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대한골절학회지제 24 권, 제 2 호, 11 년 4 월 Journal of the Korean Fracture Society Vol. 24, No. 2, April, 11 3. mm 수장측잠김압박금속판과 2.4 mm 수장측잠김압박금속판을이용한원위요골골절의수술적치료결과비교 하성식ㆍ김태호ㆍ홍기도ㆍ심재천ㆍ김종현 삼육서울병원정형외과 목적 : 원위요골골절의치료로수장측 3. mm 와 2.4 mm 잠김압박금속판을사용하여치료한환자를대상으로방사선적, 임상적치료결과를비교분석하였다. 대상및방법 : 3 년 9 월부터 9 년 6 월까지원위요골골절로본원에내원한환자중에서수장측 3. mm 또는 2.4 mm 잠김압박금속판을이용한관혈적정복술및내고정술을시행받고 1 년이상추시가가능했던 11 예를대상으로하였다. 수술후최종평가는방사선학적평가를분석하였고 Knirk 와 Jupiter 의기준으로관절염유무, Modified Mayo wrist scoring system, DASH 를이용한임상적평가를하였다. 결과 : 방사선학적평가상요골길이, 요측경사, 수장측경사, 요골원위관절면의층형성이수술전과비교하여두군에서향상된결과를보였다. Knirk 와 Jupiter 의기준으로한관절염의발생은 3. mm 와 2.4 mm 잠김압박금속판의경우각각 9 예, 7 예이었다. Modified Mayo wrist score 를이용한임상적평가는 3. mm 와 2.4 mm 잠김압박금속판을사용한군에서각각평균 86.7 점, 84.8 점이었고 DASH score 는각각평균 11.2 점,.9 점이었다. 모든예에서골유합을얻었고내고정물실패나정복소실은없었다. 결론 : 수장측 3. mm 잠김금속판과 2.4 mm 잠김금속판을이용한원위요골골절치료는방사선학적, 임상적으로만족할만한치료결과를보였다. 색인단어 : 요골, 원위요골골절, 수장측잠김압박금속판 Comparison of Operative Management in Distal Radius Fractures Using 3. mm Versus 2.4 mm Volar Locking Compression Plates Sung-Sik Ha, M.D., Tae-Ho Kim, M.D., Ki-Do Hong, M.D., Jae-Chun Sim, M.D., Jong Hyun Kim, M.D. Department of Orthopedic Surgery, Sahmyook Medical Center, Seoul, Korea Purpose: To evaluate clinical and radiological results using 3. mm & 2.4 mm volar locking compression plate (LCP) in distal radius fractures. Materials and Methods: This study reviewed the results of 11 cases of distal radius fractures treated with 3. mm volar LCP (73 cases) & 2.4 mm volar LCP (42 cases) from September 3 to June 9. The radiographic results were evaluated by radiographic assessment, and the clinical results were evaluated by Knirk and Jupiter s criteria, Modified Mayo wrist scoring system and DASH score. Results: Radiological evaluation of the radial length, radial inclination, volar tilt and intraarticular step off were improved both 3. mm volar LCP and 2.4 mm volar LCP. Nine cases of arthritis occured in 3. mm volar LCP and 7 cases in 2.4 mm volar by using the Knirk and Jupiter s criteria. The mean score evaluated by Modified Mayo was 86.7 in 3. mm volar LCP and 84.8 in 2.4 mm volar LCP. DASH score was 11.2 point in 3. mm volar LCP,.9 point in 2.4 mm volar LCP. All cases showed bone union showing no evidence of malunion, nounion, nor metal failure. 