ORIGINAL ARTICLE pissn 1598-3889 eissn 2234-0998 J Korean Soc Surg Hand 2011;16(4):204-210. JOURNAL OF THE KOREAN SOCIETY FOR SURGERY OF THE HAND 소아전완부골간부골절에서원위골단판을관통한골수강내 K- 강선고정술 Percutaneous Transphyseal Intramedullary Kirschner Wire Fixation for Pediatric Diaphyseal Forearm Fractures 한수홍 이순철 최영락최정필 이호재 차의과학대학교분당차병원정형외과학교실 접수일 2011 년 9 월 26 일수정일 2011 년 12 월 8 일게재확정일 2011 년 12 월 8 일교신저자이순철성남시분당구야탑동 351 차의과학대학교분당차병원 TEL 031-780-5270 FAX 031-703-3578 E-mail lsceline@hanmail.net * 본논문의요지는 2010 년도대한수부외과학회추계학술대회에서발표되었음. 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 noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 목적 : 수술이필요한소아전완부골절에대해경피적으로원위골단판을관통하여골수강내 K-강선고정술을시행한후, 그결과및안전성에대해평가해보고자하였다. 대상및방법 : 골수강내 K-강선고정술을시행한소아전완부골간부골절 36예에대하여후향적분석을시행하였다. 사용된 K-강선의직경을조사하였고합병증및최종추시방사선사진검사를통해전완골길이부동이나변형과같은성장이상이있는지조사하였고, 기능적평가를위해손목관절및전완의관절운동범위를측정하였다. 결과 : 평균연령은 9.5세였으며, 평균추시기간은 53개월 ( 범위 : 23-85개월 ) 이었다. 모든환자들에서한개의 K- 강선만을사용하여고정하였으며, 요골골절은 1.6 mm K-강선을, 척골골절은 1.1 mm K- 강선을주로사용하였다. 한예에서핀삽입부의염증소견이있었으나보존적치료후호전되었다. 골절부정복소실이나골단판조기유합, 불유합과같은다른합병증은없었으며, 전완골길이부동이나다른변형소견또한없었고, 건측에비해의미있는관절운동범위의차이를보인예도없었다. 결론 : 소아전완부골간부골절에대하여원위골단판을관통한골수강내 K-강선고정으로만족할만한결과를얻을수있었으며요척골의성장에영향을미치지않았다. 소아전완부골절에서수술적고정시골단판을피해통과해야할필요는없을것으로생각된다. 색인단어 : 전완골간부, 소아골절, 경골단판고정술 서론 소아의전완부골절은비교적흔히접하게되는손상의하나로수상당시성장판이열려있고성장에따라자연교정이이루어지는소아골절의특성상대부분의경우에있어도수정복및석고붕대고정으로만족스러운치료성과를얻을수있다 1-3. 그러나경우에따라서는골절의불안정성과이로인 한재전위로반복적도수정복을시행하여야하거나정복의유지가되지않아수술적치료가요구되기도한다. 간부의재골절및정복소실가능성이있어교정이필요하고 4,5, 정복후유지가안되는불안정성골절이나정복상태가만족스럽지못한경우, 또는동측상완골골절이동반된경우나병적골절, 신경혈관계손상, 부정유합및개방성골절등에서도수술적치료가고려돼야하겠다 6,7. 수술적치료를시행할경우 204 www.handsurgery.or.kr Copyright c 2011. The Korean Society for Surgery of the Hand
Soo-Hong Han, et al. Percutaneous Transphyseal Intramedullary Kirschner Wire Fixation for Pediatric Diaphyseal Forearm Fractures 그방법으로는금속판에의한관혈적내고정술과금속핀을이용한경피적골수강내고정술이있으며감염의위험성및이차적금속내고정물제거술이필요한관혈적방법보다는소아에서는최소침습적인 K-강선고정술이더선호된다 8. 금속핀을이용한골절부의고정에있어서소아의해부학적특성상성장판을관통한고정에대해의견을달리하는데, Boyden 과 Peterson 9 그리고 Horii 등 10 은성장판을관통하여고정하면핀에의한성장판손상으로 2차적인변형의가능성이있어골단판을통과하는고정은피해야한다고주장하는반면, Choi 등 11 과Richter 등 12 은핀에의한일시적성장판관통이변형을일으키지않기때문에필요시이러한고정도별문제가없다는등의이견을보이고있다. 이에저자들은수술이필요한소아전완간부골절에대해피부절개없이경피적으로원위골단판을관통하여골수강내 K-강선고정술을시행하였고, 그결과의분석과함께이러한술식의안전성에대하여평가해보고자하였다. 