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1 대한족부족관절학회지 : 제 13 권제 2 호 2009 J Korean Foot Ankle Soc. Vol. 13. No. 2. pp , 2009 관동대학교의과대학명지병원정형외과학교실 Two Part Triplane Fracture with Extention through Medial Malleolus (Four Cases Report) Seung-Do Cha, M.D., Hyung-Soo Kim, M.D., Soo-Tae Chung, M.D., Jeong-Hyun Yoo, M.D., Jai-Hyung Park, M.D., Joo-Hak Kim, M.D., Yong-Hoon Kim, M.D. Department of Orthopaedic Surgery and Pathology, Myongji Hospital, Kwandong University College of Medicine, Goyang, Korea =Abstract= The triplane fracture has been described as a fracture of the distal tibial epiphysis occurring across three planes-sagittal, transverse and coronal. The characteristic pattern of fusion of distal tibial epiphysis explains the special configuration of the fragments in the triplane fracture. According to Dias Tachdjian classification, triplane fracture is classified two part fracture, three part fracture, four part fracture and two part fracture with extension to the medial malleolus. Among four types, two part triplane fracture with extension to the medial malleolus is a relatively rare injury and generally is not treated by closed reduction. Such fractures should have an anatomic reduction and adequate fixation to restore the joint congruity and obtain an anatomic reduction of the growth plate to prevent a future growth deformity. This is usually best accomplished with an open reduction and screw fixation or k-wire fixation. We experienced two part triplane fracture with extension to medial malleolus and check the CT to define the extent of the injury completely. And then we underwent open reduction and screw fixation for the fracture. As a result, we present four cases of two part triplane fracture with extension with review of related literatures. Key Words: Distal tibial epiphyseal fracture, Dias Tachdjian classification, Two part triplane fracture with extension 삼면골절은청소년기에발생하는원위경골의성장판손상을동반한골절로원위경골의성장판이유합하는시기인청소년기에특징적으로발생한다. 이골절은 Salter- Harris 9) 제 2, 3, 4형성장판손상의복합형이고, 특히골절선이시상, 관상, 횡단의삼면에발생하기때문에삼면골 Address for correspondence Seung-Do Cha, M.D. Department of Orthopaedic Surgery, Myongji Hospital, Kwandong University College of Medicine, Hwajeong-dong, Deokyanggu, Goyang-si, Gyeonggi-do, , Korea Tel: Fax: bladeplate@hanmail.net 절이라고불린다. Dias Tachdjian 5) 분류에의하면족관절삼면골절은두부분, 세부분, 네부분그리고족관절내과를통한두부분골절로나뉘는데저자들은내과를침범한삼면골절을경험하게되었고이에대해전산화단층촬영을통해정확한진단및수술적치료의필요성을결정한뒤관혈적정복술및금속나사고정술그리고보조적으로관절경검사를실시하였다. 저자들은내과를침범한삼면골절의치료경험을문헌고찰과함께보고하고자한다. 증례보고저자들이경험한 4예에대해수상시나이, 원인, 골절

형태, 비골골절동반유무, 수술방법, 치료결과를아래의 Table 1에정리하였다. 1. 증례 1 13세남자환자로농구경기중점프했다가착지하며우측발목이꺾여발생한우측발목통증을주소로본원응급실에내원하였다. 신체검사상우측발목관절부위에전반적인압통과부종이있었다. 내원시촬영한단순방사선상에서우측족관절에성장판손상이있는원위경골및비골골절로내과를침범한골절이관찰되었다 (Fig. 1).

수상당일전신마취하에환자를앙와위로눕힌다음방사선투시기를이용하여정복을시도하였으나만족할만한정복을얻지못하여, 우측족관절에최소한의절개를통한전방도달법으로관혈적정복을시행한후방사선투시기로골절부위의정복및배열상태를확인한다음금속나사를이용하여내고정술을시행하였다 (Fig. 3). 수술후단하지석고고정을시행하였으며 6주째보조기를착용하고부분체중부하를시작하였고 8주째전체중부하를시행하였다.

