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1 ORIGINAL ARTICLE pissn eissn J Korean Soc Surg Hand 2015;20(2): JOURNAL OF THE KOREAN SOCIETY FOR SURGERY OF THE HAND Comparative Study of Outcomes between Operative and Non-Operative Treatment of Unstable Distal Radius Fracture in the Elderly Patients Jong Min Kim, Hyun Je Seo, Young Dae Jeon, Hyung Min Lee, Jung Hwan Son Department of Orthopedic Surgery, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Korea Received: March 19, 2015 Revised: June 17, 2015 Accepted: June 20, 2015 Correspondence to: Jung Hwan Son Department of Orthopaedic Surgery, Kosin University Gospel Hospital, Kosin University College of Medicine, 262 Gamcheon-ro, Seo-gu, Busan , Korea TEL: FAX: junghson@dreamwiz.com This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( licenses/bync/3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Purpose: The goal of this retrospective study is to compare radiologic outcome and clinical outcome between operative and non-operative treatment of unstable distal radius fracture in patients over 65-year-old. Methods: From December 2006 to December 2011, 114 patients over 65-yearold were enrolled in the present study. 45 patients underwent non-operative treatment, and 69 patients underwent operative treatment. We retrospectively reviewed radiologic results and clinical results and then compared the two groups. Radiologic results include radial inclination (RI), volar tilt angle (VT) and radial shortening (RS) shown on the last radiograph and clinical results including disabilities of the arm, shoulder and hand (DASH) scores, modified Mayo wrist score (MMWS), and range of motion (ROM) of wrist. Results: All cases presented bone-union. Among the patients who received non-operative treatments, average RI of 15.5, average VT of 14.1, average RS of 5.3 mm, The patients who received operative treatments showed average volar tilt of 3.9, average VT of 18.2, and average RS of 1.1 mm. RS showed a significant difference (p<0.05). At Clinical evaluation, DASH score, MMWS score, the ROM of wrist joint did not show significant difference (p>0.05). Conclusion: Our results suggest that non-operative treatment is initially recommended in patients over 65 years who have an unstable distal radius fracture in terms of functional results. Keywords: Unstable distal radius fracture, Operative treatment, Non-operative treatment 서론 원위요골골절은상지에서발생하는가장흔한골절로서, 전체상완골골절중약 74.5% 정도를차지한다 1. 과거에는불안정성이심한경우를제외하고는도수정복후석고붕대고정의비수술적치료를주로시행해왔으나, 최근에는정확한 해부학적정복으로얻어지는기능적결과에대한관심이높아지면서수술적치료를선택하는경향이늘고있다. 그러나고령환자에서는적절한치료방법을선택함에있어여전히논란의여지가있다. 이는젊은환자의불안정원위요골골절은해부학적복원이보다우수한임상적결과를기대할수있는것으로알려져있으나 2,3, 고령환자에서발생한불안정원위 Copyright c The Korean Society for Surgery of the Hand 43

J Korean Soc Surg Hand Vol. 20, No. 2, June 2015 요골골절은도수정복으로해부학적으로만족할만한결과를얻지못한다고하여도임상적으로는좋은결과를보일수있으며 4,5, 방사선학적결과와임상적결과사이에연관성이떨어진다는보고도있기때문이다 6-8.

