10-14-조재호

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1 대한수부외과학회지제 13 권제 3 호 The Journal of the Korean Society for Surgery of the Hand VOLUME 13, NUMBER 3, September 2008 아주대학교의과대학정형외과학교실 Surgical Treatment of Transolecranon Fracture-Subluxation of the Elbow Jae Ho Cho, M.D., Joon Yong Kim, M.D., Dong-Hyun Lee, M.D., Kyeong-Jin Han, M.D. Department of Orthopaedic Surgery, Ajou University School of Medicine, Suwon, Korea Purpose: The present study is to document author s results of the operative management of transolecranon fracture-subluxation of the elbow. Materials and Methods: From 2000 to 2006, 18 cases of transolecranon fracture-subluxation of the elbow were reviewed retrospectively. Anterior subluxations were 11 cases and posterior subluxations were 7 cases. Average follow-up was 18.5 months (13 28 months). 13 patients were men and 5 were women. All 28 factures were fixed with an AO reconstruction plate and screws and approached through a midline longitudinal incision. Functional outcome was assessed with Mayo Elbow Performance Score. Results: Overall outcome was rated as excellent in six, good in five of the eleven patients with anterior transolecranon fracture-subluxation, and excellent in three, good in one, fair in two, poor in one of the seven patients with posterior transolecranon fracture-subluxation. Postoperative complications were developed in three patients. In one of them, heterotrophic ossification was showed at radiographic examination and ulnar nerve compression was occurred in two cases. 통신저자 : 한경진경기도수원시원천동산5 아주대학교의과대학정형외과학교실 TEL: , FAX: kjhan@ajou.ac.kr Conclusion: We experienced 18 cases of the transolecranon fracture-subluxation. As the other pattern of the fracture around joint, the accurate anatomic reduction of the ulnar fracture, firm fixation and early ROM exercise is the key to optimal treatment of the transolecranon fracture-subluxation. Key Words: Elbow fracture, Transolecranon fracturesubluxation 서 론 주관절의횡주두골절-탈구가 Biga and Thomine 1 에의해처음보고된후전방몬테지아병변 (Monteggia Bado type I) 과구분되어분류되기시작하였다. 주관절의횡주두골절-탈구는주관절이중간정도의굴곡상태에서주두의배부에직접적인고에너지의외력이가해진경우에발생하며 2,3 횡주두골절로인한활차절흔의관절내골절및전완부의원위상완골에대한전방탈구를의미한다 1,4 (Fig. 1). 전방몬테지아병변은근위척골의골절과함께요골두의전방탈구로근위요척관절의해리가있으나 5 횡주두골절-탈구는근위요척관절은손상되지않은골성손상이주된병변이다 2,3,4,6,7. 주관절의횡주두골절-탈구에서탈구란용어는관절연골면의접촉이없는상태를뜻하므로부적절하며아탈구라고표현하는것이더정확한기술이라생각된다. 또한이전의여러연구에서주관절의횡주두골절과동반된전방혹은후방아탈구로세분하여분류한기술이많지않아 8 정확한분류및용어의사용이필요하다. 횡주두골절-전방아탈구는기존의횡주두골절-탈구와기전이유사하고, 횡주두골절-후방아탈구는후방몬테지아병변 (Monteggia Bado type II) 5 과달리근위요척관절의해리가없는주두의횡골절을통한활차절흔의관절내골절과동반된요골두의 200

$Fig. 1. (A) Lateral radiograph of anterior transolecranon fracture-subluxation. (B) Lateral radiograph of the same patient following fixation with a contoured reconstruction plate.$

2 Fig. 1. (A) Lateral radiograph of anterior transolecranon fracture-subluxation. (B) Lateral radiograph of the same patient following fixation with a contoured reconstruction plate. Normal contour of trochlear notch has been restored. Table 1. Mayo Elbow Performance Score. Function Points Definition Pain 45 None(45) Mild (30) Moderate (15) Severe (15) Motion 20 >100(20) 50~100(15) <50(5) Stability 10 Stable (10) Moderate Instability (5) Unstable (0) Function 25 Comb hair (5) Feed (5) Hygiene (5) Shirt (5) Shoe (5) Total 100 Excellent >90 Good 75~89 Fair 60~84 Poor<60 연구대상및방법 2000년부터 2006년까지횡주두골절-아탈구로수술적치료를받고 1년이상추시된 18예를대상으로후향적으로조사하였다. 이중 11예는전방아탈구였고, 7예는후방아탈구였다. 후방아탈구 2예에서요골두골절이동반되었고, 6예에서는구상돌기골절이동반되었다. 동측내측부인대손상이전방과후방아탈구각 1예에서관찰되었다. 성별은남자 13예, 여자 5예였고, 연령은 26세에서 62세로평균 43.1 세였다. 평균추시기간은 18.5 개월로 13개월에서 28개월사이였다. 수술방법은모두후방정중종절개도달법을이용한후방금속판고정술을시행하였다 (Fig. 1, 2). 내고정기구로는 AO 재건금속판 (reconstruction plate) 및나사고정을이용하였다. 필요에따라인장대강선, Steinmann핀을추가로이용하여고정하였다. 수술후 2주이내에모든환자에서능동적주관절관절운동을시행하였다. 기능평가는 Mayo Elbow Performance Score 9 를이용하였다 (Table 1). 결과 후방아탈구이다 (Fig. 2). 이에저자들은주관절횡주두골절및전방혹은후방아탈구로분류하여각 11예와 7예의수술적치료결과에대해보고하고자한다. 18예모든환자에서근위척골의관절면복원과견고한내고정이이루어졌으며골유합을얻을수있었다 (Fig. 1, 2). 수술후합병증으로이소골형성이 1예에서, 척골신경압박증이 2예에서발생하였다. 주관절의육안적인변형이나불안정성을보이는환자는없었다. 최종추시에시행한이학적검사에서전방아탈 201

