241 Figure 1. A 17-year-old male had a traffic accident. (A) Preoperative radiograph showing the shaft of the femur fracture. (B) Postoperative radiog

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1 240 pissn : , eissn : Case Report J Korean Orthop Assoc 2013; 48: 오현철 서재완 * 곽대경 * 윤한국 국민건강보험일산병원정형외과, * 연세대학교의과대학정형외과학교실 Delayed Pseudoaneurysm of the Femoral Artery after Intramedullary Nailing of a Femur Shaft Fracture Hyun Cheol Oh, M.D., Jae Wan Suh, M.D.*, Dae Kyung Kwak, M.D.*, and Han Kook Yoon, M.D. Department of Orthopedic Surgery, National Health Insurance Service Ilsan Hospital, Ilsan, *Department of Orthopaedic Surgery, College of Medicine, Yonsei University, Seoul, Korea Interlocked intramedullary nailing is widely accepted for treatment of closed femoral shaft fractures. An interlocking screw is inserted percutaneously, and especially the distal screw is inserted without use of a guide. Vascular complications associated with an interlocking screw in intramedullary nailing are rare. No case of delayed pseudoaneurysm caused by a distal interlocking screw has yet been reported in Korea. We present two cases of delayed pseudoaneurysm caused by a distal interlocking screw several months after intramedullary nailing. Key words: femur shaft fracture, pseudoaneurysm, interlocking screw 하지에서발생하는가성동맥류는외상뿐아니라혈관중재술및 내고정술, 관절경수술, 외고정술등수술치료후합병증으로도 종종발생하는것으로보고된바있다. 1) 대퇴골전자간골절의골 수강내금속정삽입술후대퇴동맥에서발생한가성동맥류에 대한사례들은보고된바있으나저자들은대퇴간부골절에서 골수강내금속정삽입술후원위부교합나사에의해발생한지 연성가성동맥류에대하여아직국내에보고된바가없어문헌 고찰과함께보고하는바이다. 2) 1. 증례 1 증례보고 17 세남자환자로오토바이운전중수상되어좌측대퇴간부의 Received October 17, 2012 Revised February 19, 2013 Accepted March 22, 2013 Correspondence to: Han Kook Yoon, M.D. Department of Orthopedic Surgery, National Health Insurance Service Ilsan Hospital, 100 Ilsan-ro, Ilsandong-gu, Goyang , Korea TEL: FAX: hangugy@hanmail.net 골절을주소로내원하여도수정복후골수강내금속정삽입술 (Cannulated femoral nail, Synthes, Oberdorf, Switzerland) 을시행하였으며, 대퇴골의근위부에 2개, 원위부에 1개의교합나사를고정하였다 (Fig. 1). 추시상부정유합, 불유합없이유합되었으나수술후 7개월후에좌측원위대퇴내측부에통증과종창을호소하여내원하였다. 단순방사선사진상에는특이소견이없었으나, 종창에대하여시행한초음파검사상좌측내측광근 (vastus medialis musle) 원위부에근막하방으로 cm 크기의혈종 (hematoma) 으로보이는무에코 (anechoic) 의액체집적 (fluid collection) 소견이발견되었다. 내부에는난류 (turbulant flow) 를보이는혈류가관찰되었다 (Fig. 2). 가성동맥류 (pseudoaneurysm) 의심하에시행한자기공명영상에서는 T1과 T2 강조영상에서혈종은비균질성음영을보이고있으며, 혈종의변연부는저신호강도음영을보이는띠모양의낭 (sac) 으로둘러싸여있고, 혈종의내측으로원위교합나사의끝부분이관찰되었다 (Fig. 3). 교합나사가주위혈관에손상을주며자극을일으켜발생한가성동맥류로확인되었다. 가성동맥류진단하에가성동맥류와연결된영양동맥 (feeding artery) 을확인하기위해시행한컴퓨터단층혈관촬영술 (computed tomography [CT] angiography) 상에서교합나사 The Journal of the Korean Orthopaedic Association Volume 48 Number Copyright 2013 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

$(A) Preoperative radiograph showing the shaft of the femur fracture.$ (B) Postoperative radiograph of the femur after intramedullary nailing. Figure 2.

