ISSN 1225-1682 (Print) ISSN 2287-9293 (Online) 대한골절학회지제 28 권, 제 3 호, 2015 년 7 월 J Korean Fract Soc 2015;28(3):169-177 http://dx.doi.org/10.12671/jkfs.2015.28.3.169 Original Article 성인주관절복합손상에서추가적인경첩성외고정술 이동주 홍택호 김낙철 인하대학교의과대학정형외과학교실 Additional Hinged External Fixation in Complex Elbow Injury Tong-Joo Lee, M.D., Ph.D., Taek Ho Hong, M.D., Nak Chul Kim, M.D. Department of Orthopedic Surgery, Inha University School of Medicine, Incheon, Korea Purpose: The purpose of this study was to evaluate the use of hinged external fixation in management of complex elbow injury. Materials and Methods: We retrospectively reviewed clinical outcomes in 10 patients with elbow dislocation and associated fractures of both the radial head and the coronoid process from January 2007 to December 2013. All ten patients were treated by hinged external fixation after open reduction and internal fixation. The indication for use of a hinged external fixator was persistent instability after fixation of the fractures. Early mobilization was started at 1 week (6.5 days) after surgery. The external fixator was removed at 6 weeks after surgery. Cassebaum classification and Mayo elbow performance score were used for clinical and functional evaluation. The follow-up period was at least 1 year. Results: At the last follow-up, the average further flexion was 127 o, and the average flexion contracture was 16 o. The average pronation was 83 o and the average supination was 78 o. By the Cassebaum classification after 1 year follow-up, patients were classified as 4 excellent, 4 good, and 2 poor. According to the Mayo elbow performance score, the average score was 87 points (65-100 points) with 3 excellent, 6 good, and 1 fair. Stability was restored in all patients at the last follow-up. There was no case of nonunion and the average union period was 11.5 weeks. Conclusion: This study advocated the additional use of a hinged external fixator in the treatment of complex elbow instability, especially when fixation of fractures and repair of soft tissues were not sufficient. Providing adequate stability and allowing early motion, additional external fixation could improve the functional outcome. Key Words: Elbow, Terrible triad, External fixator 서 론 Received January 11, 2015 Revised (1st) February 18, 2015, (2nd) April 8, 2015 Accepted May 19, 2015 Address reprint requests to: Tong-Joo Lee, M.D., Ph.D. Department of Orthopedic Surgery, Inha University Hospital, 27 Inhang-ro, Jung-gu, Incheon 400-711, Korea Tel: 82-32-890-3043ㆍFax: 82-32-890-3047 E-mail: TJLEE@inha.ac.kr Financial support: This research was supported by grant from the Inha University and Inha University Hospital. Conflict of interest: None. 