untitled

Size: px

Start display at page:

Download "untitled"

나나 사
5 years ago
Views:

1 대한정형외과학회지 : 제 44 권제 4 호 2009 J Korean Orthop Assoc 2009; 44: 상완골대결절골절을동반한양측견관절하방탈구 - 증례보고 - 서중배ㆍ민병권 단국대학교의과대학정형외과학교실 Bilateral Inferior Shoulder Dislocation with Greater Tuberosity Fracture - A Case Report - Joong-Bae Seo, M.D., and Byoung-Kwon Min, M.D. Department of Orthopaedic Surgery, College of Medicine, Dankook University, Cheonan, Korea We report here on a case of bilateral inferior shoulder dislocations (bilateral luxatio erecta) with greater tuberosity fracture that was caused by vehicle trauma. We manually reduced the dislocations at the emergency room. After 7 months of conservative treatment with rehabilitation, the range of motion and muscle strength of the shoulders recovered to almost normal. Key Words: Bilateral luxatio erecta, Greater tuberosity fracture 견관절탈구의가장흔한형태는전방탈구인반면, 하방탈구는매우드문현상으로알려져있다. 더욱이양측성하방탈구는극히드물어현재까지약 15개내외의증례가보고되어있으며, 국내에서는보고된바가없다. 대개심한외전손상으로발생하며, 상완골이외전되어만세를부르는듯한자세로고정되는양상때문에 luxatio erecta 라고불리는견관절하방탈구는회전근개의파열, 대결절의골절, 또는상완신경총의손상을동반하는경우가다른종류의탈구보다매우높다. 1) 저자들은교통사고에의해상완골대결절골절을동반한양측견관절하방탈구로응급실로내원한환자를도수정복술후고정및재활치료등의비수술적방법으로치료하여만족스러운결과를얻은예가있어보고하는바이다. 증례보고환자는 26 세남자였으며, 승용차의조수석에서안전 벨트를착용하지않은상태에서앞서가는차를추돌, 수상하였다. 추돌당시환자는무의식적으로양팔을앞으로뻗쳐양손으로조수석계기판을미는듯한자세를취하고머리는양팔사이로숙이는동작을하게되었다고진술하였다. 본원응급실방문시양측팔을외전및외회전상태였으며, 양손을머리위로올려놓은모습을하고있었다. 신체검사상주관절이하의능동운동은모두어느정도가능하였고, 감각역시별이상을호소하지않았으며, 요골동맥의맥박은촉지되었다. 단순방사선촬영결과양측모두상완골대결절골절을동반한견관절하방탈구가확인되었다 (Fig. 1). Imidazole 20 mg (Etomidate ) 을정맥주사한후양측각각상완골의종축을따라조심스럽게견인함과동시에대향견인 (counter traction) 을하였으며, 서서히내전시켜어렵지않게탈구를정복할수있었다. 정복후촬영한방사선사진상상완골대결절의골절도정복되었다 (Fig. 2). 탈구의정 접수일 :2008 년 9 월 26 일, 게재확정일 :2009 년 5 월 19 일교신저자 : 서중배충남천안시동남구안서동산 29 단국대학교의과대학정형외과학교실 TEL: ㆍ FAX: ssjb1990@dku.edu Correspondence to Joong-Bae Seo, M.D. Department of Orthopaedic Surgery, College of Medicine, Dankook University, 29 Anseo-dong, Dongnam-gu, Cheonan , Korea Tel: , Fax: ssjb1990@dku.edu 490

$상완골대결절골절을동반한양측견관절하방탈구 491 Fig. 1. Radiograph shows inferior dislocations of both shoulders with the humeral head faced downward. The greater tuberosities on both sides were fractured. Fig. 3.$ 복후신경기능과혈액순환이정복하기전과차이가없음을확인하고, 대결절골절의전위가 5 mm 이내로유지되어있어, 골절에대해서비수술적치료를하기로하였다. 우측은견관절외전보조기로, 좌측은환자의편의상팔걸이로각각 4주간고정하여, 좌측손으로식사를할수있도록허용하였다.

