364 pissn : 1226-2102, eissn : 2005-8918 Case Report J Korean Orthop Assoc 2018; 53: 364-368 https://doi.org/10.4055/jkoa.2018.53.4.364 www.jkoa.org 비후된추벽에의한발음성주관절에서초음파를이용한진단 송시정 고경환 박동준 인제대학교일산백병원정형외과 Diagnosis of a Snapping Elbow Caused by Hypertrophic Plica, Using Ultrasound Si-Jung Song, M.D., Kyoung-Hwan Koh, M.D., Ph.D., and Dongjun Park, M.D. Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, Goyang, Korea This paper reports a case of a 21-year-old male patient who complained of intermittent pain and snapping at 110 of flexion in his left elbow joint. Magnetic resonance imaging revealed a band-like low signal intensity in front of the radiohumeral joint. An ultrasound was conducted to check its association with the symptoms. Observations of a high echo escaping from the radiohumeral joint at the point when snapping occurred indicated noted that the hypertrophic plica was a cause of the snapping. The hypertrophic plica removed arthroscopically, and the results were good for up to 6 months after surgery. If snapping is observed in the elbow joint, it will be necessary to consider the symptoms from the hypertrophic plica, although rare, and ultrasound might be an effective tool for a differential diagnosis. Key words: snapping elbow, plica, ultrasonography 주관절에통증성잠김현상 (locking) 이나탄발음 (snapping) 이발생하였을때, 흔한원인은관절내유리체, 불안정성 (instability), 삼두근내측두의아탈구이다. 1) 드문경우로비후된추벽 (plica) 이요골과상완골소두사이에존재하여탄발음이발생할수있으며, 1988년에 Clarke 2) 가추벽에의한주관절의통증과탄발음 (snapping) 의관절경적치료에대해최초로보고한이후많은증례보고에서관절경적수술을통한좋은임상결과를보고하였다. 3) 발음성주관절은그병인을찾아내기만하면치료에대한판 Received June 23, 2017 Revised November 1, 2017 Accepted November 13, 2017 Correspondence to: Kyoung-Hwan Koh, M.D., Ph.D. Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang 10380, Korea TEL: +82-31-910-7995 FAX: +82-31-910-7967 E-mail: osdoc.koh@gmail.com ORCID: https://orcid.org/0000-0002-6181-9621 Kyoung-Hwan Koh s current affiliation: Department of Orthopedic Surgery, Asan Medical Center, Seoul, Korea. TEL: +82-2-3010-3322 FAX: +82-2-488-7877 단은어렵지않다. 환자의증상을듣고적절한이학적검사나검사도구를이용하여조기진단하는것이치료와합병증예방에중요하다. 저자들은이러한측면에서본증례를보고하고자하며, 자기공명영상 (magnetic resonance imaging, MRI) 만으로진단하기힘들었던환자를초음파를통해확진하였던증례에대해보고하고자한다. 증례보고 21세남자환자로약 7년전부터특별한외상력없이탄발음이좌측주관절에발생하였고, 6개월전군입대후간헐적인통증도동반되어타병원을경유하여본원외래를방문하였다. 이학적검사상주관절에압통이나부종은관찰되지않았고관절운동범위도정상이었으나주관절을굴곡할때굴곡 110도에서 2 m 거리에서도들릴정도의탄발음이발생하였다. 혈액학적검사로서백혈구수, 적혈구침강속도및 C-반응성단백등은정상범위였다. The Journal of the Korean Orthopaedic Association Volume 53 Number 4 2018 Copyright 2018 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