요골두와구상돌기골절이동반된주관절탈구는단순한주관절탈구에비하여치료가어렵고예후가불량하여성인주관절의위험 3증주 (terrible triad) 로알려져왔다. 1) 요골두및구상돌기골절이동반될경우심한불안정성을초래하고, 이로인해 70% 에이르는환자들은운동범위장해를경험하며, 2) 영구적인관절불안정성및골관절염의위험성이증가하게된다. 3) 따라서이같은합병증을최소화하기위하여주관절골절과탈구가동반된환자의치료는빠른시일내에관혈적정복및내고정술과인대및관절 Copyright c 2015 The Korean Fracture Society. 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. 169
170 Tong-Joo Lee, et al. 막의재건을통하여관절의안정성을회복하고관절운동을빠르게회복시키는것이중요하다. 4) 하지만관혈적정복및내고정술을시행한이후에도뚜렷한후방탈구가관찰되거나외반또는내반부하검사상심한불안정성이관찰되는경우에는지속적인불안정성이남아있다고평가할수있으며, 이경우장상지석고고정을비롯한관절고정이필요할수있다. 이경우관절운동범위제한및주관절의강직이발생할가능성이높으며, 이를방지하기위해서경첩형태의외고정장치를이용하여안정성을충분히제공하면서관절운동의시작시기를빠르게시작하는술기들이보고된바있다. 5) 본연구에서는총 10 예의요골두및구상돌기골절이동반된주관절탈구환자에서관혈적정복및내고정술을시행한다음경첩을이용한외고정장치를시행한후 1 년간추시관찰하여방사선적, 임상적결과를평가하였다. 1. 연구대상 대상및방법 2007 년부터 2013 년까지외상으로인한주관절탈구, 요골두골절및구상돌기골절 ( 위험 3 증주 ) 이포함된주관절복합손상환자로관혈적정복및내고정술을시행받은뒤 1 년이상의추시관찰을거친증례는총 28 예였다. 이중위험 3 증주만수상한증례는 11 예, 위험 3 증주에동반된주두골절또는상완골원위부골절, 상완부경부골절, 수근부골절이관찰된증례는 17 예있었다. 이가운데관혈적정복및내고정술시행후외고정장치를시행받은총 10 예를연구대상으로하였다. 추가적인외고정장치를시행하는기준은내고정이후에도지속적인주관절불안정성이관찰되는경우를대상으로하였다. 관혈적정복술및내고정술을시행한이후에수술도중불안정성의평가는전완부를중립에둔상태에서중력에의해주관절이신전되도록하고주관절을 20 도에서 130 도의굴곡각에서의관절운동시키면서후외방혹은후방으로탈구및아탈구가일어나는지확인하였고, 외반및내반부하검사및추축변위검사 (pivot shift test) 를통해평가하였다. 이가운데남성은 6 명, 여성은 4 명이었으며, 우측주관절이 4 예, 좌측주관절이 6 예였다. 수상시평균연령은 55.1 세 (33-77 세 ) 였고평균추시기간은 14.8 개월 (12-20 개월 ) 이었다. 위험 3 증주이외의추가적인수상이동반된환자는총 7 예로 5 예에서주두골절이동반되었으며, 상완골외과골절 2 예, 수근부골절 3 예, 상완골경부골절 1 예가있었다 (Table 1). 2. 수술방법및재활 모든증례에서측와위를취한상태에서수술적치료를시행하였다. 마취방법은 7 예에서는기도삽관하전신마취 (general anesthesia), 3 예에서는상완신경차단술 (brachial plexus block) 을사용하였다. 주두골절이동반된경우에는후방접근법을통해수술을시행하였고, 주두골절이동반되지않은경우측방접근법을이용하여수술적치료를시행하였다. 요골두에대하여 9 예, 구상돌기골절에대하여 5 예, 동반된주두골절에대하여 5 예시행하였다. 요골두골절에대하여서는 3 예에서 Acutrak headless compression screw (Acumed Inc., Beaverton, OR, USA) 를삽입하여고정하였고 1 예에서는금속판과나사, 1 예에서는핀고정술을시행하였으며 1 예에서는골편제거술만시행하였다. 나머지 3 예에서는요골두를절제한뒤인공요골두치환술 (the floating radial head prosthesis; Tornier SA, Saint-Ismier, France) 을시행하였다. 구상돌기골절에대하여서는 3 예에서나사못을이용한고정을시행했고, 1 예에서는핀고정술, 1 예에서는환상강선고정술 (circlage wiring) 을시행하였다. 나머지증례의경우분쇄로인하여고정술을시행할수없었다. 주두골절의경우 3 예에서는긴장대를이용한내고정술, 2 예에서는금속판과나사를이용한고정술을시행하였다 (Table 1, Fig. 1, 2). 모든증례에서외측측부인대복합체 (lateral collateral ligament complex) 에대하여탐색술을시행하였고, 모든증례에서부분혹은완전파열소견관찰되어해당부위에대하여봉합술을시행하였다. 모든증례에서관혈적정복및내고정술후에경첩을이용한외고정술 (hinged monofixator) 을시행하였다. 경첩외고정술의장착은우선상완골원위부에서주관절의회전중심을찾아 1.6 mm K-wire 를삽입한뒤 5.0 mm 외고정핀 (half pin) 을상완골에 2 개, 전완부척골에 2 개삽입하였다. 후방접근법을통해내고정술을시행한경우원위부핀의경우피부봉합이전에핀삽입을시행하였고, 측방접근법을시행한경우피부봉합술을시행한이후에모든핀을삽입하였다. 외고정술의시행에앞서서외측측부인대복합체를비롯한연부조직에대한탐색술및손상에대한수술적치료, 골절에대한내고정술을시행하였으며주관절회전중심에삽입된 K-wire 는외고정장치가설치된이후바로제거하였다. 최소 3 개이상의연결막대 (rod) 와주관절회전중심에위치시킨경첩을조립하여외고정장치를연결하였다. 해당외고정장치로주관절의최대굴곡과최대이완을확인하였다. 수술후 1 주경 ( 평균 6.5 일, 5-8 일 ) 부터외고정장치의경첩을이용하여관절운동을시작하였으며 90 도굴곡에서최대굴곡까지관절운동을시작하였다 (Fig. 3), 수술후 2 주부터 6 주까지관절운동범
