01-03채수욱

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1 REVIEW 대한족부족관절학회지제 17 권제 3 호 2013 J Korean Foot Ankle Soc. Vol. 17. No. 3. pp , 2013 원광대학교의과대학정형외과학교실 Acute Compartment Syndrome of the Lower Leg and Foot Soo Uk Chae, M.D. Department of Orthopedic Surgery, School of Medicine, Wonkwang University, Iksan, Korea =Abstract= Acute compartment syndrome of the lower leg and foot is a surgical emergency. The clinical symptoms is an important clue to diagnose compartment syndrome. In cases of ambiguous diagnosis, unconscious patients and children additionally need a intracompartmental pressure measuring. Immediate fasciotomy should be performed when clinical signs are obvious or when delta pressure is less than 30 mmhg or intracompartmental pressure is greater than 30 mmhg. Fasciotomy of the lower leg can be performed either by one lateral single incision or double incision, which of the foot mainly has a dorsal or medial incision. A delayed in diagnosis that leads to a delay in treatment can result in devastating disability. Acute compartment syndrome of the lower leg and foot is a relative rare but serious complication of which a surgeon should be aware. Key Words: Lower leg, Foot, Acute compartment syndrome 서 론 급성구획증후군은폐쇄된공간인구획내에서골절이나외상에의한연부조직의손상에의해압력이증가하여혈액순환의장애로통증과부종이발생하고, 신경과근육의허혈성구축으로기능소실이초래되며심하면사망에이를수있는응급을요하는질환이다. 조기에정확하고신속한진단과즉각적인감압을위한 Received: July 5, 2013 Revised: August 11, 2013 Accepted: August 20, 2013 Corresponding Author: Soo Uk Chae Department of Orthopedic Surgery, School of Medicine, Wonkwang University, 344-2, Shinyong-dong, Iksan, , Korea Tel: Fax: oschae68@hanmail.net 근막절개술이이루어지지않을경우신체기능소실로심각한장애가남게된다. 1-4) 급성구획증후군의원인은대부분골절, 연부조직손상, 압궤증후군 (crush syndrome) 등구획내내용물이증가하여발생하거나화상, 견인및석고고정등의구획의용적이감소하면서발생한다 (Table 1). 5) 특히개방성골절시에도폐쇄성골절과비교하여구획압의차이가없다고보고하고있다. 6) 전체급성구획증후군중약 40% 가경골간부골절후발생하며, 경골간부골절환자의약 2% 에서구획증후군이발생한다. 대부분이 35세미만의젊은연령층에서호발한다. 7,8) 이외에내과적으로동반질환이많은고령환자나, 최근복용이늘고있는항응고제와항혈전제사용도구획증후군의하나의원인이될수있다. 족부의구획증후군은한보고에의하면오토바이사고로인한족부손상중약

2 6% 에서발생하며주로압궤손상과중족골골절및족근중족관절의골절-탈구에서많이발생된다. 9) 본론 1. 해부학 (Anatomy) 하퇴부는전방, 외측, 표재후방, 심부후방의 4개의구획으로이루어져있으며, 각구획에는근육, 혈관과신경이주행한다. 전방과외측구획에는심부비골신경이심부후방구획에는경골신경이지나가므로손상시신경증상이나타날수있다 (Table 2). 족부의구획은초기연구에서내측, 외측, 중앙, 골간의 4개의구획으로분류하였으나, 10) 1990년에종골골절후합병증으로갈퀴족지변형이발생되는후족부의종골구획을포함하여 9개의구획으로분류한다. 11) 종골구획을포함하여족부전장을따라이루어지는내측, 외측, 천부구획과전족부의 4개의골간근구획과 1 개의내전근구획으로이루어져있다 (Table 3). 이중 종골구획에는족저방형근 (quadrates plantae) 과외측족저신경 혈관이있고, 천부구획에는단족지굴근이있으며횡격막 (transverse septum) 에의해종골구획과구분된다. 종골구획이하퇴부의심부후방구획과도연결되어있어압궤손상및경골과종골골절시이두구획에서구획증후군이발생할수있기에주의를요한다. 