대한정형외과학회지 : 제 39 권제 6 호 2004 J. of Korean Orthop. Assoc. 2004; 39: 후방골반환손상환자에서의국소마취하 CT를이용한경피적천장관절나사고정술 최원식ㆍ김병성ㆍ김하용ㆍ안재훈ㆍ정유훈 을지대학교의과대학정형외과학교실 목적

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1 대한정형외과학회지 : 제 39 권제 6 호 2004 J. of Korean Orthop. Assoc. 2004; 39: 후방골반환손상환자에서의국소마취하 CT를이용한경피적천장관절나사고정술 최원식ㆍ김병성ㆍ김하용ㆍ안재훈ㆍ정유훈 을지대학교의과대학정형외과학교실 목적 : 후방골반환손상환자에대하여국소마취하에서 CT 를이용한경피적천장관절나사고정술로치료한결과를분석하고자한다. 대상및방법 : 불안정골반환손상으로본원에서 CT 를이용한경피적천장관절나사고정술로치료받은환자 9 명을대상으로하였다. 동반된치골결합분리 4 예와, 전위된치골지골절 3 예에는먼저전방도달법으로금속판을이용한내고정술을시행하였다. 기능평가는 Iowa pelvic score 를이용하였다. 단순방사선사진과 CT 를분석하여, 수술전후의천장관절탈구의전위정도를측정하였다. 결과 : 추시기간은최소 12 개월에서최대 48 개월로평균 25 개월이었고, Iowa pelvic score 는 84 점으로만족할만한결과를얻었다. 평균 1.55 개의나사못을사용하였으며평균수술시간은나사못 1 개당 24 분이었다. 수술중나사못의척추관이나추간공의침범으로인한신경이나혈관손상은없었다. 관절간격이수술전 8.2 mm 에서 3.6 mm 로감소되었고, 나사못의해리나재전위소견은관찰되지않았다. 결론 : 후방골반환손상환자에서의국소마취하에서 CT 를이용한경피적천장관절나사고정술은비교적쉽고안전한수술방법으로사료된다. 색인단어 : 후방골반환손상, 경피적천장관절나사못고정술 Iliosacral Screw Fixation of the Posterior Pelvic Ring Using Local Anesthesia and Computerized Tomography Won-Sik Choy, M.D., Byung-Sung Kim, M.D., Ha-Yong Kim, M.D., Jae-Hoon Ahn, M.D., and Yu-Hun Jung, M.D. Department of Orthopaedic Surgery, Eulji Medical College, Daejon, Korea Purpose: To analyze the functional and radiological results after a CT-guided iliosacral screw fixation of the posterior pelvic ring using local anesthesia. Materials and Methods: Nine patients with unstable pelvic ring injuries treated by CT-guided percutaneous iliosacral screw fixation under local anesthesia were enrolled in this study. Anterior lesion including 4 cases of symphysis pubis separation and 3 cases of displaced pubic ramus fracture was stabilized using a plate and screw before the posterior iliosacral screw fixation. The Iowa pelvic score was used for a functional evaluation. A reduction of the sacroiliac joint gap was analyzed using plain radiographs and CT. Results: The mean follow-up period was 25 months (12-48) and the mean Iowa pelvic score was 84. The mean number of screws introduced was 1.55 and the mean time for the procedure was 24 minutes per screw. There were no neurovascular complications related to misplaced screws encroaching the spinal canal or neural foramen. The iliosacral joint separation was 8.2 mm preoperatively and 3.6 mm postoperatively. There was no screw loosening or breakage. Conclusion: Iliosacral screw fixation using local anesthesia and computerized tomography is an easy 통신저자 : 김병성대전광역시서구둔산동 1306 을지의과대학교정형외과학교실 TEL: FAX: kbsos@eulji.ac.kr Address reprint requests to Byung-Sung Kim, M.D. Department of Orthopaedic Surgery, Eulji Medical College, 1306 Dunsan-dong, Seo-gu, Daejon , Korea Tel: , Fax: kbsos@eulji.ac.kr 722