복후신경기능과혈액순환이정복하기전과차이가없음을확인하고, 대결절골절의전위가 5 mm 이내로유지되어있어, 골절에대해서비수술적치료를하기로하였다. 우측은견관절외전보조기로, 좌측은환자의편의상팔걸이로각각 4주간고정하여, 좌측손으로식사를할수있도록허용하였다.

수상후 9일째좌측 5번째손가락의저림을호소하여이후근 전도검사를하였으며, 상완신경총의내측코드 (medial cord) 의부분축색단열증 (partial axonotmesis) 이확인되었다. 수상후 4주째수동적관절운동을시작하였고, 수상후 6주부터는고무밴드를이용한능동운동을시작하였다.

2 상완골대결절골절을동반한양측견관절하방탈구 491 Fig. 1. Radiograph shows inferior dislocations of both shoulders with the humeral head faced downward. The greater tuberosities on both sides were fractured. Fig. 3. At 7 months after injury, the greater tuberosity fractures were healed. Fig. 2. After manual reduction, the tuberosities were reduced well in acceptable range of displacement. 복후신경기능과혈액순환이정복하기전과차이가없음을확인하고, 대결절골절의전위가 5 mm 이내로유지되어있어, 골절에대해서비수술적치료를하기로하였다. 우측은견관절외전보조기로, 좌측은환자의편의상팔걸이로각각 4주간고정하여, 좌측손으로식사를할수있도록허용하였다. 견관절및주변의동반손상을확인하기위하여수상후 4일째자기공명영상촬영을시행하였는데, 좌측견관절에서삼각근의부분파열이, 양측모두하방관절낭의부분파열이보였으나, 회전근개또는관절와순의손상등다른손상은없었다. 수상후 9일째좌측 5번째손가락의저림을호소하여이후근 전도검사를하였으며, 상완신경총의내측코드 (medial cord) 의부분축색단열증 (partial axonotmesis) 이확인되었다. 수상후 4주째수동적관절운동을시작하였고, 수상후 6주부터는고무밴드를이용한능동운동을시작하였다. 수상후 11주째견관절의운동범위및좌측손의저림은현저하게호전되었으며, 수상후 7 개월째양측견관절의능동운동범위는전방거상 160 o, 외회전 60 o, 후방내회전이 제9흉추 로거의정상운동범위를보였고외전, 외회전, 내회전의근력도정상으로회복되었다 (Fig. 3, 4). 이때시행한추시근전도시행결과좌측상완신경총내측코드의축색단열증은거의회복되었으며, 일상생활및사무직근로자로서의업무에어떠한불편도호소하지않았다 (Fig. 5). 고찰대부분의견관절탈구가전방탈구인반면, 견관절하방탈구 (luxatio erecta) 는매우드문손상이며, 더욱이양측성하방탈구는현재까지약 15예정도가보고되어있는정도로드물다 (Table 1). 2-5) 견관절하방탈구는간접손상과직접손상의두가지기전에의해발생한다. 간접손상은주로고령의환자에발생하며, 견관절의과도한외전에의해발생하거나, 이미외전되어있는견관절에외전력이더해질때발생할수있다. 3) 상완골의경부가견봉에충돌하면서지렛대역

492 서중배ㆍ민병권 Fig. 4. At 7 months after injury, full active elevation was possible for both shoulders. Fig. 5. Photograph shows the range of motion at 7 months after injury. Table 1.

2006 Sewecke, Am J Orthop 2006 Karaoglu, Acta Orthop Trauma Surg 2003 Mills, J Emerg Med 2003 Kumar, Emerg Med J 2001 Tsuchida, J Shoulder Elbow Surg 2001 F/63 Fall from sidewalk with BPI*, Right

