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1 Clinical Article The Korean Journal of Sports Medicine 2015;33(2):75-82 pissn eissn 야구선수에서척측측부인대손상의중력외반부하초음파검사 좋은삼선병원정형외과 황태혁ㆍ조형래ㆍ김형민ㆍ박기봉ㆍ조홍 Gravity Valgus Stress Ultrasonographic Assessment of Ulnar Collateral Ligament Injury among Baseball Players Tae Hyok Hwang, Hyung Lae Cho, Hyoung Min Kim, Ki Bong Park, Hong Jo Department of Orthopaedic Surgery, Good Samsun Hospital, Busan, Korea The purpose of this study is to evaluate the gravity valgus stress ultrasonographic findings of ulnar collateral ligament (UCL) injury among baseball players. Twenty-eight (age, 16 30; mean, 19.5 years) UCL injured players, diagnosed by magnetic resonance imaging (MRI), were examined by bilateral elbow ultrasonography. On MRI findings, partial and complete tears were 17 and 11 players, respectively. Ultrasonographic examinations were performed in 90 degree elbow flexion with gravity valgus stress, and abnormalities around UCL and ulnohumeral distance were compared with contralateral uninjured elbow. 22 of 28 (79%) players had sonographic abnormalities in injured elbow such as thickening, wavy contour of the UCL (32%), hypoechoic foci in the ligament (43%), osteophyte on trochlear or ulnar articular margin (36%), joint effusion (29%) and ossicles in or around the UCL (68%) that were the most common finding in both partial and complete tears. In all players, the ulnohumeral distance was significantly wider on the injured side than it was on the uninjured side (4.0±1.5 mm and 2.5±0.43 mm, respectively; p=0.015). Significant increased average ulnohumeral distance in injured elbow was observed with complete UCL tears compared with partial tears (5.4±0.9 mm and 3.1±0.8 mm, respectively; p=0.021) and the mean difference between injured and uninjured elbow was more significant in complete tears than partial tears (2.8±1.2 mm and 0.7±0.6 mm, respectively; p=0.012). Gravity valgus stress ultrasonography is rapid noninvasive diagnostic tool and can provide clinicians valuable information regarding the condition of the UCL and medial elbow laxity in partial and complete UCL tear players. Keywords: Elbow ultrasonography, Gravity valgus stress, Ulnar collateral ligament tear Received: July 9, 2015 Revised: October 26, 2015 Accepted: November 4, 2015 Correspondence: Ki Bong Park Department of Orthopaedic Surgery, Good Samsun Hospital, 326, Gaya-daero, Sasang-gu, Busan 47007, Korea Tel: , Fax: , Copyright 2015 The Korean Society of Sports Medicine CC This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 제 33 권제 2 호

