Abstract
Purpose
This study aims to evaluate the frequency and management of complications in patients who underwent percutaneous K-wire fixation for hand and wrist fractures caused by trauma.
Methods
A total of 143 patients (112 men, 31 women) with 333 K-wires were retrospectively analyzed. Demographic data, surgical techniques, postoperative care, and complications were reviewed. Minor complications included pin loosening, migration, and superficial infections, while major complications included nonunion, malunion, and osteomyelitis.
Results
Complications were observed in 23 patients (16%), including six major and 17 minor cases. The most common complications were pin loosening (five patients), infection (six patients), and pin migration (seven patients). Infections were primarily caused by Staphylococcus aureus, identified in three cases. Nonunion and malunion required secondary interventions, whereas one osteomyelitis case necessitated surgical debridement and prolonged antibiotics.
Conclusions
Complications occurred in 16% of cases, with pin migration, loosening, and infection being the most frequent issues. Although most complications were minor and manageable, major complications such as nonunion and osteomyelitis necessitated additional surgical interventions.
Type of study/level of evidence
Therapeutic IV.
Key words: Complications, Hand fractures, K-wire fixation
Hand and wrist fractures are common injuries encountered in trauma surgery, and achieving functional recovery through appropriate treatment is of paramount importance. Percutaneous Kirschner wire (K-wire) fixation is a frequently preferred method in the management of these injuries given its minimally invasive nature and ability to provide stable reduction.1,2 However, the effectiveness and success of this technique are directly related to the prevention and management of complications.1,3
Percutaneous K-wire applications are typically performed with the aim of achieving anatomic reduction, stabilization, and early mobilization of fractures. Nevertheless, complications such as infection, pin loosening, pin migration, and nonunion may adversely affect the success of this treatment modality.4 The frequency and management of these complications have been reported in a wide range in the literature, with no clear consensus on a standardized approach.3, 4, 5
This study aimed to retrospectively evaluate the frequency and management strategies of complications in patients who underwent K-wire fixation for hand and wrist fractures because of trauma. We conducted a detailed analysis of the application characteristics of K-wires in different fracture regions, the causes of complication development, and the treatment methods applied to address these complications. By doing so, the study seeks to present potential recommendations for improving the clinical outcomes and complication management associated with this surgical technique.
Materials and Methods
This retrospective study was approved by the institutional ethics review board (approval no: i08-633-24). Patients who underwent percutaneous K-wire fixation for hand and wrist fractures between October 2021 and December 2023 were identified via procedural codes 910.240 and 910.250, along with operative notes from the hospital's electronic medical record system. A total of 143 patients (112 men and 31 women; age range: 2–92 years) with trauma-related hand and wrist injuries (including fractures, dislocations, and fracture-dislocations) were included. Eighteen patients were under the age of 18 years. All procedures were performed by orthopedic residents under the supervision of a certified orthopedic and hand surgeon at a single university-affiliated hand surgery clinic.
All operations were conducted in the main operating room under sterile conditions using fluoroscopic guidance. Smooth stainless steel K-wires, ranging from 0.8 (0.031 in) to 1.8 (0.07 in) mm in diameter, were inserted percutaneously using an electric or pneumatic drill with continuous saline irrigation. For the purposes of analysis, wires <1.2 (0.047 in) mm in diameter were defined as small-diameter K-wires. Pins were either bent and left protruding or cut flush with the skin. Only patients with exposed pins could perform pin site care as instructed.
Patients were immobilized after surgery in custom-made thermoplastic functional splints for 3 weeks. These splints allowed movement of uninvolved joints and were designed with windows to allow pin site access. Pin sites were cleaned with povidone-iodine every 3 days by patients or caregivers. After 3 weeks, the splints were discontinued, and active motion was initiated. Follow-up visits were scheduled every 7–10 days. K-wire removal occurred in an outpatient setting without additional surgical intervention. In adult patients, removal was performed without sedation. Pediatric patients received local anesthesia or minimal sedation based on age and tolerance.
