Case Report J Korean Orthop Assoc 2011; 46: 426-430 http://dx.doi.org/10.4055/jkoa.2011.46.5.426 www.jkoa.org Open Reduction of a Dislocation of the Interphalangeal Joint of the Great Toe Neglected for 6 Weeks 김재광 김락규이화여자대학교의학전문대학원정형외과학교실 족무지지간관절의탈구는소수의증례만이보고되어있다. 특히간과된족무지지간관절의탈구는관절유합술로치료한 1예를포함하여더욱드물게보고되어있다. 저자들은본증례를통하여, 6주간간과된족무지지간관절의탈구에서족무지의배측을절개하여, 감입된종자골을족장판쪽으로밀어넣어성공적으로정복을얻을수있었고, 4년째의추시에서도만족할만한결과를보여보고하는바이다. 색인단어 : 족무지, 지간관절, 간과된탈구, 관혈적정복 족무지지간관절은경첩관절로써여러가지구조물들에의해안정적인관절을이루고있다. 정적인안정장치로는측부인대가있고, 동적인안정장치로는장족지신근과장족지굴근이있다. 관절낭은그자체가측부인대의연장선에있으며, 두꺼운섬유연골성족장판과함께족무지지간관절을둘러싸고있다. 1) 족무지지간관절의탈구는지간관절의축부하및과신전에의해발생하며도수정복이불가능한경우는드물다. 그런데지간관절의과신전이과도하게되어족장판이근위지골및원위지골의부착부에서파열되면서배측부에관절면을가지고있는종자골이배측으로전위되어탈구된지간관절부사이에감입되면서정복을방해하는구조물로작용할수있다. 종자골은대부분건으로싸여져있는구조물로서관절면과밀접한관계를이루고슬개골이나무지에서볼수있듯이관절면의한부분을형성하기도한다. 족무지지간관절종자골의크기는 0.05-1.0 cm까지다양하며배측에는연골로구성되어있고근위지골의두부와관절을이루고있다. 족저면은골성조직으로구성되며족무지의지간관절낭에확고히부착되어있어서특이하게관절내및관절외면을동시에가지고있다. 종자골은족무지에여러임상적문제를발생시키는데통증을유발하는과각질성족저병변과도수정복이불 접수일 2010 년 11 월 9 일게재확정일 2011 년 2 월 8 일교신저자김재광서울시양천구목 6 동 911-1, 이대목동병원정형외과 TEL 02-2650-2591, FAX 02-2642-0349 E-mail kimjk@ewha.ac.kr 가능한지간관절의탈구등이대표적질환이다. 2) 후자의경우대부분관혈적정복술이필요한데, 문헌에서도약 40예만이보고되어있다. 3) 특히간과된족무지지간관절의탈구에대한보고는더욱드물다. 이에저자들은 6주간과된족무지지간관절의탈구 1예에대하여지간관절의관혈적정복술로좋은결과를얻었기에증례보고하고자한다. 증례보고 57세남자환자로보행중넘어지며, 우측족무지지간관절의과신전외력작용후, 우측족무지의통증과부종이발생하였다. 상기주소로개인병원방문하였으나, 지간관절의이상소견발견하지못하고지내던중, 사고발생후 6주가지나도록증상의호전없어본원에내원하였다. 이학적검사상우측족무지지간관절부위의부종과배굴변형이관찰되었고, 압통을호소하였다 (Fig. 1). 또한지간관절의수동및능동운동은불가능하였으나, 족무지지간관절의신경학적이상소견, 혈류순환장애는없었다. 족부의전후방, 사면위, 측면단순방사선적검사상, 족무지의원위지골이족배부로탈구된소견보이고, 종자골또한족무지지간관절의족배부로탈구되어있는소견관찰되어 Miki 등 4) 의분류제2형의간과된족무지지간관절의탈구로진단하였다 (Fig. 2). 전신마취하에환자를앙와위로눕힌후, 족무지지간관절의배면을절개한후, 장무지신근을내측으로견인하고, 관절낭을절개하여, 지간관절내에종자골이감입되어있는것을확 대한정형외과학회지 : 제 46권제 5호 2011 Copyright 2011 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
427 Figure 1. Preoperative photograph shows dorsiflexed position of the great toe (cock-up toe). Figure 3. Intraoperative photograph shows incarcerated sesamoid of the interphalangeal joint of the great toe. Figure 4. Immediate postoperative radiographs show reduced interphalangeal joint of the great toe. Figure 2. Preoperative radiographs show dislocation of interphalangeal joint of the great toe and entrapped sesamoid bone in the interphalangeal joint. 인할수있었다 (Fig. 3). 감입된종자골확인후, 골막분리기로종자골과이에닿아있는족장판을족저부로밀어정복을시도하였다. C형영상증폭장치로정복을확인한후, K 강선을이용해고정하고, 절개한배측관절낭을봉합한후단하지석고부목을유지하였다 (Fig. 4). 수술후 2주째에단하지석고부목을제거하고, 체중부하보행을시작하였고, 4주째에 K 강선을제거하였다 (Fig. 5). K 강선제거후관절운동범위를위한운동치료를시작하였고, 수술후 4년째추시상족무지지간관절의운동범위는정상범위가되었고, 재탈구는관찰되지않았다 (Fig. 6). Figure 5. Radiographs taken right after removing a k-wire, at the 4th week of postoperative period.