2 후방골반환손상환자에서의국소마취하 CT 를이용한경피적천장관절나사고정술 723 and safe procedure for the patients with unstable pelvic ring injuries. Key Words: Posterior pelvic ring injuries, Iliosacral screw fixation, Computerized Tomography 골반골골절중후방골반환손상이동반된경우에는전방골반환단독손상에비해출혈량이세배이상이나되고합병증발생률도두배이상된다 3,13). 그러므로골절된골반환을안정시키는수술적정복과고정은골절주위연부조직의보호뿐만아니라, 환자가보다빨리거동할수있게해주므로, 장기간침상안정에따른합병증을예방하여생존율을향상시킬수가있다 4). 불안정후방골반환손상시후방골반을안정화시키는수술방법은여러가지가있는데, 방사선투시하에경피적으로천장관절을고정하는술식이도입된후, 광범위한절개가필요하지않아창상감염을현저하게줄일수있으며, 조기거동을가능하게하여합병증을줄일수있어서, 그사용이일반화되기시작했다 10,13,15,19). 그러나잘못된위치로삽입된나사못들이보고되고 5,14), 나사삽입위치의정확도를높이기위한방법들이개발되면서, CT를이용한경피적천장관절고정술이사용되고있다 1). 방사선투시하에경피적천장관절나사고정술에대한보고는있으나 9,10), 아직까지국내에서는 CT를이용한경피적천장관절나사고정술에대한보고는없는실정이다. 본교실에서는국소마취하에서 CT를이용한경피적천장관절나사고정술을시행하고있다. 이에그임상적및방사선학적결과를분석하고자한다. 대상및방법 1999년 6월부터 2003년 3월까지후방골반환손상으로본원에서국소마취하에서 CT를이용한경피적천장관절나사고정술로치료받은환자 9명을대상으로하였다. 환자의성별은남자 6예, 여자 3예였고, 최소 21 세부터최대 67세로평균 40세였다. 추시기간은최소 12 개월에서최대 48 개월로평균 25 개월이었다. Young- Burgess 23) 의분류상 LC2 1예, LC3 3예, APC3 4예, CM 1예로분류되었고 (Table 1), 수상기전은오토바이사고 4예, 자동차사고 3예 ( 경운기사고포함 ), 추락이 2 예였다. 동반손상은다른근골격계손상이 7예로가장많았고, 다음으로비뇨기계손상 5예, 복부손상 4예순이었다. 수혈량과혈색소수치를통한수술전추정출혈 량은평균 1,900 cc 정도였다. 수상후수술까지평균기간은 14일이었다. 전위된치골지골절 2예와치골결합분리가동반된 3예에서먼저관혈적정복과금속판을이용한내고정술을시행하였다. 수술시에모든환자는혈역학적으로안정적이었다. 환자를 CT의 scanner bed 위에복와위로위치시키고 CT scan을 2.5 mm 간격으로시행하였다. 전위된천장관절의영상자료를얻어나사삽입위치를결정한후 transverse laser를이용하여그위치에표시를하였다. 결정된단면의영상을분석하여나사의삽입각도를결정하고환자의피부위에미리얹어놓았던표시자를기준으로하여삽입위치를피부위에표시하였다. 이렇게하여결정된나사삽입위치를주변으로충분히소독하였다. 1% lidocaine으로국소마취를한후에약간의피부절개후유도강선을장골에위치시킨후제 3자의도움을받아삽입각을조절하였다. 먼저결정된단면의영상분석을통해얻은길이만큼유도강선을삽입하였다. 다시단면영상을촬영하여처음에계획했던대로강선이잘위치했는지확인하였다. 그후길이를재고, 유관드릴을이용하여확공한후 7.0 mm의 self-tapping 유관해면나사를와셔와함께삽입하였다 (Fig. 1). 삽입나사의수는 2개를삽입할수있도록노력하였으나, 추간공이나척추관의침범을하지않으면서도나사 2개를삽입할공간이충분하지않을때에는한개의나사만삽입하였다. 다시단면영상을촬영하여정복이잘되었는지유무와나사의위치를확인하고, 절개부위를봉합하였다. Table 1. Final functional status based on Iowa pelvic scoring system Individual score Activity of daily living 20 Work history 20 Pain 25 Limp 20 Visual pain line 10 Cosmesis 5 Total 100

724 최원식ㆍ김병성ㆍ김하용외 2 인 수술중및수술후의합병증을분석하였고, 방사선학적결과판정은수술전과수술후의골반전후면사진과 CT를분석하였고, 천장관절의전위정도는 CT 횡단면상천장관절면의전방피질골로의이행지점관절간격으로측정하였다. 또한최종추시시의골반전후면사 A C Fig. 1.

