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1 대한수부외과학회지제 13 권제 4 호 The Journal of the Korean Society for Surgery of the Hand VOLUME 13, NUMBER 4, December 2008 한림대학교강남성심병원정형외과학교실 1, 연세대학교의과대학정형외과학교실 2 노규철 1 김홍균 1,2 유희성 1 유정한 1 박진수 1 정국진 1 황지효 1 한수봉 2 Internal Fixation of Mallet Fractures using a Hook Plate Kyu Cheol Noh, M.D. 1, Jin Soo Park, M.D. 1, Hong Kyuu Kim, M.D. 1,2, Hui Seong Yu, M.D. 1, Jung Han Yoo, M.D. 1, Kook Jin Chung, M.D. 1, Ji Hyo Hwang, M.D. 1, Soo Bong Hahn, M.D. 2 Department of Orthopedic Surgery, Kangnam Sacred Heart Hospital, Hallym University Medical Center, Seoul, Korea 1 Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea 2 Purpose: The purpose of this study is to introduce the result of treatment for bony mallet finger using hook plate Materials and Methods: From September 2007 to Feburary 2008, 7 patients were treated with hook plate for bony mallet finger. Indications of operative treatment are fractures involving more than 30% of articular surface or those with palmar subluxation or fracture fragment displaced more than 3 mm. We used hook plate which prebend the 1.2 mm miniplate (Leibinger ). The mean follow-up period was 7 months. The clinical results were evaluated using Crawford classification. Results: According to Crawford classification, 6 cases were excellent and 1 case was good. There were marginal necrosis in one case and nail deformities in 3 cases. These complications were healed spontaneously. Conclusion: Internal fixation of mallet finger using 통신저자 : 김홍균서울특별시영등포구대림1동 한림대학교강남성심병원정형외과학교실 TEL: , FAX: jacobass@hallym.or.kr * 본논문의요지는 2008년도대한정형외과학회추계학술대회에서포스터전시되었음. Hook plate is a relatively easy method which can achieve anatomical reduction and firm fixation for earlier interphalangeal joint exercise. Key Words: Bony mallet, Hook plate 서 론 골성추지는원위수지기저부의견열골절로신전기전의손상이발생하여굴곡변형이생기거나, 이차적으로백조목변형이발생할수있다 1,2. 현재까지관혈적또는비관혈적정복술및다양한방법에의한고정술이소개되어왔다. 그러나 wire, K-강선, 나사못를이용한해부학적정복및견고한고정술은골편의골절및정복의소실이발생할수있고, K-강선의위치가변하거나, 원위지절의장기간고정으로인해원위지절의조기운동이불가능하며, K-강선이피부밖에위치하여감염에대한주의가요구된다 3,4. Teoh 와 Lee 는이에위의문제점을최소화할수있으면서해부학적정복및견고한고정이가능한골성추지의또다른치료방법을소개하여좋은결과를얻었기에저자들도이치료법을좀더쉽게변형하여그임상적결과에대해서보고하고자한다 5. 연구대상및방법 2007년 9월부터 2008년 2월까지골성추지로방문한환자중환측원위지절의수장부아탈구가있는경우, 골편의크기가관절면의 1/3이상인경우, 3 mm 이상의골편전위를보이는경우를대상으로전향적연구를수행하였다 6-8. 위의기준에맞는환자 8 명 (Table 1) 을대상으로관혈적정복술및내고정술을시행하였고, 추시기간은최소 6개월이상이었다. 저자들이사용한 plate는 1.2 mm miniplate (Leibinger ) 를변형시켜서갈고기모양의금속판 299

노규철 김홍균 유희성 유정한 박진수 정국진 황지효 한수봉 Table 1. Summary of cases Case No. Age/Sex Cause of Injury Rt./Lt. Injured finger Injury to operation interval (days) 1 31/M Basketball Lt. 2 nd 8 2 40/M Hit Rt.

