대한정형외과학회지 : 제 39 권제 6 호 2004 J. of Korean Orthop. Assoc. 2004; 39: 주먹가격후발생한수부및손목에발생한손상 한수봉ㆍ김주영ㆍ신승엽ㆍ강호정ㆍ이진우ㆍ강응식 연세대학교의과대학정형외과학교실 목적 : 본교실에서는주먹가격후

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1 대한정형외과학회지 : 제 9 권제 6 호 2004 J. of Korean Orthop. Assoc. 2004; 9: 주먹가격후발생한수부및손목에발생한손상 한수봉ㆍ김주영ㆍ신승엽ㆍ강호정ㆍ이진우ㆍ강응식 연세대학교의과대학정형외과학교실 목적 : 본교실에서는주먹가격후발생한다양한골절및탈구의양상을분석하였으며, 치료결과를보고하고자한다. 대상및방법 : 998 년 월부터 2002 년 9 월까지주먹가격손상으로수술혹은보존적치료를받은 69 명의환자를후향적으로비교분석하였다. 이중 6 명은다발성골절및탈구의소견을보여, 부위별로는총 9 예였다. 세부터 4 세까지로평균나이는 2.7 세, 평균추시기간은약 8 개월이었다. 평가는최종추시시 Bruce 및 Maudsley 등의방법을변형하여평가하였다. 결과 : 중수골기저부골절이 9 예 (42.9%) 로제일빈도가높았으며, 중수골원위골절은 8 예 (9.8%) 이었다. 원위중수골및중수골간부골절은주로보존적치료를하였으며, 중수골기저부골절이수근중수관절의탈구를동반한경우는대부분도수적혹은관혈적정복후경피적고정을시행하였다. 고정물은평균 4. 주경제거하였으며, 부작용은관절운동제한 4 예, 부정유합 2 예, 수술부위통증, 각형성변형, 불유합등은각 예있었다. 최종결과에서는모든경우에서골유합을얻었으며. 최종추시시 84 예에서우수, 4 예에서양호및 예에서보통의결과를얻었다. 결론 : 주먹가격후다양한형태의골절및탈구가가능하며보존적치료나도수적또는관혈적정복후경피적 K- 강선고정술을이용하여우수한결과를얻었다. 색인단어 : 중수골, 수근중수골관절, 수부골절, 주먹가격손상 Fractures of the Wrist and Hand after Punching Injury Soo Bong Hahn, M.D., Ju Young Kim, M.D., Seung Yup Shin, M.D., Ho Jung Kang, M.D., Jin Woo Lee, M.D., and Eung Shick Kang, M.D. Department of Orthopedic Surgery, Yonsei University, College of Medicine, Seoul, Korea Purpose: The purpose of this study was to describe the patterns and results of treatment of fractures of the hand and wrist after punching injury. Materials and Methods: The authors retrospectively reviewed 9cases of fractures of the hand and wrist after punching injury in 67 patients from January 998 to September The mean follow-up was 8 months. The mean age was 2.7 years old, ranging from years old to 4 years old. The results were evaluated by modified criteria of Bruce and Maudsley. Results: The most common fractures were metacarpal base fractures (42.9%), and the second most common fractures were distal metacarpal fractures (9.8%). Metacarpal base fractures were usually combined with dislocation of carpometacarpal joint, especially in the fourth and fifth metacarpal bone and single fifth metacarpal bone (29.7%). There were a few complications of limitation of motion (4 cases), pain ( case), angular deformity of distal metacarpal bone ( case), malunion of metacarpal shaft (2 cases) and nonunion of metacarpal shaft ( case). There were excellent results in 84 cases, good in 4 cases and fair in cases. Conclusion: The most common fractures after punching injury were metacarpal base fractures, especially the forth and fifth metacarpal bone. Distal metacarpal and metacarpal shaft fractures were mostly single fractures. There were diverse patterns of fracture-dislocation of the hand and wrist after punch- 통신저자 : 한수봉서울시서대문구신촌동 4 연세대학교의과대학정형외과학교실 TEL: FAX: sbhahn@yumc.yonsei.ac.kr Address reprint requests to Soo Bong Hahn, M.D. Department of Orthopaedic Surgery, Yonsei University College of Medicine, 4 Shinchon-dong, Seodaemun-gu, Seoul 20-72, Korea Tel: , Fax: sbhahn@yumc.yonsei.ac.kr 700

