| Model Number |
PIN DRIVER ATTACHMENT, 0-3.2MM |
| Medical Device Problem Code |
Material Fragmentation (1261)
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| Health Effect - Clinical Code |
No Clinical Signs, Symptoms or Conditions (4582)
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| Date of Event |
04/13/2023
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Type of Reportable Event
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Malfunction
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Event or Problem Description
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It was reported that the device has metal abrasion.There was no harm for patient, operator or third party reported.No further information received.Update 04-may-2023 (b)(6): further information revealed that this incident occurred during an osteosynthesis for radial head and crown process fracture at the left elbow.The metal abrasion occurred from the clamping fixture for kirschner wires.Clearly visible metal particles fell into the surgical site, but these could be completely removed macroscopically by mechanical cleaning/rinsing.Apart from the slight prolongation of the operating time (less than 15 minutes), there were no damage/negative consequences for the patient.The surgery was finished successfully with a new device with the same part number.It was not necessary to switch the surgical technique or do a second surgery.Update 05-may-2023 (b)(6): further information revealed, that the surgeon was not aware at this time that the particles are metal abrasions.The surgeon thought the particles were dried blood, but the surgical site was rinsed out to make sure nothing remained in the patient.
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Additional Manufacturer Narrative
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The contribution of the device to the reported event could not be determined as the device was not returned for evaluation.The root cause of the event could not be determined from the information available and without device evaluation.If the device becomes available for evaluation, a follow-up report will be submitted.
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Additional Manufacturer Narrative
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Additional information: d9, g3, h3, h6.Complaint is confirmed.Event description: it was reported that the device has metal abrasion.Further information revealed that this incident occurred during an osteosynthesis for radial head and crown process fracture at the left elbow.The metal abrasion occurred from the clamping fixture for kirschner wires.Clearly visible metal particles fell into the surgical site, but these could be completely removed macroscopically by mechanical cleaning/rinsing.Apart from the slight prolongation of the operating time (less than 15 minutes), there were no damage/negative consequences for the patient.The reported event was confirmed.The manufacturers evaluation revealed damages at two axial bearings in the shaft which caused the metal abrasion.Furthermore, a spring which holds the pin has slipped out of position.The most likely cause of this condition can be too much load during use.
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Search Alerts/Recalls
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