(B) The laser sights of the CT gantry indicated the cutaneous location of CT image slice.

(C) Local anesthesia of 1% lodicaine was administerd to the skin, subcutaneous tissue, and along the iliac periosteal surface. Using battery-powered equipment, a guide-wire for 7.

(D) The guide wire position was checked and appropriate screw length was measured using the measuring software. L 1 1 2 B D 진을분석하여나사못의해리나전위, 부러짐, 탈구부위의재전위및골유합여부를관찰하였다.

3 724 최원식ㆍ김병성ㆍ김하용외 2 인 수술중및수술후의합병증을분석하였고, 방사선학적결과판정은수술전과수술후의골반전후면사진과 CT를분석하였고, 천장관절의전위정도는 CT 횡단면상천장관절면의전방피질골로의이행지점관절간격으로측정하였다. 또한최종추시시의골반전후면사 A C Fig. 1. (A) Patients were placed in a prone position on the scanner bed. The cutaneous site of insertion was localized relative to a radiopaque marker on the skin. (B) The laser sights of the CT gantry indicated the cutaneous location of CT image slice. Using the measuring software, the distance from marker on the skin to the exact site of entry was measured on the monitor. (C) Local anesthesia of 1% lodicaine was administerd to the skin, subcutaneous tissue, and along the iliac periosteal surface. Using battery-powered equipment, a guide-wire for 7.0 mm selfdrilling and tapping cannulated cancellous screw was placed into the sacral body with appropriate angle. (D) The guide wire position was checked and appropriate screw length was measured using the measuring software. L B D 진을분석하여나사못의해리나전위, 부러짐, 탈구부위의재전위및골유합여부를관찰하였다. 임상적결과판정은 Iowa Pelvic score (Table 1) 9) 를사용하여, 술자가아닌제3 자가일상생활활동, 직업력, 동통, 파행, 시각적동통점수, 미용항목별로점수를부여하여측정하였다. 수술후 3주부터는휠체어타기를허용하였고, 10주에는전체중부하보행을실시하였다. 결과모든예에서일측성으로수술이시행되었고 ( 우측 4예, 좌측 5예 ), 9예의수술에서총 14개의나사가삽입되어, 5예에서는 2개의나사못을, 4예에서는 1개의나사못을사용하였다. 평균수술시간은나사못 1개당 24분이었다. 수술중나사못의척추관이나추간공으로의침범으로인한신경손상이나혈관손상은발생하지않았다. 또한수술후혈종이나창상감염, 창상괴사등의합병증도발생하지않았다. 모든예에서수술후수혈은필요하지않았다. 모든환자에서수술후직후부터침상내체위변동이가능하였고, 3주부터는휠체어타기를허용하였다. 수술후 10주에는모든환자에서전체중부하보행을실시하였다. 방사선학적분석결과수술전평균 8.2 mm의천장관절의전위가나사못고정후 3.6 mm로감소되었다 (Table 2). 추시기간중에실시한방사선학적검사상모든예에서평균 3개월만에만족스러운골유합을얻을수있었고나사못의해리나전위, 부러짐, 탈구부위의재전위소견은관찰되지않았다 (Fig. 2). Iowa pelvic score 를이용한임상적기능평가상평균 84점 ( 최저 57점에서최고 95점 ) 으로만족할만한결과를얻었다. Table 2. Patient data Case Classification Anterior fixation Number of screw Follow-up duration SI joint gap pre-op post-op final APC, Anteroposterior compression injuries; CM, Combined mechanism injuries; LC, Lateral compression injuries. OP time Complication 1 APC3 ORIF APC3 ORIF CM ORIF APC3 ORIF LC3 Conservative APC3 ORIF Symphysis fixation loss 7 LC3 ORIF LC3 Conservative LC2 Conservative Bed sore

$This patient, with Young-Burgess type LC3 injury, also had an associated subtrochanteric fracture and urethral jnjury. (B) CT shows widely displaced left sacroiliac joint.$ Using CT software, the desired trajectory of the screw can be drawn. The cutaneous projection of this trajectory is then measured to the radiopque marker.

Using CT software, the desired trajectory of the screw can be drawn. The cutaneous projection of this trajectory is then measured to the radiopque marker.

