2015 한국의지 보조기학회춘계학술대회 The Management of Crushing Injury In Extremities 부산대학교병원정형외과 이상현 1. Introduction 1) Crushing Injury의사전적인의미 : Crushing이란사전적으로 으스러뜨리다, 짓눌러뭉개다, 찧다 라는의미를가진다. 2) 일반적으로 Crushing Injury가심한 Mangled upper extremities의치료방법에는크게 amputation과 salvage reconstruction 두가지가있다. 이에대한결정은수술의가결정하지만객관적인평가지표로 Mangled Extremity Severity Score (MESS) 가있다. 3) Mangled Extremity Severity Score (MESS) 의의미 1 : MESS는 Simple rating scale for lower extremity trauma로서 Johansen에의해 1990년에처음기술되었고다음과같은네가지항목을각각평가하여각항목의점수를합산하는방식이다. (1) Skeletal / Soft-Tissue Damage (2) Limb Ischemia (3) Shock (4) Age. 4) Mangled Extremity Severity Score (MESS) 의평가결과 1 : MESS Score가 7을초과한경우는 poor limb viability prognosis를보인다. 9
2015 한국의지 보조기학회춘계학술대회 < 표 > 5) 새로운 fixation devices의발달과 modern microsurgical techniques으로인해다양한 type의 bony and soft tissue reconstruction 이가능해졌으며임상적, 기능적으로대부분좋은결과를보이고있다. 6) Early or even immediate (emergency) 로시행된 upper extremity reconstruction은 delayed or late reconstruction 보다좋은결과를보이며이러한조속한수술적처치는가능한한 treatment of choice가되어야한다. 7) life before limb 라는말처럼고에너지손상은대부분생명을위협하는다른손상과동반된경우가많기때문에어떠한 reconstruction이라도수술을시행하기전에다른 organ의손상이배제되어야한다. 2. Discussion 1) 사지의압궤손상에서치료대상은 Bone, Arteries, Nerves, Muscle, Skin 을대상으로한다. 10
이상현 :The Management of Crushing Injury In Extremities < 그림 > 2) Injury의 mechanism은주로외상의형태와해부학적위치에의해기술된다. 2 Distal, sharp (clean) injury는 proximal traction, torsional, and crush injury보다좋은예후를가진다. 3) 관련된 machinery에대한충분한이해를해야하고또한손상의 pattern을표현할수있어야한다. 3 : (e.g. avulsion, crush, degloving, incising injuries). Chemical and thermal injuries는더광범위한조직손상을야기할수있으며일반적으로예후가안좋은것으로알려져있다. 4) 손상을입은장소에대한정보가술전에충분히확인이되어야한다. 4 예를들면농장같은장소는 contamination 위험도가높고, 산업현장은 chemical damage, burns, and high pressure injection injures의가능성이높기때문에손상의원인을충분히파악하면수술에큰도움이된다. 5) 손상받은사지에대하여다음과같은부분에대해 careful clinical examination이시행되어야한다. 5 (1) Limb Vascularity, (2) Skeletal Stability, (3) Motor and Sensory Deficit, (4) Soft Tissue and Skin Loss 6) 현대하지보조기는환자들이잘적응하는반면에상지보조기는환자중 30% 는심지어 prostheses 사용을중단하기도한다. 6 그러므로상지손상에서더욱더적극적인치료가필요한다. 3. Treatment : Each Step in the Assessment 9 1) Radical Tissue Debridement, Prophylactic Antibiotics, Copious Irrigation with a Lavage system 11
2015 한국의지 보조기학회춘계학술대회 2) Stable Bone Fixation 3) Revascularization 4) Tendon Repairs 5) Musculotendinous Reconstructions 6) Nerve Repair 7) Soft Tissue Coverage 8) Well-Planned and Early Rehabilitation 1) Radical Tissue Debridement 6 (1) Copious irrigation과 preferably with a jet or pulsed lavage을이용하는것이유리하다. 이는 foreign material의제거에도움이되고 healthy tissues로부터 devitalized되는것을자유롭게한다. 이때 iatrogenic injury이발생하지않도록하는것이매우중요하다. 2) Stable Bone Fixation 3 (1) 골절을안정화시키는것인데 skeletal stability는 all the other tissue reconstructions 의초기시술로매우중요하다. External fixation은심각한개방골절등에서 method of choice가된다. (2) Stable Bone Fixation의일반적인방법은다음과같다. 3 1 Rigid Internal Fixation을목표로하며 a. Plate, Nail은다음경우에주로사용한다. : long bone fracture of the humerus, radius, ulna b. K-wire Fixation은다음경우에주로사용한다. : Phalangeal, Metacarpal(tarsal), Carpal (Tarsal) Bone (3) Stable Bone Fixation시 Larger Bone Defects가발생할때치료기준은다음과같다. 9 a. - > 4cm: primary bone grafting from the iliac crest b. - > 6cm: vascularized fibula grafts. : long bone fracture of the Humerus, Radius, Ulna (4) Intra-articular fracture에서는가능한 anatomically reduced, stabilized 되어야하는데치료의목적은 capsule and ligaments가회복되는동안조기관절운동을가능케하는것이다. 10 그러므로관절부위손상의치료에서는 well vascularized soft-tissue로덮여야한다. (5) Mangled Extremity의치료에서는 Bone shortening procedure을많이사용하는데이는손상된혈관과신경의 direct primary end-to-end anastomoses grafting을가능하게한다. 11.12 3) Revascularization (1) Vascular reconstruction은골절이안정화되고난후에시행한다. (2) Multiple level injury의경우보통 more proximal vascular injury부터 distally 순서로 repair를시행한다. (3) tension없이혈관봉합을원칙으로한다. 12
