대한수부외과학회지제 13 권제 1 호 The Journal of the Korean Society for Surgery of the Hand VOLUME 13, NUMBER 1, March 2008 전남대학교의과대학정형외과학교실, 광주상무병원정형외과 1 문은선 박용철 김명선 김종석 1 The Results of Extension Block Technique for Mallet Fractures Delayed Over Two Weeks Eun-Sun Moon, M.D., Yong-Cheol Park, M.D., Myung-Sun Kim, M.D., Jong-Seok Kim, M.D. 1 Department of Orthopedic Surgery, Chonnam National University Hospital, Gwang-ju, Korea Department of Orthopedic Surgery, Sangmoo Hospital, Gwang-ju, Korea 1 통신저자 : 박용철광주광역시동구학동 8 전남대학교의과대학정형외과학교실 TEL: 062-220-6336, FAX: 062-225-7794 E-mail: july407@naver.com * 본논문의요지는 2007년대한정형외과수부학회및골절학회추계학술대회에서발표되었음. Purpose: We studied the results of extension block technique for mallet fractures delayed over 2 weeks. Materials and Methods: Fifteen cases were retrospectively evaluated. Delayed period was 4.4(2~10) weeks and follow-up duration was 30(4~66) months. In Wehbe -Schneider classification, they were grouped by 4 type IB, 9 type IIB, 1 type IIC and 1type IIIB. Nine cases were treated by closed reduction and 6 cases after debridement. Six cases were composed of one case delayed for 10weeks, 2 cases for 8 weeks and 3 cases for 4weeks. Result was measured by Crawford classification, bone union and subluxation. Results: In Crawford classification, 10 cases(66.7%) showed the result of Excellent or Good. Mean range of motion was 2.3~80.4 flexion. Clinical result and range of motion had no statistically significant correlation with delayed interval. None showed nonunion, persistent subluxation. Complication rate was 40% including 2 cases of degenerative changes. Conclusion: The treatment by extension block technique showed better results than conservative treatment. We could consider in first this method to start exercise and return to work earlier, because it is simpler than other techniques. Open debridement should be considered for cases delayed over 4weeks. Key Words: Mallet fracture, Extension block technique 서 론 스포츠손상으로비교적빈번히발생하는추지골절은수지원위지골기저부의신건말단부의건열골절로신전기능손상으로인해원위지간관절의굴곡변형을가져온다. 이에대한치료는골절편의크기가관절면의 1/3 미만일경우, 원위수지관절의전방아탈구가존재하지않는경우에보존적치료를시행하고, 골절편이관절면의 1/3 을넘거나아탈구가존재하는경우수술을시행하는것이일반적으로알려져있다 1-3. 한편, 수술방법의경우는매우다양한방법이소개되었고각수술기법에따른합병증이비교적높은빈도 (3~53%) 로보고되고있다 4. 하지만, 수상초기의추지골절에대한문헌보고는많은반면치료가지연된추지골절에대한보고는거의없다. 저자들은 2주에서 10주까지치료가지연된추지골절환자를대상으로신전방지강선고정술 (extension block technique) 을이용한수술적치료의결과를연구하고이를보고하고자한다. 연구대상및방법 15예 (14 명 ) 에대해후향적으로연구하였으며, 남자가 10명, 여자가 4명이었다. 평균연령은 23세 (14~42세), 우수가 9예, 좌수가 6예, 제 3수지 4예, 26
