178 pissn : , eissn : Symposium J Korean Orthop Assoc 2015; 50: P

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1 178 pissn : , eissn : Symposium J Korean Orthop Assoc 2015; 50: Proximal Femur Fractures 젊은성인의대퇴경부골절에대한최신치료방법 여인권 임승재 성균관대학교의과대학삼성서울병원정형외과학교실 Current Treatment Strategy for Young Adult Femur Neck Fractures Ingwon Yeo, M.D. and Seung-Jae Lim, M.D. Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea Femoral neck fracture in young adults represents a relatively uncommon, high-energy injury associated with higher incidence of complications including nonunion, avascular necrosis of the femoral head, and significant shortening. Preservation of the natural hip anatomy and mechanics is a priority in their management and anatomic reduction and stable internal fixation are critical to achieving the goals of treatment in this young patient population. Current evidence is insufficient to recommend an ideal management method; however, in this article we present the rationale and evidence for timing of surgery, role of capsulotomy, open versus closed reduction, and available internal fixation options. Key words: femoral neck fractures, young adult, treatment 서론 근위대퇴부의만곡으로대퇴경부는높은기계적압력을받는 해부학적구조를가지고있다. 대퇴경부골절은전체고관절골 절의약 50% 정도를차지할정도로빈도가높은골절이다. 최근 평균수명의연장으로인한노령인구의증가및현대사회에서 교통사고의증가등으로인해그발생빈도가증가추세에있으 며 2050 년에는전세계적으로약 600 만명이상의고관절골절환 자가발생할것이라고예측된다. 1) 대퇴경부골절의발생은두가지연령분포를보이며손상기 전또한차이가있다. 일반적으로 65 세이하또는골절발생전에 생리적으로활동적인사람을젊은환자로분류한다. 2) 젊은연령 의대퇴경부골절은전체대퇴경부골절의 3%-5% 로고령에비 해훨씬적게발생하는것으로보고되고있으며, 3) 주로교통사고 Received June 3, 2014 Accepted June 7, 2015 Correspondence to: Seung-Jae Lim, M.D. Department of Orthopedic Surgery, Samsung Medical Center, 81 Irwon-ro Gangnamgu, Seoul , Korea TEL: FAX: limsj70@gmail.com 나추락과같은고에너지외상으로발생하고고관절이외반된상태에서대퇴간부의축을따라축방향힘이가해져발생한다. 4) 젊은환자에서의대퇴부골절의형태는고령의환자에서와다른양상을보이는데, 고령의환자의경우주로대퇴전자간부골절또는수평방향의골절부감입형태의대퇴경부골두하골절이많이발생하고젊은환자의경우는대퇴경부중간골절이나생역학적으로보다불안정한수직방향의골절이많이발생한다. 5-7) 젊은환자에서의대퇴경부골절은골절유합이문제없이이루어진경우에도종종골절부단축이나고관절역학의변화로인해좋지않은기능적결과를나타낼수있으며, 불유합이나대퇴골두무혈성괴사와같은합병증발생비율이상대적으로높은편이다. 8) 대퇴골두의혈액공급 대퇴골두의혈액은대부분상외측체중부하부위로공급되고이는내측대퇴회선동맥의외측골단동맥에서분지한다. 외측골단동맥은대퇴골두로혈액을공급하기전에대퇴경부의후상부를지나가고, 대퇴골두로혈액공급을하는말단혈관가지들은관절낭내에위치하므로대퇴경부골절시의전위로인해말단혈 The Journal of the Korean Orthopaedic Association Volume 50 Number Copyright 2015 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.

