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1 485 pissn : , eissn : Case Report J Korean Orthop Assoc 2014; 49: 오현철 박성진 * 윤한국 국민건강보험일산병원정형외과, * 연세대학교의과대학정형외과학교실 Surgical Treatment in Atypical Diaphyseal Femoral Fracture with Anterior and Lateral Bowing Hyun Cheol Oh, M.D., Seong Jin Park, M.D.*, and Han Kook Yoon, M.D. Department of Orthopedic Surgery, National Health Insurance Service Ilsan Hospital, Ilsan, *Department of Orthopaedic Surgery, College of Medicine, Yonsei University, Seoul, Korea In an atypical diaphyseal femoral fracture with marked anterior and lateral bowing, there are some obstacles in fixation of the fracture, such as difficulty in insertion of the intramedullary nail (IM nail) due to mismatch of the IM nail with the bow of the femur, iatrogenic fracture, nonunion due to angulation, and leg length discrepancy. We experienced a good result, which was achieved after fixation of the counterlateral curved IM nail; therefore, we report on this case with a review of the literature. Key words: femur shaft, atypical diaphyseal femoral fracture, anterior and lateral bowing, intramedullary nail 최근골다공증치료를위해장기간비스포스포네이트를사용한 환자에서의비전형적대퇴골골절의발생이보고되고있다. 비전 형적대퇴골골절은가벼운외상이나외상의경력없이주로전 자하부및대퇴골간부에비전형적인형태, 즉수평혹은짧은사 선골절이며, 분쇄상이없는단순골절로외측에서시작하여내측 에돌기형성들의특징을보이는골절양상을지칭한다. 이런비 전형적골절에서는연골내골화 (endochondral repair) 가잘이루 어지지않으며따라서금속판보다는골수강내정을사용하는것 이좋다고보고되고있다. 1) Sasaki 등 2) 의일본인을대상으로한연 구에의하면비정형적대퇴부간부골절이대퇴부의만곡이큰 경우에서높게발생한다고보고하고있으며일반적으로이렇게 만곡각이큰대퇴골에서수술시대퇴골과금속정의만곡도의 차이로인해삽입과정에서의인성골절, 각형성으로인한불유 Received January 29, 2014 Revised May 20, 2014 Accepted June 17, 2014 Correspondence to: Han Kook Yoon, M.D. Department of Orthopedic Surgery, National Health Insurance Service Ilsan Hospital, 100 Ilsan-ro, Ilsandong-gu, Goyang , Korea TEL: FAX: hangugy@hanmail.net 합, 수술측하지가길어지는하지부동등의문제가발생할수있다. 3) 저자들은이러한합병증을줄이기위하여새로운방법으로골수강내정고정술을시행하였으며좋은결과를얻었기에문헌고찰과함께보고하고자한다. 증례보고 76세여자환자로내원당일빗길에서미끄러져넘어지며발생한우측대퇴중간부위통증으로내원하였다. 골다공증으로 5년간비스포스포네이트제제와칼슘을복용하고있었으며신체검사에서우측대퇴중간부에부종이관찰되었고압통이있었다. 단순방사선전후면사진에서우측대퇴간부의외측피질골의비후와분쇄가없는짧은사상형의비전형적대퇴골골절소견이관찰되었다 (Fig. 1A). 건측의단순방사선사진상대퇴간부의전방및외측만곡은 Yau 등 4) 이사용한측정방법에의해각각 19.5 도, 19도로측정되어, 심하게증가되어있음을확인할수있었다 (Fig. 1B, 1C). The Journal of the Korean Orthopaedic Association Volume 49 Number Copyright 2014 by The Korean Orthopaedic Association 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.

$486 오현철 박성진 윤한국 Figure 1. (A) Preoperative radiograph shows an atypical diaphyseal femur fracture.$ comminution, a medial spike (black arrow), and localized periosteal thickening of the lateral cortex (white arrow).

comminution, a medial spike (black arrow), and localized periosteal thickening of the lateral cortex (white arrow).

Expert Asian Femoral Nail (A2FN; Synthes, Solothurn, Switzerland) is designed having a proximal lateral band (A) and anterior curve (B).