Additional Hinged External Fixation in Complex Elbow Injury 171 Table 1. Summary of Cases Patient No. R/L Sex Age (yr) Mayo score Cassebaum classification Bone union period (wk) Follow-up period (mo) Flexion contracture ( ) Following flexion ( ) Pronation ( ) Supination ( ) Trauma mechanism Coronoid Radial head Olecranon External fixator removal (wk) 1 L M 39 85 Good 10 15 30 120 90 80 Fall down Fixation 2 L M 47 100 Excellent 12 18 0 150 90 90 Slip down Fixation 3 R F 70 75 Poor 10 18 25 95 70 70 Slip down Fixation 4 R M 65 85 Good 11 12 25 125 85 80 Slip down Screw fixation (One) 5 R F 77 100 Excellent 12 14 0 150 90 90 Fall down Fixation 6 R F 56 70 Poor 11 13 30 80 65 50 Fall down Screw fixation 7 L F 59 100 Excellent 11 12 0 150 90 90 Fall down Fixation 8 L M 41 85 Excellent 12 14 0 150 80 70 Fall down Pinning 9 L M 33 85 Good 12 12 25 125 90 75 Slip down Circlage wiring 10 L M 64 85 Good 10 20 25 125 80 85 Fall down Screw fixation Screw fixation (two) Pinning (two) Radial head replacement arthroplasty Tension band wiring 5 Injury 9 Tension band wiring Partial excision Injury 6 Radial head replacement arthroplasty 5 Plate & screws 8 Plate & screws Plate & screws 8 Screw fixation Fixation Radial head replacement arthroplasty Screw fixation Injury 5 Injury 9 Tension band wiring 7 Injury 6 Average 55.1 87 11.1 14.8 16.0 127 83 78 6.8 R: Right, L: Left, M: Male, F: Female.
172 Tong-Joo Lee, et al. Fig. 1. A 33-year-old male, initial radiographs and computed tomography showed fracture of the radial head, coronoid process and olecranon process of ulna, and elbow dislocation. Postoperative radiographs show resection arthroplasty for radial head fracture, circlage wiringfor coronoid process fracture, and tension band wiring for olecranon process fractures and hinged external fixation for elbow instability. (A) Preoperative elbow anteroposterior (AP) image. (B) Preoperative elbow lateral image. (C) Preoperative 3-dimensional computed tomography image. (D) Postoperative elbow AP image. (E) Postoperative elbow lateral image. 위를서서히증가시켰다. 수술 6 주전, 후 ( 평균 6.8 주, 5-8 주 ) 로불안정성여부를확인한후외고정장치를제거하였다. 3. 임상적결과의평가방법 수술후 2 주, 6 주, 6 개월, 1 년에추시하여 X-ray 촬영과신체검진을통해요골두, 구상돌기와그외추가적주관절골절의유합상태, 주관절의불안정성유무및합병증여부를확인하였다. 