428 김재광 김락규 Figure 6. Radiographs taken at 4 years after surgery show maintained reduction state of the interphalangeal joint of the great toe. 고찰 Miki 등 4) 은족무지지간관절의탈구에대해두가지유형으로분류하였다. 제1형은족장판과종자골이지간관절내로감입되어관절의간격이넓어지는유형이며, 원위지골이배측으로과신전되지않는다. 제2형은족장판과종자골이배측으로전위되어, 원위지골의배측으로변형이일어나는유형이다. 그러나 Miki 등 4) 은이두가지유형모두도수정복이되지않아관혈적정복술이필요하다고하였다. 족무지지간관절탈구의관혈적정복에는여러가지접근법이있고, 종자골을절제하여정복하는방법과, 종자골을절제하지않고정복하는방법이있다. Eibel, 5) Ha 등 6) 은외측절개술을이용하여, 종자골을절제하였다. 그러나관절면의한부분을형성하는종자골을절제하는방법은지간관절의불안정성을초래할수있다. 실제로 Ha 등 6) 은종자골을족저부착부에서절개한후관절이불안정하다고보고하였다. 이는종자골의절제시종자골과함께배측으로전위되어있는족장판의손상을초래할수있기때문이다. 7) Yasuda 등 7) 은족저부에지그재그절개를가하여종자골과족장판을정복하는방법을사용하였다. 이는손상된족장판을복원하는데는추천할만한방법이나, 수술후반흔이족저부에남게되어체중부하보행시통증을유발할수있다는단점이있다. Berger 등 8) 은배측절개술을사용하여, 원위지골을축견인후, 종자골을족저부로밀어넣어, 정복후관절낭을복원해주는방법을사용하였다. 이방법은지간관절의불안정성을초래하지도않고, 반흔이족배부에남아체중부하보행시통증을유발하지도않는다. 그러나파열된족장판을정확히정복할수없고봉합도어렵고더구나지연된경우라면수축이되어있을수있어정복후관절간격이벌어진상태로남기쉬운단점이있다. 또한최 근에보고된증례에서 Woon 9) 은 K 강선을이용하여, 경피적으로종자골을족저부로밀어넣어정복을얻는방법을사용하기도하였다. 그러나 Woon 9) 의증례에서는 K 강선을이용한지간관절의 4주간고정후지간관절의강직이발생하였다. 한편간과된족무지지간관절탈구의경우, Hatori 등 10) 은 4년간간과된족무지지간관절의탈구에대해원위지골의하부와근위지골의상부를절제한후나사못을이용한족무지지간관절유합술을시행하였다. Hatori 등 10) 은관절유합술을치료방법으로선택한이유에대하여, 수술후통증을줄일수있고, 재탈구를방지할수있다는점을들었다. 그러나이러한방법은족무지지간관절의운동범위를회복하지못하고, 족무지의길이가짧아지는단점이있다. 본저자들의증례는이와는달리 6주간간과된족무지지간관절탈구로써진단이간과된시간이그리오래되지않았으므로, 지간관절의배측절개술을통한관혈적정복후, K 강선을이용하여지간관절을고정하는방법을사용하였다. 본증례의경우배측절개술로감입된종자골에쉽게접근할수있었고, 파열된족장판의만족할만한정복을얻을수있었으며, 배측관절낭의복원술도시행할수있었다. 비록수술후촬영한단순방사선적검사상 (Fig. 4) 관절간격이증가된소견이관찰되나 K 강선제거직후 (Fig. 5) 관절간격은수술후와비교하여감소하였고, 관절운동시재탈구는일어나지않았다. 또한수술후 4년째추시결과, 통증은경미하였고, 재탈구는일어나지않았으며, 족무지지간관절의운동범위는정상범위가되었다. 이처럼좋은결과를얻어문헌고찰과함께보고하는바이며, 추후보다많은증례를통해족무지지간관절탈구의치료에대한연구가이루어져야할것으로생각된다. 참고문헌 1. Sorene ED, Regev G. Complex dislocation with double sesamoid entrapment of the interphalangeal joint of the hallux. J Foot Ankle Surg. 2006;45:413-6. 2. Roukis TS, Hurless JS. The hallucal interphalangeal sesamoid. J Foot Ankle Surg. 1996;35:303-8. 3. Chung DW, Jeong BO. Irreducible dislocation of the interphalangeal joint of the great toe with lateral collateral ligament entrapment: a case report. J Korean Fract Soc. 2009;22:110-3. 4. Miki T, Yamamuro T, Kitai T. An irreducible dislocation of the great toe. Report of two cases and review of the literature. Clin Orthop Relat Res. 1988;230:200-6. 5. Eibel P. Dislocation of the interphalangeal joint of the big toe with interposition of a sesamoid bone. J Bone Joint Surg Am. 1954;36:880-2. 6. Ha KI, Hahn SH, Chung MY, Moon B, Yoo HN. Dislocations