2 주먹가격후발생한수부및손목에발생한손상 70 ing. We must be careful to evaluate combined injury when a patient visits after punching injury. Key Words: Metacarpal bone, Carpometacarpal joint, Hand fracture, Punching 수부는복잡한구조와다양한기능을가지고있으며, 인체에서외상에노출되기쉬운부분중하나이다. 그손상원인도교통사고및압착기손상이나롤러손상등작업사고이외에도다양하다. 특히중수골골절은전체골격계손상중약 0% 정도로보고되고있다 ). 이러한수부의손상원인중주먹가격손상이있다. 가격후흔히발생하는골절은원위중수골골절로알려져있으나구체적인분석이없었다. 이에가격후발생한다양한골절및탈구의양상을분석하였으며, 치료결과를문헌고찰과함께보고하고자한다. 대상및방법. 연구대상 998년 월부터 2002년 9월까지내원한환자를대상으로진단코드를이용하여수부손상으로치료를받은 6 명중차트분석을통해주먹가격손상으로수술혹은비수술적치료를시행받은 69 명의환자를후향적으로비교분석하였다. 이중 6명은다발성골절및탈구의소견을보여, 부위별로는총 9 예였다. 모두남자였으며 세부터 4세까지로평균나이는 2.7세였다. 평균추시기간은약 8 개월이었다. 결과평가는최종추시시 Bruce 6) 및Maudsley 20) 의방법을변형하여동통, 압통, 관절강직, 기능및단순방사선상유합소견등에각각 점씩, 총점 2점에우수는 2-2, 양호는 20-22, 보통은 8-20, 불량은 8점미만으로정의하였다 (Table ). 2. 수술수기원위중수골및중수골간부골절은도수정복을시도하여허용범위내의정복을얻은후보존적치료를시행하였다. 도수정복후에도만족할만한정복을얻지못한 경우나정복의유지가되지않을것으로판단된경우에경피적 K-강선삽입술을시행하였다. 수근중수골관절및중수골기저부의골절이나탈구의소견이있을경우에는전산화단층촬영을시행하여동반골절여부를확인하였다. 수근중수골관절의순수탈구는도수정복을먼저시도한후해부학적정복이어렵거나정복이되지않는경우에관혈적정복후경피적 K-강선삽입술을시행하였다. 수근중수골관절의탈구를동반한골절이있는경우역시순수탈구의경우와동일하게치료하였다. 전위가있는수근골골절은초소형나사못을이용하여내고정을시행하였다. 결과. 주먹가격후부위별수부손상정도수근중수관절의순수탈구 6예 (6.6%), 중수골원위골절 8예 (9.8%), 중수골간부골절 6예 (7.6%), 그리고중수골기저부골절은 9예 (42.9%) 로중수골기저부골절이제일빈도가높았다 (Fig. ). 수근골골절로는유구골골절 6예 (6.6%), 두상골골절 2예 (2.2%) 였으며, 주상골, 삼각골및근위지골골절이각각 예씩있었고두상유구관절의아탈구소견을보인경우도 예있었다 (Fig. 2). 2. 주먹가격후수지별수부손상정도중수골기저부골절중제 번중수골단독골절이 예였으며, 제 4번및 번중수골이동시에골절된경우도 4예였다. 중수골기저부골절중수근중수골관절의탈구를동반한경우가 8예였으며, 제 4, 번중수골이제일흔하였다. 원위중수골골절중제 번중수골이 예로가장많았으며제 번중수골를제외한나머지중 Table. Modified criteria of bruce and maudsley Score Pain Clinical tenderness Stiffness Functional state Radiologic union No No No Equal to opposite arm Union 4 Annoying pain with no compromise of activity Independent ADL Pain interfering with activity Mild Mild Unable to do ADL Incomplete union 2 Pain preventing some activity Occupational change required Pain causing outcries and preventing activities Severe Significant limitation Occupational disability Nonunion of motion