12,13) 2. 병태생리 (Pathophysiology) 구획증후군의병태생리는정확하지않지만, 혈관손상과골절에의한출혈과모세혈관의투과성의증가로부종이발생하여구획내압력의증가를초래하게되고, 모세혈관의혈류와조직내산소분압이감소하게된다. 결국대사결핍으로근육은허혈성변화와괴사가일어난다. 혈류가감소되는병태생리이론으로정맥압증가와모세혈관저항으로동 정맥사이에압력차이로모세혈관의혈류가감소된다는이론 (arterio-venous gradient theory) 과구획증후군에대해감압후재관 Table 1. Causes of compartment syndrome 5) Type of syndrome Decreased compartment size Increased compartment contents Cause Constriction by casts, dressings, garments Compression by rubble or coma Excessive traction to fracture Surgical closure of fascial defects Thermal injuries such as third-degree burns Iatrogenic injection or infusion of Hemorrhage Hereditary bleeding disorders such as hemophilia Anticoagulant therapy Trauma from fractures, osteotomies, vessel laceration Edema Postischemic Arterial injury Thrombosis Embolization Limb reimplantation Arterial spasm Tourniquet Increased capillary permeability pressure Reperfusion after Trauma Burns and frostbite

3 류동안혈관이재형성되는과정에서혈전발생과허혈성근육에서분비되는독성물질에의해다시부종과구획의압력이증가한다는이론이있다 (ischemiareperfusion syndrome) ) 허혈시작후 30분이경과하면신경의기능이상이나타나며, 허혈후 12시간부터 24시간내에비가역적으로신경손상이일어난다. 근육의이상은허혈후 2 시간에서 4시간사이에나타나고, 4시간에서 12시간후에비가역적근육손상이발생된다. 1) 이결과로구획증후군의초기에신경이상증상이나타난다. 구획증후군발생후 12시간이되면조직의비가역적손상으로인하여신경손상, 근육괴사, 허혈성구축과염증및감염이발생되며골절의지연유합이발생하기도한다. 18,19) 또한손상된근육에의해미오글로빈 (myoglobin) 이유리되어급성신부전증과산성-고칼륨혈증 (acidic-hyperkalemic blood) 에의해심장부정맥등이발생하여사망에이르기도한다. 20) 3. 진단 (Diagnosis) 구획증후군후합병증과후유증의치료는어렵고영구적인장애와법적문제가항상공존한다. 이에구획증후군의조기진단이야말로가장중요하며즉각적인감압근막절개술이필요하다. 임상증상이진단에있어중요한단서가되며진단이모호하거나의식이없는환자나소아환자에서는구획내압측정이필수적이다. Table 2. Compartments of the lower leg Structure Compartments Anterior Lateral Superficial Posterior Deep Posterior Muscles Tibialis anterior muscle Peroneus longus Gastrocnemius Tibialis posterior Extensor hallucis longus Peroneus brevis Soleus Flexor hallucis longus Extensor digitorum longus Plantaris Flexor digitorum longus Vessels Anterior tibial artery Peroneal artery Anterior tibial veins Peroneal vein Posterior tibial artery Posterior tibial vein Nerve Deep peroneal nerve Common peroneal nerve Tibial nerve Table 3. Compartment of the foot Compartments Muscles Vessels Nerves Medial Flexor hallucis brevis Abductor hallucis Lateral Abductor digiti quinti Flexor digiti minimi Superficial Flexor digitorum brevis Medial plantar nerve(?) Lumbricals Flexor digitorum longus tendons Interosseus(x4) Interossei Adductor Adductor Calcaneal Quadratus plantae Posterior tibial artery Posterior tibial nerve Posterior tibial vein Lateral plantar artery Lateral plantar nerve Lateral plantar vein Medial plantar nerve (?)