제 4수지 5예, 제 5수지 6예였다. 수상후수술까지지연된정도는평균 4.4주 (2~10주) 였으며, 수상시기는환자진술에따라판단하였다. 공과관련된스포츠손상이 10예 (66.7%) 였으며, 타격에의한외상이 2예, 기타일상활동에의한손상이 3예였다. 추시기간은평균 30개월 (4~66개월) 이었다. 수술전골절의분류는 Wehbe -Schneider 5 분류 (Table 1) 를따랐으며, type IB가 4예, IIB가 9예, IIC 가 1예, IIIB가 1예였다. 골절편의크기가관절면의 1/3 이상이거나원위지골의전방아탈구를보이는경우수술을시행하였으며, 이러한소견이보이지않으면서관절면의함몰이있는경우에는보존적치료를시행하였다. 11예 (73.3%) 에서전방아탈구를동반하였으며, 술전관절면에대한골절편의평균크기와전위정도는각각 52.0%(34.2~69%) 와 43.5% (15.3~84.7%) 였다 5. Table 1. Wehbé -Schneider classification 5 Classification Number Type I (No joint subluxation) Subtype A (fragment size <1/3 of articular surface) 0 Subtype B (fragment size 1/3-2/3 of articular surface) 4 Subtype C (fragment size >2/3 of articular surface) 0 Type II (Subluxation of DIP joint) Subtype A 0 Subtype B 9 Subtype C 1 Type III (Physis of the distal phalanx involved) Subtype A 0 Subtype B 1 Subtype C 0 Total 15 Fig. 1. Operative technique (A) Flex the DIP joint in order to reposition the bony fragment in place (B) Insert the extension blocking wire oblique to longitudinal axis of middle phalanx (C) Insert trans-articular wire after reduction of articular surface and subluxation (D) This is the picture after finish the operation. 27
문은선 박용철 김명선 김종석 수술방법은 9예에서비관혈적정복을시행하였고, 비관혈적정복이실패한 6예에서주사침을이용한변연절제술을시행하였으나역시실패하여절개후변연절제술을시행하고신전방지강선고정술을시행하였다. 이 6예는각각 10주지연된 1예, 8주지연된 2 예, 4주지연된 6예가운데골절편크기가아탈구를동반하고골절편크기가 50% 이상이었던 3예였다. 골절편주위변연절제술은늘어진 S절개를 1 cm 정도로최소화하여시행하였다. 정복및고정방법은영상증폭장치하에서신전방지강선 (extension blocking wire) 을삽입하고원위지간관절을신전시켜골편과아탈구의정복을확인하고관절고정강선 (transarticular wire) 을삽입하였다 (Fig. 1). 골절편의크기가관절면의 69% 였던 1예에대해서는신전방지강선을 2개삽입하였다. 수술후추가적인부목고정은실시하지않고, 근위 지간관절과중수지관절의관절운동을즉시허용하였으며, 강선의제거는평균 6.3주 (4~10주) 에실시하였다. 임상적결과는원위지간관절신전제한, 굴곡제한, 통증을평가하여 Crawford 1 분류 (Table 2) 를근거로측정하였으며, 방사선학적결과는골유합여부, 아탈구지속여부, 퇴행성변화를평가하였다. 그밖에피부괴사, 강선주위감염, 후방돌출, 손톱변형등의합병증발생여부를평가하였다. 결과 임상결과는 Crawford 분류상우수 6예, 양호 4예, 보통 5예로 10예 (66.7%) 에서양호이상의결과를얻었다. 원위지관절의관절운동범위는굴곡구축평균 2.3 도 (0~10), 후속굴곡평균 80.4도 (65~85) 였고, Table 2. Crawford classification 1 Classification Extension loss Flexion Pain Excellent None Full None Good 0~10 Full None Fair 10~25 Any loss of flexion None Poor >25 Any loss of flexion Persistent pain Fig. 2. A case of 14 year-old boy, 4 week-delayed, (A) Preoperative radiograph shows Wehbe -Schneider classification IIIB mallet fracture. (B) Postoperative radiograph shows the anatomical reduction of fragment using two extension blocking wires. (C) 28months after operation, this shows full extension of DIP joint and bone defect at the head of middle phalanx (arrow). (D) The full flexion of the DIP of middle finger was observed. 28