3 702 한수봉ㆍ김주영ㆍ신승엽외 인 Metacarpal shaft 7.6% (6 cases) Metacarpal base 42.9% (9 cases) Scaphoid case Triquetrum case Metacarpal neck 9.8% (8 cases) Capitate 2 cases Hamate 6 cases D/L CMC joint 6.6% (6 cases) Carpal bone 2.% ( cases) Fig.. Distribution of fracture after punching injury showed that the most common metacarpal fracture was metacarpal base fracture ,, 4,, 2,, 4, 2,, 4, 4 D/L CMC Metacarpal neck Fig.. Finger involving rate after punching injury showed the most common finger was th finger. 수골도각각 예씩있었다. 중수골간부골절 6예중제 4번중수골단독골절이 7예로가장많았으며, 제 번중수골단독골절도 6예였다 (Fig. ). 요골이나척골골절을보인경우는없었다 (Table 2). 다발성손상환자 6 명에서는대부분제 4, 번중수골기저부의골절과더불어수근중수골관절의탈구소견이보였고기타수근골골절및중수골간부의골절등이복합되어있었다.. 치료결과전체 9예중수술적치료를받은경우는 42예로중수 6 7 Metacarpal shaft Metacarpal base Fig. 2. Distribution of carpal bone fracture after punching injury showed that the most common carpal bone fracture was hamate fracture conservative O/R & percutaneous pinning C/R & percutaneous pinning O/R & I/F D/L CMC joint Metacarpal neck Metacarpal shaft Metacarpal base Carpal bone Fig. 4. Treatment method according to fracture type. In case of metacarpal base fracture, conservative treatment and open reduction & percutaneous pinning were the most common treatment methods. 골기저부골절이 7예, 수근중수골관절이단독탈구 예에서수술적치료를받았다. 즉중수골기저부혹은수근중수골을침범한경우는수술적치료가필요한경우가많았다. 수술적치료는 8예에서도수정복후경피적 K-강선고정을시행하였으며 4예에서는관혈적정복후주로경피적 K-강선고정을시행하였다. 전위된수근골은관혈적정복후초소형나사못을이용하여내고정하였다 (Fig. 4, Table 2). K-강선은평균 4.주경 2 7 2

4 주먹가격후발생한수부및손목에발생한손상 70 Table 2. Dermographic data of the patients Diagnosis Prevalence Site (finger) Treatment Complication D/L, CMC joint 6 (6.6%) 4: (.%) Conservative Tx.: LOM: case 4,:4 (4.4%) O/R & percutaneous pinning:, 2,, 4, : (.%) Metacarpal neck 8 (9.8%) 2: (.%) Conservative Tx: LOM:2 cases : (.%) C/R & percutaneous pinning: Angular deformity: case 4: (.%) O/R & percutaneous pinning: : (6.%) O/R & I/F with miniscrew: Metacarpal shaft 6 (7.6%) 4:7 (7.7%) Conservative Tx: Malunion:2 cases :6 (6.6%) O/R & percutaneous pinning: Nonunion: case 4, : (.%) O/R & I/F with miniscrew: O/R & I/F with miniplate: Metacarpal base 9 (42.9%) : (.%) Conservative Tx: LOM: case 4:8 (8.8%) C/R & percutaneous pinning:7 Pain; case : (4.%) O/R & percutaneous pinning: 4, :4 (.4%) O/R & I/F with miniscrew:2, 4, : (.%) 2,, 4, :2 (2.2%) Hamate 6 (6.6%) Conservative Tx.: O/R & I/F with miniscrew:4 O/R & I/F with Tissue kit: Capiate 2 (2.2%) Conservative Tx.:2 scaphoid (.%) Conservative Tx.: triquetrum (.%) Conservative Tx.: Prox. phalanx (.%) O/R & percutaneous pinning: Subluxation of capitatohamate joint (.%) O/R: D/L, Dislocation;, Fracture; CMC, Carpometacarpal; O/R, Open reduction; C/R, Closed reduction; LOM, Limitation of motion. 제거하였으며, 초소형나사못이나초소형금속판을이용한경우는환자들이특별한불편함을호소한경우가없어제거술을시행하지않았다. 수술후고정은평균 2. 주시행후조기재활치료를시작했으며, 비수술적치료를한경우는약4주고정후역시조기재활치료를시작하였다. 4. 부작용관절운동제한이 4예, 수술부위통증을호소한경우가 예였고중수골경부골절중비수술적치료를받은경우중환자가느낄정도의각형성변형을보인경우가 예였다. 중수골간부골절중부정유합소견을보인경우가 2예, 불유합을보인경우가 예그리고중수골간부골절로보존적치료후골유합을얻었으나다시주먹가격손상으로동일중수골간부골절이발생한경우가 예있었다. 중수골골절중부정유합을보인경우는절골수술후초소형금속판과초소형나사못을이용하여내고정술을시행하였으며, 불유합을보인경우는소파술후역시초소형금속판과초소형나사못을이용하여내 고정하였다 (Table 2). 최종결과에서는모든경우에서골유합을얻었으며임상적으로유의한동통을호소한경우가 예있었다. 4예에서관절운동의제한을호소하였고, 예에서각형성변형을호소하였다. 그러나각형성변형을호소한경우는일상생활에제한이없어수술적치료를하지않았으며관절운동의제한을보인경우완전한관절운동범위를얻지는못하였으나재활치료로일상생활에제한이없는관절운동범위를얻었다. 최종추시시 84예에서우수한결과, 4예에서양호한결과, 그리고 예에서보통의결과를얻었다. 가격후발생하는골절로는원위중수골골절이흔한것으로알려졌는데본연구에서는중수골기저부골절이가장큰빈도를보였다. 더불어중수수근관절의골절및탈구도상당한경우에서관찰할수있었고유구골을비롯한수근골의골절소견도관찰할수있었다. 일부운동범위의제한및부정유합등의부작용이있었으나원위중수골및중수골간부골절은비수술적치료로좋은결과를얻었다. 또한수근중수골관절의골절및탈구및