통신저자 : 김태호서울시동대문구휘경 2 동 29-1 삼육서울병원정형외과 Tel:2-22-381 ㆍ Fax:2-2217-1897 E-mail:oskimth@naver.com 접수 :. 8. 18 심사 ( 수정 ): 1 차. 9. 18, 2 차. 11. 9 게재확정 : 11. 2. 16 Address reprint requests to:tae-ho Kim, M.D. Department of Orthopedic Surgery, Sahmyook Medical Center, 29-1, Hwigyoung 2-dong Dongdaemun-gu, Seoul 13-711, Korea Tel:82-2-22-381 ㆍ Fax:82-2-2217-1897 E-mail:oskimth@naver.com 16

3. mm 수장측잠김압박금속판과 2.4 mm 수장측잠김압박금속판 17 Conclusion: Distal radius fractures treated with 3. mm volar LCP and 2.4 mm volar LCP show satisfying radiological and clinical outcome. Key Words: Radius, Distal radius fracture, Volar locking compression plate 서 원위요골골절은성인에서발생하는가장흔한골절로도수정복및석고부목고정등의보존적치료방법도많이사용되어왔다. 그러나, 최근에는다양한스포츠활동의증가와노인인구의급격한증가로골절의양상이복잡해지고관절내골절혹은분쇄를동반한불안정성골절이증가하고있는추세이며이런골절은해부학적도수정복이어렵고, 유지또한힘들다. 관혈적정복및금속내고정술을시행하여정확한해부학적정복을이루고, 조기관절운동을시행하여만족스런기능회복을조기에달성하는것이치료방향으로되어가고있다,8,12,16,18,,23). 원위요골골절은대개후방에골절편이있는경우가많아후방접근법및후방금속판고정술이사용되었으나, 금속판과직접적인접촉으로인한신전건의염증, 마멸, 파열과신전지대의손상, Lister 결절의절제등의문제가있다 22). 이러한문제해결을위해후방으로전위된원위요골골절치료에도전방접근법및전방금속판고정술이시도되었다 12,14,22). 잠김압박금속판은혈류장애를감소시켜골유합을촉진시키고 6,19) 금속판내나사못의유리와정복의소실을막기위해고안되었다 12). 그러나 3. mm 나사를이용하기때문에합병증으로나사와금속판으로건과연부조직자극이관찰되었고 17) 나사의크기때문에작은골편의고정시어려움이있다 21). 잠김압박금속판을사용하면서금속판과나사못의크기로인한한계점이발견되면서 2.4 mm locking distal radius system (Synthes, USA) 이고안되었고현재 2가지금 론 속판을모두사용하고있다. 이에저자들은금속판과나사의크기가치료결과에미치는영향을알아보기위해 3. mm LCP distal radius plate 와 2.4 mm locking distal radius system (Fig. 1) 을사용하여원위요골골절의치료를받은환자를대상으로방사선적, 임상적치료결과를비교분석하였다. 1. 연구대상 Table 1. Demographic data 대상및방법 3 년 9 월부터 9 년 6 월까지본원에원위요골골절로내원한환자중에서전방도달법으로수장부잠김압박금속판을이용한관혈적정복술및금속내고정술을시행받고 1 년이상추시가가능했던 11 예를대상으로하였다. Synthes 사의 3. mm LCP distal radius plate 를 73 예, 2.4 mm locking distal radius system 을 42 예에서사용하였으며남자가 33 명 (29%), 여자가 82 명 (71%) 이었고환자나이는평균.2 세 (33 7) 이었다. 수상원인으로는실족이 8 예, 낙상이 23 예, 교통사고가 12 예이었다. 골절의분류는골절형태와부위에따른 AO classification 을사용하였으며, A2 18 예, A3 29 예, B2 7 예, C1 18 예, C2 3 예, C3 13 예이었다 (Table 1). 동반손상으로는주상골골절이 4 예, Patient data 3. mm LCP distal radius plate (n=73) 2.4 mm locking distal radius system (n=42) Fig. 1. (A) Photograph shows 3. mm LCP distal radius plate. (B) Photograph shows 2.4 mm locking distal radius system. Age (years) (range) Male:female Cause Slip down Fall down Traffic accident Fracture type (AO) A2 A3 B2 C1 C2 C3 6.4 (33 74) 24:49 4 12 7 12 19 7 3.7 (36 7) 11:31 26 11 6 2 8 6

