Introduction and Aims: The ‘Boxer’s fracture’ is a common injury. Often these fractures are treated conservatively with acceptable functional results, leaving the patient with a residual deformity. A minimally invasive technique of treating these fractures was investigated.

Method: Twenty-three consecutive patients with a fractured neck of the fifth metacarpal with a volar angulation exceeding 40 degrees were offered treatment with a prograde intramedullary K-wire. All 23 patients accepted this treatment with informed consent. A 1.6 mm pre-bent K-wire was inserted via the base of the fifth metacarpal in each case. Time to regaining full function, time to union and final functional and radiological outcome were looked at.

Results: All 23 patients went on to full clinical and radiological union within six weeks. In 18 patients the reduction was anatomical with no residual angulation. In five, the residual angulation ranged from five to 15 degrees with an average of eight degrees. Two patients suffered a transient sensory neuropraxia.

Conclusion: The presented technique is a simple, cost-effective and reliable method of treating a ‘Boxer’s fracture’. Although this type of injury can often be treated without surgery, this procedure ensures a rapid return to full function with little or no residual deformity.

Introduction and Aims: Acromioclavicular dislocations and fractures of the distal clavicle present a challenging problem for the treating surgeon. The use of a new specifically designed implant was investigated. A hooked-shaped plate with fixation to the distal clavicle and ‘hook’ placement under the posterior acromion was used.

Method: The procedure was carried out on eight patients. In five patients the injury was a fractured distal clavicle. In three cases an acromioclavicular dislocation was treated. In all cases the time to returning to a functional capacity was analysed. The eventual functional result was indexed from the time of fracture union or complete stabilisation of the dislocations.

Results: All five fractures went on to anatomical union. The three dislocations were all stabilised with no instability or subluxation. In two cases patients complained of impingement symptoms with decreased overhead functional capacity. In both cases the patients regained a full and pain-free range of movement after removal of the implant.

Conclusion: This new implant provides an acceptable alternative in the management of distal clavicle fractures and acromioclavicular dislocations. The complication of impingement is encountered, but this appears to be treatable by removal of the implant after fracture union or joint stabilisation.

Introduction and Aims: With the prevalence of gunshot injuries in our society a new approach to the treatment of gunshot radius and/or ulna was analysed. These fractures are often very comminuted and surgical exposure of the fracture site may render many previously viable bone fragments devoid of a blood supply. It was decided to look at a minimally invasive method of plating these fractures.

Method: A consecutive series of nine patients with a diaphyseal gunshot of the radius or ulna or both was subjected to a ‘percutaneous plating’ procedure. This form of fixation acts as an internal form of ‘external fixator.’ Two surgeons performed the procedures.

Results: At the time of submission of this abstract five of the six patients had gone on to complete clinical and radiological union. The sixth patient is still under follow-up. The average time to full union was 12 weeks. The average pronation obtained was 60 degrees (20–80) and the average supination 50 degrees (10–70). In all patients full elbow and wrist movement was preserved.

Conclusion: Although this is a very limited series of patients it would appear that this method of treating gunshot injuries of forearm bones produces good results in injuries that are sometimes difficult to treat. The long-term effect on wrist function is difficult to predict. To date, we have had no serious complications in this small series, with no incidence of nerve injury, no sepsis and no radio-ulna synostosis.

Gunshot injuries to large joints are increasing in South Africa. If the bullet is in contact with the synovial fluid of the joint, it must be removed to prevent a foreign body effect and lead poisoning.

We devised a new extra-articular approach to removing the bullet from the joint. We used a reamer to make a tract in the bone towards the joint, and then removed the bullet and irrigated the joint through the same tract. Postoperatively patients were mobilised immediately. At follow-up they had good functional outcome.

Where reconstruction is deemed impossible, excision of the radial head has been the mainstay of treatment for shattered radial head and neck fractures. While some patients seem to do well after the procedure, some develop progressive instability and pain because of proximal translocation of the radius. We looked at a new procedure in which a metal radial head is inserted to provide greater stability after the excision. Historically silicone prostheses have been used, but these were found to fail dramatically after a time.

We recruited 11 patients requiring radial head replacements. Their ages ranged from 26 to 54 years. In five patients the dominant arm was affected. The radial head was deemed non-reconstructable in all patients, and the alternative method of treatment would have been radial head excision. In one patient, radial head replacement was performed 14 years after previous radial head excision. A standardised procedure was performed, replacing the radial head with an Evolve modular radial head prosthesis.

At follow-up, we assessed patient satisfaction, range of movement, overall stability of the prostheses, grip strength and return to full activity. The postoperative range of movement was assessed at three and six weeks, and the outcome in terms of mobility at six months. Supination ranged between 40( and 90( and pronation between 40( and 85(. Elbow extension ranged between -5( and -30 and flexion between 100( and 150(.

We concede that the follow-up period has been short, but early results suggest that radial head replacement may be a good option in patients in whom radial head reconstruction is not possible.

