02/15-030/이주엽/96-103

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1 ORIGINAL ARTICLE pissn eissn J Korean Soc Surg Hand 2015;20(3): ;20(3): JOURNAL OF THE KOREAN SOCIETY FOR SURGERY OF THE HAND Volar Locking Plate Fixation for Distal Radius Fractures in Hemodialysis Patients Jin-Hyung Im 1, Sung-Woo Huh 2, Min-Kyu Park 1, Joo-Yup Lee 1 1 Department of Orthopedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea 2 Department of Orthopedic Surgery, Hong-Ik Hospital, Seoul, Korea Received: July 26, 2015 Revised: [1] August 25, 2015 [2] September 1, 2015 Accepted: September 3, 2015 Correspondence to: Joo-Yup Lee Department of Orthopedic Surgery, St. Vincent s Hospital, College of Medicine, The Catholic University of Korea, 93 Jungbudaero, Paldal-gu, Suwon 16247, Korea TEL: FAX: jylos@gmail.com This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Purpose: Although the possibility of distal radius fractures is strong in hemodialysis patients, there are many difficult problems such as the bleeding tendency, hypervascularity and injury to arteriovenous fistula. We studied the outcomes of open reduction and volar locking plate fixation of the distal radius fractures in hemodyalisis patients with ipsilateral arteriovenous fistula. Methods: From 2007 to 2009, a retrospective chart review was performed of eleven hemodialysis patients who underwent volar locking plate fixation for treatment of distal radius fractures. Eight of them were female and three were male and mean age was 68 years (range, years). Mean follow-up period was 19 months (range, months). All patients had osteoporosis with mean T-score of All operations were performed on the next day of hemodialysis. Scheduled hemodialysis was possible on the next day of surgery without splint. We analyzed radiographic results, the wrist range of motion, Mayo wrist score and disabilities of the arm, shoulder and hand (DASH) score at the last follow-up. Results: All fractures achieved anatomical reduction and united at final followup. Complications such as hematoma or occlusion of arteriovenous fistula were not observed. Mean Mayo wrist score was 78 and mean DASH score was 22. Conclusion: Volar locking plate fixation for distal radius fractures provides immediate support for continuing hemodialysis and exercise. Open reduction of the fractures and the use of tourniquet don t seem to increase the vascular complications like hematoma and fistula occlusion. Keywords: Distal radius, Hemodyalisis, Arteriovenous fistula, Fracture, Volar locking plate 서론 원위요골골절은전세계적으로정형외과의사가접하는가장흔한상지의골절이다 1,2. 대퇴경부골절, 근위상완골골절, 척추골절과함께골다공증과관련이있는골절로알려져있으며, 폐경후여성에게서그빈도가높은것으로알려져있다 3. 만성신부전에서는신기능저하로인하여저칼슘혈증, 저인산혈증과함께칼시트리올 (1,25-dihydroxyvitamin D) 이감소하며 4, 이로인하여이차적으로부갑상선기능이항진되어 5, 골대사의이상이발생한다. 골밀도의감소뿐아니라, 피질골에도변화가생기는것으로알려져있으며 6, 투석으로인한아밀로이드증 (amyloidosis) 으로골내낭종을형성하며골파괴를유발하기도한다 7. 만성신부전환자에게서발생할수있는취 96 Copyright c The Korean Society for Surgery of the Hand