2 노규철 김홍균 유희성 유정한 박진수 정국진 황지효 한수봉 Table 1. Summary of cases Case No. Age/Sex Cause of Injury Rt./Lt. Injured finger Injury to operation interval (days) 1 31/M Basketball Lt. 2 nd /M Hit Rt. 4 th /M Football Lt. 4 th /F Hit Lt. 4 th /M Handball Lt. 3 rd /F Basketball Rt. 3 rd /F Hit Rt. 4 th /M Basketball Lt. 4 th 300 Table 2. Crawford classification Classification Extension loss Flexion Pain Excellent None Full None Good 0~10 Full None Fair 10~25 Any loss of flexion None Poor >25 Any loss of flexion Persistent pain Table 3. Operation and postoperative evaluation Case No. Anesthesia Operation time Extension loss Flexion Pain Crawford classification 1 *BPB* 45 m None 70 None Excellent 2 BPB 40 m 5 75 None Good 3 BPB 45 m None 80 None Excellent 4 BPB 45 m None 80 None Excellent 5 *0G/A** 40 m None 80 None Excellent 6 BPB 40 m None 85 None Excellent 7 BPB 40 m None 80 None Excellent 8 BPB 40 m None 85 None Excellent * Brachial Plexus Block ** General Anesthesia Fig. 1. Hook plate and Mini-screw. (hook plate) 으로만들어사용하였다 (Fig. 1). 수술방법은원위지절에횡절개를하여, 전층의피판을만들어충분히골편을노출시켜관혈적정복술을시행하고, 제작된 hook 금속판을이용해골편을고정하였다 (Fig. 2). 수술시간은마취후부터수술방을나가기전까지의시간을측정하였다. 수술후 1주간부목고정을시행하였고, 수술후 8일째 stack으로고정하였고, 매시간당 10분의능동적원위지절운동을시행하였다. 2주일째봉합사를제거하였다. 예기치않은사고로부터보호하기위해 Stack은 4주까지잠잘때와낮시간에운동을하지않을때착용하도록교육하였다. 4주이후에부목을완전히제거하도록하였다. 추시기간은최소 6개월이상이었다. 임상적인평가는수술후 24주 (6개월) 째 Crawford 판정법 (Table 2) 을기준으로원위지관절의신전소실및굴곡정도 300

Radiograph of view of finger and medical Photographs showing full flexion and extension 6 months postoperatively. 와동통의유무에따라 4 단계로나누어평가하였다 9.

3 Fig. 2. (A) Skin incision. (B) Illustration of internal fixation. (C) Medical photo of internal fixation with hook plate. (D) Radiograph showing anatomic reduction and internal fixation using hook plate and screw. Fig. 3. Radiograph of view of finger and medical Photographs showing full flexion and extension 6 months postoperatively. 와동통의유무에따라 4 단계로나누어평가하였다 9. 고 찰 결과 총 8예중 5도의신전소실이있었던 1예를제외하고는 7예에서신전소실이없었고, 골곡범위는모든예에서정상으로측정되었고, 수술부위에동통을호소하는예는없었다 (Table 2)(Fig. 3). 다만 1예에서절개부위변연부에괴사가일어났고, 경과관찰만으로도치료가되었다 (Fig. 4). 또한 3예에서손톱의변형이관찰되었으나, 수술후약 3~4 개월째정상모습으로돌아왔다. 수술시간은평균 42분이었다. 환자가원한 1예를제외하고는모두상완신경총마취로수술을진행하였다. 골성추지의수술적치료방법중비관혈적방법으로는변형된신전차단 K-강선고정술 2,10,11 과원위지간관절에손상을주지않는 Umbrella Handle technique 12 등이있다. 관혈적방법으로는관혈적정복후골편의 K-강선고정술 13,14, 압박나사고정술, 견인철사요법을이용한고정술 15,Pull-out봉합술 1 등이있다. 그리고정복의소실, 감염, 관절강직, K-강선의전이, 봉합사의절단, 신전제한, 외상성관절염등의합병증이발생할수있다 4,16,17. 그러나저자들이시행한 hook 금속판을이용한고정술에서는정복의소실이발생하지않았으며, 수술후조기운동이가능하기때문에관절강직이나외상성관절염의결과는없었 301

노규철 김홍균 유희성 유정한 박진수 정국진 황지효 한수봉 양의금속판내고정으로얻을수있는이득을고려해볼때크게중요하지않다고생각한다. 또갈고리모양의금속판이작아서골편과압박고정을하는것이쉽지않았으며, 이를위하여저자들은포겸자 (towel clip) 를변형시켜만든기구를이용골절정복후고정을용이하게하였다 (Fig. 5).

(A) Marginal necrosis at postoperative 2 weeks. (B) At postoperative 8 weeks, necrosis is fully recovered. Fig. 5. (A) Modified towel clip. (B) Fix-ation of fragment with the device. 다.

