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ISSN 1225-1682 (Print) ISSN 2287-9293 (Online) 대한골절학회지제 26 권, 제 4 호, 2013 년 10 월 J Korean Fract Soc 2013;26(4):292-298 http://dx.doi.org/10.12671/jkfs.2013.26.4.292 원 저 고령환자의상완골근위부골절에서보존적치료결과 백승길 오창욱 변영수 * 오종건 김준우 윤종필 이현주 김형섭 경북대학교의학전문대학원정형외과학교실, 대구파티마병원정형외과 *, 고려대학교의과대학정형외과학교실 The Result of Conservative Treatment of Proximal Humerus Fracture in Elderly Patients Seung-Gil Baek, M.D., Chang-Wug Oh, M.D., Ph.D., Young-Soo Byun, M.D., Ph.D.*, Jong-Keon Oh, M.D., Ph.D., Joon-Woo Kim, M.D., Ph.D., Jong-Pil Yoon, M.D., Hyun-Joo Lee, M.D., Hyung-Sub Kim, M.D. Department of Orthopedic Surgery, Kyungpook National University School of Medicine, Daegu, Department of Orthopedic Surgery, Daegu Fatima Hospital*, Daegu, Department of Orthopedic Surgery, Korea University College of Medicine, Seoul, Korea Purpose: With the increase in the old age population, proximal humerus fractures have been increasing recently. However, complications after operative treatment, such as fixation failure, are common because of osteoporosis. We treated proximal humerus fractures in patients with osteoporosis conservatively, and evaluated the radiographic and functional results by analyzing the factors affecting the results. Materials and Methods: Nineteen out of 30 cases for whom the clinical follow-up was over 1 year were included in this retrospective study. There were 17 females and 2 males, and the mean age was 73.2 years. The causes were slip from a short height (18 cases) and a minor car accident (1 case). We evaluated the union period, nonunion, malunion and the Constant score and analyzed several factors affecting the functional result, such as age, fracture pattern, and malunion. Results: Seventeen cases (89.5%) obtained union within 12.8 weeks on average. Neck-shaft angle was 125.3 o on average, with seven cases of malunion. The Constant score was 84.1 on average, and there were excellent scores in 11 cases, good scores in 4 cases, and fair scores in 2 cases. Fracture pattern, neck-shaft angle, or malunion did not affect the functional outcome, and elderly patients showed poorer shoulder function. Conclusion: Proximal humeral fractures with osteoporosis may achieve a high rate of bony union when treated with conservative methods. Despite the common occurrence of malunion, a satisfactory functional outcome may be expected. Key Words: Shoulder fracutre, Proximal humeral fracture, Aged, Conservative treatment, Osteoporosis 서 론 Received May 31, 2013 Revised July 16, 2013 Accepted August 20, 2013 Address reprint requests to: Chang-Wug Oh, M.D., Ph.D. Department of Orthopedic Surgery, Kyungpook National University Hospital, 130 Dongdeok-ro Jung-gu, Deagu 700-721, Korea Tel: 82-53-420-5630 ㆍ Fax: 82-53-422-6605 E-mail: cwoh@knu.ac.kr 상완골근위부골절은비교적흔한골절로사지골절의약 4-5% 를차지하고 3), 고령사회로빠르게진입하고있어골다공증성상완골근위부골절의발생률은가파른증가추세에있다 8). 