2 Jin-Hyung Im, et al. Volar Locking Plate Fixation for Distal Radius Fractures in Hemodialysis Patients 약골절 (fragility fracture) 을예방하고자골의강도변화를진단하기위한방사선학적검사나, 혈청학적검사에대해많은연구가이루어져있다 만성신부전환자에게서이러한이차적인골의변화에더하여폐경이나고령에의한골감소나골다공증으로인하여원위요골골절의발생가능성이높지만, 그치료에대해서는많은연구가부족한실정이다. 대부분의만성신부전환자들이혈액투석을위하여상완, 전완부에동정맥루를가지고있어동정맥루의손상에대한위험성과출혈성경향때문에 11, 동정맥루의동측에원위요골골절이발생한경우수술을결정하기어려우며, 수술을한다고하더라도침습이적은경피적핀이나 12, 외고정기를고려할수있었다. 경피적핀과외고정기의원위요골골절의수술적고정치료결과에대해다양한보고가있었으며, 정복소실을보고하는일부연구들이있었다 전방잠김금속판 (volar locking plate) 은정복소실없이전방피질골만으로도좋은결과들이보고되어 최근원위요골골절치료에널리사용되고있다. 본연구에서는만성신부전환자에게서동정맥루의동측에발생한원위요골골절에대해서전방잠김금속판을이용한수술방법과임상적결과를알아보고자하였다. 대상및방법 2007년 3월부터 2009년 11 월까지만성신부전으로혈액투석을위한동정맥루를가지고동측에발생한불안정성원위요골골절에대하여, 전방잠김금속판을이용한수술을시행하고 1년이상추시가가능하였던환자를대상으로하였다. 수술은 Lafontaine 이정의한불안정성원위요골골절에해당하는환자에게서모두시행하였으며 21, 총11명중남자가 3명, 여자가 8명이었고, 평균연령은 68세이었다. 평균추시기간은 19개월 ( 범위, 12-28개월 ) 이었다. 골밀도검사에서평균 T 점수는 -2.7이었다. 수술시행후운동범위, disabilities of the arm, shoulder and hand (DASH) 점수, Mayo wrist 점수를측정하여임상적결과를평가하였으며, 수술후방사선검사를통하여유합시기와요측경사, 전방경사, 요측길이등의방사선학적지표를측정하였고, 도플러초음파검사를이용하여동정맥루의협착여부를확인하였다. 수술은혈액투석한다음날전신마취하에시행하였으며, 모든환자에게압박대를사용하였고, 액와부의바로원위부에위치시킨후상지를거상하고있다가압착 (squeezing) 없이피부절개직전 250 mm Hg 의압력으로팽창시켰다. 전방요수굴근도달법을이용하여, 요골동맥은요수근굴근막에포함하여요측으로박리하여보호하였다. 방형회내근을상완요골근 옆요측경계부위에서박리하여골절부위를노출시키고견인없이올림기 (freer elevator) 를이용하여지렛대 (leverage) 로전방피질골을정복한후전방잠김금속판을이용하여고정하였다. 고정후압박대의압력을제거하고국소적인출혈부위를지혈한뒤, 요골의요측경계부터박리하였던방형회내근을상완요골근에봉합하여전방잠김금속판을감싸고보호한뒤, 배액관을삽입하고피부를봉합하였다. 수술다음날동정맥루를이용한혈액투석을시행하였으며, 수술후 2일째에배액관을제거한뒤, 수술후 3일째부터관절운동을시작하고, 착탈이가능한부목을 6주간착용하며관절운동을지속하였다 (Fig. 1). 결과 11명모두 1 m 이하에서발생한저에너지에의한수상이었으며, 수상일로부터평균 4.3일에수술을시행하였다. 평균압박대사용시간은 36분이었다. 방사선학적골절의유형은 AO 유형 A2: 2명, A3: 4명, C1: 2명, C3: 3명이었으며, 방사선학적검사에서모든환자에게서평균 3.2개월에골유합을얻었다. 수술후방사선학적지표들은각각평균요측경사 25, 전방경사 : 13, 요측길이 : 11 mm로해부학적정복을얻었다 (Fig. 2). 최종추시에서평균관절운동범위는수근관절신전 62, 굴곡 43, 회외전 65, 회내전 55 이었다 (Fig. 3). 평균 Mayo wrist 점수는 78점, 평균 DASH 점수는 22점이었다. 도플러초음파검사상에서의동정맥루의협착이나혈종등수술로인한합병증은관찰되지않았다 (Fig. 4). 고찰 수명의연장, 식생활과생활패턴의변화, 운동량감소등으로당뇨와고혈압환자가증가하는가운데, 이로인한합병증으로만성신부전환자가증가하고있다. 2012년 the U.S Renal Data System Annual data Report에따르면이미약 59만명이만성신부전환자로등록이되어있으며, 이들중약 41 만명이상이혈액투석을받고있고 22, 투석치료의발전으로인하여 2000년도이후 20% 정도증가되었다 23. 만성신부전으로인한칼슘-인대사의변화와칼시트리올의감소로이차적인부갑상선항진증이발생하여부갑상선호르몬이증가하고, 골교체 (bone turn over) 가감소되어골연화증 (osteomalacia), 골감소증 (osteopenia), 무력성골질환 (adynamic bone disease) 의발생이불가피하여, 이로인한골강도의변화는노화에따른변화와함께그영향이클수있으며 4-7,24, 골 97

$J Korean Soc Surg Hand Vol. 20, No. 3, September 2015 Fig. 1. (A) The upper arm which have distal radius fracture with ipsilateral arteriovenous fistula is on hand table.$ $Radiographic images of 64 aged female with distal radius fracture and ipsilateral arteriovenous fistula show normal radiologic parameters and union in last follow-up.$