18 하성식, 김태호, 홍기도, 심재천, 김종현 수지골절이 3 예, 수근관절아탈구가 예이었다. 결 과 2. 수술방법 수술은전신마취하에서원위전완부전방도달법을이용하였다. 요수근굴건 (flexor carpi radialis) 을촉지하고그위로 7 cm 가량피부절개를시행한후, 요골동맥의손상을주의하면서요수근굴근아래근막 (fascia) 을종으로절개하였다. 장무지굴건 (flexor pollicis longus) 을척측으로견인하고, 방형회내근 (pronator quadratus) 을요측에서종으로절개하여골절부위를노출하여정복을시행하였다. 정복후잠김압박금속판을사용하여고정하였으며영상증폭장치를이용하여골절의정복및나사못의위치를확인한후방형회내근을다시봉합하였다. 수술후 2 주간단상지석고부목고정을시행하였으며, 이후 2 주간은보조기를착용하면서, 하루에 2 3 회능동적관절운동을시행하였다. 이후점진적으로관절운동을늘려나갔다. 3. 평가방법 방사선학적평가를위해수술전, 수술후, 최종추시상수근관절의전후및측면방사선사진을촬영하여요골길이 (radial length), 요측경사 (radial inclination), 수장측경사 (volar tilt), 요골원위관절면의층형성 (intra-articular step off) 을측정하였으며, 임상적결과는 Knirk 와 Jupiter 8) 의기준으로관절염유무, Modified Mayo wrist scoring system 4), DASH (Disability of Arm, Shoulder, Hand score) 점수 13) 를이용하였다. 통계학적인분석은 SPSS 12. 프로그램의 ANOVA 방법을사용하였으며, p<. 인값을보이는경우에통계학적으로유의한것으로정의하였다. 수술을시행한 11 예모두에서원위요골골절부위의골유합을얻을수있었다 (Fig. 2). 요골길이는 3. mm 잠김압박금속판의경우수술전평균 7.8 mm (4.3 9.3) 에서수술후평균 11.2 mm (9. 14.8) 로향상되었고최종추시상평균 11. mm (9.3 14.3) 이었으며, 2.4 mm 잠김압박금속판의경우수술전평균 8.1 mm (4.6 9.6) 에서수술후평균 11.4 mm (9.6 14.6) 로향상되었고최종추시상평균 11.2 mm (9.2 14.1) 이었다 (p=.377). 요측경사는 3. mm 잠김압박금속판의경우수술전평균 13.4 도 (6.4 2.) 에서수술후평균 22.3 (17.2 3.8) 도로증가하였고최종추시상평균 22.1 도 (16.1 3.2) 이었으며, 2.4 mm 잠김압박금속판의경우수술전평균 13.1 도 (6.1 23.9) 에서수술후평균 22.1 도 (16.2 31.8) 로증가하였고최종추시상평균 22. 도 (1.7 3.6) 이었다 (p=.43). 수장측경사는 3. mm 잠김압박금속판의경우수술전평균 3.8 도 ( 16.1 3.2) 에서수술후평균 9.6 도 (2.3 16.7) 로증가하였고최종추시상평균 9.3 도 (1. 16.3) 이었으며, 2.4 mm 잠김압박금속판의경우수술전평균 2.6 도 ( 14.7.9) 에서수술후평균 8.8 도 (2.1 1.8) 로증가하였고최종추시상평균 8. 도 (1.2 1.3) 이었다 (p=.321). 요골원위관절면의층형성은 3. mm 잠김압박금속판의경우수술전평균 1.4 mm (1.1 3.1) 에서수술후평균.38 mm (.2.8) 로향상되었고최종추시상평균.37 mm (.2.9) 이었고, 2.4 mm 잠김압박금속판의경우수술전평균 1.7 mm (1.1 3.3) 에서수술후평균.32 mm (.1.8) 로향상되었고최종추시상평균.3 mm (.1.9) 이었다 (p=.291) (Table 2). 방사선적평가상 3. mm 잠김압박금속판을사용한군과 2.4 mm 잠김압박금속판을사용한군모두의미있는차이는없었다. Fig. 2. (A) 2 year old female patient presented with distal radius fracture as AO classification C1. (B) radiographs show acceptable reduction with 3. mm LCP distal radius plate. (C) 17 months radiographs show complete bone union.

