견봉쇄골관절을침범한원위쇄골 골절의수술적치료 연세대학교대학원 의학과 주종환

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1 견봉쇄골관절을침범한원위쇄골 골절의수술적치료 연세대학교대학원 의학과 주종환

2 견봉쇄골관절을침범한원위쇄골 골절의수술적치료 지도교수강호정 이논문을석사학위논문으로제출함 2009 년 12 월 14 일 연세대학교대학원 의학과 주종환

3 주종환의석사학위논문을인준함 심사위원강호정인 심사위원양익환인 심사위원이종석인 연세대학교대학원 2009 년 12 월 14 일

4 감사의글 석사논문을쓰는것은제게학문의바다를헤치고나갈지도와나침반을얻는과정이었습니다. 연구계획에서부터완성에이르기까지아낌없는조언과세심한가르침을베풀어주신강호정교수님께깊은감사를드립니다. 논문심사과정에서사려깊은지도와따뜻한격려로이끌어주신양익환교수님, 이종석교수님께도진심으로감사드립니다. 언제나당신의아들을이세상최고라추어올려주시며용기를주시는어머니, 머리속으로밝은영감을불어넣어주시는아버지께끝없는사랑과존경을바칩니다. 지금까지저를지켜봐주시고지지해주신모든분들과함께이작은성취의기쁨을나누고자합니다 년 12 월 저자씀

5 < 차례 > 국문요약 1 I. 서론 3 II. 재료및방법 5 III. 결과 13 IV. 고찰 15 V. 결론 22 참고문헌 23 영문요약 28

6 그림차례 그림 1. T type locking compression plate 10 그림 2. Kirschner s wire and tension band wire fixation 10 그림 3. I n t r a a r t i c u l a r t r a n s a c r o m i a l K - w i r e fixation 11 그림 4. S h o u l d e r V e l p e a u s p i c a cast 12 그림 5. S u g g e s t e d n e w classification 21

7 표차례 표 1. Demographic data of the patients 7 표 2. Classification of functional results by Kona et al 8 표 3. Suggested new classification 20

8 < 국문요약 > 견봉쇄골관절을침범한원위쇄골골절의수술적치료 대부분의쇄골골절은보존적치료로만족할만한결과를얻을수있다. 이에비해원위쇄골골절은불유합이나지연유합의가능성이높아수술적치료를먼저고려하여야한다. 특히견봉쇄골관절의손상이동반된원위쇄골골절은불유합, 골절부돌출기형, 견봉쇄골관절의아탈구, 외상성관절염등의후유증이병발할가능성이높다. 이런중요성에도불구하고견봉쇄골관절손상을동반한윈위쇄골골절에대한적절한치료와치료결과에대한보고는많지않다. 이에저자는견봉쇄골관절의손상을동반한원위쇄골골절의수술적치료에대하여연구하였다. 1997년 7월부터 2008년 5월까지견봉쇄골관절의손상을동반한원위쇄골골절로수술적치료를받은 21명의환자를대상으로후향적연구를시행하였다. 견봉쇄골관절내골절, 관절의이개, 및상방아탈구등을동반한원위쇄골골절을 Neer분류와 Craig분류를이용하여분류하였다. 수술방법은분쇄정도와골다공증유무, 정복의용이성등에따라 T형금속판고정술 (9예), K-강선및긴장대강선고정술 (10예), 견봉쇄골관절을통과하는 K-강선고정술 (2예) 로고정하였다. 견봉쇄골관절 1

9 손상으로인하여금속판고정술후 K-강선으로견봉쇄골관절을추가고정한경우가 1예이었다. 수술후에는방사선학적평가와기능적평가를시행하였다. 19예에서성공적인골유합을얻었으며골유합까지의기간은평균 8.4주이었다. Kona 등의평가표에의한기능적평가에서 19예에서우수, 1예에서양호, 1예에서보통의결과를보였다. 골절유합후 13예에서경도의견봉쇄골관절면의불일치 (6예) 나부분적이개 (4예), 또는 50% 이하의상방아탈구 (3예) 가남아있었으나견관절의운동제한이나통증이있는경우는없었다. 견봉쇄골관절손상을동반한원위쇄골골절에대한수술적치료로 T형금속판고정술및긴장대강선고정술은추천할만한치료방법이며, 원위쇄골골절의정확한정복과견고한내고정이이루어진다면추가적인오구쇄골인대복원술이나, 견봉쇄골관절의아탈구나부분적이개에대한추가적인처치는필요하지않을것으로생각된다. 핵심되는말 : 원위쇄골골절, 견봉쇄골관절손상, 관혈적정복술 2

