대한골절학회지제 17 권, 제 4 호, 2004 년 10 월 Journal of the Korean Fracture Society Vol. 17, No. 4, October, 2004 고령환자의요골원위부골절시비수술적치료의유용성 강기서 이한준 이상학 중앙대학교부속필동병원정형외과학교실 목적 : 고령의원위요골골절환자에대해서수술적치료를했던환자들과비수술적치료를했던환자들에대해각각임상적및방사선학적결과를평가하고비교분석하여비수술적치료의유용성을알아보고자하였다. 대상및방법 : 1995 년 1월부터 2000 년 12월까지요골골절로진단받고치료했던 60세이상의환자중 1년이상추시가가능했던 36예환자를대상으로하였다. 골절의분류는 Fernandez 분류법을사용하였으며치료결과판정은 Cole and Obletz의주관적평가에의한점수와완관절운동범위및 X-선판정등에의한 Scheck의객관적기준으로하였다. 방사선학적평가는요골경사, 요골길이, 수장측경사각을측정하였다. 결과 : 최종추시에서기능적결과는비수술적치료군에서양호이상이 12예 (70%), 수술적치료군에서는양호이상이 14예 (73%) 로두군간에유의한차이가없었다 (p>0.05). 방사선학적검사에서는비수술적치료군에서요골경사의소실은평균 13.0, 요골길이의소실은평균 12.3 mm, 수장측경사각소실은평균 7.2 였고, 수술적치료군에서는각각평균 5.2, 5.1 mm, 3.3 로유의한차이가있었다 (p<0.05). 결론 : 고령의환자에서원위요골골절치료시수술적치료가방사선학적으로는좋은결과를얻을수있지만기능적인만족도는방사선학적결과에반드시부합되지않을수있다고생각되며, 이는고령환자의치료선택시에환자의나이및활동정도를충분히고려하여비수술적치료를시도해볼수있을것으로사료된다. 색인단어 : 원위요골골절, 고령, 비수술적치료 The Usefulness of Non-operative Treatment of Distal Radius Fracture in Elderly Patients Ki Ser Kang, M.D., Han Jun Lee, M.D., Sang Hak Lee, M.D. Department of Orthopaedic Surgery, Phil-dong Hospital, Chung-Ang University, Seoul, Korea Purpose: To disclose the correlation between the functional and radiologic results of the treatment of distal radius fracture in elderly patients by non-operative versus operative treatment. Materials and Methods: From January 1995 to December 2000, 36 patients, more than 60 years old with fractures of distal radius were treated and followed up for more than one year. We classified them using the Fernandez classification and evaluated functional and radiological results according to the subjective point system of Cole & Obletz and objective evaluation by Scheck. Results: In functional result, excellent to good results were obtained in 12 cases (71%) in the non-operative group and 14 cases (74%) in the operative group, there were no evidence of statistical difference between two groups (p>0.05). In radiographic results, mean radial inclination, loss of radial length and volar tilt were 13, 12.3 mm, 7.2 in the non-operative goup and 5.2, 5.1 mm, 3.3 in the operative group on last follw-up radiographs, there were evidence of statistical difference between two groups (p<0.05). Conclusion: Operative treatment is radiographically better result in distal radius of elderly patients but functional satisfaction is not significantly related with radiographic result. When we decide the treatment of elderly patients, non-operative treatment can be useful method, considering with patient's age and activity status. Key Words: Distal radius fracture, Elder patient, Non-operative treatment 서 론 요골원위부골절은정형외과영역에서가장흔히접하는 골절로서특히중년기이후발생하는상지의골절중가장흔한형태이다. 