대상및방법 2000년 1월 1일부터 2010년 3월 31 일까지본원에서한명의술자에의해원위골단판을관통한 K-강선고정의수술적치료를시행하고, 1년이상추시가가능했던소아전완부골절 36예에대하여후향적분석을시행하였다. 평균추시기간은 53개월 ( 범위 : 23-85개월 ) 이었으며, 포함된대상은남아가 30명, 여아가 6명이었고, 평균연령은 9.5세 ( 범위 : 15개월- 14세 ) 였다. 36예의골간부골절중 30 예는요척골동시골절이었으며, 6예는요골간부단독골절이었다. 저자들의수술적응증은골절부가완전히전위되어양측피질골의접촉이없는골절에서도수정복이되지않는경우와, 외래추시관찰중정복소실또는전위나각형성이진행되는불안정골절이었다. 간부의분절골절이나개방성골절, 몬테지아골절 (Moteggia fracture) 과갈레아찌골절 (Galeazzi fracture) 등주위관절에탈구나불안정성이동반된경우는제외하였다. 결과분석을위해원위성장판을관통하여고정술에사용된 K-강선의직경을조사하였고, 그외감염, 재골절및정복소실과같은합병증과최종추시방사선사진검사에서건측과비교하여전완골길이부동이나변형과같은성장이상이있는지조사하였다. 기능적평가를위해, 손목관절의굴곡, 신전, 요측변위, 척측변위와전완의회내전과회외전의관절운동범위를측정하였고, 통증의잔존유무를파악하였다. 1. 수술방법수술은전신마취하에서상완부지혈대를팽창시킨후, 골절부의도수정복을시도하고, 방사선투시장치 (C-arm fluoroscopic apparatus) 를이용하여정복상태를확인한후골수강내고정술을시행하였다. 대부분의경우에있어비관혈적도수정복으로만족스러운정복을얻었으나그렇지못한경우에는경피적으로핀-지렛대방법을이용하여정복하기도하였다 (Fig. 1). 요골골절에있어서는 K-강선을요골경상돌기에서삽입하여원위골단판을통과해골수강내로삽입하였으며, 척골의경우척골경상돌기부에서한개의 K- 강선을삽입하여척골원위골단판을통과하여고정시켰고, 전예에서하나의 K-강선을사용하여고정하였다. 고정후에전완의회전, 주관절및수근관절의굴곡-신전제한이없음을확인한후, 주관절 90 굴곡및전완의중립위치에서장상지석고부목 (long arm splint) 으로안정을유지하였다. 술후약1 주일첫외래추시시장상지석고붕대 (long arm cast) 로전환하고, 고정강선의제거시기까지유지했으며, 5주이상고정이필요한경우에는단상지석고붕대 (short arm cast) 로바꿔주관절굴곡신전운동을허용하였다. 결과 총 36 예중, 요골골절의 61.1% 인 22 명에서 1.6 mm K- 강선 Fig. 1. Reduction of displaced fracture by pin leverage technique. www.handsurgery.or.kr 205
J Korean Soc Surg Hand Vol. 16, No. 4, December 2011 을, 척골골절의 73.3% 인 22명에서 1.1 mm K-강선을사용하였다 (Table 1). K-강선의제거는전후, 측면방사선사진상가골이명확히보이는시기에시행하였으며, 평균제거시기는 33일 ( 범위 : 26-48일 ) 이었다. 술후합병증으로부정유합및불유합은없었으며 1예에있어서핀삽입부의천부감염소견이있었으나소독치료및항생제처방등의보존적방법으로치료되었다. 추시중정복소실을보인경우는없었으며, 최종추시시에도건측의방사선사진과비교하여성장판손상에따른골 Table 1. Diameter of K-wires Case Radius Ulna 2.0 mm 3 0 1.6 mm 22 3 1.1 mm 10 22 0.9 mm 1 5 Total 36 30 단판조기유합, 변형, 길이부동등을보인예는없었다. 관절운동의회복에있어서는손목관절의장측굴곡은손상측 / 건측이평균83 /83, 배측굴곡은평균 81 /82, 요측변위평균 24 /26 척측변위평균 34 /34 였고, 전완의회내전평균 90 /90 와회외전 89 /88 로양측에의미있는차이를보이지않았고 (student t-test, p>0.1), 잔존통증을호소한예도없었다. 1. 증례 1 13개월남아로침대에서떨어지며우측요골골간부골절이발생되었고, 비수술적방법으로완전전위된골절이만족스럽게정복되지않아수술적치료를시행하였다. 수술시경피적핀지렛대방법을이용한정복후원위골단판을통과하는 K- 강선고정술을시행하였다 (Fig. 2A, 2B). 술후 4주째방사선학적유합을확인후 K- 강선을제거하였으며 (Fig. 2C), 술후 7 년 4개월째시행한방사선검사상전완부길이부동및골단판조기유합이나다른변형소견또한관찰되지않았다 (Fig. 2D). Fi g. 2. (A) Initial radiographs of a 13-month-old boy show displaced diaphyseal fracture of the radius. (B) Immediate postoperative radiographs. (C) Postoperative 4 weeks, the radiographs show radiological union. (D) Last follow up radiographs show no forearm length discrepancy after 7 years and 4 months. 206 www.handsurgery.or.kr