4 1) 임상증상 (Clinical presentation) 전통적인 4 Ps 징후 { 동통 (pain), 감각이상 (paresthesia), 마비 (paresis), 신전시통증 (pain with stretch)} 에서무맥박 (pulselessness) 와창백 (pallor) 을더하여현재는구획증후군의 6 Ps 징후라명명한다. 21) 이중동통이가장중요한증상으로골절과연부조직의손상등의외상에의한직접적인동통도발생할수있고약물치료에의해동통이가려질수있으나 (masking), 동통의양상이바뀌거나증상정도가심해지고, 특히신전시통증이심해지면 ( 전방구획증후군에특이적 ) 신뢰성이있는징후가된다. 동통이신경손상과동반되면소실될수있고, 하지의심부후방구획이나족부에발생하는구획증후군에서는동통이미약할수있어위음성 (false negative) 이많다고알려져있다. 22) 감각이상의징후는구획증후군에서흔히관찰되며핀찌르기 (pinprick) 검사보다두점식별 (twopoint discrimination) 검사가더의미가있고, 이환된구획내의신경허혈의첫징후일수있다. 23) 그러나감각이상이나마비의증상은구획내혈류감소로허혈이상당히진행된후나타나는징후로구획증후군이어느정도진행되었음을보여주는징후이다. 말초맥박이나미세혈관순환은동맥손상이있으면소실되나급성구획증후군에서는마지막까지맥박이촉지될수있다. 다음의 4개주증상 1) 비특이적인심한증상 2) 구획부위촉진시긴장 (tension) 과동통 3) 근육신전시동통양성반응 4) 일정부위의마비가있을시급성구획증후군으로진단할수있다. 24) 또한구획증후군과동맥손상및신경손상을상기증상들의유 무로감별할수도있다. 2) 구획내압측정 (Intracompartment pressure testing) 구획증후군이의심되는임상증상이있는경우확진을위해구획내압을측정하는데보통정상구획내압은 0~10 mmhg이내이며, 전용압력계를이용하여측정한다. 흔히사용되는압력계는혈압계에튜브와연결된바늘을구획내근막을관통하여삽입하고 1~2 cc의식염수를이용하여측정하나 (hand-held needle manometer), 식염수를구획내에직접삽입하여야하고바늘내에피떡 (blood clot) 이나이물질이들어가는등단점이있으며, 구획의압력을지속적으로감시 (monitor) 하기에는어려움이있다. 이에 wick 또는 slit 카테터를이용하기도하고, 25,26) 최근에는탐침과탐촉자을이용하는방법이개발되어소개되고있다 (electronic transducer-tipped catheter system). 27) 하퇴부의경우전방구획에서주로측정하는데, 하퇴부심부후방구획과족부종골구획을포함하여의심되는모든구획에서각각따로측정하는것을권하고있다. 구획내압이확장기혈압보다높으면혈류가부족하여허혈이발생한다. 여러문헌에서구획내압이 30~50 mmhg이상이면모세혈관압력저하로근육내모세혈류장애가발생되며, 근막탄력성이저하되어팽창의한계에도달하게된다. 1-4,28) 확장기혈압에서구획내압을제한값 (delta pressure) 이 10~35 mmhg 이내이면허혈이발생한다고보고되고있다. 8,29) 구획내압이 30 mmhg이상인경우나확장기혈압보다 30 mmhg 낮을때근막절개술을시행해야한다. 구획내압이 30 mmhg이하인경우에외상및수술후최소 24시간동안임상징후의면밀한관찰과구획내압의지속적인감시 (monitoring) 가필요하며, 상처드레싱과석고고정을반드시열어놓거나제거하여야한다. 이와함께저혈압을예방하며하지를심장위치에유지하여하지의거상으로인해구획압이높아지는것을방지해야한다. 하지와족부의과도한견인 ( 하지후방구획압증가 ) 과압박을방지하는노력또한필요하다. 3) 진단검사 (Diagnostic tests) 급성구획증후군에서보조효소 (coenzyme) 나생물표지자 (biomarker) 등의검사실소견을진단에이용하려는시도는있으나특이적이지못해이용에는어려움이있다. 맥박산소측정 (pulse oximetry) 와초음파검사, 골스캔, 컴퓨터단층촬영을이용하여구획내구조물의변화를관찰할수있으며, 자기공명영상촬영을운동유발성만성구획증후군의진단에이용하나이들모두현재에는급성구획증후군의진단에는한계가있다. 22) 최근에조직내산소포화도의변화를비침습적인방법인근적외선분광법 (near-infrared spectroscopy) 을이용하여급성구획증후군진단에활용하려는시도들이있으나, 기준치가없으며자세의변화에따라검사치가달라지는단점이있어진단의활용에제한이있다. 30)

