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1 Archives of Hand and Microsurgery Arch Hand Microsurg 2018;23(3): pissn eissn Original Article 변형된경피적역행성골수강내 K- 강선고정법을이용한중수골간부및경부분쇄골절의치료결과 홍석우 1 ㆍ이영호 2 ㆍ김민범 2 ㆍ백구현 2 1 이대목동병원정형외과, 2 서울대학교병원정형외과 The Treatment Outcomes of the Metacarpal Shaft and Neck Comminuted Fractures Using Modified Percutaneous Retrograde Intramedullary Kirschner Wire Fixation Seok Woo Hong 1, Young Ho Lee 2, Min Bom Kim 2, Goo Hyun Baek 2 1 Department of Orthopedic Surgery, Ewha Womans University Mokdong Hospital, Seoul, Korea 2 Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea Purpose: The purpose of the present study was to verify the therapeutic efficiency of modified percutaneous retrograde intramedullary fixation using Kirschner wire in metacarpal shaft and neck comminuted fractures. Methods: A total of 17 cases in 15 patients with metacarpal shaft and neck comminuted fractures diagnosed by physical examination and imaging modalities were included. For radiologic evaluations, the changes of degree of metacarpal bone shortening and that of dorsal angulation of metacarpal bone between before and six months after surgery were measured. Clinical evaluations were assessed by the timing of clinical union and visual analog scale (VAS), total active range of motion (TAM) of metacarpophalangeal joint, and complications at six months postoperatively. Results: In all cases, union was achieved without additional treatment. The degree of the metacarpal bone shortening and the degree of dorsal angulation of metacarpal bone were improved significantly at six months after operation. The clinical bone union was completed average 6.49 weeks after surgery. The mean VAS was 1.35, and the mean TAM of metacarpophalangeal joint was at 6 months postoperatively. Complications including nonunion, malunion, and refracture were not observed during follow-up period. Conclusion: Modified percutaneous retrograde intramedullary fixation using Kirschner wire showed satisfactory treatment results in metacarpal shaft and neck comminuted fractures. Thus, this method could be recommended as one of treatment modalities for metacarpal shaft and neck comminuted fractures due to its easy procedures and low occurrence rate of associate complications. Key Words: Metacarpal neck, Metacarpal shaft, Comminuted fracture, Retrograde, Intramedullary nailing Received July 24, 2018, Revised August 10, 2018, Accepted August 10, 2018 Corresponding author: Young Ho Lee Department of Orthopedic Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea TEL: , FAX: , orthoyhl@snu.ac.kr Copyright c 2018 by Korean Society for Surgery of the Hand, Korean Society for Microsurgery, and Korean Society for Surgery of the Peripheral Nerve. All Rights reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 175