골유합의기준은방사선영상에서요골두및구상돌기의전, 후, 측면사진상골연속성이유지되거나가골의성숙이골절면의 3/4 이상폐쇄된경우로하였으며, 임상적으로골절부위의압통과움직임이없는상태로정하였다. 1 년추시관찰시관절운동범위와임상적결과를기준으로주관절에대하여 Cassebaum classification 과 Mayo elbow performance score 를측정하여평가하였다 (Table 2, 3). 결 수술후 1 년경과시평균굴곡구축이 16.00±14.35 도 (0-30 도 ), 평균후속굴곡 127.00±24.52 도 (80-150 도 ) 로나타났고회내전은 83.00±9.19 도 (65-90 도 ), 회외전은 78.00± 12.52 도 (70-90 도 ) 를기록하였다. 운동범위에대한기능적평가로수술 1 년추시시 Cassebaum 분류로평가했을때우수 4 예, 양호 4 예, 불량 2 예였고, Mayo elbow performance score 에서는평균 87 점을기록하였으며우수 3 예, 양호 6 예, 보통 1 예로나타났다. Cassebaum 분류상불량하였던 2 예모두주두골절이동반되었던증례로주관절굴곡이 100 도이하 (95 도, 80 도 ) 로관찰되었고, 굴곡구축은 30 도이하 (30 도, 25 도 ) 로관찰되며이중 1 예는 Mayo elbow performance score 상에서도보통으로평가되었다. 외고정장치의제거는평균 6.8 주에시행하였으며, 외고정핀은삽입된채로연결막대만제거한뒤영상의학적인검사와불안정성에대한이학적검사를시행한다음외고정 과
Additional Hinged External Fixation in Complex Elbow Injury 173 Fig. 2. A 65-year-old male, initial radiographs and computed tomography showed fracture of the radial head, coronoid process and elbow dislocation. Postoperative radiographs show fragment resection for the radial head fracture, screw fixation for coronoid process fracture, and hinged external fixation for elbow instability. (A) Preoperative elbow anteroposterior (AP) image. (B) Preoperative elbow lateral image. (C) Preoperative 3-dimensional elbow computed tomography image. (D) Postoperative elbow AP image. (E) Postoperative elbow lateral image. Fig. 3. (A) Postoperative photo with hinged external fixator. (B) After removal of a rod of the external fixator and loosening the hinge, patients started elbow joint movement. One week after surgery. 핀에대하여제거술을시행하였다. 최종추시시주관절에서불안정성이관찰된증례는없었다. 영상의학적인검사상평균골유합기간은 11.5 주였으 며, 불유합증례는없었다. 합병증으로 1 예에서요골신경마비증상이관찰되었으나수술 3 개월추시시회복되었다. 외고정장치의핀고정부위의감염소견증례는없었
174 Tong-Joo Lee, et al. Table 2. Cassebaum Classification for Elbow Range of Motion Classification Very good Good Fair Poor Elbow range of motion Flexion >130 o, extension deficit <15 o Flexion >120 o, extension deficit <40 o Flexion >120 o, with any extension deficit Flexion <110 o 다. 이소성골형성은모든증례에서관찰되지않았고주관절의굴곡구축으로인하여관절해리술이필요했던예도관찰되지않았다. 고 주관절을침범한골절과탈구는적절한내고정을통하여안정성을확보할수있다면조기관절운동을통해골유합과운동범위를확보할수있다고알려져있다. 6) 하지만구상돌기골절과요골두골절이동반된탈구의경우 ( 위험 3증주 ) 대부분의증례에서심한불안정성이있고, 조기관절운동시골절부위에가해지는저항에의하여내고정의실패를유발할수있다. 7,8) 또한조기관절운동이실패할경우주관절강직이초래될수있다. Pugh 등 6) 은 2004년위험 3증주증례 40예에대하여연구한결과최종관절운동각도 112도, Mayo score 88점으로보고한바있고, 이가운데 8명의증례에서는후외측불안정성, 요척골신생골형성, 감염, 구축등의이유의합병증으로재수술을시행하였다고보고한바있다. 이처럼위험 3증주의치료는임상적결과가좋지않고치료가어렵다. 해당병변에대한치료에있어가장중요한원칙은일반적인주관절골절탈구에서와같이요골두와구상돌기, 그리고인대및관절막구조물에대한재건 9) 이지만환자의치료순응도와골절의정도를고려하여추가적인외고정장치가고려되어왔다. 10) 외고정방법으로는후방탈구를원천적으로예방하면서상완-척골관절운동이가능하게할수있는 Ilizarov 혹은단일외고정장치가치료방법이알려져있다. 