10 견봉쇄골관절을침범한원위쇄골골절의수술적치료 < 지도교수강호정 > 연세대학교대학원의학과 주종환 I. 서론 원위쇄골골절은쇄골근위부나중간부골절에비하여강한외력에의한손상이많고흔히견봉쇄골관절을침범하는관절내골절이나견봉쇄골관절탈구등의손상을동반한다. 대부분의쇄골골절이보존적치료로만족할만한결과를얻을수있는데비해전체쇄골골절의 12-15% 를차지하는원위쇄골골절은지연유합이나불유합의가능성이높아수술적치료를우선고려하여야한다 1-5. 특히견봉쇄골관절의손상을동반한원위쇄골골절은장기적으로견봉쇄골관절의관절증, 골용해, 관절이개등과함께통증을유발하여골절유합후에도윈위쇄골절제술등의추가수술을요하는경우도있다. 이러한중요성에도불구하고견봉쇄골관절손상을동반한원위쇄골골절에대하여견봉쇄골관절손상을주의깊게고려한적절한치료와치료결과에대한보고는많지않다. 3

11 수술적치료의방법으로는견봉쇄골관절을통과하는 K-강선, Knowles핀, Steinmann핀등을이용하여윈위쇄골과견봉을고정하는방법, 견봉쇄골관절고정없이 K-강선과긴장대강선을이용하거나다양한금속판을사용하여윈위쇄골을고정하는방법, 오구쇄골인대나사못고정술, 오구쇄골인대재건술등다양한방법이소개되었으며대체로양호한치료결과를보이고있으나관절에대한추가손상을줄이면서윈위쇄골의작은골절편을견고하게고정하고높은골유합을얻을수있는최선의수술방법에는아직논란이있다. 저자는 1997년 7월부터 2008년 5월까지견봉쇄골관절의손상을동반한원위쇄골골절로수술적치료를받은 21명의치료결과에대해분석하였다. 4

12 II. 재료및방법 1997년 7월부터 2008년 5월까지견봉쇄골관절의손상을동반한원위쇄골골절로수술적치료를받은환자중 1년이상추시가가능하였던 21명의환자를대상으로후향적연구를시행하였다 (Table 1). 수상당시연령은 16세부터 74세로평균 37.3세였으며, 남자 14명, 여자 7명이었다. 손상원인은오토바이사고등교통사고 10예, 넘어져발생한경우가 6예, 스노우보드를타다넘어져발생한경우가 2예, 다른사람과싸우다다친경우가 2예, 추락이 1예였다. 동측상지의동반손상으로는상완골대결절골절이 1예, 견봉골절이 1예, 상완신경총마비와흉골골절이동반된예, 오구돌기골절과견갑골관절와골절이동반된예가각각 1예있었다. 방사선사진및 CT 검사상원위쇄골의골절선이견봉쇄골관절로연장되어있거나, 7mm 이상의견봉쇄골관절의이개및건측과비교해서 25% 이상원위쇄골의상방전위가있는경우견봉쇄골관절의손상이있는것으로분류하였다 6, 7. 견봉쇄골관절을침범하였더라도골절의전위및분쇄가심하지않아보존적으로치료하였던원위쇄골골절은제외하였다. 골절의분류는 Rockwood가수정한 Neer분류 5 와 Craig분류 8 를이용하여분석하였으며, 술후임상적, 방사선학적평가를시행하였고 Kona 등 9 의기준을통해기능적결과를분석하였다 (Table 2). Neer I형이 1예, IIa형이 5

13 3예, IIb형이 14예이었으며 Neer III형은 3예이었다. Craig분류상으로는 I 형이 1예, IIb형이 13예, III형이 3예, V형이 4예이었다. 동반된견봉쇄골관절손상의정도는 Rockwood group의견봉쇄골관절손상분류 10 의여섯유형중대부분이 II형 (16예) 과 III형 (3예) 에해당하였으며 2예는 5형으로나눌수있었다. 6

