J Korean EMG Electrodiagn Med 대한근전도 전기진단의학회지 13(1):77~82, 2011 쇄골골절에서의팔자붕대에의한상완신경총손상 1 예 가톨릭대학교의과대학재활의학교실 오현미 박경수 정명은 김준성 고영아 나인훈 정희찬 오지혜 Abstract A Case Report of Brachial Plexus Injury after Applying Figure-of-Eight Bandage for Newborn Clavicle Fracture - A Case Report - Hyun-Mi Oh, M.D., Kyoung-Soo Park, M.D., Myung-Eun Chung, M.D., Joon-Sung Kim, M.D., Young-A Ko, M.D., In-Hoon Na, M.D., Hee-Chan Chung, M.D., Ji-Hye Oh, M.D. Department of Rehabilitation Medicine, College of Medicine, The Catholic University of Korea A clavicle fracture is a relatively common injury that occurs in any age. It occurs in 0.2%~4.4% of newborns. Newborn clavicle fractures require no or little intervention except re-examinations and repeated radiographies. Our case involves a brachial plexus injury after applying a figure-of-eight bandage for a clavicle fracture of an infant. A 15-day-old male baby was referred to our department for the left arm weakness and the left axillar skin necrosis caused by a figure-of-eight bandage, which was applied for his clavicle fracture. The fifteen days after applying the figure-of-eight bandage, the electrodiagnostic study showed a brachial plexopathy. The brachial plexus was compressed by the figure-of-eight bandage. We report a case of a brachial plexus injury due to compression of the nerves from applying the figure-ofeight bandage for the displaced mid-shaft clavicle fracture in a neonate. Key Words: Brachial plexus injury, Clavicle fracture, Figure-of-eight bandage 서 론 쇄골골절은모든연령에서흔히발생하는골절로, 분만중발생하는골절중가장흔하다. 1,2 쇄골골절은소아골절의 10~15% 에해당하며분만중발생하는쇄골골절의빈도는 0.2~4.4% 로다양하게보고되고있다. 2-4 쇄골골절의치료방법은골절의기전, 동반손상의유무등에따라다른데, 신생아의경우특별한치료가필요하지않으나, 전위가있는경우에만 8 자형붕대사용을고 려한다. 3 쇄골골절후신경학적합병증은드물게발생하나골절조각에의한직접적인압박또는비대가골형성, 쇄골하가동맥류, 흉터수축을동반한부정유합, 불유합에의한지연성신경압박으로발생할수있으며드물게꼭끼는붕대로인해초기에발생할수있다. 1,2,5-8 본연구자들은분만중전위를동반한쇄골골절환아에게 8자형붕대고정후압박에의한액와부피부괴사와상완신경총손상이발생한드문증례를경험하였기에문헌고찰과함께보고하고자한다. Address reprint requests to Kyoung-Soo Park, MD Department of Rehabilitation Medicine, St. Vincent Hospital, College of Medicine, The Catholic University of Korea, 93-6 Ji-dong, Paldal-gu, Suwon, Gyeonggi-do 442-723, Korea TEL: 82-31-249-7650, FAX: 82-31-248-5520, E-mail: ksjoa74@naver.com 투고일 : 2011년 4월 20일, 1차수정일 : 2011년 6월 1일, 2차수정일 : 2011년 6월 29일, 게재확정일 : 2011년 6월 29일 77