$Anteroposterior and lateral radiographs of the right ankle show an extension to the medial malleolus. Figur e 2. Comput erized t omographys show an intramalleolar triplane fracture. Figur e 3.$

2 형태, 비골골절동반유무, 수술방법, 치료결과를아래의 Table 1에정리하였다. 1. 증례 1 13세남자환자로농구경기중점프했다가착지하며우측발목이꺾여발생한우측발목통증을주소로본원응급실에내원하였다. 신체검사상우측발목관절부위에전반적인압통과부종이있었다. 내원시촬영한단순방사선상에서우측족관절에성장판손상이있는원위경골및비골골절로내과를침범한골절이관찰되었다 (Fig. 1). 이에전산화단층촬영을시행하여관상면상에서 Salter Harris 2 형골절과내과를침범한골절임을확인하였고시상면에서 Salter Harris 4형골절임이확인되었다 (Fig. 2). 수상당일전신마취하에환자를앙와위로눕힌다음방사선투시기를이용하여정복을시도하였으나만족할만한정복을얻지못하여, 우측족관절에최소한의절개를통한전방도달법으로관혈적정복을시행한후방사선투시기로골절부위의정복및배열상태를확인한다음금속나사를이용하여내고정술을시행하였다 (Fig. 3). 수술후단하지석고고정을시행하였으며 6주째보조기를착용하고부분체중부하를시작하였고 8주째전체중부하를시행하였다. 최종추시는수술후 16개월째로골절부위정렬상태는양호하였고임상적결과는정상관절운동시동통이없는경우를우수, 15 도관절운동범위소실이있으며격렬한운동후동통이있는경우를양호, 15~30 도의관절운동소실이있으며정상운동후동통이있는경우를보통, 30도이상의관절운동범위의소실이있으며지속적인동통이있는경우를불량으로정한장등 1) 의분류에의해평가한바우수하였으며환자는현재성장장해는남아있지않으며상태는만족스러웠다. 2. 증례 2 16세남자환자로축구를하다넘어진뒤발생한좌측발목통증을주소로외래경유내원하였다. 내원시시행한단순방사선상에서전후면사진과측면사진에서성장판손 Figur e 1. Anteroposterior and lateral radiographs of the right ankle show an extension to the medial malleolus. Figur e 2. Comput erized t omographys show an intramalleolar triplane fracture. Figur e 3. After open reduction and internal fixation, reduction was near-anatomic. 상을동반한삼면골절이의심되었다. 이에시행한전산화단층촬영상관상면에서는골절선이원위경골성장판전체에걸쳐있으며내과골절까지동반되었음을확인하였고시상면에서는 Salter Harris 4형골절이동반되었음을확인 Table 1. Summary of Cases. Case Age/Sex Cause of Dias-Tachdjian Fibular Operation Clinical (years) injury classification fracture method result 1 13/M fall down 2 part with extension accompanied open reduction & internal fixation excellent 2 16/M slip down 2 part with extension accompanied open reduction & internal fixation excellent 3 12/M fall down 2 part with extension unaccompanied open reduction & internal fixation excellent 4 13/M slip down 2 part with extension unaccompanied open reduction & internal fixation with arthroscopy excellent

$Anteroposterior and lateral radiographs of the right ankle show an injury to the distal tibia and fibular fracture with an$ $Computerized tomographys show an intramalleolar t riplane fracture with an epiphyseal injury. Figur e 6.$ After open reduction and internal fixation, reduction was near-anatomic. 할수있었다.

After open reduction and internal fixation, reduction was near-anatomic. 할수있었다.

6주째석고고정을제거하면서보조기를착용하고관절운동을시작하였으며수술후 11개월째금속나사를제거하였으며최종추시는 15개월째로특별한증상호소하지않고일상생활이가능하였다. 3.

$On arthroscopic view, a bony fragment was observed within the fracture site. 내원하였다. 내원시시행한단순방사선상성장판손상을동반한원위경골및비골골절이관찰되었다 (Fig.$

