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1 elssn plssn Journal of Trauma and Injury Vol. 26, No. 3, September, 2013 Original Article [ J Trauma Inj 2013;26: ] 자동차바퀴에의한소아아래다리의압궤손상 가천대길병원응급의학교실, 1 가천대길병원정형외과학교실 최재연, 장재호, 우재혁, 박원빈, 김진주, 현성열, 이근, 곽지훈 1 - Abstract - Car-tire-related Crushing Injury of the Lower Leg in Children JaeYeon Choi, M.D., JaeHo Jang, M.D., JaeHyuck Woo, M.D., WonBin Park, M.D., JinJoo Kim, M.D., SungYeol Hyun, M.D., Geun Lee, M.D., JeeHoon Gwak, M.D. 1 Department of Emergency Medicine, Gachon University Gil Medical Center, Incheon, Korea, 1 Department of Orthopedic Surgery, Gachon University Gil Medical Center, Incheon, Korea Purpose: Crushing injuries by car tires result from a combination of friction, shearing, and compression forces and the severity of injury is influenced by the acceleration. Because car-tire injuries of the lower leg in children are common these days but they have received little attention; thus, our purpose was to look closely into this problem. Methods: A retrospective analysis was conducted of data from children under 15 years old age who visited an emergency department because of a car-tire-related crushing injury to the lower leg in pedestrian traffic accident from January 2008 to September The patient s age, sex, site of injury, degree of injury, associated injuries, type of surgery, and complications were reviewed. Results: There were 39 children, the mean age was 8.0 years, and 71.8% were boys. The dorsal part of the leg was involved most frequently. According to the severity classification, 15 children were grade I, 6 were grade II, and 18 were grade III. Among 24 patients, 13 were treated with skin graft and 3 were treated using a sural flap. Twelve patients developed complications, such as hypertrophic scarring, contractures, and deformities with significant bone loss. Conclusion: Various degrees of skin or soft tissue defects were caused in children by car tires. In this study, patients were often also had tendon or bone damage. Proper and timely initial treatments are needed to reduce the incidence of infection, the number of operative procedures, and the hospital stay. Key Words: Pediatrics, Soft tissue injury, Leg injury, Complications Address for Correspondence : JinJoo Kim, M.D. Department of Emergency Medicine, Gachon University Gil Medical Center, 1198 Namdonggu Guwoldong, Namdong-gu, Incheon , Korea Tel : , Fax : , empearl@gilhospital.com Submitted : June 26, 2013 Revised : July 16, 2013 Accepted : September 2,