3 J Korean Soc Surg Hand Vol. 20, No. 3, September 2015 Fig. 1. (A) The upper arm which have distal radius fracture with ipsilateral arteriovenous fistula is on hand table. (B) Standard flexor carpi radialis (FCR) approach is performed. The FCR sheath including the radial artery is retracted to radial side. (C) Scheduled hemodyalisis was conducted on the first day after operation. (D) Wrist exercise was started without drain on the third day after operation. Fig. 2. Radiographic images of 64 aged female with distal radius fracture and ipsilateral arteriovenous fistula show normal radiologic parameters and union in last follow-up. 강도의변화로인한골절의발생률도증가하고있기때문에 7,25,26, 골밀도나골강도의감소를진단하기위한연구들이많이있었다 6,8-10. 골강도가감소한만성신부전환자들은동정맥루 부위의부자연스러운사용으로원위요골골절이발생한가능성이높지만, 아직이에대한뚜렷한치료방침도없으며, 일반적인방법을따른다하더라도혈액투석을하고있는상황이라 98

면동정맥루로인해지혈대및수술절개창의위치를결정하기어려워수술의적응증에해당하더라도수술적치료에어려움이발생할수있다.

4 Jin-Hyung Im, et al. Volar Locking Plate Fixation for Distal Radius Fractures in Hemodialysis Patients Fig. 3. The patients showed good range of motion in last follow-up. Fig. 4. Doppler sonography shows normal blood flow and no occlusion of fistula. 면동정맥루로인해지혈대및수술절개창의위치를결정하기어려워수술의적응증에해당하더라도수술적치료에어려움이발생할수있다. 전위가적은안정골절인경우석고고정을시행하면되겠으나유합까지석고고정으로인한압박성궤양, 피부염과같은피부합병증, 구획증후군, 관절강직등이발생하거나 27, 석고고정으로인하여차단된동정맥루로인해혈액 투석자체가중단될수밖에없는상황을초래한다 12. 불안정골절인경우수술적응증에해당되지만, 보편적으로동정맥루가있는경우지혈대를사용하는것뿐만아니라혈관손상을줄수있는압박이나, 침습적술기등을금하고있는상황에서관혈적으로골절부위에접근하기가어렵기때문에많은술자들이관혈적정복을기피하거나망설이고있을것이다. 99