Fig. 3. A case of 23 year-old woman, 10 week-delayed. (A) Preoperative radiograph shows Wehbe -Schneider classification IIB mallet fracture. The sclerotic change and roundness of fracture margin was observed. (B) After debridement, K-wire fixation was performed. (C) 27months after operation, bone union and no subluxation was observed. But, there was the degenerative change of joint space narrowing. (D) This photograph is evident that the flexion limitation of DIP joint of middle finger. 통증을호소하는예는없었다. 방사선학적결과는모든예에서최종추시상불유합이나아탈구소견은보이지않았다. 10주지연되었던 1예는골유합을얻었으나신전제한 0도, 굴곡 70도를보여보통의임상결과를보였고, 관절간격이감소되는퇴행성변화를보였다 (Fig. 3). 합병증으로는 2예의퇴행성변화, 2예의중위지골원위관절면의부분결손 (Fig. 2), 1예의강선주위감염, 1예의요측변위부정유합이발생하여발병률은 40% 였다. 퇴행성변화는 Okafor 등 6 의분류에따라 Grade I( 관절간격감소 ), Grade II( 골경화 ) 가각각 1예씩이었으며, 강선주위감염은술후 3주째발생한후 4주째에핀제거하여좋은결과를얻었다. 그밖에손톱기형, 피부괴사, 외관상문제되는원위지관절배부돌출등을보이는예는없었다. 고찰 추지골절치료에있어서수술은보존적치료에비해심각한합병증의발생률이높으면서도환자의만족도에서큰차이가없고, 매우다양한방법이있어선택의어려움이있다. 하지만 Kalainov 등 2 은관절면의 1/3 이상의골편을보이며아탈구를보이는 28예에 Table 3. Criteria that must be employed in mallet finger treatment by Abouna 25 1. It should be simple. 2. It should be effective. 3. It should be safe. 4. It should be free from complications. 5. It should not make the disability worse. 6. It should not lead to loss of earnings. 대해보존적치료를시행한결과 9도신전제한과 59 도굴곡의좋지않은결과를얻어수술적치료가필요하다고보고하였다. 대부분의관절내골절은치료가지연되면정복이어려워지고불유합가능성이높아지며추후관절염과관절운동제한가능성이높아진다. 추지골절에서는아직까지치료가지연된경우에대한별도의보고는없었으며, 각문헌에서증례의일부로포함되어언급하는수준이었다. 저자들은문헌고찰에서 43예의 2주이상지연된추지골절을찾을수있었다. Crawford 와 Kalainov 등은각각 23예와 6예에서보존적치료를시행하였다. Crawford 1 는지연기간이 11~30일인 9예에서양호이상의결과를 88.9% 얻었으며, 1~2 달인 14예에서는 71.4% 를얻었다고보고하였지 29
문은선 박용철 김명선 김종석 만골편의크기나아탈구에대한언급이없어서비교가불가능하였다. Kalainov 등 2 은 4주이상지연된 6 예에대해보존적치료를시행하여신전제한 13도의결과를얻었다고하였다. 나머지 14예의수술적치료의결과는다음과같았다. Pegoli 등 8 은 5주이상지연된 6예에서신전방지강선고정술을이용하여양호이상의결과를 50% 에서얻었다고하였고, Hofmeister 등 7 은 1달이상지연된 3예에서신전방지강선고정술을이용하여평균신전제한 2도, 평균굴곡범위 77도를얻었다고보고하였다. Kronlage와 Faust 9 는 5예에서압박나사 (compressive screw) 로치료하였으나결과를언급하지는않았다. 저자들의경우 4주이상지연된 10예에서 70% 가양호이상의결과를보여문헌보고와비슷한결과를얻었다. 합병증발생률은 41~53% 로보고되고있다 4,10. 주로피부괴사, 감염, 추지변형의재발, 손톱기형, 부정유합등이발생한다고보고되었다. 저자들의경우감염 1예, 중위지골원위관절면의부분결손 2예, 퇴행성변화 2예, 요측변위부정유합 1예가발생하여발생률은 40% 였다. 특히중위지골원위관절면의부분결손은관절고정강선의중위지골원위지골삽입부위에서발생하였으나치료결과와관련은없었다. 