ISSN 122-182 (Print) ISSN 2287-9293 (Online) 대한골절학회지제 2 권, 제 호, 213 년 월 J Korean Fract Soc 213;2():299-3 http://dx.doi.org/.1271/jkfs.213.2..299 원 저 역행성골수강내금속정을이용한상완골간부골절의치료 최기범 강수환 * 이윤민 송석환 김연준 가톨릭대학교여의도성모병원정형외과, 가톨릭대학교성바오로병원정형외과 * Treatment of Humeral Shaft Fracture with Retrograde Intramedullary Nail Ki-Bum Choi, M.D., Soo-Hwan Kang, M.D., Ph.D.*, Yoon-Min Lee, M.D., Seok-Whan Song, M.D., Ph.D., Youn-Jun Kim, M.D. Department of Orthopedic Surgery, The Catholic University of Korea Yeouido St. Mary's Hospital, Department of Orthopedic Surgery, The Catholic University of Korea St. Paul's Hospital*, Seoul, Korea Purpose: The purpose of this study was to report the outcome of treatment of humeral shaft fracture with retrograde intramedullary nail of advanced insertion opening. Materials and Methods: From April 2 and August 212, 22 patients with a humeral shaft fracture were treated by a single surgeon using the technique of retrograde intramedullary nail at Department of Orthopedic Surgery, Yeouido St. Mary's Hospital (Seoul, Korea). To avoid causing fractures at the insertion site, the entry point was more distally located than conventionally, and was extended proximally to include the proximal marginal cortex of the olecranon fossa. The outcome was evaluated clinically and radiologically. Results: The mean period of achievement of bony was.8 months (- months). Additional fixations were needed in one patient with intraoperative lateral condylar fracture and 2 patients with postoperative nonunion. There were no limitations of movement or pain in the shoulder joint, and 8 cases had a. o flexion contracture on average. Conclusion: This retrograde intramedullary fixation technique using a distal entry portal near the olecranon fossa is particularly useful in humeral shaft fractures without a neurovascular injury. The risk of an intraoperative fracture (supracondylar fracture or fracture around the entry portal) can be decreased using this treatment. We recommend this technique because of the safety and the satisfactory outcome. Key Words: Humeral shaft, Fracture, Retrograde, Intramedullar fracture fixation 서 론 성인상완골간부골절의치료는보존적혹은수술적방 Received December 27, 212 Revised July 1, 213 Accepted August 22, 213 Address reprint requests to: Seok-Whan Song, M.D., Ph.D. Department of Orthopedic Surgery, The Catholic University of Korea Yeouido St. Mary's Hospital, 3-ro, Yeongdeungpo-gu, Seoul -713, Korea Tel: 82-2-3779-92 ㆍ Fax: 82-2-783-22 E-mail: sw.song@catholic.ac.kr 법으로시행할수있으나최근금속판내고정술, 골수강내고정술등의수술적치료가증가하고있다 1). 