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1 ISSN 568 (Print) ISSN 8799 (Online) 대한골절학회지제 6 권, 제 4 호, 0 년 0 월 J Korean Fract Soc 0;6(4):667 원 저 소아상완골내과골절의치료결과 강정한 양승현 * 임극필 김휘택 부산대학교병원정형외과, 부산대학교의학전문대학원 * Results of Treatment for Medial Condyle Fracture of the Distal Humerus in Children Jeong Han Kang, M.D., Seung Hyeon Yang, M.S.*, Kuk Pil Lim, M.D., Hui Taek Kim, M.D. Department of Orthopaedic Surgery, Pusan National University Hospital, Busan, School of Medicine, Pusan National University*, Yangsan, Korea Purpose: We evaluated outcomes of treatment in medial condyle fracture of the distal humerus in children. Materials and Methods: Seven patients (4 females, males) who were treated at the Pusan National University Hospital and followedup until skeletal maturity after treatment were included. The average age at the time of fracture was 4.6 years (range, to 0 years). Treatment was performed from day to 6 months after the fracture: 4 patients underwent a surgical treatment for 7 days, months, months and 6 months after fracture, respectively. All fractures were Milch type. Five patients had Kilfoyle type, and two patients had type fractures. Final outcomes were evaluated by the Mayo elbow performance score and carrying angle. Results: There were excellent, good and fair result at the final followup. There was no elbow pain in any of the patients. One of the four patients who underwent a late surgical treatment received corrective osteotomy due to cubitus varus. All four patients had a limitation of elbow motion. The other three patients who had accurate diagnosis and treatment had a full range of motion. Conclusion: Diagnosis of medial condyle fracture of the distal humerus based on plain radiograph is difficult in children due to its cartilaginous structures. When a patient shows pain, tenderness and swelling on the medial side of the elbow, an additional examination with magnetic resonance imaging may be required even if no fracture line is found in the radiograph. Accurate diagnosis and early treatment is important for good results. Key Words: Distal humerus, Medial condylar fracture 서 론 소아상완골내과골절은골절선이성장판을통과하는 Received April, 0 Revised June 7, 0 Accepted July 4, 0 Address reprint requests to: Hui Taek Kim, M.D. Department of Orthopaedic Surgery, Pusan National University Hospital, 79 Gudeokro, Seogu, Busan 6079, Korea Tel: ㆍ Fax: kimht@pusan.ac.kr 관절내골절로그빈도는매우드물어소아주관절부골절의 % 에해당한다,,8,9,4). 다른관절내골절과마찬가지로내과골절도성장장애, 관절면의부조화및기능저하를피하기위하여정확한진단과조기정복이필요하다. 그러나내과는활차의골화가이루어지기전까지순수한연골로만구성되어있어내과골절이있다하더라도엑스선상통상적인골절편의전이를볼수없다. 따라서환자를직접세밀하게시진및촉진을하지않고엑스선만을이용하여진단할경우진단에오류가있기쉽고그에따른 Copyright c 0 The Korean Fracture Society. All rights reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution NonCommercial License ( bync/.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 6

