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1 대한골절학회지제 21 권, 제 4 호, 2008년 10월 Journal of the Korean Fractrure Society Vol. 21, No. 4, October, 2008 종설 원위요골골절의후방금속판내고정술 (Dorsal Plating for Distal Radius Fracture) 송석환 가톨릭대학교의과대학정형외과학교실 서 최근원위요골의골절부위를수술적으로내고정하기위하여전방도달법 (anterior approach) 을이용한많은금속판들이개발되어사용되고있다 13,15,17,18). 그러나전방도달법자체는관절외원위요골골편이나원위요골전방관절면의골편이전방으로전위된경우 ( 소위 volar Barton 골절 ) 전방으로전위된골절편에대한지지판 (buttress) 의기능을하기위하여이전부터사용되어오던방법이나최근에는골다공증이동반된불안정성관절내골절까지도금속판에고정된경사각을가진금속나사를이용한금속판 (fixed volar angle screw plate) 으로전방고정술을이용하는것이최근의변화된추세이다. 그러나이러한전방고정술은흔히염려하는후방고정술의신전건손상에따른합병증을상쇄하고도남는많은합병증을야기하며, 장무지굴곡건및수지굴곡건, 요골동맥의파열뿐만아니라후방의장무지신전건및수지신전건의파열등그또한많은합병증이심심하지않게보고되고있음을주지하여야할것이다 2,4-6,16). 원위요골골절의후방도달법에의한금속판 - 금속나사의고정은부착된금속판의후방으로주행하는수지신전건의손상을야기하는것으로많은논문이보고되고있으며 1,8,11), 이합병증을방지하기위하여또한많은새로운형태의금속판이개발 - 보고되고있다 7,21). 그러나저자는 1994 년이래로원위요골의심한분쇄골절과수근관절의류마티스관절염혹은외상후관절염에대하여일반적으로사용되는 T 형금속판혹은소형재건금속판 (small reconstruction plate)- 금속나사를이용하여후방도달법으로골절부위의고정과수근관절유합술에도합병증없이고정하여왔으며, 10 년이상현재까지수지의 론 신전건손상이없었음을보고하고, 통상적인방법이기는하나본원에서현재사용하고있는수술적방법을상술하고자한다. 본 론 1. 후방금속판고정의장 - 단점 흔히짐작하는후방금속판고정의단점은신전건의손상에의한파열이나건초염으로많은논문에서보고되고있으나이는수술자의술기의세련됨과관련이있다. 장무지신전건이나수지신전건을직접보고손상을피하게할수있으며, 관절면의분쇄골절시에관절면을직접보고그정복의정도를판단할수있고, 심하게분쇄되어골이식이필요한부분인후방골피질을직접보고골이식을적정하게할수있다는등의더많은장점또한논의되고있어 24) 후방도달법의장점또한간과할수없는것이다 (Table 1). 최근사용되고있는전방도달법을이용한금속판고정시후방골이식혹은요수근관절의관절면관찰을위하여요골전방의연부조직과골막, 원위요-척골사이의골간막등의심각한손상을초래할수있는광범위박리를권하고있어 18), 비록고정된각도의금속나사고정으로조기의관절운동을할수있다는장점을부각시키기는하나연부조직박리를최소화할수있는방법의개발이요구된다. 2. 수술술기 Lister 결절을확인한후수근관절배부의중간축 (midline) 으로골절의범위에따라서 zigzag 형태의약 6 통신저자 : 송석환서울시영등포구여의도동 62 가톨릭대학교의과대학성모병원정형외과 Tel: ㆍ Fax: sw.song@catholic.ac.kr Address reprint requests to:seok-whan Song, M.D. Department of Orthopedic Surgery, St Mary s Hospital, 62, Yeouidodong, Yeongdeungpo-gu, Seoul , Korea Tel: ㆍ Fax: sw.song@catholic.ac.kr 334

Able to see articular surface Easy to bone graft Repair of EDC Prevent late rupture of EPL PIN neurectomy DRUJ

!) Unable to see articular surface PQ damage Median nerve injury Flexor adhesion Volar wrist ligament injury

Posterior interosseous nerve, DRUJ: distal radioulnar joint, PQ: Pronator quadrates muscle. Fig. 1.