704 한수봉ㆍ김주영ㆍ신승엽외 인 A B 근위중수골골절은대부분도수혹은관혈적정복후경피적 K-강선고정술을시행하였고, 전위된수근골은대부분초소형나사못을이용하여내고정술을시행하였다. 고찰수부골절시치료의일차적인목적은수지의기능을회복시키는것이다.

그러나전위가심하거나정복유지가힘든골절, 연부조직손상이동반된경우나골단축과회전변형이있는골절그리고관절면이나관절주위골절등에서는수술적치료의적응이될수있다. 본연구에서도원위중수골이나중수골간부골절은대부분보존적치료를하였으며정복유지가어 C Fig.

(B) A open reduction and percutaneous K-wires pinning was done using general anesthesia. (C) Residual subluxation and arthritis were not seen in the postoperative months.

5 704 한수봉ㆍ김주영ㆍ신승엽외 인 A B 근위중수골골절은대부분도수혹은관혈적정복후경피적 K-강선고정술을시행하였고, 전위된수근골은대부분초소형나사못을이용하여내고정술을시행하였다. 고찰수부골절시치료의일차적인목적은수지의기능을회복시키는것이다. 이를위해서중수골골절시종아치와횡아치를보존하고회전변형을예방하여손가락의중첩을방지하여야하며, 수근중수골관절특히제 4, 번수근중수골관절의골절및탈구시에는정확한정복을통해정상적인수지운동범위를얻어수부의기능을회복시킬수있다 ). 중수골골절은골유합이타부위에비해빠르며보존적치료로도좋은결과를얻을수있다. 그러나전위가심하거나정복유지가힘든골절, 연부조직손상이동반된경우나골단축과회전변형이있는골절그리고관절면이나관절주위골절등에서는수술적치료의적응이될수있다. 본연구에서도원위중수골이나중수골간부골절은대부분보존적치료를하였으며정복유지가어 C Fig.. The 2 years old male who was admitted having painful swelling caused by punching. (A) The diagnosis was a from first to fifth carpometacarpal joint dislocation based on radiographs. (B) A open reduction and percutaneous K-wires pinning was done using general anesthesia. (C) Residual subluxation and arthritis were not seen in the postoperative months. 려운일부에서경피적 K-강선고정술을시행하였으며큰합병증을보인경우는없었다. 그러나중수골간부골절중부정유합이 2예, 불유합이 예그리고원위중수골골절중회전변형을보인경우가 예있어추가적인처치가필요하였다. 수근중수골관절의골절및탈구는드문수부손상으로알려져있지만 2,), Fisher 등 9) 과 Joseph 등 6) 은수근중수골관절의손상은흔하며, Boyes 4) 는치료가늦어질경우나불안전한정복은수부기능의장애등만성적인증상을일으킬수있다고하였다. 제 수근중수골관절은안장관절의특징을가지고있으며, 굴곡및회외운동이가능해제 수지와대립에중요한역할을담당하므로해부학적정복이요구된다 ). 수근중수골관절중 2, 수근중수골관절은운동성이거의없고 4, 수근중수골관절은 20-0 의관절운동이가능하다. 한편중수골기저부의모양은수부의척측에서요측으로갈수록더오목하게되고, 제 중수골은다른중수골보다더근위부에서수근골과관절을이루고있다 ). 즉이와같은이유로요측보다 4, 수근중수골관절에서적은에