2 J Korean Soc Surg Hand Vol. 20, No. 2, June 2015 요골골절은도수정복으로해부학적으로만족할만한결과를얻지못한다고하여도임상적으로는좋은결과를보일수있으며 4,5, 방사선학적결과와임상적결과사이에연관성이떨어진다는보고도있기때문이다 6-8. 이에저자들은불안정성원위요골골절을동반한 65세이상의고령환자에서수술적치료와비수술적치료의방사선학적결과와임상적만족도를비교하고자하였다. 대상및방법 1. 연구대상 2006년 12 월에서 2011년 12 월까지불안정성원위요골골절로진단받은 65세이상의환자중, 6개월이상 ( 평균, 10.8개월 ; 범위, 6-22개월 ) 추시가가능했던 114명을대상으로하였다. 환자의평균나이는 71.7세 ( 범위, 65-89세 ) 였고, 여성은 86명, 남성 28 명이었으며, 수상원인은보행중실족이 98예 (86%) 로가장많았다. 골밀도검사는 114명중 81 명의환자에서시행하였으며, 평균 T-score 는 -3.4 ( 범위, -5.8 to -0.2) 이었고, 이중 69 명 (85%) 에서 -2.5 이하로측정되어골다공증으로진단되었다. 수술적치료를받은환자가 69명이었고비수술적치료를받은환자는 45명이었다. 수술적방법으로는도수정복후 K- 강선고정술이나관혈적정복및잠김압박금속판내고정술을시행하였고, 비수술적방법으로는도수정 복후장상지석고붕대고정술을시행하였다. 모든환자는내원시응급실에서도수정복및설탕집게부목고정술을시행하였으며, 수일후부종이감소한뒤장상지석고붕대고정술을하기전또는수상 2주내에추시과정에서다시단순방사선사진을촬영하였다. 이때원위요골의배측경사가 20 이상이거나요골단축이 3 mm 이상, 도는관절면의 step-off가 2 mm 이상인불안정성골절을보일경우수술적치료를권유하였다. 비수술적치료는환자의전신상태및환자및보호자의요구등으로선택하였고장상지부목고정술을수상후 6주간시행하였다 (Fig. 1). 수상 6주이후일괄적으로석고붕대를제거하였고수동적및점진적인능동적관절운동을시행하다가단순방사선사진에서골유합이진행되는소견이보일때운동범위를증가시키는재활치료를진행하였다. 수술을시행한 69명중 31명은잠김압박금속판내고정술을시행하였고 (Fig. 2) 38 명은 K- 강선고정술을시행하였다 (Fig. 3). K-강선고정술의경우전신마취나상완신경총마취, 또는환자의전신상태가좋지않을경우국소마취하에영상증폭장치를보면서도수정복을시행하여관절내골절간격이정복되는것을확인한후 mm의 K- 강선을삽입하였다. 강선삽입시에는요골의경상돌기위에 11 번수술칼로 5 mm 정도절개를가한뒤끝이둔한기구로골막까지보이게하여신전건이나표재성요골신경에주의하며시 Fig. 1. Radiographs of 84-yerar-old female who received conservative treatment. (A) Radiograph shows 1.8mm radial shortening and 24.7 dorsal tilting. (B) Closed reduction and sugar tong splint was applied. Radial shortening reduced to 0 mm and dorsal tilting decreased to 6.4. (C) Twelve month follow-up radiographs shows 1.2 mm radial shortening and 18.5 dorsal tilting. 44

Jong Min Kim, et al. Treatment of Unstable Distal Radius Fracture in the Elderly Patients Fig. 2. Radiographs of 76-yerar-old female who underwent operative treatment.

Radial shortening reduced to 0mm and dorsal tilting decreased to 2.2. (C) Seven month follow-up radiographs shows 0.5 mm radial shortening and 4.8 dorsal tilting. Fig. 3.

3 Jong Min Kim, et al. Treatment of Unstable Distal Radius Fracture in the Elderly Patients Fig. 2. Radiographs of 76-yerar-old female who underwent operative treatment. (A) Preoperative radiograph shows 5.4 mm radial shortening and 11.7 dorsal tilting. (B) Open reduction and volar locking plate was applied. Radial shortening reduced to 0mm and dorsal tilting decreased to 2.2. (C) Seven month follow-up radiographs shows 0.5 mm radial shortening and 4.8 dorsal tilting. Fig. 3. Radiographs of 72-yerar-old female who underwent operative treatment. (A) Preoperative radiograph shows 2.0 mm radial shortening and 4.8 dorsal tilting. (B) Closed reduction and K-wire fixation was done. Radial shortening reduced to 1.7 mm and dorsal tilting decreased to 4.5. (C) Eight month follow-up radiographs shows 2 mm radial shortening and 3.1 dorsal tilting. 행하였다. 수술후단상지석고붕대고정술을 6주간시행하였고 6주후외래에서석고붕대와강선을제거한후물리치료와재활치료를시행하였다. 잠김압박금속판의경우전신마취나상완신경총마취후요수근굴건 (flexor carpi radialis) 을 촉지하고그위로 7 cm 가량피부절개를시행한후, 요골동맥의손상을주의하면서요수근굴근아래근막 (fascia) 을종으로절개하였다. 장무지굴건 (flexor pollicis longus) 을척측으로견인하고, 방형회내근 (pronator quadratus) 을요측 45