2 TH Hwang, et al. Gravity Valgus Stress Ultrasonographic Assessment of Ulnar Collateral Ligament Injury among Baseball Players 서론주관절척측측부인대손상은투구동작을주로하는야구선수에서주관절통증의흔한원인이며투구단계의후기코킹기와가속기에반복적으로가해지는주관절외반부하로인해발생한다 1-3). 야구선수에서척측측부인대의손상은투구동작시주관절의내측불안정성을유발하게되며, 내측불안정성의정도는보존적치료와수술적치료를결정하는지침의하나로사용된다 4,5). 척측측부인대파열의진단방법으로는용출검사 (milking test) 나운동외반부하검사 (moving valgus stress test) 와같은이학적검사, 외반부하방사선검사, 초음파검사, 자기공명영상검사등이있다 3,6). 이중주관절초음파검사는주관절주변골연부조직의상태를파악하는유용한검사로방사선노출의위험없이반복적으로사용가능하고건측과비교가가능하며방사선검사나자기공명영상검사와는달리관절의역동적영상을얻을수있다 7,8). 척측측부인대파열로인한주관절내측불안정성의정도는통상적인외반부하를이용한방사선검사를이용하여측정할수있으나도수적외반부하로는일정한부하를줄수없고외반부하장치와같은부수적인장비가필요하게된다. 중력외반부하초음파검사는특별한추가장비없이중력이라는일정한부하를줄수있고검사시내측부통증이없으며부하후의척상완관절간격을측정함으로써내측불안정의정도를알수있는장점이있고휴대용초음파기기를이용하면현장에서의선별검사로도활용할수있다. 본연구의목적은자기공명영상검사상우세수의척측측부인대파열로진단된야구선수에서양측주관절의중력외반부하초음파검사를시행하여척측측부인대를포함한주위골연부조직의변화를알아보고척상완관절간격을건측과비교함으로써주관절내측불안정성의정도를알아보는것이다. 연구방법 1. 연구대상 2014년 3월부터 2015년 2월까지주관절자기공명영상검사상척측측부인대파열로진단된야구선수 28명을대상으로하였다. 평균연령은 19.5세 ( 범위, 16 30세 ; standard deviation [SD], ±3.5세 ) 이며모두우세수에발생하였고우측이 24명, 좌측이 4명이었다. 고등학교선수가 16명, 대학교선수가 8명, 프로야구선수가 4명이었다. 야구를시작한기간은평균 8.9년 ( 범위, 년 ; SD, ±3.9년 ) 이었고포지션별로는투수가 19명, 야수가 9명 ( 포수 2명, 내야수 3명, 외야수 4명 ) 이었다. 전예에서투구시우세수인환측주관절의통증을호소하였고, 이학적검사상척측측부인대주위의압통과함께용출검사와운동외반부하스트레스검사에서주관절내측부의통증을보였다. 증상발현시기는평균 3.6개월 ( 범위, 개월 ; SD, ±1.4개월 ) 의만성손상이었고이전에환측주관절수술을시행한선수는없었다. 자기공명영상검사소견상척측측부인대의파열정도에따라 Kim 등 9) 의분류를적용하여 Grade I ( 부분파열 50% 이하 ) 와 Grade II ( 부분파열 50% 이상 ) 를부분파열군, Grade III를완전파열군으로분류하였는데, 부분파열이 17예, 완전파열이 11예이었고, 부분파열 17예중 Grade I이 13예, Grade II가 4예이었다 (Table 1). 자기공명영상상외측측부인대의손상이나병변을의미하는소견은없었다. 2. 초음파검사방법초음파기기는 SonoAce X8 (Samsung Medison, Seongnam, Korea) 을이용하였고전예에서 10 MHz의선형변환기 (Probe) 로스포츠의학을전공한한명의정형외과의사가검사를시행하였다. 피검자는앙와위에서주관절상부를침대바깥으로내어견관절을 90 o 외전, 외회전시키고주관절 90 o 굴곡위, 전완중립위를유지하면서자연스럽게주관절내측부가중력외반부하를받도록하였다. 중력외반부하시주관절내측부통증을호소하는경우는없었다. 검사자는변환기를상완골내상과원위부에상완골장축의 45 o 각도로위치시키고척측측부인대의방향을따라종축영상을얻어 (Fig. 1A) 척측측부인대의이상여부와인대주위및척상완관절면의골과연부조직의이상을건측과비교하였다. 척상완관절간격의측정은중력외반부하를가한상태에서종축영상상상완골활차의내측원위모서리와척골의내측근위모서리의연골하골간의거리를측정하였고 (Fig. 1B), 양측주관절척상완관절간격의각측정치를비교하였다. 자기공명영상검사상에서분류된부분파열군과완전파열군의초음파검사상의이상소견및두군간의척상완관절간격의좌우차이를비교하였다. 3. 자료의분석과통계초음파검사상관찰되는이상소견의빈도를전체환자에 76 대한스포츠의학회지

황태혁외. 야구선수에서척측측부인대손상의중력외반부하초음파검사 Table 1. Demographic characteristics of patients Characteristic Total (n=28) Partial tear* (n=17) Complete tear (n=11) Age (yr) 19.5±3.5 17.8±1.3 22.0±4.