14 Table 1. Demographic data of the patients No Sex/ Age Neer Craig Method of fixation Ass. injury AC joint Involvement Union wks Functional score 8 M/47 IIb IIb TBW* (-) D 10 Excellent 9 F/54 III III TBW Humerus D 12 Excellent G.tubercle Fx. 12 M/16 IIb IIb T-plate, BG Brachial plexus palsy, D 8 Good Sternum Fx. 14 M/16 IIb IIb T-plate (-) D 7 Excellent 20 F/74 IIb IIb T-plate, (-) D 12 Excellent Phemister 23 M/28 IIb IIb T-plate, mini (-) D 8 Excellent screw 28 M/17 IIb IIb T-plate (-) D 6 Excellent 38 M/26 IIb IIb Leibinger plate, (-) D 8 Excellent TBW 42 F/28 I I TBW (-) D 6 Excellent 44 M/41 IIa V T-plate (-) D 4 Excellent 4 M/25 IIa V TBW (-) Int 6 Excellent 6 M/26 III III TBW (-) Int Non Excellent 21 M/51 IIb IIb TBW (-) Int 9 Excellent 22 M/51 IIb IIb TBW, mini (-) Int 12 Excellent screw 27 F/60 III III TBW (-) Int 12 Excellent 33 F/36 IIb IIb TBW (-) Int 6 Excellent 40 M/37 IIb IIb T-plate, TBW Coracoid process Fx, Int 16 Fair glenoid fossa Fx 19 M/67 IIb V Phemister Acromion Fx. D & Int Non Excellent 39 F/38 IIa V T-plate, BG (-) D & Int 8 Excellent 17 M/25 IIb IIb T-plate (-) D & Int 7 Excellent 37 F/21 IIb IIb Phemister, (-) D & Int 5 Excellent miniscrew TBW* : Tension band wiring D : Dehiscence of acromioclavicular joint Int : Intra-articular extension of fracture AC joint : Acromioclavicular joint Fx. : Fracture 7

15 Table 2. Classification of functional results by Kona et al Excellent Patients were asymptomatic and capable of unrestricted use of extremity Good Patients were able to resume their former occupation but complained of a mild non-debilitating reduction in motion, loss of strength, or pain Fair Patients had persistent discomfort, weakness, or loss of motion significant enough to interrupt the patients preferred lifestyle on a daily basis but still allow the patient to pursue most desired activities or remain at his preinjury employment status, with little or no modification of work requirements Poor Patients had a residual disability causing a significant alteration in their work or lifestyle 수술방법은골절의형태및분쇄양상, 골다공증의유무에따라 T형잠김압박금속판 (locking compression plate), 스테인리스 T형금속판, 티타니움 Leibinger 소형금속판등금속판을이용한내고정술 (Figure 1) 과 K- 강선및긴장대강선고정술 (Figure 2), 소형나사못고정술, 견봉쇄골관절을가로지르는 K-강선고정술 (Figure 3) 중에서선택하였다. 원위골편이매우작고쇄골의상방전위로인해견봉쇄골간격이건측에비해 100% 이상증가되어있었던 2예에서는견봉쇄골관절 K-강선고정술을시행하였다. 대부분에서는견봉쇄골관절을추가고정하지않았으며 1예에서원위쇄골골절을해부학적으로정복하고금속판으로고정한뒤에도 90% 가량의견봉의상방아탈구가잔존하여 K-강선으로견봉쇄골관절을추가고정하였다. 분쇄가심하거나골다공증으로인해강한고정력이필요한경우에는가 8

16 급적금속판고정술을선택하였고그외상대적으로정복이용이하였던경우에는 K-강선및긴장대강선고정술을시행하였다. 금속판을이용한내고정술이 9예, K-강선및긴장대강선고정술이 10예에서시행되었다. 금속판을이용한내고정술 9예중골편의분쇄가심했던 2예에서동종골이식을동시에시행하였으며 2예에서는보다견고한고정을위하여금속판내고정과함께긴장대강선고정술을추가하였다. 수술후최소 3주이상 Velpeau 붕대고정을하였으며, 분쇄가심하거나원위골편이작아수술을통해견고한고정이어려웠던 4예에서는선택적으로변형된견관절수상붕대및석고고정술 (Shoulder Velpeau spica cast) 을시행하였다 (Figure 4). 평균고정기간은 4.2주이었으며이후에견관절의수동적및능동적관절운동을시행하였다. 골유합은쇄골의전후면및두경사방사선사진에서골소주가연결되는것을확인하는것으로판정하였으며정복여부와내고정물의이동등을관찰하였다. 9

$fracture(craig s type V) was treated with T-type locking$ $(A)Preoperative clavicle anteroposterior view presents fracture$ (B)Immediate postoperative clavicle anteroposterior view.

(B)Immediate postoperative clavicle anteroposterior view.