4 노규철 김홍균 유희성 유정한 박진수 정국진 황지효 한수봉 양의금속판내고정으로얻을수있는이득을고려해볼때크게중요하지않다고생각한다. 또갈고리모양의금속판이작아서골편과압박고정을하는것이쉽지않았으며, 이를위하여저자들은포겸자 (towel clip) 를변형시켜만든기구를이용골절정복후고정을용이하게하였다 (Fig. 5). 결 론 갈고리 (hook) 금속판을이용한고정술은해부학적으로견고한고정이가능하고, 장기간의원위지절고정이필요하지않아조기운동이가능하여골성추지의고정방법중하나의방법으로의미가있다. 그러나환자군이적고장기추기결과가부족하므로앞으로좀더많은환자및장기추기에대한연구가필요할것으로사료된다. 참고문헌 Fig. 4. (A) Marginal necrosis at postoperative 2 weeks. (B) At postoperative 8 weeks, necrosis is fully recovered. Fig. 5. (A) Modified towel clip. (B) Fix-ation of fragment with the device. 다. 또한장기간 K-강선이나 wire 를피부밖에두면서발생하는염증및위생문제에대한단점도해결할수있었다. 그러나수술후추시중손톱모양의변형이오는경우가 3예있었는데이는 hook 금속판의위치가 Germinal matrix와근접하게위치하기때문인것으로생각된다. 하지만특별한치료없이약 3~4 개월의관찰로손톱모양은정상으로돌아오는것을확인할수있었다. 수술술기중금속판이작아서골편과고정하고나사못으로고정하는것이쉽지가않아서수술시간이길어질수있는데, 우리연구에의하면평균 42분소요되어이전의다른방법들의경험과비교해보면약 10~20분의차이가있는데이는갈고리모 01) Hahn SB, Kim SH, Park SH, Kang HJ. Treatment of bony mallet finger with extension block technique. J Korean Soc Hand. 2005;10: ) Darder-prats A, Fernandez-garcia E, Fernandez-gabada R, Darder-garcia A. Treatment of mallet finger fractures by the extension-block K-wire technique. J Hang Surg Br. 1998;23: ) Hahn SB, Kang ES, Kang HJ, Lee WS. Complication of bony mallet fingers after operative treatment. J Korean Soc Surg Hand. 1998;3: ) Stern PT, Kastrup JJ. Complications and prognosis of treatment of mallet finger. J Hand Surg Am. 1998;13: ) Kim YH, Kim KW, Min HJ, Yoon SU, Baek JH. Outcome study on operative treatment of mallet finger. J Korean Soc Surg Hand. 2002;7: ) Teoh LC, Lee JY. Mallet fractures: A Novel approach to internal fixation using a hook plate. Journal of Hand surg E. 2007;32: ) Niechajev IA. Conservative and operative treatment of mallet finger. Plast Reconstr Surg. 1985;76: ) Wehbe MA, Schneider LH. Mallet fractures. J Bone Joint Surg Am. 1984;66: ) Crawford GP. The molded polythene splint for the mallet finger deformities. J Hand Surg Am. 1984;9: ) Tetik C, Gudemez E. Modification of the extension block Kirschner wire technique for mallet finger. Clin Orthop. 2002;404: ) Hofmeister EP, Mazurek MT, Shin AY, Bishop AT. 302

5 Extension block pinning for large mallet fracture. J Hand Surg Am. 2003;28: ) Rocchi L, Genitiempo M, Fanfani F. Percutaneous fixation of mallet fractures by the Umbrella handle technique. J Hand Surg Br. 2006;31: ) Badia A, Riano F, A simple fixation method for unstable bony mallet finger. J Hand Surg Am. 2004;29: ) Takami H, Takahashi S. Ando M. 2005;10: ) Kang HJ, Shim DJ, Choi CJ, Yoon KH, Lee SY, Hahn SB. Pulp traction technique for the operative treatment of bony mallet finger. J Korean Soc Surg Hand. 2005;10: ) Bischoff R, Buechler U, De Roche R, Jupiter J. Clinical results of tension band fixation of avulsion fractures of the hand. J Hand Surg Am. 1994;1: ) Damron TA, Engber WD, Lange RH. Biomechanical analysis of mallet finger fractures fixation technique. J Hand Surg Am. 1993;18:

05-01-문은선

05-01-문은선 대한수부외과학회지제 13 권제 1 호 The Journal of the Korean Society for Surgery of the Hand VOLUME 13, NUMBER 1, March 2008 전남대학교의과대학정형외과학교실, 광주상무병원정형외과 1 문은선 박용철 김명선 김종석 1 The Results of Extension Block Technique