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1 ORIGINAL ARTICLE pissn eissn J Korean Soc Surg Hand 2015;20(4): JOURNAL OF THE KOREAN SOCIETY FOR SURGERY OF THE HAND Modified Split Ulnar Gutter Splint for Treatment of Fifth Metacarpal Neck Fractures Ho-Jin Gil, Yang-Guk Chung, Seung-Han Shin, Dong-Hyun Kim, Jin-Woo Kang, Sang-Hyun Jeon Department of Orthopedic Surgery, Seoul St. Mary s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea Received: August 21, 2015 Revised: [1] September 12, 2015 [2] October 8, 2015 Accepted: October 10, 2015 Correspondence to: Yang-Guk Chung Department of Orthopedic Surgery, Seoul St. Mary s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea TEL: FAX: ygchung@catholic.ac.kr 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: To evaluate radiological results of the modified split ulnar gutter splint for the fifth metacarpal neck fracture. Methods: Between December 2008 and May 2014, 17 patients (18 cases) with fifth metacarpal neck fractures were managed with our modified split ulnar gutter splint. Radiological outcomes in oblique and lateral radiographs were evaluated. Mean immobilization period was 4.9 weeks (range, 4-7) weeks. Mean follow-up period was 17.1 week (range, 8-80 weeks). Results: All of 18 fractures were completely united. The average of prereduction dorsal angulation, 27 in the oblique radiographs and 21 in the lateral radiographs, were corrected to 17 in the oblique radiographs and 10 in the lateral radiographs after closed reduction. At the last follow-up, they were 14 and 11 respectively. The mean difference of angulation deformity between in postreduction and final follow-up radiograms were 3 in the oblique radiographs and 1 in the lateral radiographs, which was not significantly different. Conclusion: Immobilization using modified split ulnar gutter splint will be a reliable option for the fifth metacarpal neck fractures in selected patients, which will avoid the surgeries. Keywords: Fifth metacarpal neck fracture, Closed reduction, Ulnar gutter splint 서론 흔히권투선수골절 (boxer s fracture) 이라고불리는제5중수골경부골절은전체수부골절의 20% 를차지할정도로가장흔한수부골손상이다 1. 이골절은주먹을쥔상태에서물체를가격할때주로발생하며, 제5중수골은형태상다른중수골에비해가늘고, 위치상주위조직의보호가약하여비교적쉽게골절이발생하는것으로알려져있다 2. Ford 등 3 은골절부각형성이 70 까지도보존적치료가가 능하고치료후기능에있어정상과차이가없다고하였고, Theeuwen 등 4 은수술적방법으로후방각형성을교정하는것이기능에큰이득이없다고하여보존적치료가시행되어왔다. 하지만최근발표된실험결과에서골절부각형성이 30 이상이되면관절을가로지르는근육, 건의작용효율에영향을주어중수지간관절굴곡기능에장애가있음이밝혀졌고 5,6 외관상으로도골절부각형성교정이안되었을경우주먹을쥐었을때중수관절배부 (knuckle part) 의함몰이발생할수있어부적절한보존적치료로는만족할만한치료결과 Copyright c The Korean Society for Surgery of the Hand 161