(B) The entire extensor retinaculum was divided into the distal and proximal halves, and the 3 rd extensor

(C) Fracture site was reduced, (D) and temporarily fixed with K-wires.

2 원위요골골절의후방금속판내고정술 335 Table 1. Comparison of pros and cons of dorsal and volar approaches Dorsal approach Volar approach Advantages Disadvantages Able to see articular surface Easy to bone graft Repair of EDC Prevent late rupture of EPL PIN neurectomy DRUJ reconstruction Difficult (not right!!) Concern about late EDC rupture Easy No harm to EDC* (not right!!) Unable to see articular surface PQ damage Median nerve injury Flexor adhesion Volar wrist ligament injury Flexor & extensor ruptures *EDC: Extensor digitorum communis tendon, EPL: Extensor pollicis longus tendon, PIN: Posterior interosseous nerve, DRUJ: distal radioulnar joint, PQ: Pronator quadrates muscle. Fig. 1. (A) The zigzag midline incision over the dorsal wrist joint, centered on Lister tubercle, was designed. (B) The entire extensor retinaculum was divided into the distal and proximal halves, and the 3 rd extensor compartment was opened. The 2 nd and 4 th extensor compartments were dissected. (C) Fracture site was reduced, (D) and temporarily fixed with K-wires. After the confirmation of proper reduction T -plate was fixed. (E) The half of extensor retinaculum was used to cover the transverse part of the plate, protecting the extensor tendons from the plate and screws. (F) The other half of extensor retinaculum was used to cover extensor tendon like as the original function of retinaculum.

plate within 6 months to prevent the possible extensor

Note the intact extensor tendons over the plate.

Over and under the plate there is some thick fibrous

$fractured in 74-year old female patient.$ (B) Dorsal plating and autogenous iliac bone graft were

3 336 송석환 Fig. 2. (A) After the union the patients are advised to remove the plate within 6 months to prevent the possible extensor tendon injury. Note the intact extensor tendons over the plate. (B) After the removal of screws, (C) and plate. Over and under the plate there is some thick fibrous tissue protecting the extensor tendons from injury. Fig. 3. (A) Left distal radius and ulnar styloid process were fractured in 74-year old female patient. (B) Dorsal plating and autogenous iliac bone graft were done for distal radius, and K-wires were inserted into the distal ulna. (C) Thirteen months after the operation the plate and screws were removed without any complications to the extensor tendons.

원위요골골절의후방금속판내고정술 337 10 cm 의절개를가한다 (Fig. 1A).

flaps) 을형성한다 (Fig. 1B). 원위요골골절부위를노출시킨후추후금속판을부착하기위한후방골표면을고르게하고, 이미분쇄가되어있는 Lister 결절을절제하기도한다 (Fig. 1C).

금속판고정후원위부와근위부로나누어져있는신전지대를금속판의횡부분 ( T 자의 ㅡ 부분 ) 에삽입된금속나사가덮혀지도록원위혹은근위신전지대를선택하여제 2 4 신전건밑으로위치시켜금속판을덮으며 (Fig. 1E), 나머지근위혹은원위신전지대를신전건위로봉합 하여원래의신전지대의기능을하도록한다 (Fig.

증례분석 1994 년 3 월부터본원에서원위요골골절후심한분쇄골절부위를고정하기위하여후방도달법에의한금속판 - 금속나사고정술을받고 6 개월이상추시가가능하였던 52 예 ( 여 / 남 :38/14) 의평균나이는 53 세 (24 78 세 ) 였으며, 평균추시기간은 11 개월 (6 64 개월

$(A) Sixty-nine year old female patient had broken her right wrist, with severe intraarticular fracture of distal radius.$