2 Athlete grade High school 16 11 5 Collegiate 8 6 2 Professional 4 0 4 Dominant (right:left) 24:4 16:1 8:3 Position (pitcher:fielder) 19:9 9:8 10:1 Values are presented as the mean±standard

3 황태혁외. 야구선수에서척측측부인대손상의중력외반부하초음파검사 Table 1. Demographic characteristics of patients Characteristic Total (n=28) Partial tear* (n=17) Complete tear (n=11) Age (yr) 19.5± ± ±4.2 Height (cm) 180.3± ± ±3.4 Weight (kg) 89.3± ± ±6.7 Training history (yr) 8.9± ± ±4.2 Symptom duration (mo) 3.6± ± ±1.2 Athlete grade High school Collegiate Professional Dominant (right:left) 24:4 16:1 8:3 Position (pitcher:fielder) 19:9 9:8 10:1 Values are presented as the mean±standard deviation unless otherwise indicated. *Seventeen partial tear patients include 13 Grade II tear (<50%) and 4 Grade III tear (>50%) on magnetic resonance imaging. Fig. 1. (A) Photograph depicts technique for gravity valgus stress scanning of medial aspect of elbow. (B) Long axis sonographic view of uninjured medial elbow shows normal cord-like ulnar collateral ligament (asterisk) and measurement of ulnohumeral distance (d). U: ulna, H: humerus, ME: medial epicondyle. 대한백분율로표시하였으며, 부분파열군과완전파열군의초음파검사이상소견빈도차이는카이제곱검정을통해비교하였다. 측정된양측척상완관절간격수치는관찰자내오차를줄이기위해초음파화면상 2회측정하여평균값을사용하였다. 전체환자의중력외반부하초음파검사상건측과환측의척상완관절간격의평균값은 Student t-test를이용하여비교하였고, 부분파열군과완전파열군의척상완관절간격의차이는 Mann Whitney U 검정을시행하였다. 모든통계학적자료의분석은 SPSS ver (SPSS Inc., Chicago, IL, USA) 를사용하였으며 p-value가 0.05 미만일때통계학적의의가있는것으로판정하였다. 결과양측주관절의척상완관절간격차이를제외하고전체 28명의환자중 22명 (22/28, 79%) 에서환측주관절의초음파 이상소견이관찰되었다. 이상소견으로는척측측부인대의비후및이완 (9/28, 32%), 인대내부의저에코음영 (12/28, 43%) 척측측부인대내부또는주위의골편 (19/28, 68%), 활차또는척골관절면의골극 (10/28, 36%), 관절액의증가 (6/28, 29%) 가관찰되었다 (Fig. 2). 이중에서척측측부인대내부나주변의골편형성이가장흔히관찰되는소견이었다 (19/28, 68%). 초음파검사상이상소견의빈도는부분파열군에서는 12예 (12/17, 70%), 완전파열군에서는 10예 (10/11, 91%) 로완전파열군에서이상소견의빈도가높게관찰되었다 (p=0.045). 관찰된초음파상의이상소견중척측측부인대의비후및이완 (p=0.038), 활차또는척골관절면의골극 (p=0.026), 관절액의증가 (p=0.031) 는완전파열군에서의미있게높은빈도로관찰되었다 (Table 2). 전체환자의중력외반부하검사상환측과건측의척상완관절간격은각각 4.0±1.5 mm, 2.5±0.4 mm였으며, 환측이건측에비해 1.5±1.4 mm의유의한관절간격증가를보였다 제 33 권제 2 호

TH Hwang, et al. Gravity Valgus Stress Ultrasonographic Assessment of Ulnar Collateral Ligament Injury among Baseball Players Fig. 2.

Long axis views show (A) thickening and wavy contour of UCL (a) and increased joint effusion (b), (B) focal hypoechoic focus (c) corresponding to UCL tear, (C) small

sublime tubercle (g). U: ulna, H: humerus. Table 2.

in UCL substance, n (%) Ossicles in or around UCL, n (%) Osteophyte in trochlea or ulna, n (%) Increased joint effusion, n (%) Total no.