2 Archives of Hand and Microsurgery Vol. 23, No. 3, September 2018 서론 중수골골절은전체수부골절의약 30% 를차지하며그중 70% 이상이 20대에서 30대사이에발생하는것으로알려져있는데 1,2, 골절의발생위치에따라서골두, 경부, 간부, 기저부등으로나뉘고골절의형태에의하여횡형, 나선형, 사선형, 분쇄형등으로구분할수있다 3. 대부분의중수골골절은단독손상으로, 비교적안정하고전위가크지않아보존적치료만으로도치료결과가만족스럽다고알려져있다 4. 하지만불안정한형태의중수골골절에서는정확한해부학적정복을시행하지않을경우부정유합에의해가성갈퀴변형, 손가락겹침등의합병증발생가능성이높아대부분수술적치료를통한정복및견고한내고정을시행하게된다 5. 중수골골절의수술방법은골절의발생위치및형태, 그리고술자의선호도에따라다양하다. 대표적인방법으로는교차핀고정법 (crossed-pin fixation), 전향성혹은역행성골수강내고정법 (antegrade or retrograde intramedullary fixation), 금속판과나사를이용한고정법 (plate and screw fixation) 등이알려져있다 6. 최근역행성골수강내고정법중하나인변형된경피적역행성골 수강내 K-강선고정법 (modified percutaneous retrograde intramedullary Kirschner wire fixation) 을중수골간부및경부골절의치료에이용한연구들이국내외에서많이발표되어방사선학적및임상적으로좋은결과를보고하였다 이연구들은일부분쇄상형태의골절을포함한불안정성골절을그대상으로하였으나다골편성형태 (multifragmentary type) 및분절형태 (segmental type) 의분쇄골절은포함하고있지않은연구로, 전반적인분쇄상골절의치료를반영하지못한다는한계점이있다. 이에본저자들은중수골간부및경부분쇄골절의치료에서변형된경피적역행성골수강내 K-강선을이용한수술법의치료결과를알아보고그유용성을검증하고자한다. 대상및방법 1. 연구대상 2010년 3월부터 2017년 12월까지신체검진및영상검사에서중수골경부및간부의분쇄골절로진단된환자중, 변형된경피적역행성골수강내 K-강선을이용하여 Table 1. Demographic data of patients Case Sex Age at operation (yr) Injured side Concomitant injuries No. of metacarpal bone Site of fracture Type of fracture* 1 M 21 Right None 2 Neck A3 2 M 25 Right Ipsilateral tibiofibular 2 Shaft B2 3 Right shaft open fracture 3 Shaft C3 4 M 34 Right None 5 Neck A3 5 M 20 Right None 5 Shaft B2 6 M 27 Right None 5 Neck A3 7 M 33 Left None 5 Neck A3 8 M 33 Right None 4 Shaft C3 9 Right None 5 Shaft C2 10 F 61 Left None 4 Shaft B2 11 M 18 Right None 5 Shaft B3 12 F 39 Left None 4 Shaft B2 13 F 24 Left None 5 Neck A3 14 M 28 Right None 5 Neck A3 15 F 29 Left None 3 Shaft B2 16 F 80 Left None 3 Shaft B2 17 M 49 Right 5th metacarpal fracture 4 Shaft B2 M: male, F: female. *Type of fracture classified according to Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association fracture and dislocation classification compendium

$중수골경부와간부의분쇄골절로포함된골절형은 2018년개정된 AO/OTA (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association) 분류에따라중수골원위부의관절외다골편성골절 (extrarticular multifragmentary fracture of distal end segment)$ $과중수골간부의쐐기형및다골편성골절 (wedge or multifragmentary fracture of diaphysis) 로한정하였다 11,12. 총 20명의 22예를확인하였으며, 이중수술후 6개월째까지추시관찰을할수없었거나관절내골절이동반된 5예를제외한 15명의 17예를대상으로연구를진행하였다. 수술을시행할당시환자들의평균나이는 34.$