In a prospective study, we reviewed 72 distal tibial fractures treated by percutaneous plating between July 1996 and June 2001. The patient’s mean age was 36 years (19 to 76). The majority of them were men. Seven fractures were open, with three of them Gustilo grade IIIA. Of 65 closed fractures, 15 were Tscherne grade III. All fractures were type 43A according to AO classification and were less than 5 cm from the ankle joint. Most of the fractures were group A3, with 22 group A3.3. Percutaneous plating was delayed for a mean of five days (2 to 15). Pre-contoured small fragment dynamic compression plate was placed on the medial aspect of the tibia under image intensifier control, through a short distal skin incision. On average, three distal and two proximal screws were inserted. Fibular fractures were stabilised in a similar fashion. Satisfactory fracture reduction was achieved in all cases. Postoperatively a below-knee cast was applied for six weeks and weight-bearing was permitted at eight weeks. Fracture healing occurred within 12 weeks (10 to 16). One patient needed bone grafting for treatment of delayed union. All patients had a functional range of ankle movement. In one patient, breakage of all screws was observed in a united fracture with shortening of the fracture. Local late infection where the skin was tented by skin screw heads occurred in eight patients and was resolved by debridement and hardware removal.

Percutaneous plating of type A43 tibial fractures is safe, reproducible and successful and has few complications. The few adverse affects may well be eliminated by the use of newly-introduced low profile plates and screws.

Conservative treatment of the ‘boxer’s fracture’ gives acceptable functional results but often leaves the patient with a residual deformity.

Using a prograde intramedullary K-wire, we treated 23 consecutive patients with a fractured neck of the fifth metacarpal. Volar angulation exceeded 40°. A 1.6-mm pre-bent K-wire was inserted via the base of the fifth metacarpal in each case. Time to regaining full function, time to union and final functional and radiological outcome were recorded.

All 23 patients went on to full clinical and radiological union within six weeks. In 18 patients, the reduction was anatomical with no residual angulation. In five the residual angulation ranged from 5° to 15°, with a mean of 8°. There was a transient sensory neuropraxia in two patients.

This minimally invasive technique is a simple, cost-effective and reliable method of treating a ‘boxer’s fracture’ and ensures a rapid return to full function with little or no residual deformity.

In a prospective study, we reviewed 23 proximal humeral fractures treated by AO/Synthes intramedullary nailing between January 1999 and December 2000.

According to Neer’s classification, there were 12 two-part fractures, eight three-part and three four-part fractures. There was anterior dislocation of the glenohumeral joint in four patients. The mean age of the 16 men and seven women was 49 years (26 to 71). More fractures occurred in patients over 55 years of age. Anteroposterior and trans-scapular radiographs were taken and CT routinely performed. Surgery was performed within 5 to 14 days of injury. In young patients with two-part fractures, we used percutaneous integrate nailing. Three and four-part fractures were reduced and fixed through a short anterolateral deltoid split approach. The nail was inserted without reaming. The fracture fragments were reduced around the exposed proximal part of the nail and reduction secured by insertion of locking screws and a tension wire band. Ruptures of the rotator cuff were repaired. The nail was locked distally in 16 fractures.

The arm was immobilised for two or three weeks but supervised shoulder movement started as early as four to five days postoperatively. All fractures healed within 12 weeks. Functional shoulder movement returned in all but two cases. In younger patients recovery was faster and a near-full range of abduction and flexion returned. No sepsis occurred. Postoperative backing-out of the nail and varus deformity of the humeral head occurred in two patients. Two patients required re-operation. Backing-out of proximal locking screws was observed but did not affect functional outcome.

This minimally-invasive method of fixation by intramedullary nail, locking screws and tension wire band through a short incision may be an alternative way of managing complex proximal humeral fractures.

Radial and/or ulnar fractures caused by gunshots are common in our society. These fractures are often very comminuted, and surgical exposure of the fracture site may deprive previously viable bone fragments of a blood supply. We looked at a minimally invasive method of plating these fractures.

Two surgeons performed a percutaneous plating procedure on six consecutive patients with a diaphyseal gunshot of the radius and/or ulna. This type of fixation acts as an internal form of ‘external fixator’.

When this paper was prepared, five of the six patients had gone on to complete clinical and radiological union and the sixth was still under follow-up. The mean time to full union was 12 weeks. Mean pronation was 60° (20° to 80°) and mean supination 50° (10° to 70°). In all patients, full elbow and wrist movement was preserved. To date we have had no complications of nerve injury, sepsis or radioulnar synostosis.

This is a very limited series of patients, but it seems this method of treating gunshot injuries of forearm bones produces good results. The long-term effect on wrist function is difficult to predict.

In a prospective study, we reviewed 52 metaphyseal fractures of the proximal tibia treated by percutaneous plating between January 1996 and October 2000. Owing to the proximity of the fractures to the joint, intramedullary nailing was not suitable.

The mean age of the patients, most of whom were men, was 41 years (16 to 82). Five fractures were open. There were 10 comminuted fractures extending into the diaphysis and five segmental fractures. The fractures were reduced and under the image intensifier percutaneously plated through a short approach proximal to the fracture. Fracture reduction was achieved either by manipulation and traction or by use of femoral distractor and reduction clamp. Synthes tibial head buttress plates and screws were used for stabilisation. On average, three proximal and distal screws were percutaneously inserted. Satisfactory fracture reduction was achieved in the anteroposterior plane in all fractures, but in the sagittal plane tilting of the proximal fragment was observed in five cases. There were no intra-operative neuro-vascular complications. Postoperatively the leg was immobilised in a brace for 6 to 12 weeks. At a mean of six to eight weeks, when radiological signs of healing were noted, weight-bearing was permitted. The mean time to union was 12 weeks (8 to 18). There were two cases of delayed union. No patient had functional restrictions, secondary displacement or failure of fixation. In four patients the proximal screws backed out, but this did not affect functional outcome. Late sepsis, which developed at the site of the distal screws in six patients, subsided after drainage of abscesses in two patients and removal of plate and screws in four.

Percutaneous plating may be used to manage proximal tibial fractures unsuited to intramedullary nailing.