대한외상학회지 Vol. 23, No. 2, December, 2010 원 저 흉골전위골절에대한수술적정복고정술의결과 건양대학교의과대학흉부외과학교실 김영진 조현민 Abstract The Result of Open Reduction and Fixation in Sternal Fracture with Displacement Young Jin Kim, M.D., Hyun Min Cho, M.D. Department of Thoracic and Cardiovascular Surgery, Konyang University College of Medicine, Daejeon, Korea Purpose: Sternal fractures after blunt thoracic trauma can cause significant pain and disability. They are relatively uncommon as a result of direct trauma to the sternum and open reduction is reserved for those with debilitating pain and fracture displacement. We reviewed consecutive 11 cases of open reduction and fixation of sternum and tried to find standard approach to the traumatic sternal fractures with severe displacement. Methods: From December 2008 to August 2010, the medical records of 11 patients who underwent surgical reduction and fixation of sternum for sternal fractures with severe displacement were reviewed. We investigated patients characteristics, chest trauma, associated other injuries, type of open reduction and fixation, combined operations, preoerative ventilator support and postoperative complications. Results: The mean patient age was 59.3years (range, 41~79). The group comprised 6 male and 5 female subjects. Among 11 patients who underwent open reduction and fixation for sternal fracture with severe displacement, 6 cases had isolated sternal fractures and the other 5 patients had associated other injuries. Sternal fractures were caused by car accidents (9/11, 81.8%), falling down (1/11, 9.1%) and direct blunt trauma to the sternum (1/11, 9.1%), respectively. 3 of the 7 patients (42.9%) who underwent sternal plating with longitudinal plates showed loosening of fixation. Otherwise, none of the 4 patients who underwent surgical fixation using T-shaped plate had stable alignment of the fracture. Conclusion: Sternal fractures with severe displacement need to be repaired to prevent chronic pain, instability of the anterior chest wall, deformity of the sternum, and even kyphosis. In the present study, a T-shaped plate with a compression-tension mechanism constitutes the treatment of choice for displaced sternal fractures. (J Korean Soc Traumatol 2010;23:175-179). Key Words: Thoracic trauma, Sternal fractures, Open reduction and fixation Address for Correspondence : Hyun Min Cho, M.D. Department of Thoracic and Cardiovascular Surgery, Konyang University College of Medicine, 685 Gasuwon-dong, Seo-gu, Daejeon 302-718, Korea Tel : 82-42-600-9150, Fax : 82-42-600-9090, E-mail : csking1@konyang.ac.kr 접수일 : 2010 년 11 월 15 일, 심사일 : 2010 년 11 월 25 일, 수정일 : 2010 년 12 월 6 일, 승인일 : 2010 년 12 월 13 일 175
대한외상학회지제 23 권제 2 호 I. 서론흉골골절은비교적드문손상으로전체골절의 0.5% 미만을차지하며심한흉부둔상환자의약 8~10% 에서관찰된다.(1-4) 흉골골절은주로전흉벽의둔상에의해발생하는데, 일반적으로교통사고시가슴을운전대에부딪혀서생기게된다. 흉골골절의유병률과사망률은동반손상의정도에직접적으로관련되어있으며골절된흉골과는명확한관계가없다.(5,6) 대부분의경우흉골골절은직접적으로치료하지않고환자의약 95% 이상에서보존적치료가이루어지고있으나보존적치료시장기적인후유증이나골절의진행등에대한보고는제대로없으며, 지난약 50년간의보고들에의하면흉골골절에서내부장기의손상이없는경우에는사망률이낮다고되어있지만분명한흉벽기형혹은뚜렷한증상이있는경우의수술적교정법에대해서는확립된것이없는실정이다.(7,8) 이에저자들은전위를동반한흉골골절환자에서시행된수술적정복고정술의결과를분석하여심한흉골골절환자에대한적절한수술방법을찾고자하였다. II. 대상및방법 2008년 12월부터 2010년 8월까지건양대학교병원흉부외과에서흉골골절로진단받고입원치료를받은 87명의환자중에서전위를동반한심한흉골골절로진단받고환자혹은보호자의자발적동의하에연속적으로수술적정복고정술을시행받은환자 11명을대상으로후향적연구를시행하였다. 