08-05 이세원(국)

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1 CSE REPORT Print ISSN Online ISSN Dyspareunia Caused by Pelvis Malunion Se-Won Lee, MD, Kwang-Cheon Choi, MD, Man-Soo Kim, MD, Weon-Yoo Kim, MD, PhD Department of Orthopedic Surgery, Daejeon St. Mary s Hospital, The Catholic University of Korea, College of Medicine, Daejeon, Korea In unstable pelvic ring injury, if there is damage to both the anterior and posterior, both anterior and posterior fixation will be needed in order to stabilze the pelvic ring. female patient complained of dyspareunia due to malunion and additional bone bridge at the inferior ramus of the pelvis. She should have undergone both anterior and posterior fixation, but had undergone anterior fixation only. We report on a patient who was treated successfully with resection of additional bone bridge, scar tissue and adhesive band around the vagina. Key Words: Pelvic ring injury, Pelvis fracture, Sexual dysfunction 골반환손상은 10,000 명당 명의빈도로 1) 비교적드문손상으로과거에는대부분비수술적방법으로치료하였으나고정방법의발달과생역학에대한이해의발달로보다적극적인고정치료를시행하는것으로발전하였다 2). 골반환골절의고정방법에는외고정, 내고정이있으며, 특히불안정성골반환손상의경우골반환후방부의안정성여부를평가하여필요하다면후방부위를고정하는것이중요하다 3). 후방불안정성이존재하는환자에서전방고정술만을시행하면경우에따라고정물의실패나지속되는천장관절의통증이있을수있고, 이차적으로골반골의부정유합, 불유합, 하지단축, 영구적인신경장애등을나타낼수있다. Tile type C (O/OT type C) 골반환손상으로전방및후방고정술이동시에필요한환자에서전방고정술만을시행하여, 이로인한부정유합으로성교통이발생 Submitted: November 26, st revision: February 6, nd revision: February 28, 2014 Final acceptance: February 28, 2014 ddress reprint request to Weon-Yoo Kim, MD Department of Orthopedic Surgery, Daejeon St. Mary s Hospital, 64 Daeheung-ro, Jung-gu, Daejeon , Korea TEL: FX: weonkim@hotmail.com This is an Open ccess article distributed under the terms of the Creative Commons ttribution Non-Commercial License ( org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 한증례가있어문헌고찰과함께보고하고자한다. 증례보고 31 세여자환자가내원 6 년전보행중버스에부딪히는사고로발생한골반골골절로타의료기관에내원하였다. 그당시골반골골절외에도동반손상으로혈흉과골반내직장파열이진단되었다. 수상초기방사선및전산화단층촬영소견에서는우측천장관절에서천골과장골의골절및상방전위가보였고양측의치골가지에도골절이있어 Tile type C 에해당하는불안정성골반환손상이었다 (Fig. 1). 골반환후방부의완전손상으로인하여회전력과수직전단력이모두불안정한골절로전방및후방고정이필요한환자였으나외고정기를이용한전방고정술만을시행하였다 (Fig. 2). 동반손상에대해서는흉관삽관과직장절제술및결장루수술을시행하였다. 초기외고정을시행한이후술후방사선사진에서는장골의전위는관찰되지않았으며그당시상황은연부조직손상이심하여후방고정은실시하지못했다고하였다. 술후 2 개월에시행한단순방사선검사에서우측장골및천골골절편의상방전위가발생하였고 3 년간추시후다시내원하지않다가결혼을앞두고성관계시지속된성교통으로인한성교곤란을주소로해당의료기관에서문의후본원에전원되었다. 내원당시방사선및자기공명영상소견에서는골반환과치골결합부위의변형이있었고, 우측장골이 3 cm 상방전위된채로부정유합되어있었으며, 좌측치골아래가지의부정유합으로골가교가형성되어질외벽을압박하고있었다 (Fig. 3). Copyright c 2014 by Korean Hip Society 45

$() Initial pelvis anteroposterior radiograph, () comuputerized tomography image, (C) and 3-dimensional reconstructed image show both rami fracture and right sacro-iliac joint disruption (Tile type C$ [O/OT type C]). 키고서혜부를따라절개하여좌측하방치골지에도달하여질벽을압박하고있는골가교를확인한후절제하였고추가로산부인과의료진이질후외측벽의유착밴드및반흔조직을절제하였다 (Fig. 4, 5). 수술당시합병증은없었으며이후불편감을호소하지않았다. 고 찰 Fig. 2.