5 4. 치료 (Treatment) 급성구획증후군이진단이되면신속하게구획의감압을위해근막절개술을시행한다. 원칙적으로전신마취하에철저한소독후시행하게되는데정형외과적응급상황으로침상에서국소마취하에근막절개술을시행하여염증소견없이좋은결과를보인임상보고도있다. 31) 감압근막절개술의피부절개 (dermotomy) 는이환된구획의전길이 ( 최소 16 cm이상절개 ) 에완전하게시행하여야하며, 피하절개나제한된방법의절개술은권유되지않는다. 32) 또한족관절과족지를움직여보면서전체의근육들을모두관찰하는것도중요하다. 골절이동반되는경우에는피부의상태를확인하면서골절부위나고정물의노출이되지않게근막절개술을시행한다. 경골골절의경우골절에대한연부조직의지지기능감소를예방하기위해이중절개 (double incision approach) 보다는단일외측절개 (single incision approach) 를통해 4개의모든구획을감압을시행하고 (Fig. 1A-D), 33) 종골골절시종골내측절개를통해감압한다. 그러나하지의 4개의구획을모두감압시키기위해서는내 외측의이중절개술이빠르고안전한방법으로권유된다. 34) 전족부의경우내측의한개의절개를이용하거나발등쪽에서 2개의절개를하여감압하는방법이있다. 10) 그러나종골골절이있고발전체에부종이심한경우에는종골구획을포함하여족부전체의구획을감압하여야한다. 근막절개술시근섬유의손상을예방하기위해가위보다는외과용나이프를이용하여시행하는것이좋다. 1) 하지 (Lower leg) 흔히사용되고있는이중절개술은가장많이이환되는전방및외측구획의감압을위한전외측 (anterolateral) 절개술과표재후방과두번째로흔히이환되는심부후방구획감압을위한후내측 (posteromedial) 절개술이다. 전외측절개는전방경골능선과비골사이에비골두나족관절외과에서 5 cm까지연장하여측면절개하는방법으로각구획의근막을절개시전방근육사이막 (intermuscular septum) 을확인하여개방해야하며, 외측구획절개감압시에는천비골신경의손상을주의해야한다. 후내측절개는경골의후내측면후방 2 cm지점에서절개 하는방법으로표재후방근육군 (muscle bulk) 은하지근위부에서심부후방근육군은원위부에서주로감압을하며특히, 심부후방구획의근위부의완전한감압을위해가자미 (soleus) 근기시부의감압이필요하다. 후내측절개시에는복재신경 정맥손상을주의해야한다. 34) 단일외측절개술은비골에평행하게절개하는방법으로하나의피부절개를통해 4개의구획을모두감압하는방법이다. 단일외측에서후방구획의절개술은비골후방으로접근하여표재후방근막절개후가자미근과비골근사이로후방근육사이막을절개하여심부후방구획에도달한다. 심부후방구획의절개시비골혈관과후방경골혈관 신경손상을주의한다 (Fig. 2). 3) 2) 족부 (Foot) 전족부의근막절개술은발등쪽에서 2개의피부절개로감압하는방법 (dorsal approach) 와내측의한개의피부절개로감압하는방법이있다. 흔히이용되는 2개의발등절개술의내측절개는제 2중족골내측에서외측절개선은제 4중족골외측에서피부절개하여골간근구획은중족골사이에서족무지내전근구획은골간근과제 2중족골사이에서감압한다. 중족골사이로굽은지혈겸자를이용하여중앙, 내측및외측구획을감압한다. 족근중족관절의골절및탈구에대한치료도동일절개선으로이용할수있는장점이있으나절개선사이의피부괴사와종골구획에대한감압은어렵다는단점이있다. 내측의한개의절개술은제 1 중족골과족무지외전근사이로절개하여감압하는방법이다 (Fig. 3). 1,3) 종골구획을감압하는방법으로후족부의내측에피부를절개하는방법 (medial plantar approach) 이있다 (Fig. 4). 이방법은원위부로피부절개를연장하여전족부구획을감압하거나, 후족부내측절개와별도로 2 개의발등절개술을추가하여족부의모든구획을감압하기도한다. 절개방법은족무지외전근기시부 ( 족저부에서 3 cm, 발뒤꿈치후면에서 4 cm 지점 ) 부터족저부에평행하게약 6 cm정도피부절개를시행하여구획을감압하며, 내 외측족저신경혈관손상을주의하여야한다. 먼저내측구획을절개한후천부구획을절개하여감압한다. 단족지굴근 (flexor digitorum brevis) 을하방으로견인한후외측구획을확인하여