2 6 강정한, 양승현, 임극필, 김휘택 수술적치료의지연은불량한결과를야기한다. 엑스선상특이한사항이없으나주관절내측부에부종과압통을보일경우무엇보다내과골절을의심하고보다더정밀한검사가필요하다. 저자들은본교실에서치료한소아상완골원위부내과골절환자들의결과를분석하여진단의어려움과특히진단이지연된후수술적치료를한환자들의임상및방사선학적결과를고찰해보았다. 대상및방법 본연구는부산대학교병원연구윤리위원회로부터연구에대한승인을받았다 (D040704). 소아상완골의내과골절에대해부산대학교병원정형외과에서보존적치료및수술적치료를시행한후 0 년현재상완골원위부성장이완료된 7 예를대상으로결과를분석하였다 (Table ). 여자가 4 예, 남자가 예였으며, 환자의평균나이는 4.6 세 (0 세 ) 였고, 수상후치료를시행하기까지의평균기간은.5 개월 ( 일 6 개월 ) 이었다. 총 7 예중 4 예는염좌로오인되었고, 예는최초에정확한진단이되었다. 염좌로오인된 4 예는진단후적절한수술적치료가지연되어수술이이루어진시기가수상후 7 일 (Fig. 6), 개월, 개월, 6 개월이었다. 즉시진단되었던 예중 예 ( 증례 6, 7) 는나이가 8 세와 0 세로내과활차부의골화가이루어져있고골절선이골간단부위를통과하여석고고정과수술적치료를시행하였고, 나머지 예 ( 증례 ) 는수상당시 세로엑스선상에서는이상소견이없었으나주관절내측부부종과압통을보여실시한자기공명영상사진에서내과골절로진단되어수술적치료를하였다. 본연구대상군의경우내과골절의정확한진단을위하여주관절전후면과사면단순방사선사진과함께, 자기공명, 관절조영술등을이용하였다. 골절은 Kilfoyle 의분류를기준으로전이가없는경우를 형 ( 불완전상완골과상부골절형태 ), 회전이없는경우를 형 ( 골절선이내과성장판까지침범 ), 전이와회전변형이있는경우를 형으로판정하였으며, 총 7 예중 형이 예, 형이 5 예였다. 모든환자들은 Milch 형의골절을수상하여주관절의불안정성이나탈구는동반되지않았다. 치료방법은 형은석고고정, 형및 형은관혈적정복및고정술을시행하였다. 치료가지연된 4 예 ( 증례,, 4, 5) 의경우수술전보호자에게수상당시정확한골절진단의어려움과수술적치료시야기될수있는합병증등에대해상세히설명하였다. 모든환자들에서내측도달법을이용하여전이된내과골편을먼저찾고부착된정상연부조직을가능한잘보존하여해부학적정복을시행하였다. 그러나수상후 Table. Patient Data Final results ROM of affected side (normal side) Carrying angle difference Additional treatment Treatment Complication Delayed Dx (duration after trauma/diagnostic tool) Initial Dx (diagnostic tool) Kilfoyle type Milch type Mechanism of injury Age at the time of Fx (yr) Case No. Excellent Excellent 040 o (040 o ) 00 o (05 o ) 5 MCF (Xray/MRI) Sprain (Xray) Slip down Good 00 o (00 o ) 7 Cubitus varus, LOM Sprain (Xray) Good 05 o (05 o ) 6 Neurolysis 7 days/mri, months/mri, months/mri, 6 months/mri, Sprain (Xray) 4 Fair 00 o (050 o ) 0 Supracondylar osteotomy Ulnar nerve neuropathy, LOM Cubitus varus, LOM Sprain (Xray) 5 5 Excellent Good 00 o (00 o ) 00 o (040 o ) LOM Cast MCF (Xray) MCF (Xray) Pitching Tumbling Fx: Fracture, Dx: Diagnosis, MCF: Medial condyle fracture, MRI: Magnetic resonance imaging, Intraop.: Intraoperative, : Open reduction and internal fixation, LOM: Limitation of motion, ROM: Range of motion.

$(B) However, a radiograph taken 7 days after the trauma revealed a medial condyle fracture of the distal humerus (white arrow:$ $. Magnetic resonance imaging showed a displaced medial condyle fracture (white arrow) with rotation (Kilfoyle type ). Fig.$ 개월이상지난환자들의경우섬유성반흔조직의유착으로내과골편에부착된정상연부조직을온전히보존하면서박리하기가용이하지않았다.

개월이상지난환자들의경우섬유성반흔조직의유착으로내과골편에부착된정상연부조직을온전히보존하면서박리하기가용이하지않았다.