$(A) Plain radiograph showed displaced bony fragment and forth metacarpal base fracture. (B) The CT images showed hamate and metacarpal base fracture.$ (C) After open reduction and internal fixation with miniscrew for hamate, percutaneous K-wires pinng for metacarpal base was done.

(C) After open reduction and internal fixation with miniscrew for hamate, percutaneous K-wires pinng for metacarpal base was done.

수부골절의치료방법으로는도수정복, 피부견인술및기능적보조기등의보존적방법과골절정복후 K-강선고정, 외고정장치삽입그리고내고정술등의수술적방법이있다. 최근에는수부골절에대한치료에있어기능회복을위해조기관절운동을강조하는데이를위해서는튼튼한고정이강조되고있다 ).

반면내고정물의고정이완, 이동등이가능하며충분한고정력을제공하지못하여부가적인부목적인부목고정등이필요할수있으며, 경피적인삽입을하는경우수부의운동을방해하거나유착을시킬수있다는단점이있다,8,2,4). 고정을얻기위한또다른방법중금속판이나나사못내고정술이있다.

6 주먹가격후발생한수부및손목에발생한손상 70 A B C D Fig. 6. The 2 years old male who was admitted having pain after punching. (A) Plain radiograph showed displaced bony fragment and forth metacarpal base fracture. (B) The CT images showed hamate and metacarpal base fracture. (C) After open reduction and internal fixation with miniscrew for hamate, percutaneous K-wires pinng for metacarpal base was done. (D) We obtained union and good result at the postoperative 2 months. 너지손상에서도골절및탈구의빈도가높다 0). 수부골절의치료방법으로는도수정복, 피부견인술및기능적보조기등의보존적방법과골절정복후 K-강선고정, 외고정장치삽입그리고내고정술등의수술적방법이있다. 최근에는수부골절에대한치료에있어기능회복을위해조기관절운동을강조하는데이를위해서는튼튼한고정이강조되고있다 ). 고정을얻기위한방법중 K-강선을이용한수술법은 K-강선을경피적으로삽입할수있고수술을위한절개가필요없으며따라서연부조직손상을줄일수있는장점이있다. 반면내고정물의고정이완, 이동등이가능하며충분한고정력을제공하지못하여부가적인부목적인부목고정등이필요할수있으며, 경피적인삽입을하는경우수부의운동을방해하거나유착을시킬수있다는단점이있다,8,2,4). 고정을얻기위한또다른방법중금속판이나나사못내고정술이있다. 이는전위된단사형골절, 분쇄골절, 다발 성중수골골절과함께연부조직손상이동반된경우에적응이될수있다. 이수술법은많은저자들이금속판과나사가튼튼하게골과의결합을이루어조기능동운동에따른부하를견딜수있을만큼의안정성을제공한다고하였으며,2), 골소실이동반된경우길이유지가가능한장점이있으나수부의경우타부위와달리제한된작은공간안에여러가지의골을둘러싸는구조물이많은까닭에수부에고정된금속판과나사못은비교적많은부피를차지하여건의운동을방해하는내고정물이되기쉽다 7). 이러한단점으로본예에서는금속판을부정유합이나불유합된경우등매우제한적으로사용하였다. 수근중수골관절의골절및탈구의치료에대해서는의견이다양한데, 많은저자들은관절면의해부학적정복을위해관혈적정복을주장하고있고 9), 다른저자들은도수정복과경피적 K-강선고정술을선호한다 7,9,2). 단도수정복의경우조기진단및조기치료가중요한데,

