ORIGINAL ARTICLE 대한족부족관절학회지제 17 권제 3 호 2013 J Korean Foot Ankle Soc. Vol. 17. No. 3. pp.182-188, 2013 족관절의골절 - 탈구에대한임상적고찰 인제대학교의과대학일산백병원정형외과학교실 김지훈 송재광 서진수 The Clinical Study of Ankle Fracture and Dislocation Ji Hoon Kim, M.D., Jae Gwang Song, M.D., Jin Soo Suh, M.D. Department of Orthopedic Surgery, Inje University, Ilsan Paik Hospital, Koyang-si, Gyeonggido, Korea =Abstract= Purpose: We evaluate clinical manifestations and radiologic features of ankle fracture & dislocation, as well as the usefulness of computed tomography on posterior ankle fracture & dislocation to study factors contributing to ankle fracture & dislocation. Material and Methods: Ankle dislocation was defined as the center of talar body being translated over the cortex of tibia on AP or lateral view on simple X-ray. Surgical treatments of 30 patients from January 2007 to March 2012 were categorized according to the injury mechanism, the direction of dislocation and fracture site. Joint involvement of posterior malleoalr fracture was evaluated through simple x-ray and computed tomography. We treated surgically if posterior malleolus fracture involves more than 25% of dital tibial articular surface. Thereafter, clinical outcomes were identified through radiographs and by using the AOFAS score. Results: The mean age was 42(13-78) years old, and slip down was the most common injury mechanism (13 cases). Car accident (6 cases) and fall accident (4 cases) were the next frequently found injury mechanisms. As for the types of ankle fracture, posterior fracture and dislocation (21 cases, 43.3%) was most commonly found. Out of these 21 cases, 15 cases involved trimalleolar fracture, and 19 cases were associated with posterior malleolar fracture. Danis-weber type B and C patients were 11 cases and 10 cases respectively. Articular involvement of posterior malleolar fracture turned out to be average 27.9%(5.1%~49.1%) on simple x-ray. The rate was evaluated as average 31.7%(12.6%~55.3%) on computed tomography which was conducted 15 times, and led us to more meaningful data. Conclusion: Anterolateral fracture and dislocation often accompanied open dislocation. Posterior fracture dislocation was most commonly found. Posterior malleolus was an important factor that ensures posterior stability of the ankle joint. Computed tomograph is useful to evaluate the articular involvement of posterior malleolar fracture. Key Words: Ankle, Dislocation, Posterior approach, Posterior malleolus Received: June 19, 2013 Revised: August 11, 2013 Accepted: August 20, 2013 Corresponding Author: Jin Soo Suh Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, 2240 Daehwa-dong, Ilsan-seogu, Koyang-si,Gyeonggido, Korea Tel: +82-31-910-7968 Fax: +82-31-910-7967 E-mail: sjs0506@paik.ac.kr 본논문의요지는 2011 년도대한족부족관절학회추계학술대회에서발표되었음. 서론 족관절의탈구는주로고에너지손상으로알려져있으며, 족관절주변의인대에비해상대적으로약한골질로인해골절과동반하여발생한다. 1) 골절과동반되지않는발목의단독탈구는흔하지않으며내, 외측탈구는대개발목관절골절과동반되나전, 후방탈구는 - 182 -