Soo-Hong Han, et al. Percutaneous Transphyseal Intramedullary Kirschner Wire Fixation for Pediatric Diaphyseal Forearm Fractures 최종추시시손목관절의운동범위로, 장측굴곡은좌우측각 90, 배측굴곡은좌우측각 85, 요측변위와척측변위가좌우측각각25, 35 로양측모두같은범위를보여주었고, 손목관절과전완에통증이나불편감없이일상활동을유지하고있었다. 2. 증례 2 11세남아로내원전축구하다가넘어지며우측요골및척골골간부를수상하였다. 전위된골절에대해도수정복을시도하였으나만족스런정복을얻을수없어수술적치료를시행하였으며, 원위골단판을관통하는 K-강선고정술을시행하였다 (Fig. 3A, 3B). 술후 6주째방사선학적유합을확인후 K- 강선을제거하였으며 (Fig. 3C), 술후 4년째시행한방사선검사상전완부길이부동이나변형등의합병증없이정상생활을하고있었다 (Fig. 3D). 고찰 소아의전완부골절은성인과달리도수정복및석고고정에의한보존적치료방법이치료의원칙이나 1,2 전위가있는골절에서도수정복이제대로이뤄지지않거나유지되지않아수술적치료를필요로하는경우도있다. 소아전완부골절의수술적치료에있어서 Slongo 13 은금속판과나사못을사용한 15예와골수강내핀고정술을사용한 21예를비교한결과, 술후핀삽입부위감염등의사소한부작용의빈도는골수강내고정술이조금더많았으나내고정물제거시대부분이해결된반면, 금속판과나사못을이용한고정시에는관혈적정복에따른심부감염, 신경손상, 연부조직손상등좀더심각한술후합병증이발생될수있다고하였다. Van der Reis 등 14 과Kay 등 15 도금속판내고정술이소아의전완부골절에있어좋은결과를보였다고보고했지만, 감염, 부정유합, 금 Fig. 3. (A) Preoperative radiographs of 11-year-old boy show diaphyseal both forearm.bone fractures with displacement. (B) Immediate postoperative radiographs show acceptable alignment. (C) The radiographs show radiological bone union after 5 weeks and 6 days of surgery. (D) Postoperative 4 years, the radiographs show no forearm length discrepancy and other deformity. www.handsurgery.or.kr 207
J Korean Soc Surg Hand Vol. 16, No. 4, December 2011 속판제거및재골절의가능성, 신경혈관계의손상가능성등의단점이있어 16, 개방적정복술의단점을보완하면서도수정복이가능한불안정성골절인경우폐쇄적골수강내삽입술이골간부나골간단부골절에효과적인치료법으로보고하였다 6,16,17. 금속핀을이용한고정에있어서그삽입방법에도이견을보이고있어서, Horn 등 18 은성장판을관통하는고정의경우핀에의한성장판손상으로인하여추후변형발생가능성이있기때문에, 그러한고정은피하고원위부에서부터핀을삽입하는후향적고정시성장판근위부에피부절개후그로부터삽입하기를권유하였다. Boyden 과 Peterson 9 그리고 Horii 등 10 은소아원위요골골절을수술적방법으로치료한증례에서골단판조기유합및그로인한성장장애와각변형의증례 2예를보고했으나, 이증례는수상당시이미골단판의손상을동반하였거나, 수술적치료를위해경피적방법이아닌관혈적방법으로골단판을노출하여정복을시도해서, 수술당시골단판의손상가능성이있는경우의증례였다. 반면에 Choi 등 11 과Richter 등 12 은골단판을통한골수강내삽입술과관련한문헌상의성장장애는없었다고보고하였으며, Yung 등 19 은골단판고정의안정성을유지할수있는가능한작은직경의나사산이없는, 겉면이매끈한금속핀 (smooth K-wire) 을사용하고, 손상을최소화하기위해신중하게한번혹은두번만에골단판을통과시킨후골수강내고정술을시행하였는데, 이를적용한 84 예에대해평균 70개월의추시기간동안의인성성장장애나골단판조기폐쇄등을조사한바, 그러한합병증소견은없었다고보고하였다. 본저자들도수술술기에있어서두번을초과하여골단판을통과시킨예는없었고, 전예에서나사산이없는 K-강선을삽입하였다. 