정확한해부학적정복과빠른재활운동을할수있다는장점이있어관혈적정복및내고정술이근위상완골골절에많이적용되고있으며, 최근잠김금속판의 Copyright c 2013 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/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 292

고령환자의상완골근위부골절에서보존적치료결과 293 개발과수술기법의향상으로골다공성골절을보다견고히고정할수있게됨에따라 1,10) 수술적치료가더확대되고있다 2). 그럼에도불구하고, 많은연구에서수술적치료후에핀또는나사못의이동, 고정물의실패, 관절내나사못의돌출, 그리고상완골두의골괴사등은여전히드물지않으며, 이는좋지않은기능적결과를보고하고있다 4,6,19). 이에반하여, 상완골근위부골절에서가장흔히적용되고있는보존적치료는비전위골절뿐만아니라, 전위된 2 분골절에서도우수한골유합률이보고되고있다 5). 하지만보존적치료는단순하고비침습적치료방법이지만환자의협조가매우필요하므로일률적인결과를얻기힘들고, 환자의순응성이좋지않을경우부정유합이발생할가능성이높으며장기간의고정및운동제한이따르므로기능적인결과가나쁠것이라고예상할수있다. 또한근위상완골골절을보존적치료에대한연구는한국인을포함한동양인에서거의없어이에저자는보존적으로치료한근위상완골골절에서유합률과부정유합을포함한방사선결과를알아보고부정유합과보존적치료기간동안의고정이견관절의기능적결과에미치는영향을알아보고자하였다. 대상및방법 2008 년 2 월부터 2012 년 2 월까지경북대학교병원에서근위상완골골절로보존적치료를시행한환자 30 명중 55 세미만인경우, 추시기간이 1 년미만인경우, 기능평가가불가능한환자 ( 뇌혈관질환등에따른신경학적병변이있는경우 ), 병적골절, 개방성골절, 견관절골절 - 탈구손상, 상완골의해부학적경부골절, 비전위골절등을제외한 19 명, 19 예의환자에대하여후향적연구를실시하였다. 남자 2 명, 여자 17 명이었으며평균나이는 73.2 세 (55-92 세 ), 우측 7 예, 좌측 12 예였고평균추시기간은 16.1 개월 (12-49 개월 ) 이었다. 골절의발생원인은단순미끄러짐이 18 예, 교통사고 ( 조수석탑승 ) 1 예였고, 모든예에서전위골절이었다. 골절의분류는전후면및액와측면방사선사진에따른 AO-OTA 분류법에따라 11-A2 형이 8 예, 11-A3 형은 6 예, 11-B1 형은 5 예였다. 19 명의환자중에서이중에너지 x- 선흡수계측법 (DEXA, Lunar Prodigy ver 9.30; GE Healthcare Technologies, WI, USA; least significant change: L spine 2.66%, femur 2.63%) 이가능했던 12 명의평균 T- 점수는대퇴경부 2.3, 요추 2.7, 완관절에서 4.4 였고골다공증진단에부합하였다. 1. 보존적치료 어깨전후면및액와측면방사선사진상골절의위치를 파악한후되도록해부학적정복을얻으려고노력하였고건측과비교하여관상면및시상면상경 - 간각도를 10 도내로정복하였다. 골절정복이이루어지면적당한두께의패드를액와부부위에위치하게하여정복의소실이일어나지않도록한다음, U-slap 등의부목고정없이견관절고정기 (shoulder immobilizer) 를이용하여고정하였다 (Fig. 1). 이후 1, 2, 4, 6 주째방사선사진을촬영하여정복이유지되는지확인하였고, 정복상태의변화가있는경우패드의위치이동을통하여교정하였다. 4-6 주째보조기를제거하였으며, 2, 3, 6, 12 개월째방사선사진을추시관찰하였다. 환자는보조기착용중에는가능한범위안에서팔꿈치와수부의움직임을허용하였고 2 주째부터보호자의도움을받아옷갈아입기, 가벼운샤워등을허용하였고, 6 주째보조기를제거한후부터수동적진자운동을시작하였다. 점차적으로능동적 - 보조관절운동과수동적관절운동을증가시켰고이후능동적관절운동을허용하면서일상생활의복귀를격려하였다. 2. 평가방법 내원당시에전후면및액와측면방사선사진을촬영하였고추시관찰때에는액와측면방사선사진을대신하여경흉부상완골측면방사선사진을촬영하였다. 방사선학적평가로유합기간, 평균관상면경 - 간각도를측정하였으며부정유합, 불유합을확인하였다. 방사선학적유합은전후면과측면방사선사진에서 3 개의가교가골이형성되는시점으로정의하고유합까지의기간을확인하였고관상면경 - 간각도는전후면방사선사진을이용하여상완골의 Fig. 1. (A) An 80-year-old female using a shoulder immobilizer with an appropriate axillary pad. (B) An antero-posterior radiograph shows well-maintained reduction of the fracture during use of a shoulder immobilizer with axillary pad.