(B) Postoperative radiograph of the femur after intramedullary nailing. Figure 2.

the left distal thigh showed a pseudoaneurysm with internal hematoma which has

The margin of the hematoma was surrounded by a low intensity signal band shaped sac,

2 241 Figure 1. A 17-year-old male had a traffic accident. (A) Preoperative radiograph showing the shaft of the femur fracture. (B) Postoperative radiograph of the femur after intramedullary nailing. Figure 2. Ultrasonography of the left distal thigh showed an anechoic fluid collection like hematoma measuring cm under the fasica of the vastus intermedius muscle (A) and turbulent blood flow in the hematoma (B). Figure 3. Fat suppressed coronal T1 (A) and axial T2 (B) magnetic resonance contrast images of the left distal thigh showed a pseudoaneurysm with internal hematoma which has heterogenous intensity signal under the vastus intermedius muscle. The margin of the hematoma was surrounded by a low intensity signal band shaped sac, and the tip of the distal interlocking screw was detected inside the hematoma. A, anterior; P, posterior; M, medial; L, lateral. 주위에천부대퇴동맥에서기시하는작은혈관을관찰할수있 었다 (Fig. 4). 저자들은영상의학과의뢰하에색전술을고려하였으나혈관이 너무작아서시행하지못하였고초음파유도하흡인 (aspiration) 제거술을시행하였다. 약 9 ml 의혈종을흡인제거하였으나일주 일후시행한초음파검사에서동일부위에혈종이이전크기의

242 오현철 서재완 곽대경외 1 인 약 80% 정도로재발한소견이관찰되었다.

술후환자의통증과종창은감소하였으며이후재발없이호전소견을확인할수있었다. Figure 4.

around the distal screw area. 2. 증례 2 18세남자환자로오토바이운전중수상하여좌측대퇴부의골절을주소로본원응급실에내원하였다.

$(A) Preoperative radiograph showing the shaft of the femur fracture.$

3 242 오현철 서재완 곽대경외 1 인 약 80% 정도로재발한소견이관찰되었다. 원위교합나사의만성적인혈관자극이원인이라생각하여교합나사제거및혈종천자술을시행하였으며압박드레싱하며경과관찰하였다. 술후환자의통증과종창은감소하였으며이후재발없이호전소견을확인할수있었다. Figure 4. Computed tomography angiography of the lower extremity showed a small vessel (arrow) around the distal screw area. 2. 증례 2 18세남자환자로오토바이운전중수상하여좌측대퇴부의골절을주소로본원응급실에내원하였다. 대퇴간부골절로도수정복후골수강내금속정삽입술 (Cannulated femoral nail, Synthes) 을시행하였으며, 대퇴골의근위부에 2개, 원위부에 2개의교합나사를고정하였다 (Fig. 5). 수술후환자는특이소견없이퇴원하였으며외래추시중가골형성이진행중이었으나, 수술후 3개월후에환자는좌측원위대퇴내측부에통증과종창을호소하였다. 단순방사선사진상에는특이소견이없었으나, 시행한 Figure 5. An 18-year-old male had a traffic accident. (A) Preoperative radiograph showing the shaft of the femur fracture. (B) The radiograph of the femur taken six weeks after the operation showing callus formation at the fracture site. Figure 6. Ultrasonography of the left distal thigh showed a hematoma measuring cm (A) with turbulent blood flow (B).

243 Figure 7. (A) Fat suppressed coronal T1 magnetic resonance (MR) contrast image of the left distal thigh showing a pseudoaneurysm with an internal hematoma.

뒤에시행한초음파에서도재발없이호전소견을확인할수있 었다 (Fig. 8). 고찰 Figure 8. Follow-up ultrasonography of the left distal thigh showed resolution of the hematoma. 초음파검사상좌측대퇴골의원위부교합나사부위에 4.3 8.0 1.

가성동맥류의심하에시 행한 MRI 에서변연부에는 T1, T2 에서저신호강도를보이는띠 모양의중격이조영제주입시조영증강이되는양상을보였으 며, 내부에는혈종과혈액이액체층 (fluid level) 을이루고있고원 위교합나사의끝이인접하여있었다 (Fig. 7).