추지골절의치료결과에서가장문제되는점은신전제한으로알려져있다. 하지만, 본연구에서 5예는주먹을쥘때손톱의말단부가수장부원위주름보다원위부에이르지못하는굴곡제한이발생하여 Crawford 1 분류 (Table 1) 상 보통 의결과로평가되었다. 한편, Stern과 Kastrup 10 은수술한군이부목치료군에비해굴곡이 15도정도더적었다는결과를보고하였다. 저자들의경우변연절제술을시행한군과시행하지않은군의평균신전제한은각각 1.7 도, 2.0 도로, 증례수가적었지만절개에의한유착의영향이있다고평가하기는어려웠다. 신전제한강선이신전건을자극하여발생한유착이굴곡제한의원인으로추측하였으나, 좀더오랜기간의추시와많은증례를통한연구가필요할것으로생각된다. Okafor 등 6 은방사선학적퇴행성변화에대해연구하였고, 11예의추지골절에서 10예의퇴행성변화를관찰하였으며, 굴곡범위가퇴행변화를보인예에서더감소하였고, 나머지신전제한이나통증에서는통계학적관련성이없었다고하였다. 전체 31예에서 15 예 (48%) 가퇴행성변화를보였지만 28예 (90%) 가결과에만족하였다고보고하였다. 저자들의경우퇴행성변화가 2예 (13.3%) 에서보였으나임상적결과와연관성은없었다. 현재까지알려진추지골절의치료방법은신전방지강선고정술 7,8,11-14 이외에도견인철사요법 15,16, 8자형 긴장강선을이용한고정술 11, hook 금속판 17, 내부봉합술 18, K-강선고정 3,4,19,20, 압박핀고정 21, 나사고정 9, umbrella handle technique 22,23 등이있다. 견인철사요법이나금속판고정과같이관혈적정복을하는방법은피부절개에의해골인대접합부에서 11~16 mm 근위부에존재하는 avascular critical zone 24 에손상을줄수있어서, 손톱기형이나타날수있는가능성이신전방지강선고정술에비해높다. 한편, 골편을직접고정하는경우에는골편의파단이발생할위험이있다. 나사나압박핀을이용한고정은추후환자가제거술을요구할경우다시피부절개를해야하는부담이있다. 이에비해저자들은신전방지강선고정술이원위지골아탈구를정복할수있다는점, 신전방지강선에의한간접적인정복유지 13 로골편의파단이발생할가능성이낮은점, 술기가쉽고술후바로인접관절의운동을허용할수있다는점이장점이라고생각할수있었다. 이는위에서기술한수술방법가운데 Abouna와 Brown 25 이주장한추지변형치료법의 6가지기준 (Table 3) 에가장부합한다고할수있겠다. 하지만관절고정강선에의한골편의전위, 이차관절염발생가능성은단점으로지적할수있다. 저자들도 2예에서관절고정강선에의한중위지골원위관절면부분결손을경험하였다. 결론 2주이상지연되고수술의적응이되는추지골절환자에서신전방지강선고정술은보존적치료에비해더나은결과를보이며, 다른수술술기보다간단하고조기재활운동및일상복귀가가능한좋은방법으로사료된다. 지연기간이 4주이상이면골편의크기가클경우변연절제술을고려해야하며, 지연기간 10주까지골유합을얻을수있었다. 참고문헌 01) Crawford GP. The molded polythene splint for mallet finger deformities. J Hand Surg Am. 1984;9:231-7. 02) Kalainov DM, Hoepfner PE, Hartigan BJ, Carroll C 4th, Genuario J. Nonsurgical treatment of closed mallet finger fractures. J Hand Surg Am. 2005;30:580-6. 03) Lubahn JD. Mallet finger fractures: a comparison of open and closed technique. J Hand Surg Am. 1989;14:394-6. 04) Kang HJ, Shin SJ, Kang ES. Complications of operative treatment for mallet fractures of the distal phalanx. J Hand Surg Br. 2001;26:28-31. 05) Wehbe MA, Schneider LH. Mallet fractures. J Bone Joint 30
Surg Am. 1984;66:658-69. 06) Okafor B, Mbubaegbu C, Munshi I, Williams DJ. Mallet deformity of the finger. Five-year follow-up of conservative treatment. J Bone Joint Surg Br. 1997;79:544-7. 07) Hofmeister EP, Mazurek MT, Shin AY, Bishop AT. Extension block pinning for large mallet fractures. J Hand Surg Am. 2003;28:453-9. 08) Pegoli L, Toh S, Arai K, Fukuda A, Nishikawa S, Vallejo IG. The Ishiguro extension block technique for the treatment of mallet finger fracture: indications and clinical results. J Hand Surg Br. 2003;28:15-7. 