4 J Korean Soc Surg Hand Vol. 20, No. 2, June 2015 에서종으로절개하여골절부위를노출하여정복시행하였다. 영상증폭장치로정복을확인한후잠김압박금속판으로고정하였다. 수술후 1주간단상지석고부목고정으로보호한뒤통증이허락하는범위에서점진적인물리치료와재활치료를시행하였다. 2. 평가방법방사선학적평가는수술전, 수술직후, 그리고수술후 6개월이후마지막으로촬영한단순방사선사진으로골유합여부와원위골절편의배측경사, 요골의경사각, 요골의단축정도를비교하였다. 계측은두명의정형외과전문의에의하여시행되었으며, 각각의관찰자는 1주일의간격을두고 2회측정하였고각측정치의범위와평균을구하였다. 임상적인평가는 modified Mayo wrist score (MMWS) 점수와 disabilities of arm, shoulder & hand (DASH) 점수그리고관절의운동범위 ( 신전과굴곡, 요측과척측변위각, 외회전과내회전 ) 를마지막추시에서얻은결과를비교하였다. MMWS 는 100을정상적인 k손목기능을나타내는값으로측정하였고, 통증 (25점), 만족도 (25점), 관절운동범위 (25점), 악력 (25점) 을합산하였다. DASH 질문지는 30개항목으로이루어졌는데 21가지는특정한활동을수행하는능력을, 9가지는관련증상에대한것으로 0에서 100까지의범위를가지며더높은점수가더큰장애상태를의미한다. 3. 통계학적분석통계학적분석은 SPSS 통계적프로그램 (IBM SPSS ver. 19.0, IBM Co., Armonk, NY, USA) 을사용하여 t-검정법과 Mann-Whiteny U 검정법을시행하였고. 통계적유의수준은 p<0.05로하였다. 관찰자내재현성과관찰자간신뢰성은 Shrout 와 Fleiss에의해소개된집단내상관계수 (intraclass correlation coefficients, ICCs) 를이용하여평가하였다. 집단내상관계수는 0에서 1까지의값을가지며, 를불량 (poor), 를보통 (moderate), 그리고 을우수 (excellent) 로정의하였다. 결과 양측환자군에서의연령분포, 성별분포, 골절에따른분류, 평균추시기간은유의한차이를보이지않았다 (Table 1). 단순방사선사진상모든예에서골유합이관찰되었으며, 합병증으로비수술적치료환자 45명중부정유합 ( 골유합된방사선상에서요골단축이 5 mm 이상, 배측경사가 20 이상, 관절면의전위가 2 mm 이상 ) 이 17예, 복합부위통증증후군 3 예, 수근관증후군 1예에서관찰되었고, 수술적치료환자 69 명중부정유합이 11예, K- 강선주변의일시적감염이 7예, 복합부위통증증후군 5예, 표재요골신경분지의손상이 4 예, 수근관증후군 1예, 장무지굴곡건손상이 1예관찰되었다 (Table 2). 수상당시시행한방사선학적검사에서두환자군간에배측경사, 요골경사각, 요골의단축에서유의한차이를보이지않았으며, 최종방사선사진에서측정한요골단축은두군간에유의한차이를보였다 (Table 3). 최종추시에서두군간에 DASH 점수, PRWE 점수, 그리고손목관절의운동범위중굴곡, 회외전, 회내전, 요측변위, 척측변위에서의미있는차이를보이지않았다. 그러나운동범위중신전에서는수술을받은환자군에서유의하게좋은결과를보였다 (Table 4). 1주일간격으로측정한배측경사, 요골의경사각, 요골의단축정도의 ICCs는각각 0.765, 0.827, 0.883으로우수한관찰자내재현성을보였고, 관찰자간의신뢰성역시 0.723, Table 1. Summary of dermographic data Characteristic Non-operative groups (n=45) Operative groups (n=69) Age (yr) 73.1 (65-89) 70.8 (65-84) Sex, n (%) Female 36 (80) 50 (72) Male 9 (20) 19 (28) Follow-up period (mon) 10.1 (6-20) 11.4 (6-22) Cause of fracture, n (%) Slip down 39 (86) 59 (85) Fall down 3 (7) 7 (10) Trauma 3 (7) 3 (5) Values are presented as mean±æstandard deviation. 46