Expert Asian Femoral Nail (A2FN; Synthes, Solothurn, Switzerland) 은대전자삽입이가능하도록전방만곡뿐아니라근위부에

$환자를골절대 (fracture table) 에눕히고상체는반대편으로밀어고관절을중심으로약간내전되게하여유도핀과금속정삽입을용이하게하였다.$

2 486 오현철 박성진 윤한국 Figure 1. (A) Preoperative radiograph shows an atypical diaphyseal femur fracture. The radiographic features include a common location in the femoral shaft lesion, short oblique fracture configurations, absence of comminution, a medial spike (black arrow), and localized periosteal thickening of the lateral cortex (white arrow). (B, C) Uninjured femur (left side) has marked anterior and lateral bowing. Figure 2. Expert Asian Femoral Nail (A2FN; Synthes, Solothurn, Switzerland) is designed having a proximal lateral band (A) and anterior curve (B). 치료에있어일반적인골수강내정을시행할경우대퇴골의외측만곡이심하여정확히삽입하기어려우며추가적인골절의위험성이높다고판단되었다. Expert Asian Femoral Nail (A2FN; Synthes, Solothurn, Switzerland) 은대전자삽입이가능하도록전방만곡뿐아니라근위부에 5도의외측만곡이존재하고이로인해삼점고정이가능하며직경이가늘어도안정성을얻을수있는점에착안하여우측의골절에대하여반대쪽 ( 좌측 ) 용 A2FN 의고정을계획하였다. 환자를골절대 (fracture table) 에눕히고상체는반대편으로밀어고관절을중심으로약간내전되게하여유도핀과금속정삽입을용이하게하였다. 대전자부 (greater trochanter) 를삽입점으로하여유도핀을삽입하였으며유도핀을이용하여골수정의길이를 340 mm로결정하였고직경은삼점고정이가능하여가장작은크기의 9 mm로결정하였다. 1 mm 과확공 (overreaming) 후에반대쪽 ( 좌측 ) 용 A2FN 을연결대 (zig) 를 180 도 돌려서연결하였고골수정삽입은 90도세워서삽입점을통과시킨후점차수평으로돌려가면서진행하였다. 연결대를 180 도돌려서연결하여교합나사는수평방향으로밖에고정할수없었으며골절부에서먼쪽인근위부에역동구멍 (dynamic hole) 에, 원위부는정적구멍 (static hole) 에교합나사를고정하였다 (Fig. 2). 술후의정복정도는각형성없이만족스러웠으며 4개월추시상에서가골이형성되며유합진행소견을확인할수있었다 (Fig. 3). 고찰 노인인구증가로골다공증성골절이증가하고있으며이에대한예방을위해비스포스포네이트제제와같은골다공증치료약제의사용이증가하고있다. 비스포스포네이트는파골세포를억제하여골교체율을감소시킴으로써골량을증가시키는기전으로