금속판내고정술은골절부위를직접보고정확하게정복하여고정하는장점은있으나연부조직의박리가크고, 요골신경손상의위험이높으며, 개방성골절또는골다공증이심한환자에는적절하지못하여골수내정을이용한내고정술이도입되었다 3,7,9,). 골수강내고정술은선행적및역행적고정술이있으며, 선행적기법은견관절의회전근개손상및충돌증후군의위험이커서이문제점을피하기위해역행 Copyright c 213 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/3.) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 299
3 최기범, 강수환, 이윤민, 송석환, 김연준 적기법이시도된다 ). 그러나기존의고식적인삽입부 (entry portal, 주두와의상방 2 cm) 를이용한역행적골수내정삽입시과상부골절및삽입부주위로피질골의분쇄가발생하는단점이보고되었으며이를보완하는방법들이시도되었다,12). 저자들은역행적골수내정삽입부주두와의피질골을근위부로충분히절제하여금속정삽입시골수강에좀더직선상으로위치하고삽입부굽힘력을감소시켜의인성골절 (iatrogenic fracture) 을방지하고자하였으며, 수술후좋은결과를얻어이를보고하고자한다. 1. 연구대상 대상및방법 2 년 월부터 212 년 월까지가톨릭대학교여의도성 모병원정형외과에서상완골간부골절에서역행적골수내정고정술을시행한총 22 예의환자를대상으로하였다. 상완골간부골절중수술적치료의대상이되는길이단축 3 cm 이상, 회전변형 3 도이상, 각변형 2 도이상, 분절또는분쇄골절환자를대상으로하였으며, 신경혹은혈관손상이동반되었을경우는제외하였다. 상완골의삼각근결절로부터과상부융기 (supracondylar ridge) 사이에서발생한골절에서수술을시행하였다. 수술전건측상완골의가장협소한골수강의너비와원위상완골삽입부로부터상완골외과적경부까지의길이를미리측정하여삽입할기구를예상하였다. 평균수상후수술까지의기간은일주일이내를원칙으로하였으며기저질환, 전신상태가불량한경우전신마취및수술이가능한상태로회복시킨후시행하였다. Fig. 1. (A) The skin was incised curvilinearly from the midline of the distal humerus to the lateral condyle. (B) After using the triceps splitting approach, (C) a cortical window was made at the superior margin of the olecranon fossa and was extended proximally about 3 cm. (D) Nail and locking screws were inserted, without an iatrogenic supracondylar fracture occurring.
역행성골수강내금속정을이용한상완골간부골절의치료 31 2. 수술및재활 결 과 전신마취하에환자를측와위자세 (lateral decubitus postion) 로눕히고이환된상지를흉벽에붙인채로주관절을 9 도굴곡된상태에서수술을시행하였다. 원위상완부후면에상완골을촉지한후상완골의중심선과외과사이에약 7 cm 가량의곡선형의피부절개를가한뒤, 원위삼두근의중심에서이분하여 (triceps splitting approach, Campbell s approach) 상완골에도달한후골막을박리한다. 주두와상방에서. mm 드릴과천공기를이용하여너비 1 cm, 길이 cm 의구멍을만든후주두와의융기부까지피질골을절제하여삽입부를만든다. 골절을정복시킨상태에서유도강선을삽입한후미리측정해놓은골수내정 (Synthes, Waldenburg, Switzerland) 을확공을시행하지않고삽입하였다 (Fig. 1). 영상증폭장치로골절의정복정도가잘유지되는것을확인하고두개의원위잠금나사와한개의근위잠금나사를고정하였다 (Fig. 2). 수술후 3 주간상완부설탕집게부목고정 (upper arm sugar tong splint) 을시행하였고, 3 주간팔걸이를착용하면서견관절과주관절의관절운동을시작하였다. 수술후 주부터는가벼운일상적인생활을허용하였다. 