3 Figur e 4. Anteroposterior and lateral radiographs of the right ankle show an injury to the distal tibia and fibular fracture with an epiphyseal injury. Figur e 7. Anteroposterior and lateral radiographs of the right ankle show an injury to the distal tibia and fibular fracture with an epiphyseal injury. Figur e 5. Computerized tomographys show an intramalleolar t riplane fracture with an epiphyseal injury. Figur e 6. After open reduction and internal fixation, reduction was near-anatomic. 할수있었다. 치료는우측족관절에최소한의절개를통한전방도달법으로관혈적정복을시도하고금속나사를이용하여고정하였다. 6주째석고고정을제거하면서보조기를착용하고관절운동을시작하였으며수술후 11개월째금속나사를제거하였으며최종추시는 15개월째로특별한증상호소하지않고일상생활이가능하였다. 3. 증례 3 12세남자환자로의자에서뛰어내리다좌측발목이삐끗한뒤발생한좌측발목관절통증을주소로본원응급실 Figur e 8. On arthroscopic view, a bony fragment was observed within the fracture site. 내원하였다. 내원시시행한단순방사선상성장판손상을동반한원위경골및비골골절이관찰되었다 (Fig. 4). 이에시행한전산화단층촬영상관상면에서내과를침범한골절과 Salter-Harris 2형골절이동반되었고시상면에서 Salter Harris 4형골절이관찰되었다 (Fig. 5). 이에좌측족관절에최소한의절개를통한전방도달법으로정복을시행한후금속나사를이용하여고정하였다 (Fig. 6). 6주째단하지석고고정을제거하고보조기를착용하면서관절운동을시작하였으며 11개월째금속나사를제거하였으며금속나사제거후 1달째최종추시결과족관절의기능장애는없었다. 4. 증례 4 13세남자환자로체육시간에공을밟고넘어지며우측발목접질린뒤발생한우측발목관절통증을주소로본원응급실에내원하였다. 내원시시행한단순방사선상성장판손상을동반한원위경골의외측골절과원위비골골절이관찰되었다 (Fig. 7). 이에시행한전산화단층촬영상관절면사이에틈이관찰되었으며틈사이에작은골편이끼어있었다. 수상당일앙와위에서관절경을이용하여족관절내부를관찰하여골절선사이에낀작은골편을제거하

4 고 (Fig. 8), 정복을시도한다음금속나사를이용하여고정하였다. 수술후 15주째금속나사제거술을시행하였고더불어시행한관절경검사에서는원위경골의관절면후내측에부분적으로박리된연골조각이있어이를제거하였다. 이후 4개월째최종추시결과방사선학적인이상소견보이지않으며일상생활에지장이없는상태이다. 고찰삼면골절은원위경골의성장판이유합하는시기인청소년기에발생하는골절로 1970 년 Marmor 8) 가원위경골골단의골절에대해기술하면서경골간부, 골단부전외측골편, 그리고골단의나머지부분과후방의골간단부골편으로구성된세개의분리된골편에대해증명하였으며 1972년 Lynn 7) 은이러한손상에대해설명하면서처음으로삼면골절이라는용어를사용하였다. 이후 Feldman 등 6) 은내과를침범하는삼면골절에대해기술하였다. 삼면골절은단순방사선사진의전후면과측면촬영을통해대체적으로구분이가능하지만 Salter Harris 3형과 4형에서는골간단부골편이작은경우나내과를침범한경우와같이골절부위의공간배열이나골편의위치등미묘한요소가있어단순방사선사진으로구분하기힘든경우가많다. 하지만컴퓨터전산화단층촬영을통해서는미묘한요소에대해공간배열이나골절선의방향을감별하여골절부위의관절면에서전위정도, 내과침범여부등을증명할수있기때문에수술방법을결정하는데도움이된다. 일반적으로삼면골절의치료는골절편이두부분인경우는우선족관절의배부굴곡과내회전으로도수정복을시행하여정복이된경우 4주간장하지석고고정과 2주간단하지석고고정으로치료할수있으며도수정복후에도 2 mm이상의전위가관찰되는경우나골절면이세부분이상인경우에는관혈적정복술적응증이된다 4). 또한삼면골절의치료에있어서성장판손상을동반하는관절내골절이라는점은무엇보다중요하다. 즉적절한치료를시행하지않았을경우성장판의조기폐쇄나변형그리고관절면의불일치에의한퇴행성관절염등의합병증이유발될수있다. 그래서다른관절내골절과마찬가지로정확한해부학적정복이요구되며치료에있어관혈적정복을할것인지아니면도수정복만할것인지에대해서는아직도논란의대상이되고있는데, Marmor 8) 와 Lynn 7) 은수술적치료의중요성을강조하였고, Torg 와 Ruggieror 11) 도두개의골편을가진삼면골절에서관혈적정복으로좋은결과를보고하였다. 한편 Coopermann 등 3) 은 15예의삼면골절중 13 예는도수정복및석고고정만으로치료가가능하였고비골골절이동반된경우에는전위된위치에서정복이방해되어관혈적정복이필요하다고주장하기도했다. 또한몇몇저자들은삼면골절은관절면이손상된골절이기때문에해부학적으로관절면의정확한정복의중요성을보고했다. Convey 등 2) 은조랑말을이용해다양한크기의관절면결손에서손상의회복정도를관찰했는데결손이 3 mm 이하에서는 3개월후에완전히회복되었으나결손이 3 mm 이상에서는 9개월후에도완전히관절면이회복되지않았음을관찰하였고 Shapiro 등 10) 은치료된연골의변성은수술후 1년정도지나면서나타나는데이는손상된연골과기존의정상연골사이의결합이이루어지지않아이들사이에움직임이생겨연골변성이생기게된다고보고하였다. 이들에따르면관절면의정확한정복은관절내골절의치료에있어서관절연골의퇴행성변화를막는중요한역할을한다고볼수있다. 이런측면에서 Whipple 등 12) 은관절경을이용하여관절면을정복하고내고정술을이용하여삼면골절을치료한경우의효용성에대해보고하기도하였다. 저자들은본증례에서도수정복만으로만족할만한정복이이루어지지않은 3예에대해서는방사선투시기를이용한관혈적정복후내고정술을시행하였고 1예에서는관절경을이용하여관절면사이의골절부위에위치한골편을제거하고관절경하정복후내고정술을시행하였다. 관절경하에서골절의정복은비관혈적정복이나관혈적정복시확인할수없는관절면을직접관찰하고정복하기때문에보다정확한정복을가능하게하여관절면의불일치에따른조기관절염이나성장장애와같은합병증유발가능성을줄일수있는장점이있으며관혈적정복을하지않고관절경만이용하여정복을시행했을때에는관혈적정복으로인해발생할수있는피부괴사, 유착, 감염등의합병증을줄이는장점이있다. 삼면골절에있어서술전전산화단층촬영을통한정확한분석과최소한의절개로만족할만한결과를얻을수있을것으로생각되며, 보다적극적인관절경의활용도결과향상에도움을줄것으로생각된다. REFERENCES 1. Chang JD and Lee JC: A clinical study of the mechanism of injury of juvenile tillaux fracture and triplane fracture. J Korean Orthop Assoc, 25: , Convey FR, Akeson WH and Keown GH: The repair of large