2 - Journal of Trauma and Injury Vol. 26, No. 3 - I. 서론최근정부의통계자료에따르면 2013년 6월현재자동차등록대수가 1,800만대를넘어서고있으며이에따른자동차관련사고도증가하고있는추세에있는것으로보고되었다.(1) 교통사고로인한손상은세계적으로도어린이사망, 입원및장애의주요원인으로알려져있다.(2) 국내어린이교통사망사고는 1992년에 1,180명으로지속적으로증가하다가 2007년 202명으로감소추세에있으나, 아직 OECD 국가중사망률이가장높다.(3) 교통사고의수가늘어남에따라소아보행자사고중자동차바퀴에의한아래다리의손상은임상에서도드물지않게접하고있다. 소아는사물에대한많은호기심을갖고있으나신체반사운동이미발달되어있고판단력이부족하여자주외상을받는다.(4) 소아가외상을입을경우성인보다회복이빠르고치료가비교적간단할것으로인식이되나, 소아에서사지의외상후연부조직의구축과반흔, 골의성장지연과변형등이흔히관찰된다.(4,5) 자동차바퀴에의한압궤손상은주로주의력이부족한어린이들이도로나건널목등을지나면서발생한다. 자동차운전자가사고를인지하고순간적으로급제동을하면차량이가지고있던운동에너지의상당량이보행자의다리나발로전달된다. 이때전달된에너지는마찰력, 전단력 (shearing) 및압축력 (compression) 등다양한형태로전이되어수상부위에화상및복합적인조직손상을일으키게된다.(6) 자동차바퀴에의한손상은일반적인열상이나찰과상과는달리압착 (crushing) 과벗겨짐 (avulsion) 이손상의주요한인자로초기처치가미흡할경우감염의위험이높아지고피부이식등의수술적치료를필요로할확률이높아지기때문에초기손상정도를정확히판단하고적절한치료를시행하는것이필수적이다.(7) 자동차바퀴에의한소아의아래다리압궤손상은손상부위는크지않아도심부조직까지손상될가능성이있으며인대손상이나골절을동반할경우질병의이환기간이길어지고추후기능적인후유증이나타날수도있다.(8) 이러한손상은드물지않게임상에서접하고있으나이에대한통계적자료 는국내에부족한실정이다. 이에저자들은일개대학병원응급의료센터에내원한소아외상환자를대상으로자동차바퀴에의한아래다리압궤손상에대한고찰을하고자한다. II. 대상및방법 2008년 1월부터 2012년 9월까지일개대학병원응급의료센터에내원한 15세이하의소아외상환자중자동차바퀴에의한아래다리손상을받은경우를대상으로후향적연구를시행하였다. 기간내내원한총소아외상환자자료중보행자교통사고로수상한경우를분리하였으며이중발을포함한아래다리를수상당한환자를구분하였다. 이들의의무기록을통해환자의다리나발이자동차바퀴에끼이거나치인경우또는차량바퀴가밟고지나갔다는병력기록이있는환자를연구대상자로포함하였고, 대상환자의성별, 나이, 손상부위, 손상정도, 동반손상, 연부조직결손발생에따른치료방법및합병증등을조사하였다. 손상부위는 Al-Qattan (8) 의연구에따라부위별로배측, 내측, 외측으로분류하였다. 또한손상정도는 2007년한과김 (9) 이 1999년부터 2004년까지교통사고에의한 15세이하소아의족부압궤손상에대한치료결과를보고한논문에서사용한 Grade에따라분류하였다. 이에따라찰과상또는마찰화상을 Grade I, 뼈, 인대가노출된열상이나연부조직의박리손상을 Grade II, 여기에골절이나인대손상또는신경, 혈관의손상이동반된경우를 Grade III로분류하였다. 동반손상은골절이나탈구와같은골손상, 건및근육의손상, 그리고신경및혈관의손상으로구분하였다 (Table 1). III. 결과 2008년 1월부터 2012년 9월까지총 33,206명의소아외상환자가응급실에내원하였으며보행자교통사고로인한외상환자는 854명이었다. 소아보행자교통사고환자에서발및다리손상이있었던 321명중 242명은응급실에서치료받은후귀가하였으며, 나머지 79명은입원치료를받았다. Table 1. Classification of the severity of the injured foot (Hahn and Kim(9)) Severity Description Grade I Scratching or friction burn Ia With bone or joint injury Grade II Laceration or skin avulsion with tendon or bone exposure Grade III Grade II with associated injury IIIa Bone or joint injury IIIb Tendon injury IIIc Neurovascular injury IIId Mixed type, complex injury 176

3 JaeYeon Choi, et al.: Car-tire-related Crushing Injury of the Lower Leg in Children * ED: emergency department TA: traffic accident Fig. 1. This diagram shows the flow of study population from January 2008 to September 2012 다리손상환자중자동차바퀴에의한압궤손상환자는 39명이었다 (Fig. 1). 남자가 28명 (71.8%), 여자가 11명 (28.2%) 으로남아가두배이상많았으며, 수상당시평균연령은 8.0세였다. 연령별로살펴보면 7세가 10명으로가장빈도가높았으며 5세, 9세순으로나타났다. 수상당시호발연령은학령기인 6세에서 10세사이가 22명으로전체 56.4% 를차지하였다 (Fig. 2). 발생시기로살펴보았을때각월마다환자가 1~5명내외로분포하여서로크게차이가없었으며, 계절별로도봄, 여름, 가을에발생한환자수가각 10명, 11명, 11명으로차이를보이지않았다 (Fig. 3). 수상한다리의좌우발생빈도는우측이 23명 (59%) 으로좌측보다많았으며양측을수상한환자도 3명있었다. 대상자 39명의손상정도를분류하였을때 Grade I이 15명 (38.5%), Grade II (Fig. 4) 가 6 명 (15.3%), 동반손상이있는 Grade III가 18명 (46.2%) 이었다. Grade III에해당하는손상을동반손상종류에따라다시나누어보면연부조직손상과함께골절및탈구 (IIIa) 가있었던경우 (Fig. 5) 가 13명, 건손상 (IIIb) 이 1명, 혼합손상 (IIId) (Fig. 6) 이 4명있었다 (Table 2). 골절이있는경우하나의뼈만골절된예도있으나두개이상의뼈에골절이있는경우도있어총 46예로조사되었고, 이중정강뼈의골절이 22예로가장많았고종아리뼈가 15예, 발부위뼈가 6예, 넓적다리뼈가 2예, 골반뼈골절이 1예가있었다. 손상부위를배측, 내측, 외측으로분류하였을때, 배측이 14명, 내측이 15명으로비슷한숫자를보였고외측손상은 10명으로다소적었다 (Table 2). 연부조직결손으로봉합이나수술적처치를시행한경우가 18예있었으며일차또는지연봉합이 2예, 부분층피부이식술이 12예 (66.7%), 전층피부이식술이 1예, 비복피판을시행한경우가 3예로조사되었다 (Table 3). 봉합, 피부이식, 피판술과같은연부조직손상의치료는수상 Fig. 2. This graph shows the number of injured children according to age 177

