336 pissn : 1226-2102, eissn : 2005-8918 Original Article J Korean Orthop Assoc 2017; 52: 336-343 https://doi.org/10.4055/jkoa.2017.52.4.336 www.jkoa.org 자세에따른견관절부초음파진단비교 고광표 문상호 * 신병건 한마음정형외과, * 서울성심병원정형외과, 충남대학교병원정형외과 Sonography of the Rotator Cuff: Comparison of Arm Positions Kwang Pyo Ko, M.D., Sang Ho Moon, M.D., Ph.D.*, and Byungkon Shin, M.D. Hanmaeum Orthopaedic Clinic, Daejeon, *Department of Orthopedic Surgery, Seoul Sacred Heart General Hospital, Seoul, Department of Orthopedic Surgery, Chungnam National University Hospital, Daejeon, Korea Purpose: To evaluate the objective difference of the shoulder position during ultrasound examination regarding diagnostic value for shoulder lesion, view range and visibility. Materials and Methods: A prospective study was performed enrolling 312 patients who underwent diagnostic ultrasonography due to shoulder pain between January 2016 and June 2016. Examination was performed by a single orthopaedic surgeon with 5 years of musculoskeletal ultrasonography experience. Images of the longitudinal and transverse plane of the supraspinatus tendon and the nearby soft tissues (subscapularis and biceps long head tendon, subdeltoid bursa, etc.) were obtained in the three different positions, shoulder extension, modified Crass, and Crass position. The correlation between the demographic data (age, sex and body mass index) and the visual analogue scale (VAS) of the affected shoulder & the capable shoulder position was analyzed. Another orthopaedic independently measured the size of the tear and using classified the image visibility of the supraspinatus, subscapularis, and biceps long head tendon on the shortaxis view from the rotator interval into I to III and X. Results: Of the 312 patients, 126 were excluded and total of 186 cases were included in this study. None of the demographic data were related to the possible arm position. However, VAS for pain was the only factor related with the number of possible arm positions during sonography. Kappa agreements for the diagnosis were mostly high of over 0.90. Grades of the short-axis view from the rotator interval in each position were mostly grade II or grade III, which refers to that the anterior portion of supraspinatus tendon, which is the most fragile portion to the tear and it was well-defined regardless of the arm position. The average longitudinal tear sizes were 1.48, 1.52, and 1.61 cm in the shoulder extension, modified Crass (Middleton), and Crass position, respectively. Conclusion: Shoulder extension position during ultrasonography examination of shoulder shows similar diagnosis rate of supraspinatus tendon tear or calcific tendinitis compared to modified Crass (Middleton) or Crass position, the two well-known standard positions. It is also a useful position for patients who suffer with severe shoulder pain. Key words: ultrasound, shoulder, supraspinatus 서론 어깨관절은상완골, 견갑골, 쇄골이만나는관절로다섯개의관 절, 즉관절와 - 상완관절, 견쇄관절, 흉쇄관절, 견흉관절, 견봉 Received October 29, 2016 Revised February 16, 2017 Accepted March 17, 2017 Correspondence to: Kwang Pyo Ko, M.D. Hanmaeum Orthopaedic Clinic, 32 Munjeong-ro, Seo-gu, Daejeon 35261, Korea TEL: +82-42-484-7575 FAX: +82-42-472-7525 E-mail: borameos@hanmail.net 하공간의움직임으로어깨가운동을하게된다. 그렇기때문에어깨관절어느곳에서나질병혹은외상이발생할수있다. 이러한다양한병변을감별하기위해자기공명영상, 관절조영술, 초음파검사등여러영상검사들을시행해왔는데최근에는초음파가자기공명영상에비해상대적으로저렴한검사비용, 초음파장비의발전으로진단의민감도와특이도향상, 어깨를움직이면서실시간으로병변을확인할수있는역동적검사의가능, 그리고진단과함께중재적치료를동시에시행할수있는장점등이있어널리사용되고있다. 1-3) 하지만초음파는뼈와같은단단 The Journal of the Korean Orthopaedic Association Volume 52 Number 4 2017 Copyright 2017 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.
