CASE REPORT pissn 1598-3889 eissn 2234-0998 J Korean Soc Surg Hand 2016;21(4):225-229. http://doi.org/10.12790/jkssh.2016.21.4.225 JOURNAL OF THE KOREAN SOCIETY FOR SURGERY OF THE HAND Volar Dislocation of the Distal Radioulnar Joint Blocked by Displaced Dorsal Barton Fracture Jong Hun Baek 1, Jae Hoon Lee 2, Duke Whan Chung 1, Young Jun Kim 1 1 Department of Orthopaedic Surgery, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, Korea 2 Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea Distal radioulnar dislocation is commonly associated with radius fracture. Most common dislocation pattern is the dorsal dislocation. We present the unique case of volar dislocation of the distal radioulnar joint blocked by displaced dorsal Barton fracture of distal radius and discuss the injury mechanism and anatomic lesions. Keywords: Distal radioulnar joint, Dorsal Barton fracture, Distal radius fracture, Galeazzi fracture Received: August 11, 2016 Revised: September 20, 2016 Accepted: October 1, 2016 Correspondence to: Jae Hoon Lee Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, 892 Dongnam-ro, Gangdong-gu, Seoul 05278, Korea TEL: +82-2-440-6153 FAX: +82-2-440-7497 E-mail: ljhos69@naver.com This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/bync/ 3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 서론 원위요척관절의탈구는드문질환으로흔히 Galeazzi 골절과같이요골골절과동반하여발생한다. 이탈구는부적절한방사선학적검사로쉽게간과될수있으며, 진단이늦게되는경우에는재건을위해복잡한수술술기가필요하고불량한임상결과의원인이되기때문에수상당시의적절한진단 과치료가중요하다. 요골의골절이동반된원위요척관절탈구는골절을해부학적정복및고정을한후에도정복에실패하거나방사선학적검사에서연부조직의감입이명확한경우에관혈적정복술이요구된다. 후방탈구의경우에감입을유발하는가장흔한구조물은척수근신전건이고, 그외에도총수지신전건이있다. 반면매우드물지만전방탈구의경우에는척골신경 Copyright c 2016. The Korean Society for Surgery of the Hand http://www.jkssh.org/ 225
J Korean Soc Surg Hand Vol. 21, No. 4, December 2016 및혈관의감입이발생할수있고, 이러한경우는응급감압이요구된다. 대부분의원위요척관절탈구는후방으로발생하며탈구의방향을결정하는기전은아직명확하지않다. 앞선보고들에서드물게 Galeazzi 골절또는단독으로발생한원위요척관절의전방탈구가보고된바있지만,, S형절흔의 / 이상을침범하고척측으로전위된배측 Barton 골절편에의해도수정복이불가능하였던원위요척관절의전방탈구에대한보고는없다. 저자들은배측 Barton 골절과동반된도수정복이불가능하였던원위요척관절의전방탈구 예와이와관련된수상기전및해부학적인병변을보고하고자한다. 증례 세남자가내원당일운전하던중앞차와충돌하면서발생한좌측손목의통증으로타병원에서원위요골골절진단하에본원으로전원되었다. 좌측손목의심한부종, 무지구에타박상과손목운동범위의제한이관찰되었으나신경과혈관의상태는정상이었다. 초기 X-ray 에서원위요척관절의전방탈구와함께배측 Barton 골절과척골경상돌기기저부의골절이관찰되었다 (Fig. A). 컴퓨터단층촬영 (computed tomography) 에서 S형절흔의 > / 을침범하는배측 Barton 골절의골절편이척측으로전위되어있고, 원위요척관절이전방으로탈구되어있는것을확인할수있었다 (Fig. B). 환 자는정맥유도진정하에도수정복을시도하였으나정복이 되지않았다. 자기공명영상검사 (magnetic resonance imaging, A B Fig. 2. Intraoperative photographs, (A) shows ulnarly displaced dorsal Barton fracture. (B) Open reduction and internal fixation were conducted through a dorsal approach. A B Fig. 1. Preoperative plain radiographs of left wrist. (A) Anteroposterior and lateral radiographs show displaced dorsal Barton and ulnar styloid process fracture with volar dislocation of the distal radioulnar joint (DRUJ). (B) Computed tomography axial view shows that the size of the displaced bone fragment have involved an area 1/2 of the sigmoid notch and the fragment is trans-positioned ulnarly to the DRUJ. 226 http://www.jkssh.org/
