17-변영수( )

Transcription

1 대한견 주관절학회지제 11 권제 2 호 J. of Korean Shoulder and Elbow Society Volume 11, Number 2, December, 2008 금속판을이용한구상돌기골절의치료 대구파티마병원정형외과 신동주 변영수 * 조영호 박호원 윤희민 한재휘 Plate Fixation for Fractures of the Coronoid Process of the Ulna Dong-Ju Shin, M.D., Young-Soo Byun, M.D.*, Young-Ho Cho, M.D., Ho-Won Park, M.D., Hee-Min Youn, M.D., Jae-Hui Han, M.D. Department of Orthopedic Surgery, Fatima Hospital, Daegu, Korea Purpose: The purpose of this study was to evaluate the results of eight cases of coronoid process fractures that were fixed with a plate. Materials and Methods: Eight coronoid process fractures were treated by plating and these cases were reviewed retrospectively. Six patients were men and two were women. The average age was 41 years (range: 22-79) at the time of injury. According to Regan s classification, there were five type 2 and three type 3. According to O Driscoll s classification, there were five anteromedial type and three base type. Open reduction and internal fixation with a plate were performed through a medial approach by splitting of the two heads of the flexor carpi ulnaris. The patients were follow-up for a mean of 15.8 months (range: 6-25). We evaluated the clinical outcomes with using the Mayo Elbow Performance Score. Results: The average active motion of the elbow joint was 120. The average Mayo Elbow Performance Score was There were 5 excellent results, 1 good result and 2 fair results. Summary: Plating through a medial approach of the elbow provided stable fixation and satisfactory union for treating displaced coronoid process fractures with the unstable elbow. Key Words: Coronoid process fracture, Plate fixation, Internal fixation 서론척골구상돌기골절은주로축성외력과동반된내반후내측또는후외측회전력에의하여발생하며비교적드문골절로보고되어왔다 6,8,11,16). 과거골절된골편의 크기를기초로한분류방법이주로사용되었으나 15), 최근골편의위치와모양이주관절의전반적인손상정도와연관이있어그중요성이강조되고있다 20). 단지골편의크기에따라치료방법을결정했던과거와달리, 작은골편이라할지라도안정된고정만이기능을보존 통신저자 : 변영수대구광역시동구신암동 대구파티마병원정형외과 Tel: 053) , Fax: 053) , fatimaos@unitel.co.kr 본논문의요지는 2008 년도대한골절학회추계학술대회에서발표되었음. 177