(C) Roentgenogram after removal of wires at postoperative 9 months.

17 Fig. 1A Fig. 1B Fig. 1C Fig. 1A-C. A 38-year-old woman with left distal clavicle intra-articular fracture(craig s type V) was treated with T-type locking compression plate. (A)Preoperative clavicle anteroposterior view presents fracture line extending to acromioclavicular joint. (B)Immediate postoperative clavicle anteroposterior view. Satisfactory reduction and T-type LCP fixation were seen. (C) Roentgenogram after removal of wires at postoperative 9 months. It shows congruent acromioclavicular joint. Fig. 2A Fig. 2B Fig. 2C Fig. 2A-C. Kirschner s wire and tension band wire fixation was selected to treat a 60- year-old woman with left distal clavicle intra-articular fracture(craig s type III) due to car accident. (A)Preoperative clavicle anteroposterior view of Craig type III fracture. 10

(B)She was treated by additional tension band wiring because of comminution. (C)Roentgenogram after removal of wires at postoperative 15 months.

$Intraarticular transacromial K-wire fixation was used to treat a 21-year-old female with right distal clavicle fracture(craig type V) and acromioclavicular$ (B)She was treated by intra-articular acromioclavicular fixation. The inferior comminuted fragment was fixed using 5 mini screws.

(B)She was treated by intra-articular acromioclavicular fixation. The inferior comminuted fragment was fixed using 5 mini screws.

18 (B)She was treated by additional tension band wiring because of comminution. (C)Roentgenogram after removal of wires at postoperative 15 months. A little incongruency of acromioclavicular joint was seen. But function result was excellent. Fig. 3A Fig. 3B Fig. 3C Fig. 3A-C. Intraarticular transacromial K-wire fixation was used to treat a 21-year-old female with right distal clavicle fracture(craig type V) and acromioclavicular joint injury due to car accident. (A)Preoperative anteroposterior view of shoulder. Note the periosteal sleeve type fracture and inferior comminuted fragment. (B)She was treated by intra-articular acromioclavicular fixation. The inferior comminuted fragment was fixed using 5 mini screws. The lateral ends of K-wires were inserted subcutaneously. (C)After removal of K-wires. Roentgenogram shows no dislocation and no upward displacement of distal clavicle. No superior subluxation of acromioclavicular joint was seen. 11

19 Fig. 4. Shoulder Velpeau spica cast. We bind the elastic bandage about trunk and upper extremity and then wrap fiberglass cast. It supports weight of upper extremity and neutralizes displacement force by reducing load on fracture site. 12

20 III. 결과 방사선학적추시에서골막소매골절 (periosteal sleeve fracture) 형태한예와 K-강선주위의감염으로인하여술후 5주째내고정물을제거한한예를제외한 19예에서골유합을확인할수있었으며평균골유합의기간은술후 8.4주 (4-16주) 였다. 유합에실패한골막소매골절의예는술후 1년후에도 50% 이상의견봉의상방아탈구가잔존하고있으나통증이나운동제한이없었고감염으로인해 K-강선을제거한예는골유합에는실패하였으나감염은적절히치료되었으며골편의이동이나골절부의압통, 운동제한없이일상생활이가능하였다. 그러나불유합된 2예모두수술후 13개월가량으로추시기간이짧아후유증의발생여부를정확히판단하려면좀더장기간의연구가필요하다. 수술후평균 11개월경과후내고정물을제거하였다. Kona 등 9 의평가기준에의한기능평가는 19예에서우수, 1예에서양호, 1예에서보통의결과를보였다. 방사선추시상골절유합후에도 13예에서견봉쇄골관절면의불일치 (6예) 나부분적이개 (4예) 또는 50% 이하의상방아탈구 (3예) 가남아있었으나기능상의장애, 운동범위의감소나통증을호소하는경우는없었다. K-강선및긴장대강선으로수술한 5예에서 K-강선이피하돌출소견이있었으나한예에서만피부자극등의증상을이유로술후약 4개월째조기에내고정물을제거하였다. 13