4 원위요골골절의후방금속판내고정술 cm 의절개를가한다 (Fig. 1A). 신전지대 (extensor retinaculum) 를제 2 신전건구획에서제 4 구획까지원위부와근위부로횡으로이분하여놓고제 3 신전구획에서종으로절개하여장무지신전건을유리시키며, 신전지대를제 2 및 4 구획으로박리하여내 - 외측으로신전지대판 (extensor retinaculum flaps) 을형성한다 (Fig. 1B). 원위요골골절부위를노출시킨후추후금속판을부착하기위한후방골표면을고르게하고, 이미분쇄가되어있는 Lister 결절을절제하기도한다 (Fig. 1C). 골절부위를정복후일시적인고정을위하여 K- 강선을삽입한후투시방사선검사로만족한정복이되었는지확인하며, T 형의금속판을원위요골배부의모양에맞게변형시키고금속판내고정을한다 (Fig. 1D). 골이식술이필요한경우자가장골의해면골을이식한다. 금속판고정후원위부와근위부로나누어져있는신전지대를금속판의횡부분 ( T 자의 ㅡ 부분 ) 에삽입된금속나사가덮혀지도록원위혹은근위신전지대를선택하여제 2 4 신전건밑으로위치시켜금속판을덮으며 (Fig. 1E), 나머지근위혹은원위신전지대를신전건위로봉합 하여원래의신전지대의기능을하도록한다 (Fig. 1F). 장무지신전건은봉합된신전지대위로 ( 피하에 ) 위치하도록보호하여파열을방지하고, 피하및피부봉합을한다. 골유합이확인되면수술후약 6 개월이내에금속판 - 금속나사의제거술을실시한다 (Fig. 2). 3. 증례분석 1994 년 3 월부터본원에서원위요골골절후심한분쇄골절부위를고정하기위하여후방도달법에의한금속판 - 금속나사고정술을받고 6 개월이상추시가가능하였던 52 예 ( 여 / 남 :38/14) 의평균나이는 53 세 (24 78 세 ) 였으며, 평균추시기간은 11 개월 (6 64 개월 ) 이었다. 수술후평균 5.7 개월 (3 16 개월 ) 만에금속판 - 금속나사를제거하였으며, 19 예는 6 개월이상추시되었으나금속판 - 금속나사의제거술을받지않았다. 본증례들에서수술에의하여삽입된금속판 - 금속나사의영향으로신전건파열이발생한증례는없었다. Fig. 4. (A) Sixty-nine year old female patient had broken her right wrist, with severe intraarticular fracture of distal radius. (B) Combined volar and dorsal plating were done to gather up the burst fracture fragments, and external fixation to reduce compressive pressure on the radial articular surface. (C) Seven weeks after the operation external fixator was removed. (D) Five months after the operation removal of plates and extensor tenolysis were done. (E) Twenty months after the operation. There is no evidence of post-traumatic arthritis and soft tissue complications.

(B) Pi (π) plate R (Synthes, Paoli, PA) is thin and easily malleable to adapt to the complicated dorsal surface of distal radius.

$(D) Trimed System R (Trimed, Valencia, CA) was applied to the severely comminuted distal radius fracture. (E) Trimed and 2.$ the opportunity to fix each fragment with specifically designed small plates. 1) 증례 1 74 세여자가넘어져서수상한좌측원위요골및척골골절로내원하였다.

the opportunity to fix each fragment with specifically designed small plates. 1) 증례 1 74 세여자가넘어져서수상한좌측원위요골및척골골절로내원하였다.

5 338 송석환 Fig. 5. Low profile plates for dorsal plating. (A) Forte plate R (Zimmer, Warsaw, IN, USA) is thinner than the conventional AO plate, and the screw head sinks into the screw hole. (B) Pi (π) plate R (Synthes, Paoli, PA) is thin and easily malleable to adapt to the complicated dorsal surface of distal radius. Left or right preference can be chosen. (C) Lister tubercle can be saved. (D) Trimed System R (Trimed, Valencia, CA) was applied to the severely comminuted distal radius fracture. (E) Trimed and 2.4-mm AO plate (Synthes, Paoli, PA) import the concept of column from Melone s classification of comminuted intraarticular fracture of distal radius, and give the opportunity to fix each fragment with specifically designed small plates. 1) 증례 1 74 세여자가넘어져서수상한좌측원위요골및척골골절로내원하였다. 관절면은포함하지않았으나후방골피질의심각한손상으로불안정성골절이었으며, 척골의경상돌기는기저부에서골절되어전위되어원위요척관절의안정성을위하여수술적인치료가요구되었다 (Fig. 3A). 후방도달법으로골절부위를정복한후자가장골이식을하였으며, 척골경상돌기도관혈적정복및 K- 강선내고정을하였다 (Fig. 3B). 원위요골및척골의 K- 강선은수술후약 6 주에제거하였으며, 원위요골에부착되어있었던금속판금속나사는수술후약 1 년 1 개월에제거하였 다 (Fig. 3C). 최종추시시굴곡 60 도, 신전 70 도, 회내전 70 도, 회외전 80 도였으며, 수지신전건및굴곡건의손상은없었다. 2) 증례 2 69 세여자가산행도중넘어져우측손목관절의골절로내원하였다. AO 분류 C3 형으로심한관절내골절을동반하였다 (Fig. 4A). 관절면을모아놓기위하여전방및후방도달법으로전 - 후방의금속판을부착하였으며, 관절면의압박을피하기위하여외고정기기를사용하였고, 골결손부위는자가장골이식을하였다 (Fig. 4B). 수술후 7 주에외

