66 pissn : , eissn : Case Report J Korean Orthop Assoc 2018; 53: 삼방연골손

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1 66 pissn : , eissn : Case Report J Korean Orthop Assoc 2018; 53: 삼방연골손상후발생한골가교의보존적치료 차용한 을지대학교의과대학정형외과학교실 Yong Han Cha, M.D., Ph.D. Department of Orthopedic Surgery, Eulji University School of Medicine, Daejeon, Korea We report a patient who experienced no function problems during the 5-year follow-up after a conservative treatment for minimally displaced acetabular fracture that developed as a result of the formation of physeal bar. According to the computed tomography, triradiate cartilage was fractured and minimally displaced, which was identified as a Salter Harris type II physeal injury. A fracture of the anterior wall of the acetabulum was also observed. It was judged as a stable fracture, and conservative treatment was performed. On the followup x-ray, the physeal bar was formed in the damaged triradiate cartilage. At 5-year follow-up, physeal injury of the triradiate cartilage has influenced the acetabular growth, resulting in acetabular dysplasia, pelvic asymmetry, hypoplasia of pubis, and widening of the tear drop. However, anteversion and inclination of the injured acetabulum were similar with those of the contralateral side. Our patient also did not complain of any hip discomfort. Key words: triradiate cartilage, physeal bar 골반의성장판인삼방연골 (triradiate cartilage) 은골반의일차골화중심 3개가비구에서만나서형성되며, 세에유합되어성장이완료된다. 1) 소아에서의삼방연골의손상은적절한비구의발달을저해할수있다. 비구의성장은삼방연골의성장, 간질성장 (interstitial growth in the acetabular cartilage) 과부가성장 (appositional growth of the periphery of this cartilage) 을통해깊이와높이성장을이루는데, 장좌골의테두리에성장에관여하는세포수가가장많아이곳의손상시성장장애의위험이높다. 2,3) 소아에서비구골절은전체소아골절의 0.03%-0.3% 정도로매우드물다. 4) 1982년 Bucholz 등 2) 은소아의비구골절에대해성장판손상 I, II형에해당하는전단형 (shearing type) 과성장판손상 V 형에해당하는압궤형 (crushing type) 의 2가지로분류하였다. 전단형보다압궤형의예후가좋지못하고골가교 (physeal bar) 가형성 Received March 2, 2017 Revised May 8, 2017 Accepted June 23, 2017 Correspondence to: Yong Han Cha, M.D., Ph.D. Department of Orthopedic Surgery, Eulji University School of Medicine, 95 Dunsanseo-ro, Seo-gu, Daejeon 35233, Korea TEL: FAX: cyh@eulji.ac.kr 되어성장판의조기폐쇄를유발한다. 저자들은비전위소아비구골절의보존적치료후골교형성으로비정상적인비구발달에도불구하고기능적문제를야기하지않고 5년이상경과관찰한환자의증례를보고하고자한다. 증례보고 6세여아가보행자교통사고로응급실에내원하였다. 환자는좌측고관절부통증및운동장애를호소하였다. 신경학적손상은관찰되지않았고혈역학적으로안정되어있었으며동반된다른손상은관찰되지않았다. 응급실에서촬영된골반골전후면단순방사선사진상좌측치골하지의골절이관찰되었고, 전위는심하지않았다 (Fig. 1). 3 차원컴퓨터단층촬영 (computed tomography, CT) 상내측골편을동반한삼방연골손상 (Salter-Harris 제2형성장판골절 ) 과비구전벽의골절이관찰되었다 (Fig. 2). 내측골편은장좌골테두리부위 (ilioischial flange) 의전방일부를침범하였고전위는경미하였다. 비구전벽의골절은장치골테두리 (iliopubic flange) 를침범하 The Journal of the Korean Orthopaedic Association Volume 53 Number Copyright 2018 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.

$At both pelvic anteroposterior radiograph, left pubic ramus fracture with mild displacement$ is observed (white arrows). 통증조절및침상안정을하였다. 수상 2주째부터휠체어거동을시작하였고, 2주이후에는기립과부분체중부하를허용하였다.

is observed (white arrows). 통증조절및침상안정을하였다. 수상 2주째부터휠체어거동을시작하였고, 2주이후에는기립과부분체중부하를허용하였다.