21 T 형금속판을이용한 2 예에서일부나사못의이완 (Pull-out) 이관찰되었으 나골유합에는영향이없었다. 1 예에서술후 3 주째수술창상감염으로절 개배농술을시행하였으나역시골유합에영향을미치지않았다. 14

22 IV. 고찰원위쇄골골절은근위부나중간부쇄골골절과달리불유합등의합병증으로인하여보존적치료보다수술적치료를우선고려하여야한다 1-3. Nordqvist 등은 110예를대상으로한 15년추시연구에서윈위쇄골골절에대한수술이필요하지않다고주장하였으나동시에 10예의불유합을경험하였다고하였다. 또한 Hessmann 등 11 은안정골절은보존적치료로충분하였으나견봉쇄골관절을침범하거나오구쇄골인대손상을동반한불안정원위쇄골골절에대한보존적치료는그결과가불량하였다고보고한바있다. 이에따라본연구에서는윈위쇄골골절중보존적치료가가능하였던안정골절을제외하고견봉쇄골인대손상을동반한불안정윈위쇄골골절을연구대상으로하였다. Neer 3, 12 가원위쇄골골절의보존적치료시 30% 의불유합을보고한이래다양한수술방법이소개되어왔다. 골편의크기와위치, 오구쇄골인대의파열여부및견봉쇄골관절의손상여부에따라수술방법을결정하게되는데 K-강선이나 Steinmann pin을견봉에서견봉쇄골관절을통과하여골절부위를고정하는방법 1, 3, 9, 골절면의근위부와원위부에 K-강선을삽입하고 8자형긴장대법으로강선을고정하는술식 13, T형금속판이나 Wolter 금속판등금속판을이용하는방법 2, 14, 쇄골을오구돌기에고정하 는 Bosworth 술식 15 등의오구쇄골나사못고정술, Dacron tape 나 PDS 봉합 15

23 사를이용하는오구쇄골인대재건술, 근이전술등이있다. 다양한수술방법을통한여러저자들의치료결과와함께합병증과단점또한보고되고있다. 우선흔히쓰이는수술방법으로견봉쇄골관절을통과하는 K-강선고정법을들수있는데 Neer 12 는이방법을통하여평균 6주만에골유합을얻었다고보고하고훌륭한수술방법으로추천하였고이후 K-강선대신 Knowles핀등을이용한다른연구에서도우수한결과를보이고있다. 그러나 Kona 9 는같은방법으로다수의불유합과심부감염을경험하였다고보고하였으며 Craig 8 는 Knowles핀을이용한연구에서견봉쇄골관절염의우려가있음을지적하였고이밖에내고정물의파손이나이동이보고된예도많다. 금속판을이용하여고정하는방법또한널리쓰이고있는데고정력이우수하다는장점이있으나외측단부에두세개의나사못을삽입할수있을만큼의충분한골편의부족등으로사용상제한이있을수있고상대적으로피부절개와골막박리가광범위하다는한계점이있다 2. 마지막으로 Yamaguchi 등 16 은일시적인오구쇄골나사못고정으로우수한결과를얻었으나수술술기가다소어렵고관절운동의제한이있을수있음을단점으로지적하였으며 Goldberg 등 17 은 Dacron tape를이용한오구쇄골인대재건술을동시에실시하여우수한결과를얻을수있었으나쇄골및오구돌기의미란, 골용해가능성을언급하였다. 이러한단점을극복하기위해새로운수술방법이제시되었는데 Kao 등 13 16

24 은견봉쇄골관절을통과하지않는 K-강선및긴장대강선고정술을통하여우수한결과를보고하였고강등 18 도같은방법으로 95% 이상의골유합을얻었다고하였다. 또한고식적인금속판의단점을보완한 T형잠김압박금속판등의새로운금속판을사용하여원위골편이짧거나분쇄가심한경우, 노인의골다공증성원위쇄골골절에도견봉쇄골관절에추가적인손상을주지않고골편을견고하게고정하여좋은결과를보고하고있다 14. 본연구에서도주된수술방법으로 5예에서원위요골용 T형금속판, 3예에서 T형잠김압박금속판, 1예에서 Leibinger 소형금속판과동시에추가적인소형나사를이용하는금속판고정술과 10예에서긴장대강선고정술을선택하여우수한치료결과를얻을수있었다. K-강선및긴장대강선고정술을이용한경우내고정물의이완이좀더발생하여핀부위의돌출이촉지되었으나불유합이나내고정물로인한조기의돌출핀제거술은한예를제외하고는없었다. 동반된견봉쇄골관절손상에대하여서는오구쇄골간간격이건측에비해 100% 이상증가한이른바 Rockwood 분류상 V형에해당하는 2예에서견봉쇄골관절을통과하는 K-강선고정술을이용하여수술하였고그외한예에서금속판고정에추가하여 K-강선을이용한견봉쇄골관절고정을시행하였다. 이를제외한 18예에서는오구쇄골인대재건이나견봉쇄골관절고정없이원위쇄골골절만정복후고정하였는데이는 Galpin 19, Larsen 17