최근생활구조의복잡화, 교통사고및산업재해, 스포츠활동, 고령층활동인구의증가등으로고에너지손상에의한요골원위부의불안정성골절의증가로 통신저자 : 강기서 Address reprint requests to : Ki Ser Kang, M.D. 서울특별시중구필동 2가 82-1 Department of Orthopaedic Surgery, Phildong Hospital, Chung-Ang Uni- 중앙대학교부속필동병원정형외과학교실 versity, 82-1, Phildong 2 ga, Chung-ku, Seoul 100-272, Korea. Tel : 02-2260-2281 Fax : 02-2271-1710 Tel : 02-2260-2281 Fax : 02-2271-1710 E-mail : 7901220@hanafos.com E-mail : 7901220@hanafos.com * 본논문의요지는 2002년대한골절학회춘계학술대회에서발표되었음. 345
346 강기서, 이한준, 이상학 Table 1. Distribution according to Fernandez's classification Type Table 3. Point system for objective evaluation based on wrist motion (Scheck) Amount of loss (%) (n=17) Results Numeric value 보존적치료보다는적극적인수술적치료의필요성이증가되고있지만, 고령환자의경우에서는대개골다공증이동반되어있고골절양상이복잡하며재전위가잘일어날수있다는점에서일반성인의골절과는다르며또한수술적치료후에도많은문제점이생길수있다 12,13). 이에본연구의목적은요골원위부골절로진단된고령의환자에대해서수술적치료를했던환자들과비수술적치료를했던환자들에대해각각임상적및방사선학적결과를평가하고비교분석하여비수술적치료의유용성을알아보고자하였다. 대상및방법 1995년 1월부터 2000년 12월까지요골원위부골절로치료한 60세이상의환자중 1년이상추시가가능했던 36예의환자를대상으로하였다. 1. 연령, 성별및손상원인 연령분포는 60세부터 85세로평균 69.1세 ( 표준편차 ±6.7) 였고남자가 15예, 여자가 21예였다. 추시기간은최단 12개월최장 92개월로평균 54개월 ( 표준편차 ±24.2) 이었으며골절의원인으로는단순한낙상이 20예로가장많았고교통사고가 8예, 실족사고가 5예, 직접손상 3예였다. 2. 골절분류및치료방법 Operative treatment (%) (n=19) Motion Total (%) (n=36) I 9 (52.9) 7 (36.8) 16 (44.4) II 2 (11.8) 4 (21.1) 6 (16.7) III 6 (35.3) 8 (42.1) 14 (38.9) IV 0 0 0 V 0 0 0 Range of numeric value 0~15 Excellent 0 Flexion 0~3 16~30 Good 1 Extension 0~3 30~45 Fair 2 Pronation 0~3 45 Poor 3 Supination 0~3 골절의분류는 Fernandez 분류법 3) 을사용하였으며비수술 Table 2. Criteria for subjective evaluation of results of treatment (Cole and Obletz) Results Discription Points Excellent Good Fair Poor 적치료군에서는제1형이 9예, 제2형이 2예, 제3형이 6예였고수술적치료군에서는제1형이 9예, 제2형이 2예, 제3형이 6예였고두군모두에서제4형과제5형은없었다 (Table 1). 비수술적치료한 17예는비관헐적정복술후에장상지석고부목으로 4주에서 6주간고정후재활치료를하였고, 수술적치료를한경우는 19예였다. 수술적치료에사용한내고정물로는 K-강선, small T-plate를사용하였고, 외고정시에는일측성외고정기를사용하였다. 치료방법의선택에있어서수술전에절대적인적응증을가지고치료방법을선택하지는않았으나, 환자의전신상태및활동성, 골절의양상, 연부조직의손상정도그리고다발성손상의유무등을고려하여치료방법을선택하였다. 3. 