365 Snapping Elbow Caused by the Plica on Ultrasonography 단순방사선검사상전후사진, 측면사진에서정상소견을보였고, MRI상에서요골상완골관절전방에저신호강도의띠가관찰되었다 (Fig. 1). MRI와탄발음과의연관성을확인하기위해초음파 (HD11 XE; Philips, Andover, MA, USA) 를시행하였다. 환자를앙와위로하였고, 먼저좌측주관절을신전시킨상태에서 12-5 MHz 선형변환기 (HD11 XE; Philips) 를위치시켜요골상완골관절에대해종방향영상 (longitudinal image) 을관찰하였다. 이후주관절을굴곡시키며동적으로관찰하였고, 요골상완골관절사이의고에코가신전시에는관절안에존재하다가굴곡 110도이상에서관절밖으로빠져나가는소견이관찰되었으며 (Fig. 2), 탄발음은고에코가요골상완골관절을빠져나갈때발생하였다. 관절경소견상요골과상완골의관절면은정상적이었으나주관절전외측에서기시하여요골두전외측일부를덮고있는추벽이관찰되었고, 굴곡 110도이상에서는요골상완골관절밖에위치하였다. 추벽은두껍고단단한섬유성조직으로존재하였다. 하지 만전신마취후에는관절의굴곡신전시탄발음은없었다. 관절내시경을통해비후된추벽을완전히제거하였으며 (Fig. 3) 수술직후환자의증상은소실되었고관절운동범위는정상적이었다. 수술후 6개월까지추시관찰에서환자는증상의재발이없었다. 고찰 증례에서환자의주소는간헐적통증을동반하는주관절의탄발음이었다. 저자들은탄발음이발생하는여러원인중에어떤구조물이탄발음을일으키는지명확하지않은환자에서초음파를통하여그러한구조물을특정할수있었고이를관절경을이용하여쉽게제거할수있었다. 흔히알려진주관절의잠김현상이나탄발음의원인은관절내유리체, 불안정성, 삼두근내측두의아탈구이다. 1) 불안정성과삼두근내측두의탈구는이학적검사를통해서진단할수있다. 4) 관절내유리체의진단은방사선 A B Figure 1. A band-like structure with low signal intensity (white arrows) was observed on (A) an axial T1- weighted image and (B) a sagittal T2- weighted image located at anterior to the radiocapitellar joint. A B Figure 2. A hyperechoic band-like structure was observed between the radial head and capitellum on the longitudinal scan of ultrasonography. The thickened plica (arrows) was captured between the radial head and capitellum on extension of elbow (A) and came outside the radiocapitellar joint on flexion of the elbow with large clunk sound (B). Radius. Humerus.
366 Si-Jung Song, et al. A B C Figure 3. (A) During the arthroscopic examination, a thickened plica was observed anterior to the radiocapitellar joint (arrow). It was caught between the radial head and capitellum on an extended elbow position. (B) The plica (arrow) came out of the raidocapitellar joint on elbow flexion of more than 110 degrees. (C) Arthroscopic excision of plica was performed and impingement of plica disappeared even in the extended position of elbow. Radius. Humerus. 적검사나 MRI를이용할수있다. 하지만증례와같이비후된추벽에의한발음성주관절은이러한검사만으로진단이힘든경우가있다. 