25 등 20 이주장한바와같이 Rockwood 분류상 II형, III형견봉쇄골관절손상에서는보존적치료의임상결과가더우수하다는최근의보고와도일치하는것이다. 본연구에서도 13예에서방사선추시상골절유합후에도경도의관절면의불일치 (6예) 나쇄골의상방전위 (3예) 가남아있었으나통증, 운동장애, 돌출기형등을호소하는경우는없었는데이것은 Rockwood 분류상 II, III형의견봉쇄골관절의손상에서견봉쇄골관절의해부학적정복이임상결과에큰영향을미치지않는다는이전의연구결과와다르지않다 그러나 Mouhsine 등 25 은 Rockwood I, II형손상의 6년추시연구에서 52% 의환자에서통증과불편감이발생하였다고보고한바, 후외상성관절염의발생여부등은더많은증례와장기추시가필요할것으로생각한다. Allman 26 은골절의위치에따라서쇄골골절을세그룹으로나누었으며 Neer 3, 12 는원위쇄골골절의특이점에주목하여이를다시오구쇄골인대가온전한 I형과내측골편과오구쇄골인대의연결이소실된불안정골절인 II형, 관절면의손상이있는 III형의세가지로분류하였다. 이후 Rookwood 5 는 Neer II형골절을원추인대 (Conoid ligament) 와능형인대 (Trapezoid ligament) 가손상되지않은 IIa형과원추인대가손상된 IIb형으로세분하였다. Craig 8 는 Allman과 Neer의분류를통합하면서골막소매 (Periosteal sleeve) 골절, 관절내분쇄골절을추가하여원위쇄골골절 18

26 을 5가지유형으로좀더상세하게분류하였다. 그러나기존의분류법은형태가복잡한원위쇄골골절의유형을정확히나누는데한계가있으며특히본연구에서와같이견봉쇄골관절의손상을적절히반영하지못하는단점이있다. Rookwood IIa형, IIb과 Craig II형의경우오구쇄골인대의손상여부와골절편의위치에만초점을두어견봉쇄골관절의이개가있거나골절선이관절내로확장된경우를고려하지않았고특히관절내골절이동반된경우 Neer III형및 Craig III형과구분하여분류하고자할때혼란을초래할수있다. 또한오구쇄골인대의파열이있더라도원위쇄골골절을해부학적으로정확히정복하고견고한고정을한다면오구쇄골인대의추가적인재건없이도우수한치료결과를얻을수있으므로 Neer II형골절을원추인대와능형인대손상유무에따라 IIa, IIb형으로다시세분하는것은임상적인의미가떨어진다하겠다. 다시말해 Neer 분류법과 Craig 분류법은견봉쇄골관절의손상을고려하지않고오구쇄골인대의손상과오구돌기쇄골간간격의증가에초점을두어원위쇄골골절을분류하고있다. 오히려골절에동반된견봉쇄골관절의손상의정도를평가하여수술적치료의필요여부를결정하는데도움을줄수있도록견봉쇄골관절손상을단순화하는것이필요하다. 저자는견봉쇄골관절손상이동반된원위쇄골골절에대해다음과같이새로운분류를제안하였다 (Table 3). 기존의 Neer III형과동일한단순관절내안정골절인제 1형 19

27 과관절내골절과함께관절의 7mm 이상의이개가동반된제 2 형, 관절 내로확장된골절선과함께건측에비해 50% 이상의쇄골의상방아탈구가 있는제 3 형으로분류하였다 (Figure 5). 제 1 형과 2 형은원위쇄골골절을 정복하여견고하게고정한다면견봉쇄골관절에대한추가적인수술이필 요하지않으나제 3 형의경우상방으로전위된쇄골을정복하고견봉쇄골 관절을고정하는술식을필요로한다. 견봉쇄골관절의단순관절내안정 골절, 오구돌기쇄골간간격의증가와이로인한이차적인견봉쇄골관절 의아탈구는본연구의결과치료결과에영향을미치지않으므로, 견봉쇄 골관절손상이동반된원위쇄골골절의치료에있어복잡한기존의분류 대신에저자의새로운분류법은치료방법을선택하고예후를예측하는데 도움을줄수있을것으로생각한다. Table 3. Suggested new classification of distal clavicle fractures with acromioclavicular joint injuries Type I Simple intraarticular fracture Type II Type III Intraarticular fracture and Separation of joint above 7mm, but under 50% superior subluxation Superior dislocation above 50% comparing to opposite side, or Severely comminuted intraarticular fracture with superiorly displaced fragments 20

