MinimallyInvasiveSurgeryinWristFractures

Nattakul Yamprasert, MDDepartment of Orthopedics

Maharat Nakhon Ratchasima Hospital

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What is MIS?Smallincision

Lesstissueinjury

Indirectreduction

XSufficient

2

MISinWristFracture

• Distal end radius fracture

• Scaphoid fracture

3

ChecklistsBeforeMIS

• Fracture configuration

• Soft tissue condition

• Osteosynthetic device

• C-arm

• +/- Arthroscope

4

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

15

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 #

1

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

40

KirschnerWire

Pitfall #

2

Pin tract infection

Solutionfor#Pitfall2

• Make larger incision allowing adequate space for pin-skin interface during wrist movement

Pitfall #

3

Solutionfor#Pitfall3

• Use larger pin ( at least 2.0 mm) for radioulnar fixation

• Entry point proximal to DRUJ

Pitfall #

4

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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