척골에있어서도전예에서원위골단판을통한고정을시행하였는데, 저자와같은핀-지렛대방법을이용한전위골절의정복시정복의유지및핀삽입이비교적더용이하여같은방향으로핀삽입을시행하였고, Choi 등 11 도일부증례에서같은방법으로고정하였으나, 별문제를보고하지않았다. Horn 등 18 은 3.0 mm 직경의 K-강선을사용하여소아의원위대퇴골골절을치료함에있어일부성장판손상으로인한각변형등부작용을야기한증례를보고하기도하였으나, Choi 등 11 은주로 1.6 mm 굵기의 K-강선을사용하였으며, 여러문헌에서성장판을관통한 K-강선의굵기는다양한분포를보이나 2.0 mm 혹은그이상까지도성장판손상에대한문제는없었다고하였다 4,11,18,19. 본저자들의증례에서도직경 1.1 mm 및 1.6 mm K-강선을주로사용하였고, 필요시 2.0 mm 또는 0.9 mm K-강선을사용하였는데, 정복의유지에있어서불안정성을보이지않았으며, 최종추시까지성장장애나골단판조기폐쇄를보인예도없었다. 또한성장판을피한고정을위해서핀삽입부위의피부절개를 2-3 cm 가하는방법도있으나, 이는경피적으로삽입하는방법에비해피부절개에따른감염이나반흔, 기타합병증의이환가능성이상대적으로높을수있다. 그리고, 드릴로미리삽입부에구멍을만들고전완골모양에맞게휜강선을삽입하는방법도저자들의방법과거의같은개념으로적용될수있어서, 술자의선호에따라약간의변형된술기는가능하다고생각된다. 골수강내삽입술시전완골에서회전변형에대한안정성부여및골내부지지대역할과정복을유지하기위해삼점고정의개념을적용하지만 20, 저자들은소아에서는골유합시기가빠르고, 부목고정으로도회전변형을방지할수있다고판단하여삼점고정보다는드릴을이용해 K- 강선을곧게삽입하였다. 회전변형방지를위해술후 K-강선제거시기까지부목고정을시행하였고, 최종추시시회전변형에의한기능장애를호소한예는없었다. 회전제한의원인으로간부각형성에의한축성변형도중요한부분을차지하는데본저자들은수술에의한정복및고정으로이러한변형이발생되지않도록방지한것도회전제한의예방에역할을한것으로판단된다. 결론 수술이필요한소아전완부골절치료시원위골단판을관통한 K-강선고정이요척골의성장에별영향을미치지않았고기능적으로도만족할만한결과를얻을수있었다. 소아전완부골절에서수술적고정시반드시피부절개를동반하면서골단판을피해통과해야할필요는없을것으로생각되는바이다. 참고문헌 1. Bhaskar AR, Roberts JA. Treatment of unstable fractures of the forearm in children. Is plating of a single bone adequate? J Bone Joint Surg Br. 2001;83:253-8. 2. Calder PR, Achan P, Barry M. Diaphyseal forearm fractures in children treated with intramedullary fixation: outcome of K-wire versus elastic stable intramedullary nail. Injury. 2003;34:278-82. 3. Pugh DM, Galpin RD, Carey TP. Intramedullary Steinmann pin fixation of forearm fractures in children. 208 www.handsurgery.or.kr
Soo-Hong Han, et al. Percutaneous Transphyseal Intramedullary Kirschner Wire Fixation for Pediatric Diaphyseal Forearm Fractures Long-term results. Clin Orthop Relat Res. 2000;(376): 39-48. 4. Carey PJ, Alburger PD, Betz RR, Clancy M, Steel HH. Both-bone forearm fractures in children. Orthopedics. 1992;15:1015-9. 5. Daruwalla JS. A study of radioulnar movements following fractures of the forearm in children. Clin Orthop Relat Res. 1979;(139):114-20. 6. Jones K, Weiner DS. The management of forearm fractures in children: a plea for conservatism. J Pediatr Orthop. 1999;19:811-5. 