4 243 Figure 7. (A) Fat suppressed coronal T1 magnetic resonance (MR) contrast image of the left distal thigh showing a pseudoaneurysm with an internal hematoma. (B) Blood fluid level was shown adjacent to the distal interlocking screw tip in a hematoma on a fat suppressed axial T2 MR image. A, anterior; P, posterior; M, medial; L, lateral. 뒤에시행한초음파에서도재발없이호전소견을확인할수있 었다 (Fig. 8). 고찰 Figure 8. Follow-up ultrasonography of the left distal thigh showed resolution of the hematoma. 초음파검사상좌측대퇴골의원위부교합나사부위에 cm 크기의무에코성액체집적소견을보이는혈종이관찰되 었다. 혈종은내측광근근막하방에위치하였으며내부에는난 류를보이는혈류가관찰되었다 (Fig. 6). 가성동맥류의심하에시 행한 MRI 에서변연부에는 T1, T2 에서저신호강도를보이는띠 모양의중격이조영제주입시조영증강이되는양상을보였으 며, 내부에는혈종과혈액이액체층 (fluid level) 을이루고있고원 위교합나사의끝이인접하여있었다 (Fig. 7). 가성동맥류진단하 에가성동맥류와연결된동맥을확인하기위해시행한 CT angiography 상에서연결된동맥은관찰되지않았다. 가성동맥류에 대하여혈종천자술및연부조직에자극을주지않는적절한길 이의원위부교합나사로의교환술을시행하였으며압박드레싱 을시행하였다. 술후환자의통증과종창은감소하였으며, 6 개월 대퇴동맥은서혜인대 (inguinal ligament) 를지나면서천부대퇴동맥 (superficial femoral artery) 과심부대퇴동맥 (deep femoral artery) 으로나뉘어져주행한다. 천부대퇴동맥은심부대퇴동맥보다좀더내측면으로주행하며, 대퇴골의전방부에위치하다가대퇴골근위 1/3 지점부터는대퇴골과같은관상면으로주행하며대퇴골원위 1/3 지점에이르러서는내측으로하행슬동맥 (descending geniculate artery) 을분지하고내전근관 (adductor canal) 으로들어가오금동맥 (popliteal artery) 이되어오금 (popliteal fossa) 으로들어가대퇴골의후과간구역 (posterior intercondylar fossa of femur) 으로지나간다. 내전근관에는천부대퇴동맥, 정맥, 복재신경 (saphenous nerve) 과내측광근으로향하는근육신경이포함되어있으며내전근관내부의근위부에서천부대퇴동맥은봉공근 (sartorius muscle) 과박근 (gracilis muscle) 으로가는영양혈관과내측광근으로향하는여러개의작은혈관을분지한다. 2-4) 본저자들은금속정삽입술시행시길이가짧게삽입되어원위교합나사의위치가슬관절에서약 13 cm 근위부에위치하였고, 이부위에서나사의끝이천부대퇴동맥에서내측광근으로분지되는작은무명혈관에만성적인자극을일으켜서가성동맥류를형성하게된것이라생각한다. 가성동맥류는손상된혈관에서혈액이유출되고이것이혈종을형성한후, 이러한혈종이섬유조직으로변하면서중심부는손상된혈관과연결되어가성동맥류가형성된다. 5) 수술후발생하는가성동맥류는주로드릴이나나사못에의한손상, 재활과정중의내고정물에의한지속적인자극에의해발생하는혈관손상에의한것으로알려져있다. 4)

