CASE REPORT pissn eissn J Korean Soc Surg Hand 2016;21(4): JOURNAL OF THE KORE

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1 CASE REPORT pissn eissn J Korean Soc Surg Hand 2016;21(4): JOURNAL OF THE KOREAN SOCIETY FOR SURGERY OF THE HAND Chronic Instability of the Carpometacarpal Joint of the Thumb after Trauma: A Report of 3 Cases Sam-Guk Park, Young-Jin Ko Department of Orthopedic Surgery, Yeungnam University Medical Center, Daegu, Korea Received: September 28, 2016 Revised: [1] November 1, 2016 [2] November 2, 2016 Accepted: November 3, 2016 Correspondence to: Sam-Guk Park Department of Orthopaedic Surgery, Yeungnam University Medical Center, 170 Hyeonchung-ro, Nam-gu, Daegu 42415, Korea TEL: , FAX: radiorth@naver.com Posttraumatic instability of the carpometacarpal joint of the thumb are rarely reported. Consequently little is known about clinical and radiologic diagnosis, natural progress or treatment method. We report three cases of chronic instability of the carpometacarpal joint of the thumb treated with Eaton and Littler s ligament reconstruction. Satisfactory thumb functions were restored without arthritic change or recurrent subluxation. Keywords: Thumb, Carpometacarpal joint, Anterior oblique ligament, Dorsoradial ligament, Instability, Ligament reconstruction This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( 3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 서론 무지수근중수관절 (carpometacarpal joint of the thumb) 은무지의굴신, 내 외전및회전운동을가능하게하는관절이기에정상적인손의기능을위해서는통증이없고안정적인무지수근중수관절의기능이필수적이다. 무지수근중수관절의불안정성과관절의퇴행성변화의관계에관해서는많은연구가있었고,, 무지중수골기저부의견연골절 (Bennet s facture) 에관해서도생역학적원인과적절한치료방법이밝혀져있는상태이다. 그러나외상후불안정성에관한보고는아주드물고,, 관절불안정성의자연경과,, 임상및방사선학적진단방법, 그리고적절한치료기준에관한연구 도아직미비한상태이다,. 불안정성의원인이되는인대에관한생영학적연구들도아직논란중에있으며,,,, Eaton 과 Littler 의전방경사인대 (anterior oblique ligament: beak or volar ligament) 재건술외에여러가지인대재건술, 인대봉합술및강선고정술, 경피적핀고정술, 석고고정및보존적치료등의여러가지치료방법이시도되고있다,, -. 저자들은외상후초기에는일반방사선사진상이상소견을확인할수없었으나, 개월이상보존적치료후증상이지속되어시행한추적검사상무지수근중수관절의불안정성을확인하여전방경사인대재건술을시행한 예에대하여문헌고찰과함께보고하는바이다 Copyright c The Korean Society for Surgery of the Hand

