Intrapelvic migration of a guide pin during fixation of a hip fracture: who and what is to blame?

The authors report the case of a 61-year-old patient who underwent internal fixation with a dynamic hip screw for a stable intertrochanteric fracture of the right hip. The immediate postoperative radiograph showed complete intrapelvic migration of the threaded guide pin, which has gone unnoticed during operation. The pin was removed by laparotomy, and was found to have damaged no pelvic viscera; the patient made an uneventful recovery. The authors analyse the mechanism of such iatrogenic complications and the possible means to avoid them.