- Journal of Trauma and Injury Vol. 26, No. 3 - Fig. 3. This graph shows the number of injured children according to month of occurrence Fig. 4. This picture shows 9-year-old male with type II injury.

수상당일일차봉합을시도한경우가 2예있었으며, 8예는 30일이내에수술적치료를받았고, 3예는 60일이내에, 1예는수상후 9개월이지나연부조직손상으로인한비후성반흔에대해치료를받았다. 자동차바퀴에의한압궤손상으로치료를받은환자에서추후합병증이발생한것으로기록된경우는총 12예가있었고, 비후성반흔이 8예, 구축이 3예, 골소실로인한변형이온경우가 1예있었다 (Table 3).

4 - Journal of Trauma and Injury Vol. 26, No. 3 - Fig. 3. This graph shows the number of injured children according to month of occurrence Fig. 4. This picture shows 9-year-old male with type II injury. Conservative management was done for 5 5 cm sized skin injury on right lateral malleolar 일로부터평균39.8(±66.1) 일이지나시행되었다. 수상당일일차봉합을시도한경우가 2예있었으며, 8예는 30일이내에수술적치료를받았고, 3예는 60일이내에, 1예는수상후 9개월이지나연부조직손상으로인한비후성반흔에대해치료를받았다. 자동차바퀴에의한압궤손상으로치료를받은환자에서추후합병증이발생한것으로기록된경우는총 12예가있었고, 비후성반흔이 8예, 구축이 3예, 골소실로인한변형이온경우가 1예있었다 (Table 3). IV. 고 찰 우리나라교통사고로인한사망자수는매년감소추세에있으나아직도 OECD 국가중에서높은편으로, 교통사고에 의한소아사망은악성신생물에의한사망에이어 2위를차지하고있다.(1,19) 2007년경찰청교통사고통계자료에의하면, 어린이교통사망사고는 2007년에 202명으로보고되었으며, 202명중 63% 인 127명이보행자교통사고인것으로보고되었다.(3) 2001년부터 2003년사이의미국에서발생한통학버스에의한소아교통사고의유병률을보면 10~14세가 43%, 5~9세가 27.3% 였고, 손상부위로는두부손상이 30% 로가장많았으며그다음으로하지의손상이 21% 로발표되었다.(10) 5세에서 9세사이아동의교통사고빈도가높다는점은한과김 (9) 의연구에서도 5세에서 9세사이의어린이가전체환자의반이상을차지할정도로빈도가높았다는점과일치한다. 본연구에서도 5세에서 9세까지의소아가 39명중 27명으로전체의 69.2% 를차지하여높은비율을보였다. 이는이시기에어린이들이유치원, 초등학교입학으로통학하면서활동반경은크게넓어지지만주의집중력이아직부족하고보호자의지원도약화되기쉽기때문으로판단된다. 소아가외상을입는시기에대해언급한연구로는 Vollman 등 (11) 이잔디깎는기계에의한소아손상에대한역학조사에서사고가 4월에서 8월까지따뜻한계절에가장많이발생하며, 손상부위로는족부를포함한하지의손상이 36.6% 로가장많았고손상정도는열상이 41.2%, 연부조직손상이 21.4%, 찰과상및화상이 15.5%, 골절이 10.3% 순으로나타났다고보고했다. 국내연구의사고발생시기에대한분석 (9) 에서도사고가 4월에서 8월사이가장많은것으로나타났다. 본연구에서는 4월에서 8월까지수상한소아가 18명으로보고되어 50% 에이르기는하나월별발생빈도를살펴보면각 1~5명사이로크게차이가없었다. 성별에서는앞선연구 (8-9,12-14) 들과마찬가지로남아가여아보다사 178