특히발음성주관절에서소리가내측에서발견될경우에는삼두근내측두의아탈구등을추정해볼수있으나외측에서관찰되는경우에그원인을특정하기어려울수있다. Antuna 와 O Driscoll 1) 은주관절외측에통증이국한되어있고전완을내회전 (pronation) 한상태에서주관절굴곡과신전을하였을때탄발음이발생한다면요골상완골관절의활액막성추벽 (synovial plica) 을고려해야한다고하였다. 하지만이러한이학적검사에서양성을보이는경우는 25%-50% 정도로보고되고있으며, 1) 추벽의해부학적위치나다른해부학적변이에의해다양하게나타날수있다. 관절형성과정중에발생하는격막의잔여물인추벽은해부학적으로전방, 외측, 후외측, 주두외측으로분류할수있으며, 5) 외상이나반복적인미세손상에의해염증반응이발생하고두꺼워지면요골상완골관절내충돌과발음을일으킨다. 통증은보통후외측에발생하며, 외상과나신전근기시부를따라일어나지는않는다. 통증은잠김이나끼임증상이나타나기전에발생할수있다. 3) 요골두에대한반복적인충돌은연골연화증까지초래할수있다. 1) 많은임상의사들이주관절질환의원인규명을위해서 MRI 를선호하며, 본증례의환자도본원외래방문전에타병원에서 MRI를시행하였다. 이전의연구들에서는 MRI에서 3 mm 이상의두께를가진추벽을비후된추벽이라보고하였다. 6) MRI에서다른이상소견은보이지않았으나, 요골상완골관절전방에비후된추벽으로생각되는띠형태의저신호강도가관찰되었다. MRI는주관절이신전된상태에서시행되었으며, 추벽은요골상완골관절에서관찰되었다. 이러한 MRI 소견만으로는탄발음과 의연관성을확인하기는힘들었으며, 초음파를시행하였다. 초음파는 MRI에비해비후된추벽의형태를정확히파악하기어려웠으나탄발음이발생하는시점에서추벽으로생각되는고에코가요골상완골관절을빠져나가는소견을실시간으로정확히관찰할수있어비후된추벽이탄발음의원인임을확신할수있었다. 초음파를이용한발음성주관절의진단은이전에도다수보고되었다. Chai 등 7) 은동적초음파를이용하여발음성요골윤상인대를효과적으로진단하였다고보고하였으며, Jeong 등 8) 은척골신경탈구와동반된발음성삼두근증후군에서동적초음파검사를통한진단을보고하였다. 증상을일으키는추벽의치료는초기에활동제한, 물리치료, 비스테로이드성소염진통제투여와같은비수술적치료가선호되며, 관절연골의손상을조기관절경적절제를통해예방할수있어보존적치료의장기화로인해수술적치료가지연되어서는안된다는보고가있었다. 1,3) 본증례와같이큰탄발음으로인하여집단생활에불편함이있거나통증이지속되는경우에는비교적수술이간단하기때문에수술적치료를고려해볼수있다. 진단과치료를위해시행한관절경에서신전시요골상완골안쪽에, 굴곡시바깥쪽에존재하는추벽이관찰되었으나전신마취로인한근이완효과때문인지탄발음은없었다. 하지만관절경상에서도비후된추벽이외에다른해부학적이상소견은보이지않아증상의원인을비후된추벽으로생각하고이를완전히제거하였다. 이전에도많은보고가있었듯이관절경적치료를통해만족할만한결과를얻을수있었다. 3) 외래진료에서발음성주관절을주소로방문하는환자는흔하지않다. 임상의사들에게발음성주관절은익숙하지않고, 관련문헌도적어진단이쉽지않기때문에원인을찾기위해바로 MRI를시행하기쉽다. 하지만 MRI는정적인검사이며, 대부분
367 Snapping Elbow Caused by the Plica on Ultrasonography 주관절신전상태에서시행되므로본증례와같이영상소견과증상의연관성을증명하기어려운경우가있다. 관절경검사또한전신마취나상완신경총차단후에시행되는탓에마취전환자의증상을재현하기힘들수있다. 초음파는환자에게부담이적고외래에서쉽게시행할수있으며, 증상과영상을동시에확인할수있는동적인검사이다. 초음파상정상적인추벽은얇은저에코에의해둘러싸인삼각형의고에코로관찰되며, 9) 병적인추벽은두꺼워져보이고불규칙한에코와경계를보인다. 이러한병적인추벽의발견과함께동적초음파와증상과의연계성을확인하여비후된추벽에의한발음성주관절을확진할수있다. 추벽은주관절에서비교적표면에위치하고있어초음파로관찰하기용이한편이다. Yiannakopoulos 10) 는초음파검사는검사를시행하는술자의주관적의판단이중요하므로많은경험이필요하다고지적하였으나주관절에서초음파를통한진단의장점은반대쪽주관절과비교를할수있으며, 임상증상과연관해검사가가능하고, 동적인검사라는점이다. 이러한이유로발음성주관절환자에서요골상완골관절의비후된추벽이원인이라고생각된다면초음파가좋은진단도구로생각된다. 주관절에서탄발음이관찰된다면드물지만요골상완골관절의비후된추벽에의한증상일수있으므로이를고려하여야하고초음파가이러한증상의감별진단에도움이될수있다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES radiocapitellar chondromalacia. Arthroscopy. 2001;17:491-5. 2. Clarke RP. Symptomatic, lateral synovial fringe (plica) of the elbow joint. Arthroscopy. 