K-wire duration varied by fracture location: 1–6 weeks for phalangeal fractures, 4–18 weeks for metacarpal fractures, and 6–8 weeks for carpal and distal radius fractures. One pin was removed after only 1 week because of loosening and was therefore considered prematurely removed. All patients completed at least one follow-up after K-wire removal. The mean follow-up period was 6.3 months (range: 2–12 months).
All adult patients received 1 g intravenous cefazolin before surgery (0.5 g for pediatric patients), administered three times daily during hospitalization. No oral antibiotics were prescribed upon discharge.
Complications were categorized using the Clavien-Dindo classification. Delayed union was defined as lack of radiographic healing by 8 weeks, and nonunion was defined as absence of healing by 12 weeks. Pin migration and loosening were defined radiographically. Infections were diagnosed based on clinical findings (erythema, drainage) and supported by swab cultures when applicable. The occurrence, timing, and type of complications were recorded during routine follow-up visits.
Statistical analysis was conducted using Jamovi version 2.3.2. The Shapiro-Wilk test was used to assess normality. Descriptive statistics are reported as mean ± standard deviation (SD) and range for continuous variables and as frequencies and percentages for categorical data.
Results
A total of 143 K-wire fixation cases were analyzed. The mean age of the patient population was 31.9 years, with a man-to-woman ratio of 3.6:1. A total of 84 K-wires were inserted into phalanges, 61 into metacarpals, six into carpals, and one into the distal radius. Demographic data, surgical technical details, and complications are summarized in the Table 1.
Table 1.
Demographic Data, Surgical Technical Details, and Complications
| Demographic Data, Surgical Technical Details, and Complications | Number of Patients |
|---|---|
| Age | 31.9 ± 17.0 (2–92) |
| Gender | |
| Male | 112 (78.3%) |
| Female | 31 (21.7%) |
| Side | |
| Left | 57 (60.1%) |
| Right | 86 (39.9%) |
| Pin location | |
| Phalanx | 84 (55.3%) |
| Metacarpal | 61 (40.1%) |
| Carpus | 6 (3.95%) |
| Distal radius/ulna | 1 (0.7%) |
| Finger location | |
| 1 | 30 (19.1%) |
| 2 | 15 (9.5%) |
| 3 | 13 (8.3%) |
| 4 | 34 (21.7%) |
| 5 | 65 (41.4%) |
| Pin configuration | |
| Transverse | 9 (6.3%) |
| Cross | 63 (44.1%) |
| Intramedullary | 10 (7%) |
| Cross-transverse | 30 (21%) |
| Cross-intramedullary | 26 (18.2%) |
| Transverse-intramedullary | 5 (3.5%) |
| Number of pins | 2.3 ± 0.9 (1–7) |
| 1 | 9 (6.3%) |
| 2 | 100 (69.9%) |
| 3 | 21 (14.7%) |
| 4 | 8 (5.6%) |
| 5 | 2 (1.4%) |
| 6 | 2 (1.4%) |
| 7 | 1 (0.7%) |
| Mean pin duration (wk) | 4.1 ± 1.2 (1–18) |
| Pin loosening | |
| Yes | 5 (3.5%) |
| No | 138 (96.5%) |
| Pin migration | |
| Yes | 7 (4.9%) |
| No | 136 (95.1%) |
| Nonunion requiring surgery | |
| Yes | 3 (2.1%) |
| No | 140 (97.9) |
| Malunion requiring surgery | |
| Yes | 2 (1.4%) |
| No | 141 (98.6%) |
| Superficial pin track infection | |
| Yes | 5 (3.5%) |
| No | 138 (96.5%) |
| Osteomyelitis | |
| Yes | 1 (0.7%) |
| No | 142 (99.3%) |
| Fracture through pin track | |
| Yes | 0 (0%) |
| No | 143 (100%) |
| Postoperative rehabilitation needs | |
| Yes | 41 |
| No | 102 |
Among the 143 patients treated, complications were observed in 23 cases (16%), consisting of six major and 17 minor complications. Major complications included three nonunions, two malunions, and one case of osteomyelitis. Minor complications included five cases of pin loosening, seven cases of pin migration, and five cases of superficial infections. Forty-one patients were referred to the hand therapy unit because of joint stiffness and restricted movement, with the majority of cases (35 patients) resolving after pin removal. Most infections and pin migrations occurred between 3 and 5 weeks postinsertion, with nonunion presenting at an average duration of 5.33 weeks. This suggests a possible relationship between longer pin duration and more serious complications.