3 492 서중배ㆍ민병권 Fig. 4. At 7 months after injury, full active elevation was possible for both shoulders. Fig. 5. Photograph shows the range of motion at 7 months after injury. Table 1. Review of the Cases Reported in the International Literature with Bilateral Luxatio Erecta Author Case Cause Associated injury Musmeci, J Orthop Trauma 2008 Foad, Am J Orthop 2007 Garcia, J Trauma 2006 Sewecke, Am J Orthop 2006 Karaoglu, Acta Orthop Trauma Surg 2003 Mills, J Emerg Med 2003 Kumar, Emerg Med J 2001 Tsuchida, J Shoulder Elbow Surg 2001 F/63 Fall from sidewalk with BPI*, Right both shoulder abduction RCT, Bilateral (direct) M/40s Motorcycle accident Knee dislocation, Bilateral GT Fx, Right M/41 Struck by a truck and rolled over by the truck M/41 Motor vehicle accident (ejected from the vehicle) F/70 Hanged on the shelf (indirect) M/58 Fall with both hands holding the ladder M/58 Not identified BPI, Bilateral Partial RCT, Bilateral F/76 Hanged on a tree with pulled by other person (indirect) Method of reduction Result C/R Full recovery at 7 th month with some motor weakness on right shoulder C/R Follow-up lost DVT and BPI, Left C/R Full recovery at 3 rd month with some sensory deficit GT Fx, Left C/R Full recovery at 5 th year (phone interview) RCT, Bilateral C/R Regained shoulder function at 3 rd month Axillary nerve injury, Right RCT, Bilateral (pre-existing) C/R Full use of his arms after 2 weeks C/R Returned to work at 6 th month with some motor weakness on right side C/R Occasional pain after 3 years Gelczer, J Trauma M/45 Thrown from horse back C/R Full range of motion after 2 months 1996 (direct) Lill, Unfallchirurg 1996 M/36 Fall from height (20 m) Multiple fracture C/R Mesa, Acta Orthop M/32 Vehicle over-turned C/R Complete recovery after 4 months Belg 1996 several times Brady, J Emerg Med F/80 Hanged on the wall while Complete range of motion after 1 month C/R 1995 slipping down (indirect) Newman, Injury 1993 F/73 Thrown forward after Able to eat and wash (follow-up period C/R being hit by a car not defined) Peiro, Injury 1975 M/49 Handed on a rotating machine Axillary nerve palsy, Left C/R Full recovery (follow-up period not defined) *BPI, brachial plexus injury; RCT, rotator cuff tear; C/R, closed reduction; GT Fx, greater tuberosity fracture; O/R, open reduction; DVT, deep vein thrombosis.