3. mm 수장측잠김압박금속판과 2.4 mm 수장측잠김압박금속판 19 Table 2. Results according to the radiographic evlauation Radiographic index 3. mm LCP distal radius plate (n=73) 2.4 mm locking distal radius system (n=42) p-value Radial length (mm) Radial inclination ( o ) Volar tilt ( o ) Intra-articular step off (mm) 7.8 (4.3 9.3) 11.2 (9. 14.8) 11. (9.3 14.3) 13.4 (6.4 2.) 22.3 (17.2 3.8) 22.1 (16.1 3.2) 3.8 ( 16.7 7.4) 9.6 (2.3 16.7) 9.3 (1. 16.3) 1.4 (1.1 3.1).38 (.2.8).37 (.2.9) 8.1 (4.6 9.6) 11.4 (9.6 14.6) 11.2 (9.2 14.1) 13.1 (6.1 23.9) 22.1 (16.2 31.8) 22. (1.7 3.6) 2.6 ( 14.7.9) 8.8 (2.1 1.8) 8, (1.2 1.3) 1.7 (1.1 3.3).32 (.1.8).3 (.1.9).377.43.321.291 Table 3. Radiologic evaluation by fracture type treated with 3. mm LCP distal radius plate Radiologic index Postop. p-value Radial length (mm) Radial inclination ( o ) Volar tilt ( o ) Intraarticular step off (mm) A (11.8) B (.) A (22.9) B (21.) A (9.8) B (9.3) A (.3) B (.41) A (11.) B (.1) A (22.6) B (21.1) A (9.6) B (9.) A (.37) B (.44).322.611.213.27 Group A: Fracture type A2,3, B2, C1 (46 cases), Group B: Fracture type C2,3 (27 cases). Table. Arthritic grading system of Knirk and Jupiter and results of this study Grade I II III Finding None Slight joint-space narrowing Marked Joint space narrowing Osteophyte formation Bone-on-bone Osteophyte formation Cyst formation 3. mm LCP distal radius plate (n=73) 64 7 2 2.4 mm locking distal radius system (n=42) 3 6 1 Table 4. Radiologic evaluation by fracture type treated with 2.4 mm locking distal radius system Radiologic index Postop. p-value Radial length (mm) Radial inclination ( o ) Volar tilt ( o ) Intraarticular step off (mm) A (11.6) B (.4) A (22.9) B (21.2) A (8.9) B (8.4) A (.29) B (.34) A (11.4) B (.3) A (22.6) B (21.4) A (8.8) B (8.1) A (.28) B (.31).297.88.233.247 Group A: Fracture type A2,3, B2, C1 (46 cases), Group B: Fracture type C2,3 (27 cases). 골절양상에따서분석한결과 3. mm 잠김압박금속판을사용한군에서관절외골절 (AO type A2, A3) 이나비분쇄성관절내골절 (AO type B2, C1) 46 예와분쇄상골절 (AO type C2, C3) 27 예의통계학적유의성은없었으며 (Table 3), 2.4 mm 잠김압박금속판을사용한군또한관절외골절 (AO type A2, A3) 이나비분쇄성관절내골절 (AO type B2, C1) 26 예와분쇄상골절 (AO type C2, C3) 16 예의통계학적유의성은없었다 (Table 4). 최종추시상관절염발생은 Knirk 와 Jupiter 8) 의기준으로평가하였는데, 3. mm 잠김압박금속판의경우 Grade I 이 7 예, Grade II 가 2 예이었고총 9 예 (12.3%) 에서관절염이발생하였으며, 2.4 mm 잠김압박금속판의경우 Grade I 이 6 예, Grade II 가 1 예로총 7 예 (%) 에서관절염이발생하였다 (Table ). 2.4 mm 잠김압박금속판을사용한