2 179 Young Adult Femur Neck Fractures 관가지들이파열되고꼬일 (kinking) 수있어무혈성괴사로의진행에중요한역할을하게된다. 9) 대퇴경부골절발생후에대퇴골두로의영양공급은전적으로원형인대동맥과일부유지되고있는지대혈관에의존하게되고, 10) 비록대퇴골두내의여러영양혈관들사이의문합 (anastomosis) 이존재하나대개대퇴골두로의영양공급에는부족하게된다. 11) 진단및분류 대퇴경부골절의 25%-60% 에서발생초기에비전위성이고, 12) 단순방사선사진에서 2%-10% 는골절선이명확히관찰되지않아컴퓨터단층촬영이나자기공명영상이진단에도움이된다 (Fig. 1). 13) 또한젊은환자에서발생하는대퇴경부골절의경우외상의강도가심할수록연부조직손상이나골절의분쇄가심하며동측 대퇴간부골절과같은동반손상이 9% 까지발생하며 (Fig. 2), 동측간부골절이동반되는경우의약 30% 에서진단을놓치는경우가있으니상당히주의하여야한다. 14,15) 대퇴경부골절은골절의해부학적위치, 골절선이이루는각의방향, 골절의전위정도등에따라서다양한분류법이개발되어사용되고있으나어느분류법도대퇴경부골절의치료방법및예후를명확히반영하고있지는못한실정이다. 해부학적위치에따라서는대퇴골두하 (subcapital), 중간 (transcervical), 기저부 (basicervical) 골절로분류한다 (Fig. 3). Pauwels는대퇴경부골절선이수평선과이루는각도에따라대퇴경부골절을세가지형으로분류하였다 (Fig. 4). 특히 Pauwels 3형골절은고정실패나부정유합, 불유합, 무혈성괴사의발생률이상대적으로높게보고된다. 5-7,16,17) 현재임상적으로가장널리사용되고있는분류법은 Garden 분류로고관절전후면단순방사선사진상대퇴골두와비 A Figure 1. A 64-year-old woman presented with a painful right hip after a fall. (A) No fracture was clearly visible on radiograph. (B) An undisplaced femoral neck fracture was identified on magnetic resonance imaging. B A Figure 2. A 35-year-old man showing an ipsilateral femoral neck and shaft fractures on radiograph (A) and computed tomography (B). B A B C Figure 3. Classification of femoral neck fracture according to anatomical position of the fracture line. Subcapital (A), transcervical (B), and basicervial fracture (C).

3 180 Ingwon Yeo and Seung-Jae Lim < >50 Type I Type II Type III Figure 4. The Pauwels classification of femoral neck fracture based on vertical orientation of fracture line. Type I is Pauwels angle less than 30 degrees, Type II is Pauwels angle between 30 and 50 degrees, and Type III is Pauwels angle more than 50 degrees. A B C D Figure 5. The Garden s classification of femoral neck fracture. (A) Garden type I is an incomplete fracture, typically shown as valgus impacted type. (B) Garden type II is a nondisplaced complete fracture, typically associated with medial gap of the femoral neck. (C) Garden type III is a partially displaced complete fracture. (D) Garden type IV is a totally displaced complete fracture with definite superior displacement of the proximal femur, typically trabecular pattern of the femoral head lining up with those of the acetabulum. 