10 (64) (45) (73) (55) (45) (91) p-value 0.038* 0.051 0.069 0.026* 0.031* 0.

05) between partial and complete tears. Table 3.

4 TH Hwang, et al. Gravity Valgus Stress Ultrasonographic Assessment of Ulnar Collateral Ligament Injury among Baseball Players Fig. 2. Various abnormalities in gravity valgus stress sonographic scanning in ulnar collateral ligament tear players. Long axis views show (A) thickening and wavy contour of UCL (a) and increased joint effusion (b), (B) focal hypoechoic focus (c) corresponding to UCL tear, (C) small ossicles in UCL substance (d), (D) unfused apophyseal bone fragment (e) near UCL origin, (E) marginal osteophyte on medial trochlear edge (f) and (F) on ulnar sublime tubercle (g). U: ulna, H: humerus. Table 2. Abnormalities of injured elbow in gravity valgus stress ultrasonography Sonographic abnormalities Total (n=28) UCL thickening and wavy contour, n (%) Hypoechoic foci in UCL substance, n (%) Ossicles in or around UCL, n (%) Osteophyte in trochlea or ulna, n (%) Increased joint effusion, n (%) Total no. of abnormalities, n (%) (32) (43) (68) (36) (29) (79) Partial tear (n=17) Complete tear (n=11) (12) (41) (65) (24) (6) (70) (64) (45) (73) (55) (45) (91) p-value 0.038* * 0.031* 0.045* The values in parentheses were used to calculate percentages of sonographic abnormalities. UCL: ulnar collateral ligament. *Statistically significant (p 0.05) between partial and complete tears. Table 3. Ulnohumeral joint space in gravity valgus stress ultrasonography in all patients (total players n=28) Injured elbow Uninjured elbow Differences p-value 4.0±1.5 mm 2.5±0.4 mm 1.5±1.4 mm 0.015* Values are presented as mean±standard deviation. *Statistically significant difference (p 0.05) between injured and uninjured elbow in all patients. (p=0.015) (Table 3). 중력 외반 부하 검사상 척상완 관절 간격은 2.6±0.5 mm (p=0.017)로, 두 군 모두 환측이 건 측보다 의미 부분 파열의 경우 환측은 3.1±0.8 mm, 건측은 2.4±0.4 mm 있게 관절 간격이 증가되었다(Table 4) (Fig. 3). 두 군의 건측 (p=0.025), 완전 파열의 경우는 환측이 5.4±0.9 mm, 건 측이 척상완 관절 간격은 부분 파열과 완전 파열 각각 2.4±0.4 mm, 78 대한스포츠의학회지

황태혁외. 야구선수에서척측측부인대손상의중력외반부하초음파검사 Table 4. Ulnohumeral joint space in gravity valgus stress ultrasonography between two groups Partial tear (n=17) Complete tear (n=11) p-value* Injured elbow 3.1±0.

*Statistically significant difference (p<0.05) between partial and complete tear group; Statistically significant difference (p<0.05) between injured and uninjured elbow in each group. Fig. 3.

