Archives of Hand and Microsurgery Arch Hand Microsurg 2019;24(1):63-67. https://doi.org/10.12790/ahm.2019.24.1.63 pissn 2586-3290 eissn 2586-3533 Case Report 리듬게이머에서발생한자발적장무지신전건파열 : 증례보고 양석원ㆍ윤성현ㆍ김성현ㆍ권순민ㆍ김종필 단국대학교의과대학정형외과학교실 Spontaneous Rupture of the Extensor Pollicis Longus Tendon in a Rhythm Gamer: A Case Report Seokwon Yang, Sung-Hyun Yoon, Sung-Hyun Kim, Soon-Min Kwon, Jong-Pil Kim Department of Orthopedic Surgery, Dankook University College of Medicine, Cheonan, Korea Spontaneous rupture of the extensor pollicis longus (EPL) tendon can occur in the 3rd extensor compartment after a distal radius fracture involving Lister s tubercle, steroid injections, or rheumatoid arthritis. We report a case of spontaneous rupture of the EPL tendon in a 26-year-old male patient who played a rhythm game, which requires repetitive wrist motions to play the drums. We also provide a comprehensive literature review along with the case report. From the authors point of view, excessive and repetitive motion of the wrist, as shown in our case, can be a potential cause of spontaneous rupture of the EPL tendon. Key Words: Extensor pollicis longus, Spontaneous rupture, Tendon graft 장무지신전건 (extensor pollicis longus, EPL) 의자연파열은흔하게발생하지는않지만, 원인으로는주로요골원위부의리스터결절 (Lister s tubercle) 에골절발생이후, 손목관절의활액막염 (synovitis), 건막염 (tenosynovitis), 류마티스관절염등으로알려져있다 1. 그외매우드문원인으로는손목신전건에스테로이드주사, 요골원위부또는주상골골절이후발생한골극, 주상골의불유합등이보고되고있다 2. 본저자들은양측손목스냅을이용하여드럼을연주하는리듬게임 기타도라 (GITADORA) (Fig. 1) 를취미로하던환자에게서발생한자발성장무지신전건파열 1예를경험하였으나기존문헌에는보고된바없었으며리듬게임과같은과도하고반복적인손목관절운동으로도장무지신전건 이자연파열될수있음을본증례를통해보고하고자한다. 증례 26세남자환자로본원에내원 2주전에오락실에서리듬게임을즐기던중갑자기발생한좌측손목통증과좌측무지지간관절의신전소실로인근병원에서약물치료, 손목보조기등의보존적치료를시행받았으나증상이호전되지않아본원에내원하였다. Steroid injection, 손의외상등특이할만한과거력은없었다. 환자는본원내원한달전부터 기타도라 (GITADORA) 라고하는리듬게임을 1주에 10-20회씩취미로즐겨했다고하며, 직업은사무직직원이었다. 우측우세수였으며특이기저질환은없었다. 이 Received December 14, 2018, Revised [1] January 2, 2019, [2] January 4, 2019, Accepted January 7, 2019 Corresponding author: Jong-Pil Kim Department of Orthopedic Surgery, Dankook University College of Medicine, 119 Dandae-ro, Dongnam-gu, Cheonan 31116, Korea TEL: +82-41-550-6579, FAX: +82-41-556-0551, E-mail: kimjp@dankook.ac.kr Copyright c 2019 by Korean Society for Surgery of the Hand, Korean Society for Microsurgery, and Korean Society for Surgery of the Peripheral Nerve. All Rights reserved. 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. 63