3 Seok Woo Hong, et al. Retrograde Intramedullary Nailing 내고정술을시행한환자를대상으로후향적연구를시행하였다. 중수골경부와간부의분쇄골절로포함된골절형은 2018년개정된 AO/OTA (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association) 분류에따라중수골원위부의관절외다골편성골절 (extrarticular multifragmentary fracture of distal end segment) 과중수골간부의쐐기형및다골편성골절 (wedge or multifragmentary fracture of diaphysis) 로한정하였다 11,12. 총 20명의 22예를확인하였으며, 이중수술후 6개월째까지추시관찰을할수없었거나관절내골절이동반된 5예를제외한 15명의 17예를대상으로연구를진행하였다. 수술을시행할당시환자들의평균나이는 34.1세 ( 범위, 16-80세 ) 였으며, 우측이 11예, 좌측이 6예였다. 골절의위치는제2중수골이 2예, 제3중수골이 3예, 제4중수골이 4예, 제5중수골이 8예였다 (Table 1). 본연구는 2018년 6월병원기관윤리심의위원회 (Institutional Review Board) 의승인을받아진행하였다 (IRB No ). 2. 수술방법모든수술은수상후 3일이내에전신마취하 1명의술자에의하여시행되었다. 먼저투시방사선유도하 Jahss 방법을이용하여골절을정복하고, 중수수지관절과근위지관절을 90 로유지한상태로중수골두에 K-강선을근위방향으로삽입하여중수골의기저부를통과하도록하였다. K-강선이중수골기저부를통과한후에는신전건및척골신경배측분지의손상을최소화하기위하여망치를이용해강선의원위부끝을쳐서연부조직을통과시켰다. 이후, 빠져나온 K-강선부위를바이스그립과망치를이용하여조심스럽게근위부로이동시켜 K-강선의원위부끝이중수골두의피질하골 (subchondral bone) 에위치하도록조정하였다 (Fig. 1). 마지막으로손목을최대한신전시킨상태를유지하면서근위부로빠져나온 K-강선을등쪽방향으로구부려근위방향으로의 K-강선이동을방지하였다. 환자의중수골골수강의크기에따라 0.9 mm와 1.1 mm 크기의 K-강선을적절히조합하여 2개또는 3개의 K-강선을삽입하였으며, 손목관절 30 신전, 중수수지관절 70 굴곡및수지관절들을완전히신전한상태인내인근양성자세 (intrinsic plus position) 로배면제한단상지부목 (dorsal blocking short arm splint) 을거치하였다. 3. 수술후관리모든환자는수술직후부터지간관절의능동적운동 (active exercise) 을시작하였으며, 매주외래를방문하여골유합의과정및합병증발생유무를확인하였다. 술후 3주째간헐적수장면단상지부목 (removable volar short arm splint) 으로교체하고중수수지관절및손목관절의능동적운동을시작하였다. 임상적골유합을확인한후 K-강선을제거하고손목관절, 중수수지관절및지간관절의능동보조적운동 (active assistive exercise) 을시작하였다. 4. 수술후평가방법영상의학적평가로는환자에게사용된 K-강선의개수와골유합의여부, 수술전과수술후 6개월째의중수골의 A B Fig. 1. (A) Wires were inserted retrogradely using a mallet at a maximal wrist flexed position. (B) The surgeon moved the Kirschner wire to proximal side using mallet and vice grip

Archives of Hand and Microsurgery Vol. 23, No.

이때, 윌콕슨부호순위검정 (Wilcoxon signed rank test) 을통하여두군간의통계적차이를검증하였고, 유의확률은 0.05 (p<0.

임상적평가로는임상적골유합시점및술후 6개월째의시각통증척도 (visual analogue scale, VAS) 와중수수지관절의총능동운동범위 (total

임상적골유합시기는관절운동시통증이없으며, 골절부위의압통이완전히소실될때로정의하였고 13, 중수수지관절의총능동 운동범위는최대능동굴곡각도에서굴곡구축각도를뺀

The diameter and number of intramedullary Kirschner wires used in present study No.

$27-year-old man with comminuted 2nd metacarpal neck fracture.$ $(B) Pre-operative oblique radiograph of the hand with metacarpal neck fracture which$

4 Archives of Hand and Microsurgery Vol. 23, No. 3, September 2018 단축정도및배면각형성 (dorsal angulation) 정도를수부전후면및사면단순촬영영상에서의계측을통해비교하였다. 이때, 윌콕슨부호순위검정 (Wilcoxon signed rank test) 을통하여두군간의통계적차이를검증하였고, 유의확률은 0.05 (p<0.05) 로설정하였다. 임상적평가로는임상적골유합시점및술후 6개월째의시각통증척도 (visual analogue scale, VAS) 와중수수지관절의총능동운동범위 (total active motion, TAM), 그리고합병증발생여부를확인하였다. 임상적골유합시기는관절운동시통증이없으며, 골절부위의압통이완전히소실될때로정의하였고 13, 중수수지관절의총능동 운동범위는최대능동굴곡각도에서굴곡구축각도를뺀 것으로하였다. 또한합병증으로는부정유합, 불유합및 재골절여부와감염, 신전건손상등의여부를확인하였다. Table 2. The diameter and number of intramedullary Kirschner wires used in present study No. of wires Diameter Cases Two wires 1.1 mm mm 1, 0.9 mm 1 2 Three wires 1.1 mm mm 2, 0.9 mm 1 1 A B C D G E F H Fig. 2. (A) Pre-operative true antero-posterior radiograph of the involved right hand of 27-year-old man with comminuted 2nd metacarpal neck fracture. (B) Pre-operative oblique radiograph of the hand with metacarpal neck fracture which showed dorsal angulation. (C, D) Antero-posterior and lateral view of radiographs taken immediately after operation which showed satisfactory fracture reduction. (E, F) Six-month postoperatively taken radiograph showed that complete bony union was achieved with acceptable alignment. (G, H) The patient fully recovered the range of motion of the involved hand at 6 months after the operation

Seok Woo Hong, et al. Retrograde Intramedullary Nailing 결과 1. 영상의학적평가 총 17예의환자중 2개의 K-강선을사용한경우가 10 예, 3개의 K-강선을사용한경우가 7예있었다 (Table 2).