족관절의골절 - 탈구에대한임상적고찰 단독으로도가능하다. 2) 족관절의탈구는후방탈구가전방탈구보다발생빈도가높으며, 이는경골의후방에타격을가함으로써발생한다고알려져있다. 후과의모양은족근관절의후방안정성에중요한역할을하는구조물로여러저자들에의해측면방사선사진을기준으로 25~30% 이상의침범시수술적고정이필요하다고여겨지고있다. 3,4) 하지만족관절골절의다양성을고려할때평면에서후과골절편을정확하게평가하기에는한계가있으며, 실제로수술도달방법및고정방법에대해서도일치된의견이정립되어있지않다. 또한슬관절, 고관절, 견관절등다른대관절과는달리족관절에서의골절탈구에대한연구는보고된바가없다. 본연구의목적은족관절의골절및탈구가동반된사례의분석을통해족관절골절탈구의임상적양상과방사선학적특징및나아가후방탈구시후방관절의침범정도를단순방사선검사와컴퓨터단층촬영을통해비교분석하여그유용성을알아보고자하였다. 대상및방법 1. 대상 2007 년 1 월부터 2012 년 3 월까지본원에서족관절 골절및탈구로수술적치료를받은총 33명의환자중 1년이상의추시가가능하였으며동측의거골및원위경골관절면골절이동반되었던 1례및 18세미만이었던 2례를제외한 30례를대상으로하였으며, 족관절탈구의정의는단순방사선사진상전후면, 측면사진중적어도하나이상의영상에서거골체부의중심부가원위경골의피질골이상으로전위되었을때를기준으로하였다. 총 30례중개방성골절은 6례이었다. 평균연령은 42(13-78) 세였고, 남성 23명과여성 7명이었으며, 평균추시기간은 14.6(12-19) 개월이었다. 2. 연구방법 30명에대한후향적연구를시행하였으며, 족관절탈구환자가내원하면도수정복을우선적으로시행하였고, 개방성골절탈구인경우응급수술을통한정복및고정술을시행하였다. 내원시전례에서신체검사를통해동반된신경, 혈관손상여부를확인하였으며, 정복이전의단순방사선사진을통해탈구방향을파악하고, 동반된골절부위를확인하였다. 후방탈구환자군에서후과골절의관절침범정도를단순방사선사진의측면상에서원위경골관절면에대한비율로구하였으며 (Fig. 1A) 또한컴퓨터단층촬영의시상면상후 A B Figure 1. A 35 years old suffered from ankle anterolateral dislocation after traffic accident. (A) On simple x-ray lateral view: calculate articular involvement of posterior malleolus: A/A+B X100% (B) On computed tomography sagital view: calculate articular involvement of posterior malleolus: A/A+BX100% - 183 -
김지훈 송재광 서진수 과골편의원위관절침범비율이가장큰영상 (Fig. 1B) 에서의비율을측정하여비교분석하였다. 족관절의후과골절이동반된환자에서후과골절이관절면의 25% 이상을침범하였거나 2 mm이상의전위가있는경우에대해서는후과골절에대한수술적고정법을시행하였다. 수술을시행한전례에서술후 2 주, 1개월, 2개월, 3개월, 6개월에주기적인방사선추시관찰을시행하였고, 임상결과는최종추시시의임상적결과를 AOFAS에서제시한 Ankle-Hindfoot scale을적용하여평가하였다. 3. 통계적검증후방탈구환자군에서후과골절의관절침범정도를방사선사진및컴퓨터단층촬영을통해측정하였고이는 Wilcoxon test를통한 p-value를통해통계적유의성을확인하였다. 결과 1. 손상기전 손상기전은실족사고가 13 례로가장많았고, 스포 츠손상 7례, 교통사고 6례, 낙상 4례이었다. 실족사고는대표적고에너지손상인스포츠손상과교통사고보다높게발생하였다. 2. 탈구의방향과골절부위탈구의방향은방사선측면사진을기준으로후방탈구가총 21례 (70%) 로가장많았고, 이를좀더세분하여보자면순수한후방탈구가총 13례후외측탈구가 8례였으며, 전방탈구는 6례모두전외측이었다. 순수한외측탈구가 2례, 내측탈구가 1례였다. 전외측탈구 6례중 5례는개방골절이동반되었다. 이경우경골의내과가피부외측으로노출되어있었고연부조직감입으로도수정복되지않아 (Fig. 2A, B) 응급수술을통한정복및고정술을시행하였다 (Fig. 2C). 후방및후외측탈구환자 21례중족관절골절은삼과골절이 15례로가장많았고, 외과및후과의동반골절이 4례로나타났지만후과골절이없이외과골절과동반된후외측탈구도 2례에서관찰되었다. 내과및후과만의골절은없었다. 후방탈구환자 (21례) 에서외과골절에대한 Danis-Weber type에의한분류는 B 군이 11례 C군이 10례로관찰되었다 (Table 1). A B C Figure 2. A 54 years old male suffered from ankle anterolateral dislocation after fall. (A) Clinical photo: Irreducible dislocation due to impaction of soft tissue. (B) Initial radiographs of anterolateral dislocation. (C) Immediate postoperative radiographs. - 184 -