Among the included patients, one case involved a distal radius fracture treated with two 1.6 mm K-wires. No complications were observed in this case during the follow-up period.
Management of complications
Pin loosening was observed in five patients at an average of 4.8 weeks postinsertion, occurring exclusively in phalanges and metacarpals. Infection around the pin site developed in six patients (two with pin loosening, one with pin migration). Four of these patients had positive cultures, with Staphylococcus aureus being the most commonly identified organism (three cases). Superficial infections were managed with local wound care (five patients), oral antibiotics (four patients), and pin removal (two patients) (Fig. 1). One patient with osteomyelitis required parenteral antibiotic therapy. Treatment involved debridement, curettage, and removal of all infected tissue.
Figure 1.
A, B Pin site infection following percutaneous K-wire fixation for mallet finger surgery in the fifth finger of the right hand. C Profuse purulent discharge observed after K-wire removal.
Pin migration was noted in seven patients, attributed to the use of small-diameter K-wires. Migrated pins that were mobile were removed, whereas stable pins were left in place for an additional 1–3 weeks to allow bone healing. Two patients with nonunion underwent plate fixation (Fig. 2), and two patients with malunion underwent percutaneous osteotomy and refixation with K-wires.
Figure 2.
Radiographic evaluation of a right hand proximal phalanx fracture. A, B Preoperative x-rays showing the fracture. C, D Postoperative x-rays after percutaneous K-wire fixation. E, F X-rays following K-wire removal. G, H X-rays after plate fixation, demonstrating definitive stabilization.
Two patients with complications demonstrated poor adherence to postoperative instructions. One patient failed to perform any pin care, resulting in spontaneous pin migration under the skin; the K-wires were removed during a follow-up visit at 18 weeks. The other noncompliant patient, who worked in construction, presented with deep infection and osteomyelitis during their single follow-up visit, 5 weeks after proximal phalanx pinning. A detailed analysis of the complications is provided in the Table 2.
Table 2.
A Detailed Analysis of the Complications
| Complications | Pin Loosening | Pin Migration | Malunion | Nonunion | Superficial Pin Track Infection and Osteomyelitis | Postoperative Rehabilitation Needs |
|---|---|---|---|---|---|---|
| Pin location | ||||||
| Phalanx | 1 | 6 | 1 | 3 | 4 | 30 |
| Metacarpal | 4 | 1 | 1 | 0 | 2 | 6 |
| Carpus | 0 | 0 | 0 | 0 | 0 | 4 |
| Distal radius/ulna | 0 | 0 | 0 | 0 | 0 | 1 |
| Finger location | ||||||
| 1 | 1 | 0 | 0 | 1 | 0 | 11 |
| 2 | 0 | 2 | 0 | 0 | 0 | 5 |
| 3 | 0 | 2 | 0 | 0 | 0 | 6 |
| 4 | 1 | 1 | 2 | 1 | 4 | 9 |
| 5 | 3 | 4 | 0 | 1 | 2 | 15 |
| Pin configuration | ||||||
| Transverse | 0 | 1 | 0 | 0 | 0 | 2 |
| Cross | 2 | 2 | 2 | 2 | 5 | 18 |
| Intramedullary | 0 | 1 | 0 | 0 | 0 | 2 |
| Cross-transverse | 2 | 2 | 0 | 1 | 0 | 7 |
| Cross-intramedullary | 1 | 1 | 0 | 0 | 1 | 9 |
| Transverse-intramedullary | 0 | 0 | 0 | 0 | 0 | 3 |
| Number of pins | ||||||
| 1 | 0 | 1 | 1 | 0 | 0 | 1 |
| 2 | 2 | 3 | 1 | 2 | 4 | 28 |
| 3 | 3 | 0 | 0 | 1 | 2 | 6 |
| 4 | 0 | 1 | 0 | 0 | 0 | 2 |
| 5 | 0 | 1 | 0 | 0 | 0 | 2 |
| 6 | 0 | 1 | 0 | 0 | 0 | 1 |
| 7 | 0 | 0 | 0 | 0 | 0 | 1 |
| Mean pin duration (wk) | 4.8 | 4.42 | 4 | 5.33 | 4.5 | 4.17 |
Discussion
Percutaneous K-wire fixation is widely used as a minimally invasive and effective method for treating hand and wrist fractures. This study comprehensively evaluated the complication rates, and the effect of patient compliance on clinical outcomes following K-wire fixation for trauma cases.