2 대한견 주관절학회지제 11 권제 2 호 할수있다고보고되고있으며 20), 이에따라여러가지고정방법이제시되고있으나개별적인방법에대한연구는드물다. 본연구는구상돌기골절에대하여금속판을이용한관혈적정복및내고정을시행하고결과를분석하여그유용성에대하여알아보고자한다. 연구대상및방법 2006년 4월부터 2008년 8월까지내원한구상돌기골절환자중불안정한주관절과동반된전위된구상돌기골절에대하여금속판을이용하여관혈적정복및내고정술을시행하였으며, 6개월이상추시된 8예를대상으로하였다. 추시관찰기간은평균 15.8개월 (6~25 개월 ) 이었다. 총 8예중남자가 6예, 여자가 2예였고, 연령분포는최하 22 세에서최고 79 세로평균 41 세였으며, 우측이 3예, 좌측이 5예였다. Regan과 Morrey 15) 의구상돌기골절분류에의하면제2형이 5 예, 제3형이 3예였고, O Driscoll 11,20) 의분류에의하면 2-1 형이 1예, 2-2형이 4예, 3-1형이 1예, 3-2형이 2예였다. 개방성골절은없었으며수상원인은넘어진경우가 4예, 낙상이 3예, 교통사고가 1예였다. 2예에서외측측부인대파열이, 2예에서내측측부인대파열이동반되었으며, 2예에서경주두골절탈구가, 나머지 2예에서주관절의위험삼징후가동반되었다. 임상적검사및방사선촬영후, 전예에서골절양상및관절면의정확한분석을위해전산화단층촬영및삼차원재건을시행하였다. 최종치료후 Mayo Elbow Performance Score 10) 로임상적결과를판정하였다 (Table 1). 1. 수술방법다발성골절이동반된 1예는 24 시간이내에수술을 시행하였고, 6예는부종이심하여장상지부목고정및거상을시행하고 2주이내에수술을시행하였다. 나머지 1예는경주두골절탈구가동반되었던경우로최초수술시후방접근법으로주두골절과구상돌기골절을각각금속판과강선을이용하여고정하였으나술후 3주경에구상돌기골절편의재전위및주관절의아탈구가발생하여, 수상 4주경에전내측접근을통하여구상돌기골절을수술한예이다. 전예에서전신마취후주관절안정성여부를평가하였으며, 지혈대를착용후수술을시행하였다. 주관절의내측부에종절개를가한후척수근굴근의양두사이를따라절개를시행하여척골의구상돌기골절면으로접근하였으며, 요골두골절, 주두골절등동반손상이있는경우에는외측또는후방도달법을추가로시행하였다. 관절면의골편은해부학적정복후 K-강선을이용하여임시고정하였으며, 영상증폭기를통하여정복된골편과관절면의상태를확인하였다. 전예에서 2.0 mm Mini-plate (Synthes, Switzerland) 를지지금속판형태로고정하였으며, 골편의크기나위치에따라금속판고정에제약이있는경우에는 K-강선및긴장대강선을추가로고정하였다. 동반된요골두골절은금속판, K-강선, 금속나사등을이용하여내고정하였으며, 내측측부인대파열이동반된 2예에서는봉합나사를이용한일차봉합술을같이시행하였다 (Fig. 1, 2, 3, 4). 2. 술후관리술후주관절을 90 도굴곡한상태로장상지후방부목으로고정하였으며, 부종과통증의호전정도에따라술후 1주후부터주관절의능동적굴곡및신전운동을시작하였고술후 4주까지는야간에부목을하였다. Table 1. Summary of cases Case Age/Sex Injury mechnism Rt/Lt Associated injury O'Driscoll R-M FC FF SUP PRO MEPS complication 1 79/M FG Lt. transolecranon fx /M FH Lt. terrible triad /F TA Lt. MCL /M FG Rt. MCL /M FG Lt. LCL /M FH Lt. terrible triad OA 7 22/F FH Rt transolecranon fx, OA,synostosis radial head fx 8 30/M FG Rt. LCL (O Driscoll: O Driscoll classification, R-M: Regan-Morrey classification, M:male, F:female, FG: fall on the ground, FH: fall from a height, TA: traffic accident, Rt:right, Lt:left, MCL: medial collateral ligament, LCL: lateral collateral ligament, fx: fracture, FC: flexion contracture, FF: further flexion, SUP: supination, PRO: pronation, MEPS: Mayo Elbow Performance Score, OA: osteoarthritis) 178

3 신동주 : 금속판을이용한구상돌기골절의치료 A B C D Fig. 1. The anteroposterior, lateral and both oblique radiographs of the right elbow in this 30-years old man after fall on the ground show a coronoid process fracture, but it is difficult to figure out the configuration of the fracture. 4주후부터장상지부목을완전히제거하였으며, 능동적근육강화운동을시작하였다. 결과 1. 골절의정복및유합전예에서술후시행한방사선사진에서해부학적정복을얻었으나, 주관절위험삼징후가있었던 1예에서술후 1주일에재전위가발생하였다. 이는골절편의분쇄가심하였던예로금속판과긴장대강선을이용하여고정하였으나긴장대강선으로고정한골편의고정실패가발생하여금속판을이용하여재고정하였으며, 술후 20 주에골유합을얻었다. 단순방사선사진상골유합이 이루어질때까지의평균기간은 13 주 (8~24주) 였다. 2. 관절의가동범위최종추시상주관절가동범위는평균 120 도 ( 굴곡구축 -20~30도, 후속굴곡 120~144도 ) 였으며, 평균회내전범위는 74.25도 (60~90도), 회외전범위는 도 (35~112도) 였다. 8예중 5예에서일상생활에필요한주관절의기능적가동범위 (30~130도) 를얻었으며, 과거외상으로인한주관절구축이있었던 1예, 외상성관절염이발생한 1예, 고령환자 1예등총 3예에서주관절의가동범위가불량하였다. 최종추시상과신전 20 도를보인증례는건측과같은범위로회복된것으로특이사항은없었다 (Fig. 5). 179