6 원위요골골절의후방금속판내고정술 339 고정기기를제거하였으며 (Fig. 4C), 수술후 5 개월에관절운동제한을풀기위하여금속판금속나사제거와신전건박리술을실시하였다 (Fig. 4D). 수상후 1 년 8 개월현재외상후관절염의소견은없으며 (Fig. 4E), 굴곡 15 도, 신전 40 도, 회외전 80 도, 회내전 45 도이나건측에비교하면 63% 의관절운동을회복하였다. 4. 새롭게개발된후방고정을위한금속판 Low profile plate라고불리우는, 금속판의두께가얇거나원위요골의후방골표면에밀착되고, 금속나사의머리가작거나낮아수지신전건을자극하지않도록개발된금속판을몇가지소개하면, Forte plate R (Zimmer, Warsaw, IN, USA) (Fig. 5A) 는기존의금속판과모양은유사하나두께가얇고나사못의머리가금속판속으로낮게위치하여그위를지나가는신전건의자극을피하기위하여개발되었다 3,7,10,19). Pi (π) plate R (Synthes, Paoli, PA) (Fig. 5B, 5C) 는얇고가늘은, 미리구부러진금속판으로좌측혹은우측의요골에선택하여사용할수있으며, 요골후방의골표면에적응하여비교적쉽게구부릴수있도록고안되어있다 9,12,14,16,22,23). Pi plate를사용하기위하여는위에서제시한 Lister 결절을제거하지않아도된다는장점을제시하고있으나사실이미심하게손상된 Lister 결절이골절부위에얼마나안정성을부여할지는의문이다. Trimed System R (Trimed, Valencia, CA) 과 AO의 2.4 mm 금속판 (Synthes, Paoli, PA) 은각각의골절편을각각따로고정하는지주고정 (columnar fixation) 의개념 20,24) 을도입한고정방법이다 (Fig. 5D, 5E). 원위요골은요골경상돌기의요골주 (radial column), 월상골와의전방주와후방주로구분되며, 이들골편을고정하기위한각각의모양이고안되어있다. 이러한노력에도불구하고각각의금속판에따른신전건손상과금속판의골절등합병증에대한보고는없어지지않고있으므로심한분쇄골절의원위요골골절의치료를위한완벽한내고정물은아직없다고보여진다. 결 원위요골골절의수술적치료시후방도달법에의한금속판 - 금속나사의내고정은후방의수지신전건손상을초래하는것으로보고되고있다. 그러나적정한수술술기로후방으로전위된관절면을포함한심한분쇄골절도외고정기기와골이식술을동반한금속판내고정술로적절한치료를제공할수있고, 합병증을최소화할수있으며, 골유합이확인되면조기에금속판 - 금속나사를제거하여그 론 합병증을방지할수있는것으로판단된다. 참고문헌 1) Axelrod TS, McMurtry RY: Open reduction and internal fixation of comminuted, intraarticular fractures of the distal radius. J Hand Surg Am, 15: 1-11, ) Bell JS, Wollstein R, Citron ND: Rupture of flexor pollicis longus tendon: a complication of volar plating of the distal radius. J Bone Joint Surg Br, 80: , ) Carter PR, Frederick HA, Laseter GF: Open reduction and internal fixation of unstable distal radius fractures with a low-profile plate: a multicenter study of 73 fractures. J Hand Surg Am, 23: , ) Cross AW, Schmidt CC: Flexor tendon injuries following locked volar plating of distal radius fractures. J Hand Surg Am, 33: , ) Dao KD, Venn-Watson E, Shin AY: Radial artery pseudoaneurysm complication from use of AO/ASIF volar distal radius plate: a case report. J Hand Surg Am, 26: , ) Douthit JD: Volar plating of the dorsally comminuted fractures of the distal radius: a 6-year study. Am J Orthop, 34: , ) Finsen V, Aasheim T: Initial experience with Forte plate for dorsally displaced distal radius fractures. Injury, 31: , ) Fitoussi F, Ip WY, Chow SP: Treatment of displaced intra-articular fractures of the distal end of the radius with plates. J Bone Joint Surg Am, 79: , ) Hahnloser D, Platz A, Amgwerd M, Trentz O: Internal fixation of distal radius fractures with dorsal dislocation: pi-plate or two 1/4 tube plates? A prospective randomized study. J Trauma, 47: , ) Herron M, Faraj A, Craigen MA: Dorsal plating for displaced intra-articular fractures of the distal radius. Injury, 34: , ) Hove LM, Nilsen PT, Furnes O, Oulie HE, Solheim E, Mölster AO: Open reduction and internal fixation of displaced intraarticular fractures of the distal radius. 31 patients followed for 3 7 years. Acta Orthop Scand, 68: 59-63, ) Kambouroglou GK, Axelrod TS: Complications of the AO/ASIF titanium distal radius plate system (pi plate) in internal fixation of the distal radius: a brief report. J Hand