수술직후, 1 주, 3 주, 주, 3 개월, 이후 3 개월간격으로상완골의단순방사선사진 ( 전후면, 측면, 사면 ) 을촬영하여골유합을확인하였고최종추시시주관절의관절운동범위와주관절신전력을평가하였다. 골절의형태는횡골절은 예, 나선형골절이 예, 사선형골절이 3 예, 분쇄골절이 3 예였다. 손상기전은낙상이 9 예, 교통사고가 8 예, 스포츠손상이 예, 직접가격이 1 예였다. 평균연령은 7.2 세 (21-8 세 ) 였고, 남자가 1 명, 여자가 8 명이었다. 평균추시기간은 17. 개월 (- 개월 ) 이었으며 개월에골유합이확인된 3 명의환자는더이상외래에방문하지않았다. 평균골유합기간은.8 개월 (- 개월 ) 이었다. 1 예에서외과의골절이발생하여강선술등의추가적인내고정을시행하였고, 2 예에서소절개를이용한환형강선고정술을추가로시행하였다. 수술중삽입부의의인성골절이발생한경우는없었다. 2 예에서수술 8 주후에도지연유합소견을보여술후 개월에자가장골이식술을시행하여최종추시시성공적인골유합을얻었다. 7 예에서는술후평균 2 개월 (17-3 개월 ) 에기구를제거하였고 1 예에서는개인사정, 추시소실및고령등의이유로기구제거술을시행하지않았다. 최종추시에서견관절의운동제한및통증은없었고, 주관절의관절운동범위는 1 예에서정상범위를보였으며 8 예에서약. 도 (- 도 ) 의굴곡강직이남았다. 그외의합병증인감염, 신경손상, 고정실패는없었으나상완골외과적경부까지나선형골절이연장된 3 세환자와분쇄골절이었었던 7 세의환자에서불유합이발생하였고추가적수술을거부하여술후 7 개월이후부터추시되지않았다 (Table 1). Fig. 2. (A) Initial radiographs show a short oblique fracture of the humeral shaft area. (B) After fixation by a retrograde intramedullar nail, the fracture site was reduced, with a minimal gap. (C) At postoperative months, the fracture site was completely united.
32 최기범, 강수환, 이윤민, 송석환, 김연준 Table 1. Summary of Cases Case No. Sex/Age (yr) Cause of injury Fracture type Duration of union (mo) F/U duration (mo) Flexion contracture ( o ) Last F/U Elbow arc ( o ) Shoulder arc 1 2 3 7 8 9 12 13 1 1 1 17 18 19 2 21 22 M/21 F/23 M/3 F/ M/2 F/7 F/7 M/3 F/ M/7 M/3 F/8 M/2 M/3 M/ M/ M/33 F/3 M/9 F/8 M/33 M/8 Driver's TA Passenger s TA Passenger s TA Direct blow Driver s TA Motorcycle TA Motorcycle TA Motorcycle TA Passenger s TA Oblique Oblique Comminuted Comminuted Oblique Comminuted Nonunion 7 Nonunion 8 33 2 2 13 38 1 8 18 2 21 3 13 1 3 12 13 13 12 13 13 12 12 13 12 13 13 13 13 13 13 12 13 13 13 12 13 13 M: Male, F: Female, TA: Traffic accident, F/U: Follow up. 고 상완골간부골절은견관절과주관절이큰운동범위를보이기때문에어느정도의각형성및단축등의변형이있어도기능적제한이적어, 비수술적치료로도높은골유합을보인다 8,1). 그러나내고정물의형태 (implant design) 와수술기법 (surgical technique) 이발달하고, 보존적치료시장기간의고정으로인한관절의운동제한, 각변형, 지연유합, 불유합등의합병증을수술적치료로극복할수있기때문에최근에는수술적치료가증가하는추세이다,9,13). 현재많이시도되고있는수술적치료는금속판내고정술 (plate osteosynthesis) 과골수강내고정술이다. 금속판을이용한수술은해부학적정복및견고한고정으로높은골유합률을보이며훌륭한기능적회복이보고되었지만, 광범위한연부조직의박리, 요골신경손상의위험성이있고, 개방성골절, 분쇄및분절골절, 병적골절및골다공증이심한경우에제한된다고하였다 3,7,9,). Lin 9) 은최근금속판내고정술의술기의발달로이러한합병증이상당히감소하였지만여전히위험성을가지고있다고보고하였다. 