5 황태혁외. 야구선수에서척측측부인대손상의중력외반부하초음파검사 Table 4. Ulnohumeral joint space in gravity valgus stress ultrasonography between two groups Partial tear (n=17) Complete tear (n=11) p-value* Injured elbow 3.1±0.8 mm 5.4±0.9 mm 0.021* Uninjured elbow 2.4±0.4 mm 2.6±0.5 mm Differences 0.7±0.6 mm 2.8±1.2 mm 0.012* p-value Values are presented as mean±standard deviation. *Statistically significant difference (p<0.05) between partial and complete tear group; Statistically significant difference (p<0.05) between injured and uninjured elbow in each group. Fig. 3. Bilateral gravity valgus stress sonographic images in (A) partial and (B) complete ulnar collateral ligament tear players show increased ulnohumeral distance (d 1 d 2) of 0.8 mm and 2.4 mm than uninjured left elbows, respectively. U: ulna, H: humerus. 2.6±0.5 mm로의미있는차이를보이지않았으나 (p=0.395), 두군의환측척상완관절간격은각각 3.1±0.8 mm, 5.4±0.9 mm로완전파열군에서더증가되어있었고 (p=0.021), 환측과건측의차이도부분파열의경우 0.7±0.6 mm, 완전파열인경우 2.8±1.2 mm로완전파열에서더욱큰차이를보였다 (p=0.012). 고찰척측측부인대의전사주섬유 (anterior oblique bundle) 는 주관절내측부의주된정적안정화구조물로서동적안정화구조물인내측굴근군과함께투구동작시주관절외반력에저항하게된다. 주관절완전신전시에척측측부인대는외반력에대해 33% 정도만저항하지만투구동작이이루어지는주관절굴곡각도 90 o 에서는 54% 를담당하게되어반복적부하시손상이가장흔히발생하는주관절연부조직이며만성적인손상은투구시주관절내측불안정성을유발하여투수의경우구속의감소와제구력저하를가져오는요인이된다 2,10). 척측측부인대손상의영상의학적진단방법중단순방사선검사는주로골성변화를알아보는검사로골극, 제 33 권제 2 호

6 TH Hwang, et al. Gravity Valgus Stress Ultrasonographic Assessment of Ulnar Collateral Ligament Injury among Baseball Players 낭종성변화, 관절간격의협소, 유리체의존재여부를알수있으나척측측부인대와같은연부조직에대한직접적인정보를알기는어려우며 11,12), 자기공명영상검사는척측측부인대의파열상태를포함하여동반된굴곡근의손상및골수부종의여부를잘보여주지만비용적으로고가의검사이다 13). 또한두검사모두주관절신전상태에서검사하는정적인검사이므로, 인대파열로인한내측불안정성의정도를파악하기는힘든단점이있다. 주관절초음파검사는최근주목받고있는진단보조적검사로숙련도가요구된다는단점이있으나, 이용이쉽고동적인검사가가능하므로자기공명영상에서는얻을수없는내측불안정성의정도를알수있으며척측측부인대포함한주위골연부조직의상태를신속히파악할수있다는장점이있다 7,8,14). 정상적인척측측부인대는초음파상코드형 (cord-like) 의압축된고에코성섬유다발구조를보이나만성파열의경우인대가잘관찰되지않거나, 인대내부실질의단열로인한저에코음영이나인대가이완되어파동형 (wavy pattern) 을보이기도한다 7,14). 