5 Jong Min Kim, et al. Treatment of Unstable Distal Radius Fracture in the Elderly Patients Table 2. Complications of distal radius fracture for both Value Non-operative groups (n=45) Operative groups (n=69) Malunion 21 (47) 11 (16) Complex regional pain syndrome 3 (7) 7 (10) Carpal Tunnel syndrome 1 (2) 5 (7) Pin-site infection - 4 (6) Superficial radial nerve injury - 1 (1.5) Flexor tendon injury - 1 (1.5) Values are presented as number (%). Table 3. Radiologic measurements for both groups Value Non-operative groups (n=45) Operative groups (n=69) p-value Dorsal tilt Preoperative -17.7± ± Postoperative -18.2± ± Last follow-up -15.5± ± Radial inclination Preoperative 16± ± Postoperative 15.6± ± Last follow-up 14.1± ± Radial shortening Preoperative -6.2± ± Postoperative -6.4± ± Last follow-up -5.3± ± Values are presented as mean±standard deviation. Table 4. Functional outcomes at final follow-up for both groups Value Non-operative groups (n=45) Operative groups (n=69) p-value Range of motion Flexion 51.4± ± Extension 44± ± Supination 71.8± ± Pronation 76.1± ± Radial deviation 17.4± ± Ulnar deviation 20.9±5.5 23± Disabilities of arm, shoulder and hand 19.5± ± Modified Mayo wrist score 81.9± ± Values are presented as mean±standard deviation , 으로높은신뢰성을보였다. 고찰 원위요골골절은 1814년 Abraham Colles에의해처음기술된이래많은사람에의하여연구되어왔다 9. 일반적으로노년층여자에서잘발생하며대부분의경우실족등의저에 너지손상에서발생한다고알려져있다 10. 과거에는불안정성이심한경우를제외하고는도수정복후석고붕대고정의비수술적치료를주로시행해왔으나최근에는노년인구의증가와더불어복지및활동영역의확대로기능적결과에대한관심이높아지면서치료의방향이좀더해부학적정복에가깝도록변하고있다 또한 Makhni 등 14 은원위요골골절로보존적치료를받은환자의 78% 이상에서이차전위가발 47

