Archives of Hand and Microsurgery Arch Hand Microsurg 2018;23(2):78-86. https://doi.org/10.12790/ahm.2018.23.2.78 pissn 2586-3290 eissn 2586-3533 Review Article 주관절의내측불안정성 정형석 1 ㆍ박민종 2 1 중앙대학교의과대학정형외과학교실, 2 성균관대학교의과대학삼성서울병원정형외과학교실 Medial Instability of the Elbow Hyoung Seok Jung 1, Min Jong Park 2 1 Department of Orthopedic Surgery, Chung-Ang University School of Medicine, Seoul, Korea 2 Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea Medial elbow instability has been a debilitating problem for the athlete performing overhead throwing and the increase in the number of participants in throwing sports has brought increase in its incidence in non-athletes. Instability can occur as a result of a single traumatic event, but, in most cases, it develops as a result of repetitive micro-trauma over a long period of time. During the overhead throwing, tensile force is applied to the medial stabilizing structures and compressive force is applied to the lateral structures. Common injuries encountered in the throwing elbow include medial collateral ligament tear, ulnar nerve neuropathy, flexor-pronator tendinitis or tear and valgus extension overload syndrome. Knowledge of the anatomy and biomechanics of the elbow joint, along with an understanding of throwing mechanism, is necessary to properly diagnose and treat the throwing athlete. The purpose of this article is to review the functional anatomy of medial elbow stabilizing structure, pathophysiology of medial elbow instability and its diagnostic method and treatment option including reconstruction of medial collateral ligament. Key Words: Medial elbow instability, Medial collateral ligament, Ulnar nerve 서론 주관절의내측불안정성 (medial instability) 은주로투구동작 (overhead throwing) 을하는스포츠에서반복적인미세손상 (micro-trauma) 에의해발생하며, 일상생활에의해유발되는증상은거의없으나, 공을던지는동작을하는중증상이나타나게된다. 급성탈구와같은외상후발생한내측측부인대 (medial collateral ligament) 의손상은치유가잘되며일상의기본동작이나물건을드는동 작등직업과관련한활동에서외반력 (valgus force) 이강하게부하되지않기때문에환자가기능적으로장애를호소하는경우는드물다 1. 따라서외상후내측불안정성이남는환자가있더라도실제로불안성의치료를위해인대재건술이필요한환자는상대적으로적은편이다. 외반안정성이결정적으로중요한동작은공이나물체를강하게던질때이므로임상에서내측불안정으로치료가필요한환자의대부분은일반인이아니라투구동작을하는운동선수, 특히투수가가장많으며최근에는투구동작을하는 Received May 11, 2018, Revised May 15, 2018 Accepted May 15, 2018 Corresponding author: Min Jong Park Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea TEL: +82-2-3410-3506, FAX: +82-2-3410-0061, E-mail: mjp3506@skku.edu Copyright c 2018 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. 78