오현미 박경수 정명은 김준성 고영아 나인훈 정희찬 오지혜 증 례 생후 15 일된남아가좌측상지의근위약과좌측액와부조직괴사로본원소아청소년과입원하여근전도검사의뢰되었다. 남아는개인병원에서 41 주 -3.66 kg- 제왕절개로분만하였으며분만후좌측상지의움직임이우측과비교하여감소되어있었으나 pin prick test 에대하여양측에서회피반응유사하게관찰되었고양측 Moro 반사는양성반응을보였다. 이에시행한단순방사선검사상전위가동반된좌측쇄골골절전위가 (Fig. 1) 관찰되어 8 자형붕대를사용하였다. 8 자형붕대고정하고 3 일후부터그전관찰되었던집단운동성이더이상관찰되지않았고우측과비교하여좌측에서 pin prick test 반응이현저히감소되어있었다. 7 일후좌측액와부의피부괴사와분비물발견되어생후 8 일경본원응급실경유소아청소년과로입원하였다. 생후 15 일에근전도검사의뢰되었으며검사당시좌측손가락의주먹쥐기는약하게관찰되나그밖의어깨, 팔꿈치, 손목의자발적움직임이전혀관찰되지않았고 pin prick test 에대한반응도현저히감소되어있었으며 Moro 반사는좌측에서유발되지않았다. 관찰에의한좌측견관절외전근및굴근은의학연구위원회 (Medical Research Council, MRC) 등급 2, 주관절이하부위는등급 0 으로추정되었다. 좌측액와부로 3 5 cm 가량의조직괴사및분비물이관찰되었다 (Fig. 3A). 검사는운동신경전도검사에서 sensitivity 는 5 mv 로, sweep speed 는 50 ms/div 로, filter 는 0.01~10 khz 로설정하여시행하였고, 감각신경전도검사에서 sensitivity 를 20 uv 로, sweep speed 를 15 ms/div 로, filter 는 20~2 khz 로설정하여시행하였다. 침근전도검사에서 sensitivity 는 100 uv~1 mv 로, sweep speed 는 100 ms/div 로, filter 는 10~5 khz 로설정하였다. 감각신경전도검사에서는좌측정중신경, 척골신경, 요골신경, 외측전완피신경및양쪽내측전완피신경은유발되지않았으며운동신경전도검사에서는좌측정중신경, 척골신경, 요골신경의복합근육활동전위가유발되지않았다. 좌측액와신경및근피신경의원위부잠시는느려져있었고진폭은감소되어있었다 (Table 1). 침근전도검 Fig. 1. Plain radiography and left shoulder magnetic resonance image. Chest AP shows a left mid-shaft clavicular fracture. A B Fig. 2. T2-weighted magnetic resonance images show (A) the clavicle fracture site (B) the injury of brachial plexus at thoracic inlet level (Non-enhanced, 3.0T). 78
쇄골골절에서의팔자붕대에의한상완신경총손상 1 예 사상좌측가시위근 (supraspinatus muscle) 에서는비정상자발전위가관찰되지않았으며위팔두갈래근 (biceps brachii muscle), 어깨세모근 (deltoid muscle), 공통손가락폄근 (extensor digitorum communis muscle), 짧은엄지벌림근 (abductor pollicis brevis muscle), 첫번째등쪽뼈사이근 (first dorsal interossei muscle) 에서비정상자발전위및증가된삽입활동전위소견보여 (Table 2) 근전도검사및임상증상을토대로 8 자형붕 Table 1. Results of 1 st Nerve Conduction Studies Nerve/recording Sites Motor Lat (ms) Amp (mv) Dist (mm) Con Vel (m/s) R median (APB) (Wrist) 2.2 3.5 (Elbow) 4.6 2.3 65 27.0 L median (APB) (Wrist) NR NR (Elbow) NR NR R ulnar (ADM) (Wrist) 1.7 3.4 (Elbow) 3.9 2.4 70 31.8 L ulnar (ADM) (Wrist) NR NR (Elbow) NR NR R radial (EIP) 4.4 4.3 L radial (EIP) NR NR R axillary (deltoid) 2.6 2.6 L axillary (deltoid) 5.5 1.1 R musculocutaneous (biceps) 2.9 2.0 L musculocutaneous (biceps) 5.7 0.2 Sensory Lat (ms) Amp (uv) R median (3 rd finger) 2.70 16.7 L median (3 rd finger) NR NR R ulnar (5 th finger) 2.60 21.7 L ulnar (5 th finger) NR NR R radial (thumb) 2.10 32.6 L radial (thumb) NR NR R LABC 1.80 26.4 L LABC NR NR B MABC NR NR Lat: latency, Amp: amplitude, Con vel: conduction velocity, NR: no response, APB: abductor pollicis brevis, ADM: abductor digiti minimi, LABC: lateral antebrachial cutaneous nerve, MABC: medial antebrachial cutaneous nerve, R: right, L: left, B: bilateral. Table 2. Results of 1 st Needle Electromyography ASA MUAP IA Fib PSW Amp Dur. Poly C5-T1 paraspinal None None L