4 대한견 주관절학회지제 11 권제 2 호 A B C D E Fig. 2. (A, B) Two-dimensional CT scan shows an anteromedial fracture of the coronoid process of the ulna. (C, D) Three-dimensional reconstructed CT scan demonstrates type 2-1 fracture by O Driscoll classification. (E) The photographs show neutral, valgusand varus-stress views under the C-arm fluoroscopy. 3. 불안정성 2예의주관절위험삼징후와 2예의경주두골절탈구가동반되었으나, 최종추시상경주두골절탈구가동반되었던 1예에서만경도의외반불안정성을호소하였고, 그외탈구가동반되었던모든경우에서내반또는외반불안정성은관찰되지않았다. 4. 합병증 Fig. 3. The photographs show fixation of the coronoid process fracture with a mini-plate through the medial approach. 전예에서감염은발생하지않았고, 술중신경이나혈관손상을보인경우는없었다. 술전척골신경손상 180

5 신동주 : 금속판을이용한구상돌기골절의치료 이있었던경우가 2예, 술후척골신경지배부의감각이상이발생한경우가 2예있었으나최종추시상모두호전되었다. 긴장대강선의고정실패로재고정을시행한 1예에서추시관찰상요골두골절의불유합이발생하여골이식및내고정을시행하여유합되었으나, 최종추시상외상성관절염이발생하여기능적점수가불량하였다. 후방접근을통한내고정의실패로금속판으로재고정한 1예는추시관찰상근위요척골의골성유합이발생하여절골술을시행하였다. 최종추시상굴곡구축 10 도, 후속굴곡 130 도, 회내전 60 도, 회외전 90 도로관절의가동범위는호전되었으나경도의외반불안정성과외상성관절염이발생하였다. 5. 기능적점수 Mayo Elbow Performance Score10) 에따른주관 절의기능은평균 86.8점 (60~100점) 이었고, 평균동통 36.2점 (15~45점), 운동 18.7점 (15~20점), 안정성 9.3점 (5~10점), 기능 23.1점 (20~25점) 을보였으며, 최우수가 5예, 우수가 1예, 양호가 2예였다. 8예중요골두골절의불유합및외상성관절염이발생한 1예, 요척골유합증및외상성관절염이생긴 1예에서중등도의통증을호소하였으나진통제의복용이필요할정도는아니었으며, 1예에서경도의통증을호소하였고, 나머지 5예에서는통증이없는것으로조사되었다. 고찰척골의구상돌기골절은단독손상은드물며주관절의탈구, 요골두골절및주두골절등과동반되어발생하는것이보통이다 14). 과거견열골절로설명한적도있으나 5), 상완요근은구상돌기의원위부에부착하므 A B C D Fig. 4. (A-D) The postoperative radiographs show anatomical reduction and stable fixation of the coronoid process with a buttress plate. 181

6 대한견 주관절학회지제 11 권제 2 호 A B C D E F Fig. 5. (A, B) The anteroposterior and lateral radiographs after removal of the implant at 24 month after operation show good healing of the coronoid process. (C-F) The photographs show a good functional result with nearly normal range of motion of the injured elbow. 로견열보다는활차에대한충격에의한것으로생각되고있다 12,17). 구상돌기는주관절내측측부인대의전방속, 관절낭앞쪽의반이부착하고, 주관절의전방지지대로작용하여골절시해부학적정복및내고정이필요한것이정설로생각되고있으나 2,17), 그방법에있어서는아직이견이많다. Regan과 Morrey의분류 15) 는측면상의단순방사선사진을이용해골절편의크기에따라구분하였으며, 지금까지구상돌기골절의분류에있어서가장보편적으로사용되어왔다. 최근구상돌기골절의전내측골편의위치가손상기전과연 관이있으며그에따라치료방법또한다른구상돌기골절과구분되어야함이강조되고있다 20). 이에 O Driscoll 분류 11,20) 는골절의위치및골편에따른정보를제공해주어전반적인손상기전을평가하는데좀더유용할것으로판단된다. Song 등 21) 은정확한구상돌기골절의형태파악을위해 coronoid view를제시한바있으나, 전내측골절의경우에는그형태및크기를확인하기어려워 3차원전산화단층촬영을통한정확한진단이필요할것으로사료된다 6,18). Doornberg 와 Ring 등 20) 은구상돌기골절중골편이전내측이있 182