또한반복적미세손상으로유발된인대의퇴행성변화로인해인대자체가두꺼워지거나인대내부에석회화음영과이로인한후방그림자가관찰되기도한다 15). 본연구에서척상완관절간격의증가를제외한초음파이상소견이 79% (22/28명) 에서관찰되었고, 이중인대내부나주위의골편이가장흔히관찰되는소견이었으며, 이는부분파열 (65%) 과완전파열 (73%) 환자모두에서유사하게높은빈도로관찰되었다. 관찰된골편이인대에산재한석회화인지진정한골편인지초음파검사만으로는감별이힘든데, Pappas 등 2) 은만성척측측부인대손상의 18% 에서단순방사선소견상인대의석회화가관찰된다고하였고, Cain 등 16) 은손상환자의 9% 에서인대의이소성석회화가방사선소견상보인다고하였으며, Nazarian 등 17) 은무증상프로야구선수에서우세수의초음파검사상 35% 에서인대의석회화가관찰된다고하여연구마다다소차이를보인다. 이는초음파검사가단순방사선보다석회화나골편의검출에대한민감도가높은데기인할수도있고 18), 본연구에서대상환자 28명중 16명이고교생으로, 유소년기에발생한내상과견인골단판염으로인해인대의내상과부착부에유합되지않은골편이존재하는것과도연관이있을것으로생각된다 19). 또한대학이나프로선수와같은성인에서는만성적인대손상으로인한인대내부의석회화가골편과같은음영으로보일수있어전반적으로골편의관찰빈도가높아진것으로생각된다. 전체환자의초음파이상소견의빈도및초음파이상소견중 인대의손상과재생이반복되어발생하는인대의비후나활차또는척골부착부의골극, 척상완관절간격의과도한이완으로인한관절액의증가는완전파열군에서의미있게높은빈도로관찰되었는데, 이는파열정도가심해질수록더흔히관찰되는소견으로생각된다. Thompson 등 20) 에의하면척측측부인대재건술을시행한환자의 21% 에서자기공명영상상척측측부인대의특별한이상소견을발견할수없었다고하였는데, 본연구에서도 28명의환자중 6명의환자는초음파검사상척상완관절간격의증가이외에뚜렷한초음파이상소견을발견할수없었고, 6명모두자기공명영상소견상부분파열군으로분류된환자이었다. 또한자기공명영상소견상완전파열로분류한환자에서골편의그림자효과에의해초음파상인대실질부의저에코음영이 45% 에서만관찰되었다. 자기공명영상검사와초음파검사간의진단적일치도여부는본연구의범위외사항이나초음파검사술기나자기공명영상의판독상의오류와도관련될것으로생각되어추가적인증례연구가필요할것으로생각된다. 척측측부인대의파열로인한주관절내측불안정성을검사하는영상의학적방법으로외반부하방사선검사가있으며일정한무게의추를이용하거나, 중력이나상용화된부하장비 (Telos) 를이용할수있다. 외반부하방사선검사를통해 Conway 등 5) 은 2 mm 이상의척상완관절간격은척측측부인대의상대적이완, 3 mm 이상은인대의절대적기능부전을의미하며, Thompson 등 20) 도척측측부인대재건술을시행한환자의 88% 에서관절간격이 2 mm 이상이었다고하였다. 그러나이러한외반부하방사선검사는척측측부인대의상태를알수없고, 도수적으로는일정한부하를줄수없으므로대부분부하장치와같은특수한장비를이용한연구가많으며, 방사선촬영시주관절굴곡각도가 30 o 정도의낮은각도를유지해야관절간격을잘관찰할수있으므로, 척측측부인대에과부하가걸리는후기코킹기와가속초기의주관절굴곡각도 60 o 90 o 에서의불안정성을나타내는데는한계가있다. 저자들은본연구에서비교적재현성이좋고투구동작시척측측부인대가주된기능을하는주관절 90 o 굴곡상태에서, 특별한장치없이일정한부하를줄수있는중력을이용하여척측측부인대손상환자들의척상완관절간격을측정한결과우세수인환측이비우세수에비해평균 1.5 mm 증가되어있고, 부분파열일경우 0.7 mm, 완전파열일경우 2.8 mm 증가되었음을알수있었다. Lee 등 21) 은중력을이용한외반부하방사선검사는중력을가하지않은상태보다의미있게척상완관절간격이증가하였다고하여 80 대한스포츠의학회지