Jae Hoon Lee, et al. Irreducible Volar Dislocation of the Distal Radioulnar Joint Fig. 3. Postoperative anteroposterior and lateral radiographs show internal fixation of dorsal Barton fracture and tension band wiring of unlar styloid process fracture maintaining distal radioulnar joint reduction in anatomic alignment. MRI) 에서원위요척관절에연부조직의감입은확인되지않 았다. 환자는수상후 일째, 후방도달법을통하여배측 Barton 골절에대하여해부학적정복을하였고, 그후에전방으로탈 구되었던원위요척관절은자발적으로정복되었다 (Fig. ). 원위요골을금속판을이용하여고정한후원위요척관절의 전방불안정성이확인되어척골경상돌기를긴장강선고정 술을이용하여고정하였다 (Fig ). 환자는 주간장상지부 목, 그후 주간단상지부목을이용하여고정하였고, 수술 후 주째에수동및능동적손목관절운동을시작하였다. 년추시에서손목관절의운동범위는신전, 굴곡, 회 내전, 회외전 였고, 악력은우측에비하여 % 수준이 었다. 전방탈구의기전과는같지않다. 따라서본증례에서는배측 Barton 골절의골절편이척측으로전위되면서원위척골을전방으로탈구시켰을것으로판단된다. 원위요척관절의주요안정화구조물은삼각섬유연골복합체로복합체중에척골경상돌기와경상돌기와에붙는전방및후방요척인대가가장중요한역할을한다. May 등 은심한전위를동반한척골경상돌기기저부골절이있을경우에는원위요척관절의불안정성이증가한다고보고하였다. 이러한소견이있을경우, 요골을해부학적정복및고정한후에원위요척관절이정복되었더라도전완을회내, 회외전하면서관절의안정성을검사해야한다. 불안정성이있을경우 Kirschner wire 로척골경상돌기를고정해야원위요척관절의안정성을얻을수있다. 본증례의환자역시척골경상돌기기저부의골절이있었고, MRI 에서삼각섬유연골복합체가이골절편에붙어있는상태로척골과는분리된상태였다. 이는원위요척관절의불안정성을시사하는소견으로정복된후에도불안정성이관찰되었고척골경상돌기를고정한후에안정성을획득할수있었다. 원위요척관절의탈구가정복이되지않을경우연부조직의감입을의심해야한다. 후방탈구의경우는주로척수근신전건의감입이발생하고, 전방탈구는매우드물지만척골신경및혈관의끼임이발생할수있다. 이경우에는관혈적정복술이요구되며, 특히전방탈구에서척골신경및혈관의끼임발생하였을경우에전방접근을통하여응급감압을하여야한다. 본증례에서연부조직의감입은없었지만원위요척관절이정복되지않았고이는 Barton 골절의골편이 S형절흔의 / 이상을침범하고척측으로전위되어있어원위요척관절의정복을방해하였을것으로생각한다. 이처럼원위요척관절의정복이불가능할경우연부조직의감입외에도 S형절흔을침범한척측으로전위된골편에의한원인을고려해야하며이런경우전위된골절의해부학적정복및고정을해야한다. 고찰 원위요척관절탈구의수상기전은명확하지않지만, 후방탈구는전완이과회내전되고손목이신전된상태에서축성압력을받았을때발생하고, 전방탈구는전완이과회외전된상태에서발생하는것으로알려져있다. 본증례에서환자는수상당시운전대를잡고있어전완이회내전상태였으며, Barton 골절을보았을때손목에전단력이작용하였다고판단된다. 이와같은수상기전은일반적인원위요척관절의 REFERENCES 1. Mikic ZD. Galeazzi fracture-dislocations. J Bone Joint Surg Am. 1975;57:1071-80. 2. Macule Beneyto F, Arandes Renu JM, Ferreres Claramunt A, Ramon Soler R. Treatment of Galeazzi fracture-dislocations. J Trauma. 1994;36:352-5. 3. Itoh Y, Horiuchi Y, Takahashi M, Uchinishi K, Yabe Y. Extensor tendon involvement in Smith s and Galeazzi s frac- http://www.jkssh.org/ 227
J Korean Soc Surg Hand Vol. 21, No. 4, December 2016 tures. J Hand Surg Am. 1987;12:535-40. 4. Magill P, Harrington P. Complex volar dislocation of the distal radioulnar joint in a Galleazi variant associated with interposition of the ulnar neurovascular bundle. Eur J Orthop Surg Traumatol. 2009;19:265-7. 5. Werthel JD, Masmejean E, Silvera J, Boyer P, Schlur C. Acute isolated volar dislocation of the distal radioulnar joint: case report and literature review. Chir Main. 2014;33:364-9. 6. Rose-Innes AP. Anterior dislocation of the ulna at the inferior radio-ulnar joint: case report, with a discussion of the anatomy of rotation of the forearm. J Bone Joint Surg Br. 1960;42:515-21. 7. Kihara H, Short WH, Werner FW, Fortino MD, Palmer AK. The stabilizing mechanism of the distal radioulnar joint during pronation and supination. J Hand Surg Am. 1995;20:930-6. 8. May MM, Lawton JN, Blazar PE. Ulnar styloid fractures associated with distal radius fractures: incidence and implications for distal radioulnar joint instability. J Hand Surg Am. 2002;27:965-71. 228 http://www.jkssh.org/
Jae Hoon Lee, et al. Irreducible Volar Dislocation of the Distal Radioulnar Joint 전위된배측 Barton 골절에의해정복이불가능하였던원위요척관절의전방탈구 백종훈 1 이재훈 2 정덕환 1 김영준 1 1 경희대학교경희의료원정형외과학교실, 2 경희대학교강동경희대학교병원정형외과학교실 원위요척관절의탈구는흔히원위요골골절과동반되며주로후방으로발생한다. 본증례에서는 S 형절흔의 / 이상 을침범하고척측으로전위된배측 Barton 골절편에의해도수정복이불가능하였던원위요척관절의전방탈구 예와 이와관련된수상기전및해부학적원인을보고하고자한다. 색인단어 : 원위요척관절, 배측 Barton 골절, 원위요골골절, Galeazzi 골절 접수일 2016 년 8 월 11 일수정일 2016 년 9 월 20 일게재확정일 2016 년 10 월 1 일교신저자이재훈서울시강동구동남로 892 강동경희대병원정형외과학교실 TEL 02-440-6153 FAX 02-440-7497 E-mail ljhos69@naver.com http://www.jkssh.org/ 229