3 소아상완골내과골절의치료결과 6 Fig.. (A) A yearold girl had trauma in the left elbow which was misdiagnosed as a sprain, and was treated with a splint (Case ). (B) However, a radiograph taken 7 days after the trauma revealed a medial condyle fracture of the distal humerus (white arrow: scattered calcification in the medial condyle). Fig.. Magnetic resonance imaging showed a displaced medial condyle fracture (white arrow) with rotation (Kilfoyle type ). Fig.. Arthrogram confirmed a medial condyle fracture (white arrow) with rotation (Kilfoyle type ). 개월이상지난환자들의경우섬유성반흔조직의유착으로내과골편에부착된정상연부조직을온전히보존하면서박리하기가용이하지않았다. 먼저일반주사바늘을이용하여골편주위를찔러보면서골편의윤곽을확인하고, 원위부에서근위부로조심스럽게박리를시행함으로써후방으로유입되는혈류의손상을방지하여골편의무혈성괴사를방지하기위해노력하였다. 그러나골편의박리가잘이루어졌다하더라도골편을고정해야하는상완골원위부의위치가육안으로잘판별되지않았을뿐아니라이부위로골편을정복시부착된연부조직의구축으로과도 한주관절굴곡을해야하는어려움이있었다. Carm 영상 (GE Healthcare, Salt Lake City, UT, USA) 증폭장치의도움으로연골골편이위치해야할부위를확인한후 K 강선 (Zimmer, Warsaw, IN, USA) 을이용하여골편을고정하였다. 이들환자들의경우 4 주간의장상지석고고정후주관절운동을시행하였다. 치료결과판정은 Mayo 주관절실행점수 (elbow performance score) 를기준으로통증, 운동, 안정성, 기능을각각점수화하여 90 점이상인경우를최우수, 7589 점사이인경우를우수, 6074 점사이인경우를보통, 60 점이하

Anteroposterior radiograph taken months after surgery showed an irregular margin of medial side of the distal humerus with an ossification center of medial epicondyle. Fig. 6.

At the latest followup, her elbow performance score in the left side was 94 (excellent) with a slight limitation of motion (00 o ).

Anteroposterior radiographs of both elbows taken 4 years after surgery (when the patient was 7 years old) showed deformity of the distal humerus in the left elbow. 인경우를불량으로하였다.

4 64 강정한, 양승현, 임극필, 김휘택 Fig. 4. Reduction of the fragment and internal fixation with Kwire was performed with a careful dissection of soft tissues from the fragment to preserve blood supply from flexor muscle group. Anteroposterior radiograph taken months after surgery showed an irregular margin of medial side of the distal humerus with an ossification center of medial epicondyle. Fig. 6. Anteroposterior radiographs of both elbows taken years after surgery (when the patient was 6 years old) showed undergrowth of trochlea on the affected side. At the latest followup, her elbow performance score in the left side was 94 (excellent) with a slight limitation of motion (00 o ). Five degrees difference of carrying angle from the normal side was noticed. Fig. 5. Anteroposterior radiographs of both elbows taken 4 years after surgery (when the patient was 7 years old) showed deformity of the distal humerus in the left elbow. 인경우를불량으로하였다. 엑스선상운반각의측정에는외관을가장잘나타내어주는 humeroelbowwrist (HEW) 각을이용하였다 ). 예중 예 (4.9%) 에서최우수였다 (Table ). 전예에서주관절동통은없었으며, 운동범위감소는치료가지연된 4 예에서보였으나정확한진단과함께즉각적인치료가시행된 예에서는모두정상측과큰차이를보이지않았고기타다른합병증도보이지않았다. 치료가지연된 4 예는모두미끄러지거나낙상후주관절의동통성부종이발생하여타병원에서부목을이용하여보존적치료를받았으나호전되지않은주관절굴곡구축과운동장애및통증을주소로내원하였다. 내원당시단순방사선사진에서는내과의부분골화소견및골절편이인지되어내과골절로비교적쉽게진단되었고관혈적정복및금속핀고정술로치료하였다. 이들의경우수술시골편과연부조직의유착으로주위와경계가명확하지못했으며골절편의정복을위해연부조직의과도한박리가불가피하였고, 최종추시관찰시모두정상측에비해운반각감소를보였다. 운반각의감소가있었던증례중한예는활차부무혈성괴사로인한심한내반주로교정절골술이시행되었다. 또한예는합병증으로술후유착으로인한척골신경마비증상이발현되어술후 6 개월에척골신경해리술이필요하였고, 최종추시시증상회복이있었다. 결 과 고 찰 최종결과는최우수 예, 우수 예, 보통 예로전체 7 소아상완골내과골절진단시발생하는문제점은소아