337 Sonography of the Rotator Cuff: Comparison of Arm Positions 한구조물은투과가어렵다는단점이있어견관절의병변중많은부분을차지하는회전근개병변, 특히극상근과그주변의병변을초음파로확인하기위해다양한자세들이연구되어왔다. 극상근은천정위치에해당하는견봉에의해중립위치에서얻을수있는영상이제한적이므로극상근의대결절부착부위를견봉전면으로노출시키기위한표준화된자세로견관절을내전, 내회전, 신전시키는 Crass 자세 4) 와변형된 Crass (Middleton) 자세 5) 가제시되었으나이는견관절의운동범위제한이심하지않거나통증이심하지않은환자를대상으로한연구였기에제한점이있었다. 하지만저자의임상적경험에서심한어깨통증을가진환자는위의두자세를취하기어려운경우가많이있어환자가통증을견딜수있는정도에서견관절을신전만시킨자세 6) 로초음파검사를시행하였고상기두표준화된자세와비교할만한진단적가치와장점이있어실제로 Crass 자세, 변형된 Crass (Middleton) 자세, 신전자세간의초음파영상의회전근개주위병변의진단가능성및영상의범위와가시성등에대한객관적인차이와장단점을알아보고자본연구를시행하였다. 대상및방법 1. 연구대상 2016년 1월부터 2016년 6월까지단일병원에서약 5년간의근골격계초음파경험이있는한명의정형외과의사에게어깨통증으로처음으로내원하여견관절운동범위제한이있거나충돌유 발검사에서양성인경우혹은견관절주위압통부위가저명하여견관절자체의병변이의심되어초음파검사를받은환자 312 명을대상으로하여전향적인연구를시행하였다. 연구대상에서제외기준은첫째, 어깨통증과감별이필요한경추부신경근병변이있는경우, 둘째, 종양혹은심장질환같은연관통이의심되는경우, 셋째, 내원 3개월이내동측의어깨에타병원에서중재술을시행받은경우, 넷째, 동측의어깨에수술종류와관계없이수술을받은기왕력이있는경우로하였다. 이에최종연구대상자는 186명이었고남자는 88명, 여자는 98명, 평균연령은 57.5± 9.2세였다. 2. 검사방법초음파검사는 ECUBE 15EX (ALPINION Medical Systems, Seoul, Korea) 기기를이용하여, 선형탐촉자 (8-17 MHz) 로시행하였다. 환자는등받이가없는의자에바른자세로앉은후신전자세, 변형된 Crass (Middleton) 자세, Crass 자세순으로검사를시행하였고각각의자세에서극상근의횡축및종축영상및극상근의주변조직의영상을얻었다. 신전자세는주관절을 90도로굽힌후옆구리에팔을붙인채신전을하는것으로일정한신전각도로검사를시행하지는않았으나연구의객관성을위해환측손목의두상골이동측전상장골극과만나는신전정도를기준으로하였고, 변형된 Crass (Middleton) 자세는환측의손바닥을동측의둔부에대면서동측뒷주머니에넣는자세로, Crass 자세는환측의상완부를옆구리에붙이고손등을반대측의둔부에댄자세를기준자세로삼았으며통증으로세가지모든자세를취할수없었 A B C Figure 1. This figure shows positioning of the arm during sonography. (A) Shoulder extension position. (B) Modified Crass position. (C) Crass position.