49 로감소하였다 (Fig. 2, 3). 중수골의 단축정도및배면각형성정도모두수술전과수술후 6 개월째통계적으로유의한차이가있었다 (Table 3). 2. 임상적평가임상적골유합시기는평균 6.49±0.97주로확인되었다. 또한수술후 6개월째시각통증척도는 1.35±0.

$fracture. (C, D) Anteroposterior and lateral view of radiographs taken immediately after operation which showed satisfactory fracture reduction.$ (E, F) One-year postoperatively taken radiograph showed that complete bony union was achieved with acceptable alignment. Table 3.

(E, F) One-year postoperatively taken radiograph showed that complete bony union was achieved with acceptable alignment. Table 3.

months after operation p-value 3.37±1.12 0.19±0.32 <0.001* 21.72±7.26 5.04±2.49 <0.001* Values are presented as mean±standard deviation.

Average period of clinical bony union and the pain VAS and TAM of metacarpophalangeal joint 6-month after surgery Measured value Value Average

5 Seok Woo Hong, et al. Retrograde Intramedullary Nailing 결과 1. 영상의학적평가 총 17예의환자중 2개의 K-강선을사용한경우가 10 예, 3개의 K-강선을사용한경우가 7예있었다 (Table 2). 전예에서추가적인치료없이골유합을얻었다. 중수골의단축정도는수술전 3.37±1.23 mm에서수술후 6개월째 0.19±0.32 mm로변화하였고, 배면각형성 (dorsal angulation) 정도는수술전 ±7.26 에서수술후 6개월째 5.04 ±2.49 로감소하였다 (Fig. 2, 3). 중수골의 단축정도및배면각형성정도모두수술전과수술후 6 개월째통계적으로유의한차이가있었다 (Table 3). 2. 임상적평가임상적골유합시기는평균 6.49±0.97주로확인되었다. 또한수술후 6개월째시각통증척도는 1.35±0.93 이었고, 중수수지관절의총능동운동범위는 ± 5.66 로측정되었다 (Table 4). 17예전부에서불유합, 부정유합및재골절은추시기간동안없었으며, 감염및신전건손상과신경손상도발견되지않았다. A B C D E F Fig. 3. (A, B) Pre-operative true antero-posterior and oblique radiograph of the involved left hand of 80-year-old man with comminuted 3rd metacarpal shaft fracture. (C, D) Anteroposterior and lateral view of radiographs taken immediately after operation which showed satisfactory fracture reduction. (E, F) One-year postoperatively taken radiograph showed that complete bony union was achieved with acceptable alignment. Table 3. Average dorsal angulation and shortening of metacarpal bone Measured value Average dorsal angulation ( ) Average shortening (mm) Before operation 6 months after operation p-value 3.37± ±0.32 <0.001* 21.72± ±2.49 <0.001* Values are presented as mean±standard deviation. Data obtained from Wilcoxon signed rank test. *p<0.001 by Wilcoxon signed rank test. Table 4. Average period of clinical bony union and the pain VAS and TAM of metacarpophalangeal joint 6-month after surgery Measured value Value Average period of clinical bony union 6.49±0.97 (wk) Pain VAS at 6 months after operation 1.35±0.93 TAM of metacarpophalangeal joint at 85.88± months after operation ( ) Values are presented as mean±standard deviation. VAS: visual analog scale, TAM: total active motion. 179