294 경부와 간부의 각도로 정의하였다. 최종 추시 때 관상면 상완골 경-간 각도가 110도 미만일 경우 내반변형으로 정 의하였다. 부정유합은 내반변형과 유합 후 대결절의 5 mm 이상 전위가 있는 경우로 정의하였고 불유합은 6개월 내에 유합을 얻지 못할 때로 정의하였다. 기능적 평가는 최종 추시 관찰 때 견관절의 운동 범위와 통증, 활동 정도 등을 확인하여 Constant 점수를 측정하였 다. Constant 점수는 0-50점을 불량, 51-65점을 보통, 66-80 7) 점을 양호, 80점 이상을 우수로 구분하였다. 통계학적 평가는 PASW Statistics version 18.0 (IBM Co., Armonk, NY, USA)를 사용하였고 Student t-test, MannWhitney test, Fisher exact test, Linear by linear associa- 백승길, 오창욱, 변영수, 오종건, 김준우, 윤종필, 이현주, 김형섭 tion test, Pearson correlation analysis test를 이용하였고, 유의수준 0.05 미만을 통계적으로 유의하다고 평가하였다. 결 과 총 19예 중 17예(89.5%)에서 유합을 얻었고(Fig. 2), 2예 의 수술적 치료로의 전환은 불충분한 가골의 형성 1예와 환자 순응성 결여로 인한 조기에 수술적 치료로 전환된 경 우가 1예 있었다. 평균 유합 기간은 12.8주(범위, 7-25주) 였으며, 평균 경-간각은 125.3도(범위, 92-170도)였다. 합병 증으로 부정 유합이 7예(내반변형 4예, 대결절의 부정유합 2예, 내반변형과 대결절의 부정유합이 같이 있는 경우 1예) Fig. 2. (A) A 78-year-old female with a displaced proximal humerus fracture (AO/OTA 11-A2). (B) Satisfactory reduction was achieved. (C) After 16 weeks, bony union was obtained, with acceptable alignment. (D) At 1 year, the patient had almost full recovery of her shoulder movements with a Constant score of 93 points. Fig. 3. (A) An 84-year-old female sustained a proximal humerus fracture (AO/OTA 11-A2). (B) Reduction was achieved. (C) At 12 weeks, bony union was obtained, with varus deformity. (D) At 4 years, the patient showed a good functional outcome with mildly limited movements of the shoulder.

고령환자의상완골근위부골절에서보존적치료결과 295 Table 1. Summary of Cases Age (yr) Number Union time (wk) Coronal neck-shaft angle ( o ) Constant score 55-59 60-69 70-79 80 Average 3 3 7 (1 case: nonunion) 6 (1 case: poor compliance) 19 7.7 10.8 15.9 15.0 12.8 121.5 126.8 125.0 127.6 125.3 92.8 84.1 80.9 76.0 84.1 가있었으며 (Fig. 3), 그외다른합병증은없었다. 평균 Constant 점수는 84.1 점 ( 범위, 53-100 점 ) 이었으며, 우수 11 예, 양호 4 예, 보통 2 예로대부분에서양호이상의견관절기능을보였다 (Table 1). 방사선학적결과의분석에서, 나이가상완골경 - 간각도과부정유합에미치는영향은없었으며, 나이가증가할수록골의유합기간이증가함을보였다 ( 상관계수 0.507, p=0.027). 그외골절형태등에따른방사선결과의차이는없었다. 기능적결과의분석에서, 부정유합이없는군의 Constant 점수는 87.2 점으로부정유합군의 78.7 점에비하여다소높았으나, 통계적으로유의한차이를보이지않았다 (p=0.255). 하지만, 나이가증가할수록 Constant 점수가낮아지는결과를보였고 ( 상관계수 0.506, p=0.027), 또한 75 세미만군의 Constant 점수는 92.2 점으로 75 세이상군의 75 점에비하여의미있는견관절기능의차이를보였다 (p=0.028). 고 전위되지않은상완골근위부골절은보존적치료가가장흔히이용되는치료방법이나, 전위된골절의경우정복의실패또는유지실패등의요인을고려하고, 조기에견관절의기능을회복하기위하여, 최근적극적인수술적치료가증가하고있는추세이다 12). 경피적핀고정술, 관혈적정복및금속판고정술, 골수강내고정술과같은다양한수술적치료가행해지고있으나나사못의관절면침투, 금속물의이완, 금속판의파손과불유합과같은수술후의합병증도 30% 까지보고되고있다 6,9,16,19). 