[O/OT type C]). 키고서혜부를따라절개하여좌측하방치골지에도달하여질벽을압박하고있는골가교를확인한후절제하였고추가로산부인과의료진이질후외측벽의유착밴드및반흔조직을절제하였다 (Fig. 4, 5). 수술당시합병증은없었으며이후불편감을호소하지않았다. 고 찰 Fig. 2.

2 C Fig. 1. () Initial pelvis anteroposterior radiograph, () comuputerized tomography image, (C) and 3-dimensional reconstructed image show both rami fracture and right sacro-iliac joint disruption (Tile type C [O/OT type C]). 키고서혜부를따라절개하여좌측하방치골지에도달하여질벽을압박하고있는골가교를확인한후절제하였고추가로산부인과의료진이질후외측벽의유착밴드및반흔조직을절제하였다 (Fig. 4, 5). 수술당시합병증은없었으며이후불편감을호소하지않았다. 고 찰 Fig. 2. On the situation of extensive soft tissue damage around sacrum, despite Tile type C (O/OT type C), posterior stabilization did not be performed, but the reduction and anterior stabilization were achieved by external fixator. 좌측하치골가지의골가교는우측장골의상방전위로인하여부가적으로생성된것으로판단되었다. 골가교가성교통의직접적원인인것으로진단하고이를제거하기위한수술을시행하였다. 환자를수술대에앙와위로위치시 불안정성골반환손상은대부분고에너지손상이며후복막부의혈관손상, 비뇨기계손상, 신경계의손상, 다발성골절등을흔히동반하고, 적절한치료가이루어지지않은경우사망률이 20% 까지이를수있다고보고되었다 4,5). 골반환손상의초기치료목적은역학적으로골반환을안정시켜출혈과통증을감소시키는것이고, 2 차적인목적은골반환의부정유합, 불유합을줄이고영구적인신경마비등의후유증을막는것이다. 적절한고정이이루어지지못하면천장관절의전위로인한통증, 골반환의불유합및부정유합으로인한골반의변형및하지단축등심각한휴유증을초래하게된다. Gänsslen 등 1) 은골반골골절의후유증으로인한성기능장애빈도를보고하였는데, 남성의경우 12% 에서발기부전을, 여성의경우 2% 에서성교통을호소한다고보고하였다. 외고정기를이용한전방고정술은골반환골절의치료에매우중요한역할을하고있으며, Riska 등 6) 은전방고정만으로도최종치료를할수있다고보고하였다. 하지만이후 Schweitzer 7) 은외고정장치가수직전단력에는불안정하기때문에추가적인견인이나골반환후방의고정이필요하다고하였다. 사체연구와임상연구를통해골반환후방의천장관절골 - 인대요소가골반환의안정성에중요한역할을하는것이밝혀져있으며, Kellam 등 8) 은불안정골반환의붕괴예후는천장관절정복의정확도와관련이있다고하였 46

Consequently, vaginal wall compressed by the protruded bony bridge is seen in axial image of T2 weighted magnetic resonance imaging. D C D Fig. 4.

3 Se-Won Lee et al. Dyspareunia Caused by Pelvis Malunion C Fig. 3. () fter 6 years of operation. Plain radiograph, () coronal image, (C) and axial image of computed tomography scan (D) show the superior migration of right ilium and the formation of bony bridge at left inferior ramus. Consequently, vaginal wall compressed by the protruded bony bridge is seen in axial image of T2 weighted magnetic resonance imaging. D C D Fig. 4. () Gross photo shows the incision line for inguinal approach. () The protruded bony bridge was exposed through inguinal approach. (C) Excised fragments which were consisted of the bony bridge. (D) The excision of constricting band formed by scar tissue was performed using trans-vaginal approach. 47

Fig. 5. Plain radiograph () and 3-dimensional computed tomography image () show the finding that the protruded bony bridge was excised. R: right, L: left, H: head, F: feet 다.