구의골소주형태에기초하여골절의전위정도에따라대퇴경부골절을네가지형태로구분하였다 (Fig. 5). 치료 젊은환자의대퇴경부골절의치료의가장큰목표는원래관절을보존하는것이며적절한내고정물을이용하여해부학적정복과안정된내고정을하는것이예후에가장중요하다는것은여러문헌을통하여증명되었다 ) 또한해부학적정복과안정된내고정을시행하는것을통해대퇴골두로가는혈류를보존하고재혈관화 (revascularization) 의과정을보호할수있으며 21) 부적절한정복은혈관싹 (vascular bud) 이대퇴골두로자라들어가기위 한충분한공간을제공하지못하여무혈성괴사로인한후기대퇴골두함몰을유발하게된다. 22) 하지만, 대퇴경부골절의치료에있어수술시기, 관절낭절개술 (capsulotomy) 의필요성, 정복의방법, 내고정물의선택에대해서는아직까지논란의여지가많은실정이다. 1. 수술시기젊은환자의대퇴경부골절치료에있어응급수술 (emergency operation) 과긴급수술 (urgency operation) 중어느것이우월한결과를보이는지에대해서는여전히논란이되고있다. 23,24) Manninger 등 25) 은 6시간이내에정복과고정이이루어질경우무혈성괴사와불유합빈도가줄어든다고하였으나 Razik 등 26) 은 6시간

4 181 Young Adult Femur Neck Fractures 이내정복군과 48시간이후정복군에서무혈성괴사의빈도에차이가없다고하여상반된결과를보여주었다. 조기수술을주장하는이들은전위성대퇴경부골절의즉각적인정복을통해대퇴골두로가는영양혈관들의되꼬임 (unkinking) 과관절낭내압력을증가시키는혈종의제거를통해관절낭내압력을감소시켜대퇴골두혈류를보존하고, 무혈성괴사의발생을줄일수있다고주장한다. 4,9) 하지만대퇴경부골절후에발생하는무혈성괴사와후기골두함몰의기전에는다양한요인들이작용하며, 가장최근의연구들에서수술시기와무혈성괴사또는불유합과의연관성은발견하지못했다. 그럼에도불구하고골절의정복및고정을통해잔존하는대퇴골두혈류의추가손상을방지하고골절전위로인해꼬이고막혔던외측골단동맥혈류를빨리회복한다는것이조기수술의이론적근거가되고있다. 27) 하지만지금까지의대퇴경부골절의수술시기에관한연구들은제한된후향적관찰연구였으며, 좀더의미있는결론을내기위해서는향후대규모전향적연구가필요하겠다. 2. 관절낭절개술관절낭절개를통해관절낭내압력이감소하고대퇴골두혈류가증가한다는보고는있으나관절낭절개를했을때결과가향상됐다는임상적연구는아직까지발표되지않고있다 ) 또한 Maruenda 등 31) 은관절낭내압력은대퇴골두혈류및골절전위유무와상관이없음을보고하였고, Upadhyay 등 32) 은골절정복시관절낭절개유무가수술후무혈성괴사의빈도에영향을주지않는다고하였다. 관절낭절개술의방법은관혈적정복시에관절낭절개를하는방법과도수정복을하면서방사선투시기하에서경피적으로피막절개를하는방법이있으며, Christal 등 33) 은후자가안전하고관절내압을낮추는데에효과적이라고하였다. 현재로서는골절치료후무혈성괴사가발생하는원인으로관절낭내압력상승에의한탐폰 (tamponade) 효과는미미한것으로보고있고그보다는골절발생당시의고에너지손상여부나골절전위정도가더깊은연관이있는것으로생각하고있다. 따라서현재로서는젊은환자의대퇴경부골절의치료시에관절낭절개를일상적으로시행하는것을권장하지는않는다. ASIS Cranial V. lateralis G. medius Caudal A B C Cranial G. medius Vastus ridge Caudal D E Figure 6. (A) A displaced femoral neck fracture in a 46-year-old woman was seen on radiograph. (B) Open reduction was performed through a Watson-Jones approach. (C) Illustration demonstrating the Watson-Jones approach. (D) Intraoperative photograph showing a well-reduced fracture line (arrow). (E) Postoperative radiograph after fixation with three cannulated screws. ASIS, anterior superior iliac spine; G., gluteus; V., vastus.