2 Sam-Guk Park, et al. Chronic Instability of the Carpometacarpal Joint of the Thumb after Trauma 증례 저자들은무지수근중수관절에외상으로인한급성손상으로환자가내원한경우단순방사선사진상탈구나아탈구소견이관찰되면도수정복을한후무지의대립 (opposition) 자세에서 주간의단무지석고붕대 (thumb spica cast) 고정시행후부종이없어지고, 통증이호전되면일상생활을시작하도록하였다. 전방경사인대재건술의적응증은수상후 주이상의보존적치료를시행하였으나무지기저부의통증을호소하고, 신체검사상무지의요측외전, 신전, 회외전상태에서전방불안정성이있는환자로일반방사선소견상골관절염소견이없이무지수근중수관절의아탈구소견을확인할수있는경우에시행하였다. 수술방법은 Eaton 과 Littler 의전방경사인대재건술을사용하였다. 먼저, modified Wagner s surgical approach 를이용하여무지수근중수관절위로피부절개를가하여요골신경의표재분지 (superficial dorsal branch of the radial nerve) 을확인한후대능형골 (trapezium) 관절면의연골을확인하였다. 손목관절의약 cm 근위전완부에 cm 피부절개후요수근굴건의요측절반을원위부의부착부위를유지한채얻어내고, 와이어루프 ( -gauge stainless steel wire loop) 를이용하여수근중수관절위로가한피부절개를통해꺼낸뒤, 무지중수골의기저부에 guide wire 로. mm kirschner-wire 를사용하여삽입한후. mm 드릴을이용하여구멍을뚫어요수근굴건을통과시켜장무지외전건 (abductor pollicis longus) 밑으로꺼내어봉합하였다 (Fig. ). 수술후단무지부목고정을하였고, 수술후재활은통증이호전된수술후 일경부터가벼운수동운동을시작하였다. 수술후 주경부터부목을제거하고능동운동을시작하였으며, 수술후 주경정상적운동범위를얻고정상적관절정열 이유지되어가벼운일상생활을시작하였다. 수술후결과의평가는임상적으로시각상사척도 (visual analogus score, VAS), 무지의운동범위, 집기력측정계 (Jamar, hydraulic pinch gauge, Patterson Medial, Warrenville, IL, USA) 를이용하여정상측과비교하였고, the disabilities of the arm, shoulder and hand score (Quick DASH) 를사용하여손의기능을수술전 후로비교하였으며, 영상의학적으로는수술후아탈구의재발및관절염의발생여부에대하여추적관찰을시행하였다. 1. 증례 1 세여자환자로학교체육시간에뜀틀하면서넘어지며바닥을짚은후우측무지수근중수관절의통증을주소로내원한환자로무지기저부부종이동반된상태였으나단순방사선검사상이상소견이관찰되지않아 (Fig. A, B) 단무지부목 (short arm thumb spica splint) 고정을 주간시행하였다. 주간의보존적치료후에도무지기저부의통증을호소하고, 집기 (pinching) 에어려움을호소하여추적관찰한단순방사선사진상이상소견이확인되지않아추가적인 주간의단무지석고붕대고정시행후부종이없어지고, 통증이호전되어일상생활을시작하였다. 외상후 개월경다시내원한환자는그사이외상이나과용한병력이없었으나일상생활이어려운정도의통증, 특히책상이나의자를짚고일어설때, 또는집기동작에불안정성이동반된통증을호소하였다. 우측손목의전후방사선사진상무지중수골이대능형골의요측으로 - mm 전위되었으며 (Fig. C), 사선영상 (semi-pronated oblique view) 을수상당시촬영한일반방사선사진과비교했을때무지중수골과제 중수골기저부사이간격이벌어졌고, 무지수근중수관절의관절간격이일정하게유지되지않는소견을확인할수있었다 (Fig. D). 관절면의부조화 (articular surface incongruity) A B C Fig. 1. Intraoperative photographs for the reconstruction of the volar oblique ligament according to the Eaton and Littler technique. (A, B) Radial half of the flexor carpi radialis was passed through a drill hole in the base of the first metacarpal bone. (C) It was placed beneath the abductor pollicis longus then passed around the remaining flexor carpi radialis and secured over the dorsal capsule

J Korean Soc Surg Hand Vol. 21, No. 4, December 2016 A B C D Fig. 2. (A, B) Plain radiographs at 3 days after injury showed normal positioning of the carpometacarpal joint of the thumb with uniform joint space.

(D) Oblique radiograph of semipronated wrist at 4 months after injury showed widened interval between first and second metacarpal bone base and non-parallel joint space in comparison with initial

(A) Radiograph demonstrating reduced carpometacarpal joint of the thumb with a hole at the metacarpal base made to pass the split of flexor carpi radialis tendon.