7 황태혁외. 야구선수에서척측측부인대손상의중력외반부하초음파검사 중력이외반부하검사에이용할수있음을보고하였다. Sasaki 등 22) 도 30명의대학야구선수에서중력외반부하주관절초음파검사를실시한결과우세수가비우세수에비해 1.1 mm 관절간격이증가하였다고하였는데주관절통증이있는선수는 1.3 mm 증가하였고, 활차내측부에골극이형성된경우는 2.1 mm까지증가한다고하였다. 그러나대상선수 30명중 17명의무증상선수들이혼재되어있어척측측부인대손상으로진단된환자를대상으로한저자들의결과와는다소차이를보인다. Nazarian 등 17) 은 26명의무증상미국메이저리그투수에대하여주관절 30도굴곡각도에서도수적부하를가한후의척상완관절간격을측정하였는데우세수가비우세수에비해 1.2 mm 더증가하였으나본연구와는달리무증상프로야구선수를대상으로하였으며, 정량화되지않은도수부하를사용하였다. Ciccotti 등 23) 은사체주관절의초음파검사를통해척상완관절간격은척측측부인대가건재할경우평균 2.8 mm이며척측측부인대의전사주섬유의전방부를절제한후 150 N의외반부하를가하면관절간격이 2.0 mm 증가하고전사주섬유전체를절제할경우는간격이 3.4 mm 증가한다고하였다. 또한 Ciccotti 등 24) 은이와같은결과를바탕으로무증상프로야구선수 368명의 150 N 외반부하초음파검사를실시한결과우세수가비우세수보다 0.9 mm 증가하였다고하였다. 본연구에서저자들이부분파열과완전파열에서각각측정한건측대비 0.7 mm와 2.8 mm의증가는통계적의미는있으나다른초음파연구들에서 17,24) 도수적부하나외반부하장비를이용한증가치보다는작은데이는본연구에서사용한부하자체가중력인점을감안하면타당성이있을것으로생각되며, 특히부분파열 17 예중자기공명영상검사상 50% 이하의파열로판정한경우가 13예이었으므로상대적으로증가치가적었을것으로생각된다. Bruce 등 25) 은 150 N 외반부하방사선검사상부분파열의경우는관절간격이 0.1 mm 증가하여건측과거의차이가없으며완전파열의경우도 0.6 mm만증가하였다고보고하여본연구의측정치와는상당한차이를보이는데, 이는척상완관절간격의측정이초음파를이용하여관절간격외연에서측정한본연구와는달리방사선상관절면의중앙에서측정하였고, 저자들이단점으로지적했듯이측정시외반부하통증으로유발된반사성근육긴장으로인해관절간격이과소측정되었을가능성이있다. 본연구에서사용한중력외반부하는검사시통증을유발하지않으므로내측불안정측정시근긴장으로인한위음성의비율도줄일수있는장점이있을것으로생각한다. 본연구의단점으로는대상환자의수가적은후향적연구이며, 척측측부인대손상이없는대조군을설정하지않고단지환자의비우세수와비교하였으며, 동일관절에서중력부하전후의척상완관절간격증가정도에대한분석을하지는않았다. 또한자기공명영상검사에서부분파열과완전파열의판독상오류도있을수있다. 마지막으로본연구는한명의관찰자에의해이루어져오차분석이없는점을들수있는데, Bica 등 8) 의연구에의하면경험있는단일검사자에의해시행된초음파검사의급내상관계수는 의비교적우수한신뢰도와정확도를가지므로적절한검사술기획득이필수적이라할수있다. 저자들은본연구를통해투구동작을하는야구선수에서흔한손상부위인주관절척측측부인대손상을중력부하초음파검사를통해건측과비교되는척측측부인대의이상소견을발견하고약 1.5 mm의내측불안정성을확인하였으며, 이는잦은시합이나훈련으로의료기관을방문하지못하는선수들에게간단한현장초음파검사를통한주관절척측측부인대손상정도를파악하는지침으로도이용될수있으며인대재건수술전보조진단이나수술후의추시검진에도활용할수있을것으로생각된다. Conflict of Interest No potential conflict of interest relevant to this article was reported. References 1. Jobe FW, Nuber G. Throwing injuries of the elbow. Clin Sports Med 1986;5: Pappas AM, Zawacki RM, Sullivan TJ. Biomechanics of baseball pitching: a preliminary report. Am J Sports Med 1985;13: Chen FS, Rokito AS, Jobe FW. Medial elbow problems in the overhead-throwing athlete. J Am Acad Orthop Surg 2001;9: Indelicato PA, Jobe FW, Kerlan RK, Carter VS, Shields CL, Lombardo SJ. Correctable elbow lesions in professional baseball players: a review of 25 cases. Am J Sports Med 1979;7: Conway JE, Jobe FW, Glousman RE, Pink M. Medial instability of the elbow in throwing athletes: treatment by repair or reconstruction of the ulnar collateral ligament. J Bone Joint Surg Am 1992;74: 제 33 권제 2 호

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Kbcs002.hwp Does Real-time Compound Imaging Improve Evaluation of reast Cancer Compared to Conventional Sonography? o Kyoung Seo, M.D., Yu Whan Oh, M.D., Kyu Ran Cho, M.D., Young Hen Lee, M.D., Hyung Joon Noh, M.D.,