Post on 08-Apr-2017
transcript
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
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
KirschnerWire
Definitivefixation
Provisionalfixation
Reductiondevice
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External Fixator + K-wires
Case Examples
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DER FxFernandez III
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Male 48 y.o.
TipandTrick#1
• Transtyloid Fixation
• Divergent K-wires configuration
TipandTrick#2
• Use ulnar head to compress the lunate fossa fragment
Fixation of Dorso-Ulnar Fragment
Pinning under extensor tendons
Small incision
TipandTrick#3
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immediate postop.
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
TipandTrick#4Unloading radiocarpal joint
Buttress plate
subchondral supporting pins
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1 mo. postop.
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2 mo. postop.
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!
TipandTrick#6Posterior
Anterior
TipandTrick#7
• Locked K-wires for more stability
29Courtesy of Dr. Samran Pookhang
30Courtesy of Dr. Samran Pookhang
31Courtesy of Dr. Samran Pookhang
32Courtesy of Dr. Samran Pookhang
33Courtesy of Dr. Samran Pookhang
34Courtesy of Dr. Samran Phookang
35Courtesy of Dr. Samran Phookang
PITFALLS
Pitfall #
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Pitfall #
1
Solutionfor#Pitfall1
• Use smaller K-wires for periarticular fixation / multi-fragment fixation
• Increase amount of contact point
Diameter (in.) Diameter (mm.)
0.035 0.89
0.045 1.14
0.0625 1.58
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KirschnerWire
Pitfall #
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Pin tract infection
Solutionfor#Pitfall2
• Make larger incision allowing adequate space for pin-skin interface during wrist movement
Pitfall #
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Solutionfor#Pitfall3
• Use larger pin ( at least 2.0 mm) for radioulnar fixation
• Entry point proximal to DRUJ
Pitfall #
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Over-traction
Solutionfor#Pitfall4
• Bone graft
• Internal fixation
ScaphoidFracture
Indication
• Nondisplaced or minimally displaced fracture
• Multiple fractures
FixationDevice
• Headless screws
TipandTrick#1:Positioning
• Wrist extension + ulnar deviation
TipandTrick#2:EntryPoint
• Provisional K-wire driven through proximal volar corner of the trapezium
• More radial entry point in oblique fracture
TipandTrick#3:Anti-rotationalPin
• Use in unstable fracture
ScaphoidNonunion
Male : 21 y.o.Wrist pain for 1 years
SL angle = 58 degrees
3 mo. postop.
14 mo. postop.
20 mo. postop.
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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