7 706 한수봉ㆍ김주영ㆍ신승엽외 인 수상후 일이상지연된경우는관혈적정복이요구된다고보고되고있다 4). 본연구에서수근중수골관절의골절및탈구의예가가장많았으며도수정복으로안정적정복이되지않는경우에는관혈적정복으로해부학적정복을얻은후 K-강선고정술을시행하였다. 결론주먹가격후수부에발생한골절로는일반적으로알고있는원위중수골골절보다는중수골기저부손상이빈발하였으며또한동반손상의가능성이높으므로세심한관찰이요하며, 이외도다양한형태의골절이가능하다. 중수골기저부골절을비롯한대부분의골절에서관혈적정복후 K-강선고정술을이용하여우수한결과를얻었다. 참고문헌. Bade H, Koebke J and Bilger H: Functional anantomy of the fifth carpometacarpal joint. Handchir Mikrochir Plast Chir, 2: 6-20, Berg EE and Murphy DF: Ulnopalmar dislocation of the fifth carpometacarpal joint-successful closed reduction. J Hand Surg, -A: 2-2, Bloom ML and Stern PJ: Carpometacarpal joints of fingers. Orthop Rev, 2: 77-82, Boyes JH: Bunnell s surgery of the hand. th ed. Philadelphia, J.B. Lippincott, , Browner BD, Jupiter JB, Levine AM and Trafton PG: Skeleton trauma. st ed, Philadelphia, WB Saunders Co: 92-96, Bruce HE, Harvey JP and Wilson JC Jr: Monteggia fracture. J Bone Joint Surg, 6-A: 6-76, Clement BL: Fracture-dislocation of the base of the fifth metacarpal. J Bone Joint Surg, 7: , De Beer JD, Maloon S, Anderson P, Jones G and Singer M: Multiple carpometacarpal dislocation. J Hand Surg, 4-B: 0-08, Fisher MR, Ronger LF and Hendrix RW: Carpometacarpal dislocation. CRC Crit Rev Diagn Imaging 22: 9-26, Gunther SF: The carpometacarpal joints. Orthop Clin North Am, : , Hartwing RH and Louis DS: Multiple carpometacarpal dislocation. J Bone Joint Surg, 6-A: , Harwin SF, Fox JM and Sedlin ED: Volar dislocation of the bases of the second and third metacarpals. J Bone Joint Surg, 7- A: 849-8, 97.. Heim U and Pfeiffer KM: Internal fixation of small fracturestechnique recommended by the AO-ASIF Group, rd Ed. Berlin, Springer-Verlag, 7-74, Jeon SJ, Yoon HK, Jung KW, Lee YJ and Noh KS: Closed reduction and percutaneous pinning in fracture-dislocations of carpometacarpal joints. J Korean Orthop Assoc, 6: 99-20, Jones WW: Biomechanics of small bone fixation. Clin Orthop, 24: -8, Joseph RB, Linscheid RL, Dobyns JH and Bryan RS: Chronic sprains of the carpometacarpal joints. J Hand Surg, 6-A: 72-80, Kim BH, Yim JI and Kang DJ: Miniplate and miniplate fixation for the metacarpal and phalangeal fractures. J Korean Fracture Soc, 0: 0-, Laforgia R, Specchiulli F and Mariani A: Dorsal dislocation of the fifth carpometacarpal joint. J Hand Surg, -A: 46-46, Lilling M and Weinberg H: The mechanism of dorsal fracturedislocation of the fifth carpometacarpal joint. J Hand Surg, 4-A: 40-42, Maudsley RH and Chen SC: Screw fixation in the management of the fractured carpal scaphoid. J Bone Joint Surg, 4-B: 42-44, Vanik RK, Weber RC, Matloub HS, Sanger JR and Gingrass RP: The comparative strengths of internal fixation technique. J Hand Surg, 9-A: 26-22, 984.

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