5 182 Ingwon Yeo and Seung-Jae Lim 3. 골절정복법골절고정수술시가장먼저결정해야할사항은골절정복을도수정복으로하느냐관혈적정복으로하느냐를결정하는것이다. 비전위성 Garden 1형과 2형의골절에서는도수정복을통한내고정술을시행하는데대부분동의하지만, 전위성 Garden 3형과 4 형의골절에서도수정복과관혈적정복에대해서는상당한논란이있다. 34) Bosch 등 35) 은수술중방사선투시기를이용하여해부학적정복이가능하므로도수정복이비용을줄이고덜침습적이며수술시간을줄인다고하였고, Upadhyay 등 32) 과 Damany 등 36) 은관혈적정복과비관혈적정복간의수술결과의차이는없는것으로보고하였으며, 오히려관혈적정복을시행한경우에불유합발생률이더높았다고하였다. 도수정복은최대 2-3회이상시도하지않는것이좋으며, Kregor 37) 는여러번정복을시도하게되면무혈성괴사의발생이증가한다고하였다. 최근에발표된체계적문헌고찰 (systematic review) 에서는관혈적정복술이도수정복술에비하여불유합이나무혈성괴사의발생을줄여준다는근거는미약하나도수정복술이수술부위감염률이낮게발생한다는근거를제시하고있다. 38) 골절의정복정도평가는주로 Garden의정렬지수 (Garden Alignment Index) 와 Lowell의방법을사용한다. 전후방방사선사진에서 160도이하의내반변형과측면사진에서 5도이상의후방전위는불만족스런정복을의미한다. 32,34) 수술중도수정복의평가는방사선투시영상을보고하기때문에간혹불완전한정복을허용할만한정복으로오인하기도하므로주의를요한다. 39) 도수정복을통해만족할만한정복을이룰수없는경우에는관혈적정복을시행하는데, 일반적으로 Watson-Jones 도달법 34) 이나 Smith-Peterson 도달법 40) 이사용된다. Watson-Jones 도달법은근위대퇴부외측으로일직선의절개를가하고보다근위부에서는장골극을향해전방으로곡선절개를한후에대퇴근막장근을앞쪽으로당긴다음중둔근의원위부일부를절개하여뒤쪽으로당긴다. 이후에소둔근의전방대전자부착부위를절개하면관절낭앞쪽을관찰할수있고, 전자간능선을따라관절낭을유리함과동시에대퇴경부와나란히 T자형관절낭절개술을시행하면관절내혈종이나오며경부골절을직접관찰할수있다 (Fig. 6). 4,41) 또다른관혈적정복을위한도달법으로는 Smith-Peterson 방법이있으며, 특히대퇴경부골두하골절의시야확보에유리하나이 A B C D E F Anterior Posterior G Figure 7. A communited femoral neck fracture in a 33-year-old woman was seen on radiograph (A) and computed tomography (B). (C, D) The fracture was reduced through a Watson-Jones approach using a Hohmann Retractor and a ball-spike pusher, temporally fixed with multiple K-wires. (E, F) Partially threaded cannulated screws and cancellous screws were placed to achieve stable fixation at the fracture site. (G) At 6 months follow-up, no evidence of avascular necrosis of the femoral head was observed on 3 phase bone scan.

6 183 Young Adult Femur Neck Fractures 방법은내고정물삽입시에별개의절개가필요하다는단점이있다. 젊은환자에서자주발생하는분쇄가아주심한골절의경우에는관혈적정복으로도해부학적정복의유지가힘들어수술자의판단에의해정복법과내고정물을선택해야하는경우가종종발생한다 (Fig. 7). 핀삽입술이압박고나사고정술에비하여고정실패율이높다. 하지만골두하골절이나경부중간골절에서는두고정기구사이에고정력의차이는없는것으로밝혀졌다. 42) Pauwels 3형의골절에서는압박고나사를사용한경우에다발성유관나사삽입술을사용한경우에비해재수술률이 50% 가량감소하였다. 43) 4. 내고정물의선택젊은환자의대퇴경부골절치료에는다발성핀삽입술과압박고나사를사용한내고정술이일반적으로사용되지만골절유합을촉진하고무혈성괴사를줄이는데에가장이상적인고정물이무엇이냐에대해서는아직까지논란의여지가있다. 26) 비전위성골절은대부분의정형외과의사들이다발성핀삽입술을선호하지만전위성골절에서는다발성핀삽입술과압박고나사고정술에대한일관된선택기준이아직없는실정이며지속적으로두내고정물에대한비교연구들이보고되고있다. 현재까지의연구들을종합해보면대퇴경부기저부골절의경우에는다발성 1) 다발성핀삽입술유관나사 (cannulated screw), knowles 핀, Moore 핀, Hagie 핀등을사용하여내고정하는방법으로현재다발성유관나사를이용한고정법이가장많이사용되고있다. 비전위성골절에서는두개의나사로고정하기도하지만전위성골절에서는세개내지네개의나사못을사용한다. 세개의유관나사를사용하는경우에생역학적연구에서는역삼각형모양 (Fig. 8) 으로평행하게삽입하는것이삼각형모양보다우수한고정력을제공하는것으로밝혀졌다. 7,44-46) 최근이에대한 Yang 등 47) 의임상연구에의하면삼각형모양으로삽입하는경우에역삼각형과비교하여불유합의발 A B C Figure 8. A displaced femoral neck fracture was reduced and fixed with three cannulated screws in a reverse triangle configuration on anteroposterior (A) and lateral (B) radiographs. (C) Illustration demonstrating the reverse triangle configuration. A B C D Figure 9. A femoral neck fracture was fixed with three cannulated screws. (A) The most inferior cannulated screw was placed below the lesser trochanter. (B) Screws were placed in a triangle configuration. (C, D) Subtrochanteric fracture occurred at 3 years postoperatively.