Hyoung Seok Jung, et al. Medial Elbow Instability 운동에대한참여가증가하고있어이와관련된손상도증가하고있는추세이다 1. 이런환자들을치료하기위해서는주관절의정상해부학 (anatomy) 및생역학 (biomechanics) 에대해정확히알고있어야할뿐만아니라투구기전에대한이해도필요할것이다. 따라서주관절의내측안정성에기여하는구조물과불안정성의발생기전및치료방법에대해여러문헌고찰을통해알아보고자한다. 해부학및생역학 주관절의내측안정성은골성결합 (bony articulation) 과인대, 관절막등의정적 (static) 안정화구조물그리고공통굴곡근 (common flexor muscle) 등의동적 (dynamic) 안정화구조물이유기적으로결합하여이루어진다. 골성결합중특히척상완관절결합 (ulnohumeral articulation) 은서로요철이맞물려있는형태로 20도이하및 120도이상의주관절굴곡범위에서일차안정화구조물의역할을하며 2 투구동작 (overhead throwing) 이일어나는 20도이상및 120도이하의굴곡범위에서는전, 후방관절막 (anterior and posterior capsule) 과내, 외측측부인대가일차안정성을제공하는역할을하게된다 3,4. 내측측부인대는전방 (anterior), 후방 (posterior), 횡 (transverse) 의세부분으로구성된다 (Fig. 1A). 이중전방대는상완골내상 (medial epicondyle) 과전하방에서기시하여척골구상돌기 (coronoid process) 의내측돌출부에붙게된다. 전방대는해부학적으로굴곡-신전운동이이루어지는동안길이의변화가거의없는등척성 (isometricity) 에가까운형태를가지고있으며육안적으로도후방대에비해훨씬두껍고강해 5 운동범위에관계없이외반력에대한저항역할을가장효과적으로제공할수있다 (Fig. 1B). 요소두관절 (radiocapitellar joint) 은외반안정성의이차안정화구조물로작용한다. 외반력에대한일차안정화구조물은내측측부인대이지만이인대의역할이소실되면요골골두와소두간의관절접촉에의한안정성이중요한역할을하게된다 6. 수상기전 앞서언급했듯이, 치료를요하는대부분의내측측부인대의손상은급성외상이아니라반복적인스트레스에의해발생하는전형적인과사용손상 (overuse injury) 이다. 강한투구능력을발휘하기위해서는주관절에강한외반스트레스를가해야하기때문에투구횟수가증가하면할수록내측측부인대는조금씩손상을받을수밖에없다. 투구동작에대한분석은여러연구를통해잘알려져있으며문헌마다차이가있으나크게 6단계로나누어볼수있다 7. 1단계는공을던지기위한준비단계 (wind-up) 로주관절이굴곡되고전완부가회내전자세를유지하게된다. 2단계는공이글러브를나오는시점부터지면에발을내딛는순간까지를의미하는초기코킹 (early cocking) 단계로견관절의외전및외회전이일어나고주관절을굴곡하여외반자세로꺾게되면다음단계인후기코킹 (late cocking) 단계로진행하게된다. 4단계는주관절이외반자세를풀고신전되면서손이앞으로나와공을놓는가속 (acceleration) 단계, 5단계는공을던진후급속하게속 Anterior Medial epicondyle Anterior band Transverse Posterior Posterior band A B Fig. 1. (A) Anatomy of the medial collateral ligament. (B) The anterior band is the most important structure for valgus stability. Cited from the Park MJ. Hand and Upper Extremity Surgery: The Wrist and Elbow. Seoul: Panmun; 2017. www.handmicro.org 79