2 J Korean Soc Surg Hand Vol. 20, No. 4, December 2015 를얻지못할수있다. 임상적으로가장많이이용되는보존적치료법은도수정복없는부목고정, 도수정복및부목고정, 단기간의고정후조기관절운동등의다양한방법이있고, 부목고정에도많은방법이있으나 3,4,7-11 그중가장흔히사용되는것은척측구형성부목 (ulnar gutter splint) 을이용한치료이다. 저자들은전통적인척측구형성부목의취약한접촉면과삼점고정의문제점을보완한절개변형한척측구형성부목을이용하여고정후좋은결과를얻었기에방사선학적결과를보고하고자한다. 대상및방법 2008년 12 월부터 2014년 5월까지본원에서제5중수골경부골절로비관혈적정복술및절개변형한척측구형성부목고정술을시행받은 17명, 18 예를대상으로하였다. 비관혈적정복은마취없이외래에서영상증폭관찰하에서시행하였다. 17 명모두남자였고, 평균연령은 24세 ( 범위, 10-53세 ) 였으며, 평균고정기간은 4.9주 ( 범위, 4-7주 ) 였다. 평균추시기간은 17.1( 범위, 8-80주 ) 였다. 손상수지는우세수지 16예및비우세수지 2예였다. 손상기전은주먹으로가격후골절된경우가 13예로가장많았고, 이외에도실족 4예, 스포츠손상은 1예였다. 보존적치료의대상은 2주이내의골절로분쇄골절이아니고도수정복후사면, 측면방사선사진상남은각변형이 30 이하이며, 회전변형이없는환자로하였다. 예외로 1명의환자가수술적치료를거부하고석고고정술을선호하여정복후 50 이상의각변형이있었으나보존적치료를하였다. 부목을착용한이후외래에서정기적으로일반방사선사진을촬영하여 4-6주째가골등유합이순조롭게이루어지는과정이관찰될경우부목을제거하고능동적관절운동을시작하였으며 8주째일반방사선사진에서유합이완전히되었을경우수동적관절운동을시작하였다. 이후중수지관절의운동범위가완전히회복되고일반방사선사진에서이상이없을경우추시를그만하도록하였다. 제5중수골골절의배측각형성을정복하기위해흔히 Jahss 12 방법을사용하지만본원에서는정복시영상증폭관찰하에서종방향견인 (longitudinal traction) 함과동시에근위지골은배측으로들어올리고, 중수골간부는수장측으로밀어정복하였다 (Fig. 1). 정복을유지하면서석고붕대 (3M Scotchcast One-step Splint, 3 12) 를이용하여고정하는데 Fiberglass 석고붕대로내재근양성위치로척측구형성부목을만들기위해중수지관절을굴곡하면석고내빈공간이생겨골절부를정확하게접촉하여삼점고정을시켜주지못해 고정력이떨어지는단점이있다 13. 이에본원에서는이러한단점을보완하기위해중수골간부부터손가락끝까지석고붕대에접하는부분에종절개를미리가한후앞, 뒤의석고붕대절개된면을이용하여골절부의빈공간을최소화하는동시에접촉면을극대화하여삼점고정을시킬수있게변형시켰다 (Fig. 2) 결과판정은방사선학적으로정복전, 직후및최종추시의사면및측면방사선사진에서각형성을측정하여, 정복직후및최종추시시의각형성의변화를비교하여고정의안정성을평가하였다. 이때사면및측면방사선사진에서근위골절편과원위골절편의후방피질골음영을따라선을그어교차각으로각형성을측정하였다 14. 방사선학적결과분석을위하여 IBM SPSS ver. 19 (IBM Corp., Armonk, NY, USA) 를사용하여 paired t-test로검증하였으며유의수준은 0.05 이하로하였다. 결과 전체 17명, 18 예에서골유합이관찰되었고, 사면방사선사진상정복전각변형이평균 27 에서정복후평균 17 로교정되었고, 측면방사선사진상에서도 21 에서 10 로교정되어만족할만한결과를보였다 (p<0.001). 최종추시시의사면방사선사진상의교정각의변화는평균 3 였고, 측면방사선사진상 1 로석고고정기간중각변형의진행이없이정복후최 Fig. 1. Reduction method under image intensifier. Longitudinal traction applied while proximal phalanx was elevated toward dorsal direction and metacarpal shaft put down. 162

$Radiographic angulation in patients treated with closed reduction and ulnar gutter splint immobilization for the fifth metacarpal neck fracture Variable Radiographic evaluations Pre-reduction p-value$