7 184 Ingwon Yeo and Seung-Jae Lim 생률이높았으며전자하골절의발생위험이증가하였다 (Fig. 9). 일부저자들은대퇴경부골절시에후방피질골의분쇄가있는경우에네번째나사를다이아몬드형태로삽입하는것이도움이된다고하였다. 4,48-50) 하지만네번째나사는정복부위의기계적인강도를높이는것이아니라골절부의회전을막아주는기능을한다 (Fig. 10). 51) 유관나사삽입시첫번째나사는가장아래에위치하며치밀한피질하대퇴골두, 대퇴거, 외측대퇴피질입구세부위에서의 3점지지를위해대퇴거에걸치도록하여내반전위에저항할수있도록하고, 두번째나사는후상방피질골을따라 3 mm 이내에, 세번째나사는전상방피질골에접하도록하여역삼각형모양으로평행하게삽입하여야한다. 특히가장아래나사가소전자의가장아래부위보다하방에위치하는경우에는전자하골절이발생할위험이있기때문에주의를요하며 (Fig. 10) 가능한외측피질골에드릴구멍을적게내도록한다. 45,46) 또한충분한고정력을 얻기위해서삽입되는나사는대퇴골두의연골하골 5 mm 이내까지삽입되어야하지만연골용해증의발생을예방하기위해유도강선이대퇴골두를관통하지않도록주의하여야한다. 골질이약한경우에는외측피질골만확공하여충분한고정력을얻도록하고필요한경우 washer를추가로사용할수있다. 52) 또한유관나사들은골절부에적절한압박력을주기위해가능한한골절선에수직이되면서서로평행하게위치하여야한다. 44) 2) 압박고나사압박고나사는대퇴골두내고정력의증가와지속적인골절면의압박이가능하여대퇴경부기저부골절이나 Pauwels 3형골절의경우에다발성핀삽입술보다안정적인고정력을제공하는것으로여러생역학연구에서밝혀졌다. Blair 등 53) 은대퇴경부기저부골절에서여러가지고정방법에대한생역학연구결과를근거로고정력이가장우수한압박고나사사용을권장하였다 B A C D E F Figure 10. (A) A displaced femoral neck fracture in a 51-year-old man was seen on radiograph. (B, C) Posterior wall communition was identified on computed tomography. Postoperative anteroposterior (D) and lateral (E) radiographs showing four cannulated screws fixed in a diamond configuration. (F) Illustration demonstrating the diamond configuration. A B C D E Figure 11. A basicervical femoral neck fracture was seen on radiograph (A) and computed tomography (B, C). (D, E) The fracture was fixed with a dynamic hip screw.