7. Luhmann SJ, Gordon JE, Schoenecker PL. Intramedullary fixation of unstable both-bone forearm fractures in children. J Pediatr Orthop. 1998;18:451-6. 8. Cheng JC, Ng BK, Ying SY, Lam PK. A 10-year study of the changes in the pattern and treatment of 6,493 fractures. J Pediatr Orthop. 1999;19:344-50. 9. Boyden EM, Peterson HA. Partial premature closure of the distal radial physis associated with Kirschner wire fixation. Orthopedics. 1991;14:585-8. 10. Horii E, Tamura Y, Nakamura R, Miura T. Premature closure of the distal radial physis. J Hand Surg Br. 1993; 18:11-6. 11. Choi KY, Chan WS, Lam TP, Cheng JC. Percutaneous Kirschner-wire pinning for severely displaced distal radial fractures in children. A report of 157 cases. J Bone Joint Surg Br. 1995;77:797-801. 12. Richter D, Ostermann PA, Ekkernkamp A, Muhr G, Hahn MP. Elastic intramedullary nailing: a minimally invasive concept in the treatment of unstable forearm fractures in children. J Pediatr Orthop. 1998;18:457-61. 13. Slongo TF. Complications and failures of the ESIN technique. Injury. 2005;36 Suppl 1:A78-85. 14. Van der Reis WL, Otsuka NY, Moroz P, Mah J. Intramedullary nailing versus plate fixation for unstable forearm fractures in children. J Pediatr Orthop. 1998;18:9-13. 15. Kay S, Smith C, Oppenheim WL. Both-bone midshaft forearm fractures in children. J Pediatr Orthop. 1986;6: 306-10. 16. Sage FP, Smith H. Medullary fixation of forearm fractures. J Bone Joint Surg Am. 1957;39:91-8. 17. Lascombes P, Prevot J, Ligier JN, Metaizeau JP, Poncelet T. Elastic stable intramedullary nailing in forearm shaft fractures in children: 85 cases. J Pediatr Orthop. 1990; 10:167-71. 18. Horn J, Kristiansen LP, Steen H. Partial physeal arrest after temporary transphyseal pinning--a case report. Acta Orthop. 2008;79:867-9. 19. Yung PS, Lam CY, Ng BK, Lam TP, Cheng JC. Percutaneous transphyseal intramedullary Kirschner wire pinning: a safe and effective procedure for treatment of displaced diaphyseal forearm fracture in children. J Pediatr Orthop. 2004;24:7-12. 20. Verstreken L, Delronge G, Lamoureux J. Shaft forearm fractures in children: intramedullary nailing with immediate motion: a preliminary report. J Pediatr www.handsurgery.or.kr 209