4 상완골대결절골절을동반한양측견관절하방탈구 493 할을하여, 여기에외전력이더해지면하관절와상완인대 (inferior glenohumeral ligament) 가파열되면서상완골이하방으로탈구된다는것이다. 6) 문헌에보고된양측성하방탈구중사다리에서미끄러지거나나무에매달려발생한예와굴러가는차에매달려끌려가다가발생한예들이간접손상에해당한다. 3,5,7) 직접손상은비교적드문경우로, 외전상태의견관절에상완골의종축을따라외력이가해질때상완골두가하방으로탈구되는경우이다. 1,2) 본증례는안전벨트를착용하지않고조수석에앉은상태로전방의차량을추돌하여발생한것인데, 추돌직전무의식적으로두팔을뻗쳐양손을계기판 (dashboard) 에올려놓은상태에서, 추돌순간축성압박이가해져탈구가발생한것으로추정되며, 위의손상기전중직접손상에의한것으로보인다. Garcia 등 7) 은일측성하방탈구는주로과도한견관절의외전으로인한간접손상이주된원인이며, 양측성일경우축성압박에의한직접손상이주된원인이라고하여, 양측성과일측성의기전이다소다르다고주장하였다. 그러나본저자들의문헌고찰에의하면, 양측성일경우사고의성격상발생기전을파악하기어려운경우가많으며, 2,8,9) 직접손상보다는간접손상으로보이는증례가많고, 3,4,9) 그가보고한증례역시트럭에매달려끌려가는동안과외전상태에견인력이더해져서발생한간접손상이라고본저자들은판단하고있다. 견관절하방탈구는동반손상이많은것이또다른특징이라할수있다. Mallon 등에의하면약 80% 에서회전근개의파열또는상완골대결절의골절을, 약 60% 에서신경손상이동반된다고하였다. 1) 신경손상은액와신경의손상이대부분이며, 보통축색단열증으로예후는양호하여, 2주내지 1년이내에대부분회복된다고한다. 1) 회전근개파열의빈도가높은것에대하여 Tsuchida 등은견관절하방탈구에회전근개의파열이흔히발견되지만고령의환자가많기때문에이것이항상탈구에따른손상이라고단정할수없다고하였다. 그가보고한증례는 76세의여자환자로탈구이전에이미광범위회전근개파열로진단받은환자였다. 5) Karaoglu 등 3) 이보고한증례도양측성회전근개파열이있었으나, 별도의치료는하지않았고, 경과도양호하다고하였다. 이밖에도액와동맥의폐색, 액와정맥혈전증등의혈관합병증이보고되기도하였다. 7) 액와동맥의손상은하방 탈구의 3.3% 정도에불과하지만다른탈구에비하면월등히높은것이라고한다. 1) 본증례는양측모두대결절의골절이동반되었는데, 전방탈구의경우대결절골절이주로고연령층에서동반되는것을고려하면매우특이한경우라고간주된다. 또한정복후대결절골절이 5 mm 이내의전위를보여내고정의적응증은아니라고판단하여비수술적치료를선택하였다. 10) 탈구의정복은상완골을종축을따라견인함과동시에대향견인을하여도수정복을시도하는데, 대개는본증례의경우처럼도수정복이가능하지만, 상완골두가파열된관절막에끼어서도수정복이불가능한경우가있어, 너무무리한도수정복은시도하지말아야하며이때는수술적정복이필요하다고한다. 4) Table 1에요약한증례들은모두도수정복이가능하였던경우이며, 대부분의보고에서어렵지않게도수정복이가능하였다고기술되어있다. 예후는비교적양호하여, 수주내지는수개월이내에일상생활에지장이없을정도로회복된증례가대부분이었다. 감사의글이연구는 2006학년도단국대학교대학연구비지원으로연구되었습니다. 참고문헌 1. Mallon WJ, Bassett FH 3rd, Goldner RD. Luxatio erecta: the inferior glenohumeral dislocation. J Orthop Trauma. 1990;4: Foad A, LaPrade RF. Bilateral luxatio erecta humeri and bilateral knee dislocations in the same patient. Am J Orthop. 2007;36: Karaoglu S, Guney A, Ozturk M, Kekec Z. Bilateral luxatio erecta humeri. Arch Orthop Trauma Surg. 2003;123: Musmeci E, Gaspari D, Sandri A, Regis D, Bartolozzi P. Bilateral luxatio erecta humeri associated with a unilateral brachial plexus and bilateral rotator cuff injuries: a case report. J Orthop Trauma. 2003;22: Tsuchida T, Yang K, Kimura Y, Taniwaki M, Ishigaki S, Itoi E. Luxatio erecta of bilateral shoulders. J Shoulder Elbow Surg. 2003;10:595-7.

5 494 서중배ㆍ민병권 6. Yanturali S, Aksay E, Holliman CJ, Duman O, Ozen YK. Luxatio erecta: clinical presentation and management in the emergency department. J Emerg Med. 2005;29: Garcia R, Ponsky T, Brody F, Long J. Bilateral luxatio erecta complicated by venous thrombosis. J Trauma. 2006;60: Kumar KS, O'Rourke S, Pillay JG. Hands up: a case of bilateral inferior shoulder dislocation. Emerg Med J. 2001;18: Sewecke JJ, Varitimidis SE. Bilateral luxatio erecta: a case report and review of the literature. Am J Orthop. 2001;35: Flatow EL, Cuomo F, Maday MG, Miller SR, McIlveen SJ, Bigliani LU. Open reduction and internal fixation of two-part displaced fractures of the greater tuberosity of the proximal part of the humerus. J Bone Joint Surg Am. 1991;73: = 국문초록 = 저자들은교통사고로발생된상완골대결절골절을동반한양측견관절하방탈구를체험하여보고한다. 환자는양측상지가외전된상태로내원하였으며, 도수정복술로탈구를정복한후, 보존적치료를시행하여 7 개월만에양측견관절의운동범위및근력이일상생활에전혀지장이없을정도로거의완전히회복되었다. 색인단어 : 양측성견관절하방탈구, 상완골대결절골절

P.P.Templat Korea

P.P.Templat Korea Physical examination of the shoulder Range of motion Range of motion 1. active ROM test - Apley scratch test Range of motion 2. passive ROM test - limitation in ROM 신경학적검사 (neurologic examination) 2. Muscle