5 소아상완골내과골절의치료결과 65 주관절의해부학적특성에기인한다. 소아상완골외과부에해당하는소두 (capitellum) 는내과부에해당하는활차 (trochlear) 보다먼저골화되고활차는이후 9 세경에골화가일어난다. 따라서내과골절의대부분은골화중심이나타나는 9 세이후에많으나드물게골화중심이나타나기이전에발생할경우연골만으로구성된내과골절의진단은쉽지가않다 4,8). Chacha ) 에따르면내과골절은상완골원위부성장판에서불완전한골화가있는곳에서발생하는골절이라고하였으며, 상완골원위부성장판이닫히기전인 8 세사이에잘발생한다고하였다. Fowles 와 Kassab 4) 가 8 예의내과골절환자를대상으로한연구의평균연령은 세였으며, Bensahel 등 ) 은비전위성골절은 5 세주위의연령에서, 전위성골절은 7 세주위의연령에서잘발생한다고하였다. 그러나 Leet 등 ) 은 예환자의평균연령은 4.7 세였다고보고하였으며 De Boeck 등 ) 은 6 개월에발생한내과골절환자를보고하여호발연령대가넓음을알수있다. 본연구에서내과골절발생의평균연령은 4. 세였다. 연령분포는다른보고들에서와같이 세에서부터 0 세까지비교적넓었으며특히 5 세사이환자 5 예중 4 예가수상초기에정확한진단을받지못한환자들이었다. 내과골절은성장판손상이생길수있는 SalterHarris 4 형에해당한다,8,6). 손상기전은굴곡된주관절상태에서떨어지면서땅을짚거나신전된주관절에외반력이작용되면서힘이주두와관상돌기를통해내과에전달되어골절이발생하는것으로알려져있으며,6,,4), 때때로전완부굴근에의한견열골절로발생할수있다 4). 주관절의아탈구또는탈구의지지목역할을하는활차의외측벽으로골절이연장될경우주관절의골절탈구가같이발생될수있다,4). 내과골절은골간단골편, 내상과 (epicondyle), 연골로되어있는활차를같이침범하는경우가많으며종종내상과골절로오인하게된다 4,6,7). 따라서골화중심이나타나기이전의나이에내과골절이의심스러울경우전후면단순방사선뿐만아니라사면단순방사선촬영과함께자기공명영상, 관절조영술등의진단검사법을이용하고, 또한마취하에서외반력이주어진상태로방사선사진을촬영하여내과골절과내상과골절을구별해야한다 4,7,7). 내과골절의치료는 Kilfoyle, 형의경우대부분수술적치료를통한골절편의정확한해부학적정복과함께견고한금속내고정이다. 그러나골절의전이정도가경미한 형의경우단순석고고정만으로우수한기능적결과를얻을수있다,5,6). 그러나 Leet 등 ) 은 예의경미한골절중 예에서불유합이생겼다는보고와함께세심한추시관찰을요한다고했다. 또한 Ghawabi 5) 는흡수봉합사 (catgut) 로내과를봉합하였으나골절편의불충분한고정으 로불유합이발생했다고보고했다. 본연구에서는경미한전이를보인 예에서단순석고고정만으로우수한결과를얻었으며, 나머지 6 예에서는모두수술적정복과함께 K 강선을이용한금속내고정을시행하였다. 소아주관절내과부의혈액공급은부가적혈류공급이없이활차에서끝나게되며내과의후방으로들어오게된다. 따라서골절수상당시나수술적치료시뒤쪽연부조직및혈관에손상이발생하면내과로가는혈류공급이차단되어무혈성괴사가발생될수있다. Leet 등 ) 은 예의내과골절중 % 에서활차부골괴사, 불유합, 정복소실을포함하는후유증이발생하였음을보고하였다. 내과골절후의불유합은불충분한고정이외에, 수술시과도한연부조직박리와함께후방으로유입되는혈류에손상을줄때에도발생할수있다. 특히불유합으로수술적치료를시행하는경우골절면의노출을위하여전완부굴곡근을포함하여연부조직을박리해야하기때문에내과로분포되는혈류장애를초래하여다시불유합이발생하거나 4,0), 혹은골편의무혈성괴사가초래될수있다. 이러한위험성을우려하여 Papavasiliou 등 6) 은불유합에대한치료대신상완골과상부절골술을시행하여운동범위의회복과변형을감소시켰다. 본연구에서는진단이지연된경우라하더라도수술시연부조직의박리에따른혈류차단을방지하기위해최대한의노력을기울이면서골편의정복및금속고정을시행하였으며다행히무혈성괴사가발생한 예를제외한모든예에서골유합을얻을수있었다. 내과골절에서간혹골절편에의한척골신경자극으로인하여척골신경마비증세를보이는경우가있다,,). 본연구에서도수술후지속된척골신경마비증상으로척골신경해리술을시행한경우가 예 ( 증례 4) 있었으며, 수술후증상이해소되었다. 본연구의경우척골신경마비증상 ( 증례 4) 과무혈성괴사 ( 증례 5) 와같은후유증은모두정확한진단이이루어지지못하고치료가지연된경우에서발생하였으며이들최종결과는조기에정확한진단및치료가시행된예들에비해서크게좋지못하였다. 특히내과골편에부착된연부조직의완전박리가불가피했던 예 ( 증례 5) 에서는내과의무혈성괴사및내반주변형으로상완골과상부교정절골술을시행하였다 5). 결 소아상완골내과골절은정확한진단과함께조기에치료하면큰기능적장애없이운동범위의완전한회복, 또는경도의운동범위감소를보이는것이보통이다. 그러나진단의오류와이에따른부적절한치료후지연된수술적치료를시행할경우그결과는매우불량할수있으므로 론