6 감압을시행한다. 11) 이외에족저절개 (plantar approach) 와외측절개 (lateral approach) 방법도소개되고있으나많이사용되고있지않다. 3) 창상봉합 (Wound closure) 근막절개후일차적으로봉합을하면다시구획압이 증가할수있기에절개부위를약 5~7일정도경과후지연봉합을시행하는데, 최고점의부종이감소되면근육의활성도를평가하여죽은조직을제거 (debridement) 하고염증정도를관찰하여상황에맞게봉합하여야한다. 직접봉합이불가능한경우피부이식술 (split thickness skin grafting) 을하기도하지만 (Fig. 1E), 피부의긴장없이접근봉합 (reapproximation) 을시행하 A B C D G E F H Figure 1. A patient with a mid-shaft tibia fracture and a segmental fibular fracture in right leg, and a proximal fibular fracture in left leg (A, B) showed severe swelling and multiple bullae formation of right leg compared to the left leg. (C, D) Single lateral fasciotomy was performed with intramedullary nailing. (E) Fasciotomy wound was covered with split thickness skin graft. At post-operative 7 months, (F) the fracture site shows callus formation, (G, H) and claw toe deformity correction by flexor tenotomy of the tendinous interconnection from the flexor hallucis longus (FHL) tendon to the flexor digitorum longus tendon and FHL at the master knot of Henry

7 거나피부봉합기 (staples) 와혈관루프 (vessel loops) 또한인공피부 (artificial skin) 을이용하여순차적으로상처를봉합하기도한다 (dermatotraction). 최근에진공흡입창상기기 (vacuum-assisted dressing system) 을이용하여창상치료에좋은결과들이보고되고있다. 35) 5. 합병증 (Complication) 급성구획증후군의진단이지연되어적절한감압술이이루어지지않을경우구획내혈액순환의제한으로신경및근육과인대의손상을초래하게된다. 신경압박손상특히, 비골신경손상이근육손상보다먼저일어나게되며, 근육과인대의반흔 (scar) 형성과주 위조직과유착으로길이단축및운동제한이발생되어인접관절의운동감소와구축을초래하게된다 (Fig. 1F-H). 신경손상으로인하여만성통증, 감각저하와운동제한등이발생한다. 족부족관절의변형은하지구획에서의외재적원인과족부구획에의한내재적인원인으로나누어지며, 첨족 (equinus), 내반첨족 (equinovarus), 요족 (cavus) 변형과칼퀴족 (claw toe) 및망치족 (hammer toe) 이많이발생된다. 36) 외재적원인에의한족부변형은주로경골골절후발생하는것으로심부후방구획내의후경골근과경골신경손상으로거주상관절의아탈구가초래되어요족변형이발생하며, 천부후방구획손상으로첨족이나내반첨족변형이발생한다. 내반변형은비복근과후경골 A B Figure 2. Schematic drawing of anatomical section view of the lower leg. (A) single lateral approach. (B) double approach. (A: anterior compartment, L: lateral compartment, SP: superficial posterior compartment, DP: deep posterior compartment) A B Figure 3. Schematic drawing of anatomical section view of the foot. (A) dorsal approach use two longitudinal incisions. (B) medial plantar approach. (M: medial compartment, A: adductor compartment, L: lateral compartment, S: superficial compartment, MT: metatarsal)