골반방사선사진상 tear drop의확장, 경한치골의저형성증이관찰되었고삼방연골손상부위에는골가교가형성되었다 (Fig. 3).

골반방사선사진상에는뚜렷한치골의저형성증, tear drop의확장, 비구의 under-coverage 등비구이형성이관찰되었다 (Fig. 4).

최종추시상관절운동범위 ( 우측 / 좌측 ) 는고관절굴곡 130/120도, 외전 45/45 도, 내전 20/20도, 내회전 35/35, 외회전

추시 CT에서측정한비구전염각 ( 우측 / 좌측 ) 은 14/12도이며기울기 ( 우측 / 좌측 ) 는 48/50도로, 양측간에차이는크지않았다 (Fig. 5).

(A) It is an axial view of the computed tomography (CT).

2 67 였고, 전위의정도는 2 mm 이내였다. 전위가경미한안정형골절로보존적치료를시행하였다. 수상후첫 1주간은약물에의한 Figure 1. At both pelvic anteroposterior radiograph, left pubic ramus fracture with mild displacement is observed (white arrows). 통증조절및침상안정을하였다. 수상 2주째부터휠체어거동을시작하였고, 2주이후에는기립과부분체중부하를허용하였다. 수상 4주이후에는전체중부하를시작하였다. 수상 1.5년후에외래방문하여환자는통증이나파행없이별다른증상을호소하지는않았다. 골반방사선사진상 tear drop의확장, 경한치골의저형성증이관찰되었고삼방연골손상부위에는골가교가형성되었다 (Fig. 3). 수상 5년후추시방문에서환자는골반의비대칭성을호소하였으나통증이나파행등은보이지않았다. 골반방사선사진상에는뚜렷한치골의저형성증, tear drop의확장, 비구의 under-coverage 등비구이형성이관찰되었다 (Fig. 4). 환측의 tear drop은폭이넓어진것외에도형태가원래의 U자형태보다는치우쳐진갈매기형태 (tilted chevron shape) 로보였다. 최종추시상관절운동범위 ( 우측 / 좌측 ) 는고관절굴곡 130/120도, 외전 45/45 도, 내전 20/20도, 내회전 35/35, 외회전 45/35도로관절운동의제한은거의없었다. 추시 CT에서측정한비구전염각 ( 우측 / 좌측 ) 은 14/12도이며기울기 ( 우측 / 좌측 ) 는 48/50도로, 양측간에차이는크지않았다 (Fig. 5). 비구이형성의정도를평가하는방사선적계측의추시에따른변화는 Table 1과같았다. A B C Figure 2. (A) It is an axial view of the computed tomography (CT). (B) It is a sagittal view of the CT of the left acetabulum. (C) On 3-dimensional CT, fracture line of anterior wall and fracture fragment of triradiate cartilage are observed (white arrows). A B C Figure 3. (A) A both pelvic anteroposterior radiograph taken at 1.5 years after injury. The physeal bar is formed on the axial view (B) and coronal view (C) of the computed tomography (white arrows).

68 Yong Han Cha 1 1 2 Acetabular diameter Acetabular depth 2 Tear drop, not U-shaped, but tilted chevron-shaped Figure 4. A both pelvic anteroposterior radiographs taken at 5 years after injury.

특히나 CT를이용한골절의검사는동반된골반과복부장기의손상을검사할수있을뿐만아니라 3차원적영상으로골절을보다쉽게이해하게도와준다. 5,6) 소아비구골절의치료방법으로보존적치료와수술적치료를고려할수있다. 기존의보존적치료방법은비전위안정형골절일경우에주로침상안정과물리치료, 그리고조기 ( 수상후약 1 주후 ) 에부분체중부하를허락하였다.

(B) At the final follow-up CT coronal view, right/left inclination was measured as 48/50 degree. Table 1.