16 하성식, 김태호, 홍기도, 심재천, 김종현 군에서관절염발생이많았으나통계학적유의성은없었다 (p=.17). Modified Mayo wrist scoring system 을이용한임상적평가결과 3. mm 잠김압박금속판의경우평균 86.7 점으로 Excellent 4 예 (4%), Good 28 예 (38%), Fair 예 (8%) 이었고 2.4 mm 잠김압박금속판의경우평균 84.8 점으로 Excellent 21 예 (%), Good 1 예 (3%), Fair 6 예 (1%) 이었으며두군간의통계학적유의성은없었다 (p=.223) (Table 6). DASH (Disability of Arm, Shoulder, Hand score) 점수 13) 는 3. mm 잠김압박금속판과 2.4 mm 잠김압박금속판을사용하여수술한환자는 DASH score 가평균 11.2 점 ( 19),.9 점 ( 17) 으로두군간의통계학적유의성은없었다 (p=.89). 합병증으로는수근동통이 3. mm 잠김압박금속판과 2.4 mm 잠김압박금속판각각 7 예 (9.%) 와 예 (14.2%) 에서발생하였고, 교감신경이영양증은두금속판모두 1 예에서발생하였다. 수근관증후군, 건초염, 건손상등의 합병증은없었다. 고 과거에는요골원위부골절은비수술적방법으로도치료가잘되며예후가좋은골절로인식되어왔지만최근에는적극적인치료를하지않으면합병증이많은골절로인식되고있다 2,7,11,13,21). 치료방법중의하나인금속판고정술은안정된고정을통한수술후조기재활이용이하다는장점이있으며, 최근그사용이증가하고있는추세이다 3,1). 잠김압박금속판은나사못의머리와금속판나사구멍에나삿니 (screw thread) 가존재하여나사못의움직임이없어서외고정장치의경우와같이외력이나사못과금속판사이의서로맞물린부분을통해피질골에서금속판으로전달된다 3). 따라서, 해부학적형태의수장측잠김금속판은최소한의절개로최대한의고정력을얻을수있으며관절면을포함하는골절이면서골다공증이동반된경우일반금속판을이용하여고정하는것보다강한고정을가능 찰 Table 6. Clinical evaluation by Mayo wrist score system Category Score Findings Pain (2 points) Satisfaction (2 points) Range of motion (2 points) Grip strength (2 points) 2 1 2 2 2 1 No pain Mild pain with vigorous activities Pain only with weather changes Moderate pain with vigorous activities Mild pain with activities of daily living Moderate pain with activities of daily living Pain at rest Very satisfied Moderately satisfied No satisfied, but working No satisfied, unable to work % percentage of normal 7 99% percentage of normal 74% percentage of normal 2 49% percentage of normal 24% percentage of normal % percentage of normal 7 99% percentage of normal 74% percentage of normal 2 49% percentage of normal 24% percentage of normal Final result (total points) 9 Excellent 8 89 Good 6 79 Fair <6 Poor Results according to Mayo wrist score system Grade 3. mm LCP distal radius plate (n=73) 2.4 mm locking distal radius system (n=42) Excellent Good Fair Poor 4 (4%) 28 (38%) (8%) 21 (%) 1 (3%) 16 (1%)