연구방법 No pain, no disability, no Limitation of motion Occsional pain, no disability, slight Limitation of motion Occasional pain, no disability if careful, slight Limitation of motion, slight restriction of activity Constant pain, limitation of activities because of wrist problem, Limitation of motion, disability Table 4. Point system for objective evaluation based on X-ray appearance (Scheck) Angle or length Degree or mm Results Points 18~23 Excellent 0 Radial angle Radial length Volar angle 10~17 Good 1 <10 Poor 2 10~13 mm Excellent 0 5~9 mm Good 1 <5 mm Poor 2 6~11 Excellent 0 0~5 Good 1 Negative angle Poor 2 치료결과판정은 Cole and Obletz 1) 의주관적평가에의한점수와완관절운동범위및 X-선판정등에의한 Scheck 18) 의객관적기준에의해판정하였다 (Table 2~4). 최종적인결과판정은주관적평가기준에의한점수와객관적평가에의한 0 4 8 12
고령환자의요골원위부골절시비수술적치료의유용성 347 A B Fig. 1. 69-year-old woman of displaced extraarticular distal raidus fracture was treated conservatively, gets poor radiologic result but, relatively good fuctional result after follow up 1 year. (A) post trauma on plain radiographs. (B) after 1 year on plain radiographs. Table 5. The total result of evaluation according to Cole and Obletz method and Scheck method Functional score (%) (n=17) Operative treatment (%) (n=19) Excellent 5 (29.4) 8 (42.1) Good 7 (41.2) 6 (31.6) Fair 4 (23.5) 2 (10.5) Poor 1 ( 5.9) 3 (15.8) Total 17 (100) 19 (100) Table 6. The result of radiographic assessment Radial angle loss ( ) Radial length loss (mm) volar angle loss ( ) (n=17) Operative treatment (n=19) p-value 13.0 (±4.6) 5.1 (±4.1) <0.001 12.3 (±4.1) 5.2 (±3.6) <0.001 7.2 (±3.2) 3.3 (±3.3) 0.001 점수를합하여 0~4점인경우는우수 (Excellent), 5~11점은양호 (Good), 12~20점은보통 (Fair), 20점이상은불량 (Poor) 으로하였다. 통계분석은 Student's t-test를사용하였으며, p<0.05 를통계적인유의수준으로하였다. 결과최종추시에서 Cole and Obletz의주관적평가에의한점수와완관절운동범위및 X-선판정등에의한 Scheck의객관적기준에따른결과에따른최종적인결과판정에서비수술적치료군에서우수 5예 (29.4%), 양호 7예 (41.2%), 보통 4예 (23.5%), 불량 1예 (5.9%) 로양호이상이 12예 (70.6%) 였으며, 수술적치료군에서는우수 8예 (42.1%), 양호 6예 (31.6%), 보통 2예 (10.5%) 례, 불량 3예 (15.8%) 로양호이상이 14예 (73.7%) 였고, 두군간의최종점수의합계에있어서비수술적치료군에서평균 9.5 ( 표준편차 ±5.6) 점이며수술적치 료군에서는평균 8.4 ( 표준편차 ±7.4) 점으로통계학적으로유의한차이는없었다 (p>0.05) (Table 5, Fig. 1). 방사선학적검사에서는비수술적치료군에서요골경사의소실은평균 13.0 ( 표준편차 ±4.6) 요골길이의소실은평균 12.3 mm ( 표준편차 ±4.1), 수장측경사각소실은평균 7.2 ( 표준편차 ±3.2) 였고, 수술적치료군에서요골경사의소실은평균 5.2 ( 표준편차 ±3.6), 요골길이의소실은평균 5.1 mm ( 표준편차 ±4.1), 수장측경사각소실은평균 3.3 ( 표준편차 ±3.3) 로통계학적으로유의한차이가있었다 (p<0.05) (Table 6). 합병증으로는비수술적치료군에서관절강직이 2예있었으며수술적치료군에서감염이 1예, 관절강직이 1예가있었으나양군에서신경증상을보이는경우는없었다. 고찰원위요골골절은 65세이상의고령에상부골절중가장흔한골절로서양에서는 1000명당 8에서 10명의발생률을