8 185 Young Adult Femur Neck Fractures (Fig. 11). Bonnaire와 Weber 7) 는압박고나사가 Pauwels 3형골절의치료에있어다발성핀삽입술보다더안정된내고정방법이라고하였고, Broos 등 16) 과 Blair 등 53) 은압박고나사의위쪽으로추가항회전나사를대퇴경부의두부에위치시키는것은내고정물의회전안전성을증가시킨다고하였다. Baitner 등 6) 은압박고나사와항외전나사를사용한경우에다발성유관나사를사용한경우보다대퇴골두의하방전위, 전단력에의한전위가적었고, 고정실패에대한더큰저항을가진다는결과를보고하였다 (Fig. 12). Swiontkowski 54) 는추가적인항회전나사를삽입하지않는경우에는압박고나사삽입시에대퇴골두의회전불안정성이발생할가능성이높음을지적한바있다. 3) 고정각내고정물다발성핀삽입술과압박고나사를이용한경우골절치유과정에서골절부의단축이발생할수있으며, 이는외전근긴장의감소로인한보행시불편감과대퇴경부단축으로인해내고정물이피부밑에서돌출되어자극을주고통증이발생할수있다. 이러한골절치유과정에서의대퇴경부단축으로인한문제점이대두되어고정각내고정물을이용한대퇴경부골절고정에대한연구들이있어왔다. 최근에는 Pauwels 3형의대퇴경부골절에대한여러내고정물들의생역학적안정성에대한실험에서근위대퇴정 (cephalomedullary nail) 이축상부하에대하여가장우수한결과를보였다. 55,56) 한편근위대퇴잠김금속판 (proximal femoral locking plate) 은골절부의압박을허용하지않는고정물고유의특성과고정전에적절한해부학적정복과골절부의압박이선행되어야하는문제점이지적되어왔으나 57) Boraiah 등 58) 이수술중골절부위를압박후길이안정적인 (length-stable) 고정을하는방법을소개하였고, Della Rocca 59) 는골질이좋지않은 (poor bone quality) 환자의대퇴경부골절의경우에고정각내고정물을사용하는것이골절전위를예방하는데에도움이된다고의견을제시한바있다. 하지만고정각내고정물을이용한대퇴경부골절치료에대한임상적결과보고가아직까지불충분하며향후지속 적인임상연구가필요할것으로보인다. 4) 관절치환술고관절치환술은젊은환자의대퇴경부골절에서일차적인치료법으로고려되지않고있으며, 내고정실패나무혈성괴사증의합병증발생시에시행한다. 60,61) 합병증 1. 불유합대퇴경부는해부학적으로장관골의골막과달리얇고형성층 (cambium layer) 이없어골막성신생골형성이잘일어나지않고골수성가골형성으로만골유합이이루어지며, 관절내골절이므로관절액이골절부위를씻어내어골유합을지연시키므로불유합의발생빈도가높다. 비전위성골절에서는드물게발생하지만전위성골절의경우 20%-30% 의불유합빈도가보고되고있다. 1) 불유합에의한증상은내고정수개월후부터생기며무혈성괴사보다일찍나타난다. 대부분통증은지속적이고서혜부와동측하지전외측에국한되며체중부하에의해심해진다. 불유합의진단을위해서는내고정후 3-6개월이경과되어야하지만고정실패의증거가있다면좀더일찍진단될수있다. 62) 방사선학적으로투과성골절구역 (lucent fracture line), 골감소또는골소실, 1 cm 이상의골절면변화, 5% 이상의유관나사의각도변화, 2 cm 이상의유관나사탈출 (screw back out), 유관나사의대퇴천공등이발생한경우의심해볼수있으며, Angelini 등 63) 은수술후 4-6 개월이경과한후에도지속되는통증이있다면골유합을평가하기위해컴퓨터단층촬영을시행할것을권장하였다. 젊은환자에서의불유합발생에는주로기계적요인이작용하는것으로생각하는데, Rawall 등 64) 과 Upadhyay 등 32) 은젊은환자에게서는대퇴경부후방분쇄골절이나 Pauwels 3형골절이고령의환자에비해높은빈도로발생하여이로인해고정실패와불유합이많이발생한다고하였다. 젊은환자의경우에도생물학적요인에의하여 A B C D Figure 12. A Pauwels type III femoral neck fracture was seen on radiograph (A) and computed tomography (B). (C, D) The fracture was fixed with a dynamic hip screw and a superior derotation screw.

