07/15-019/이재성(종설)77-84

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1 REVIEW ARTICLE pissn eissn J Korean Soc Surg Hand 2015;20(2): JOURNAL OF THE KOREAN SOCIETY FOR SURGERY OF THE HAND Dorsal Approach for Distal Radius Fractures Hyeok Bin Kwon, Jae-Sung Lee Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University School of Medicine, Seoul, Korea Received: June 5, 2014 Revised: June 9, 2015 Accepted: June 10, 2015 Correspondence to: Jae-Sung Lee Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University School of Medicine, 102 Heukseok-ro, Dongjak-gu, Seoul , Korea TEL: FAX: boneman@cau.ac.kr Since the advent of volar locking plate, volar approach for internal fixation has become a major trend in the treatment for unstable distal radius fracture. However, dorsal approach is preferred for certain fracture pattern include AO type C3, dorsal Barton s fractures and concomitant intercarpal ligament injury, because it can afford excellent exposure of the articular surface. Although dorsal approach and plating technique has inherent disadvantages include extensor tendon irritation and rupture, improvements in implant design lead to decrease complication rate. Here, we provide overview of the pros and cons through historic perspective, indications, and surgical technique of the dorsal approach for the distal radius fracture. Keywords: Distal radius fracture, Dorsal approach This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( licenses/bync/3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 서론 원위요골골절은비교적젊은연령에서는주로스포츠활동과관련된고에너지손상으로관절면을포함한복합골절의형태가많으며, 50-60대폐경기이후여성에서는골다공증과관련되어실족에의한저에너지손상으로안정형골절의형태로많이발생한다 1. 과거에는어느정도의부정유합은기능상큰이상이없다고하여, 많은경우석고고정등보존적치료를하였으나, 최근에는해부학적정복과견고한고정으로조기관절운동을허용하는것이더좋은기능적결과를얻을수있다는개념의변화와이에따른새로운수술기법및내고정물의발전으로관혈적정복및금속내고정술이더선호되고있다 2. 여러금속내고정술중전방잠김금속판 (volar locking plate) 은불안정한원위요골골절에충분한고정강도를제공하여조기관절운동이가능하게하며, 후방금속판에비해신전건자극이덜하다고알려져있으며, 대개의경우전방피질골이상대적으로두껍고분쇄정도가심하지않아비교적쉽게해부학적정복이가능하기때문에최근유행처럼전방접근법이원위요골골절수술에쓰이고있는것이사실이다. 그러나, 모든형태의원위요골골절을전방접근법만으로치료하는것은불가능하며, 후방접근법으로치료해야할적응증이있고, 또한이방법이나름대로여러장점도있으며, 최근엔기존의후방금속판의단점을보완한새로운형태의금속판이소개되고있어좋은임상결과들이보고되고있다 3. 그리고, 관절면을침범한복잡한골절의경우, 얇은금속판의개발로전방고정뿐아니라후방고정을동시에하는방법 (com- Copyright c The Korean Society for Surgery of the Hand 77

2 J Korean Soc Surg Hand Vol. 20, No. 2, June 2015 binde plating technique) 도소개되고있기도하여 4, 여기서는후방접근법및금속판고정의역사적고찰을통해장, 단점을살펴보고적응증및수술기법을소개하고자한다. 역사적고찰 원위요골골절은손목이신전된상태에서넘어지면서압박력이손목에가해져발생하여원위골절편이후방으로전위된다. 이에따른수술적치료로후방접근법에의한고정은자연스러운흐름이었다. 후방금속판고정술이인기를얻은것은정확한관절면정복의중요성이대두된 1980년중, 후반기이며, AO type C2-3의복잡골절의관절면정복도후방접근을통해가능하다고보고되어유행하게되었다 5. 