3 J Korean Soc Surg Hand Vol. 21, No. 4, December 2016 A B C D Fig. 2. (A, B) Plain radiographs at 3 days after injury showed normal positioning of the carpometacarpal joint of the thumb with uniform joint space. (C) Antero-posterior radiograph of the wrist at 4 months after injury showed radially displaced carpometacarpal joint of the thumb. (D) Oblique radiograph of semipronated wrist at 4 months after injury showed widened interval between first and second metacarpal bone base and non-parallel joint space in comparison with initial radiograph. A B Fig. 3. Two dimensional computed tomography coronal image suggested an air density (arrow) in the carpometacarpal joint of the thumb. Fig. 4. (A) Radiograph demonstrating reduced carpometacarpal joint of the thumb with a hole at the metacarpal base made to pass the split of flexor carpi radialis tendon. (B) Follow-up radiograph at 23 months after the surgery shows congruent joint with no arthritis. 를확인할목적으로촬영한 computed tomography 상명확한부조화소견을찾을수없었으나, 관절내공기음영 (air density) 을관찰할수있었다 (Fig. ). 이환부위의돌출소견은없었으나무지기저부의압통을확인할수있었고, 무지의운동범위는제한이없었다. 기능적검사상시각상사척도로측정한통증점수는 점이었으며, 집기력은건측의 / 정도로감소되었고, 손의기능은 Quick DASH. 점으로측정되었다 (Table ). 무지의수장측외전, 신전, 회내전상태에서는확인되지않던전방불안정성을요측외전, 신전, 회외전상태에서는통증이동반된전방불안정성을느낄수있었다. Eaton 과 Littler 의전방경사인대재건술을시행하였으며, 수술후방사선사진상아탈구되었던관절의정복및관절면의 조화를확인할수있었다 (Fig. A). 수술후 개월경측정한주관적통증의정도는 점이었으며, 무지의운동범위는요측외전, 수장측외전, 내전은제 지근위부까지닿는정도, 굴곡, 신전모두건측과같은범위를보였고 (Fig. ), 집기력은건측과비슷한정도로회복되었으며, 손의기능은 Quick DASH. 점으로호전되었다 (Table ). 수술후 개월시행한방사선사진에서는관절정열의변화나관절의퇴행성변화를관찰할수없었으며 (Fig. B), 추적관찰기간동안특별한합병증은관찰되지않았다. 2. 증례 2 세남자환자로 년전넘어진후지속되는우측무지수근중수관절의통증을주소로내원한환자로무거운물건을 232

4 Sam-Guk Park, et al. Chronic Instability of the Carpometacarpal Joint of the Thumb after Trauma Table 1. Summary of the case No. Age/sex Injured side Dominant side Durations of follow-up (mo) Preoperative Final follow-up Right Left Right Left 1 14/Female Right Right 24 VAS (0 10) Pinch power (kg) Quick DASH (0 100) Palmar abduction Radial abduction Adduction 5th finger base - 5th finger base /Male Right Right 18 VAS (0 10) Pinch power (kg) Quick DASH (0 100) Palmar abduction Radial abduction Adduction 5th finger base - 5th finger base /Female Left Right 12 VAS (0 10) Pinch power (kg) Quick DASH (0 100) Palmar abduction Radial abduction Adduction - 5th finger base VAS, visual analogus score; DASH, Disabilities of the Arm, Shoulder and Hand Score. - 5th finger base A B Fig. 5. (A, B) Follow-up photograph at 23 months after the surgery shows full range of motion in all planes. 들면빠지는느낌을호소하였다. 환자는수상당시타병원에서시행한단순방사선검사상 (Fig. A) 이상이없다는이야기를들었다고하며부목고정, 물리치료, 환부주사 (local injection) 요법등을받았다고하였다. 이환부위는약간돌출되어있었고, 무지의요측및수장측외전이 정도로제한이있었다 (Table ). 단순방사선검사상무지중수골이대능형골의요측으로전위되었으며, 제 중수골기저부사이간격이벌어져있었다 (Fig. B). 단무지부목고정을 주간시행하였으나증상호전이없어서추가적으로약 주간의외전보조기를착용하였으나통증, 불안정성이지속되고요측외전, 신전, 회외전상태에서는통증이동반된전방불안정성을확인할수있었다. 인 233

(B) Radiograph of the wrist at 1 year after injury showed radially displaced carpometacarpal joint of thumb.