3 487 Figure 3. (A, B) Using contralateral curved intramedullary nailing, the operation was performed. Radiographs of the femur taken four months after the operation show callus formation at the fracture site, diminished lateral bowing and gap of the fracture. 골다공성골절을예방하는초기약물로사용되어왔으나장기간 의사용은골의재생성을과도하게억제하여골의기계적강도를 저해하고골에일어나는미세한손상을복원을지연시켜대퇴간 부비외상성비전형적인형태의골절을증가시키는것으로알려 져있다. 1) 최근비전형적대퇴부골절과임상적연관성에대해 Lo 등 5) 은 아시아인에서부전골절의빈도가많음을보고하였다. 미국캘리 포니아와캐나다토론토에서비전형적대퇴골골절에대한역학 조사를실시한결과이환된환자의 45% 가아시아계이민자였으 며백인에비하여약 4 배가높았다고한다. 6) Saita 등 7) 은하지의해 부학적축과대퇴골과경골의해부학적축의편차가클수록대퇴 간부에비전형적대퇴부골절발생가능성이크다고보고하였다. 이는대퇴골만곡이심한경우체중부하선에서멀어지며이로 인해외측피질골에강한견인력이작용하여피로가누적되고금 이가는손상이발생하지만이를적절히보수하지못하기때문에 사소한외상으로도골절이발생하는것으로추정된다. 이러한비전형적대퇴간부골절의수술적치료로금속판및 골수강내정고정술이있다. 잠김압박금속판이모든골절치료 시많이사용되고있으나대퇴골만곡이심한환자에서는금속판 과피질골간의간격이존재하게된다. 만곡이심한골에서역학 적축 (mechanical axis) 과내고정물사이의거리가증가하게되고 굽힙응력 (bending moment) 이증가하게되어외측만곡이가장 심한부위에서체중부하시에골절부의내반력으로인해금속판 의파절가능성이높아지게된다. 비전형적대퇴간부골절의수술적치료시에골수강내정은 하중을직접견디는 (load bearing) 금속판에비해하중을나누어 갖는 (load sharing) 특성을가지며, 골수혈행과내골막은파괴하 나외골막은보전하여골막성골형성을장해하지않고골유합을얻는장점이있는유용한치료방법으로생각된다. 그러나각개인의골수강의형태와골수강내정의형태는일치하지않으며특히골다공증과함께대퇴골의심한만곡이있는경우합병증의발생가능성이더욱높아진다. Harma 등 8) 은대퇴골과현존하는골수강내금속정과의만곡도를비교하였고, 이에따르면현존하는금속정의만곡반경 (radius of curvature) 은 cm이며대퇴골의평균만곡반경은평균 77 cm ( cm) 로불일치가존재함을보고하였다. 대퇴골과금속정의불일치로인해대퇴골원위부피질골에서골절이발생할수있으며그외에각형성으로인한불유합, 회전부정렬 (rotational misalignment), 나사못잠금장치의불일치 (interlocking screws mismatch), 금속정의제거의어려움, 골수강내정삽입후수술측하지가길어지는하지부동등의합병증이유발될수있다. 이러한문제점을해결하기위해이상적인금속정삽입점및만곡을반영한금속정에대한연구가진행되었다. 금속정삽입점에대해 Gausepohl 등 9) 은곧은금속정 (straight nail, R=800) 의경우이상근와가이상적인삽입점 (ideal entry point) 이며금속정의만곡반경이작아질수록삽입점이후외측 (dorsal & lateral side) 으로이동해야한다고하였다. 또한대퇴골만곡이골형태에맞도록고안된골수강내정이개발되어활용되기시작하였다. 대퇴골의형태에따라전방만곡 (anterior curvature) 이있고기술적편이를위해대전자 (greater trochanter) 삽입이가능하며, 이로인한내반변형의위험성을줄이기위해근위부외측굽힘 (trochanteric proximal lateral bend) 이있는골수강내정이사용되고있다. 하지만전방및외측만곡이심한환자에서골수강내정의삽입은기술적어려움뿐만아니라형태학적불일치로인해위에서언급한합병증이발생할가능성이존재하며, 자연적인외측만곡이억지로펴진효과로인해체중부하시에내반력이작용하여골수강내정파절이일어날수있고하지길이의차이가발생할수있다. 이러한증례에서본저자들은 A2FN 에서근위부에 5도의외측굽힘이존재하는점에착안하여반대쪽금속정을삽입함으로써대퇴골의해부학적축과일치하는고정을얻을수있었다. 대퇴골같이휘어져있는뼈는부하가편심으로걸린다. 체중부하를하게되면오목한내측피질에는압박력이가해지고볼록한외측피질에는인장력이가해진다. 이러한경우본증례와같이골수강내정을삽입할경우볼록면에는인장대 (tension band) 와오목면에는지지 (buttress) 의역할을한다. 해부학적으로일치하는골수강내정은고유의생역학적장점과더불어인장대금속판과지지금속판 2개를부착한역할을할수있다. 즉골절고정의삼점원칙을지키면서굴곡에대한저항력과회전에대한고정력도우수하였고본증례에서도약 4개월후골유합이진행됨을확인할수있었다.

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5 489 pissn : , eissn : Case Report J Korean Orthop Assoc 2014; 49: 오현철 박성진 * 윤한국 국민건강보험일산병원정형외과, * 연세대학교의과대학정형외과학교실 만곡을가진비전형적대퇴골골절의내고정에있어골수강내정고정술은만곡된대퇴골과골수정과의불일치로인한삽입의어려움, 의인성골절, 각형성으로인한불유합, 하지부동등의문제가생길수있다. 저자들은심한전방및외측만곡이있는비전형적대퇴골간부골절환자에서반대쪽용만곡된골수강내금속정을이용하여정복술을시행하여좋은결과를얻었기에문헌고찰과함께보고하고자한다. 색인단어 : 대퇴골간부, 비전형적대퇴골골절, 전방및외측만곡, 골수강내정 접수일 2014 년 1 월 29 일수정일 2014 년 5 월 20 일게재확정일 2014 년 6 월 17 일책임저자윤한국고양시일산동구일산로 100, 국민건강보험일산병원정형외과 TEL , FAX , hangugy@hanmail.net 대한정형외과학회지 : 제 49 권제 6 호 2014 Copyright 2014 by The Korean Orthopaedic Association 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.

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untitled 대한골절학회지제23권, 제2호, 2010년 4월 Journal of the Korean Fracture Society Vol. 23, No. 2, April, 2010 증례보고 대퇴골간부골절의금속정삽입도중발생한대퇴골근위부의방출형골절 - 증례보고 - 김지완 * ㆍ변성은ㆍ오원혁 ㆍ김정재 울산대학교의과대학서울아산병원정형외과학교실, 인제대학교의과대학해운대백병원정형외과학교실