Archives of Hand and Microsurgery Vol. 23, No. 2, June 2018 도를줄이는감속 (deceleration) 단계이며마지막으로주관절이완전히신전되는팔로우스루 (follow-through) 단계로나눌수있다 (Fig. 2). 가속을붙이기직전어깨가완전히외회전된상태에서주관절을최대한외반자세로꺾어야팔이앞으로나오면서가속을높일수있는데, 외반스트레스에대해내측측부인대가장력 (tension) 을견뎌주어야가능하다. 결국후기코킹단계와초기가속단계에서얼마나강한외반자세를취할수있느냐에따라가속도가달라지고공의스피드와거리가결정된다. 여러생역학연구에따르면투구동작이일어나면내측에약 300 N의전단력 (shear force) 이발생하고외측에약 900 N의압박력 (compressive force) 이발생하며가속단계에서는추가적으로약 64 N 외반력이주관절에부과된다고알려져있다 8,9. 반복적인외반스트레스가가해지게되어요소두관절의관절염이진행될수있으며내측측부인대의손상이있으면관절염이더욱악화되게된다. 또한공을놓는단계에서주관절이강하게신전되면서후방의주두 (olecranon) 와주두와 (olecranon fossa) 사이에반복적인충돌이발생하게되면주두내측에골극이생기고이로인해충돌이더심해지는악순환이이어진다. 이렇게반복되는신전과외반스트레스로인해발생하는주두내측의특징적인충돌현상을외반신전과부하증후군 (valgus extension overload syndrome) 이라고부른다. 또한척골신경에도외반력에의한반복적인견인스트레스와내측측부인대손상으로인한이차적인압박과자극이가해져척골신경병증 (ulnar neuropathy) 이발생할수있으며투구할때강한손목의굴곡과회내전 을반복하기때문에굴곡-회내근의과다사용으로인한내상과염 (medial epicondylitis) 을일으키기도한다 10. 진단 1. 이학적검사 주증상은투구할때, 구체적으로말하면후기코킹단계와가속단계에서팔꿈치내측에느껴지는통증이다. 만일공을던지고난마지막단계에서통증이더심하다면후방의충돌또는외반신전과부하증후군이동반되어있는것으로보아야한다. 척골신경병증이동반될수있기때문에이에대한이학적검사도필요하며의심되는경우신경전도와근전도검사를통해객관적인상태를정확하게파악해야한다. 내측불안정성을확인하는검사로는외반부하검사 (valgus stress test), milking test, moving valgus stress test가대표적이다. 외반부하검사는주두돌기가주두와에잠겨있지않게약 20-30도주관절을굴곡시킨후외반력을주어통증이발생하는지를보거나반대측보다많이꺾이는지를확인하는검사이다 (Fig. 3A). 하지만반복적으로외반력이부과되었기때문에대부분의환자들에서정상측과비교할경우어느정도의이완성 (laxity) 이나타나게되므로벌어지는정도보다는통증의정도를더중요하게생각해야된다 8. 더객관적인검사를위해, 방사선촬영을하여반대쪽과비교하여 2.9 mm 이상내측척상완관절이벌어지면의미가있는것으로알려져있으나외반력이일정하지않을경우임상적가치는떨어질것 Wind-up Early cocking Late cocking Acceleration Decelaration Follow-through Fig. 2. The 6 phases of the overhead thrwoing motion. Cited from the Park MJ. Hand and Upper Extremity Surgery: The Wrist and Elbow. Seoul: Panmun; 2017. 80 www.handmicro.org
Hyoung Seok Jung, et al. Medial Elbow Instability A B Fig. 3. (A) Valgus stress test. (B) Moving valgus stress test. A B Fig. 4. Schematic of medial collateral ligament reconstruction with figure of 8 technique (A) and docking technique (B). Cited from the Park MJ. Hand and Upper Extremity Surgery: The Wrist and Elbow. Seoul: Panmun; 2017. 으로생각된다 11. Milking maneuver는이환된주관절을완전굴곡, 회외전시킨상태에서검사자가이환된팔의엄지손가락을잡고외반력을가하여통증의유무를확인하는검사법이다 12. Moving valgus stress test는어깨를완전히외회전시킨후 Milking test하듯주관절을굴곡, 신전시키면서지속적으로외반력을가해하는검사로 70도에서 120도사이에주관절내측에통증이나타나면양성으로보며 13 한연구에의하면 100% 의민감도 (sensitivity) 와 75% 의특이도 (specificity) 를보인다고알려져있다 (Fig. 3B) 14. 2. 영상의학검사주관절의단순방사선사진에서내측불안정과관련이있는과거골절, 즉요골골두, 구상돌기, 내상과골절의유합상태와변형을확인한다. 내측측부인대의석회화 (calcification) 도보일수있는데내측측부인대의만성적인손상을의미하나드물게는급성손상이후에도발생 할수있다 8. 그외에요소두관절의간격감소, 주두의골극, 관절내유리체 (loose body) 등이있는지확인한다. 골극이나유리체등관절내골병변은단순방사선사진보다전산화단층촬영 (computed tomography) 으로더자세히관찰할수있다. 자기공명영상 (magnetic resonance imaging) 은내측측부인대손상의진단에필수적인검사로여겨지고있으며치료방침을결정하는데있어서도중요한역할을한다. 내측측부인대손상에서자기공명영상을이용한연구에따르면, T2에서신호강도가높을수록보존적치료에잘반응하지않는다고발표하였다 15. 초음파 (ultrasound) 로도내측측부인대를관찰할수있는데특히최근에는정적검사가아닌주관절에부하를가하면서내측측부인대를동적으로관찰할수있어신뢰할만한진단적방법으로여겨지고있다 16. www.handmicro.org 81