3 Ho-Jin Gil, et al. Modified Split Ulnar Gutter Splint for Treatment of Fifth Metacarpal Neck Fractures Fig. 2. Molding method of modified split ulnar gutter splint. Table 1. Radiographic angulation in patients treated with closed reduction and ulnar gutter splint immobilization for the fifth metacarpal neck fracture Variable Radiographic evaluations Pre-reduction p-value Post-reduction p-value Last follow-up Anteroposterior radiographs < Mean angulation (range) ( ) 31.9 ( ) 16.8 (2-52.5) 17.1 (7-35.3) Oblique radiographs < Mean angulation (range) ( ) 27.2 ( ) 17.4 ( ) 14.5 ( ) Lateral radiographs < Mean angulation (range) ( ) 20.8 (6-38) 10.4 (2-22) 11.1 (2-19) 초고정상태가잘유지되었다 (p>0.05) (Table 1, Figs. 3, 4). 고찰 제5중수골경부골절은주로주먹을쥔상태에서가격시직접압박력에의해발생하며, 수부골절의약 20% 를차지하는흔한골절이다. 모든제5중수골의경부골절은전형적인배측각형성및불안정성으로인하여정복후원래의위치로돌아가려는경향을보여교정소실이나타난다 1. 제5중수골경부골절시골절부의후방각형성측정이어려운데이는정상적으로중수골두가캠 (cam) 모양을하고있고 중수골경부의정상적인전방경사로인하여중수골의시상축이직선이아니며, 측면방사선사진에서모든중수골들이겹쳐져보이기때문이다 14,15. 이러한이유로대부분저자들이사면방사선사진만으로각형성을측정한경우가많았으나이는방사선촬영각도에따라측정각이달라질수있다 16. 본연구에서저자들은사면뿐아니라측면방사선사진에서도각형성을추가로측정하여두방향에서의각변형을비교분석하여골절부가후방각형성외에회전변형이나척측각형성이될수있음을고려하여사면방사선사진에서각형성만을측정시발생할수있는오류를최대한보완하고자하였다. 측면방사선사진에서중수골들이겹쳐보여각형성을측정하기어려 163

$J Korean Soc Surg Hand Vol. 20, No. 4, December 2015 Fig. 3. (A) A 50-year-old man sustained a fifth metacarpal neck fracture with 24.$ $(C) 24-month follow-up radiographs show good union without any reduction loss or rotational deformity. Fig. 4. (A) A 28-year-old man sustained a fifth metacarpal neck fracture with 16.$

4 J Korean Soc Surg Hand Vol. 20, No. 4, December 2015 Fig. 3. (A) A 50-year-old man sustained a fifth metacarpal neck fracture with 24.5 angulation deformity on oblique radiograph, 18 angulation on lateral radiograph. (B) Post-reduction radiographs show 14.4, 9 residual angulation on oblique and lateral radiographs, respectively. (C) 24-month follow-up radiographs show good union without any reduction loss or rotational deformity. Fig. 4. (A) A 28-year-old man sustained a fifth metacarpal neck fracture with 16.5 angulation deformity on oblique radiograph, 6 angulation on lateral radiograph. (B) Post-reduction radiographs show 1.6, 2 residual angulation on oblique and lateral radiographs, respectively. (C) 10-week follow-up radiographs show good union and 2.3, 2 angulation on oblique and lateral radiographs, respectively. 웠지만사진을확대하여골절면의후방피질골의경계를찾는것이가장정확하고재현성있게잴수있어사면및측면방사선사진에서각형성측정시 Leung 등 14 과같이중수골의후방피질골의경계를기준으로하여측정하였다. 제5중수골골절의치료에있어서는크게보존적치료와수술적치료가있고각각에있어서도다양한방법이있다. 많은 문헌에서보존적치료로도우수한치료결과를얻을수있고보존적치료와수술적치료를비교할때기능적결과에차이가없음이발표되고있어서실제로임상에서가장많이사용되는것이보존적치료이다 7,9,10. 보존적치료의적응이되는범위는후방각형성이최소 20 이하에서최대 70 이하까지다양하게제기되었다 1,3,4,17,18. 하지만보존적치료후에골절부의 164