supraspinatus None None No MUAP L deltoid None 1+ No MUAP L biceps brachii None 1+ No MUAP L EDC None 1+ No MUAP L APB None 1+ No MUAP L FDI None 1+ No MUAP ASA: abnormal spontaneous activity, IP: interferece pattern, MUAP: motor unit action potential, IA: insertional activity, Fib: fibrillation, PSW: positive sharp wave, L: left, B: bilateral, NT: not testable, EDC: extensor digitorum communis, APB: abductor pollicis brevis, FDI: first dorsal interosseous. 79
오현미 박경수 정명은 김준성 고영아 나인훈 정희찬 오지혜 대고정후압박에의한좌측모든신경속을침범한좌측상완신경총손상으로진단하였다. 이후좌측견관절의자기공명영상검사를시행하였다 (Fig. 2). 자기공명영상검사상좌측액와부위부터흉곽입구부위까지는상완신경총의형태가유지되나흉곽입구부위부터는상완신경총의형태가유지되지않아흉곽입구부위에서발생한상완신경총손상으로진단되었고상완신경총손상을유발할수있는쇄골골절조각에의한직접적인상완신경총압박이나제 1~2 늑골골절등주위연부조직손상은관찰되지않았다. 이후좌측액와부의조직괴사에대해성형외과에서변연절제술및봉합시행하였다 (Fig. 3B). 퇴원후재활의학과외래내원하여재활 치료시작하였으며 8 개월후근전도추적검사상처음시행한우측운동신경전도검사와비교하여좌측정중신경및근피신경은잠시지연및진폭감소, 요골신경은진폭감소소견관찰되었으나호전된양상관찰되었고척골신경은거의유사하게회복되었음을알수있었다. 감각신경검사에서는여전히활동전위관찰되지않았으며침근전도검사상비정상자발전위는더이상관찰되지않았다 (Table 3, 4). 환아생후 6 개월경기어가기시작하였고주로우측으로추진하는모습이관찰되었다. 9 개월경손잡고걷기가능하였고좌측어깨와팔꿈치의굴곡, 신전운동은우측과비교하여양측차이없었으나주먹쥐는힘이나검지손가락의독립적 A B Fig. 3. These figures show (A) the skin necrosis (3 5 cm) with pus like discharge at the left axilla and (B) debridment and closure. Table 3. Results of 3 rd Nerve Conduction Studies Nerve/recording Sites Motor Lat (ms) Amp(mV) Dist (mm) Con Vel (m/s) L median (APB) (Wrist) 3.5 1.9 (Elbow) 5.2 1.4 65 38.2 L ulnar (ADM) (Wrist) 1.4 2.9 (Elbow) 3.5 2.3 68 30.9 L radial (EIP) (Wrist) 1.4 0.6 (Elbow) 2.3 0.3 30 33.3 L axillary (deltoid) 2.6 2.6 L musculocutaneous (biceps) 3.5 1.8 Sensory Lat (ms) Amp (uv) L median (3 rd finger) NR NR L ulnar (5 th finger) NR NR L radial (Thumb) NR NR L LABC NR NR L MABC NR NR Lat: latency, Amp: amplitude, CV: conduction velocity, NR: no response, NE: not evoked, LABC: lateral antebrachial cutaneous nerve, MABC: medial anterbrachial cutaneous nerve. 80
쇄골골절에서의팔자붕대에의한상완신경총손상 1 예 Table 4. Results of 3 rd Needle Electromyography ASA MUAP IA Fibs PSW Amp Dur Poly L supraspinatus None None N N None L deltoid N None None N N None L biceps brachii N None None N N None L EDC N None None N N None L APB N None None N N None L FDI N None None N N None ASA: abnormal spontaneous activity, IP: interferece pattern, MUAP: motor unit action potential, IA: insertion activity, Fib: fibrillation, PSW: positive sharp wave, Dur: duration, Poly: polyphasic motor unit potential, L: left, B: bilateral, N: normal, NT: not testable, EDC: extensor digitorum communis, APB: abductor pollicis brevis, FDI: first dorsal interosseous 사용은우측에비교하여약간떨어지며네발기기자세시좌측세번째, 네번째, 다섯번째손가락이굴곡되는모습관찰되었다. 