Archives of Hand and Microsurgery Vol. 23, No. 2, June 2018 Table 1. Summary of studies of medial collateral ligament reconstruction Author Year (yr) Sport Number Mean age (yr) Surgical approach Fixation method Ulnar nerve transposition Rate of return to play (%) Rate of postoperative ulnar neuropathy (%) Mean follow-up (yr) Jobe et al. 18 1986 Baseball, javelin 16 25.3 FPM detachment Figure of 8 Yes (SM) 63 31.3 4.3 Azar et al. 25 2000 Baseball, football, 59 21.6 FPM retraction Figure of 8 Yes (SC) 81 1.7 2.95 wrestling, tennis Thompson et al. 26 2001 Baseball, javelin, football, platform diver, softball Rohrbough et al. 21 2002 Baseball, lacrosse, tennis, golf 33 24.3 FPM muscle split Figure of 8 No 82 4.8 3.1 36 23 FPM muscle split Docking No 92 2.8 3.3 Koh et al. 27 2006 Baseball 19 21.7 FPM muscle split Modified docking (3 strand) No 95 5.3 3.5 Paletta and 2006 Baseball 25 24.5 FPM muscle split Modified docking No 92 4 2.5 Wright 28 (4 strand) Dines et al. 22 2007 Baseball, football, 22 20.1 FPM muscle split DANE TJ No 86 9.1 3 hockey Bowers et al. 29 2010 Baseball 21 20 FPM muscle split Modified docking No 90 0 2.3 (3 strand) Dugas et al. 30 2012 Baseball 120 21.7 FPM retraction Figure of 8 Yes (SC) 88 20.8 2.8 No 83 2.6 3.25 Savoie et al. 31 2013 Baseball, softball, javelin Jones et al. 32 2014 Baseball, javelin, gymnastics 116 20.4 FPM muscle split Multiple technique Ulnar : bone tunnel or interference screw, Humerus : docking or figure of 8 55 17.6 FPM muscle split Docking No 87 7.3 2.6 FPM: flexor-pronator mass, SM: submuscular, SC: subcutaneous. 82 www.handmicro.org
Hyoung Seok Jung, et al. Medial Elbow Instability 치료 1. 비수술적치료방법 운동선수가아닌경우비수술적치료는대부분의환자에서만족할만한결과를보인다. 어느정도의불안정성이있더라도일상생활에서외반안정성이필요한동작이거의없기때문에직업이나일상생활에큰지장이없다면반드시수술이필요한것은아니다. 운동선수의경우에도처음부터파열정도가심한것이아니기때문에투구동작을중단하고재활치료를통해극복하려는노력을시도해보는것이우선이다. 재활치료는처음에는주관절관절운동범위의유지와굴곡-회내근의근력강화운동에중점을두어야한다. 또한견관절주변의근력을강화시킴으로써주관절로부하되는힘을줄일수있으며주관절의통증이완전히없어진이후에 2-3개월에걸쳐천천히투구동작을시작하는것이좋다 17. 2. 수술적치료방법내측측부인대의완전파열을가진운동선수에서통증이지속시인대재건술의적응이되며부분파열인경우에도적극적인비수술적치료후증상의호전이없다면수술적치료를고려할수있다. 