5 Ho-Jin Gil, et al. Modified Split Ulnar Gutter Splint for Treatment of Fifth Metacarpal Neck Fractures 각형성의교정이되지않았거나교정했어도교정의소실이일어날경우주먹을쥐었을때중수골두부의함몰이발생하여외관상문제가생길수있다. Ali 등 5 과 Birndorf 등 6 은실험결과상중수골경부의각형성이 30 이상일경우제5수지굴곡건 (flexor digiti minimi) 의굴곡력저하, 운동범위의감소, 건활주 (tendon excursion) 에요구되는힘의증가및제5 수지의위갈퀴손변형 (pseudoclawing deformity) 등이발생할수있음을발표하였다. 이에본원에서는영상증폭관찰하에도수정복후사면, 측면방사선사진상남은각변형이 30 이하이며, 회전변형이없는환자를보존적치료의대상으로하였다. 보존적치료의방법에도많은논란이있을수있는데특히반드시석고붕대고정을해야하는가에대한많은문헌이발표되었다. Braakman 등 7 은제5 중수골골절이있는 50명의환자를대상으로척골구상석고붕대와 buddy tapping으로치료하는무작위대조실험을시행하였다. 석고붕대군은골절부각형성이 27 였고, buddy tapping 군은 25 였다. 6개월후두군간의증상이나관절운동범위의유의한차이는없었다. Harding 등 19 은골절부각형성이 40 이내인 73명의환자를대상으로중수골보조기 (molded metacarpal brace) 와 buddy tapping으로치료하는무작위대조실험을시행하였는데, 보조기군이통증이덜했고관절운동범위가좀더나았으며, 더일찍일상생활복귀가가능하다고하였다. Kuokkanen 등 20 은 29 명의환자를대상으로 4주간중수지관절을 60 굴곡시켜석고붕대한군과 1주간탄력붕대만으로고정한군으로나누어치료하는무작위대조실험을시행하였는데 3개월후골절부각형성의중앙값 (median fracture angulation) 이석고붕대군은 29, 탄력붕대군은 42 였다. 수상 6주후석고붕대군이악력 (grip strength) 이더나았으나, 3개월후에는두군간의운동이나악력이유의한차이를보이지않았다. Statius Muller 등 21 은 40 명의환자를대상으로 3주간척측구형성부목으로고정한군과 1주간압박탄력붕대로치료한군으로나누어무작위대조실험을시행하였다. 평균각형성은 39 였고, 수상 3개월후석고붕대군은 93% 에서, 탄력붕대군은 95% 에서통증이없고정상관절운동범위를보였다. 이처럼석고붕대를꼭하지않아도기능적인결과는석고붕대를한군과유의한차이를보이지않는다는문헌이많지만, 치료후에각형성이석고붕대를한군이고정을하지않은군보다나은결과를보이고 20, 골절부각형성이35-40 이상계속남을경우에수부변형이발생할수있고그것이환자들이치료만족도에큰영향을주기때문에본원에서는척측구형성부목을치료방법으로설정하였다. 하 지만전통적인척측구형성부목은 Fiberglass 제품을이용하여부목을만들면석고내빈공간이생겨골절부를정확하게접촉하여삼점고정을시켜주지못해고정력이떨어지는단점이있어고정력을극대화하기위해척측구형성부목을변형하였다. Ford 등 3 과 Theeuwen 등 4 은보존적치료에서는도수정복직후에골절부각형성이교정되더라도고정기간중에다시골절부의재전위가발생함을보고하였다. Kang 등 18 도보존적치료시치료전평균 38.5 의각형성이, 도수정복후 24.1 로호전되었으나최종추시상은 34.2 로악화되어정복의유지가잘되지않는것을보여주었다. 따라서환자가수술적치료에동의하지않거나수술적치료를시행할상황이안되는경우, 혹은골절부각형성이 40 미만인경우에는무리해서반복적인도수정복을시행하지말고부목고정및조기관절운동을하는보존적요법을주장하였다. 하지만본연구에서와같이절개변형한척측구형성부목을이용해치료한경우도수정복직후와비교하여최종추시시골절부각형성의변화가사면방사선사진상의교정각의변화는평균 3 였고, 측면방사선사진상평균 1 로골절부의고정력이우수한것으로판단되어보존적치료의적응증의대상을좀더넓힐수있을것으로생각된다. 본연구에서임상적결과를분석하지않은점은제한사항이나젊은남자의경우골절의유합이확인될때외래추시를자의로하지않은경우가대부분이라임상적결과를측정하고분석할수있는추시기간을확보할수없었다. 향후더많은예를대상으로임상적결과를포함하고전통적인척측구형성부목이나수술적치료와비교연구하는것이필요할것으로생각된다. 결론 제5중수골경부골절치료로영상증폭관찰하에서도수정복후절개변형한척측구형성부목 (modified split ulnar gutter splint) 고정술은보존적치료의적응증을넓힐수있을것으로생각된다. REFERENCES 1. Hunter JM, Cowen NJ. Fifth metacarpal fractures in a compensation clinic population: a report on one hundred and thirty-three cases. J Bone Joint Surg Am. 1970;52:

6 J Korean Soc Surg Hand Vol. 20, No. 4, December McCue FC 3rd, Meister K. Common sports hand injuries: an overview of aetiology, management and prevention. Sports Med. 1993;15: Ford DJ, Ali MS, Steel WM. Fractures of the fifth metacarpal neck: is reduction or immobilisation necessary? J Hand Surg Br. 1989;14: Theeuwen GA, Lemmens JA, van Niekerk JL. Conservative treatment of boxer's fracture: a retrospective analysis. Injury. 1991;22: Ali A, Hamman J, Mass DP. The biomechanical effects of angulated boxer's fractures. J Hand Surg Am. 1999;24: Birndorf MS, Daley R, Greenwald DP. Metacarpal fracture angulation decreases flexor mechanical efficiency in human hands. Plast Reconstr Surg. 1997;99: Braakman M, Oderwald EE, Haentjens MH. Functional taping of fractures of the 5th metacarpal results in a quicker recovery. Injury. 1998;29: Lowdon IM. Fractures of the metacarpal neck of the little finger. Injury. 1986;17: Maitra A, Sen B. Displaced boxers' fractures: a simple and effective method of external splintage. Br J Clin Pract. 1990;44: McKerrell J, Bowen V, Johnston G, Zondervan J. Boxer's fractures: conservative or operative management? J Trauma. 1987;27: Porter ML, Hodgkinson JP, Hirst P, Wharton MR, Cunliffe M. The boxers' fracture: a prospective study of functional recovery. Arch Emerg Med. 1988;5: Jahss SA. Fractures of the metacarpals. J Bone Joint Surg Am. 1938;20: Pace GI, Gendelberg D, Taylor KF. The effect of closed reduction of small finger metacarpal neck fractures on the ultimate angular deformity. J Hand Surg Am. 2015;40: Leung YL, Beredjiklian PK, Monaghan BA, Bozentka DJ. Radiographic assessment of small finger metacarpal neck fractures. J Hand Surg Am. 2002;27: Foucher G. "Bouquet" osteosynthesis in metacarpal neck fractures: a series of 66 patients. J Hand Surg Am. 1995;20:S Lane CS, Kennedy JF, Kuschner SH. The reverse oblique x-ray film: metacarpal fractures revealed. J Hand Surg Am. 1992;17: Bloem JJ. The treatment and prognosis of uncomplicated dislocated fractures of the metacarpals and phalanges. Arch Chir Neerl. 