9 186 Ingwon Yeo and Seung-Jae Lim 불유합이발생하는경우가있는데, Kuo 등 65) 은만성신질환이있는환자는대퇴경부골절에대한골접합수술후에불유합의발생빈도가높다고하였다 (Fig. 13). Duckworth 등 66) 은알코올중독, 만성신질환이나호흡기질환이있는경우에고정실패가잘발생한다고하였다. 최근에는비타민D 부족이불유합과연관되어있었고대퇴경부골절의위험인자일가능성에대한논문들 67,68) 이발표되었으며, 비타민D와젊은환자에서의대퇴경부골절발생과치료에대해서는추가적인연구를통해보다명확한상관관계가밝혀져야할것으로보인다. 여러가지불유합의원인들에대한연구와가설들이있었지만현재까지가장확실하게고정실패와불유합을줄일수있는인자는수술자에의한정확한해부학적정복과안정된고정으로알려져있다. 49) 2. 대퇴골두무혈성괴사무혈성괴사는대퇴경부골절의가장심각한합병증중하나로서그발생빈도는비전위골절에서 10%-20%, 전위골절에서 15%-35% 로보고된다. 1) 괴사를유발하는인자들로관절내압의상승, 골절후정복까지의시간, 대퇴경부안의총내고정물의양과위치, 수술후체중부하시기, 동반된동측대퇴간부골절의유무등이연구되어왔으며, 현재까지무혈성괴사가발생하는가장중요한원인으로는대퇴경부골절에서골편의전위로인한상지대동맥 (superior retinacular artery) 의손상으로알려져있다 (Fig. 14). 따라서도수정복시나금속내고정물삽입시에남아있는혈관이추가적으로손상받지않도록과격한정복은피하고대퇴골두가회전되지않도록유의하여한다. 1,23,30) Schweitzer 등 69) 은젊은환자의대퇴경부골절중에서는 53.5세이상의환자에게서대퇴골두괴사가잘발생한다고보고하였고, 최근에는인슐린유사성장인자-1 (insunlin-like growth factor-1), 혈관내피성장인자 (vascular endothelial growth factor) 와같은특정한유전자의변이를가진환자에서대퇴경부골절후무혈성괴사가발생하기쉽다는연구도있었다. 70) 무혈성괴사의원인인자에대한여러연구가있어왔지만아직까지어떤특정한인자또는인자들의조합이괴사발생에더 A B C D Figure 13. (A) A valgus impacted femoral neck fracture in a 64-year-old man with end stage renal disease was seen on radiograph. (B, C) Multiple diamond shaped cannulated screws were placed. (D) Radiograph at 6 months showing collapse with loss of fixation and nonunion. A B C Figure 14. (A) A displaced femoral neck fracture in a 57-year-old woman was seen on radiograph. (B) The fracture was reduced and fixed with three cannulated screws. (C) Radiograph at 7 months showing collapse of the femoral head indicating avascular of the femoral head.