J Korean Soc Surg Hand Vol. 16, No. 4, December 2011 Percutaneous Transphyseal Intramedullary Kirschner Wire Fixation for Pediatric Diaphyseal Forearm Fractures Soo-Hong Han, MD, Soon-Chul Lee, MD, Young-Rock Choi, MD, Jung-Pil Choi, MD, Ho-Jae Lee, MD Department of Orthopedic Surgery, CHA Bundang Medical Center, CHA University, Seongnam, Korea Purpose: Percutaneous pin fixation is commonly applied for pediatric diaphyseal forearm fractures. We analyzed the results of percutaneous transphyseal intramedullary K-wires fixation for pediatric forearm fractures and evaluated the safety of this procedure in terms of growth. Materials and Methods: Thirty-six pediatric patients with forearm diaphyseal fractures treated with transphyseal intramedullary K-wire fixation were reviewed retrospectively. Authors analyzed size and number of fixed K-wires and evaluated postoperative complications, bone length discrepancy and any deformity at the last follow-up. We also evaluated range of motion of wrist and forearm as a functional result. Results: The mean age was 9.5 years old and the average period of follow-up was 53 months (range: 23-85 months). Single wire was applied in each bone, and 1.6 mm sized K-wire was most commonly used for radius fractures and 1.1 mm K-wire for ulnar fractures. There was one superficial pin site infection which was healed by conservative treatment. There were no other complications such as premature epiphyseal closure, discrepancy of forearm length or any deformity. All patients showed no significant difference in range of motion compared to opposite side at the last follow-up. Conclusion: Percutaneous transphyseal intramedulaary K-wire fixation is one of the effective and safe operative treatment for pediatric forearm fractures without any deleterious effects on subsequent growth of radius and ulna. Keywords: Forearm diaphysis, Pediatric fracture, Transphyseal fixation Received: September 26, 2011 Revised: December 8, 2011 Accepted: December 8, 2011 Correspondence to: Soon-Chul Lee, MD Department of Orthopedic Surgery, CHA Bundang Medical center, CHA University, 351 Yatap-dong, Bundang-gu, Seongnam 463-712, Korea TEL: +82-31-780-5270 FAX: +82-31-703-3578 E-mail: lsceline@hanmail.net Orthop. 1988;8:450-3. 210 www.handsurgery.or.kr