บรรยายครั้งแรกในการประชุมวิชาการประจำปีของชมรมศัลยแพทย์ทางมือแห่งประเทศไทย ครั้งที่ 32 วันพฤหัสบดีที่ 17 มีนาคม 2559 ณ โรงพยาบาลภูมิพลอดุลยเดช กรมแพทย์ทหารอากาศ Revision 26 พฤษภาคม 2559 บรรยายในการประชุมวิชาการของภาควิชาออร์โธปิดิกส์ โรงพยาบาลมหาราชนครราชสีมา

1. Minimally
Invasive
Surgery
in Wrist Fractures
Nattakul Yamprasert, MD
Department of Orthopedics
Maharat Nakhon Ratchasima Hospital
1

2. What is MIS?
Small incision
Less tissue injury
Indirect reduction
XSufficient
2

3. MIS in Wrist Fracture
• Distal end radius fracture
• Scaphoid fracture
3

4. Checklists Before MIS
• Fracture configuration
• Soft tissue condition
• Osteosynthetic device
• C-arm
• +/- Arthroscope
4

5. Distal Radius Fracture

6. External Fixator
Pros Cons
Less invasive Pin tract infection
Rigid construction Joint stiffness
Neutralize axial load
Friendly with wound care
6

7. Pros Cons
Low profile Non-compressive
Cheap
No resistant to pull-out
force
Availability Less stability
7
Kirschner Wire

8. Kirschner Wire
Definitive fixation
Provisional fixation
Reduction device
8

9. External Fixator + K-wires

10. Case Examples
10

11. DER Fx
Fernandez III
11
Male 48 y.o.

12. Tip and Trick #1
• Transtyloid
Fixation
• Divergent K-
wires
configuration

13. Tip and Trick #2
• Use ulnar head
to compress
the lunate
fossa fragment

14. Fixation of Dorso-Ulnar Fragment
Pinning under extensor tendons
Small incision
Tip and Trick #3

15. 15
immediate postop.

16. ROME at 6 wks p.o.

17. 17
2 mo. postop.

18. 18
3 mo. postop.

19. 19
4 mo. postop.

20. 20
Male 41 y.o.
Fernandez V

21. 21

22. 22
Displaced volar lipcollapse radiocarpal joint
1 wk. after CR

23. Tip and Trick #4
Unloading radiocarpal joint
Buttress plate
subchondral supporting pins

24. 24
1 mo. postop.

25. 25
2 mo. postop.

26. Tip and Trick #5
4 mm-Schanz pin
Distal pin at
metaphyeal area
Proximal pin at
junction between
middle & distal
1/3 of radius
Avoid SRN
injury!

27. Tip and Trick #6
Posterior
Anterior

28. Tip and Trick #7
• Locked K-wires
for more
stability

29. 29Courtesy of Dr. Samran Pookhang

30. 30Courtesy of Dr. Samran Pookhang

31. 31Courtesy of Dr. Samran Pookhang

32. 32Courtesy of Dr. Samran Pookhang

33. 33Courtesy of Dr. Samran Pookhang

34. 34Courtesy of Dr. Samran Phookang

35. 35Courtesy of Dr. Samran Phookang

36. PITFALLS

37. Pitfall #1

38. Pitfall #1

39. Solution for #Pitfall1
• Use smaller K-wires for
periarticular fixation / multi-
fragment fixation
• Increase amount of contact point

40. Diameter (in.) Diameter (mm.)
0.035 0.89
0.045 1.14
0.0625 1.58
40
Kirschner Wire

44. Pitfall #2
Pin tract infection

45. Solution for #Pitfall2
• Make larger incision allowing
adequate space for pin-skin
interface during wrist movement

46. Pitfall #3

47. Solution for #Pitfall3
• Use larger pin ( at least 2.0 mm)
for radioulnar fixation
• Entry point proximal to DRUJ

48. Pitfall #4
Over-traction

49. Solution for #Pitfall4
• Bone graft
• Internal fixation

50. Scaphoid Fracture

51. Indication
• Nondisplaced or minimally displaced fracture
• Multiple fractures

52. Fixation Device
• Headless
screws

54. Tip and Trick #1 :
Positioning
• Wrist extension
+ ulnar
deviation

55. Tip and Trick #2 :
Entry Point
• Provisional K-wire driven through
proximal volar corner of the
trapezium
• More radial entry point in oblique
fracture

56. Tip and Trick #3 :
Anti-rotational Pin
• Use in unstable fracture

57. Scaphoid Nonunion

58. Male : 21 y.o.
Wrist pain for 1 years
SL angle = 58 degrees

60. 3 mo. postop.

61. 14 mo. postop.

62. 20 mo. postop.

63. Take Home Messages
• Timing and method of treatment could be
managed individually.
• Always prepare instruments for conventional
fixation method.
• Postoperative rehabilitation program is
mandatory.
63