10 187 Young Adult Femur Neck Fractures A B C Figure 15. A 20-year-old man presented with a painful right hip after a military training. An inferior femoral neck stress fracture was seen on radiograph (A), computed tomography (B), and magnetic resonance imaging (C). 큰위험인자인지에대한확실한증거는없다. 대퇴경부골절의 합병증으로서의무혈성괴사를이해할때는초기의무혈성괴 사와후기골두함몰을구분하는것이중요한데, 초기무혈성괴 사는대퇴경부골절이후발생하는국소적허혈에의해골괴사 가발생하는것으로현미경적소견이다. 이에반해후기분절함 몰은경색 (infarct) 된골조직위에놓인연골하골과관절연골이 함몰되는것으로임상적소견이며골절후 6 개월이후부터수년 까지언제든지나타날수있으나 80% 이상은 2 년이내에발생한 다. 1,71) 그러므로골절후적어도 2 년동안은무혈성괴사의임상 적, 방사선적징후발생유무를면밀히관찰해야한다. 무혈성괴 사가발생한경우환자는서혜부에국한된통증, 허벅지전내측 또는동측의무릎으로방사되는통증을호소하며, 대개심부의 박동성통증이고, 체중부하활동후또는야간에통증이심해진다. 무혈성괴사의진단에여러가지방법들이거론되어왔지만단순 방사선영상과자기공명영상이현재까지는가장유용한것으로 알려져있다. 71,72) 대부분의경우에무혈성괴사가발생하여증상이 생기면결국연골하함몰과이차성골관절염으로진행하며이경 우의확실한치료법은고관절치환술이다. 71) 젊은환자에서의대퇴경부스트레스골절 젊은연령에서도종종저에너지외상으로골절이발생하는것 으로보고되며, 상당수는불량한골질과연관된취약골절 (insufficiency fracture) 이다. 골질을약하게하는알코올중독, 만성신 질환이나호흡기질환이있는젊은환자에게서저에너지외상에 의한대퇴경부골절이종종발생하며수술시에고정실패의위 험도높은것으로알려져있다. 73,74) Egol 등 75) 은운동선수나군인 에서대퇴경부피로골절 (fatigue fracture) 이종종발생하는것으로보고하였다 (Fig. 15). 따라서젊은환자에서발생하는대퇴경부골절의진단과치료에있어서생역학적, 기계적관점외에도생리학적, 대사적인관점에서의주의깊은고찰도함께요구된다. 결론 젊은환자에서의대퇴경부골절은환자의남은인생에치명적인결과를가져오는골절일수있다. 대부분의경우단순방사선영상을통해진단할수있으나진단을놓칠수있는가능성이있음을염두에두고철저한이학적검사와동반손상에대한파악이함께이루어져야하겠다. 젊은환자의대퇴경부골절의치료에있어환자본인의관절을보존하는것을우선시하여야하고, 정확한해부학적정복과안정적인내고정이치료의승패를결정하는인자라고하겠다. 최근인공관절치환술의비약적인발전과우수한장기치료결과들이보고되고있으나아직젊은환자의대퇴경부골절치료의일차선택법으로고려되기에는이르다고하겠다. 젊은환자의대퇴경부골절치료후의불유합과무혈성괴사의발생빈도는여전히높은편이며, 이에대한원인인자및예방과치료에대한지속적인연구가필요하겠다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Fractures of the neck of femur. In: The Korean Fracture So-

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14 191 pissn : , eissn : Symposium J Korean Orthop Young Assoc Adult 2015; Femur 50: Neck Fractures 대퇴골근위부골절 젊은성인의대퇴경부골절에대한최신치료방법 여인권 임승재 성균관대학교의과대학삼성서울병원정형외과학교실 젊은성인환자들에서발생하는대퇴경부골절은비교적드물게고에너지손상에의해발생하며골절치유과정에서대퇴골두무혈성괴사, 불유합또는단축과같은합병증이발생할가능성이높은것으로보고되고있다. 이런환자의치료에있어서는고관절의정상해부학적구조와역학을보존하는것이가장중요하며, 정확한해부학적정복과안정된내고정은이러한치료목표를달성하는데에필수적인요소이다. 아직까지젊은성인환자의대퇴경부골절에대한이상적인단일치료법을제시할수는없지만본종설을통해수술시기, 관절낭절개술의역할, 골절정복의방법및적절한내고정물의선택에대한현재까지의연구결과와근거들을제시하고자한다. 색인단어 : 대퇴경부골절, 젊은성인, 치료방법 접수일 2015 년 6 월 3 일게재확정일 2015 년 6 월 7 일책임저자임승재서울시강남구일원로 81, 삼성서울병원정형외과 TEL , FAX , limsj70@gmail.com 대한정형외과학회지 : 제 50 권제 3 호 2015 Copyright 2015 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.