338 Kwang Pyo Ko, et al. 던환자는취할수있었던자세만으로초음파검사를시행하였다 (Fig. 1). 3. 평가및분석우선인구통계학적요소 ( 나이, 성별, 체질량지수 [body mass index, BMI]), 환측어깨통증에대한시각통증등급 (visual analogue scale, VAS) 과초음파검사시환자가취할수있었던자세와의상관관계에대해분석하였다. 환자가취할수있었던자세는신전자세만가능한환자를그룹 E, 신전자세와변형된 Crass (Middleton) 자세가가능한환자를그룹 EM, 세가지모든자세가가능한환자를그룹 EMC로나누었다. 본연구에서는확정적진단을위하여자기공명영상이나관절경검사를시행하지않았고초음파검사만시행하였기때문에자세에따른진단의민감도나특이도를 평가하지는않았다. 하지만자세에따른극상건파열이나석회화건염의진단빈도를조사하였고신전자세를기준으로변형된 Crass (Middleton) 자세와, Crass 자세에서의진단의일치도 (kappa 값 ) 를평가하였다. 또한자세에따른극상건주위의초음파검사범위를비교하기위해세가지모든자세를취할수있었던환자 127명에대해각각의자세에서회전근개간극 (rotator interval) 을기준으로단축영상을통해극상건과견갑하근, 이두건장두간의영상가시성을평가하였다. 이때회전근개간극 (rotator interval) 의초음파영상가시성을평가할수있는참고문헌이없어저자들이새롭게이두장건과극상건의경계가저명하게관찰되지않은경우를 grade I, 이두장건과극상건의경계가저명하게관찰되나견갑하건과이두장건의경계가저명하게관찰되지않은경우를 grade II, 견갑하건과이두장건, 극상건의경계가한시 A B C D Figure 2. These sonographic images show the grading of the short-axis view of the rotator interval. (A) Grade I, when the border between the BLHT and the SST tendon is not observed prominently. (B) Grade II, when the border between the BLHT and the SST tendon is observed prominently, while the border between the BLHT and the SSC tendon is not observed prominently. (C) Grade III, when the border between the SSC tendon, the BLHT, and the SST tendon is prominently observed in one field of view. (D) Grade X, when the border is ambiguous due to a complete rupture of the SST tendon or BLHT or an extensive rupture of the rotator cuff. DE, deltoid muscle; SST, supraspinatus; GT, greater tubercle; BLHT, biceps long head tendon; SSC, subscapularis.
339 Sonography of the Rotator Cuff: Comparison of Arm Positions 야에저명하게관찰되는경우를 grade III, 극상건이나이두박건의완전파열혹은회전근개의광범위파열로경계가모호한경우는 grade X로정의하였고 (Fig. 2) 저장된각영상에대해 5년이상의초음파경험이있는다른한명의정형외과의사가독립적으로평가하여일치도 (kappa 값 ) 를계산하였다. 또한파열이확인된경우세가지자세에서각각극상건파열의크기가가장크게보이는지점에서단축과장축의영상을얻어파열의길이변화를비교하였다. 본연구에서모든통계값은 SPSS ver. 13.0 for Windows (SPSS Inc., Chicago, IL, USA) 를이용하여분석하였고유의수준은 p<0.05 로하였다. 인구통계학적요소 ( 나이, 성별, BMI), 환측어깨통증에대한 VAS와초음파검사시환자가취할수있었던자세와의상관관계는모수변수 ( 나이, BMI, 통증에대한 VAS) 에대해서는 one-way ANOVA로, 비모수변수 ( 성별 ) 에대해서는 Kruskall- Wallis test로분석하였다. 