minimally invasive surgery in wrist fractures
TRANSCRIPT
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MinimallyInvasiveSurgeryinWristFractures
Nattakul Yamprasert, MDDepartment of Orthopedics
Maharat Nakhon Ratchasima Hospital
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What is MIS?Smallincision
Lesstissueinjury
Indirectreduction
XSufficient
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MISinWristFracture
• Distal end radius fracture
• Scaphoid fracture
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ChecklistsBeforeMIS
• Fracture configuration
• Soft tissue condition
• Osteosynthetic device
• C-arm
• +/- Arthroscope
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DistalRadiusFracture
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ExternalFixatorPros Cons
Less invasive Pin tract infection
Rigid construction Joint stiffness
Neutralize axial load
Friendly with wound care
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Pros Cons
Low profile Non-compressive
Cheap No resistant to pull-out force
Availability Less stability
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KirschnerWire
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KirschnerWire
Definitivefixation
Provisionalfixation
Reductiondevice
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External Fixator + K-wires
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Case Examples
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DER FxFernandez III
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Male 48 y.o.
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TipandTrick#1
• Transtyloid Fixation
• Divergent K-wires configuration
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TipandTrick#2
• Use ulnar head to compress the lunate fossa fragment
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Fixation of Dorso-Ulnar Fragment
Pinning under extensor tendons
Small incision
TipandTrick#3
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immediate postop.
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ROME at 6 wks p.o.
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2 mo. postop.
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3 mo. postop.
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4 mo. postop.
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Male 41 y.o.Fernandez V
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Displaced volar lipcollapse radiocarpal joint
1 wk. after CR
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TipandTrick#4Unloading radiocarpal joint
Buttress plate
subchondral supporting pins
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1 mo. postop.
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2 mo. postop.
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TipandTrick#5
4 mm-Schanz pin
Distal pin at metaphyeal area
Proximal pin at junction between middle & distal
1/3 of radius
Avoid SRN injury!
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TipandTrick#6Posterior
Anterior
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TipandTrick#7
• Locked K-wires for more stability
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29Courtesy of Dr. Samran Pookhang
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30Courtesy of Dr. Samran Pookhang
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31Courtesy of Dr. Samran Pookhang
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32Courtesy of Dr. Samran Pookhang
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33Courtesy of Dr. Samran Pookhang
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34Courtesy of Dr. Samran Phookang
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35Courtesy of Dr. Samran Phookang
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PITFALLS
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Pitfall #
1
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Pitfall #
1
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Solutionfor#Pitfall1
• Use smaller K-wires for periarticular fixation / multi-fragment fixation
• Increase amount of contact point
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Diameter (in.) Diameter (mm.)
0.035 0.89
0.045 1.14
0.0625 1.58
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KirschnerWire
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Pitfall #
2
Pin tract infection
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Solutionfor#Pitfall2
• Make larger incision allowing adequate space for pin-skin interface during wrist movement
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Pitfall #
3
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Solutionfor#Pitfall3
• Use larger pin ( at least 2.0 mm) for radioulnar fixation
• Entry point proximal to DRUJ
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Pitfall #
4
Over-traction
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Solutionfor#Pitfall4
• Bone graft
• Internal fixation
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ScaphoidFracture
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Indication
• Nondisplaced or minimally displaced fracture
• Multiple fractures
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FixationDevice
• Headless screws
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TipandTrick#1:Positioning
• Wrist extension + ulnar deviation
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TipandTrick#2:EntryPoint
• Provisional K-wire driven through proximal volar corner of the trapezium
• More radial entry point in oblique fracture
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TipandTrick#3:Anti-rotationalPin
• Use in unstable fracture
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ScaphoidNonunion
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Male : 21 y.o.Wrist pain for 1 years
SL angle = 58 degrees
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3 mo. postop.
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14 mo. postop.
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20 mo. postop.
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Take Home Messages
• Timing and method of treatment could be managed individually.
• Always prepare instruments for conventional fixation method.
• Postoperative rehabilitation program is mandatory.
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