348 강기서, 이한준, 이상학 보인다고보고되고있다 2). 여러임상적인보고에서고령환자의경우낙상에의해쉽게일어날수있는손상으로고령의골다공증이있는환자에서는대부분단순관절외골절이잘생기며이런환자들에서는대개좋은임상적인결과를보인다고알려져있으나, 이의치료에대해논란이많이되고있으며적절한치료를받지못하였을때관절강직, 관절면의불일치, 골절의재전위등의비기능적장애를가져올수있어관심의대상이되고있다 10,12,13). Molly 등 14) 은고령의원위요골골절의위험인자로저하된골밀도, 반복되는낙상, 골절의병력과호르몬치료를하지않은것을보고하였으며, 이런위험인자들에대한일차적인인지가중요하다고하였다. 특히, 당뇨병에있어서는관절면을포함한복잡골절이많이발생하였다고하였고, 저자들도당뇨나골절의병력이있는환자들이높은비율을차지하였으나좀더많은수의추시관찰이필요할것으로생각되었다. 많은저자들이예후를결정하는중요인자로관절외단축, 관절내는 2 mm 이상의관절면불일치라고말하고있으며, 허용할만한정복의기준으로는요골길이소실이 5 mm 이하, 후방각형성이 10 이내그리고, 관절면의불일치가 2 mm 미만이라고기술하고있다 17). Hove 등 6) 은초기의배부전위, 환자의나이와초기의요골길이가재전위와예후에중요한영향을미치며특히고령에서는요골길이단축이가장중요하다고하였다. 해부학적인정복과기능적결과는젊고활동적인경우에는그상관관계가인정되고있으나고령의경우는시간이지남에따라점점그중요성이덜한것으로생각된다. 여러저자들의보고에서관헐적정복술을통한금속고정술이나금속외고정술등이보존적치료에비해우수한해부학적및기능적인결과를보인다고되어있으나이연구들이대부분이전체연령군을포함하거나비교적젊은연령군을대상으로하고있다 4,7,8,15~17). Zwack 등 19) 은 460예의원위요골골절환자를대상으로한후향적연구에서고령환자의원위요골골절에서경피적강선고정한군이보존적치료를한군에비해결과적으로우수하지못하다고보고하였으며, Koji 등 11) 도 60세이상의 76예의원위요골골절에대한연구에서보존적으로치료한군에서기능적인결과에서는수술한군에비해주관적인만족도와객관적인방사선적결과를비교하여차이가없었음을보고하였다. Jakob 등 9) 은고령환자에대한보존적치료가장기적인효과에서비교적우수하며방사선적부정정렬에대해순응도가있어수술적치료의적응증을선택하는것을신중히할것으로보고하였다. 저자들의경우도비수술적치료군에서해부학적정복이수술적치료군에비해차이가있었으나기능적인면에서차이를보이는않는결과를보였다. 이는여러요인이있겠으나고령환자의경우골다 공증이동반되어있어정복의유지가어렵고퇴행성관절염으로인하여만족스러운결과를가질수없는것으로생각되었다. 그러므로고령환자에있어서비교적심한양상의골절에서도비수술적치료를고려할수있을것으로생각된다. Herrera 등 5) 은관절내분쇄골절이나복잡골절에대해경피적고정술이나외고정술을시행은기능적인예후가불량하였으며외고정술에부가적인내고정술및골이식술을시행하여만족할만한결과를얻을수있다고보고하였다. 고령의원위요골골절에서도도수정복및석고고정만으로만족할만한관절면조화및정복유지가불가능한경우특히, 현저한요골길이손실이있는경우관헐적정복을통한내고정및골이식술과외고정술을병합한보다적극적인치료를통하여좀더좋은기능적인결과를기대해보는것이좋을것으로사료된다. 결론고령의환자에서원위요골골절치료시수술적치료가방사선학적으로는좋은결과를얻을수있지만기능적인만족도는방사선학적결과에반드시부합되지않을수있다고생각되며, 이는골다공증을동반한고령의환자에서어떠한분류의골절에서도비수술적치료를고려할수있을것으로사료되며, 환자의전신상태및활동정도와기대수준을충분히고려해야할것으로생각된다. 참고문헌 1) Cole JM and Obletz BE: Communited fractures of the distal end of the radius treated by skeletal transfixation in plaster cast: An end-result study of thirty-three cases. J Bone Joint Surg, 61-A: 840-845, 1979. 2) Cummings SR, Black DM and Rubin SM: Lifetime risks of hip, Colles', or vertebral fracture and coronary heart disease among white postmenopausal women. Arch Intern Med, 149: 2445-2448, 1989. 3) Fernandez DL: Fractures of the distal radius: Operative treatment, in Heckman JD (ed): Instr Course Lect, Vol 42, Rosemont, II, American Academy of Orthopaedic Surgeons: 73-88, 1993. 4) Ha SH, Lee SH, Shin DM, Pyo YB and Mun HS: Conservative treatment for distal radius fractures. J Korean Fracture Soc, 9: 319-325, 1996. 5) Herrera M, Chapman CB, Roh M, Strauch RJ and Rosenwater MP: Treatment of unstable distal radius fractures with cancellous allograft and external fixation. J Hand Surg Am,