극상건파열의크기는신전-변형된 Crass (Middleton) 자세, 변형된 Crass (Middleton)-Crass 자세, 신전-Crass 자세각각에대해대응표본 t-검정을시행하였다. 결과 인구통계학적검사, 통증에대한 VAS와초음파검사시환자가취할수있었던자세는 Table 1에서기술하였고통증에대한 VAS 변수에대해서는그룹 E와그룹 EMC 간 (p=0.001), 그룹 EM과그 룹 EMC 간 (p=0.006) 에는통계적으로유의한차이가있었으나그룹 E와그룹 EM 간 (p=0.999) 에는유의한차이가없었다. 또한다른변수에대해서는유의한차이가없었다. 본연구에서검사시자세에따른극상건의부분층파열 (partialthickness tear), 전층파열 (full-thickness tear), 석회화건염 (calcific tendinitis) 의진단빈도는 Table 2에정리하였고, 환자삼각근하활액막염 (subdeltoid bursitis) 이나회전근개건증 (tendinosis), 유착성관절낭염 (adhesive capsulitis) 과같이초음파로의진단기준이모호하거나독립적인질환으로나타나기보다는다른질환과동반되는경우가많은질환들은이연구에서는평가하지않았다. 자세에따른진단의일치도는극상건의전층파열과석회화건염에대해서는대부분에서 0.90 이상의높은 kappa 값을가졌으나부분층파열에서신전자세와 Crass 자세의비교에서는 0.86으로상대적으로낮은 kappa 값이나타났다. 하지만여전히 0.81 이상으로절대적으로는아주높은일치도를보여주었다 (<0.20, Poor; 0.21-0.40, Fair; 0.41-0.60, Moderate; 0.61-0.80, Good; 0.81-1.00, Very good). 구체적인진단의일치도는 Table 2에정리하였다. 자세에따른회전근개간극에서의단축영상은저자 ( 검사자 A) 와다른한명의정형외과의사 ( 검사자 B) 가독립적으로평가하였고, grade에대한검사자간일치도는신전자세에서의 kappa 값은 0.86, 변형된 Crass (Middleton) 자세에서는 0.92, Crass 자세에서는 0.93이었다. 검사자 A, B 모두신전자세와변형된 Crass (Middleton) 자세에서는 grade III이가장많았으나 Crass 자세에서 Table 1. Comparisons of Demographic Data Variable Group E Group EM Group EMC p-value No. of patient 22 37 127 Age (yr) 57.2±6.3 59.7±10.3 56.9±12.1 0.837 Gender 0.550 Male 9 17 62 Female 13 20 65 BMI (kg/m 2 ) 25.1±3.2 24.8±3.7 24.6±5.1 0.714 VAS for pain 7.3 (6 10) 7.0 (6 9) 5.4 (2 8) 0.027 Values are presented as number only, mean±standard deviation, or median (range). Group E, shoulder extension position; Group EM, shoulder extension and modified Crass position; Group EMC, shoulder extension, modified Crass position, and Crass position; BMI, body mass index; VAS, visual analogue scale. Table 2. Frequency of Findings in Each Position and Kappa Agreements among 3 Positions Variable Calcific tendinitis Full-thickness tear Partial-thickness tear No. of patient 23 15 17 Position E-M E-C M-C E-M E-C M-C E-M E-C M-C Kappa agreement 1.00 1.00 1.00 1.00 0.93 0.94 0.91 0.86 0.93 E, shoulder extension position; M, modified Crass; C, Crass.