이는악화된견관절의기능을가져올뿐아니라최고 40% 까지의추가적인수술적치료를필요로하므로수술적치료의큰단점이되며, 특히골다공증이동반된경우위의합병증의가능성은높아진다 4,13-15,18,19). 보존적치료는수술적치료가어려운내과적질환이있는환자에서적응증이될수있다는보고가있지만 11), 본연구는수술적제한이없는환자에서보존적치료를시행한연구이며, 치료의순응실패는 1 예에 찰 불과하였다. 또한, 평균 70 세이상의환자들의전위된골절이주요대상인본연구에서는 19 예의환자중 17 예에서골유합을얻어높은유합률을보이고있어, 수술적치료에따른위험성을줄일수있는안전한선택으로생각할수있다. 보존적치료의가장큰단점은일률적인정복및그유지가힘들고, 정확한해부학적정렬을얻지못하므로, 부정정렬의가능성이높은것이다. 본연구에서관상면상완골경 - 간각은평균 125.3 도로양호한결과를보였으나, 내반변형과대결절의전위된유합등의 7 예의부정유합이있어비교적많은부정정렬의발생이있었다. 그럼에도불구하고대부분의환자의견관절기능은양호이상의결과를보였고, 부정유합의유무가견관절의기능적결과에큰영향을미치지않는것으로나타났는데, Torrens 등 17) 은 75 세이상의환자에서보존적치료가매우성공적이며, 일상생활에지장이없는견관절의기능을보인다고보고하였다. 또한, Yüksel 등 21) 은고령의환자의경우보존적치료후의방사선적결과가기능적결과에큰영향은미치지않고, 성공적인치료결과를얻을수있다고하였는데, 본연구에서도비슷한결과를보이고있어, 다소의부정유합은운동범위가큰견관절에서뚜렷한기능저하를일으키지않는것으로생각한다. 장기간의고정후에발생하는견관절의강직및운동제한은전통적인보존적치료의큰단점중의하나이다. 하지만, 본연구에서대부분의환자에서견관절의강직은발생하지않았으며, 일상생활에큰제한이없는기능적결과를보였다. 노인들의상완골근위부골절을보존적으로치료한다른연구에서도, 비록다치지않은쪽의견관절에비하여다소의 Constant 점수의감소는있었으나, 임상적으로일상생활에영향을미치지않는다는보고가있는데 17,20), 이는활동적인젊은연령군과는달리활동이적은고령의환자에서는다소의운동제한이견관절에미치는영향은적다고할수있겠다. 나이가많은한국인의근위상완골골절에대한보존적치료로서는비교적드문연구이나, 후향적연구와비교적

296 백승길, 오창욱, 변영수, 오종건, 김준우, 윤종필, 이현주, 김형섭 증례수가작은점, 그리고골절골편수가작은 AO 분류상 A2, A3, B1 골절을대상으로한점은본연구의단점에해당한다. 이에, 보다발전적인연구를위해서는수술적치료군을대조군으로하는전향적연구가시도되어야할것으로생각한다. 결 고령환자의상완골근위부골절에서보존적치료는높은유합률과최소한의합병증을동반하며만족할만한기능적결과를얻을수있으므로, 수술적치료전에먼저시도되는것이좋을것으로생각한다. 론 References 1) Badman BL, Mighell M: Fixed-angle locked plating of two-, three-, and four-part proximal humerus fractures. J Am Acad Orthop Surg, 16: 294-302, 2008. 2) Bell JE, Leung BC, Spratt KF, et al: Trends and variation in incidence, surgical treatment, and repeat surgery of proximal humeral fractures in the elderly. J Bone Joint Surg Am, 93: 121-131, 2011. 3) Court-Brown CM, Garg A, McQueen MM: The translated two-part fracture of the proximal humerus. Epidemiology and outcome in the older patient. J Bone Joint Surg Br, 83: 799-804, 2001. 4) Fjalestad T, Hole MØ, Hovden IA, Blücher J, Strømsøe K: Surgical treatment with an angular stable plate for complex displaced proximal humeral fractures in elderly patients: a randomized controlled trial. J Orthop Trauma, 26: 98-106, 2012. 5) Iyengar JJ, Devcic Z, Sproul RC, Feeley BT: Nonoperative treatment of proximal humerus fractures: a systematic review. J Orthop Trauma, 25: 612-617, 2011. 6) Konrad G, Audigé L, Lambert S, Hertel R, Südkamp NP: Similar outcomes for nail versus plate fixation of three-part proximal humeral fractures. Clin Orthop Relat Res, 470: 602-609, 2012. 