5 osteochondral defects. An experimental study in horses. Clin Orthop, 82: , Cooperman DR, Spiegel PG and Laros GS: Tibial fractures involving the ankle in children. The so-called triplane epiphyseal fracture. J Bone Joint Surg, 60-A: , Dias LS and Giegerich CR: Fractures of the distal tibial epiphysis in adolescence. J Bone Joint Surg, 65-A: , Dias LS and Tachdjian MO: Physeal injury of the ankle in children: classification. Clin Orthop, 136: , Feldman DS, Otsuka NY and Hedden DM: Extra-articular triplane fractures of the distal tibial epiphysis. J Pediatr Orthop, 15: , Lynn MD: The triplane distal tibial epiphyseal fracture. Clin Orthop, 86: , Marmor L: An unusual fracture of the tibial epiphysis. Clin Orthop, 73: , Salter RB and Harris WR: Injuries involving the epiphyseal plate. J Bone Joint Surg, 45-A: , Shapiro F, Koide S and Glimcher MJ: Cell origin and differentiation in the repair of full-thickness defects of articular cartilage. J Bone Joint Surg, 75-A: , Torg JS and Ruggiero RA: Comminuted epiphyseal fracture of the distal tibia: A case report and review of the literature. Clin Orthop, 110: , Whipple TL, Martin DR, McIntyre LF and Meyers JF: Arthroscopic treatment of triplane fractures of the ankle. Arthroscopy, 9: ,

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untitled 대한정형외과학회지 : 제 43 권제 6 호 2008 J Korean Orthop Assoc 2008; 43: 672-676 소아족관절성장판손상후성장판조기유합에영향을미치는인자 김정렬ㆍ송광훈 전북대학교의학전문대학원정형외과학교실, 임상의학연구소 Factors Influencing Premature Physeal Closure following Physeal Injury