6 J Korean Soc Surg Hand Vol. 20, No. 2, June 2015 생하며, 초기도수정복을시행받은군에서최대 89% 의정복소실이발생하였고, 특히 60세이상의고령은정복후 2차소실의높은유발요인으로설명하였다. 그러나 Young과 Rayan 15, 그리고 Jaremko 등 10 은고령의환자들에서불만족스러운방사선적결과가반드시불만족스러운기능적결과를가져오지는않는다고하였다. Arora 등 16 은 65 세이상환자 73명을대상으로수술적치료와비수술적치료를비교한연구결과에서수술적치료를시행한환자군에서파악력은더나은결과를보였지만, 관절운동범위와일상생활의활동정도의개선정도에있어서는차이를보이지않았다고하였다. 또한 Egol 등 17 은 65 세이상의 90명을대상으로시행한연구에서비수술적치료군에서신전과파악력에서수술적치료를받은환자보다약간저조한결과를보였으나 1 년뒤 DASH를이용한임상적결과에서는두군간에유의한차이가없다고보고하였다. 본연구에서도비록수술적치료를받은환자군에서요골단축을포함하여방사선학적으로의미있게우수한결과를보였으나, 임상적결과에서는의미있는결과차이를보이지않았다. 이의해석을두고젊은환자에비해고령의환자에서의기능잔존도와요구도가이미감소되어있는경우가많으며, 삶의질평가에있어기능이차지하는비율이젊은환자에비해비교적낮기때문에이러한결과가나온점을고려될수있으나, 근본적으로는고령의원위요골골절의환자에서방사선학적인평가와임상적평가사이에연관성이없다고결론을내는것이더바람직할것으로생각된다. 그렇다고노인환자를대상으로한모든연구에서방사선학적결과가나빠도임상적결과가좋다고하는것은아니다. 원위요골골절을치료하는데있어서방사선사진의결과를무시할수는없으며, 대부분의정형외과의사는이를기준으로치료를하고있다. 해부학적결과의판정에있어서골절편의만족스러운정복여부를측정하기위해 Lidstrom 18 이측정한수장측경사각, 요골길이, 그리고 Frykman 19 이첨가한요골측경사각등이장기적인치료결과를예측하는중요한인자로알려져있고, Knirk 와 Jupiter 20 은요측길이단축이 5 mm 이상, 후방경사각 20 이상, 그리고관절면의전위가 2 mm 이상인경우예후가불량하다고하였으며, 균일한관절면의회복이임상적및방사선학적결과를결정하는가장중요한요소라고주장하였다. 본연구에서도이를근거로하여도수정복시행후에도, 위기준에만족하지못하는경우에환자에게수술적치료를권하는기준으로삼았다. Rodriguez-Merchan 21 는원위요골골절의가장큰합병증으로부정유합, 손목관절통증, 손목불안정성, 신경압박증후 군, 손목관절염등을보고하였고, 본연구에서도부정유합이비수술적치료를시행한군에서 47%, 수술적치료를시행한군에서 16% 로가장높게관찰되었다. 특히관절면의해부학적정복의소실을동반한부정유합에서수상후관절염의발생이증가한다는보고가있어본연구에서관절면의해부학적정복이되지않은환자군에대하여향후관절염의발생시기에대하여추가적인관찰이필요할것이라생각된다 22. Gehrmann 등 23 은노인환자의스포츠및여가활동증가등사회, 문화적여건의변화로생리적인나이뿐만아니라활동성을고려하여치료방법을달리할것을권유하였고향후이러한점을고려한치료선택기준에대한연구가필요할것으로생각된다. 또한본연구에서수술을시행한군에서수술방법의차이로인한방사선학적, 기능적결과의차이에대한분석과골밀도에따른골절의정복과영상학적지표들의변화에대해서는추후보다자세한연구가필요할것으로생각된다. 결론 본연구에서수술적치료를한환자에서방사선학적평가는더우수하나, 기능적측면에서는차이를보이지않는것으로보아불안정성원위요골골절을진단받은 65세이상의고령의환자에있어비수술적치료를우선고려해야할것으로생각된다. REFERENCES 1. Abbaszadegan H, Jonsson U. External fixation or plaster cast for severely displaced Colles' fractures? Prospective 1-year study of 46 patients. Acta Orthop Scand. 1990;61: Abbaszadegan H, Jonsson U, von Sivers K. Prediction of instability of Colles' fractures. Acta Orthop Scand. 1989;60: Alffram PA, Bauer GC. Epidemiology of fractures of the forearm: a biomechanical investigation of bone strength. J Bone Joint Surg Am. 1962;44: Anzarut A, Johnson JA, Rowe BH, Lambert RG, Blitz S, Majumdar SR. Radiologic and patient-reported functional outcomes in an elderly cohort with conservatively treated distal radius fractures. J Hand Surg Am. 2004;29: Azzopardi T, Ehrendorfer S, Coulton T, Abela M. Unstable extra-articular fractures of the distal radius: a 48