7 신동주 : 금속판을이용한구상돌기골절의치료 는경우내측접근법및금속판을이용한고정이필요하다고강조하였다. 작은견열골절의경우요수근굴근과장장근사이의절개를통하여 bone tunnel을이용한봉합사등으로고정할수있고, 전내측골편의경우척수근굴근의양두사이로절개하여쉽게골절면에접근할수있으며, 아주큰골편의경우굽힘-회내근전체를척골로부터분리하여접근하여금속판등으로고정하는방법등을보고하였다 21). 본저자들은전예에서척수근굴근의양두사이로골절면에접근하여금속판을이용한고정에충분한시야및공간확보가가능하였으나, 절개시척골신경이노출될때까지세심한주의가필요하였고노출후에는신경표시줄로표시하여척골신경을과도하게견인하지않도록조심하였으며, 내측측부인대에추가적인손상을주지않기위해세심한주의가필요하였다. 구상돌기골절에대한여러연구에서견고한고정을통한조기관절운동만이만족할만한결과를가져올수있는것으로보고되고있다 1,3,7,8,9,22). 특히주관절의위험삼징후는주위연부조직및골조직의심한손상을초래하여치료후주관절의불안정성및외상후강직등으로인해예후가불량한것으로알려져있다 1,8,13,19). 본연구에서는주관절위험삼징후가있었던 2예중긴장대강선의고정실패및요골두의불유합으로두번의재수술을하였던증례에서최종추시상부분강직및외상성관절염이발생하여예후가불량하였다. 또한경주두골절탈구가있어후방접근을통하여강선으로구상돌기를고정하였으나골절편의전위및관절탈구가발생하였던증례에서요골두골절및심한연부조직손상이동반되어내측접근으로금속판을이용하여재고정후유합을얻었으나근위요척골의골유합증이생겼으며, 최종추시상주관절의불안정성과외상성관절염으로인해결과가좋지않았다. 결과적으로 8예의환자중에서골편의재전위가있었던 2예는후방강선고정을한 1예와내측접근을통하여긴장대강선으로고정한 1예였으며, 금속판을이용하여고정을시행한나머지 6예에서는재전위가발생하지않았다. 또한고정실패가발생하였던 2예모두금속판으로재고정하여모두안정된고정으로골유합을얻을수있었다. 불량한기능적결과를보인증례들은불안정한구상돌기골절의고정으로인해재수술이요했던이유도있겠지만요골두골절의불유합, 연부조직손상에의한요척골유합증, 인대손상에의한불안정성등의동반손상에의한합병증과관계가있을것으로생각된다. Doornberg 등 20) 은앞쪽관절낭이부착된골절편의고정만큼이나동반된내측측부인대및외측측부인대파열의치료또한중요하다고강조하였다. 본증례에서는내측측부인대가파열된 2예는봉합나사를이 용하여일차봉합하였고외측측부인대가파열된 2예는술후이학적검사상경도의불안정성만관찰되어장상지부목을통한보존적치료를시행하였다. 최종추시상무증상의외반불안정성을보였던 1예이외의불안정성은관찰되지않아정확한이학적검사를통한동반된손상의적절한치료가예후에중요한것으로생각된다. 요 8예의불안정한주관절이동반된전위된구상돌기골절들을내측접근법을통한금속판고정으로안정된고정과만족스러운골유합을얻을수있었다. 약 REFERENCES 01) Ahn EH, Lee ST, Ahn HS: Posterior dislocation of elbow joint with fracture of radial head and coronoid process (Terrible triad of elbow fracture and dislocation): case report. J Korean Fracture Soc. 13: , ) Cage DJ, Abrams RA, Callahan JJ, Botte MJ: Soft tissue attachments of the ulnar coronoid process. An anatomic study with radiographic correlation. Clin Orthop, 320: , ) Cho DY, Lee JM, Kim HC, HC, Kim HJ: Clinical analysis of fractures around the elbow joint in adults. J Korean Fracture Soc. 8: , ) Doornberg J, Ring D: Fracture of the anteromedial facet of the coronoid process. J Bone Joint Surg Am, 88: , ) Gil DE, Delgado E, Alonso-Llamas M: Recurrent dislocation of the elbow, Int Orthop 14: 41-45, ) Jeon IH, Min WK, Oh CW, et al.: Operative treatment of type Ⅲ coronoid process fracture, J Korean Fracture Soc, 17: , ) Lee JM, Lee JH, Song KJ, Kim KI: Clinical experience of surgical treatment of fracture of the coronoid process of ulna. J Korean Hand Surg Soc. 10: 45-50, ) Lee ST, Choi JH, Seo JB, Park JY: Elbow Dislocation Combined with Coronoid Process and Radial Head Fracture. J Korean Fracture Soc, 18: , ) Morrey BF: Current concepts in the treatment of fractures of the radial head, the olecranon, and the coronoid. Instr Course Lect, 44: , ) Morrey BF, An K-N: Functional evaluation of the elbow. In: Morrey BF ed. The elbow and its disorders. 3rd ed. Philadelphia, WB Saunders: 74-83, ) O Driscoll SW, Jupiter JB, Cohen MS, Ring D, Mckee MD: Difficult elbow fracture: pearls and pit- 183