09) Kronlage SC, Faust D. Open reduction and screw fixation of mallet fractures. J Hand Surg Br. 2004;29:135-8. 10) Stern PJ, Kastrup JJ. Complications and prognosis of treatment of mallet finger. J Hand Surg Am. 1988; 3:329-34. 11) Bischoff R, Buechler U, De Roche R, Jupiter J. Clinical results of tension band fixation of avulsion fractures of the hand. J Hand Surg Am. 1994;19:1019-26. 12) Darder-Prats A, Fernandez-Garcia E, Fernandez-Gabarda R, Darder-Garcia A. Treatment of mallet finger fractures by the extension block K-wire technique. J Hand Surg Br. 1998;23:802-5. 13) Inoue G. Closed reduction of mallet fractures using extension-block Kirschner wire. J Orthop Trauma. 1992;6:413-5. 14) Tetik C, Gudemez E. Modification of the extension block Kirschner wire technique for mallet fractures. Clin Orthop Relat Res. 2002;404:284-90. 15) Damron TA, Engber WD. Surgical treatment of mallet finger fractures by tension band technique. Clin Orthop Relat Res. 1994;300:133-40. 16) Niechajev IA. Conservative and operative treatment of mallet finger. Plast Reconstr Surg. 1985;76:580-5. 17) Teoh LC, Lee JY. Mallet fractures: a novel approach to internal fixation using a hook plate. J Hand Surg Eur. 2007;32:24-30. 18) Bauze A, Bain GI. Internal suture for mallet finger fracture. J Hand Surg Br. 1999;24:688-92. 19) Fritz D, Lutz M, Arora R, Gabl M, Wambacher M, Pechlaner S. Delayed single Kirschner wire compression technique for mallet fracture. J Hand Surg Br. 2005;30 :180-4. 20) Stark HH, Gainor BJ, Ashworth CR, Zemel NP, Rickard TA. Operative treatment of intra-articular fractures of the dorsal aspect of the distal phalanx of digits. J Bone Joint Surg Am. 1987;69:892-6. 21) Yamanaka K, Sasaki T. Treatment of mallet fractures using compression fixation pins. J Hand Surg Br. 1999; 24:358-60. 22) Badia A, Riano F. A simple fixation method for unstable bony mallet finger. J Hand Surg Am. 2004;29:1051-5. 23) Rocchi L, Genitiempo M, Fanfani F. Percutaneous fixation of mallet fractures by the umbrella handle technique. J Hand Surg Br. 2006;31:407-12. 24) Warren RA, Kay NR, Norris SH. The microvascular anatomy of the distal digital extensor tendon. J Hand Surg Br. 1988;13:161-3. 25) Abouna JM, Brown H. The treatment of mallet finger. The results in a series of 148 consecutive cases and a review of the literature. Br J Surg. 1968;55:653-67. 31