28 Type I: simple AC intraarticular type Type II: above 7mm AC separation type under 50% sup. subluxation Type III: above 50% AC superior dislocation type Fig. 5. Suggested new classification of distal clavicle fractures with acromioclavicular joint injuries 21

29 V. 결론 견봉쇄골관절의이개, 상방아탈구또는관절내골절을동반한원위쇄골골절 21예중 18예에서견봉쇄골관절고정없이 T형금속판혹은소형금속판을수술방법과 K-강선과긴장대강선을이용한수술방법으로만족한만한결과를얻었다. 술후 1년간추시에서경도의견봉쇄골관절면의불일치 6예 (28%), 4예의부분적이개 (19%), 및 50% 이하의상방아탈구 3예 (14%) 의결과를보였으나이러한소견이임상적결과에영향을미치지는않았다. 또한견봉쇄골관절손상을간과한기존의복잡한분류대신치료방법을선택하고예후를예측하는데도움을줄수있는간편한새로운분류법이임상적으로필요하다. 원위쇄골골절의치료에있어동반된견봉쇄골관절의손상에항상주의하여야하나원위쇄골골절을해부학적으로정복하고견고하게고정한다면전위가심하지않은동반된견봉쇄골관절의손상에대하여추가적인수술은필요하지않을것으로생각된다. 22

30 참고문헌 1. Edwards DJ, Kavanagh TG, Flannery MC. Fractures of the distal clavicle: a case for fixation. Injury 1992;23: Hessmann M, Kirchner R, Baumgaertel F, Gehling H, Gotzen L. Treatment of unstable distal clavicular fractures with and without lesions of the acromioclavicular joint. Injury 1996;27: Neer CS, 2nd. Fracture of the distal clavicle with detachment of the coracoclavicular ligaments in adults. J Trauma 1963;3: Nordqvist A, Petersson C, Redlund-Johnell I. The natural course of lateral clavicle fracture. 15 (11-21) year follow-up of 110 cases. Acta Orthop Scand 1993;64: Rockwood CA. Fractures of the outer clavicle in children and adults. J Bone Joint Surg Br 1982;64: Petersson CJ, Redlund-Johnell I. Radiographic joint space in normal acromioclavicular joints. Acta Orthop Scand 1983;54:

31 7. Zanca P. Shoulder pain: involvement of the acromioclavicular joint. (Analysis of 1,000 cases). Am J Roentgenol Radium Ther Nucl Med 1971;112: Craig EV. Fractures of the clavicle. In: Rockwood CA, Matsen FA, editors. The shoulder. Philadelphia: WB Saunders; p Kona J, Bosse MJ, Staeheli JW, Rosseau RL. Type II distal clavicle fractures: a retrospective review of surgical treatment. J Orthop Trauma 1990;4: Tossy JD, Mead NC, Sigmond HM. Acromioclavicular separations: useful and practical classification for treatment. Clin Orthop Relat Res 1963;28: Hessmann M, Gotzen L, Kirchner R, Gehling H. [Therapy and outcome of lateral clavicular fractures]. Unfallchirurg 1997;100: Neer CS, 2nd. Fractures of the distal third of the clavicle. Clin Orthop Relat Res 1968;58: Kao FC, Chao EK, Chen CH, Yu SW, Chen CY, Yen CY. Treatment of distal clavicle fracture using Kirschner wires and tension- 24

32 band wires. J Trauma 2001;51: Kang HJ, Park KK, Yoon HK, Song HK, Hahn SB. T Plate Fixation for Unstable Fracture of Distal Clavicle. J Korean Fracture Soc 2006;19: Tsou PM. Percutaneous cannulated screw coracoclavicular fixation for acute acromioclavicular dislocations. Clin Orthop Relat Res 1989: Yamaguchi H, Arakawa H, Kobayashi M. Results of the Bosworth method for unstable fractures of the distal clavicle. Int Orthop 1998;22: Goldberg JA, Bruce WJ, Sonnabend DH, Walsh WR. Type 2 fractures of the distal clavicle: a new surgical technique. J Shoulder Elbow Surg 1997;6: Kang HJ, Chung JB, Sung SY, Hahn SB, Ha JW. Tension Band Wire Fixation for Comminuted Distal Clavicle Fracture. J Korean Soc Surg Hand 2004;9: Galpin RD, Hawkins RJ, Grainger RW. A comparative analysis of operative versus nonoperative treatment of grade III acromioclavicular separations. Clin Orthop Relat Res 1985:150-25