$These pictures show 5-old-year male sustained Type IIIa car-tire crushing injury on left lower leg (A) Open fracture of tibia with skin avulsion and soft tissue injury was checked (B) 1 cm sized open$

5 JaeYeon Choi, et al.: Car-tire-related Crushing Injury of the Lower Leg in Children 고발생빈도가높았으며이는남아가보다활동적이고야외활동을많이하는경향이있기때문으로생각된다. 본연구에서는연부조직손상의부위가배측, 내측, 외측순서로나타났는데 Al-Qattan(8) 의연구에서는배측손상이현저히많았고, Suliman 등 (12) 이 35명의자동차바퀴에의한손상환자를대상으로조사한연구에서도배측손상이 28명으로빈도가가장높았으며, 다음은내측, 외측의순서 로보고되었다. 자동차타이어에의한마찰화상을연구한이와최 (7) 의연구에서도 18명의환자들대부분은발등부위의손상을입었고, 그중에서도발등의내측손상이다수였던점을확인할수있었다. 자동차바퀴압궤손상의경우몸무게를지탱하는발바닥부분에심한마찰화상이나연부조직의손상은관찰되지않았는데이는이와최 (7) 의결과에서도마찬가지였다. Suliman 등 (12) 은오른쪽발을수상한경우가 A B C Fig. 5. These pictures show 5-old-year male sustained Type IIIa car-tire crushing injury on left lower leg (A) Open fracture of tibia with skin avulsion and soft tissue injury was checked (B) 1 cm sized open wound was checked on medial side of lower leg (C) Multiple superficial injuries with an area of skin loss were existed A B Fig. 6. These pictures show 4-year-old male with type IIId injury (A) Open fracture of right distal tibia with skin defect was checked (B) Sural flap and split thickness skin graft were done for 5 10 cm sized skin defect 14 days after the accident 179

6 - Journal of Trauma and Injury Vol. 26, No. 3 - 왼쪽보다더많은점을지적하였는데, 대부분의사람들이오른쪽발을중심으로움직이는것이더우세하며수상당시왼쪽발은뒤쪽으로쳐져있고먼저내딛어진오른발이중심축이되어회전하기때문으로해석했다. 저자들의연구에서도양쪽발을수상한 3명을제외하고오른쪽발을수상한경우가 23명 (59%) 으로왼쪽발을수상한 13명보다더많았다. Nuzumalail 등 (15) 은 1996년자동차타이어에의한발의연부조직손상에대해유리피판술을시행한경험을보고한바있고, Al-Qattan(8) 은 2000년자동차타이어에의한마찰화상의치료경험을보고한바있다. 국내에서는자동차바퀴에의한손상과관련하여한과김 (9) 이 2007년교통사고에의한 97명의소아족부압궤손상에대한치료결과를발표한바있으며이와최 (7) 등이발에발생한자동차타이어마 찰화상 18예에대한결과를, 최등 (16) 이자동차타이어마찰화상환자에서유리피판을이용한종아리증대술을시행한경험을보고한바있다. Nuzumalail 등 (15) 의연구에서는 8 명의환자에서모두연부조직손상및발가락폄근손상이나타났고, Al-Qattan(8) 은대상자 25명중 2명의환자에서연부조직손상및발가락폄근손상이나타났다고하였다. 본연구에서는연부조직손상이있었던경우가 24예로건의손상이 6예에서동반되었고 13예에서는전층또는부분층피부이식술이, 3예에서는피판술을필요로연부조직결손이있었다. Nuzumalail 등 (15) 은발허리뼈, 발꿈치뼈, 복사뼈등의동반골절을보고하였으며한과김 (9) 은전족부골절이총 92예의동반골절중 51예로가장많았으며, 정강뼈골절이 18 예, 종아리뼈의골절이 10예의순으로나타났다고보고했다. Table 2. Severity grade, associated fractures and affected site of injured leg (N=39) Severity grade I 04 Ia 11 II 06 IIIa 12 IIIb 01 IIIc 00 IIId 05 Total patients 39 Associated fracture site Foot 06 Tibia 22 Fibula 15 Femur 02 Pelvis 01 Total cases 46 Affected sites of lower leg Dorsal 14 Medial 15 Lateral 10 Total patients 39 No Table 3. Treatment method of soft tissue defect and complications (N=39) Treatment method of soft tissue defect Primary or delayed closure 02 STSG * 12 FTSG 01 Sural Flap 03 Total cases 18 Delayed complications Hypertrophic scar 08 Contracture 03 Deformities with significant bone loss 01 Total cases 12 * STSG: split thickness skin graft FTSG: full thickness skin graft No 180

