Clinical Practice and Cases in Emergency Medicine

Introduction: Hip fractures are a concern in older adults, with incidence expected to rise as the population ages. Despite advances in surgical technique and hardware design, complications remain, influenced by patient factors and surgical choices. Rarely, hardware migration into the pelvis occurs, which poses serious risks. In the emergency setting, abdominal pain is a common complaint, and when evaluating patients with complex histories or prior orthopedic surgeries, clinicians must maintain a broad differential. This case details the discovery of a medially displaced hip screw into the pelvis as the cause of abdominal pain in a patient in the emergency department (ED).

Case Report: A 44-year-old female with end stage renal disease on hemodialysis, anemia, and osteoporosis presented to the ED with sudden-onset, bilateral lower quadrant abdominal pain, vomiting, and diarrhea. The patient reported undergoing left hip open reduction and internal fixation seven months prior. Imaging of the abdomen noted medial displacement of the cephalomedullary nail through the left acetabulum into the pelvis with associated extraperitoneal hematoma. She underwent hardware removal and exploratory laparotomy without bowel injury. 

Conclusion: Orthopedic screw migration is a rare but serious complication, with limited documentation in the literature. Risk increases in patients with poor bone quality and healing, often due to chronic conditions. In patients with multiple comorbidities, careful history and a thorough exam when presenting to the ED are critical to identifying complications. Strategic use of imaging and clinical judgement can help emergency physicians refine their differential diagnosis.