6 66 강정한, 양승현, 임극필, 김휘택 초기에정확한진단을하는것이가장중요하다. 특히주관절내측부부종과압통을보일경우내과골절을의심하고단순엑스선이외자기공명영상등을이용한정밀한검사가필요하다. References ) Bensahel H, Csukonyi Z, Badelon O, Badaoui S: Fractures of the medial condyle of the humerus in children. J Pediatr Orthop, 6: 404, 986. ) Chacha PB: Fracture of the medical condyle of the humerus with rotational displacement. Report of two cases. J Bone Joint Surg Am, 5: 45458, 970. ) De Boeck H, Casteleyn PP, Opdecam P: Fracture of the medial humeral condyle. Report of a case in an infant. J Bone Joint Surg Am, 69: 44444, ) Fowles JV, Kassab MT: Displaced fractures of the medial humeral condyle in children. J Bone Joint Surg Am, 6: 596, ) Ghawabi MH: Fracture of the medial condyle of the humerus. J Bone Joint Surg Am, 57: , ) Gogola GR: Pediatric humeral condyle fractures. Hand Clin, : 7785, ) Hanspal RS: Injury to the medial humeral condyle in a child reviewed after 8 years. Report of a case. J Bone Joint Surg Br, 67: 6869, ) Haraldsson S: On osteochondrosis deformas juvenilis capituli humeri including investigation of intraosseous vasculature in distal humerus. Acta Orthop Scand Suppl, 8:, ) Ingersoll RE: Fractures of the humeral condyles in children. Clin Orthop Relat Res, 4: 4, ) Ippolito E, Tudisco C, Farsetti P, Caterini R: Fracture of the humeral condyles in children: 49 cases evaluated after 845 years. Acta Orthop Scand, 67: 778, 996. ) Kilfoyle RM: Fractures of the medial condyle and epicondyle of the elbow in children. Clin Orthop Relat Res, 4: 450, 965. ) Leet AI, Young C, Hoffer MM: Medial condyle fractures of the humerus in children. J Pediatr Orthop, : 7, 00. ) Lins RE, Simovitch RW, Waters PM: Pediatric elbow trauma. Orthop Clin North Am, 0: 9, ) Milch H: Fractures and fracture dislocations of the humeral condyles. J Trauma, 4: 59607, ) Oppenheim WL, Clader TJ, Smith C, Bayer M: Supracondylar humeral osteotomy for traumatic childhood cubitus varus deformity. Clin Orthop Relat Res, (88): 49, ) Papavasiliou V, Nenopoulos S, Venturis T: Fractures of the medial condyle of the humerus in childhood. J Pediatr Orthop, 7: 44, ) Ryu K, Nagaoka M, Ryu J: Osteosynthesis for nonunion of the medial humeral condyle in an adolescent: a case report. J Shoulder Elbow Surg, 6: e8e, 007.