$구가동반된 11예의횡주두골절에서는주관절평균굴곡은 132 도 (120 140 도 ) 였고평균주관절굴곡구 축은 14도 (5 20도) 였다. 후방아탈구가동반된 7예의횡주두골절에서는주관절평균굴곡은 134 도 (120 Fig. 2. (A) Lateral radiograph of posterior transolecranon fracture-subluxation with radial head fracture.$

3 구가동반된 11예의횡주두골절에서는주관절평균굴곡은 132 도 ( 도 ) 였고평균주관절굴곡구 축은 14도 (5 20도) 였다. 후방아탈구가동반된 7예의횡주두골절에서는주관절평균굴곡은 134 도 (120 Fig. 2. (A) Lateral radiograph of posterior transolecranon fracture-subluxation with radial head fracture. (B) Anteroposterior radiograph of the same patient following fixation of radial head with two mini-screws. (C) Lateral radiograph of the same patient following fixation with a contoured reconstruction plate. Table 2. Functional assessment of the anterior transolecranon fracture-subluxation 성별 / 나이추시 ( 개월 ) Pain Motion Stability Function Total 01 여 /42 우 (20) G 02 남 /58 좌 (15) G 03 남 /48 우 (20) E 04 남 /55 우 (20) E 05 남 /48 우 (20) G 06 남 /50 좌 (20) E 07 남 /47 좌 (20) G 08 남 /26 우 (20) E 09 남 /40 좌 (20) E 10 여 /35 우 (20) E 11 남 /37 우 (20) G 202

4 Table 3. Functional assessment of the posterior transolecranon fracture-subluxation. 성별 / 나이추시 ( 개월 ) Pain Motion Stability Function Total 1 여 /43 좌 (20) F 2 남 /33 우 (15) E 3 여 /32 우 (20) F 4 남 /62 좌 (20) P 5 여 /34 좌 (20) E 6 남 /41 좌 (20) E 7 남 /44 우 (20) G 140 도 ) 였고평균주관절굴곡구축은 17도 (5 35도) 였다 Mayo Elbow Performance Score 9 를이용한기능적평가결과는전방아탈구가동반된 11예의횡주두골절에서 6예는우수, 5예는양호였다 (Table 2). 후방아탈구가동반된 7예중 3예는우수, 1예는양호, 2예는보통, 1예는불량한결과를보였다 (Table 3). 고찰 주관절의횡주두골절-전방아탈구는흔히전방몬테지아병변으로잘못진단되어아직까지정확한유병률을알지못한다. 전방몬테지아병변에서보이는윤상인대의손상및근위요척관절의해리가없는골성병변이횡주두골절-전방아탈구의주된병변이라는점을인지하고진단시유의해야할것이다. 주관절의횡주두골절-후방아탈구역시후방몬테지아병변과는달리주두의횡골절을통한활차내관절내골절과동반된전완부의후방아탈구이다. 다른주관절관절내골절과마찬가지로관절면의정확한해부학적정복과활차용적의유지및견고한내고정을통한주관절의조기주관절운동이기능적예후에중요하다 10. 내고정방법에있어 Ring등 3,11 은 LC-DCP 3.5 mm를추천하였고 1/3 금속판은얇아서견고하지못해사용하지않을것을권고하였다. 인장대강선은단순주두골절시에적절하다고하였다 3. Boyer등 12 도 3.5 mm의재건금속판이나 LC-DCP사용을권고하였고 1/3 금속판은얇아서금속파단의위험이있어골절이매우근위부인경우에한해제한적으로사용해야한다고하였다. 최등 6 에의한 13예의수술결과에서는금속판고정술이인장대강선보다좋은결과를보인다고하였다. 저자들은 AO 재건금속판과나사고정을이용하여견고한내고정을하였고, 모든예에서수술후 2주이내에조기운동이가능하였으며최종추시에서골절유합을얻을수있었다. 횡주두골절-후방아탈구의경우결과가좋지않은 경우가있는데이는요골두골절이나구상돌기골절이동반되는경우가많은것이그이유의하나로추정된다. 이는후방몬테지아병변에서전방몬테지아병변보다동반골절이더흔하고예후가좋지않은것과유사한소견으로 13 동반골절이있으면재활에더어려움이있어그결과가나쁜것으로생각된다. 또한주관절의강직은전방연부조직손상정도 1 및술후관절운동제한기간이길수록 14 기능적평가결과가나쁜것으로생각된다. 횡주두골절-탈구에서큰절편의구상돌기골절이동반시만성적주관절불안정과외상후관절증과연관이있으나 15,16,17,18 해부학적정복및고정이잘된경우반드시나쁜기능적결과를보이지는않는다고하였으며 3 이연구에서는구상돌기동반골절이후방몬테지아병변의경우와마찬가지로예후에나쁜영향을끼치는것으로생각된다. 주두골절의분쇄정도에비해측부인대손상이드물고외상후관절염의발생빈도도낮은것이횡주두골절-아탈구의특징으로 2,3 이연구에서는전방및후방아탈구각 1예에서내측측부인대손상이동반되었고외상후관절염은관찰되지않았으나보다장기간의추시가요할것으로보인다. 수술전에는주관절불안정에대한이학적검사를시행하기어려우므로수술장에서내고정을시행한다음주관절불안정이있는지를반드시확인하여야하고수술이필요한인대파열이동반된경우에는이를골절과함께동시에교정해주는것이좋을것으로생각된다. 결론 주관절의횡주두골절-아탈구는다른관절주위골절과마찬가지로관절면의정확한해부학적정복과견고한내고정및조기관절운동이주관절의기능적예후에중요하다. 본저자들은 18예의주관절횡주두골절-아탈구의수술적치료를경험하여그결과를보고하는바이다. 203