이러한금속판을이용한내고정술의단점을극복하기위하 찰 여골수강내정을이용한내고정술이많이시도되며, 주로선행적기법 (antegrade nailing) 을흔히사용하고있다. McCormack 등 ) 및 Flinkkilä 등 ) 은선행적골수강내정삽입시회전근개의손상이필연적이며수술후충돌증후군으로인한견관절의견관절의동통및운동제한을문제점으로지적하였다. 반면역행적골수정 (retrograde nailing) 은상완골원위부의골수강이좁고굴곡되어골수내정삽입시저항이크고의인성골절, 즉과상부골절, 삽입부주위피질골골절등의위험도가높아 2,12) 선행적골수강내정삽입술보다는널리이용되지는않는다. 이러한단점을보완하기위해, 저자들은기존의삽입부인주두와근위부경계로부터약 2 cm 상방에서삽입했지만주두와의근위부를포함한피질골을약 cm 가량충분히절제하여저항을줄여골수내정삽입이용이하고수술중발생할수있는과상부골절도막을수있었다. 하지만후방피질골을많이제거하게되면가장원위부에삽입한잠금나사는원위피질골 (far cortex) 만을고정하게되어고정력이떨어질가능성이있다. 이는인접원위잠금나사의이중피질골고정 (bicortical fixation) 을통해고정력을향상시킬수있었다. 근위잠금나
역행성골수강내금속정을이용한상완골간부골절의치료 33 사삽입시신경주행을고려하면서소절개후천공유도관 (drill guide) 을피질골표면에완벽하게밀착시켜영상증폭장치로나사구멍이원형으로보이는상태에서천공하여, 신경손상을막으면서보다쉽게나사를삽입할수있었다. 총 22 예의환자에서수술시외과골절 1 예, 지연유합 2 예가발생하였으나, 추가적인내고정으로성공적인골유합을얻었고, 견관절및주관절의운동제한및통증은거의없었다. 불유합이발생한 2 예는고령이었으며분쇄골절과근위부까지연장되는긴나선형골절이었다. 분쇄가있는골절에서추가적인고정을시행하지않아불유합이발생한것으로판단되며, 이와같이골수내정삽입후정복이불완전한경우소절개후추가적인환형강선고정술을시행했다면불유합을막을수있었을것이며, 근위부까지연장된나선형골절은역행성골수내정보다는선행적기법으로수술하는것이유합률을높일수있었을것으로판단된다. 주두와의피질골을절제한삽입부를이용한수술 ( 주두와도달법 ) 은주관절강직이발생할수있다는예상과는달리실제수술중주두와상방에서피질골을제거하기때문에주관절관절낭에는손상을주지않아관절운동범위의감소가거의없으며, 삼두근분리접근법 (triceps splitting approach) 시그범위가 cm 미만이고적절한봉합을시행하게되면주관절신전기능또한정상으로회복된다. 이논문은증례의수가적고후향적연구라는한계가있다. 또한보다객관적인수술결과를평가하기위해서는전향적골수강내고정 (antegrade intramedullary nailing) 또는기존의삽입부 (entry portal) 를이용한증례들과의통계적인분석을통한비교등의보완이요구되며, 골유합이확인된후외래에방문하지않아추시기간이짧은증례들을포함하였다는단점이있다. 그러나진보된삽입구를통한보다쉽고유용한수술법으로좋은임상결과를가져올수있을것으로생각한다. 결 동반된신경및혈관손상이없는상완골간부골절에서연장된주두와삽입부를통한역행적교합성골수강내고정술은기존의과상부골절및삽입부주위의견열골절의위험을줄이면서만족할만한임상결과를보여이를보고하는바이다. 론 References 1) Barnes CE, Shuler TE: Complications associated with the Seidel nail. Orthop Rev, 22: 99-7, 1993. 2) Blum J, Janzing H, Gahr R, Langendorff HS, Rommens PM: Clinical performance of a new medullary humeral nail: antegrade versus retrograde insertion. J Orthop Trauma, 1: 32-39, 21. 3) Brumback RJ: The rationales of interlocking nailing of the femur, tibia, and humerus. Clin Orthop Relat Res, (32): 292-32, 199. ) Cheng HR, Lin J: Prospective randomized comparative study of antegrade and retrograde locked nailing for middle humeral shaft fracture. J Trauma, : 9-2, 28. ) Crates J, Whittle AP: Antegrade interlocking nailing of acute humeral shaft fractures. Clin Orthop Relat Res, (3): -, 1998. ) Flinkkilä T, Hyvönen P, Lakovaara M, Linden T, Ristiniemi J, Hämäläinen M: Intramedullary nailing of humeral shaft fractures. A retrospective study of 12 cases. Acta Orthop Scand, 7: 133-13, 1999. 