(D) CT shows that the final seating of SI screw gives reduction of the diastasis. 고찰불안정하고전위된골반환손상의특징은고에너지손상으로발생되며, 출혈량이많아사망률또한높고, 기타신체다른장기의동반손상이흔하며, 합병증및후유증을남길수있다.

외고정장치를이용한골반환의외고정은빠르고간단하게시행할수있지만, 후방골반환에대한고정으로는견고하지못 하다 13). 이에반해관혈적정복및내고정은골절부위를직접보면서정확한정복을얻을수있다는장점이있지만, 광범위한절개로인한창상괴사및감염, 골반개방시압박효과소실로인한출혈량의증가, 그리고신경및혈관손상의위험이있다 6,16,18).

4 후방골반환손상환자에서의국소마취하 CT 를이용한경피적천장관절나사고정술 A 3 B C D Fig. 2. (A) Anteroposterior pelvic radiograph of 20-year-old patient with left sacroiliac joint separation made at the time of the injury. This patient, with Young-Burgess type LC3 injury, also had an associated subtrochanteric fracture and urethral jnjury. (B) CT shows widely displaced left sacroiliac joint. Using CT software, the desired trajectory of the screw can be drawn. The cutaneous projection of this trajectory is then measured to the radiopque marker. This corresponding length is marked with pen mark along the transverse laser sight. (C) Postoperative AP radiograph, showing reduction and the position of the screws. (D) CT shows that the final seating of SI screw gives reduction of the diastasis. 고찰불안정하고전위된골반환손상의특징은고에너지손상으로발생되며, 출혈량이많아사망률또한높고, 기타신체다른장기의동반손상이흔하며, 합병증및후유증을남길수있다. 그러나, 해부학적인구조의어려움과동반손상으로인해수술적치료는어려운문제로인식되어왔다. 이러한불안정골반환손상의경우보존적인치료만으로는만족스러운결과를얻을수없기때문에, 해부학적인정복과견고한고정이반드시필요하다고할수있다 4,21). 최근들어경험이축적됨에따라불안정후방골반환손상시, 후방골반을안정화시키는수술적방법은여러가지가소개되고있다. 외고정장치를이용한골반환의외고정은빠르고간단하게시행할수있지만, 후방골반환에대한고정으로는견고하지못 하다 13). 이에반해관혈적정복및내고정은골절부위를직접보면서정확한정복을얻을수있다는장점이있지만, 광범위한절개로인한창상괴사및감염, 골반개방시압박효과소실로인한출혈량의증가, 그리고신경및혈관손상의위험이있다 6,16,18). 방사선투시하에나사못으로천장관절을고정하는술식은 Matta 등 10,13,15,19) 이처음으로소개하였는데, 광범위한절개가필요하지않아창상감염을현저하게줄일수있으며, 조기거동을가능하게하여합병증을줄일수있어서, 그사용이일반화되기시작했다. 그러나장내가스나비만으로인해영상의질이좋거나천골의해부학적변이로인해나사못의삽입이잘못되면, 제5 요추나제1천추신경근및장골혈관과복강내장기가손상될가능성이있다 15). Routt 등 14) 은체위와장내가스그