5 참고문헌 01) Biga N, Thomine JM. La luxation trans-olecranienne du coude. Rev Chir Orthop Reparatrice Appar Mot. 1974;60: ) Mouhsine E, Akiki A, Castagna A, Cikes A, Wettstein M, Borens O et al. Transolecranon anterior fracture dislocation. J Shoulder Elbow Surg. 2007;16: ) Ring, David, Jupiter, Jesse B, Sanders, Roy W et al. Transolecranon Fracture-Dislocation of the Elbow. J Orthop Trauma. 1997;11: ) Kang YS, Lee HJ, Han JN, Kim KH. Treatment of transolecranon fracture-dislocation of the elbow. J Korean Fracture Soc. 2001;14:No1. 05) Bado JL. The Monteggia lesion. Clin Orthop Relat Res. 1967; ) Choy WS, Park YB, Lee KW, Kim HJ, Kim HY, An JH et al. Functional Results of Olecranon Fracture-Dislocation, According to the Methods of Internal Fixation. J Korean Fracture Soc. 2000;13:No2. 07) Mortazavi S, Asadollahi S, Tahririan M. Functional outcome following treatment of transolecranon fracture-dislocation of the elbow. Injury. 2006;37: ) Lindenhovius AL, Brouwer KM, Doornberg JN, Ring DC, Kloen P. Long-term outcome of operatively treated fracture-dislocations of the olecranon. J Orthop Trauma. 2008;22: ) Morrey BF, An KN, Chao EYS. In: Morrey BF, editor. The elbow and its disorders. 3rd ed. Philadelphia: Saunders;2000. p ) Cabanela ME, Morrey BF. Fractures of the olecranon. In: Morrey BF, editor. The elbow and its disorders. 3rd ed. Philadelphia: Saunders;2000. p ) Ring D, Jupiter JB, Sanders RW, Mast J, Simpson NS. Fracture-dislocation of the elbow. J Bone Joint Surg Am. 1998;80: ) Boyer MI, Galatz LM, Borrelli J Jr, Axerold TS, Ricci WM. Intraarticular fractures of the upper extremity: new concepts in surgical treatment. Instr Course Lect ; ) Ring D, Jupiter JB, Simpson NS. Monteggia Fractures in Adult. J Bone Joint Surg Am. 1998;80: ) Wilppula E, Bakalim G. Fractures of the olecranon 3. Fractures complicated by forward dislocation of the forearm. Ann Chir Gynaecol Suppl. 1971;60: ) Bracq H. Fracture de l apophyse corono1 de. Rev Chir Orthop Reparatrice Appar Mot. 1987;73: ) Copf F, Holz U, Schauwecker HH. Biomechanische probleme bei ellenbogenluxationen mit frakturen am processus coronoideus und radiusköpfchen. Langenbecks Arch Surg. 1980;350: ) Morrey BF. Current concepts in the treatment of fractures of the radial head, the olecranon, and the coronoid. J Bone Joint Surg Am. 1995;77: ) Regan W, Morrey BF. Fractures of the coronoid process of the ulna. J Bone Joint Surg Am. 1998;71:

The Journal of the Korean Society of Fractures Vol.11, No.3, July, 1998 Department of Orthopaedic Surgery, College of Medicine Chungnam National Unive

The Journal of the Korean Society of Fractures Vol11, No3, July, 1998 Department of Orthopaedic Surgery, College of Medicine Chungnam National University Hospital, Taejon, Korea and Taejon Sungshim General