12 개월경좌측네번째, 다섯번째손가락의미세운동의저하이외대부분호전되었다. 고 찰 쇄골골절은모든연령에서흔히발생하는골절로분만시발생하는골절중가장흔하며빈도는 0.2~ 4.4% 까지다양하게보고되고있다. 1-4 주로자연분만시발생하나제왕절개술시에도드물게발생할수있다. 2 쇄골골절의치료방법은동반손상의유무, 골절의기전, 골절의성질및환자의연령에따라달라지는데신생아의경우특별한치료가필요치않으며전위가있는경우 8자형붕대로고정할수있으며대부분예후는좋다. 2 일반적으로중간부위쇄골골절의경우단순팔걸이나팔자형붕대가가장보편적치료로사용되며전위가동반된경우수술적방법을고려할수도있다. 1,5,6 단순팔걸이와팔자형붕대사이의기능적또는미용적측면에서치료결과에는차이가없으나팔자형붕대의경우환자가불편함을호소하거나액와부욕창, 신경혈관다발의압박, 불유합등의합병증이발생할수있으며이러한이유로단순팔걸이가가장널리사용되고있다. 1,6,7 쇄골골절의합병증으로는불유합, 부정유합, 신경학적합병증, 재골절, 견봉쇄골관절의관절염, 수술적합병증등이있으며이중쇄골골절로인한상완신경총손상은드물며약 1% 에서발생하는것으로알려져있다. 1,8 쇄골골절후발생하는상완신경총손상발생원인으로는골절조각에의한직접적인압박또는비대가골형성, 쇄골하가동맥류, 흉터수축을동반한부정유합, 불유합에의한지연성신경압박으로발생할수있으며드물게꼭끼는붕대로인해초기에발생할수있다. 1,2,5-8 쇄골골절후직접압박에의한상완신경총손상은중간부위쇄골골절에서가장흔하며지연성신경압박에의한상완신경총손상의경우내측및후신경속의 압박이가장흔하나외신경속압박이동반된경우도있으며대부분예후는좋다. 5,8 본증례의경우분만시전위가동반된쇄골골절이발생하여 8 자형붕대를사용하였고팔자형붕대를사용하기전까지는부자연스럽긴하나왼쪽상지의움직임보였으나팔자형붕대를고정하고 3 일후좌측상지의움직임감소및 7 일후발생한좌측액와부에피부괴사소견이관찰되었다. 이에전기진단학적검사후좌측상완신경총손상을진단하였고자기공명영상검사시행후혈관손상, 제 1~2 번늑골손상, 쇄골골절에의한직접적상완신경총손상을배제할수있었다. 본증례의경우팔자형붕대고정후압박에의한좌측액와부피부괴사및좌측상완신경총손상이발생한경우로팔자형붕대는단순팔걸이와함께중간부위쇄골골절에널리사용되는보존적치료법이나액와부욕창, 신경혈관다발의압박, 불유합등의합병증이발생할수있으므로특히신생아와같이팔자형붕대적용후피부손상및신경손상등의합병증이발생하더라도정확한의사표현을하지못하는환자들의경우팔자형붕대를적용후팔의움직임이떨어지거나피부손상이발생할경우이미지검사와전기진단검사를통하여상완신경총손상을반드시확인해야할것으로사료된다. 참고문헌 1. Kashif LA, Bradnock TJ, Scott C, Robinson CM: Fractures of the clavicle. J Bone Joint Surg Am 2009 Feb: 91(2): 447-460. 2. Jeong MY, Kim MJ, Jin KH, Song R, Choi JH, Hur SY, et al.: Study of the risk factors of neonatal clavicle fractures. Korean Society of Maternal Fetal Medicine 2006: 2: 261-265. 3. Roberts SW, Hernandez C, Mabbery MC, Adams MD, Leveno KJ, Wendel GD, Jr.: Obstetric clavicular fracture: The Enigma of Normal Birth. Obstet Gynecol 1995: 86: 81
오현미 박경수 정명은 김준성 고영아 나인훈 정희찬 오지혜 978-981. 4. Joseph PR, Rosenfeld W: Clavicular fractures in neonates. Am J Dis Child 1990: 144: 165-167. 5. Chen-Chiang L, Jinn L: Brachial plexus palsy caused by secondary fracture displacement in a patient with closed clavicle fracture. Orthopedics 2009 Oct: 32: 769-771. 6. Andersen K, Jensen PO, Lauritzen J: Treatment of clavicular fractures. Figure of eight bandage versus a simple sling. Acta Orthop Scand 1987: 58: 71-74. 7. Faldini C, Nanni M, Leonetti D, Acri F, Galante C, Luciani D, et al.: Nonoperative treatment of closed displaced midshaft clavicle fractures. J Orthop Trauma 2010: 11: 229-236. 8. Barbier O, Malghem J, Delaere O, Vande Berg B, Rombouts JJ: Injury to the brachial plexus by a fragment of bone after fracture of the clavicle. J Bone Joint Surg Br 1997: 79: 534-536. 82