3 days after surgery with a normal chest radiogram. One month after surgery, the patient underwent new thoracic and left shoulder X-rays, confirming the healing of the shoulder fracture and the absence of radiographically evident sequelae about the lung. A specialist consultation by thoracic surgeons was performed, assessing the complete recovery of lung function without complications or negative outcomes.
A 60-year-old woman presented to us with pain over medial aspect of right knee joint. The pain was non radiating. The pain was relieved by rest and was exacerbated by squatting and sitting cross legged. The patient had difficulty in climbing stairs. On physical examination there was tenderness along the medial aspect of knee joint and a curved scar mark was present over the anterior aspect of knee joint (). While history taking the patient told us that she had a patella fracture around 4 years back which was treated by open reduction and internal fixation and she subsequently underwent implant removal 2 years back. The patient had full range of motion (ROM) at knee joint (Figs. , ) and moderate pain was observed on medial side while flexing and extending knee joint. There was no history of any recent trauma to knee joint. A provisional diagnosis of osteoarthritis knee joint was made and weight bearing standing antero-posterior and lateral x-rays ofleft knee joint were ordered. On X-rays it was found that multiple pieces of broken circlage wire were present around knee joint and one piece had migrated posteriorly (). On examination patient did not had distal neurovascular deficit and patients pain was not related to these broken pieces, rather it was due to degenerative changes in the knee joint. It is believed that the surgeon who did implant removal removed only the K wires leaving behind the circlage wires which broke into multiple pieces over the passage of time due to the repeated stresses at knee joint. Patient was advised to undergo total knee replacement along with subsequent removal of broken hardware as potential undue complications can occur because ofbroken hardware in the form of damage to neuro vascular structure due to migration of pieces posteriorly. It was also explained to the patient that cases have been reported where broken pieces migrate to heart and sternum and produce life threatening complications. However, patient refused to undergo any type of surgery. she was warned and told to be alert whenever the nature of her pain changes or she experiences new onset of symptoms which is different in character from the pain she is experiencing now and was kept on regular follow up.