The overall complication rate in our cohort was 16.1% (95% confidence interval [CI], 10.5% to 23.1%), consistent with prior studies reporting rates between 10% and 20%.3, 4, 5 The most common complications observed in this study were pin loosening, infection, and pin migration. Infections were primarily superficial and successfully managed with pin removal and antibiotics. Particularly, pin loosening and infection are frequently emphasized complications in the literature, and it has been reported that careful surgical techniques, hygiene education, and patient compliance can help prevent these issues.2,6,7 In our study, Staphylococcus aureus was the most commonly isolated microorganism in cases of infection, and similar to the literature, successful outcomes were achieved with appropriate antibiotic treatment and pin removal.2,8,9 However, one case of deep infection and osteomyelitis demonstrated that such complications might require surgical intervention and prolonged antibiotic therapy.
The occurrence of infections, particularly in distal fractures, can be explained by the typically weaker skin and soft tissue quality in this region, limited vascularization, and consequently reduced ability to combat infections.10 Infection rates appeared higher in distal phalanx fractures. This may be attributed to increased exposure of distal pins and the challenge of maintaining hygiene in more mobile and sensitive area.5 Additionally, thermal damage during high-speed drilling in small bone segments has been hypothesized to contribute to local tissue vulnerability; however, this was not directly investigated in our study.11
Pin migration was observed more frequently with thinner K-wires, particularly in phalangeal fractures. Although this finding is consistent with prior reports, we acknowledge that our study did not perform multivariable or nested statistical modeling to assess the independent effect of wire diameter.12 Therefore, this association should be interpreted with caution and confirmed in future studies. In particular, the thinner K-wires preferred for phalangeal fractures brought stability issues. Serious complications such as nonunion or malunion were infrequent but required secondary surgical interventions, including plate fixation in some cases.13 Although no single configuration was clearly associated with complications, transverse and cross-intramedullary techniques appeared more frequently in cases with loosening and migration.
Another noteworthy finding in our study, consistent with some other studies, was the considerable effect of patient compliance on complication rates.3,4,8 Complications were markedly higher in patients who did not adhere to pin care and postoperative recommendations. Specifically, in two cases, serious infections and pin migration occurred because of patient noncompliance, underscoring the importance of prioritizing postoperative patient education. Both serious complications involved patients with limited follow-up and occupational challenges, suggesting that patient compliance is influenced by external factors such as work demands and health literacy. Postoperative instructions and support should be tailored to account for these variables.
Joint stiffness, especially at the metacarpophalangeal level, remained a notable issue, likely because of extensor tendon impingement. Early hand therapy remains crucial for recovery, as highlighted in prior research.6
This study is limited by its retrospective design and lack of multivariable statistical analysis to assess confounders. Although this study primarily employed descriptive statistics, future prospective studies should evaluate whether anatomical location, wire diameter, or age are predictive of complications. Furthermore, the absence of long-term follow-up restricts interpretation of late complications. Nonetheless, the relatively large sample size and comprehensive review of complication types provide valuable clinical insight into outcomes following K-wire fixation. Although only one case involved the distal radius, its uneventful recovery supports the feasibility of percutaneous K-wire fixation in carefully selected wrist fractures. However, further studies with larger distal radius cohorts are needed to validate this observation.
Percutaneous K-wire fixation remains an effective and minimally invasive technique for treating hand and wrist fractures, with a manageable complication profile. In this retrospective cohort, complications occurred in 16.1% of patients, with pin migration, infection, and loosening being the most frequent. While most were minor, serious complications such as osteomyelitis and nonunion required additional interventions.
Conflicts of Interest
No benefits in any form have been received or will be received related directly to this article.
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