대한고관절학회지제 18 권제 1 호 Vol. 18, No. 1, March, 2006 대퇴골두무혈성괴사환자에서의대퇴골골두및경부골절 -4 례보고 - 포천중문의과대학분당차병원정형외과학교실 대퇴골두무혈성괴사환자에서속발되는대퇴골두및경부의골절발생은매우드물며이에대한골절의양상에대한분석과연관된보고는별로이루어져있지않은상태이다. 이에대한국내문헌상보고도거의없는실정이어서, 저자들은무혈성괴사로진단받아추시관찰중인환자들중에서초생달형태의골절과는전혀다른, 작은외상에의해발생한스트레스성골절로기인된것으로사료되는비교적수직형태의대퇴골두및경부골절을동반한환자 4례를경험하였기에골절의발생원인, 무혈성괴사에대하여그원인, 골절의위치, 형태, 방향및수상기전등에관한것을분석하여이를문헌고찰과함께증례보고하고자한다. 색인단어 : 대퇴골두, 대퇴골두및경부골절, 무혈성괴사 성인의대퇴골두무혈성괴사는국소적인혈류장애로대퇴골두에골괴사가발생하여대퇴골두의변형과고관절의기능장애를초래하는진행성질환이다. 그원인에관해서는여러요인이제시되고있고병의진행과정중에초생달형태의골절이발생하는것이일반적이나대퇴골두무혈성괴사진행과정중대퇴골두및경부골절이발생되는것은매우드물고, 특히골절의양상에대한보고도이루어져있지않은실정으로, 현재까지이에대한국내의문헌상보고도없는실정이다. 이에저자들은무혈성괴사로진단받아추시관찰중인환자중초생달형태의골절과는전혀다른형태의대퇴골두및경부골절들을경험하였는데작은외상에의해발생한스트레스성골절이라사료되며수직형태의대퇴골두및경부골절의양상을보이는것으로분석된 4례의증례를분석, 이를보고하고자한다. 통신저자 : 한수홍경기도성남시분당구야탑동 351 중문의대분당차병원정형외과 Tel: 82-31-780-5289 Fax: 82-31-708-3578 E-mail: hsoohong@hanmail.net 본논문의요지는 2005 년대한고관절학회춘계학술대회에서포스터제출되었음. 증례보고증례 1. 59세여자환자가내원 3일전화장실에서실족후발생한우측고관절부위동통을주소로내원하였으며과거력상 2년전뇌내출혈로인해좌측편마비를보여신경외과적치료받았다. 이학적소견상고관절부위동통과운동제한을호소하였으며단순방사선소견상대퇴골두를포함하는대퇴골두하수직형태의골절로써대퇴골두내체중부하부분의방사선음영밀도증가소견보이나관절간격은정상소견보였다. 자기공명영상소견상우측대퇴골골두무혈성괴사소견보이면서관절강내삼출소견보였다 (Fig. 1-,). 증례 2. 52세남자로내원3일전실족으로발생한좌측고관절부위동통을주소로입원하였다. 입원당시고관절운동시심한동통과압통을호소하였으며과거력상일주일에 3~4 일음주력갖고있었고 2년전양측성고관절무혈성괴사를자기공명영상소견으로진단받고추시중작은외상에의한골절로단순방사선검사상대퇴골두포함한대퇴골두상방에서대퇴골두하방까지이어지는수직의골절을보였다 (Fig. 2-,). 증례3. 66 세남자환자로서단순방사선소견상양측성대퇴골무혈성괴사진단받은후 6개월가량점진적으로좌측고관절동통지속되어내원하였다. 특별한외상의기왕력은없었으며과거력상일주일에 2~3 일음주력을갖 79
고있었다. 이학적소견상압통은없었으나 Patrick test 상양성소견보였다. 통증발현후단순방사선검사상좌측대퇴경부하의단축및감입골절소견의심스러웠으며자기공명영상소견상좌측고관절의대퇴경부골절및우측고관절관절강내삼출소견보였다 (Fig. 3-,, C). 증례 4. 66 세남자환자로내원 3개월전좌측대퇴골무혈성괴사진단, 추시관찰중, 내원 2일전실족후발생한좌측고관절통증을주소로내원하였다. 과거력상 6년전요추제 4번과 5번척추전위증진단하에수술시행하였으며하루에소주 1~2 병씩일주일에 3회정도마시는약 10 년의과거력갖고있었다. 이학적소견상좌측고관절 Fig. 1. () 59 years old female patient, Simple X-ray of high subcapital right femur head fracture with avascular necrosis. () MRI shows avascular necrosis of the right entire femur head with subcapital fracture and large amount of joint effusion. Fig. 2. () MRI of 52 years old male patient shows avascular necrosis of both femur head. () Simple X-ray shows subcapital fracture of left femoral head with vertical direction. 80
대퇴골두무혈성괴사환자에서의대퇴골골두및경부골절 -4 례보고 - 운동시제한및동통소견보이며 Patrick test 양성소견보였다. 단순방사선검사상좌측대퇴골두포함하는대퇴 골두의수직형의대퇴골두하골절을보였다 (Fig. 4-,). 고 찰 C Fig. 3. () 66 years old male patient, simple X-ray shows avascular necrosis of both femoral head. () Simple X- ray shows impacted subcapital fracture of left femur. (C) MRI shows fracture of the left femoral head with necrosis and marrow edema of right femur head. 무혈성괴사에서발생하는대퇴골두및경부골절은대퇴골두무혈성괴사이후발생되는초생달형골절과는전혀다른대퇴골두및대퇴경부에발생하는골절로서, Glimcher등이대퇴골두무혈성괴사환자에서대퇴골두괴사부위와신생부위의경계지역의골절에대해처음설명하였으며이는드물게보고되어있어국내에서의문헌상보고는없으나국내학자에의한외국논문이있고, Min 등과 Kim 등에의해발표되었다 2,3,4,6). 성인의대퇴골두무혈성괴사는대부분 30 대에서 50 대사이에발생하며, 남녀의발생빈도는 3:1 내지 5:1 로남자에서호발되어발생하며대부분이는수술적가료를하게되나경우에따라서는여러가지사정으로약물적가료등의보존적치료를하는경우가있는데이과정중에발생되는골절은아주드물다 1,4). 이런골절의양상은특징적으로 2가지형태로관찰할수있었는데 3례에서는수직형의대퇴골두하골절소견을보이며 1례에서는대퇴경부감입형골절을보여주고있었다. 골절부위의위치는대퇴경부와골두의경계선을포함하는골절이 3례있었으며이는무혈성괴사와정상경부사이의스트레스골절로사료되었다. 이부위의골절원인으로는골조직간의스트레스상승효과에의한것으로추측되었으며 Glimcher등은성인의대퇴골두무혈성괴사후골절의양상은일반적으로무혈성괴사후괴사골의분해와손상치유과정에서의섬유조직의대체에의해발생한대퇴골두하의구조적취약성에기인한미세피로골절이주원인이라고보고하고있다 2). 본증례중 3례도이러한양상의대퇴골두하골절을보여주고있었으나 1례의대퇴경부감입골절의경우는드문형 Fig. 4. () 66 years old male patient, simple X-ray shows avascular necrosis of left femur head. () Simple X-ray shows subcapital fracture of left femur head, 3month later. 81