7 ISSN 568 (Print) ISSN 8799 (Online) 대한골절학회지제 6 권, 제 4 호, 0 년 0 월 J Korean Fract Soc 0;6(4):667 원 저 소아상완골내과골절의치료결과 강정한 양승현 * 임극필 김휘택 부산대학교병원정형외과, 부산대학교의학전문대학원 * 목적 : 상완골원위부내과골절에대한치료결과를고찰하였다. 대상및방법 : 소아상완골내과골절에대해부산대학교병원정형외과에서치료후 0년현재상완골원위부성장이완료된 7예를대상으로하였다. 남자가 예, 여자가 4예였으며수상당시의나이는 세에서 0세로평균 4.6세였다. 수상후치료까지의기간은최소 일에서최고 6개월이었으며, 4예에서수상후 7일, 개월, 개월, 6개월때수술적치료를받았다. 모든골절이 Milch 형이었으며, 5예에서 Kilfoyle 형, 예에서 형이었다. Mayo 주관절실행점수와운반각의변화에따라최종결과를판정하였다. 결과 : 최우수 예, 우수 예, 보통 예의결과를보였다. 모든예에서주관절동통은없었으며, 진단이지연된 4예중 예에서내반변형으로교정절골술을받았고이들모두운동장애를보였다. 치료가지연되지않은 예에서는정상운동범위를보였다. 결론 : 소아상완골내과는연골로구성되어골절시단순엑스선만으로정확한진단이어렵다. 엑스선상골절선이보이지않더라도주관절내측부위의부종과압통등을보일경우자기공명영상등의추가검사가필요할수있다. 정확한진단과함께조기치료하면우수한결과를얻을수있으므로정확한진단이무엇보다중요하다. 색인단어 : 상완골원위부, 내과골절 접수일 수정일 게재확정 교신저자김휘택부산시서구구덕로 79, 부산대학교병원정형외과 Tel , Fax , kimht@pusan.ac.kr Copyright c 0 The Korean Fracture Society. All rights reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution NonCommercial License ( bync/.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 67

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( )Jkfs095.hwp 대한골절학회지제 19 권, 제 4 호, 2006 년 10 월 Journal of the Korean Fractrure Society Vol. 19, N o. 4, October, 2006 팔씨름에의해발생한상완골간부및내상과골절 윤여헌 하종경 * 최경업 * 이관희 신상진 이화여자대학교의과대학목동병원정형외과, 서울적십자병원정형외과 * 목적 : 팔씨름중발생한상완골골절의발생기전및치료의결과를분석하였다.