7) Ingman AM, Waters DA: Locked intramedullary nailing of humeral shaft fractures. Implant design, surgical technique, and clinical results. J Bone Joint Surg Br, 7: 23-29, 199. 8) Klenerman L: Fractures of the shaft of the humerus. J Bone Joint Surg Br, 8: -1, 19. 9) Lin J: Treatment of humeral shaft fractures with humeral locked nail and comparison with plate fixation. J Trauma, : 89-8, 1998. ) Lin J, Hou SM: Locked nailing of severely comminuted or segmental humeral fractures. Clin Orthop Relat Res, (): 19-2, 23. ) McCormack RG, Brien D, Buckley RE, McKee MD, Powell J, Schemitsch EH: Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail. A prospective, randomised trial. J Bone Joint Surg Br, 82: 33-339, 2. 12) Scheerlinck T, Handelberg F: Functional outcome after intramedullary nailing of humeral shaft fractures: comparison between retrograde Marchetti-Vicenzi and unreamed AO antegrade nailing. J Trauma, 2: -71, 22. 13) Seidel H: Humeral locking nail: a preliminary report. Orthopedics, 12: 219-22, 1989. 1) Zagorski JB, Latta LL, Zych GA, Finnieston AR: Diaphyseal fractures of the humerus. Treatment with prefabricated braces. J Bone Joint Surg Am, 7: 7-, 1988.
ISSN 122-182 (Print) ISSN 2287-9293 (Online) 대한골절학회지제 2 권, 제 호, 213 년 월 J Korean Fract Soc 213;2():299-3 http://dx.doi.org/.1271/jkfs.213.2..299 원 저 역행성골수강내금속정을이용한상완골간부골절의치료 최기범 강수환 * 이윤민 송석환 김연준 가톨릭대학교여의도성모병원정형외과, 가톨릭대학교성바오로병원정형외과 * 목적 : 상완골간부골절에서주두와의삽입부를이용한역행적교합성골수강내고정술의결과에대하여보고하고자한다. 대상및방법 : 2년 월부터 212년 9월까지가톨릭대학교여의도성모병원정형외과에서상완골간부골절에서역행적교합성골수내정을이용하여치료한 22예를대상으로임상적및방사선학적결과를분석하였다. 결과 : 평균골유합기간은.8개월 (-개월) 이었다. 1예에서수술도중외과의골절이발생하여강선술등의추가적인내고정을시행하였고수술후 2예에서상완골간부의지연유합이발생하였으나골이식술을시행하여골유합을얻었으며, 2예에서불유합이발생하였다. 술후견관절의운동제한및통증은없었으며주관절은 8예에서평균.도의굴곡강직과평균약 131도의운동범위를보였다. 결론 : 동반된신경및혈관손상이없는상완골간부골절에서보다안전한원위골수강삽입부를통한역행적교합성골수강내고정술은과상부골절및삽입부주위피질골골절의위험을줄일수있고술후좋은결과를얻을수있는술식이라생각한다. 색인단어 : 상완골간부, 골절, 역행적, 골수강내고정술 접수일 212. 12. 27 수정일 213. 7. 1 게재확정 213. 8. 22 교신저자송석환서울시영등포구 3 로, 가톨릭대학교여의도성모병원정형외과 Tel 2-3779-92, Fax 2-783-22, E-mail sw.song@catholic.ac.kr Copyright c 213 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/3.) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 3