또한팔의사용이많은환자나투구동작을전문적으로하는운동선수에서발생한내측측부인대의급성완전파열은조기수술적치료를고려할수있다. 내측측부인대의재건술은 1986년에 Jobe 등 18 에의해처음으로기술되었고그수술기법이발전하면서현재는투구동작을하는운동선수를대상으로널리시행되고있다. 한역학연구에따르면최근 10년에걸쳐재건술이꾸준히증가하였으며특히 17세에서 20세사이의젊은연령층에서그빈도가증가하고있다고보고하였다 19. 재건술전관절경시행은외반불안정성이불확실한경우나관절앞쪽으로유리체가있을경우를제외하고는정기적으로시행할필요는없다 20. 재건술은이식건을내측측부인대전방대의해부학적위치에삽입하고정상장력을준상태로고정함으로써등척성 (isometric) 인대를재현하는수술방법이다. 수술적술기에있어이식건의선택, 접근및고정방법, 척골신경의이전여부등에관해서는일치된의견은없으나대부분에있어서자가건을이용하고굴곡-회내근사이를갈라서 (splitting) 접근하며척골신경을이전하지 않는방법을가장많이사용하고있다. 고정방법으로는척골에 2개, 내상과에 3개의터널을만들어이식건을 8자모양으로통과시켜서로교차한상태에서봉합하는 Figure of 8 방법 (Fig. 4A) 18 과기시부에큰터널을먼저만든후내상과위쪽에서실이통과할수있는두개의작은터널을만드는 docking method가가장많이이용되고있다 (Fig. 4B) 21. 그외에간섭나사 (interference screw) 를이용하는 DANE TJ technique 22 이나앞선고정방법을혼합하거나변형 (modified) 시킨여러수술방법들이보고되고있다. 최근발표된체계적고찰에의하면내측측부인대재건술은 79% 에서수술전상태로회복 (return to sports at previous level) 이가능하고 90% 에서운동으로의복귀 (return to sports) 가가능하다고알려져있으며합병증은약 19% 로보고하고있는데이중척골신경손상이가장빈번하게나타나고있다고알려져있다 (Table 1) 23,24. 결론 주관절의내측불안정성은주로투구동작을하는운동선수특히투수에서문제가되는경우가많다. 투구동작시반복적인외반및신전힘이지속적으로가해짐에따라내측에견인력, 외측에압박력이부하되게되고이로인해내측측부인대의손상, 후내측충돌, 요소두관절염이문제가될수있다. 세심한병력청취및이학적검사와영상의학적검사를통해정확한진단이필요하며이를위해선주관절의해부학적구조뿐만아니라투구동작의생역학적인분석에대한이해도필요할것이다. 수술적치료는주로내측측부인대재건술을시행하게되며수술적기법이발전함에따라그임상결과도좋아지고있으나운동으로복귀시지속적인부하가다시갈수밖에없으므로치료방법을결정함에있어서의사와환자의충분한상의가필요할것으로생각된다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Cain EL Jr, Dugas JR, Wolf RS, Andrews JR. Elbow injuries in throwing athletes: a current concepts review. Am J Sports Med. 2003;31:621-35. www.handmicro.org 83
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Archives of Hand and Microsurgery Vol. 23, No. 2, June 2018 주관절의내측불안정성 정형석 1 ㆍ박민종 2 1 중앙대학교의과대학정형외과학교실, 2 성균관대학교의과대학삼성서울병원정형외과학교실 주관절의내측불안정성은투구동작을하는운동선수에있어서기능적으로문제를일으키는경우가많으며최근일반인에있어서도투구동작을하는운동에대한참여가증가하고있어이와관련된손상도증가하고있다. 내측불안정성은한번의손상으로도발생할수있지만대부분투구동작과정중내측에견인력, 외측에압박력이부하되게되고이런반복적인손상이축적되어발생하게된다. 이와관련해서내측측부인대의파열, 척골신경병증, 굴곡-회내근육의손상또는건염및외반신전과부하증후군이문제가될수있다. 이런환자들을치료함에있어서주관절의정상해부학및생역학에대해정확히알고있어야할뿐만아니라투구기전에대한이해도필요할것이다. 따라서여러문헌고찰을통해주관절의내측안정성에기여하는구조물및불안정성의발생기전과이를진단하는방법을살펴보고내측측부인대재건술을포함한치료방법에대해서도알아보고자한다. 색인단어 : 주관절의내측불안정성, 내측측부인대, 투구동작, 척골신경 접수일 2018 년 5 월 11 일수정일 2018 년 5 월 15 일게재확정일 2018 년 5 월 15 일교신저자박민종 06351, 서울시강남구일원로 81, 성균관대학교의과대학삼성서울병원정형외과학교실 TEL 02-3410-3506 FAX 02-3410-0061 E-mail mjp3506@skku.edu 86 www.handmicro.org