그러나, 정확하게관절면을정복할수있다는장점에도불구하고, 신전건을광범위하게박리하여반흔형성으로관절운동제한을초래하며, 신전건에직접금속고정물이접촉하게되어신전건염혹은신전건파열이되는경우가보고되었고, 후방에있는작은분쇄골절편에혈류차단이유발되어골절치유를방해할수있는어쩔수없는단점을가지고있어많게는 50% 넘는합병증발생율이보고되기도하였다 6,7. 이에따라그사용빈도가점차줄어드는추세에있었지만, 신전건문제등여러합병증을최소화하고자지속적으로수술기법개발과금속삽입물의발전이이어져왔다. 1990년대중반 AO Hand Group 에서는보다얇고, 원위요골에윤곽성형 (precontoured) 되어골절편고정을쉽게하고, 손목운동제한이나신전건자극을최소화할목적으로파이 (Π) 금속판을개발하게되었다. 이것은원위요골에특화된선구적인금속판으로 AO 분류 C2, 3 골절에사용할수있게되어초기몇몇연구에서는만족할만한임상결과를보고하였다 6,8,9. 그러나, 일부연구에서는금속판모양을맞추기위해변형시키거나일부를잘라내어날카로운면이생기게되면신전건이파열되고, 많게는 45% 정도의환자에서지속적인손목통증이발생하여금속제거가필요했다고보고하여이금속판은시장에서점차사라졌다 10. 특히 Ruch 와 Papadonikolakis 11 의전방금속판과후방금속판을사용한비교연구에서후방금속판을사용한 20예중 5 예에서전방으로붕괴되는현상을발견하고생역학적인문제를제시하기도하였다. 1990년대후방에 Rikli와 Regazzoni 12 는원위요골골절의삼주이론 (three column) 을소개하면서, 각지주정복의중요성을강조하였다. 요측지주 (radial column) 는요골경상돌기와주상골와면 (scaphoid facet), 중간지주 (intermediate column) 는월상골와면 (lunate facet) 과 S상절흔 (sigmoid notch), 척측지주 (ulnar column) 는원위척골과삼각섬유인대복합체로구성되며, 특히이중중간지주는월상골과의관절면을이루는것뿐아니라원위요척관절의기능에도중요한역할을한다 12. 원위요골골절시원위골편이주로요측편위, 회외전되기때문에중간지주 (intermediate column) 와요골지주 (lateral column) 의지지가중요하다고인식되었다 12,13. 그에따라 2개의 plate를따로고정하여 Lister tubercle 을남길수있고, 원위에서신전지대판을이용하여금속판을덮어신전건자극을감소시킬수있게되었다. 따라서, 최근의후방금속판은신전건자극을최소화하고자보다얇으면서 (1.6 mm), 나사못이금속판으로감입되도록하였고, 둥근끝처리에, 보다해부학적모양으로개발되고있어신전건관련된합병증발생을과거에비해유의하게감소시키고있다. 또한잠김금속판의사용은골질이좋지않은경우에도보다안정적인고정이가능하여전방잠김금속판만큼조기운동을가능하게하였다. 그러나, 현재국내에서사용가능한후방잠김금속판은종류가몇가지되지않는다. 1. AO (Depuy Synthes, West Chester, PA USA) Dorsal plate 원위요골삼주설에맞추어설계된금속판으로요골경상돌기에윤곽성형된요골지주금속판과 T-/L- 형태의중간지주금속판이있다. 이전에금속판의단점을보완하여얇고, 둥근끝처리, 보다해부학적윤곽에맞게만들어졌다. 원위부는가변각의 2.4 mm 잠김나사못으로고정하고, 근위부에는 2.7 mm 일반나사못혹은 2.4 mm 잠김나사못으로고정한다 (Fig.1) Acu-Loc (Acumed, Hillsboro, OR, USA) 후방원위요골에맞춰윤곽성형된금속판으로원위부가볼록하며, AO 제품에비해약간크고두껍다. 원위부에는 2.3 mm 고정각의잠김나사못으로근위부에는 3.5 mm 나사못으로고정한다. 최근 Acu-Loc 2가시판되었고 AO Pi 금속판과지주금속판같은형태의개량된제품이있으나, 국내출시는아직미정이다 (Fig. 1) 14. 후방접근법의장, 단점 후방접근법의가장큰장점은 1) 관절면을침범한골절의경우관절면을직접시야에서확인하면서정복할수있다는점이다. 또한, 2) 신전건의손상, 동반된수근골간인대의손상, triangular fibrocartilage 손상을확인할수있고필요한 78

3 Hyeok Bin Kwon, et al. Dorsal Approach for Distal Radius Fractures Fig. 1. Recent dorsal plate. (A) AO (Depuy Synthes) dorsal plate. (B) Acumed dorsal plate. 경우수술을같이할수있으며, 3) 후방골간단부에골결손이발생한경우쉽게골이식이가능하다 3,15. 그리고전방접근시발생할수있는정중신경의견인손상이나, 수근관터널증후군같은 4) 신경손상의위험성이낮다 7,16. 과거엔분쇄가동반된후방피질골에금속판을고정하여생역학적으로강한고정이가능하다고하였으나 17, 잠김금속판의등장으로전방고정과비교해서큰차이는없다고한다 6. 이러한장점에도불구하고최근에후방전위골절을간접정복 (indirect reduction) 후에잠김금속판을이용하여전방금속판으로고정하는경향이생긴것은전술한여러단점이있기때문이다. 이를정리하면 3,5-7,10,15,16,18, 원위요골후방은피부와골표면사이에여유공간이적고, 요골후방이볼록하여신전건과금속판이직접접촉하여마찰하게되면 1) 신전건염및파열, 유착이나타날수있다는점, 2) 원위골편으로가는혈관들이주로후방에위치하여골절치유를방해할수있다는점, 기술적으로 3) 같은형태의골절이면전방접근보다더큰피부절개가필요하고, 손등에흉터가생긴다는점, 4) 접근이신전건을골막에서들어야하기때문에전방보다용이하지않다는점, 5) 주로후방에분쇄된골절편이있어이를정복하기가쉽지않다는점, 6) 창상봉합시신전건및신전지대봉합을신경써서해야한다는점등이있다 16. 따라서, 특정접근법을일괄적으로사용하기보다는각증례나의사의경험을토대로최상의결과를얻을수있도록수술방법이선택되어야할것이다. 