5 J Korean Soc Surg Hand Vol. 20, No. 3, September 2015 동정맥루가있을경우지혈대의사용에대한연구가많지않으나, 만성신부전환자에게발생한동정맥루동측의수근관증후군에대하여압박대를사용하고성공적인수술결과를보고한연구가있으며 28, 동정맥루를형성한환자들에게지혈대를사용한운동을이용하여동정맥루의성숙 (maturation) 을성공적으로유도한연구도있는것으로보아 29, 짧은시간의지혈대의사용이절대적금기에해당하지는않는다고여겨진다. 지혈대의적용에있어 Green 등 30 은상완두동정맥루를가진경우동정맥루보다원위부에위치하는전완부압박대의사용을권고하였으나, 저자들은수술시지혈대를동측의액와부바로원위부에적용시켜, 상완두동정맥루, 요두동정맥루모든경우에서동정맥루보다근위부에위치하였다. 압력은 250 mm Hg 으로하였으며, 실제적용시간도피부절개직전부터금속판고정까지평균 36분으로그사용을최소화하였다. Sugiyama 등 31 은동정맥루와동측의원위요골골절 3예에대한치료결과를발표하며, 수술시압박대를사용하지않았다고하였으나, 증례가적으며, 평균환자연령등에서본연구와차이가있어더많은연구가필요할것으로보인다. 본연구에서모든환자는수술전일과수술다음날혈액투석시헤파린을사용하였으며, 혈액투석시작시 1,500 IU를일시주사 (bolus) 로사용하고 4시간의투석동안시간당 500 IU을투여하였다. 동정맥루의혈전형성방지를위하여사용하는헤파린은수술전, 후적용에대해고민할수있으나, 문헌에따라투석후 2-4시간이면헤파린은체외로배설되어항응고작용을하지않는다고보고하고있어 32,33, 투석을예정대로진행하고투석다음날수술을하는것에큰문제가없을것으로생각하였으며, 수술후혈종이나동정맥루의합병증등이발생하지않았다. 수근관증후군은혈액투석과관련된아밀로이드증으로인한가장흔한합병증으로문헌마다차이는있으나약 10% 정도의발생률이보고되고있다 34. 본연구에서는수상전과수술전, 수술후수근관증후군의증상을보인환자는없었으며, 수술시수근관유리술을시행하지않았다. 이는증례수가적어그러할것으로예상되며증례수가많아지면발생을예상할수있는합병증으로생각된다. 원위요골골절수술시고정방법선택을논함에있어외고정기기나, 경피적핀고정이불안정골절치료에효과적인지에대해서는아직까지논란이있다. 많은저자들이두가지의치료방법에따른결과와전방잠김금속판과의결과를비교하였으며, 발표한결과는저자들마다다양하였다 16-19,35, 그러나많은연구들의환자군과본연구의만성신부전환자군의골강도가다르기때문에여러가지고려해야할점들이있을것 으로생각된다. 두방법모두핀주위감염의가능성을가지고있으며, 외고정기기는고정기간에따른관절강직발생이가능하며, 경피적핀고정은핀의이동이나신경자극등이발생할수있다 36. 가장중요한점은외고정기기, 경피적핀고정모두고정물을제거한후에정복의소실에대해보고가있었으며 13-15, 만성신부전환자군의골강도가더욱약하기때문에전방피질골만으로도견고한고정이가능한전방잠김금속판이적합할것으로생각된다. 본연구에서는수술시수장측피질골을정확히맞추어전방경사를회복하고, 전방잠김금속판으로정복의소실을예방하여이로인해골유합후충분한파악력을유지할수있도록하는것을중요하게생각하였다. 전방잠김금속판내고정을통하여외고정기기나경피적핀고정에비해서유합까지정복소실없이견고하게고정하고조기에운동을시작하며, 쉽게착용과제거가가능한부목을사용하여고정기간을단축하였다. 본연구는몇가지제한점을가지고있다. 첫째, 의무기록평가를이용한후향적연구이며, 대조군없이전방잠김금속판이용한환자군만의평가의결과로, 다른고정방법으로수술한환자와의방사선학적, 임상적결과의비교가어려운제한점이있다. 둘째, 증례수가많지않아일반화하기에어려운점이있다. 따라서, 본연구에서는합병증없이만족할만한방사선학적, 임상적결과를보이고있으나, 압박대의사용이나관혈적정복술에의한동측의동정맥루에손상가능성을염두하여수술시주의해야할것으로생각된다. 여러가지제한점에도혈액투석환자의불안정성원위요골골절시동정맥루에발생할수있는손상을주의하여전방잠김금속판을이용한관혈적정복술을고려해볼수있을것으로생각된다. 결론 만성신부전환자에게동정맥루동측에발생한불안정원위요골골절에대하여, 조기운동을가능하게하고즉각적인혈액투석재개를위하여전방잠김금속판을이용한수술적치료를고려할수있다. REFERENCES 1. Karl JW, Olson PR, Rosenwasser MP. The epidemiology of upper extremity fractures in the United States, J Orthop Trauma. 2015;29:e Mehrpour SR, Nabian MH, Oryadi Zanjani L, Foroughmand-Araabi MH, Shahryar Kamrani R