5 244 오현철 서재완 곽대경외 1 인 가성동맥류의치료는크기가작거나증상이없는경우는합병증이거의발생하지않아경과관찰할수있으나, 증상이있으며큰혈종을동반하거나, 6주이상지속되는경우에는혈전형성, 원위부색전및동맥류파열등의합병증이생길수있으므로수술적치료가필요하다. 6) 가성동맥류발생을보고한논문중많은사례에서색전술 (embolization), 혈종제거술, 혈관이식술등의수술적치료방법등이보고되고있다. 7-9) 하지만 Bose 등 2) 은가성동맥류제거를위한시술등을행하기보다보존적치료로도충분하다고발표하였고, Toursarkissian 등 10) 이발표한논문에서도적절한환자선택을통해보존적치료도가성동맥류의자연완화를이끌수있다고보고하고있다. 본사례에서는가성동맥류의치료에있어색전술이가능한정도의뚜렷한영양혈관을발견할수없어색전술등의시술을시행하지못하였고, 혈관자극증상을일으키는원인이었던원위부교합나사를제거및교체, 단순천자후압박등으로가성동맥류를치료할수있었다. 대퇴간부골절의골수강내금속정삽입술시행시원위부교합나사에의해생긴가성동맥류는드물게발생하지만발생시심각한합병증을초래할수있다. 이를예방하기위해도수정복시대퇴골의해부학적인위치를고려하여금속정삽입방향및금속정의길이등을신중하게고려하여야하며, 원위교합나사삽입술과정에서도연부조직의손상을최대한으로줄일수있도록드릴사용시주의하여야하며, 교합나사삽입각도및길이선택에도신중해야할것으로생각한다. 참고문헌 1. Cho SH, Kim DH, Jeong ST, et al. Therapeutic embolization for pseudoaneurysm of the anterior tibial artery after tibial nailing. J Korean Orthop Assoc. 2010;45: Bose D, Hauptfleisch J, McNally M. Delayed pseudoaneurysm caused by distal locking screw of a femoral intramedullary nail: a case report. J Orthop Trauma. 2006;20: Faure C, Merloz P. Transfixation: atlas of anatomical sections for the external fixation of limbs. Berlin, New York: Springer- Verlag; Park SJ, Yang KH. Pseudoaneurysm of the superficial femoral artery following gamma nail fixation for trochanteric fracture: a case report. J Korean Orthop Assoc. 2000;35: Turek SL. Orthopaedics: principles and their application. 4th ed. Philadelphia: Lippincott; Rutherford RB. Vascular surgery. 4th ed. Philadelphia: W.B. Saunders; Han KJ, Won YY, Kim TY, Khang SY. Pseudoaneurysm of the anterior tibial artery after closed intramedullary nailing of a tibial shaft fracture: a case report. J Korean Orthop Assoc. 2002;37: Lee SH, Ahn JH. Diagnosis and treatment for delayed pseudoaneurysm of deep femoral artery: a case report. J Korean Orthop Assoc. 2008;43: Yoon HK, Kim BK, Shin DE, Kim MD, Chang JH. Pseudoaneurysm of superficial femoral artery following proximal femoral nail fixation. J Korean Fract Soc. 2004;17: Toursarkissian B, Allen BT, Petrinec D, et al. Spontaneous closure of selected iatrogenic pseudoaneurysms and arteriovenous fistulae. J Vasc Surg. 1997;25:803-8.

6 245 pissn : , eissn : Case Report J Korean Orthop Assoc 2013; 48: 오현철 서재완 * 곽대경 * 윤한국 국민건강보험일산병원정형외과, * 연세대학교의과대학정형외과학교실 대퇴간부골절에서골수강내금속정삽입술은널리사용되는방법으로교합나사의삽입은경피하에삽입하며특히원위부는가이드없이삽입하게된다. 교합나사에의한혈관에대한합병증은드물게생기며원위부교합나사에의해발생한지연성가성동맥류 (delayed pseudoaneurysm) 에대해서는아직국내에서보고된바가없었다. 이에저자들은지연성가성동맥류 2예를경험하여문헌고찰과함께보고하는바이다. 색인단어 : 대퇴간부골절, 가성동맥류, 교합나사 접수일 2012 년 10 월 17 일수정일 2013 년 2 월 19 일게재확정일 2013 년 3 월 22 일교신저자윤한국고양시일산동구일산로 100, 국민건강보험일산병원정형외과 TEL , FAX , hangugy@hanmail.net 대한정형외과학회지 : 제 48 권제 3 호 2013 Copyright 2013 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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