4 Fig. 5. Plain radiograph () and 3-dimensional computed tomography image () show the finding that the protruded bony bridge was excised. R: right, L: left, H: head, F: feet 다. 또한역학적연구에의하면편측또는양측불안정성손상시전방외고정만으로는견고한고정이불가능하므로후방내고정을병행하여시행하는것이가장견고하다고하였다 9). 2 차적합병증을막기위해초기수상형태에따라적절한고정방법을선택하여골반환을안정시켜야하고, 특히골반환후방부의불안정성을간과하지말고전방에외고정또는내고정을실시하고부가적으로후방에도내고정을시행하여골반골골절의치료목적을달성해야한다. 또한가임기여성의골반환치료에서는임신과출산문제에대해서도고려하여야하는데, Vallier 등 10) 은골반환골절환자에서해부학적정복이불충분할수록제왕절개출산비율이유의하게증가한다고하였고, 정상분만중분만곤란을겪어제왕절개출산으로전환한경우가있다고보고하였다. 따라서출산을앞둔가임기여성에서더욱더정확한해부학적정복을얻고골절의안정성을유지하는것이매우중요한일이라하겠다. REFERENCES 01.Gänsslen, Pohlemann T, Paul C, Lobenhoffer P, Tscherne H. Epidemiology of pelvic ring injuries. Injury. 1996;27 Suppl 1:S Simonian PT, Routt ML Jr. iomechanics of pelvic fixation. Orthop Clin North m. 1997;28: Dujardin FH, Roussignol X, Hossenbaccus M, Thomine JM. Experimental study of the sacroiliac joint micromotion in pelvic disruption. J Orthop Trauma. 2002;16: Papadopoulos IN, Kanakaris N, onovas S, et al. uditing 655 fatalities with pelvic fractures by autopsy as a basis to evaluate trauma care. J m Coll Surg. 2006;203: Matewski D, Szymkowiak E, ilinski P. nalysis of management of patients with multiple injuries of the locomotor system. Int Orthop. 2008;32: Riska E, von onsdorf H, Hakkinen S, Jaroma H, Kiviluoto O, Paavilainen T. External fixation of unstable pelvic fractures. Int Orthop. 1979;3: Schweitzer G. Open reduction and internal fixation of vertical shear pelvic fractures. J Trauma. 1987;27: Kellam JF, McMurtry RY, Paley D, Tile M. The unstable pelvic fracture. Operative treatment. Orthop Clin North m. 1987;18: erg EE, Chebuhar C, ell RM. Pelvic trauma imaging: a blinded comparison of computed tomography and roentgenograms. J Trauma. 1996;41: Vallier H, Cureton, Schubeck D. Pregnancy outcomes after pelvic ring injury. J Orthop Trauma. 2012; 26:

5 Se-Won Lee et al. Dyspareunia Caused by Pelvis Malunion 국문초록 골반골부정유합으로발생한성교통 이세원 최광천 김만수 김원유가톨릭대학교의과대학대전성모병원정형외과학교실 불안정성골반환손상은불안정성이전후방에함께존재하는경우에는전방고정과후방고정을함께사용하여안정시켜야한다. 전방과후방모두안정시켜야할불안정성골반환골절여성환자에서전방고정만을실시하여, 추시상골반골부정유합으로형성된골가교가질벽을기계적으로압박하여성교통을호소하였다. 저자들은골편과질내반흔조직및유착밴드를제거하여이를성공적으로치료한증례를경험하였기에문헌고찰과함께보고하고자한다. 색인단어 : 골반골손상, 골반골골절, 성기능부전 49

종골 부정 유합에 동반된 거주상 관절 아탈구의 치료 (1예 보고) 정복이 안된 상태로 치료 시에는 추후 지속적인 족부 동통의 원인이 되며, 이런 동통으로 인해 종골에 대해 구제술이나 2차적 재건술이 필요할 수도 있다. 2) 경종골 거주상 관절 탈구는 외국 문헌에 증례

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