후방접근법의적응증 이론상대부분의후방전위된불안정성골절과관절을침범한골절에사용할수있으나, 관절외골절은물론관절을침범한골절중시상면상 3.5 mm 이내의후방관절면을침범한후방피질골절편 (dorsal rim fracture) 은전방잠김금속판만으로고정후약간의전위 (3 mm 이내 ) 가되더라도기능상별문제는없다고알려져있어 19, 최근에는전방접근에따른잠김 금속판고정이선호되고있다. 그러나, 후방접근법에유용한경우를정리하면, 전방접근으로관절면의간접정복및고정이어려운 1) 후방전단골절 (dorsal shear fracture, dorsal barton) 과 2) 후방요수근관절탈구및골절 (dorsal radiocarpal dislocation and fracture), 3) 후방피질골의관절내전위 4) 월상와의관절감입골절 (die-punch fracture of lunate facet) 과 5) 원위요골의후방부정유합에서교정적절골술이필요한경우는후방접근및후방금속판단독사용이가능하다. 또한, 전방피질의분쇄골절이동반되고, 6) 월상와쪽에시상면상 3.5 mm 이상후방관절면침범하면서후방전위되어월상골이후방으로아탈구되는경우 20 와 7) 골간단부와관절내골절이심한경우 (AO-C3) 는전방접근으로골간단부의길이유지를하고, 후방접근을통해관절면의정복및고정을하는전, 후방동시접근법이가능하다 (Fig. 2). 그외에 8) 수술적고정이필요한주상월상인대손상이동반된골절 (associated with scapholunate ligament injury) 등이있을수있다 3,15. 후방접근법의술기 Lister 결절척측으로손목관절후방, 중간축 (mid-line) 으로골절양상에따라 Zig-zag, 혹은직선의피부절개를가한다. 피하층을 Blunt 하게박리하고피부를전층피판 (fullthickness skin flap) 으로들어올려신전지대 (extensor retinaculum) 를노출시킨다. 표재성요골신경이장무지신전건 (extensor policis longus) 원위부에서가로질러가는것을확인한다. 무지와수지를각각수동적으로움직여장무지신전건 ( 세번째구획 ) 과총수지신전건 ( 네번째구획 ) 사이의경계를확인한후세번째구획을종으로열어장무지신전건을유리시켜요측으로젖힌후네번째구획의건하지대 (infratendinous retinaculum) 를바로아래의배측수근관절막 (dorsal wrist capsule) 과분리된층으로박리하거나골막하 79

4 J Korean Soc Surg Hand Vol. 20, No. 2, June 2015 박리를통해배측관절막과같은층으로박리한다 (Fig. 3). 이때분쇄된골편들이골막과같이들어올려질수있어주의가필요하다. 요골경상돌기까지노출시키기위해서두번째구획도같은방법으로박리하여내-외측으로신전지대판 (extensor retinaculum flaps) 을만든다. 경우에따라 T형금속판고정이필요할때는수술후금속판이바로신전건에닿지않도록하기위해신전지대를두번째구획에서네번째구획까지횡으로이분하여 ㄹ 형태의절개를한뒤, 후에원위지대를 T형금속판의 ㅡ 부분을덮어줄때이용하기도한다 3,21. 관절면노출을위해수근골을덮고있는배측관절막을종으로절개하여관절막전층을하나의판으로요, 척측으로들어올리면관절면을노출시킬수있다. 원위요골골절부위를노출시킨후금속판을부착하기위한후방골표면을고르게하고, 이미분쇄가되어있는 Lister 결절을절제하기도한다. 골절부 위를정복한후일시적인고정을위하여 K-강선을삽입하고투시방사선검사로만족할만한정복이되었는지확인한다. 이때, 심한관절내골절이있는경우 (AO C type) 큰골절편중심으로원위수근골접촉면에맞추어정복을한후 K-강선혹은심한경우연골하골에골이식을하여지지를해줄수도있다. 후방피질분쇄가심한경우에도조각조각맞추어혈류저하를유발하는대신가급적연부조직에붙어있는큰골편중심으로정복을한다. L형혹은 T형의금속판을원위요골배부의모양에맞게변형시키는데, 이때잠금나사가이드를나사구멍에위치시켜놓고휘어야잠김나사의손상을방지할수있다. 원위골편부터잠김나사를이용하여고정하는데, 나사못이관절면을뚫지않도록하기위해고정각잠김금속판 (fixed locking plate, Acumed) 의경우금속판위치를조절하고, 가변각잠김금속판 (variable locking plate, AO) 의경우 Fig. 2. Combined volar and dorsal plating (dual plating). (A) Preoperative radiographs of a 52-year-old women after slipping and landing to outstretched arm. Note the comminuted dorsal Barton type fracture. (B) Twelve months postoperative anterior-posterior (AP) and lateral radiograph displaying anatomical reduction with the dual plate. (C) Preoperative radiographs of a 56-year-lod women after fall from the stair. Note the severe comminuted articular and metaphyeal fracture, AO type C. (D) Fifteen months postoperative AP and lateral radiographs displaying stable dual plate fixation. 80