1988;4:112-6. 3. Steinert AF, Goebel S, Rucker A, Barthel T. Snapping elbow caused by hypertrophic synovial plica in the radiohumeral joint: a report of three cases and review of literature. Arch Orthop Trauma Surg. 2010;130:347-51. 4. Spinner RJ, Goldner RD. Snapping of the medial head of the triceps and recurrent dislocation of the ulnar nerve. Anatomical and dynamic factors. J Bone Joint Surg Am. 1998;80:239-47. 5. Cerezal L, Rodriguez-Sammartino M, Canga A, et al. Elbow synovial fold syndrome. AJR Am J Roentgenol. 2013;201:W88-96. 6. Awaya H, Schweitzer ME, Feng SA, et al. Elbow synovial fold syndrome: MR imaging findings. AJR Am J Roentgenol. 2001;177:1377-81. 7. Chai JW, Kim S, Lim HK, Bae KJ. Ultrasonographic diagnosis of snapping annular ligament in the elbow. Ultrasonography. 2015;34:71-3. 8. Jeong WK, Park SW, Song DI, Lee SH. Snapping triceps syndrome with dislocation of the ulnar nerve. J Korean Orthop Assoc. 2008;1:27-30. 9. Koh S, Morris RP, Andersen CL, Jones EA, Viegas SF. Ultrasonographic examination of the synovial fold of the radiohumeral joint. J Shoulder Elbow Surg. 2007;16:609-15. 10. Yiannakopoulos CK. Imaging diagnosis of the snapping triceps syndrome. Radiology. 2002;225:607-8; author reply 608. 1. Antuna SA, O'Driscoll SW. Snapping plicae associated with
368 pissn : 1226-2102, eissn : 2005-8918 Case Report J Korean Orthop Assoc 2018; 53: 364-368 https://doi.org/10.4055/jkoa.2018.53.4.364 www.jkoa.org 비후된추벽에의한발음성주관절에서초음파를이용한진단 송시정 고경환 박동준 인제대학교일산백병원정형외과 발음성주관절은관절내유리체, 불안정성, 삼두근내측두의아탈구에의해주로일어나지만, 드물게비후된추벽에의해일어나기도한다. 저자들은주관절의간헐적통증과탄발음을호소한 21세남자환자에대해보고하고자한다. 환자는좌측주관절을굴곡할때굴곡 110도에서탄발음이발생하였고, 타병원에서시행한자기공명영상에서요골상완골관절전방에띠형태의저신호강도가관찰되었다. 증상과의연관성을확인하기위해초음파를시행하였고탄발음이발생하는시점에서추벽으로생각되는고에코가요골상완골관절을빠져나가는소견을통해발음성주관절의원인이비후된추벽임을알수있었다. 관절경을통해비후된추벽을제거하였고 6개월뒤추시에서만족할만한임상결과를얻을수있었다. 주관절에탄발음이관찰된다면드물지만요골상완골관절의비후된추벽에의한증상일수있음을고려해보아야하며이러한증상의감별진단에초음파가도움이될수있다. 색인단어 : 발음성주관절, 추벽, 초음파 접수일 2017 년 6 월 23 일수정일 2017 년 11 월 1 일게재확정일 2017 년 11 월 13 일책임저자고경환 10380, 고양시일산서구주화로 170, 인제대학교일산백병원정형외과 TEL 031-910-7995, FAX 031-910-7967, E-mail osdoc.koh@gmail.com, ORCID https://orcid.org/0000-0002-6181-9621 고경환저자현소속 : 서울아산병원정형외과. TEL 02-3010-3322, FAX 02-488-7877 대한정형외과학회지 : 제 53권제 4호 2018 Copyright 2018 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.