태로서, Usui등은이러한골절은대퇴경부와대퇴골두의경계부에서발생한구조적취약성에의해발생하는것으로일반적으로골다공증의진행에의해발생하는일반적대퇴경부골절과유사한발생기전을갖는다고보고하고있다 7). 본증례에서대퇴골두와대퇴경부의경계부의체중부하부분인상부부분은골흡수와섬유조직의침윤에의해약해져있는부분으로실족등에의한수상당시약해진이부위로하중과염전력이가해져골절이발생, 대퇴경부의하부까지이어지는사선형태의경부골절을나타낸다고추측할수있었다. 1례의대퇴경부감입골절을제외한나머지 3례의경우괴사부외연의체중부하부분에서골절이시작되어수직혹은사선형의골절상을단순방사선소견과자기공명영상을비교하여알수있었는데이는외연부위의무혈성괴사는구조적으로취약한상태에서스트레스에의한골절을유발하는것으로사료된다. 즉, Usui등은무혈성괴사후발생한골절은 2가지형태를갖게되며, 대퇴골두하골절의경우는탄성률의차이에의한점진적인피로골절이주원인으로발생한것이고, 대퇴경부감입골절은작은외상에의한병적골절에기인한것으로보고하고있다 7). 따라서대퇴골두하골절은점진적인피로골절에의한것이고, 작은외상에기인한골절의경우대퇴경부골절이올수있고이는체중부하와염전력에의해주로발생하는것으로골절면이불규칙한특징을갖게된다. 무혈성괴사의추시중에작은외상에의해갑자기발생하는동통은무혈성괴사중병적골절이발생하였다는강 하게의심을할좋은증상이며, 또한그형태가대퇴골두포함하는경부로향하는대퇴경부하수직형의특징을갖고있음을보고하고자한다. REFERENCES 01) Cruess, RL: Cortisone-induced avascular necrosis of the femoral head. J one and Joint Surg, 59 : 308-317, 1977. 02) Glimcher MJ, Kenzora JE: The biology of osteonecrosis of the human femoral head and its clinical implication. Clin Orthop, 140:273-312, 1979. 03) Kim YM, Kim HJ: Pathological fracture of the femoral neck as the first manifestation of osteonecrosis of the femoral head. J Orthop Sci 5:605-9, 2000. 04) Kim SK, Lee DY, Lee HK: Clinical study of idiopathic femoral avascular necrosis. J Korean Orthopadic ssociation, 9: 60-64, 1984. 05) Kim YM, Jang JK: idiopathic avascular necrosis of adult femoral head. J Korean Orthopadic ssociation,10 : 156-166, 1975. 06) Min W, Koo KH, Song HR et al.: Subcapital fractures associated with extensive osteonecrosis of the femoral head. CORR, 390:227-31,2001. 07) Usui Masaaki, Hajime Inoue, Shigehumi Yujihiro, Nobuhiro be: Femoral neck Fracture following avascular necrosis of the femoral head. cta med Okayama, 50:111-117, 1996. 82
대퇴골두무혈성괴사환자에서의대퇴골골두및경부골절 -4 례보고 - STRCT Femoral Head and Neck Fractures developed in vascular Necrosis of the Femoral Head - report of 4 Cases- Hyung Ku Yoon, M.D., Duck Yun Cho, M.D., Soo Hong Han, M.D., Yong Sub Han, M.D., Ki Sik Nam, M.D. Department of Orthopaedic Surgery, undang CH Hospital, College of Medicine, Pochon CH University, Sung-Nam, Korea Femoral head and neck fractures during the course of avascular necrosis are rare with only few reports in the English literature. Moreover, there are very few reports on an analysis of the patterns of these fractures. Four cases of femoral head fracture caused by minor trauma, which were quite different from the crescent fractures during the course of avascular necrosis were analyzed in regard to the underlying disease, causes, sites, types, directions, pattern of fractures and the injury mechanism of the fractures. The results are reported with special regard to the pattern of the stress fracture of the femoral head and neck during the course of avascular necrosis. Key Words: Femoral head, Femoral head and neck fractures, vascular necrosis 83