8 대한견 주관절학회지제 11 권제 2 호 falls. Instr Course Lect, 52: , ) O Driscoll SW, Jupiter JB, King JW, Hotchkiss RN, Morrey BF: Unstable elbow, Instr Course Lect. 50: , ) Puch DM, McKee MD: The terrible triad of elbow. Techniques in hand and upper extremity surgery, 6: 21-29, ) Regan W, Morrey BF: Coronoid process and monteggia fractures, In: Morrey DF ed The elbow and its disorders. 3rd ed.philadelphia, WB Saunders: , ) Regan W, Morrey BF: Classification and treatment of coronoid process fractures. Orthopedics, 15: , ) Regan W, Morrey BF: Fractures of the coronoid process of the ulna. J Bone Joint Surg Am 71: , ) Rhee YG, Cha JR: The role of the coronoid process fracture in the elbow dislocation. J Korean Fracture Soc, 14: , ) Ring D, Jupiter JB: Surgical exposure of coronoid fracture. Technique in Shoulder and Elbow Surgery, 3: 48-56, ) Ring D, Jupiter JB, Jilberfarb J: Posterior dislocation of the elbow with fractures of radial head and coronoid. J Bone Joint Surg, 84-A: , ) Ring D, Doornberg J: Fracture of the anteromedial facet of the coronoid process. Surgical technique. J Bone Joint Surg Am, 89: , ) Song JH, Lee JY, Yang SC, Lee HY, Kim JI: Coronoid view: A new radiograph for the evaluation of the coronoid fractures. J Korean Shoulder Elbow Soc, 10: , ) Tandon H, Arora SS: Fractured coronoid process and fractured olecranon with subluxation of the elbow in an adult. J Trauma, 48: , 초록 목적 : 금속판을이용하여치료한 8예의구상돌기골절의치료결과를분석하여보고하고자한다. 대상및방법 : 금속판을이용하여고정한 8예의구상돌기골절에대하여후향적연구를시행하였다. 남자가 6예, 여자가 2예였고, 평균나이는 41 세였다. Regan의골절분류에의하면제2형이 5예, 제3형이 3예였으며, O Driscoll의분류에의하면전내측형이 5예, 기저형이 3예였다. 전예에서척수근굴근분리를통한내측도달법을이용하였으며, 골편정복후금속판으로골편을지지고정하였다. 추시기간은평균 15.8 개월이었으며, Mayo Elbow Performance Score로임상적결과를판정하였다. 결과 : 능동적주관절가동범위는평균 120 도였고, Mayo Elbow Performance Score는평균 86.9 점으로 5예에서최우수, 1예에서우수, 2예에서양호의결과를보였다. 요약 : 불안정한주관절이동반된전위된구상돌기골절들을내측접근법을통한금속판고정으로안정된고정과만족스러운골유합을얻을수있었다. 색인단어 : 구상돌기골절, 금속판, 내고정술 184