11) 외고정장치를시행할때외고정핀 (half pin) 과경첩의위치를정확히설치하는것은기술적으로쉽지않다. 가장중요한술기는경첩을이용한외고정시주관절의회전중심에맞도록고정하는것으로이는마찰로안한저항과나사의이완을막는데있어중요한요소로 12) 알려져있다. 상완골의장축과척골의장축이교차하는각인이행각 (carrying angle) 은정상성인에서 10-15도가량의외반 (valgus) 양상을보이며, 주관절회전의중심축은상완골의간부에서내린수직선에대하여 6도외반, 5도내회전한지점에위치한다. 이를감안하여주관절의회전중심축에맞도록외고 찰 Table 3. Mayo Elbow Performance Score Function Point Definition (point) Pain 45 None (45) Mild (30) Moderate (15) Severe (0) Motion 20 Arc >100 o (20) Arc >50 o -100 o (15) Arc <50 o (5) Stability 10 Stable (10) Moderate instability (5) Gross instability (0) Function 25 Comb hair (5) Feed (5) Perform hygiene (5) Done shirt (5) Done shoe (5) Total 100 Classification: Excellent >90; Good 75-89; Fair 60-74; Poor <60. 정기의위치를선정해야해부학적인관절운동이가능하다. 13) 회전중심으로부터 5도축의편위가일어날경우관절운동에필요한에너지가 3.7배가량증가하는것으로보고된바있다. 14) 본연구에서도외고정장치를설치할때경첩의위치에해당하는부위에 K-wire 를삽입하였으며그위치가주관절의회전중심에위치하는지확인한후 half pin의삽입과외고정장치의설치를진행하였다. 특히경첩의중심부에위치한 K-wire 가나머지외고정장치가설치될때장력을받지않고자연스럽게유지되도록하였고외고정장치가설치된이후에주관절의굴곡, 이완을통해회전중심에경첩이위치하는지를다시확인하였다. 요골두골절및구상돌기골절은주관절탈구에동반되는골절중흔한골절이며, 이에대하여관혈적정복술및내고정술을시행하는것이관절의불안정성과이에따른합병증을방지하는데있어서중요하다. 본연구에서도외고정장치를시행하기에앞서모든증례에서관혈적정복및내고정술을시행하였다. 요골두골절이주관절의탈구와동반되어발생한경우요골두의관절면과소두의관절면이접촉하면서후방불안정성이유발될수있어분쇄가심한경우에도단순요골두절제술은금기로알려져있다. 15) 요골두의경우분쇄가심하지않은경우금속판혹은 acutrak 나사못을이용한내고정술을시행하였으며, 분쇄가심하여절제술이불가피한경우에는인공골두치환술을시행하였다. 구상돌기골절의경우 Morrey 분류상 III에해당하는 50% 이상을침범한골절일때후방탈구에대한안정성이확보되지않는것으로알려져있고골절면
Additional Hinged External Fixation in Complex Elbow Injury 175 이내측측부인대및상완근의삽입부로연결될경우불안정성이심화된다. 16) 또한분쇄가동반된골절이나골절편이작은경우에는견고한내고정이어렵다. 이같은경우구상돌기골편에후방탈구에대하여저항이어렵기때문에불안정성을원천적으로방지하기위하여외고정장치가도움이될수있겠다. 13) 이전에진행된연구에서 Kim과 Kim 13) 이 2007년 Ilizarov 기기를이용하여위험 3증주 7예를포함한총 8예의주관절복합골절탈구에대하여수술적치료를시행한결과에서평균관절운동각도 116도, Mayo score 86점의결과를보고한바있다. 본연구에서는경첩외고정장치를단고정장치 (monofixator) 를이용하여시행하였는데, 연결막대 (rod) 가 Ilizarov 기기와는달리후외측으로국한되어있어관절운동시외고정기기로인한불편감을줄일수있는장점이있으므로결과에유리한영향을미쳤을것으로생각된다. 국외연구로는 Berendes 등 10) 이 2010년주관절복합골절탈구손상에대하여내고정장치를시행한뒤환자순응도가떨어지는군을대상으로추가적경첩외고정장치를총 11예에서시행한연구에서평균주관절운동각도 112도, 내회전 64도, 외회전 53도를기록한바있다. 본연구에서는시행된환자군들의연령이비교적젊고, 환자순응도에어려움이있었던증례가없어수술후관절운동진행이용이하였다는점에서더좋은결과가관찰된것으로판단된다. Stavlas 등 11) 이주관절복합손상을수상한 8명의증례에서내고정후부가적으로시행한단고정, 경첩외고정장치를이용한수술적치료에서는주관절운동각도 125도, 회외전 70, 회내전 70도로본연구와큰차이가없었다. 본연구에서주관절의관혈적정복술및내고정술을시행한이후에수술도중불안정성의평가는전완부를중립에둔상태에서중력에의해주관절이신전되도록한상태에서주관절을 20-130도의굴곡각에서의관절운동시키면서후외방혹은후방으로탈구및아탈구가일어나는지확인하였고, 외반및내반부하검사및추축변위검사 (pivot shift test) 를통해평가하였다. 기존의연구에서관혈적정복술및내고정술을시행한상태에서주관절의불안정성이지속될때시행하는술기로외측측부인대봉합과내측측부인대봉합을시행할수있고이를대체하는방법혹은이같은시술을시행하였음에도불안정성이유지될경우사용하는술기로외고정장치를시행하는것 6) 으로알려져있다. Chemama 등 17) 은외측연부조직의복원후불안정성이유지될때내측측부인대봉합술을시행하여 30-130도의굴곡각에서안정성을얻었다고보고하였으며, Pugh 등 6) 도같은술식을포함한 protocol을통하여 Mayo score 88 점을비롯한임상결과를발표한바있다. 