6 Archives of Hand and Microsurgery Vol. 23, No. 3, September 2018 고찰 분쇄골절이란 3조각보다많은골절편으로나뉘어진다골편성골절을뜻한다 14. 이형태의골절은일반적으로매우불안정하고골절주변에광범위한연부조직손상이있는경우가많아해부학적정복의유지및안정성고정이어렵다고알려져있다. 또한치료후에도불유합및부정유합을포함한합병증의발생비율이높다 15. 중수골간부와경부에발생한분쇄골절도일반적인분쇄골절과마찬가지로정복의유지및고정이매우어려운것으로여러연구들에서보고하고있다 16. 현재까지중수골경부및간부의분쇄골절에대한다양한수술적고정방법중어떤방법이특별한우위에있다는통합된의견은없지만 4,17, 골절주변부의골소실및폐쇄적정복의어려움때문에금속판과나사를이용한관혈적정복및내고정술을고려하는경우가많다 18. 하지만관혈적정복및내고정술의경우힘줄이나인대의유착및반흔의형성, 심부감염등이발생할위험성이높은데 19, 이미연부조직의광범위한손상이동반되어분쇄골절에서는그위험성이훨씬올라갈것으로생각한다. 이에본연구에서는변형된역행성골수강내 K-강선삽입법을이용해연부조직의추가적인손상을최소화하였고, 수술직후부터능동적관절운동을허용함으로써유착및반흔형성이진행되지않도록하였다. 역행성골수강내 K-강선삽입법의가장큰장점은손등의흉터가적고, K-강선의삽입및제거가용이하다는점이다 7. 손등의경우손바닥에비해일상적인활동중더자주노출되는데, 대부분의중수골골절환자가 30대이하의젊은환자임을고려한다면 1 손등에최소한의흉터를남기는것은이수술법의매우큰장점이라생각한다. 또한전향적골수강내 K-강선삽입법이중수골근위부에서 K-강선을삽입하기가상대적으로어렵고 K-강선의제거시에추가적인피부절개가필요할수있음을고려할때 8, 역행성골수강내 K-강선삽입법은중수골두에서삽입점을찾기용이하며근위부로노출된 K-강선을이용하여외래에서비교적쉽게내고정물을제거할수있기때문에, 중수골경부및간부골절환자의치료에있어서비교적쉽게적용할수있는방법이라고생각한다. 수부의외상에대한수술적치료후능동적관절운동을빨리시작하면, 고정을오래한경우에비하여임상결과가우수한것으로보고되어있다 20. 능동적관절운동을시작하는시점을결정할때, 골절에대한안정적인고정력을확보하였는가는매우중요한고려요소중하나이다. 하지만 중수골골절에서골수강내 K-강선법은회전변형력에대한안정성이낮기때문에 21, 나사와금속판을이용한고정방법에비하여고정력이떨어진다 22. 특히골절의형상이분쇄상인경우훨씬더불안정하기때문에안정적인고정력의확보가필수적이다. 따라서이번연구에서는충분한고정력을확보하기위해세가지사항을중점적으로고려하였다. 우선 K-강선을역행성으로삽입한후근위부피부를통과하여나온 K-강선을잡아이동시킬때, K-강선의원위부끝을정확히연골하골 (subchondral bone) 에위치하도록조정하였다. 이를통하여 K-강선이분쇄골절된원위부에지지대 (buttress) 역할을할수있게하여중수골의길이및정렬을유지하도록하였다. 특히분쇄골절의경우는중수골이단축되는경향이더두드러지는데 23, 이러한 K-강선의위치조정을통하여골절정복후중수골의길이를유지할수있었다. 두번째로는골수강내로다양한굵기의 K-강선여러개를적절히삽입하여골수강내맞춤 (medullary fitting) 이충분히일어나도록하였다. 마지막으로는전산화단층촬영 (computed tomography, CT) 을이용하여단순촬영영상에서보이지않은중수골골두의미세한골절을정확하게찾아내고자하였다. CT 검사에서중수골골두의골절이발견될경우, 관혈적정복술및내고정술을이용하여골절을치료하였다. 이러한과정을통하여본연구의모든증례에서수술후 6개월째중수골의단축및배면각형성이모두적합한범위내로교정됨을확인하였고, 통증및관절운동의범위도정상수준으로회복되었다. 또한지연유합이나불유합없이임상적인골유합도평균 6.5주라는비교적빠른시간내에얻을수있었다. 본연구에서는 2명의환자를제외하고는주로 40대이하의건강한환자들이연구대상으로포함되었고개방성골절이동반된광범위한수부연부조직의손상의증례가없었는데, 이러한점들이좋은임상결과를나타낼수있었던또다른이유였을것으로생각한다. 또한수술직후부터 3 주간최대한의손목신전상태에서내인근양성자세를정확하게유지하며배면제한단상지부목을거치하였는데, 이를통하여내인근의구축을막고지간관절의능동적운동을수술직후부터허용할수있었던점은관절운동범위의정상회복에중요하게작용하였을것으로생각한다 24. 본연구는몇가지한계점이존재한다. 먼저후향적연구로서환자군의선택에비뚤림이있었을가능성이크고, 선택된환자들도이질적인특성을가지고있었다. 또한증례수가 17예로충분하지않아통계적인검정력이떨어졌다