7 JaeYeon Choi, et al.: Car-tire-related Crushing Injury of the Lower Leg in Children 본연구에서는족부의골절은총 6예로빈도가높지않았으나정강뼈의골절이 46예중 22예에서동반되었고종아리뼈의골절이 15예로국내의앞선연구와비슷한결과를보였다. 사지의급성복합성손상의경우생존력이떨어지는조직을제거하고건강한연부조직을이식하여빠른시간에상처를덮어줌으로써상처주위의감염을예방하고이차적으로발생할수있는인대나뼈등의손상을방지하는것이재건의원칙이다.(7) 발의배측부분의피부는아랫부분에얇고유연하며평편한근막층이있어발가락폄힘근들이자유롭게움직일수있게해주는해부학적특징이있는데이점이연부조직재건술의어려움으로지적된다.(14) 또한연부조직결손에대한다양한치료방법중소아에서피부이식은정상조직의성장과이식된피부의성장이부적절해관절의구축이올수있어연부조직재건에피판술이우수하다고보는연구들이있었다.(6,15) 한과김 (9) 저자들의경우에도국소피판술및유리피판술을이용한연부조직재건이 53예 (61.5%) 로가장많았으며이중에는 1차봉합이나피부이식술을시행하고반흔구축이온뒤에재수술을시행한경우도 9예가있었다. 그러나최 (7) 등의연구에서는연부조직결손을치료받은 18 명의환자중 11명이부분층피부이식술을시행받았고 3명에서는전층피부이식술을시행한것으로나타났고이후추적관찰기간동안환자에서운동기능의제한이나반흔구축은나타나지않았다고보고되었다. Fujita 등 (14) 의보고를보면 15 명중 11명의환자에서전층또는부분층피부이식술을시행한것으로보고되었다. 본연구에서도실제로피판술은 3예에서만시행되었고부분층피부이식술이 12예로가장많이시행되었다. 소아족부손상후에발생하는문제점으로는반흔구축, 중족족지관절의신전구축, 갈퀴발가락변형, 첨족변형, 후족부의내반또는외반변형, 편평, 성장판손상에따른성장장애등이있다.(5,8,15) Suliman(12) 등은연부조직결손치료받은 13명중 14.3% 인 5명에서비후성반흔의합병증이나타났다고보고했다. 한과김 (9) 은 80예의시술에서구축이 9예, 족부변형이 7예, 절단이 8예있음을발표하였다. 본연구에서는 18예의치료에서비후성반흔이나타난경우가 8예로가장흔하였고구축이 3예, 심한골소실로인한변형이 1 예보고되었다. 환자에게다른기저질환이없는경우대부분의상처는특별한처치없이 2차유합 (secondary intention) 에의해회복되나, 피부나연부조직의결손이있는경우에는흉터, 감염, 주위조직의손상, 치료기간연장등으로치료방법의선택에있어서는이견이있다.(17) 1960년대상처부위의습기유지가상처회복에도움이되는것이알려졌고, 1970년대이후로폴리우레탄제재의필름이나폼 (foam), 하이드로콜로이드 (hydrocolloid), 알긴산염 (alginate), 하이드로겔 (hydrogel) 등을사용한새로운상처드레싱제재들이개발 되어임상에적용되고있다.(18) 손상부위에대한수술적처치이후에도다양한드레싱제재의적용을통해상처회복을촉진시키고합병증을줄이는방법에대한연구가필요하겠다. 또한본연구는일개대학병원응급의료센터를내원한환자를대상으로했다는것과환자표본수가적고후향적으로시행된연구라는제한점이있다. V. 결론 일개대학병원응급의료센터에서경험한소아보행자교통사고에서자동차바퀴에의한아래다리압궤손상은다양한정도의피부결손및연부조직손상이나타날수있으며인대나뼈의손상도동반되는경우가많았다. 따라서자동차바퀴에의한소아외상환자에서수상초기에손상정도를정확히파악하고빠른시간에적절한치료를시행함으로써합병증을방지하여환자의치료기간, 후유증을줄이고개인및사회적인비용을최소화하는것이중요할것으로생각되며, 이에대한전향적인연구가필요할것으로생각된다. REFERENCES 01) Ministry of Land, Infrastructure and Transport Available at: molit.go.kr/portal/main/portalmain. do 02) Durkin MS, Laraque D, Barlow B. Epidemiology and prevention of Traffic Injuries to Urban Children and Adolescents. Pediatrics 1999; 103: e74. 03) National police agency Available at: go.kr/portal/main/contents.do?menuno= ) Kim ID, Lee SY, Kim PT, Park BC, Lee CH. Clinical study of the multiple injuries in children. J Korean Orthop Assoc 1984; 19: ) Lin CH, Mardini S, Wei FC, Lin YT, Chen CT. Free flap reconstruction of foot and ankle defects in pediatric patients: long-term outcome in 91 cases. Plast Reconstr Surg 2006; 117: ) Thomson HG. Children s fractures. In: Rang M, editor. Soft tissue injuries. Philadelphia: JB Lippincott, p ) Lee SW, Choi YW, Nam SH, Kim H. Friction Burn on Foot Caused by Car-Tire. J Korean Burn 2010; 13: ) Al-Qattan MM. Car-tyre friction injuries of the foot in children. Burn 2000; 26: ) Hahn SB, Kim HK. The Results of Treatment for Motor Vehicle-related Crushing Injuries of Foot in Children. J Korean Microsurg 2007; 16: ) McGeehan J, Annest JL, Vajani M, Bull MJ, Agran PE, Smith GA. School bus- related injuries among children and teenagers in the United States, Pediatrics 2006; 118: ) Vollman D, Smith GA. Epidemiology of lawn mower-related injuries to children in the United States, Pediatrics 181