Archives of Hand and Microsurgery Vol. 24, No. 1, March 2019 학적검사상좌측무지의지간관절의굴곡은가능하였으나신전은불가능하였고, 무지의신전시손목후방부위에서장무지신전건은촉지되지않았다. 단순방사선검사및혈액검사소견상이상소견은없었으며 (Fig. 2), 촬영한자기공명영상 (magnetic resonance imaging) 에서후방손목관절부위에서장무지신전건의파열이관찰되었다 (Fig. 3). 상완신경총마취하에수술이시행되었고수술소견상장무지건이제 2 신전건구획 (The 2nd extensor compartment) 과교차하는부위에서완전파열되어건의근위단과원위단이각각이교차부위의근위부와원위부로후퇴되어있었고제 2 신전건구획을이루는단요수근신건의표면에부분적인열상이관찰되었다. 이는장무지신전건과제 2 신전구획내의신전건들사이의마찰로인하여장무지신전건이파열되었을것으로생각되었다 (Fig. 4A). 장무지신전건의근위부및원위부파열부위를변연절제술을시행하고동측장장근건 (palmaris longus tendon) 을채취한후파열부위사이에건이식술 (tendon graft) 시행하여장무지신전건재건술 (EPL tendon reconstruction) 을시행하였다 (Fig. 4B). 수술후손목관절신전및무지신전, 외전된상태로단완부목을 2주간적용하였고이후무지보호대 (thumb brace) 를 4주간적용하고무지관절운동을시작하였다. 수술후 12주째외래에서시행한이학적검사상무지의능동적신전가능하였고신전시장무지신전건이촉지되었다. 고찰 류마티스관절염, 스테로이드주사, 건막염, 활액막염, 요골원위부골절은장무지신전건의자연파열의흔한원인으로알려져있다 1-3. 그러나이러한병변없이손목관절의반복적인운동으로인해장무지신전건이자연파열되는것은매우드문것으로보고되고있다 4. 본증례는다른위험인자없이단기간의리듬게임으로도자발성장무지신전건의파열이발생할수있음을보여준매우드문경우라할 Fig. 1. A rhythm game which is called as GITADORA. Fig. 2. Simple radiographs of the left thumb in a 26-year-old male patient. He couldn t make extension of his left thumb. A B Fig. 3. Axial T2 magnetic resonance imaging images. (A) Note absence of the tendon in 3rd extensor compartment around wrist joint (arrow). (B) Note synovial fluid collection in 2nd extensor compartment tendon sheath (arrowheads). 64 www.handmicro.org
Seokwon Yang, et al. EPL Rupture in Gamer ECRB ECRL * * EPL A B Fig. 4. Intra-operative findings. (A) Note attrition at the ECRB (arrow) and a EPL rupture (asterisks). (B) A EPL tendon reconstruction using palmaris longus tendon graft was performed. ECRB: extensor carpi radialis brevis, ECRL: ex tensor carpi radialis longus, EPL: extensor pollicis longus. 수있다. 일반적으로자발성장무지신전건의파열의원인은기계적인원인 (mechanical factor) 과혈관성원인 (vascular factor) 의 2가지이론으로설명된다 1,3. 기계적이론 (mechanical theory) 에따르면리스터결절의척측으로주행하는장무지신전건의해부학적배치로인해요골원위부골절시장무지신전건이마모될수있고, 이런기계적인원인으로파열이일어날수있다 1. 혈관성원인설은리스터결절위치에서건초내증가된압력으로장무지신전건의허혈성변화를야기하고이로인해지연성파열 (delayed rupture) 을일으킬수있다는이론이다 3. 본저자들의증례의경우환자는특이위험인자가없는건강한젊은남자환자였다. 환자는직업적활동과관계없는과도하고반복적인리듬게임으로인해손목관절의반복적인신전-굴곡운동이발생했고, 이로인해장무지신전건의기계적인마찰, 특히제 2 신전건구획과제 3 신전건구획사이의마찰을일으켰을것이라생각된다. 환자가장무지신전건의자연파열이발생했을경우외상이나골절, 관절염등이없다면반복적인손목관절운동으로인해장무지신전건의기계적인마찰을병인으로써고려할수있다고판단된다. 리스터결절주위로의기계적인마찰뿐아니라제 2 신전건구획과제 3 신전건구획사이에서도마찰이발생할수있으며이것이장무지신전건의자연파열을일으킬수있다고생각된다. 본증례와비슷하게보고된자연파열예로서는 Zvijac 등 5 이나이와다른위험인자와관계없이리스터결절주위에서마모되어장무지신전건의자연파열을보고한바있 www.handmicro.org 고, Lloyd 등 6 은킥복싱선수 (kickboxer) 에서발생한장무지신전건의자연파열을보고하였는데, 저자들은직업적활동 (occupational activity) 이위험인자로작용하여손목관절의과도하고반복적인운동에의해자연파열된것이라고하였다. Ghee 등 7 은단요측수근신근건봉합후발생한장무지신전건의마찰성파열 (attrition rupture) 을보고하였으나본증례처럼다른기저원인없이손목의반복운동으로인한자연파열은매우드문것으로생각된다. 장무지신전건파열의수술적치료로써단단봉합술, 건이전술, 건이식술등이흔히사용되고있다. 급성외상성파열에서는일차적으로단단봉합술을시행할수있지만, 대부분의자연파열은원인이허혈에의한것이기때문에건이전술또는건이식술로재건술을시행할수있다고알려져있다 8. 건이전술은주로시지고유신전건을이용하는데이는장무지신전건의작용하는방향과가동력 (excursion) 이유사하기때문이다. 그러나이술식은인지의근력약화나신전제한을남길수있어독립적인시지의운동이필요한직업에서는권고되지않는다 9. 건이식술은대부분장장근건을이용하여시행하게되며, 시지의기능저하없이장무지신전건의기능을회복할수있는장점이있지만파열기간이경과되어근섬유화가진행되고건의활주 (gliding) 가잘이뤄지지않을경우에는시행하기어려울수있다 10. 본증례에서는내원 2주전에발생한것으로단단봉합술이불가능하였지만파열의기간이길지않고사무직으로컴퓨터사용을많이하는환자에게시지의기능을보존하기위하여장장근건을이용한건이식술을시행하였다. 65