340 Kwang Pyo Ko, et al. Table 3. Grading of the Short-Axis View of the Rotator Interval in Each Position by Two Examiners Examiner A Variable Grade I Grade II Grade III Grade X Shoulder extension position 0 50 71 6 Modified Crass position 2 49 70 6 Crass position 3 61 57 6 Examiner B Shoulder extension position 0 48 73 6 Modified Crass position 1 52 68 6 Crass position 3 65 53 6 Values are presented as number only. Grade I, when the border between the biceps long head tendon and the supraspinatus tendon is not observed prominently; Grade II, when the border between the biceps long head tendon and the supraspinatus tendon is observed prominently, while the border between the biceps long head tendon and the subscapularis tendon is not observed prominently; Grade III, when tthe border between the subscapularis tendon, the biceps long head tendon, and the supraspinatus tendon is prominently observed in one field of view; Grade X, when the border is ambiguous due to a complete rupture of the supraspinatus tendon or biceps long head tendon or an extensive rupture of the rotator cuff. Table 4. The Mean Tear Size of Supraspinatus in Each Position Variable Elbow drawn backward Modified Crass Crass Short axis (cm) 1.53±0.23 1.62±0.17 1.58±0.28 Long axis (cm) 1.48±0.16 1.52±0.25 1.61±0.33 Values are presented as mean±standard deviation. 는 grade II가가장많았다. 검사자나자세와관계없이 grade I의빈도수는가장낮았다. Grade X는검사자나자세와관계없이빈도수가일치하였고총 6명으로모든케이스진단은회전근개의광범위파열이었다 (Table 3). 또한파열이확인된 31명의환자중초음파로파열의길이측정이어려웠던 grade X를제외한 25명중측정된파열의크기는 Table 4와같고대응표본 T-검정에서파열의단축길이는자세에따라유의한차이가없었으나장축길이는신전자세와 Crass 자세에서각각평균 1.48 cm, 1.61 cm로통계적으로유의한차이가있었다 (p=0.016). 고찰 저자들은본연구를통해견관절의초음파검사시신전자세가지금까지표준화된자세로알려진변형된 Crass (Middleton) 자세및 Crass 자세에비교하였을때극상건의파열, 석회화건염의진단에있어유사한진단율을보이면서도환자의통증이심할때유용하게사용될수있는자세임을확인하였다. 근골격계초음파검사는환자의체격이나자세와같은환자요인, 초음파를시행하는검사자의숙련도나검사방법에따른검사자요인에의해상대적인결과가나올수있다. 그렇기때문에객관적이고일관성있는진단을위해초음파검사시표준화 된자세나순서가제시되고많은연구가이루어졌다. 특히극상건파열의초음파진단은 2000년이전의문헌에서도 90%-95% 의민감도와 90% 에가까운특이도를보여준다고하였고, 7-11) 최근 Yablon 등 12) 은초음파검사와관절경검사를비교하였고민감도와특이도가 95% 에이른다는보고를하였다. 또한 1984년 Crass 등 13) 이피검자의상완을내회전하면서전완을등에가로지르게올려놓은자세에서초음파로극상건의종축에서파열을진단한것을첫문헌으로, 1985년 Middleton 등 14) 이전완을무릎위에올리고최대로내전한정중립자세 (true neutral position) 에서극상건의전층파열진단의 93% 민감도를보고하였다. 1987년 Crass 등 4) 은현재의 Crass 자세로알려진어깨의신전및내회전자세로중립자세보다더극상건을견봉바깥으로이동시킴으로써더많은건부위를확인할수있었고극상건파열진단의 97% 정확도를보고하였다. Middleton 11) 은 1992년피검자의손을동측의뒷주머니에위치시키는변형된 Crass (Middleton) 자세를발표하였고, Teefey 등 15) 은이자세에서초음파진단으로극상건의전층파열은 100% 정확도를, 부분층파열은 77% 의정확도를보고하였다. Shah 등 7) 은초음파검사에서확인되는극상건의길이가중립자세, 변형된 Crass (Middleton) 자세, Crass 자세에서각각평균 1.78 cm, 2.77 cm, 2.83 cm였음을보고하였다. 본연구에서는극상건전체길이를측정하지않았으나파열이확인된환자에서각자세에서의파열의최대길이를측정하였고신전자세에서보다