7 Seok Woo Hong, et al. Retrograde Intramedullary Nailing 따라서본연구의결과를일반화하는데에는한계가있다. 마지막으로는대조군이없어중수골경부및간부골절에서시행할수있는수술적치료법간의우위를밝히기어려웠다. 향후중수골경부및간부의분쇄골절의여러치료법에대하여비교한후속연구가있기를기대한다. 결론 중수골경부및간부의분쇄골절에서변형된경피적역행성골수강내 K-강선고정을통한치료법은만족스러운결과를보여주었다. 따라서비교적술기가간단하며창상관련합병증이적고, 기능적으로우수한역행성골수강내고정법은중수골경부및간부분쇄골절의치료방법중하나로고려될수있을것이다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am. 2001;26: Stanton JS, Dias JJ, Burke FD. Fractures of the tubular bones of the hand. J Hand Surg Eur Vol. 2007;32: Diaz-Garcia R, Waljee JF. Current management of metacarpal fractures. Hand Clin. 2013;29: Kollitz KM, Hammert WC, Vedder NB, Huang JI. Metacarpal fractures: treatment and complications. Hand (N Y). 2014;9: Bloom JM, Hammert WC. Evidence-based medicine: metacarpal fractures. Plast Reconstr Surg. 2014;133: Padegimas EM, Warrender WJ, Jones CM, Ilyas AM. Metacarpal neck fractures: a review of surgical indications and techniques. Arch Trauma Res. 2016;5:e Rhee SH, Lee SK, Lee SL, Kim J, Baek GH, Lee YH. Prospective multicenter trial of modified retrograde percutaneous intramedullary Kirschner wire fixation for displaced metacarpal neck and shaft fractures. Plast Reconstr Surg. 2012;129: Lee SK, Kim KJ, Choy WS. Modified retrograde percutaneous intramedullary multiple Kirschner wire fixation for treatment of unstable displaced metacarpal neck and shaft fractures. Eur J Orthop Surg Traumatol. 2013;23: Han SH, Yoon HK, Shin DE, Han SC, Kim YW. Percutaneous retrograde intramedullary pin fixation for isolated metacarpal shaft fracture of the little finger. J Korean Fract Soc. 2010;23: Moon CS, Jeon HS, Jeon SJ, Seo YR, Noh HK. Treatment of metacarpal shaft fractures with retrograde intramedullary Kirschner-wire fixation. J Korean Soc Surg Hand 2010;15: Kellam JF, Meinberg EG, Agel J, Karam MD, Roberts CS. Introduction: fracture and dislocation classification compendium-2018: International Comprehensive Classification of Fractures and Dislocations Committee. J Orthop Trauma. 2018;32 Suppl 1:S Hand and carpus. J Orthop Trauma. 2018;32 Suppl 1:S Morshed S. Current options for determining fracture union. Adv Med. 2014;2014: Shimizu T, Omokawa S, Akahane M, Murata K, Nakano K, Kawamura K, et al. Predictors of the postoperative range of finger motion for comminuted periarticular metacarpal and phalangeal fractures treated with a titanium plate. Injury. 2012;43: Cooney WP 3rd, Dobyns JH, Linscheid RL. Complications of Colles fractures. J Bone Joint Surg Am. 1980;62: Omokawa S, Fujitani R, Dohi Y, Okawa T, Yajima H. Prospective outcomes of comminuted periarticular metacarpal and phalangeal fractures treated using a titanium plate system. J Hand Surg Am. 2008;33: Agashe MV, Phadke S, Agashe VM, Patankar H. A new technique of locked, flexible intramedullary nailing of spiral and comminuted fractures of the metacarpals: a series of 21 cases. Hand (N Y). 2011;6: Sung YG, Song SW, Lee YM. Modified bouquet technique for treatment of metacarpal neck fractures. J Korean Soc Surg Hand. 2016;21: Fusetti C, Meyer H, Borisch N, Stern R, Santa DD, Papaloïzos M. Complications of plate fixation in metacarpal fractures. J Trauma. 2002;52: Crowley TP, Stevenson S, Taghizadeh R, Addison P, Mil