7 Jong Min Kim, et al. Treatment of Unstable Distal Radius Fracture in the Elderly Patients prospective, randomised study of immobilisation in a cast versus supplementary percutaneous pinning. J Bone Joint Surg Br. 2005;87: Barton T, Chambers C, Bannister G. A comparison between subjective outcome score and moderate radial shortening following a fractured distal radius in patients of mean age 69 years. J Hand Surg Eur Vol. 2007;32: Beumer A, McQueen MM. Fractures of the distal radius in low-demand elderly patients: closed reduction of no value in 53 of 60 wrists. Acta Orthop Scand. 2003;74: Boyd LG, Horne JG. The outcome of fractures of the distal radius in young adults. Injury. 1988;19: Christensen OM, Christiansen TC, Krasheninnikoff M, et al. Plaster cast compared with bridging external fixation for distal radius fractures of the Colles' type. Int Orthop. 2001;24: Jaremko JL, Lambert RG, Rowe BH, Johnson JA, Majumdar SR. Do radiographic indices of distal radius fracture reduction predict outcomes in older adults receiving conservative treatment? Clin Radiol. 2007;62: Ark J, Jupiter JB. The rationale for precise management of distal radius fractures. Orthop Clin North Am. 1993;24: Howard PW, Stewart HD, Hind RE, Burke FD. External fixation or plaster for severely displaced comminuted Colles fractures? A prospective study of anatomical and functional results. J Bone Joint Surg Br. 1989;71: McQueen M, Caspers J. Colles fracture: does the anatomical result affect the final function? J Bone Joint Surg Br. 1988;70: Makhni EC, Ewald TJ, Kelly S, Day CS. Effect of patient age on the radiographic outcomes of distal radius fractures subject to nonoperative treatment. J Hand Surg Am. 2008;33: Young BT, Rayan GM. Outcome following nonoperative treatment of displaced distal radius fractures in lowdemand patients older than 60 years. J Hand Surg Am. 2000;25: Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older. J Bone Joint Surg Am. 2011;93: Egol KA, Walsh M, Romo-Cardoso S, Dorsky S, Paksima N. Distal radial fractures in the elderly: operative compared with nonoperative treatment. J Bone Joint Surg Am. 2010;92: Lidstrom A. Fractures of the distal end of the radius: a clinical and statistical study of end results. Acta Orthop Scand Suppl. 1959;41: Frykman G. Fracture of the distal radius including sequelae: shoulder-hand-finger syndrome, disturbance in the distal radio-ulnar joint and impairment of nerve function: a clinical and experimental study. Acta Orthop Scand. 1967:Suppl 108: Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg Am. 1986;68: Rodriguez-Merchan EC. Management of comminuted fractures of the distal radius in the adult: conservative or surgical? Clin Orthop Relat Res. 1998;(353): Fitoussi F, Ip WY, Chow SP. Treatment of displaced intra-articular fractures of the distal end of the radius with plates. J Bone Joint Surg Am. 1997;79: Gehrmann SV, Windolf J, Kaufmann RA. Distal radius fracture management in elderly patients: a literature review. J Hand Surg Am. 2008;33:

8 J Korean Soc Surg Hand Vol. 20, No. 2, June 2015 고령의불안정원위요골골절에대한수술적치료와비수술적치료의비교 김종민 서현제 전영대 이형민 손정환고신대학교복음병원정형외과학교실 목적 : 불안정성원위요골골절을동반한고령환자에서수술적치료와비수술적치료결과를비교하였다. 방법 : 2006년부터 2011년까지불안정성원위요골골절을동반한 65세이상의고령환자 114명을대상으로하였으며, 비수술적치료를받은환자가 45명, 수술적치료를받은환자가 69명이었다. 방사선학적평가는요골의배측경사, 요골경사각, 요골단축을측정하였고, 임상적평가는 disabilities of arm, shoulder & hand 점수와 modified Mayo wrist score 점수, 손목관절운동범위를바탕으로비교하였다. 결과 : 비수술적환자군에서요골의배측경사가평균 15.5, 요골경사각이평균 14.1, 요골단축이평균 5.3 mm였고, 수술적환자군에서는요골의장측경사가 3.9, 요골경사각이 18.2, 요골단축이 1.1 mm였으며, 요골단축에서의미있는차이를보였다 (p<0.05). 임상적평가로최종추시에서두환자군간에의미있는차이는보이지않았다 (p>0.05). 결론 : 65세이상에서발생한불안정원위요골골절은기능적인측면에서볼때비수술적치료를우선적으로고려해야할것으로생각된다. 색인단어 : 불안정성원위요골골절, 관혈적치료, 비관혈적치료 접수일 2015 년 3 월 19 일수정일 2015 년 6 월 17 일게재확정일 2015 년 6 월 20 일교신저자손정환부산시서구암남동 34 번지고신대학교복음병원정형외과학교실 TEL , FAX junghson@dreamwiz.com 50

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