341 Sonography of the Rotator Cuff: Comparison of Arm Positions Crass 자세에서통계적으로유의하게종축길이가길게측정되었다. 이는 Table 2에서와같이 Crass 자세가극상건을신전시켜이론적으로는중립또는신전자세에서관찰이어려운작은파열을크게확대하여진단이유리할수있음을시사한다. 또한 Singh 6) 는초음파로파열이빈번하게일어나는극상건의앞부위를관찰하기위해신전자세에서단축영상의확인을강조하였다. 이는극상건의해부학적위치가이두건장두의바로뒤에위치하면서이두건장두와평행하게진행하는데 Crass 자세나, 변형된 Crass (Middleton) 자세는상완을내회전시켜극상건의앞부위가오구돌기밑으로들어가게되어뚜렷한영상을얻을수없게되기때문이다. 저자도이러한의견에대해동의하나의사마다극상건앞부위의범위가달라질수있고일반적으로파열이한부위에국한되기보다는앞에서뒤로진행된경우가많아본연구에서는자세에따른진단의민감도나특이도를평가한것이아니라자세에따른초음파영상의진단가능범위를비교하였는데자세와관계없이대부분 grade II 혹은 grade III의영상을얻을수있었다. 이는이두건장두와극상건의경계부위 ( 극상건앞부위 ) 병변의진단만을평가했을때자세에따른진단의제한이크지않음을보여준다. 또한 Table 2에서보는바와같이병변의위치를고려하지않고석회성건염, 극상건의부분혹은전층파열에대해자세에따른진단의일치도가아주높다는것 (kappa, 0.86-1.00) 을확인하였다. 종합적으로극상건의병변을확인하기위해서는어떤특정한자세가유리한것이라기보다는어느자세에서든환자나검사자가익숙하고편안한자세에서검사를하는것이중요하고크기가작은파열에대해서는병변을종축으로신전시켜주는자세인 Crass 자세가이론적으로는조금더유리할수있다고할수있다. 또한 Crass 자세인경우견쇄관절하방부에서관상면에수직으로극상건의건부위가주행하기때문에탐측자로종축과횡축의영상을잡기가비교적용의하다는장점도있다. 다만 Table 1에서확인한것처럼통증이심한경우에는신전자세밖에환자가취할수없는경우도있기때문에신전자세에서극상건의주행방향이나탐측자의각도에따른영상에대해익숙해져야될필요가있다. 16) 특히극상건의파열의초음파기준으로 Middleton은첫째정상적인회전근개에코의불연속성, 둘째회전근개퇴축에의해보이지않을때, 셋째활액막의비후가파열간극을채움으로써발생하는고에코상의밴드를제시하였고간접적인진단기준으로대결절표면이불규칙하게울퉁불퉁해지는경우, 회전근개의덮음이없어짐으로써관절연골이잘보이게되는연골경계부징후 (cartilage interface sign), 견봉하-삼각근하점액낭의액체저류혹은극상건쪽으로함몰되는경우, 상완골두가상방전위되는경우, 이두박건주위의액체저류등의관찰이필요한데이러한여러소견을놓치지않기위해서는다양한자세에서의면밀한검사가필요할것이다. 14) 본연구의제한점으로는첫째, 이미많은문헌에서근골격계초음파진단의민감도나특이도가 90%-95% 라는보고를하고있기때문에본연구에서는자기공명영상이나관절경과같이초음파의진단을확인해줄부가적인진단을하지않았고진단의정확도보다는일치율에초점을맞추었다. 또한극상건병변에서초음파검사가검사자나환자의자세에크게영향을받지않고비교적일관적인진단을할수있음을보여주었다. 둘째, 통증에대한견관절초음파자세의비교시 frozen shoulder 등강직이동반된환자를구분하여평가하지않은점이다. 이에강직정도를고려한분석을위해서는더광범위한규모의연구가필요할것이다. 셋째, 한환자에서검사자마다각각의초음파검사를시행하기에는비용문제나환자의불편감같은현실적인어려움으로한검사자가저장한초음파영상을기준으로다른검사자와의비교분석을시행한연구이기때문에정보바이어스 (information bias) 가있을수있다. 하지만두검사자모두 5년이상의근골격계초음파경험이있는전문가로연구결과의해석에있어신뢰할수있는결과를얻기위해노력하였다. 넷째, 어깨통증이있는환자들만대상으로한연구이기때문에무증상의회전근개병변이있는환자는본연구에서제외가되어선택바이어스 (selection bias) 가있을수있다. 이에대해서는좀더광범위한규모의연구가필요할것으로생각된다. 결론 결론으로본연구에서는견관절의초음파검사시신전자세가지금까지표준화된자세로알려진변형된 Crass (Middleton) 자세및 Crass 자세에비교하였을때극상건의파열, 석회화건염의진단에있어유사한진단률을보이면서도환자의통증이심할때유용하게사용될수있는자세임을확인하였다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Bianchi S, Martinoli C. Ultrasound of the musculoskeletal system. Berlin: Springer; 2007. 189-91. 2. Adler RS, Sofka CM. Percutaneous ultrasound-guided injections in the musculoskeletal system. Ultrasound Q. 2003;19:3-12. 3. Cardinal E, Chhem RK, Beauregard CG. Ultrasound-guided interventional procedures in the musculoskeletal system. Radiol Clin North Am. 1998;36:597-604.