6 Jin-Hyung Im, et al. Volar Locking Plate Fixation for Distal Radius Fractures in Hemodialysis Patients Descriptive epidemiology of traumatic injuries in adults: a 5-year-study in a tertiary trauma center in iran. Asian J Sports Med. 2015;6:e Stein EM, Kepley A, Walker M, et al. Skeletal structure in postmenopausal women with osteopenia and fractures is characterized by abnormal trabecular plates and cortical thinning. J Bone Miner Res. 2014;29: Moe S, Drueke T, Cunningham J, et al. Definition, evaluation, and classification of renal osteodystrophy: a position statement from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int. 2006;69: Reiss E, Canterbury JM, Kanter A. Circulating parathyroid hormone concentration in chronic renal insufficiency. Arch Intern Med. 1969;124: Nickolas TL, Stein EM, Dworakowski E, et al. Rapid cortical bone loss in patients with chronic kidney disease. J Bone Miner Res. 2013;28: Nickolas TL, McMahon DJ, Shane E. Relationship between moderate to severe kidney disease and hip fracture in the United States. J Am Soc Nephrol. 2006; 17: Maeno Y, Inaba M, Okuno S, Yamakawa T, Ishimura E, Nishizawa Y. Serum concentrations of cross-linked N- telopeptides of type I collagen: new marker for bone resorption in hemodialysis patients. Clin Chem. 2005; 51: Shidara K, Inaba M, Okuno S, et al. Serum levels of TRAP5b, a new bone resorption marker unaffected by renal dysfunction, as a useful marker of cortical bone loss in hemodialysis patients. Calcif Tissue Int. 2008;82: Ishimura E, Okuno S, Ichii M, et al. Relationship between serum sclerostin, bone metabolism markers, and bone mineral density in maintenance hemodialysis patients. J Clin Endocrinol Metab. 2014;99: Deykin D. Uremic bleeding. Kidney Int. 1983;24: Ishiguro S, Oota Y, Sudo A, Uchida A. Calcium phosphate cement-assisted balloon osteoplasty for a Colles' fracture on arteriovenous fistula forearm of a maintenance hemodialysis patient. J Hand Surg Am. 2007;32: Clancey GJ. Percutaneous Kirschner-wire fixation of Colles fractures: a prospective study of thirty cases. J Bone Joint Surg Am. 1984;66: Oskam J, Kingma J, Bart J, Klasen HJ. K-wire fixation for redislocated Colles' fractures. Malunion in 8/21 cases. Acta Orthop Scand. 1997;68: Ludvigsen TC, Johansen S, Svenningsen S, Saetermo R. External fixation versus percutaneous pinning for unstable Colles fracture: equal outcome in a randomized study of 60 patients. Acta Orthop Scand. 1997;68: Kumbaraci M, Kucuk L, Karapinar L, Kurt C, Coskunol E. Retrospective comparison of external fixation versus volar locking plate in the treatment of unstable intraarticular distal radius fractures. Eur J Orthop Surg Traumatol. 2014;24: Costa ML, Achten J, Plant C, et al. UK DRAFFT: a randomised controlled trial of percutaneous fixation with Kirschner wires versus volar locking-plate fixation in the treatment of adult patients with a dorsally displaced fracture of the distal radius. Health Technol Assess. 2015;19: Franceschi F, Franceschetti E, Paciotti M, Cancilleri F, Maffulli N, Denaro V. Volar locking plates versus K- wire/pin fixation for the treatment of distal radial fractures: a systematic review and quantitative synthesis. Br Med Bull. 2015;115: Roh YH, Lee BK, Baek JR, Noh JH, Gong HS, Baek GH. A randomized comparison of volar plate and external fixation for intra-articular distal radius fractures. J Hand Surg Am. 2015;40: Williksen JH, Husby T, Hellund JC, Kvernmo HD, Rosales C, Frihagen F. External fixation and adjuvant pins versus volar locking plate fixation in unstable distal radius fractures: a randomized, controlled study with a 5-year follow-up. J Hand Surg Am. 2015;40: Lafontaine M, Hardy D, Delince P. Stability assessment of distal radius fractures. Injury. 1989;20: O'Banion LA, Van Buren D, Davis JW. Radiocephalic fistulas for hemodialysis: a comparison of techniques. Am Surg. 2015;81: Lok CE. Fistula first initiative: advantages and pitfalls. Clin J Am Soc Nephrol. 2007;2: Levin A, Bakris GL, Molitch M, et al. Prevalence of abnormal serum vitamin D, PTH, calcium, and phosphorus in patients with chronic kidney disease: results of the study to evaluate early kidney disease. Kidney Int. 2007;71: Kaji H, Yamauchi M, Yamaguchi T, Shigematsu T, Sugimoto T. Mild renal dysfunction is a risk factor for a 101