족관절의골절 - 탈구에대한임상적고찰 3. 후과골절의관절면침범정도 고 찰 후방탈구시후과골절의윈위경골관절의침범정도는단순방사선사진에서평균 27.9% 로측정되었고, 컴퓨터단층촬영에서평균 31.7% 로측정되어컴퓨터단층촬영을통한침범정도가통계학적으로의미있게높게측정되었다 (p<0.05, Table 2). Danis- weber type B와 C간의후과관절면의침범정도를단순방사선사진및컴퓨터단층촬영을통해비교하였지만, 의미있는차이는보이지않았다. (p>0.05, Table 2) 하지만 Danis-weber type B와 C 군모두에서컴퓨터단층촬영을통한관절면의침범정도가단순방사선사진보다높게측정되었다 (p<0.05, Table 2). 4. 후과골절환자에서수술적치료 족관절후과골절이동반되었던 19례중후과골절이원위경골관절면의 25% 이상을침범하였거나 2 mm 이상의전위가있어수술한경우는총 10례 (56%) 였고, 후방접근법을통해나사고정술을시행하였다. 정복후전례에서평균 1 mm이하의골편간극을보였으며, 골유합을얻었다. 최종추시시 AOFAS score는평균 93.29 점으로양호한임상결과를얻었다 (Fig. 3A, B). Table 1. Fracture type of posterior & posterolateral dislocation Fracture type Trimalleolar Fx. 15 (71.4%) Lat. & Post. Malleolar Fx. 04 (19%)0. Lateral mallolar Fx. 02 (09.5%) Danis-Weber type Type B 11 (52.4%) Type C 10 (47.6%) 족관절의골절탈구는아주드물지는않게경험할수있는손상이지만슬관절, 고관절등다른대관절의골절탈구와는달리족관절골절탈구에대한연구는국내및국외를통틀어찾아보기힘들다. 저자는그원인을족관절탈구라는정의의모호함으로판단하였다. 전통적인족관절탈구의정의는경골거골관절이정상적인해부학적관절을형성하지못하는상태를의미하지만족관절은비교적쉽게정복되며족관절탈구환자가정복후병원을방문할경우정상해부학적관절을형성하는경우가많다. 비슷한이유로슬관절의경우 2개의십자인대가완전파열된상태를슬관절탈구로정의한다. 저자는족관절탈구의정의를단순방사선사진상전후면, 측면사진중적어도하나이상의영상에서거골체부의중심부가원위경골의피질골이상으로전위되었을때를기준으로하여본연구를진행하였다. 족관절탈구는후방및후외측탈구가 21례 (70%) 가장흔하게관찰되었으며후방및후외측탈구 21례중 19례 (90.5%) 에서후과골절이동반되었다. 이는후과가족관절후방안정성을담당하는중요한해부학적구조임을나타내는직접적증거가되며 Macko 등 5) 와 Hartfor 등 6) 의연구와일치한다. 후과는단독골절형태가아닌삼과골절의양상을흔히나타낸다고보고되어지고있으며, 7-9) 본연구에서도후과골절과동반된족관절골절탈구환자 21례중 15례 (71.4%) 가삼과골절환자였다. 일반적으로대부분의저자들은후과골절편이경골원위관절면의 25~33% 이상을차지하는비교적큰골절편에있어서관혈적정복을통한해부학적정복및내고정술을시행하는것을추천하고있다. 10,11) 저자의경우에도 25% 이상의원위경골관절면을포함하는후과골편에대해관혈적정복술을시행하였다. 본연구에서후방탈구와동반된후과골편의관절침범정도는평균 27.9% 로나타났다. 이는일반적 Table 2. Statistical analysis of articular involvement of posterior malleolus Danis-weber type X-ray CT p-value Type B 27.0±17.3% (5-49%) 30.8±17.6% (12.6-55.5%) 0.02 Type C 000024.1±10.9% (11.5-41.6%) 32.1±9.9% (19.3-46.7%)0 0.01 P-value 0.67 0.61-185 -
김지훈 송재광 서진수 으로받아들여지고있는후과골절의치료지침을고려해보건데후과골편에대한정복술을타당하게만들며, 나아가 Sache 등 12) 이보고한후과골절의비관헐적정복후거골의후방탈구가발생하였던 25% 와도유사하다. 하지만후방및후외측골절탈구와동반된후과골절중윈위경골관절면의침범정도가 25% 이하인경우도 9례 (42.9%) 가있어후방관절면의침범정도만으로후방탈구를일으키는결정적요인이라고판단하는데무리가있다고본다. 후과골절의양상을정확히파악하기위해 Ebraheim 13,14) 은족관절을 50도외회전상태에서촬영한측면사진을제안하였으며, Haraguchi 15) 등은 7~21도외회전을제안하였다. Victor 16) 은단순방사선촬영상후과골편의크기가과소평가되는경향이있다고보고하였으며, Lee 등 17) 은후과골절의형태를정확히파악하고치료계획을정하는데컴퓨터단층촬영이필수적이라고보고하였다. 본연구에서도단순방사선촬영으로측정한후과골편의크기 (27.9%) 가컴퓨터단층촬용을이용하였을경우 (31.7%) 보다통계학적으로의미있게작게측정되었다. 이는후과골편이윈위경비인 A B Figure 3. A 71 years old female suffered from ankle posterior dislocation after slip down. (A) Initial radiographs of posterior dislocation with about 30% posterior articular involvement (B) Immediate postoperative radiographs articular reduction of post.malleolus. - 186 -