3 68 Yong Han Cha Acetabular diameter Acetabular depth 2 Tear drop, not U-shaped, but tilted chevron-shaped Figure 4. A both pelvic anteroposterior radiographs taken at 5 years after injury. 고찰 소아비구골절환자의초기치료시중요한것은우선고에너지손상으로동반된다른중요기관과장기의손상을치료하는것이며, 비구손상자체에대하여는먼저조기에정확한진단을하고, 치료방침을결정하는것이다. 소아에서비구골절은삼방연골이열려있고대퇴골과겹쳐져있어전위가경미할경우발견하기어렵다. 그렇기때문에세심한이학적검사와관찰, 그리고방사선검사가필요하다. 특히나 CT를이용한골절의검사는동반된골반과복부장기의손상을검사할수있을뿐만아니라 3차원적영상으로골절을보다쉽게이해하게도와준다. 5,6) 소아비구골절의치료방법으로보존적치료와수술적치료를고려할수있다. 기존의보존적치료방법은비전위안정형골절일경우에주로침상안정과물리치료, 그리고조기 ( 수상후약 1 주후 ) 에부분체중부하를허락하였다. 전위된불안정골절의경우에는통상 6주정도의비체중부하후에체중부하등의재활 A B Figure 5. (A) At the final follow-up computed tomography (CT) axial view, right/left anteversion was measured as 14/12 degree. (B) At the final follow-up CT coronal view, right/left inclination was measured as 48/50 degree. Table 1. Changes in Radiographic Measurements to Assess the Degree of Acetabular Dysplasia Parameter Initial 1 year after injury 2 years after injury 5 years after injury CE angle ( ) Ipsilateral Contralateral Sharp angle ( ) Ipsilateral Contralateral Acetabular diameter (mm) Ipsilateral Contralateral Acetabular depth (mm) Ipsilateral Contralateral

4 69 치료를시작하는데, 3-4주간의과상부견인으로해부학적정복을얻은후 2-4주간침상안정을취하거나 3-4주간골반부석고고정을적용할수도있다. 7) 수술적치료는전위된골절의정복이어려울경우, 체중부하관절면에 2 mm 이상의전위가있을경우, 고관절이불안정한경우, 비구후벽이관절면의 50% 이상침범한경우, 감돈골편이있는경우에시도해볼수있다. 7) 하지만어떤방법을선택하든가장중요한것은삼방연골의혈액공급에추가손상을유발하지않으면서해부학적정복을얻는것이다. 1) 본증례는전위가심하지않은안정형골절로판단하고보존적치료를시행하였고수술적치료에의한삼방연골의혈액공급에추가적인손상을가하지않았음에도골교가형성되었으며비구의발달장애가관찰되었다. 이처럼소아비구손상환자에서삼방연골의성장장애가발생하는것을예측하는것은어려운문제이다. Rodrigues 8) 는비전위소아비구골절환자에서골교의형성은골절부위의혈종에골화가진행되어발생한다고하였고, Ponseti 9) 는삼방연골의골반내부위에서연골주위조직들이벗겨지고이곳에골화가진행되면서발생할수있다고하였다. 그렇기때문에전위가적더라도주기적경과관찰이중요하다. 소아골반에서삼방연골의조기폐쇄에따른비구이형성의방사선적양상은골반의비대칭, 대퇴골두의외측아탈구, 관절면의부조화, tear drop과사각판 (quadrilateral plate) 의외측신전및확장, center-edge angle 감소등이보고되어있다. 2,10) 이런방사선적변화를추시하고, 적절한치료를하기위해서는청소년이될때까지매년골반골 x-ray 촬영을요한다. 만약골교가형성되어증상이동반되거나방사선적변형이심하거나진행할경우에는수술적치료를시도할수있다. 수술적치료방법은골가교절제술처럼변형의진행을방지하는수술과비구재정렬 ( 전자간절골술, 비구주변절골술 ) 같은변형의교정수술로크게분류할수있다. 8) 본증례의경우도위와같이단순방사선사진에서비구이형성이관찰되지만 5년이상의추시관찰에서환자는특별한불편감을호소하지않았고좌측고관절이정상측과유사한관절운동범위를보였다. 이것은골절의침범위치가성장에가장많은영향을주는장좌골의테두리 (ilioischial flange) 의전방일부만을침범한비전위골절이었고전벽의골절또한심한전위를동반하지않았기때문으로생각된다. 어느정도의삼방연골손상이향후증상을유발할지또는어느시점에증상이발생할지에대한연구는진행되지않았기때문에추가적인연구가필요하지만이환자에서관찰되는삼방연골전방부의손상은비구전염각과기울기형성에장애를덜남겨정상측과유사한관절운동범위를보이는것으로생각된다. 하지만마지막 5년추시에서비구의직경 (44.9 mm) 과깊이 (10.6 mm) 가건측 ( 직경 53.2 mm, 깊이 14.3 mm) 에비하여많은차이를보이기시작하였고, 아직성장이남은청소년임을감안할때, 비구이형성증은더욱악화될것으로예측되며, 지속적인추시가필요할것으로생각된다. 다만, 수상후 5년이상경과된시점에서의골교절제술은그결과를예측하기가어려울것으로생각된다. CONFLICTS OF INTEREST The author has nothing to disclose. REFERENCES 1. Watts HG. Fractures of the pelvis in children. Orthop Clin North Am. 1976;7: Bucholz RW, Ezaki M, Ogden JA. Injury to the acetabular triradiate physeal cartilage. J Bone Joint Surg Am. 1982;64: Trousdale RT, Ganz R. Posttraumatic acetabular dysplasia. Clin Orthop Relat Res. 1994;305: Spiguel L, Glynn L, Liu D, Statter M. Pediatric pelvic fractures: a marker for injury severity. Am Surg. 2006;72: Sharma UK, Basnyat A, Rijal K, Shrestha BK, Banskota B, Banskota AK. CT evaluation of pelvic and hip fractures. JNMA J Nepal Med Assoc. 2013;52: Guerra MR, Braga SR, Akkari M, Santili C. Pelvic injury in childhood: what is its current importance? Acta Ortop Bras. 2016;24: Gänsslen A, Hildebrand F, Heidari N, Weinberg AM. Acetabular fractures in children: a review of the literature. Acta Chir Orthop Traumatol Cech. 2013;80: Rodrigues KF. Injury of the acetabular epiphysis. Injury. 1973;4: Ponseti IV. Growth and development of the acetabulum in the normal child. Anatomical, histological, and roentgenographic studies. J Bone Joint Surg Am. 1978;60: Tavares JO. Modified Pemberton acetabuloplasty for the treatment of congenital hip dysplasia. J Pediatr Orthop. 2004;24:501-7.