7 J Korean Soc Surg Hand Vol. 20, No. 3, September 2015 decrease in bone mineral density and vertebral fractures in Japanese postmenopausal women. J Clin Endocrinol Metab. 2010;95: Ball AM, Gillen DL, Sherrard D, et al. Risk of hip fracture among dialysis and renal transplant recipients. JAMA. 2002;288: Boyd AS, Benjamin HJ, Asplund C. Principles of casting and splinting. Am Fam Physician. 2009;79: Naito M, Ogata K, Goya T. Carpal tunnel syndrome in chronic renal dialysis patients: clinical evaluation of 62 hands and results of operative treatment. J Hand Surg Br. 1987;12: Salimi F, Majd Nassiri G, Moradi M, et al. Assessment of effects of upper extremity exercise with arm tourniquet on maturity of arteriovenous fistula in hemodialysis patients. J Vasc Access. 2013;14: Green DP, Wolfe SW, Hotchkiss RN, et al. Green's operative hand surgery. 6th ed. Philadelphia: Elsevier Churchill Livingstone; Sugiyama Y, Naito K, Igeta Y, Obata H, Kaneko K, Obayashi O. Treatment strategy for distal radius fractures with ipsilateral arteriovenous shunts. J Hand Surg Am. 2014;39: Sagedal S, Hartmann A, Sundstrom K, Bjornsen S, Fauchald P, Brosstad F. A single dose of dalteparin effectively prevents clotting during haemodialysis. Nephrol Dial Transplant. 1999;14: Wilhelmsson S, Lins LE. Heparin elimination and hemostasis in hemodialysis. Clin Nephrol. 1984;22: Kopec J, Gadek A, Drozdz M, et al. Carpal tunnel syndrome in hemodialysis patients as a dialysis-related amyloidosis manifestation: incidence, risk factors and results of surgical treatment. Med Sci Monit. 2011;17: CR Williksen JH, Husby T, Hellund JC, Kvernmo HD, Rosales C, Frihagen F. External fixation and adjuvant pins versus volar locking plate fixation in unstable distal radius fractures: a randomized, controlled study with a 5-year follow-up. J Hand Surg Am. 2015;40: Strohm PC, Muller CA, Boll T, Pfister U. Two procedures for Kirschner wire osteosynthesis of distal radial fractures: a randomized trial. J Bone Joint Surg Am. 2004; 86:

8 Jin-Hyung Im, et al. Volar Locking Plate Fixation for Distal Radius Fractures in Hemodialysis Patients 혈액투석환자의동정맥루동측의원위요골골절에서전방잠김금속판을이용한수술적치료 임진형 1 허성우 2 박민규 1 이주엽 1 1 가톨릭대학교의과대학정형외과학교실, 2 홍익병원정형외과 목적 : 만성신부전환자에서혈액투석중인상완에원위요골골절발생가능성이높으나, 과다출혈이나동정맥루의손상등으로치료에어려운점이많다. 저자들은혈액투석환자에서발생한원위요골골절에대하여전방잠김금속판고정술을시행하고그결과를알아보고자하였다. 방법 : 2007년부터 2009년까지전방잠김금속판을이용하여동정맥루동측의원위요골골절을치료한 11명의만성신부전환자를대상으로하였다. 남자가 3명, 여자가 8명이었으며, 평균연령은 68세이었다. 평균추시기간은 19개월 ( 범위, 12-28개월 ) 이었다. 평균 T-score 가 -2.7로골다공증이있었다. 혈액투석은원래시행하던대로수술전날과다음날시행하였다. 최종추시에서골유합여부, 관절운동범위, Mayo wrist score, disabilities of the arm, shoulder and hand (DASH) score 를측정하였다. 결과 : 전례에서방사선학적해부학적정복을얻었으며, 동정맥루의협착이나혈종등수술로인한합병증은관찰되지않았다. 평균 Mayo wrist score 는 78 점, 평균 DASH score 는 22점이었다. 결론 : 혈액투석을시행하는환자의원위요골골절에서도조기에수장잠김금속판으로견고한고정을시행하는것이조기운동및빠른혈액투석의재개에도움이되며, 수술적치료및지혈대의사용이혈종이나동정맥루의폐쇄와같은합병증을증가시키지않는다. 색인단어 : 원위요골, 혈액투석, 동정맥루, 골절, 전방잠김금속판 접수일 2015 년 7 월 26 일수정일 1 차 : 2015 년 8 월 25 일, 2 차 : 2015 년 9 월 1 일게재확정일 2015 년 9 월 3 일교신저자이주엽경기도수원시팔달구중부대로 93 가톨릭대학교의과대학성빈센트병원정형외과학교실 TEL FAX jylos@gmail.com 103

원위부요척골관절질환에서의초음파 유도하스테로이드주사치료의효과 - 후향적 1 년경과관찰연구 - 연세대학교대학원 의학과 남상현

원위부요척골관절질환에서의초음파 유도하스테로이드주사치료의효과 - 후향적 1 년경과관찰연구 - 연세대학교대학원 의학과 남상현 원위부요척골관절질환에서의초음파 유도하스테로이드주사치료의효과 - 후향적 1 년경과관찰연구 - 연세대학교대학원 의학과 남상현 원위부요척골관절질환에서의초음파 유도하스테로이드주사치료의효과 - 후향적 1 년경과관찰연구 - 지도김석원교수 이논문을석사학위논문으로제출함