하지만본연구 에서는내측측부인대의봉합을위하여추가적으로주관절내측을절개하거나박리하는과정에서척골신경주변의연부조직을박리하게되고수술후해당부위의유착으로인하여척골신경병증이발생하는사례가많다는점을고려하여해당술기는시행하지않았다. 본연구는증례수가많지않다는점과대조군이없다는점에서한계를가지고있다. 하지만위험 3 증주에해당하는증례발생률이높지않아대규모연구결과가드물고, 본연구의결과에서임상적, 기능성치료결과의우수성이관찰되고있다는점에서의미가있다. 특히해당술기를시행할경우모두후방탈구가재발하지않으면서조기관절운동에성공하였다는점은주관절의탈구와동반된골절의치료에있어중요한요소이다. 차후광범위한증례와외고정장치를사용하지않은대조군을포함하여추가적인연구가필요할것으로생각된다. 결 주관절의탈구, 요골두골절, 구상돌기골절이동반된위험 3 증주를포함한주관절복합손상의수술적치료중부가적인경첩성외고정장치는관절안정성을제공하면서조기관절운동을시행할수있으며술후우수한임상결과를보였다. 론 References 1) Josefsson PO, Gentz CF, Johnell O, Wendeberg B: Dislocations of the elbow and intraarticular fractures. Clin Orthop Relat Res, (246): 126-130, 1989. 2) Ball CM, Galatz LM, Yamaguchi K: Elbow instability: treatment strategies and emerging concepts. Instr Course Lect, 51: 53-61, 2002. 3) Broberg MA, Morrey BF: Results of treatment of fracture-dislocations of the elbow. Clin Orthop Relat Res, (216): 109-119, 1987. 4) Zilkens C, Graf M, Anastasiadis A, Smajic S, Muhr G, Kälicke T: Treatment of acute and chronic elbow instability with a hinged external fixator after fracture dislocation. Acta Orthop Belg, 75: 167-174, 2009. 5) McKee MD, Bowden SH, King GJ, et al: Management of recurrent, complex instability of the elbow with a hinged external fixator. J Bone Joint Surg Br, 80: 1031-1036, 1998. 6) Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD: Standard surgical protocol to treat elbow dislocations
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ISSN 1225-1682 (Print) ISSN 2287-9293 (Online) 대한골절학회지제 28 권, 제 3 호, 2015 년 7 월 J Korean Fract Soc 2015;28(3):169-177 http://dx.doi.org/10.12671/jkfs.2015.28.3.169 Original Article 성인주관절복합손상에서추가적인경첩성외고정술 이동주 홍택호 김낙철 인하대학교의과대학정형외과학교실 목적 : 본연구에서는성인주관절복합손상에서관혈적정복및내고정술후추가적인경첩성외고정술의임상결과를분석하고자한다. 대상및방법 : 2007년부터 2013년까지주관절탈구, 요골두골절및구상돌기골절을포함한주관절복합손상환자중내고정술후외고정장치를시행받은뒤 1년이상추시한 10예를대상으로하였다. 추가적외고정장치를시행하는기준은내고정이후에도지속적인주관절불안정성이관찰되는경우로하였다. 1년추시시 Cassebaum 분류와 Mayo elbow performance score (MEPS) 를측정하여임상적결과를평가하였다. 결과 : 수술후 1년추시시평균관절운동범위는굴곡구축 16도, 후속굴곡 127도, 회내전 83도, 회외전 78도로측정되었다. 임상적평가상 Cassebaum 분류로평가했을때우수 4예, 양호 4예, 불량 2예였고, MEPS상평균 87점을기록했다. 최종추시시주관절불안정성이관찰된증례는없었고평균골유합기간은 11.5주였으며, 불유합증례는없었다. 결론 : 성인주관절복합손상증례에서경첩을이용한외고정장치는관절안정성을제공하면서조기관절운동을시행할수있으며 1년추시관찰시우수한임상결과를보였다. 색인단어 : 주관절, 위험 3증주, 외고정장치 접수일 2015. 1. 11 수정일 1 차 2015. 2. 18, 2 차 2015. 4. 8 게재확정 2015. 5. 19 교신저자이동주인천시중구인항로 27, 인하대병원정형외과 Tel 02-32-890-3043, Fax 02-32-890-3047, E-mail TJLEE@inha.ac.kr 이연구는인하대학교의학전문대학원및인하대병원의지원으로이루어졌음. Copyright c 2015 The Korean Fracture Society. 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. 177