5 70 pissn : , eissn : Case Report J Korean Orthop Assoc 2018; 53: 삼방연골손상후발생한골가교의보존적치료 차용한 을지대학교의과대학정형외과학교실 저자들은비전위소아비구골절의보존적치료후골교 (physeal bar) 형성으로인하여비정상적인비구발달이발생하였음에도 5년경과관찰결과기능적문제가없었던환자의증례를보고하고자한다. 수상후촬영된컴퓨터단층촬영 (computed tomography, CT) 상전위가적은내측골편을동반한삼방연골손상 (Salter-Harris 제2형성장판골절 ) 과비구전벽의골절이관찰되었다. 안정형골절로판단하여보존적치료및경과관찰하던중삼방연골손상부위에골교가형성되었고 5년이상의방사선추시관찰상골반의비대칭성, 뚜렷한치골의저형성증, tear drop 확장등의비구이형성소견이관찰되었다. 단순방사선사진상비구의변화에비하여 CT 상측정된비구의전염각 (anteversion) 및기울기 (inclination) 는정상측과유사하였고환자도특별한불편함을호소하지않았다. 색인단어 : 삼방연골, 골가교 접수일 2017 년 3 월 2 일수정일 2017 년 5 월 8 일게재확정일 2017 년 6 월 23 일책임저자차용한 35233, 대전시서구둔산서로 95, 을지대학교의과대학정형외과학교실 TEL , FAX , cyh@eulji.ac.kr 대한정형외과학회지 : 제 53권제 1호 2018 Copyright 2018 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.

05-08김원유

05-08김원유 J Korean Hip Soc 22(2): 116-121, 2010 Review Article Treatment for the Acetabular Fracture Weon-Yoo Kim, MD Department of Orthopedic Surgery, Daejeon St. Mary s Hospital, The Catholic University of Korea,