고령환자의요골원위부골절시비수술적치료의유용성 349 24: 1269-1278, 1999. 6) Hove LM, Solheim E, Skjeie R and Sorensen FK: Prediction of secondary displacement in Colles fracture. J Hand Surg Br, 19: 731-736, 1994. 7) Howard WP, Stewart HD, Hind ER and Burke DF: External fixation or plaster for severely displaced comminuted Colles' fractures? J Bone Joint Surg, 71-B: 68-73, 1989. 8) Jakim I, Pleterse HS and Sweet MB: External fixation for intra-articular fractures of the distal radius. J Bone Joint Surg, 73-B: 302-306, 1991. 9) Jakob M, Mielke S, Keller H and Metzger U: Results of therapy after primary conservative menagement of distal radius fractures in patients over 65 years of age. Handchir Mikrochir Plast Chir, 31(4): 241-245, 1999. 10) Jupiter JB: Fractures of the distal radius. Instr Course Lect, 41: 13-23, 1992. 11) Fujii K, Henmi T, Kanematsu Y, Mishiro T, Sakai T and Terai T: Fracutures fo the distal end of radius in elderly patients: A comparative study of anatomical and functional results. J Orthop Surgery, 10(1): 9-15, 2002. 12) McQueen M and Caspwers J: Colles' fracture-dose the anatomical result affect the final function? J Bone Joint Surg, 70- B: 649-651, 1988. 13) Missakian LM, Cooney WP, Amadio PC and Glidewell HL: Open reduction and interanl fixation for distal radius fractures. J Hand Surg Am, 17: 745-755, 1992. 14) Molly TV, Jane AC, Matthew MT, Katie S, James R and James HH: Distal radius fractures in older women: A 10-year follow up study of descriptive characteristics and risk factors. The study of osteoporotic fractures. J American Geriatrics Society, 50: 97-103, 2002. 15) Park SW, Kang KH and Lee KH: Non-operative treatment of fracture of distal radius in adults. J Korean Fracture Soc, 12: 145-152, 1999. 16) Ring D, Jupiter JB, Brennwald J, Buchler U and Hastings HII: Prospective multicenter trial of a plate for dorsal fixation of distal radius fractures. J Hand Surg Am, 22: 777-784, 1997. 17) Rodriguez-Merchan EC: Management of comminuted fractures of the distal radius in the adult. Conservative or surgical? Clin Orthop, 353: 53-62, 1998. 18) Scheck M: Long term follow up of treatment of communited fractures of the distal end of the radius by transfixation with Kirschner wires and cast. J Bone Joint Surg, 44-A: 337-351, 1962. 19) Zwack M, Kempf P and Stelzig HH: Distal radius fracture- Indication for conservative, partial surgical and surgical therapy. Unfallchirurgie, 14: 125-132, 1988.