5 Hyeok Bin Kwon, et al. Dorsal Approach for Distal Radius Fractures Fig. 3. Dorsal approach. (A) Dorsal longitudinal skin incision along just ulnar side to Lister tubercle (B) exposed the extensor retinaculum and incised over the third extensor compartment. Needle tip indicated the extensor policis longus. (C) Optional retinacular incision method. (D) Exposed the fracture site after elevation of the second, fourth extensor compartment. 나사방향을조절하여준다. 이렇게원위골절편과하나가된금속판을근위부에요골의종축에맞추어나사못을고정한다. 요골지주고정이나척골지주고정이추가로필요할경우같은방법으로고정을하게된다. 금속고정후다시한번 C- arm을이용하여나사못위치와길이를확인한다. 이때원위나사못은전방피질골을가급적뚫지않도록하는것이좋고 ( 대개 20 mm 이내 ), 근위나사못은전방피질골을뚫어고정시키는경우드릴사용에주의가필요하다. ( 대개원위부는 mm, 근위는 mm) 창상봉합시각각요, 척측으로견인되었던신전건을제자리로위치시키고신전지대를봉합한다. 이때장무지신전건은구획내의건초에다시넣지말고요측으로봉합된신전지대위로 ( 피하에 ) 위치하도록하여도수술후무지신전기능이상실되지않는다 (Fig. 4) 3,15,21. 결론 최근불안정성원위요골골절의치료는전방잠김금속판 을이용한관혈적정복및금속내고정이치료의근간을이루고있다해도과언이아니다. 그러나, 관절면의전위가동반된원위요골골절의경우전방접근만으로는관절면의정복이불충분하거나, 간과되기쉽기때문에불만족스러운임상결과가발생할수있다. 후방접근이신전구획을골막하박리후들어야하고, 전방에비해더분쇄된골절편을제대로맞추는것은쉽지않으며, 연부조직공간이작아금속판고정시신전건이자극되는등여러단점에도불구하고, 관절내골절의기본적인치료원칙인해부학적관절면정복및고정을할수있는장점이있다. 그러므로, 후방접근법은후방피질골분쇄및전위가있는원위요골골절이나후방 Barton 골절, 후방피질골의전위가심한경우등에서단독사용도가능하며, 관절면및골간단부분쇄가심한 AO C3 골절의경우전방금속판고정을통해길이유지를해놓고후방접근으로관절면의정복을하는전, 후방동시접근및금속판고정을통해임상적으로만족할만한결과가보고되고있다. 따라서, 특정접근법을일괄적으로사용하기보다는각접근법의장, 단점을고 81

6 J Korean Soc Surg Hand Vol. 20, No. 2, June 2015 Fig. 4. Dorsal plating technique. (A) Applied appropriate dorsal plate after fracture reduction and temporary fixation. (B) Fixation plate with 2.7 mm conventional screw proximally and 2.4 mm locking screw distally. (C) The extensor policis longus is left dorsal to the extensor retinaculum to minimize tendon scarring. (D) Postoperation radiographs. 려하여골절형태에따라사용한다면보다좋은임상결과를얻을수있을것으로판단된다. REFERENCES 1. Robertsson GO, Jonsson GT, Sigurjonsson K. Epidemiology of distal radius fractures in Iceland in Acta Orthop Scand. 1990;61: Chung KC, Shauver MJ, Yin H, Kim HM, Baser O, Birkmeyer JD. Variations in the use of internal fixation for distal radial fracture in the United States medicare population. J Bone Joint Surg Am. 2011;93: Tavakolian JD, Jupiter JB. Dorsal plating for distal radius fractures. Hand Clin. 2005;21: Ring D, Prommersberger K, Jupiter JB. Combined dorsal and volar plate fixation of complex fractures of the distal part of the radius. J Bone Joint Surg Am. 2004;86: Axelrod TS, McMurtry RY. Open reduction and internal fixation of comminuted, intraarticular fractures of the distal radius. J Hand Surg Am. 1990;15: Rozental TD, Beredjiklian PK, Bozentka DJ. Functional outcome and complications following two types of dorsal plating for unstable fractures of the distal part of the radius. J Bone Joint Surg Am. 2003;85: Yu YR, Makhni MC, Tabrizi S, Rozental TD, Mundanthanam G, Day CS. Complications of low-profile dorsal versus volar locking plates in the distal radius: a comparative study. J Hand Surg Am. 2011;36:

7 Hyeok Bin Kwon, et al. Dorsal Approach for Distal Radius Fractures 8. 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. 1998;23: Kamath AF, Zurakowski D, Day CS. Low-profile dorsal plating for dorsally angulated distal radius fractures: an outcomes study. J Hand Surg Am. 2006;31: 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 Surg Am. 1998;23: Ruch DS, Papadonikolakis A. Volar versus dorsal plating in the management of intra-articular distal radius fractures. J Hand Surg Am. 2006;31: Rikli DA, Regazzoni P. Fractures of the distal end of the radius treated by internal fixation and early function. A preliminary report of 20 cases. J Bone Joint Surg Br. 1996;78: Campbell DA. Open reduction and internal fixation of intra articular and unstable fractures of the distal radius using the AO distal radius plate. J Hand Surg Br. 2000; 25: Geissler WB. Management distal radius and distal ulnar fractures with fragment specific plate. J Wrist Surg. 2013; 2: Lutsky K, Boyer M, Goldfarb C. Dorsal locked plate fixation of distal radius fractures. J Hand Surg Am. 2013;38: Wei J, Yang TB, Luo W, Qin JB, Kong FJ. Complications following dorsal versus volar plate fixation of distal radius fracture: a meta-analysis. J Int Med Res. 2013;41: 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. 2003;28: Letsch R, Infanger M, Schmidt J, Kock HJ. Surgical treatment of fractures of the distal radius with plates: a comparison of palmar and dorsal plate position. Arch Orthop Trauma Surg. 2003;123: Kim JK, Cho SW. The effects of a displaced dorsal rim fracture on outcomes after volar plate fixation of a distal radius fracture. Injury. 2012;43: Ikeda K, Osamura N, Tada K. Fixation of an ulnodorsal fragment when treating an intra-articular fracture in the distal radius. Hand Surg. 2014;19: Na KT, Song SW, Lee YM, Kang BM. Dorsal plate fixation for dorsally displaced distal radius fractures. J Korean Soc Surg Hand. 2014;19:

8 J Korean Soc Surg Hand Vol. 20, No. 2, June 2015 원위요골골절의후방접근법 권혁빈 이재성중앙대학교의과대학정형외과학교실 전방잠김금속판의소개로최근불안정성원위요골골절의치료는전방접근후금속판을이용한치료가주를이루고있다. 그러나, 전방접근은관절면을노출하는데한계가있어서, 관절면의정복이필요한경우나후방골절편이비교적심하게전위된경우혹은수근관절내동반손상이있는경우등은후방접근법을통한치료가필요하다. 후방접근을통한후방금속판고정은신전건의자극및파열등많은합병증이보고된후제한적으로만사용되었으나, 금속삽입물디자인의향상으로이러한단점을극복하고있다. 여기서는역사적고찰을통해후방접근법의장, 단점과적응증, 수술기법을살펴보고자한다. 색인단어 : 원위요골골절, 후방접근법 접수일 2015 년 6 월 5 일수정일 2015 년 6 월 9 일게재확정일 2015 년 6 월 10 일교신저자이재성서울특별시동작구흑석로 102 중앙대학교병원정형외과학교실 TEL , FAX boneman@cau.ac.kr 84