3. mm 수장측잠김압박금속판과 2.4 mm 수장측잠김압박금속판 161 Fig. 3. (A) 64 year old male patient presented with distal radius fracture as AO classification C2. (B) radiographs show volar fixation using 2.4 mm locking distal radius system. (C) 12 months radiographs show locking compression screws are involved on the artricular surface. The patient had limitation in range of motion as flexion, extension because of wrist pain. 하게하였고금속판과요골사이의공간을허용하여혈류장애를줄일수있게되었다 6,9,). 현재까지사용되어온수장측잠김압박금속판은잠김나사직경이 3. mm 를사용하였으며불안정분쇄골절에서뛰어난고정력을보여왔다. 하지만 Strohm 등 21) 은 3. mm 잠김나사의직경이골편에비해큰경우내고정에제한이있음을발표하였으며, Pichon 등 17) 은 3. mm 잠김압박금속판과나사자체의크기로연부조직자극이수술후주된합병증으로보고하였다. 저자들의경우 3. mm 잠김압박금속판은단단한고정력을보여금속실패를보인예는없었으나, 원위요골정복후에해부학적구조에맞춰잠김압박금속판을성형하는불편함이있었으며성형하는과정에서나삿니 (screw thread) 가변형되어나사못을고정하는데어려움이있었다. 또한원위부에잠김나사를 3 곳에만고정할수있어골편수가많은분쇄골절의경우관혈적정복을유지하는데어려움이있었다. 이러한환자들은석고부목고정을 2 주한후에도약 1 2 주간더연장하여석고부목을유지하여야만하였다. 그러나해부학적구조에맞게제작된 2.4 mm 잠김압박금속판은원위부에여러개의나사를삽입하여관절내골절에서도견고한고정을얻을수있도록고안되었다. 또한, 보다적은절개를가하여수술이가능한장점이있다. 그러나, Arora 등 1) 은 2.4 mm 잠김압박금속판을이용하여내고정후 31 예 (27%) 에서굴건과신건의파열, 건초염, 교감신경이영양증, 나사풀림등의합병증이발생하였다고보고하였다. 저자들의경우체구가작아서 3. mm 잠김압박금속판으로견고한고정이어려운경우 2.4 mm 잠김압박금속판을사용하여견고한고정을얻을수있었으며굴건과신건의파열, 건초염, 나사풀림등의합병증은보이지않았고교감신경이양증은 1 예에서발생하였다. 본연구에서 3. mm 수장측잠김압박금속판과 2.4 mm 수장측잠김압박금속판을사용하여수술한결과, 방 사선적결과와임상적결과두군간의통계학적유의성은없었다. 수술적치료이후수근관증후군, 건초염, 건손상등의합병증은없었고수근동통이각각 7 예와 예에서, 교감신경이영양증이두군모두 1 예에서발생하였는데, 이는관절내분쇄골절의경우해부학적정복이어려웠고일부나사못의길이선택이잘못된것으로판단된다. 잠김나사못을고정한후영상증폭장치로나사못의길이를확인하였으나일부에서관절면을침범하였고이로인해수근동통이발생한것으로생각된다 (Fig. 3). 이들중 3 예에서는수술후약 1 년후에금속판제거술을시행하였으며수근동통이상당호전되었다. 본연구에서는환자의연령, 골다공증의정도, 환자의순응도를고려하지않은채골절의형태만가지고분류하여비교한한계점이있다. 또한 Modified Mayo wrist scoring system 4) 을사용하여관절운동범위에대한평가를반영하였으나, 수근관절의배굴, 장굴, 요사위, 척사위, 회내전, 회외전각각에대한세밀한평가를하지못한제한점이있다. 각집단간의체계적인분류를통해좀더세분화된비교가필요할것으로생각되며보다많은증례를대상으로장기간의추시관찰이필요할것으로판단된다. 결 원위요골골절환자의치료에서 3. mm 수장부잠김압박금속판과 2.4 mm 잠김압박금속판을이용한내고정술은방사선학적, 임상적으로만족할만한결과를보였다. 론 참고문헌 1) Arora R, Lutz M, Hennerbichler A, Krappinger D, Espen D, Gabl M: Complications following internal fixation of unstable distal radius fracture with a palmar lock-

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