8 근의단축으로, 족지변형은신전, 굴곡근의단축에의해발생하게된다. 내재적원인에의한족부변형은골간근과충양근 (lumbrical muscles) 손상으로발생하게된다. 이중족무지굴근이가장많이손상이되며후경골근과장족지굴근손상이그다음으로많으나, 비복근과가자미근의손상은흔하지않다 ) 변형들의치료목적은통증소실과족저보행 (plantigrade foot) 으로삶의질을높이는것이다. 경도의변형은먼저보조기나신발교정으로치료를시행하며교정이어려운경우에는수술적치료를시행한다. 수술적치료는먼저반흔조직제거와연부조직에대한수술및골에대한교정수술을병행하는것이다. 결 론 이드물지않게발생할수있기에외상후나수술후면밀한증상관찰로빠른진단이필요하다. 특히, 다발성손상으로의식이없 Figure 4. Schematic drawing of anatomical section view of the hindfoot. The plantar medial approach allow acess to the calcaneal compartment. (C*: compartment) 는환자나소아환자에서구획내압을측정하여구획내압이 30 mmhg이상인경우나이완기혈압보다 30 mmhg 낮은경우에는응급으로감압근막절개술이필요한상황이다. 적절한근막절개술의치료가이루어지지않게되면피부와연부조직손상, 신경손상및근육의기능소실로변형이발생되어치명적인장애가초래되기에질환의특성에대한충분한숙지가중요하다고하겠다. REFERENCES 01. Fulkerson E, Razi A, Tejwani N. Review: acute compartment syndrome of the foot. Foot Ankle Int. 2003;24: Kirsten GB, Elliott, Alan J, Johnstone. Review article: Diagnosing acute compartment syndrome. J Bone Joint Surg Br. 2003;85: Frink M, Hildebrand F, Krettek C, Brand J, Hankemeier S. Compartment syndrome of the lower leg and foot. Clin Orthop Relat Res. 2010;468: Oh CW, Lee HJ. Acute compartment syndrome after trauma. J Korean Fract Soc. 2010;23: Tollens T, Janzing H, Broos P. The pathophysiology of the acute compartment syndrome. Acta Chir Belg. 1998;98: McQueen MM, Christie J, Court-Brown CM. Compartment pressures after intramedullary nailing of the tibia. J Bone Joint Surg Br. 1990;72: McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is at risk? J Bone Joint Surg Br. 2000;82: McQueen MM, Christie J, Court-Brown CM. Acute compartment syndrome in tibial diaphyseal fractures. J Bone Joint Surg Br. 1996;78: Jeffers RF, Tan HB, Nicolopoulos C, Kamath R, Giannoudis PV. Prevalence and patterns of foot injuries following motorcycle trauma. J Orthop Trauma. 2004;18: Myerson MS. Experimental decompression of the fascial compartments of the foot--the basis for fasciotomy in acute compartment syndromes. Foot Ankle. 1988;8: Manoli A 2nd, Weber TG. Fasciotomy of the foot: an anatomical study with special reference to release of the calcaneal compartment. Foot Ankle. 1990;10:

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untitled 대한골절학회지제 23 권, 제 4 호, 2010년 10월 Journal of the Korean Fracture Society Vol. 23, No. 4, October, 2010 골절학회심포지엄종설 외상후발생하는급성구획증후군 (Acute Compartment Syndrome after Trauma) 오창욱ㆍ이현주 경북대학교의과대학정형외과학교실 서 급성구획증후군