33 Larsen E, Bjerg-Nielsen A, Christensen P. Conservative or surgical treatment of acromioclavicular dislocation. A prospective, controlled, randomized study. J Bone Joint Surg Am 1986;68: Bannister GC, Wallace WA, Stableforth PG, Hutson MA. The management of acute acromioclavicular dislocation. A randomised prospective controlled trial. J Bone Joint Surg Br 1989;71: Bannister GC, Wallace WA, Stableforth PG, Hutson MA. A classification of acute acromioclavicular dislocation: a clinical, radiological and anatomical study. Injury 1992;23: Bjerneld H, Hovelius L, Thorling J. Acromio-clavicular separations treated conservatively. A 5-year follow-up study. Acta Orthop Scand 1983;54: Dias JJ, Steingold RF, Richardson RA, Tesfayohannes B, Gregg PJ. The conservative treatment of acromioclavicular dislocation. Review after five years. J Bone Joint Surg Br 26

34 1987;69: Mouhsine E, Garofalo R, Crevoisier X, Farron A. Grade I and II acromioclavicular dislocations: results of conservative treatment. J Shoulder Elbow Surg 2003;12: Allman FL, Jr. Fractures and ligamentous injuries of the clavicle and its articulation. J Bone Joint Surg Am 1967;49:

35 Abstract Operative treatment of distal clavicle fracture involving acromionclavicular joint Jonghwan Joo Department of Medicine The Graduate School, Yonsei University (Directed by Professor Hojung Kang) While conservative treatment can be a satisfactory option for common clavicle fracture, surgical treatment must be a primary consideration for distal clavicle fracture because of the risk of nonunion and delayed union. Especially, as for the distal clavicle fracture accompanied by acromioclavicular joint injury, sequeale such as nonunion, bony prominence, acromioclavicular joint protrusion and posttraumatic arthritis can occur after the union of fracture. In spite of such importance, there are not enough studies about proper treatment choices and their results for the distal clavicle fracture accompanied by acromioclavicular joint injury. I have obtained positive results from performing surgical treatment including open reduction and internal fixation for the distal clavicle fracture with 28

36 acromioclavicular joint injury. Here, I intend to explain such cases with literature investigation. I conducted retrospective study of twenty one patients who received surgical treatment for distal clavicle fracture with acromioclavicular joint injury between July 1997 and May I classified cases of distal clavicle fracture accompanied by intraarticular fracture, dehiscence, or subluxation of acromioclavicular joint, using Neer s classification and Craig s classification. Considering severity of comminution, grade of osteoporosis and simplicity of fracture reduction, T-type plate fixation(9 cases), K-wire and tension band wiring(10 cases), and intraarticular transacromial K-wire fixation(2 cases) was used when performing internal fixation. In one case, additional intraarticular transacromial K-wire fixation was performed with T-type plate fixation. After the surgery, radiological evaluation and functional assessment were conducted. In 19 cases, we obtained bone union, and the average period of bone union was 8.4 weeks. According to Kona s functional assessment scale, 19 cases showed excellent results, one case good, and one case fair. After the 29

37 bone union, in acromioclavicular joint of 13 cases, incongruency(6 cases), slight dehiscence(4 cases) or superior subluxation(3 cases) below 50% was found. However, none of patients complained of bony protrusion, pain or limitation of motion. Surgical treatment such as T-type plate fixation and tension band wiring without transarticular acromioclavicular fixation are highly recommended for distal clavicle fracture with acromioclavicular joint injury. In cases of acromioclavicular joint injuries without serious displacement, no additional surgery such as coracoclavicular ligament reconstruction or transacromial K-wire fixation is necessary if accurate reduction and firm fixation of distal clavicle fracture are performed Key Words : distal clavicle fracture, acromioclavicular joint injury, internal fixation 30

10-19강호정

10-19강호정 대한견 주관절학회지제 10 권제 2 호 J. of Korean Shoulder and Elbow Society Volume 10, Number 2, December, 2007 원위쇄골불유합의수술적치료 연세대학교의과대학정형외과학교실 강호정 * 윤항섭 한수봉 김성재 Operative Treatment of Distal Clavicle Fracture Nonunion