5 J Korean Soc Surg Hand Vol. 21, No. 4, December 2016 A B C Fig. 6. (A) Plain radiograph made at several days after injury in a local clinic showed normal alignment of the carpometacarpal joint of the thumb with uniform joint space. (B) Radiograph of the wrist at 1 year after injury showed radially displaced carpometacarpal joint of thumb. (C) Follow-up radiograph 18 months after the surgery showed sustained alignment with no arthritic change. A B Fig. 7. (A, B) Follow-up photograph at 18 months after the surgery shows full range of motion in all planes. 대재건술을권유하였으나, 타병원으로전원한환자는약 년후다시내원하였으며, 지속되는통증과불안정성을호소하며수술적치료를원하였다. 추적관찰한단순방사선사진상아탈구상태는변화가없었고관절염소견은관찰되지않았다. 컴퓨터단층촬영 (computed tomography, CT) 검사상명확한관절면의부조화는없었으나관절내공기음영을관찰할수있었다. 시각상사척도로측정한통증점수는 점이었으며, 집기력은건측의 / 정도로감소되었고, Quick DASH. 점으로측정되었다 (Table ). Eaton 과 Littler 의전방경사인대재건술을시행하였으며, 술후 개월경측정한주관적통증의정도는. 점이었으며, 운동범위는정상이었고 (Fig. ), 집기력은건측과비슷한정도로회복되었으며, 손의기능은 Quick DASH. 점으로호전되었다 (Table ). 수술후 개월시행한방사선사진에서특별한이상소견없었으며 (Fig. C), 추적관찰기간동안특별 한합병증은관찰되지않았다. 3. 증례 3 세여자환자로선박사고로선상에서넘어진후좌측무지의통증을주소로타병원에서단무지부목고정을적용한상태로내원하였다. 무지기저부압통, 부종이동반된상태였으나관절운동범위는정상이었으며, 통증으로집기력과불안정성은확인할수없었다. 단순방사선검사 (Fig. A) 및타병원에서시행한 CT 영상에서공기음영과같은이상소견을관찰할수없었으며, 수상후 주까지부목고정시행하였으나통증, 압통지속되어수상후 주경시행한추적방사선검사상무지수근중수관절의확연한요측아탈구소견을확인할수있었다 (Fig. B). 자기공명영상검사상명확한전방경사인대의파열을확인할수있는소견을찾을수는없었으며, 골관절염또는골좌상소견 234

(B) Radiograph of the wrist at 1 month after injury showed radially displaced carpometacarpal joint of the thumb. (C) Follow-up radiograph at 12 months after the surgery showed congruent joint space.