7) Lam F, Mok D: Open repair of massive rotator cuff tears in patients aged sixty-five years or over: is it worthwhile? J Shoulder Elbow Surg, 13: 517-521, 2004. 8) Lind T, Krøner K, Jensen J: The epidemiology of fractures of the proximal humerus. Arch Orthop Trauma Surg, 108: 285-287, 1989. 9) Min WK, Sin SJ, Jeon IH, et al: Fixation failure of LCP during the treatment of proximal humerus fractures. J Korean Fract Soc, 19: 188-192, 2006. 10) Nho SJ, Brophy RH, Barker JU, Cornell CN, Mac- Gillivray JD: Innovations in the management of displaced proximal humerus fractures. J Am Acad Orthop Surg, 15: 12-26, 2007. 11) Oh JH, Kim YH: The current concepts in the treatment of proximal humerus fracture. J Korean Fract Soc, 25: 94-104, 2012. 12) Okike K, Lee OC, Makanji H, Harris MB, Vrahas MS: Factors associated with the decision for operative versus non-operative treatment of displaced proximal humerus fractures in the elderly. Injury, 44: 448-455, 2013. 13) Robinson CM, Amin AK, Godley KC, Murray IR, White TO: Modern perspectives of open reduction and plate fixation of proximal humerus fractures. J Orthop Trauma, 25: 618-629, 2011. 14) Solberg BD, Moon CN, Franco DP, Paiement GD: Locked plating of 3- and 4-part proximal humerus fractures in older patients: the effect of initial fracture pattern on outcome. J Orthop Trauma, 23: 113-119, 2009. 15) Sproul RC, Iyengar JJ, Devcic Z, Feeley BT: A systematic review of locking plate fixation of proximal humerus fractures. Injury, 42: 408-413, 2011. 16) Südkamp N, Bayer J, Hepp P, et al: Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study. J Bone Joint Surg Am, 91: 1320-1328, 2009. 17) Torrens C, Corrales M, Vilà G, Santana F, Càceres E: Functional and quality-of-life results of displaced and nondisplaced proximal humeral fractures treated conservatively. J Orthop Trauma, 25: 581-587, 2011. 18) van den Broek CM, van den Besselaar M, Coenen JM, Vegt PA: Displaced proximal humeral fractures: intramedullary nailing versus conservative treatment. Arch Orthop Trauma Surg, 127: 459-463, 2007. 19) Voigt C, Geisler A, Hepp P, Schulz AP, Lill H: Are polyaxially locked screws advantageous in the plate osteosynthesis of proximal humeral fractures in the elderly? A prospective randomized clinical observational study. J Orthop Trauma, 25: 596-602, 2011. 20) Withrow PM, Stoecker JL, Stevens K, Clark K: Nonoperative management of a patient with a two-part minimally displaced proximal humerus fracture: a case report.

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