8 - Journal of Trauma and Injury Vol. 26, No ; 118: e ) Suliman MT, Aizaz S. Car tire injuries: a review of 35 patients. Ann Saudi Med 2008; 28: ) Lickstein LH, Bentz ML. Reconstruction of pediatric foot and ankle trauma. J Craniofac Surg. 2003; 14: ) Fujita M, Yokoyama K, Nakamura K, Uchino M, Wakita R, Itoman M. Tibial fractures associated with crush injuries to the soft tissues of the dorssal foot in children. Injury 2004; 35: ) Nuzumalali E, Gurbuz C, Kantarci U, Cepel S, Bayri O, Polatkan O. Moving car- tyre injuries of the foot: Reconstruction with microvascular free flaps. J Reconstr Microsurg 1996; 12: ) Choi JH, Choi YW, Nam DH, Youn KY. Calf Augmentation with Latissimus Dorsi Muscle Free Flap in Car Tire Friction Burn Patient. J Korean Burn 2008; 11: ) Rivera AE, DO, Spencer JM. Clinical aspects of full-thickness wound healing. Dermatol Clin 2007; 25: ) Hom DB, Adams G, Koreis M, Maisel R. Choosing the optimal wound dressing for irradiated soft tissue wounds. Otolaryngol Head Neck Surg 1999; 121: ) Statistics Korea Available at: 01List01.jsp?pubcode =YD 표 6. 성 연령 사망원인별사망자수, 표 7. 성 연령 사망원인별사망률 182

Lumbar spine

Lumbar spine CT 32 111 DOI : 10.3831/KPI.2010.13.2.111 Lumbar Spine CT 32 Received : 10. 05. 23 Revised : 10. 06. 04 Accepted : 10. 06. 11 Key Words: Disc herniation, CT scan, Clinical analysis The Clinical