7 340 송석환 Surg Am, 23: , ) Keating JF, Court-Brown CM, McQueen MM: Internal fixation of volar-displaced distal radius fractures. J Bone Joint Surg Br, 76: , ) Lowry KJ, Gainor BJ, Hoskins JS: Extensor tendon rupture secondary to the AO/ASIF titanium distal radius plate without associated plate failure: a case report. Am J Orthop, 29: , ) Musgrave DS, Idler RS: Volar fixation of dorsally displaced distal radius fractures using 2.4-mm locking compression plates. J Hand Surg Am, 30: , ) Nunley JA, Rowan PR: Delayed rupture of the flexor pollicis longus tendon after inappropriate placement of the pi plate on the volar surface of the distal radius. J Hand Surg Am, 24: , ) Orbay JL: The treatment of unstable distal radius fractures with volar fixation. Hand Surg, 5: , ) Orbay JL, Touhami A: Current concepts in volar fixedangle fixation of unstable distal radius fractures. Clin Orthop Relat Res, 445: 58-67, ) Osada D, Viegas SF, Shah MA, Morris RP, Patterson RM: Comparison of different distal radius dorsal and volar fracture fixation plates: a biomechanical study. J Hand Surg Am, 28: , ) Peine R, Rikli DA, Hoffmann R, Duda G, Regazzoni P: Comparison of three different plating techniques for the dorsum of the distal radius: a biomechanical study. J Hand Surg Am, 25: 29-33, ) Ring D, Jupiter JB, Brennwald J, Büchler U, Hastings H Jr: Prospective multicenter trial of a plate for dorsal fixation of distal radius fractures. J Hand Surg Am, 22: , ) Schnur DP, Chang B: Extensor tendon rupture after internal fixation of a distal radius fracture using a dorsally placed AO/ASIF titanium pi plate. Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation. Ann Plast Surg, 44: , ) Suckel A, Spies S, Münst P: Dorsal (AO/ASIF) pi-plate osteosynthesis in the treatment of distal intraarticular radius fractures. J Hand Surg Br, 31: , ) Tavakolian JD, Jupoiter JB: Dorsal plating for distal radius fractures. Hand Clin, 21: , 2005.

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( )jkfs106.hwp 대한골절학회지제 19 권, 제 4 호, 2006년 10월 Journal of the Korean Fractrure Society Vol. 19, N o. 4, October, 2006 종 설 원위요골골절의수술적치료 (Operative Treatment of Distal Radius Fracture) 박종웅 고려대학교의과대학정형외과학교실 서론 원위요골골절치료의원칙