족관절의골절 - 탈구에대한임상적고찰 대에부착되어외측에서관절면침범정도가크게골절되는경향이있어, 즉사면으로골절방향이발생하는것과관련이있다. 손상기전으로는예상과달리실족사고가 (13례) 가장많았으며, 대표적인고에너지손상인스포츠 (7례) 나교통사고 (6례) 보다높은수치로관찰되었다. 이는대표적인고에너지손상인고관절및슬관절탈구와는달리족관절에서는비교적작은에너지로도탈구가발생한다는것을알수있다. 개방성탈구는 6례 (20%) 에서관찰되었으며그중 5례에서전외측탈구였다. 이는족관절후방에비해전방의연부조직이상대적으로얇고적은것과관련이있다고판단된다. Wroble 등 18) 은골절없이발생한족관절탈구의약 10% 에서동반된혈관신경손상을보고하였다. 본연구에서는전례에서골절이동반되었기에탈구만발생한경우는없었지만개방성탈구를보인 4례를포함한전례에서표재신경을제외한동반된혈관신경손상을관찰할수없었다. Danis-Weber type B와 C는 11례및 10례로관찰되었고, Danis-Weber type 간의후과침범정도의차이는없어 (p<0.05) 외과골절편의높이와후과골편침범정도간의연관성은관찰할수없었다. 본연구에서후과골절이동반되어수술적치료를시행한 10례의 AOFAS score는평균 93.26점으로매우우수한임상결과를얻을수있었다. 전례에서 1 mm 미만의정확한해부학적정복을얻었기때문으로판단된다. 이는족관절후과골절에서 1 mm미만의해부학적정복시후과골편의크기와관계없이좋은결과를얻은 Hai-lin Xu 등 19) 의결과와일치한다. 본연구의단점으로는저자의연구가 30례의비교적적은증례를이용한후향적연구이었으며, 추시기간이최소 12 개월로짧아장기적으로관절염발생빈도등을조사할수없었다는점이다. 추후더많은증례를통한장기적이고전향적인분석이있어야할것으로판단된다. 결론 족관절골절탈구는후방골절탈구가가장흔하였으며후과는족관절의후방안정성을구성하는중요한요 인으로후과골절의원위경골관절면침범범위를결정하기위해서는컴퓨터단층촬영을통한적극적인평가가필요하다. REFERENCES 01. D Anca AF. Lateral rotatory dislocation of the ankle without fracture: A case report. J Bone Joint Surg Am. 1970;52:1643-6. 02. Krishnamurthy S, Schultz RJ. Pure posteromedial dislocation of the ankle joint. ClinOrthop. 1985;201:68-70. 03. Jaskulka RA, Ittner G, Schedl R. Fractures of the posterior tibial margin: their role in the prognosis of malleolar fractures. J Trauma. 1989;29:1565-70. 04. McDaniel WJ, Wilson FC. Trimalleolar fractures of the ankle. An end result stydy. Clin Orthop Relat Res. 1977;122: 37-45. 05. Macko VW, Matthews LS, Zwirkoski P, Goldstein SA. The joint-contact area of the ankle: The contribution of the posterior malleolus. J Bone Joint Surg Am. 1991;73(3):347-51. 06. Hartford JM, Gorczyca JT, McNamara JL, Mayor MB. Tibiotalar contact area: Contribution of posterior malleolus and deltoid ligament. Clin Orthop Relat Res. 1995;320:182-7. 07. Nugent JF, Gale BD. Isolated posterior malleolar ankle fractures. J Foot Surg.1990;29:80-3. 08. Neumaier Probst E, Maas R, Meenen NM. Isolated fracture of the posterolateral tibial lip (Volkmann s triangle). Acta Radiol. 1997;38:359-62. 09. Boggs LR. Isolated posterior malleolar fractures. Am J Emerg Med.1986;4:334-6. 10. Jaskulka RA, Ittner G, Schedl R. Fractures of the posterior tibial margin: their role in the prognosis of malleolar fractures. J Trauma. 1989;29:1565-70. 11. McDaniel WJ, Wilson FC. Trimalleolar fractures of the ankle: An end result stydy. Clin Orthop Relat Res. 1977;122: 37-45. 12. Sachs W, Kanat IO, McLaughlin E and Burns D E. A Surgical approach to a displaced ankle fracture. J Foot Surg, 1984:23-4:302-7. 13. Ebraheim NA, Mekhail AO, Haman SP. External rotationlateral view of the ankle in the assessment of the posterior malleolus. Foot Ankle Int.1999;20:379-83. 14. Ebraheim NA, Wong FY. External rotation views in the - 187 -
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