5 726 최원식ㆍ김병성ㆍ김하용외 2 인 리고방사선투시기기의부실등으로인해 10% 에서영상에문제가있을수있다고하였고, 잘못된위치로삽입된나사못 5예를보고한바있는데, 이는 13% 까지발생하는것으로알려져있다. 또한, Templeman 등 17) 은나사못의각도가 4 만차이나게삽입되더라도신경, 혈관손상을야기할수있다고하였다. 이를예방하기위한방법으로수술중에초음파, 유발전위나근전도검사를시행해야한다는주장이제기되고있는실정이다 11,12,20,22). 그렇다해도수술중정확한영상을얻고, 혈관손상을피해야하는근본적인문제점이해결된것은아닌데, 이러한문제점은 CT를이용한영상으로해결될수있게되었다. Nelson과 Duwelius 1) 는 CT를이용한경피적천장골나사고정술을처음소개하였고, Ebraheim 등 2) 은그결과를보고하였다. 비록이러한연구들이좋은결과들을보고하고있지만, CT 테이블위에서전신마취후에수술을시행하여야하므로, CT실을수술실로전용하는데따르는여러문제점이있다. 이에본교실에서는환자에게국소마취와진통제만으로수술을시행하여서마취과의사의도움이필요하지않았고, 마취비용을절감할수도있을뿐아니라, 간단한환자감시기구 ( 심전도기와 pulse oxymeter) 와환자와의대화를통해환자의신경학적상태를모니터링할수있었다. 하지만정복이적절치않거나정복술중환자가동통을참을수없다면, 환자를다시수술방으로옮겨마취하에고정술을시행해야하는단점을갖고있다. 따라서, 전위가심하거나, 전방골반환손상이동반된경우는, 수상초기에수술장에서전방고정을시행하면서, 미리충분한정복을얻은후환자가어느정도안정되었을때후방고정을시행하는것이, 무리한정복을시도하는것보다유리할것이다. 실제로본연구에서도나사삽입시, 삽입방향으로의압박력만으로천장관절간격의감소효과를얻었다. 특히나사삽입점과삽입각도를조절함으로써, 관절간격정복효과를극대화할수있었다. 이런조작은방사선투시기하에서는불가능한것이다. Ziran 등 24) 도같은원리로소위정복용나사를천장관절을가로질러삽입함으로써, 전위된경우에도정복을시도하였는데, 전위정도가경미하면서임상적으로불안정하다고판단되는후방골반환손상의경우는, 따로정복을시도하지않고, 나사를삽입하였다. 또한전위된경우라하더라도전방고정을시행한후에후방골반환을다시평가하여, 적절한정복이얻어지면, 그상태로천장관절나사고정을시행하였다고보고하였다. 이처럼이시술의한계를파악하고적절한적응에사용한다면, 기존의방사선투시하에시행하던천장관절고정술의단점을보완할수있는방법이될수있을것이고, 특히술자가천장관절나사삽입술의경험이많지않다면, 안전하면서도손쉽게익힐수있는방법으로생각한다. 향후 Fluoroscopic CT의사용이본격화된다면, 실시간영상을얻는것이가능해지기때문에, 이시술에걸리는시간을더욱단축할수있을것이다. 본연구의증례는모두혈역학적으로안정된후에후방골반환에대한고정을시행하였는데, 실제혈역학적으로불안정한초기에는후방골반환에대한응급고정술보다는골견인과더불어수혈을시행하면서, 조기에전방골반환손상에대한정복및내고정을시행하였다. 본연구에서는심한전위와분쇄를동반한전방골반환손상과더불어, 전위된후방골반환의손상이있는생역학적으로불안정한골반환손상에대해, 조기에전방골반환손상에대한정복및내고정후에후방골반환전위가줄어드는것을관찰할수있었다. 그러나, 후방골반환고정술을추가로시행하지않고서는골반환전체의안정성을회복할수없다고판단되어, 후방골반환에대한경피적핀고정술을추가하게되었다. 이로써골견인없이후방골반환재전위의위험성을줄이면서도, 보다빠른재활치료가가능하였다. 또한, 단순방사선사진상으로는전방골반환전위는심하지않지만, 전후방골반환모두가손상되어임상적으로불안정골반환손상으로판돤된경우는후방골반환고정술을비교적조기에시행하여, 보존적치료보다빠른거동을시작할수있었다. 나사못을이용한천장관절고정술은여러체위에서그고정이가능한데저자들은모두복와위에서시행하였다. 복와위의단점은전방골반환의조작이어렵다는것인데, 저자들의경우전방골반환에대해서미리수술전에앙와위에서정복을얻을수있었고, 복와위에서는무리한조작을시행할필요가없었기때문에체위로인한문제는특별히없었다. 특히다양한골절형태에따라그에따른가장적절한체위로전방골반환고정시에정복을얻고나서, 남아있는천장관절이완에대해서는 CT 를통해관절의이완된형태에따라나사의삽입점및삽입방향을달리함으로써정복을최적화할수있었다.