429 of the interphalangeal joint of the great tow with interposition of a seamoid bone - a report of two cases - J Korean Orthop Assoc. 1987;22:815-8. 7. Yasuda T, Fujio K, Tamura K. Irreducible dorsal dislocation of the interphalangeal joint of the great toe: report of two cases. Foot Ankle. 1990;10:331-6. 8. Berger JL, LeGeyt MT, Ghobadi R. Incarcerated subhallucal sesamoid of the great toe: irreducible dislocation of the interphalangeal joint of the great toe by an accessory sesamoid bone. Am J Orthop (Belle Mead NJ). 1997;26:226-8. 9. Woon CY. Dislocation of the interphalangeal joint of the great toe: is percutaneous reduction of an incarcerated sesamoid an option?: A report of two cases. J Bone Joint Surg Am. 2010;92:1257-60. 10. Hatori M, Goto M, Tanaka K, Smith RA, Kokubun S. Neglected irreducible dislocation of the interphalangeal joint of the great toe: a case report. J Foot Ankle Surg. 2006;45:271-4.
430 김재광 김락규 Open Reduction of a Dislocation of the Interphalangeal Joint of the Great Toe Neglected for 6 Weeks Jae Kwang Kim, M.D., and Rag-Gyu Kim, M.D. Department of Orthopedic Surgery, School of Medicine, Ewha Womans University, Seoul, Korea Dislocation of the interphalangeal joint of the great toe is a condition which is reported rarely. Especially, it is extremely rarely reported as for the case of neglected dislocation. Here, we report one case of neglected dislocation for 6 weeks of the interphalangeal joint of the great toe. Reduction followed by a push of the incarcerated sesamoid bone based on dorsal approach, was done successfully, and we found satisfactory results after a 4 years of follow-up. Key words: great toe, interphalangeal joint, neglected dislocation, open reduction Received November 9, 2010 Accepted February 8, 2011 Correspondence to: Jae Kwang Kim, M.D. Department of Orthopedic Surgery, Ewha Womans Mokdong Hospital, 911-1, Mok 6-dong, Yangcheon-gu, Seoul 158-710, Korea TEL: +82-2-2650-2591 FAX: +82-2-2642-0349 E-mail: kimjk@ewha.ac.kr