1971;23: Kang HJ, Song KW, Park KK, Sung SY, Hahn SB. Comparison between operative and conservative treatment of the 5th metacarpal neck fracture. J Korean Orthop Assoc. 2004;39: Harding IJ, Parry D, Barrington RL. The use of a moulded metacarpal brace versus neighbour strapping for fractures of the little finger metacarpal neck. J Hand Surg Br. 2001;26: Kuokkanen HO, Mulari-Keranen SK, Niskanen RO, Haapala JK, Korkala OL. Treatment of subcapital fractures of the fifth metacarpal bone: a prospective randomised comparison between functional treatment and reposition and splinting. Scand J Plast Reconstr Surg Hand Surg. 1999;33: Statius Muller MG, Poolman RW, van Hoogstraten MJ, Steller EP. Immediate mobilization gives good results in boxer's fractures with volar angulation up to 70 degrees: a prospective randomized trial comparing immediate mobilization with cast immobilization. Arch Orthop Trauma Surg. 2003;123:

7 Ho-Jin Gil, et al. Modified Split Ulnar Gutter Splint for Treatment of Fifth Metacarpal Neck Fractures 절개변형한척측구형성부목을이용한제 5 중수골경부골절의치료 길호진 정양국 신승한 김동현 강진우 전상현가톨릭대학교의과대학서울성모병원정형외과 목적 : 전통적인척측구형성부목 (ulnar gutter splint) 의문제점을보완한절개변형한척측구형성부목 (modified split ulnar gutter splint) 을이용하여보존적으로치료한제5중수골경부골절환자의방사선학적결과를분석하고자하였다. 방법 : 2008년 12 월부터 2014년 5월까지본원에서치료받은 17명, 18 예를대상으로하여방사선학적결과를분석하였다. 수술전, 직후및최종추시의사면및측면방사선사진에서각형성을측정하여교정각및고정의안정성을평가하였다. 평균고정기간은 4.9주 ( 범위, 4-7주 ) 였고, 평균추시기간은 17.1 주 ( 범위, 8-80주 ) 였다. 결과 : 전체 17명, 18 예에서골유합이관찰되었고, 사면방사선사진상정복전각변형이평균 27 에서정복후평균 17 로교정되었고, 측면방사선사진상에서도 21 에서 10 도로교정되어만족할만한결과를보였다 (p<0.001). 최종추시시의사면방사선사진상의교정각의변화는평균 3, 측면방사선사진상 1 로우수한골절고정력을보였다. 결론 : 제5중수골경부골절치료로영상증폭관찰하에서도수정복후절개변형한척측구형성부목 (modified split ulnar gutter splint) 고정술은고정력이우수하여보존적치료의적응증을넓힐수있을것으로생각된다. 색인단어 : 제 5 중수골경부골절, 도수정복, 척측구형성부목 접수일 2015 년 8 월 21 일수정일 1 차 : 2015 년 9 월 12 일, 2 차 : 2015 년 10 월 8 일게재확정일 2015 년 10 월 10 일교신저자정양국서울시서초구반포대로 222 가톨릭대학교의과대학정형외과학교실 TEL FAX ygchung@catholic.ac.kr 167

대한정형외과학회지 : 제 39 권제 2 호 2004 J. of Korean Orthop. Assoc. 2004; 39: 제 5 중수골경부골절의보존적치료와수술적치료결과의비교 강호정ㆍ송계욱ㆍ박관규ㆍ성승용ㆍ한수봉 연세대학교의과대학정형외과학교실 목적 : 각형성된제

대한정형외과학회지 : 제 39 권제 2 호 2004 J. of Korean Orthop. Assoc. 2004; 39: 203-9 제 5 중수골경부골절의보존적치료와수술적치료결과의비교 강호정ㆍ송계욱ㆍ박관규ㆍ성승용ㆍ한수봉 연세대학교의과대학정형외과학교실 목적 : 각형성된제 5 중수골경부골절의보존적치료와수술적치료결과, 합병증에대한비교및수술적치료에대한적응증을알아보고자하였다.