이상현 :The Management of Crushing Injury In Extremities (4) Vein grafts는 vessel viability에대한우려와 tissue tension이있을때사용된다. (5) Vein graft에서 Reversed saphenous vein grafts가널리사용되며 Smaller diameter vein grafts는 dorsum of the hand의 superficial forearm veins가사용되기도한다. 13 4) Nerve Repair (1) Nerves 가능한보존되어야하고가능한신경주위조직이 vascularized tissue에서신경봉합이이루어져한다. 14 (2) Nerve 손상에서는가능한손상후바로 repair되어야하며, secondary reconstruction 때에는 scar tissue formation과같은 technical problem가발생하기도한다. (3) 술후기능적인결과는섬세한 surgical repair에의해좌우된다. 이외에도 Level of the injury level(the more proximal the more unpredictable) 과 tissue damage 정도에의해서도술후결과가영향을받는다. 15 (4) Epineural microsurgical suture는흔히행해지며, gap이큰경우는 microsurgical interfascicular nerve grafting 이사용된다. 16 5) Tendon Repair (1) Early primary tendon restoration이선호되며, early protected motion / dynamic immobilization은 tendon function 을보존하고 scar tissue adhesions을막는데중요하다. 17,18 (2) Flexor tendon은가능한 directly하게 repair되어야한다. (3) Tendon transfers and transpositions at a later stage (4) Silicone tendon rods is considered : prevention of scar tissue 6) Musculotendinous Reconstructions 19 (1) 심한근육손상은 free microsurgical functional muscle transfer를필요로하며, 이때 Gracilis와 Latissumus Dorsi muscle transfer가자주이용된다. 7) Soft Tissue Coverage (1) Severe open fractures는 open된상태로두어야하지만 early coverage of soft-tissue defects에대한개념은갈수록널리인정받고있다. 가능한일찍 well-vascularized tissue(preferably muscle flaps) 로양호한 wound coverage 를시행해주는것은중요하다. (2) 이러한 muscle flaps은 bones, joints, tendons, vessels, and nerves를 cover하고보호하여손상부위에 vascularity, oxygenation, biological agents, immune elements and antibiotics를가능케한다. 8) Postoperative Rehabilitation 수술이후 reconstructed limb은또한 tendon gliding을촉진하고 joint contracture와 tissue edema를예방하기위해 early motion을시행해야한다. Rehabilitation는각각의다른단계로나누어진다. 13
2015 한국의지 보조기학회춘계학술대회 (1) Early-protective (2) Immediate-mobilization (3) Late-strengthening (4) Consists of static and dynamic bracing (5) Physical therapy and occupational therapy 4. Complication (1) 가장흔하고심한합병증은 deep infection, osteomyelitis, loss of tissue flaps, reflex sympathetic dystrophy, and vein graft thrombosis 등이있다. (2) Secondary procedure는 simple adhesiolysis, tenolysis, capsulotomies, Z-lengthening of contracted scars, local flaps, nerve grafting, and tendon transfers를포함한다. (3) Postoperative Rehabilitation에꼭확인해야하는것으로 catastrophic injury에서 post-traumatic stress disorder (PTSD) 와 depression에대한 support는흔히뒤따르게된다. 20 5. Conclusion (1) Accurate understanding of the patient's preoperative status (2) Appropriate emergency treatment (3) Good operative skill and op team cooperation (4) Appropriate postoperative care (5) Cooperation between the patient and surgeon (6) Rehabilitation therapist all help to achieve a better final functional outcome 6. Reference 1. JOHANSEN KAJ, DAINES M, HOWEY T, HELFET D, HANSEN S. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma 1990;30:568-572. 2. BROWN JB, CANNON B, GRAHAM W, DAVIS WB. Restoration of major defects of the arm by combination of plastic, orthopedic and neurologic surgical procedures. Plast Reconstr Surg 1949;4:337 340. 3. Gupta A, Shatford RA, Wolff TW, Tsai TM, Scheker LR, Levin LS. Treatment of the severly injured upper extremity. Instr Course Lect 2000;49:377 396. 4. Ring D, Jupiter JB. Mangling upper limb injuries in industry. Injury 1999;30:B5 13 5. Seal A, Stevanovic M. Free functional muscle transfer for the upper extremity. Clin Plast Surg 2011;38:561 575. 6. Neumeister MW, Brown RE. Mutilating hand injuries: principles and management. Hand Clin 2003;19:1 15. 7. Tintle SM1, Baechler MF, Nanos GP 3rd, Forsberg JA, Potter BK. Traumatic and trauma-related amputations: part II:upper extremity and future directions. J Bone Joint Surg Am 2010;92:2934 2945. 8.Korompilias AV, Beris AE, Lykissas MG, Vekris MD, Kontogeorgakos VA, Soucacos PN. The mangled extremity and attempt for limb salvage. J Orthop Surg Res 2009;4:4-13. 9. Bumbasirevic M, Stevanovic M, Lesic A, Atkinson HD. Current management of the mangled upper extremity. Int Orthop 2012;36:2189-2195. 10. Godina M. Early microvascular reconstruction of complex trauma of extremities. Plast Reconstrct Surg 1986;78:285 292. 14
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