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343 pissn : 1226-2102, eissn : 2005-8918 Original Article J Korean Orthop Assoc 2017; 52: 336-343 https://doi.org/10.4055/jkoa.2017.52.4.336 www.jkoa.org 자세에따른견관절부초음파진단비교 고광표 문상호 * 신병건 한마음정형외과, * 서울성심병원정형외과, 충남대학교병원정형외과 목적 : 견관절의초음파검사시견관절자세간의회전근개주위병변의진단가능성및영상의범위와가시성등에대한객관적인차이와장단점을알아보고자본연구를시행하였다. 대상및방법 : 2016년 1월부터 2016년 6월까지단일병원에서어깨통증으로처음으로내원하여약 5년간의근골격계초음파경험이있는한명의정형외과의사에게초음파검사를받은환자 312명을대상으로하여전향적인연구를하였다. 초음파검사는검사자가신전자세, 변형된 Crass (Middleton) 자세, Crass 자세순으로검사를시행하였고각각의자세에서극상근의횡축및종축영상및극상근의주변조직 ( 견갑하근, 이두건장두, 삼각근하점액낭등 ) 의영상을얻었다. 인구통계학적요소 ( 나이, 성별, 체질량지수 ), 환측어깨통증에대한시각통증등급 (visual analogue scale, VAS) 과초음파검사시환자가취할수있었던자세와의상관관계에대해분석하였다. 또한저장된각영상에대해다른한명의정형외과의사가독립적으로파열의크기를측정하였고회전근개간극에서의단축영상을통해극상건과견갑하근, 이두건장두간의영상가시성을 grade I-III & X로평가하였다. 결과 : 312명환자중 126명이제외되었고 186명이최종적으로연구에포함되었다. 인구통계학적요소와통증에대한 VAS 중통증에대한 VAS가유일하게초음파검사시가능한자세의수와관계되었다. 자세에따른진단의일치도는대부분 0.90 이상으로높은일치도를보였다. 회전근개간극에서의단축영상평가는 grade II 혹은 grade III가대부분이었고이것은파열이잘일어나는극상건의앞부위가자세와관계없이초음파로잘확인될수있음을뜻한다. 파열의평균장축길이는신전자세, 변형된 Crass (Middleton) 자세, Crass 자세에서각각 1.48 cm, 1.52 cm, 1.61 cm였다. 결론 : 견관절의초음파검사시신전자세가지금까지표준화된자세로알려진변형된 Crass (Middleton) 자세및 Crass 자세에비교하였을때극상건의파열, 석회화건염의진단에있어유사한진단율을보이면서도환자의통증이심할때유용하게사용될수있는자세임을확인하였다. 색인단어 : 초음파, 견관절, 극상건 접수일 2016 년 10 월 29 일수정일 2017 년 2 월 16 일게재확정일 2017 년 3 월 17 일책임저자고광표 35261, 대전시서구문정로 32, 한마음정형외과 TEL 042-484-7575, FAX 042-472-7525, E-mail borameos@hanmail.net 대한정형외과학회지 : 제 52 권제 4 호 2017 Copyright 2017 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.