Archives of Hand and Microsurgery Vol. 24, No. 1, March 2019 본증례는특이위험인자가없는젊고건강한환자에서직업적활동과관계없이과도하고반복적인리듬게임으로장무지신전건이제 2 신전건구획과제 3 신전건구획사이의마찰로인하여자연파열된것으로판단되는바본증례와같이자연적인건파열환자의경우에서는원인을분석하기위해서는환자의직업뿐아니라취미활동등기계적원인을일으킬수있는위험인자에대한신중한병력청취가이루어져야할것이다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Björkman A, Jörgsholm P. Rupture of the extensor pollicis longus tendon: a study of aetiological factors. Scand J Plast Reconstr Surg Hand Surg. 2004;38:32-5. 2. Harvey FJ, Harvey PM. Three rare causes of extensor tendon rupture. J Hand Surg Am. 1989;14:957-62. 3. Engkvist O, Lundborg G. Rupture of the extensor pollicis longus tendon after fracture of the lower end of the radius--a clinical and microangiographic study. Hand. 1979;11:76-86. 4. Choi JC, Kim WS, Na HY, et al. Spontaneous rupture of the extensor pollicis longus tendon in a tailor. Clin Orthop Surg. 2011;3:167-9. 5. Zvijac JE, Janecki CJ, Supple KM. Non-traumatic spontaneous rupture of the extensor pollicis longus tendon. Orthopedics. 1993;16:1347-50. 6. Lloyd TW, Tyler MP, Roberts AH. Spontaneous rupture of extensor pollicis longus tendon in a kick boxer. Br J Sports Med. 1998;32:178-9. 7. Ghee CK, Sebastin SJ, Kin-Sze Alphonsus C. Attrition rupture of the extensor pollicis longus tendon following Becker repair of extensor carpi radialis brevis tendon. J Plast Reconstr Aesthet Surg. 2009;62:e592-3. 8. Strauch RJ. Extensor tendon injury. In: Green DP, Hotchkiss RN, Pederson WC, editors. Green s Operative Hand Surgery. 7th ed. Philadelphia, PA: Elsevier; 2017. 179. 9. Tubiana R. Lesions of the extensors of the thumb. In: Tubiana R, editor. The Hand, Vol. III. Philadelphia, PA: WB Saunders; 1988. 155-6. 10. Magnell TD, Pochron MD, Condit DP. The intercalated tendon graft for treatment of extensor pollicis longus tendon rupture. J Hand Surg Am. 1988;13:105-9. 66 www.handmicro.org
Seokwon Yang, et al. EPL Rupture in Gamer 리듬게이머에서발생한자발적장무지신전건파열 : 증례보고 양석원ㆍ윤성현ㆍ김성현ㆍ권순민ㆍ김종필 단국대학교의과대학정형외과학교실 장무지신전건의자연파열은주로요골원위부의리스터결절 (Lister s tubercle) 부위에발생한골절, 스테로이드주사, 그리고류마티스관절염과같은염증성병변에의해서제 3 신전구획에서주로발생할수있다. 저자들은반복적으로손목관절의운동을이용하여드럼연주를하는리듬게임후발생한장무지신전건의자연파열 1예를경험하였고, 본증례와같이반복적이고과도한손목관절의운동에의해서도장무지신전건이파열될수있음을문헌고찰과함께보고하고자한다. 색인단어 : 장무지신전건, 건파열, 건이식술 접수일 2018 년 12 월 14 일수정일 1 차 : 2019 년 1 월 2 일, 2 차 : 2019 년 1 월 4 일게재확정일 2019 년 1 월 7 일교신저자김종필 31116, 천안시동남구단대로 119, 단국대학교의과대학정형외과학교실 TEL 041-550-6579 FAX 041-556-0551 E-mail kimjp@dankook.ac.kr www.handmicro.org 67