6 Sam-Guk Park, et al. Chronic Instability of the Carpometacarpal Joint of the Thumb after Trauma A B C Fig. 8. (A) Plain radiograph made after injury showed normal alignment of the carpometacarpal joint of the thumb with uniform joint space. (B) Radiograph of the wrist at 1 month after injury showed radially displaced carpometacarpal joint of the thumb. (C) Follow-up radiograph at 12 months after the surgery showed congruent joint space. 되지않았다. 고찰 A Fig. 9. T2 weighted magnetic resonance coronal image (A) and T1 weighted sagittal image (B) suggested no specific abnormal finding at volar oblique ligament (arrows) in the carpometacarpal joint of the thumb. 도관찰되지않았다 (Fig. ). 시각상사척도로측정한통증점 수는. 점이었으며, 집기력은건측의 / 정도로감소되었 고, Quick DASH. 점으로측정되었다 (Table ). Eaton 과 Littler 의전방경사인대재건술을시행하였으며, 술 후 개월경측정한시각상사척도는 점이었으며, 운동범위 는정상범위였고, 집기력은건측과비슷한정도로회복되었으 며, 손의기능은 Quick DASH. 점으로호전되었다 (Table ). 수술후 개월시행한방사선사진 (Fig. C) 에서특별한이 상소견없었으며, 추적관찰기간동안특별한합병증은관찰 B 무지의가장중요한기능인대립 (opposition) 은무지수근중수관절에서외전과회내전이가능해야하므로통증이없고안정적인무지수근중수관절은정상적인손의집기기능에필수적이다,. 무지수근중수관절은양면이오목 (biconcave) 한말안장관절 (saddle joint) 로 개의주된인대에의해서관절의안정성이유지된다,. 전방경사인대는대능형골의수장측결절에서기원하여제 중수골기저부의돌출부에넓고두껍게붙는구조물로무지수근중수관절의안정성에가장중요한인대로알려져왔다,,. 그러나, 무지가대립기능을할때중수골의배측전위를막아주는가장크고, 두껍고, 튼튼한구조물로후방요측인대 (dorsoradial ligament) 의중요성이강조되어왔고,,, 대능형중수관절탈구의치료방법으로후방요측인대봉합술을주장하기도하며, 전통적인 Eaton 과 Littler 의인대재건술도전방경사인대와, 후방요측인대를같이재건하는수술로설명되기도한다,. 외상후대능형중수관절의아탈구는문헌보고가매우드물고,, 임상적, 방사선학적진단이어려워과소인지 (under detect) 되는경우가많다. 임상적으로전방경사인대가파열되었을때 Eaton 과 Littler 가제안한토크검사 (torque test) 를 235

7 J Korean Soc Surg Hand Vol. 21, No. 4, December 2016 시행할수있으나활막염이있는경우에도확인되기에특이적이지않고, 부하방사선검사, 관절강조영술, 관절내시경, CT, 자기공명영상검사등이시도되었으나명확한이상소견을확인하기어렵다. 저자들은외상후무지중수골기저부통증을호소하는환자에게보존적치료후에도통증, 불안정성이지속되는경우전후방및사선영상을수상당시촬영한일반방사선사진과비교하였으며, 무지중수골이요측으로전위되고, 제 중수골기저부와의간격이벌어지고, 관절면의부조화가관찰되는경우 Takwale 등 이제안한방법을따라무지의요측외전, 신전, 회외전상태에서중수골기저부에전방압력을가했을때저항이느껴지지않고통증을호소하는경우외상성무지수근중수관절의아탈구로진단하였다. 전통적인 Eaton 과 Littler 의인대재건술은주로일반방사선검사상제, 단계의퇴행성변화가동반된무지수근중수관절의불안정성에시행되었으나, 저자들은외상후보존적치료후에확인된불안정성으로퇴행성변화가관찰되지않는경우에인대재건술을시행하였고, 최소 년이상추적관찰한결과특별한합병증및불안정성의재발이없이거의정상적인운동범위와집기력을회복한것을확인할수있었다. Zhang 등 은외상후발생한무지수근중수관절의탈구혹은아탈구시에인대재건을하는새로운수술방법을소개하였다. 요수근굴건의요측절반을활용하는방법은동일하나두개의작은피부절개를이용하여연부조직의손상이적고, 대능형골과무지중수골기저부에두개의터널을뚫어인대재건을하기에더튼튼한전방경사인대의재건이가능할것으로생각된다. 하지만 Eaton 과 Littler 의술식과달리후방요측인대의재건은얻을수가없고, 무지수근중수관절의운동범위에어떤영향을줄것인지장기추시관찰이필요할것으로생각된다. 무지수근중수관절은위증례및고찰을통해살펴보았듯이외상후초기에는불안정성을확인할수없는경우가있고, 임상적, 방사선학적진단이어려운경우가많아밀접한추적관찰을요할것으로생각되며, 전통적인 Eaton 과 Littler 의전방경사인대재건술은후방요측인대를포함한두개의면에서관절을안정시키는수술로, 조기에관절운동을시작할수있는안정성을부여할수있고, 정상적운동범위와집기력을기대할수있는수술로생각된다. 앞으로좀더많은증례와장기적추적관찰로중, 장기적치료결과관찰및외상후무지수근중수관절의불안정성이지 연되어나타나는원인과기전, 자연경과및효율적진단방법, 불안정성이확인된후시행한 CT상관찰된공기음영의의미와진단적가치에관한연구가진행될수있기를바라는바이다. REFERENCES 1. Eaton RG, Littler JW. Ligament reconstruction for the painful thumb carpometacarpal joint. J Bone Joint Surg Am. 1973;55: Pellegrini VD Jr, Olcott CW, Hollenberg G. Contact patterns in the trapeziometacarpal joint: the role of the palmar beak ligament. J Hand Surg Am. 1993;18: Edmunds JO. Traumatic dislocations and instability of the trapeziometacarpal joint of the thumb. Hand Clin. 2006; 22: Takwale VJ, Stanley JK, Shahane SA. Post-traumatic instability of the trapeziometacarpal joint of the thumb: diagnosis and the results of reconstruction of the beak ligament. J Bone Joint Surg Br. 2004;86: Park JS, Kim HK, Jung YK, Yoo JH, Kwon IH, Rah J. Ligament reconstruction for the posttraumatic instability of the carpometacarpal joint of the thumb: a report of three cases. J Korean Orthop Assoc. 2008;43: Simonian PT, Trumble TE. Traumatic dislocation of the thumb carpometacarpal joint: early ligamentous reconstruction versus closed reduction and pinning. J Hand Surg Am. 1996;21: Strauch RJ, Behrman MJ, Rosenwasser MP. Acute dislocation of the carpometacarpal joint of the thumb: an anatomic and cadaver study. J Hand Surg Am. 1994;19: Colman M, Mass DP, Draganich LF. Effects of the deep anterior oblique and dorsoradial ligaments on trapeziometacarpal joint stability. J Hand Surg Am. 2007;32: Bettinger PC, Linscheid RL, Berger RA, Cooney WP 3rd, An KN. An anatomic study of the stabilizing ligaments of the trapezium and trapeziometacarpal joint. J Hand Surg Am. 1999;24: Zhang X, Shao X, Huang W, Zhu H, Yu Y. An alternative technique for stabilisation of the carpometacarpal joint of the thumb after dislocation or subluxation. Bone Joint J. 2015;97B:

8 Sam-Guk Park, et al. Chronic Instability of the Carpometacarpal Joint of the Thumb after Trauma 외상후무지수근중수관절의만성불안정성 : 3 예보고 박삼국 고영진영남대학교의료원정형외과 무지수근중수관절의외상후불안정성에대해서는보고가드물고, 그결과임상적, 영상의학적진단방법, 자연경과, 그리고치료방법에대해잘알려져있지않다. 저자들은외상후보존적치료후에무지수근중수관절의만성불안정성이발생한 예를 Eaton 과 Littler 의전방경사인대재건술을이용하여치료하였다. 예모두퇴행성변화나불안정성의재발없이만족스러운무지기능의회복을얻었기에문헌고찰과함께보고하는바이다. 색인단어 : 무지, 수근중수관절, 심부전방경사인대, 요배측인대, 불안정성, 인대재건술 접수일 2016 년 9 월 28 일수정일 1 차 : 2016 년 11 월 1 일, 2 차 : 2016 년 11 월 2 일게재확정일 2016 년 11 월 3 일교신저자박삼국대구광역시남구현충로 170 영남대학교병원정형외과 TEL , FAX radiorth@naver.com 237

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untitled 대한정형외과학회지 : 제 43 권제 호 200 J Korean Orthop Assoc 200; 43: 2-7 외상후발생한무지의수근중수관절의불안정성에대한인대재건술 -3 예보고 - 박진수ㆍ김홍균ㆍ정영기ㆍ유정한ㆍ권인협ㆍ나중호 * 한림대학교의과대학강남성심병원정형외과학교실, 연세대학교원주의과대학정형외과학교실 * Ligament Reconstruction for the