A Subtle Intra-Operative Complication of the IMHS That May Go Unnoticed

We present two cases with intra-operative complications during the placement of intra-medullary hip screw (IMHS). In both occasions, the implant accidentally breached the anterior cortex of the distal femur. Lateral view with image intensifier confirmed the perforation. This intra-operative complication has not been reported before. It is unclear how often this occurs and how often we miss these subtle complications with potentially disastrous consequences. In the event that it does occur, it is arguable whether any intra-operative or post-operative precautions should be taken. Intra-operative complications with particular reference to femoral fractures is a risk, which when occurring could drastically change the course of management. Although this can be subtle, in general, this will be easily visible on image intensifier. On the other hand, femoral shaft perforations can be a lot more subtle if they are noticed at all. If this complication is not noted and the management does not take this into account, a consequential fracture (eg. Supracondylar or peri-prosthetic) and further complications can result. Possible causes for femoral cortex breaching can be numerous. It is questionable if the breaching is noted whether it should be protected with further internal fixation, casting support or altering the weight-bearing state post-operatively. In one of our cases, the surgeon used extra-medullary device (LISS plate) and for the other, the surgeon managed this conservatively. Different surgeon different management but similar good outcome.