8 Archives of Hand and Microsurgery Vol. 23, No. 3, September 2018 ner RH. Early active mobilization following UCL repair with Mitek bone anchor. Tech Hand Up Extrem Surg. 2013;17: Kim JY, Lee YK, Kong GM, Kim DY, Park JH, Jung YR. Comparison of intramedullary K-wire nailing versus plate for fixation in metacarpal midshaft fracture. J Korean Orthop Assoc. 2016;51: Black D, Mann RJ, Constine R, Daniels AU. Comparison of internal fixation techniques in metacarpal fractures. J Hand Surg Am. 1985;10: Ben-Amotz O, Sammer DM. Practical Management of metacarpal fractures. Plast Reconstr Surg. 2015;136:370-9e. 24. Paksima N, Besh BR. Intrinsic contractures of the hand. Hand Clin. 2012;28:

9 Seok Woo Hong, et al. Retrograde Intramedullary Nailing 변형된경피적역행성골수강내 K- 강선고정법을이용한중수골간부및경부분쇄골절의치료결과 홍석우 1 ㆍ이영호 2 ㆍ김민범 2 ㆍ백구현 2 1 이대목동병원정형외과, 2 서울대학교병원정형외과 목적 : 중수골간부및경부의분쇄골절에서변형된경피적역행성골수강내 K-강선고정법의치료결과를알아보고그유용성을검증하고자한다. 방법 : 신체검진및영상검사에서중수골간부및경부의분쇄골절로진단된총 15명의 17예를대상으로후향적분석을시행하였다. 영상의학적평가로는수술전및수술후 6개월째중수골의단축정도및배면각형성정도의변화를계측하여비교하였다. 임상적평가를위해서임상적골유합시점및술후 6개월째의시각통증척도와중수수지관절의총능동운동범위, 그리고합병증발생여부를확인하였다. 결과 : 전증례에서추가적인치료없이골유합을얻을수있었고, 중수골의단축정도및배면각형성정도는수술전에비하여수술후 6개월째통계적으로유의하게호전되었다. 임상적골유합시기는평균 6.49주였고, 수술후 6개월째평균시각통증척도는 1.35, 중수수지관절의평균총능동운동범위는 로측정되었다. 불유합, 부정유합및재골절을포함한합병증은추시기간동안관찰되지않았다. 결론 : 변형된경피적역행성골수강내 K-강선고정법은비교적술기가간단하고창상관련합병증이적으며기능적으로우수한치료법으로서, 경부및간부분쇄골절의치료방법중하나로고려될수있을것이다. 색인단어 : 중수골경부, 중수골간부, 분쇄골절, 역행성, 골수내정 접수일 2018 년 7 월 24 일수정일 2018 년 8 월 10 일게재확정일 2018 년 8 월 10 일교신저자이영호 03080, 서울시종로구대학로 101, 서울대학교병원정형외과 TEL FAX orthoyhl@snu.ac.kr 183

Lumbar spine

Lumbar spine CT 32 111 DOI : 10.3831/KPI.2010.13.2.111 Lumbar Spine CT 32 Received : 10. 05. 23 Revised : 10. 06. 04 Accepted : 10. 06. 11 Key Words: Disc herniation, CT scan, Clinical analysis The Clinical