6 후방골반환손상환자에서의국소마취하 CT 를이용한경피적천장관절나사고정술 727 결론국소마취하에서 CT를이용한경피적천장관절나사고정술은간편한장비와인력으로시술할수있으며, CT 를이용하여양호한방사선학적정보를얻을수가있어서, 나사못의정확한삽입점위치와각도의결정으로합병증을방지할수있었다. 그러므로후방골반환손상환자에서국소마취하에서 CT를이용한경피적천장관절나사고정술은비교적간편하며안전한수술방법으로생각된다. 참고문헌 1. Duwelius PJ, Allen MV, Bray TJ and Nelson D: Computed tomography-guided fixation of the unstable posterior pelvic ring disruptions. J Orthop Trauma, 6: , Ebraheim NA, Coombs R, Jackson WT and Rusin JJ: Percutaneous computed tomography-guided stabilization of posterior pelvic fractures. Clin Orthop, 307: , Gansslen A, Pohlemann T and Paul CH: Epidemiology of pelvic ring injuries. Injury, 27: 13-20, Goldstein A, Phillips T, Sclafani SJ, et al: Early open reduction and internal fixationof the disrupted pelvic ring. J Trauma, 26: , Keating JF, Werier J, Blachut P, et al: Early fixation of the vertically unstable pelvis: the role of iliosacral screw fixation of the posterior lesion. J Orthop Trauma, 13: : Kellam J, Mcmurty R, Parley D and Tile M: The unstable pelvic fracture: Operative treatment. Ortho Clin N Am, 18: 25-41, Kim JJ, Kimm DH, Chang JS and Kim KY: Early results of percutaneous Iliosacral fixation I unstable posterior pelvic ring injury. J Korean Orthop Assoc, 32: , Kim JJ, Jeong YG, Chang JS, Kim KY and Baek SK: Percutaneous Iliosacral fixation I unstable posterior pelvic ring injury. J Korean Orthop Assoc, 34: , Martin JG, Nepola JV and Marsh JL: The treatment of unstable pelvic injuries with external fixation. Orthop Trans, 18: 1053, Matta JM and Saucedo T: Internal fixation of pelvic ring fractures. Clin Orthop, 242: 83-97, Moed BR and Ahmad BK: Intraoperative monitoring with stimulus-evoked electromyography during placement of iliosacral screws. J Bone Joint Surg, 80-A: , Moed BR, Hartman MJ, Ahman BK, Cody DO and Craig JG: Evaluation of intraopertive nerve monitoring during insertion of an iliosacral implant in an animal model. J Bone Joint Surg, 81-A: , Routt ML Jr, Kregor PJ, Simonian PT and Mayo KA: Early results of percutaneous iliosacral screws placed with the patient in the supine position. J Orthop Trauma, 9: , Routt ML Jr, Simonian PT and Mills WJ: Iliosacral screw fixation: Early complications of the percutaneous technique. J Orthop Trauma, 11: , Shuler TE, Boone DC, Gruen GS and Peitzman AB: Percutaneous iliosacral screw fixation: Early treatment for unstable posterior pelvic ring disruptions, J Trauma, 38: , Simpson LA, Waddell JP and Leighton RK: Anterior approach and stabilization of the disrupted sacroiliac joint. J Trauma, 27: , Templeman D, Schmidt A, Freese J and Weisman I: Proximity of iliosacral screws to neurovascular structures after internal fixation. Clin Orthop, 329: , Tile M: Fracture of the pelvis and acetabulum. 2nd ed, Philadelphia, Williams and Wilkins: , Tile M: Acute pelvic fractures. II. Principles of management. JAAOS, 4: , Tonetti J and Carrat L: Percutaneous ilioscaral screw placement using image guided techniques. Clin Orthop, 354: , Trunkey DD, Champman MW, Lim RC Jr and Dunphy E: Management of pelvic fractures in blunt trauma injury. J Trauma, 14: , Webb LX, de Araujo W, Donofrio P, et al: Electromyography monitoring for percutaneous placement of iliosacral screws. J Orthop Trauma, 14: , Young JW, Burgess AR, Brumback RJ and Poka A: Pelvic fractures: Value of plain radiography in early assessment and management. Radiology, 160: , Ziran BH, Smith WR, Towers J and Morgan SJ: Iliosacral screw fixation of the posterior pelvic ring using local anesthesia and computerised tomography. J Bone Joint Surg, 85-B: , 2003.

10-06 오광준(국)

10-06 오광준(국) ORIGINAL ARTICLE http://dx.doi.org/10.5371/hp.2012.24.2.139 Surgical Fixation of Sacroiliac Joint Complex in Unstable Pelvic Ring Injuries Kwang-Jun Oh, MD, Seok-Min Hwang, MD Department of Orthopedic