환자들의내원초진기록, 입퇴원및수술기록과단순흉부사진, 3차원흉부전산화단층촬영을분석하여환자의임상적특성, 흉부손상, 동반손상, 흉골골절 고정방법, 동반손상에대한수술, 수술전인공호흡기치료, 수술후합병증등을조사하였다. 흉골골절의수술적정복술의적응증은골절에의한심한통증과활동의제한이있는상태에서단순흉부촬영및 3차원흉부전산화단층촬영에서골절편의심한전위가관찰되거나전흉벽의동요흉으로인해인공호흡기이탈이불가능한경우로하였다. 흉골골절정복고정술은환자혹은보호자의자발적동의후전신마취하에시행되었으며마취유도시항생제를정맥주사하였다. 모든환자에서흉골절흔 (sternal notch) 과검상돌기 (xyphoid process) 사이흉골의중앙부에약 10 cm정도길이의정중절개를통해흉골골절부위를박리한다음양쪽골절편을정복하고골절부위주변의연부조직을제거한후티타늄금속판 (titanium plate, HANKIL TECH) 과나사 (titanium cortical screw, HANKIL TECH) 를이용하여고정하였으며필요한경우철사 (stainless wire) 를이용하여보강하였다 (Fig. 1). 흉골고정술시금속판의선택은초기에는주로직선금속판 (longitudinal plate) 을사용하였으나최근들어 T자형금속판 (T-shaped plate) 을이용하여고정하였다. 고정후흉골의뒷면에유착방지제를도포하고골절고정술부위에배액관을삽입한후정중절개부위를봉합하였다. 수술직후단순흉부촬영을통해혈흉이나기흉여부를확인하였고보행이가능한모든환자에서흉골측면사진을통해유합상태가제대로유지되는지추적관찰하였다. 통계방법은 PASW Statistcs v17.0.2 (SPSS Inc., Chicago, IL, USA) 를이용하여두군의차이를Chi-square test 로검증하였으며 p값이 0.05 미만인경우통계적으로유의한것으로판정하였다. Fig. 1. Open reduction and fixation of sternum with longitudinal plate (left) and T-shaped plate (right). 176
김영진외 : 흉골전위골절에대한수술적정복고정술의결과 III. 결과흉골전위골절로수술적정복고정술을시행받은환자는남자가 6명 (54.5%), 여자가 5명 (45.5%) 이었고, 평균나이는 59.3세 (41~79) 이었다. 수술적정복고정술후환자들의평균추적기간은 9.7개월 (2~22) 이었으며사망한경우는없었다. 입원일로부터수술일까지의평균기간은 11.5일 (4~24) 이었고일차수술후퇴원까지의평균기간은 20.7 일 (7~53) 이었다. 다른부위의골절이나손상없이흉골골절만있는경우가 6명 (54.5%) 이었고흉부손상은늑골골절 5례 (45.5%), 혈흉 4례 (36.4%), 혈기흉 1례 (9.1%), 기흉 1례 (9.1%), 견갑골골절 1례 (9.1%) 가각각확인되었으며다른부위의손상으로는간의다발성열상과안면골골절이각각 1례씩있었다. 흉골골절정복고정술의방법은 직선금속판 (longitudinal plate) 를사용한경우가 7명 (63.6%) 이었고 T자형금속판 (T-shaped plate) 을사용한경우가 4명 (36.4%) 이었다. 동반수술은 5명 (45.5%) 에서시행되었는데그중 4명에서늑골골절정복고정술, 나머지 1 명에서는견갑골골절정복고정술을각각시행받았다. 11 명의환자중 2명 (18.2%) 에서합병증이발생하였는데, 모두호흡기합병증으로적절한치료후호전되었으며사망한경우는없었다. 그중1명은전흉벽의동요흉및급성폐손상으로인해수술전인공호흡기치료를받았던환자로수술후폐렴및호흡부전증후군이발생하여흉골골절수술후 8일째기관절개술시행받았고나머지 1명은수술후약 2개월후에시행한흉부전산화단층촬영에서폐렴및흉막삼출액이확인되어항생제치료및배액술후호전되었다 (Table 1). Table 1. General characteristics of patients (n=11) Characteristics N (%) Gender Male 6 (54.5) Female 5 (45.5) Mean age at operation, years 059.3±13.2 (41~79) Mean follow up, months 9.7±6.2 (2~22) Duration from admission to surgery, days 11.5±6.8 (4~24)0 Duration from surgery to discharge, days 20.7±13.8 (7~53) Injury mechanism In car TA* 7 (63.6) Pedestrian TA 2 (18.2) Fall down 1 (09.1) Assault 1 (09.1) Thoracic injuries Rib fracture 5 (45.5) Traumatic hemothorax 4 (36.4) Traumatic hemopneumothorax 1 (09.1) Traumatic pneumothorax 1 (09.1) Associated injuries Liver laceration 1 (09.1) Scapular fracture 1 (09.1) Facial bone fracture 1 (09.1) Type of sternal fixation Longitudinal plate 7 (63.6) T-shaped plate 4 (36.4) Combined operations O/R & I/F of ribs 4 (36.4) O/R & I/F of scapula 1 (09.1) Postoperative complications Pneumonia 2 (18.2) ARDS 1 (09.1) Pleural effusion 1 (09.1) Late mortality 0 (00.0) *Traffic accidents Open reduction and internal fixation 177
대한외상학회지제 23 권제 2 호 환자들을수술방법에따라두군으로나누어비교한결과 T자형금속판고정술군이직선금속판군에비해동반손상이더많았음에도불구하고수술후합병증발생에는차이가없었다. 이것은수술후합병증의발생이수술방법에따라차이가나는것이것이아니라동반손상의정도에의해결정되기때문으로생각된다. 수술결과를보면직선금속판을사용한 7명의환자중 3명 (42.9%) 에서외래추적관찰중고정된나사가풀려있는것이확인된반면에 T자형금속판을사용한 4명의환자에서는모두수술부위의유합상태가잘유지되고있었다 (Table 2). 동일한수술방법으로금속판의종류만다르게하여고정술을시행한결과직선금속판군에서만고정부위의이탈이관찰되었는데, 이것은직선금속판이 T자형금속판과달리고정부위의장력과압박에모두견딜수있는구조가아니기때문으로생각된다. 외래추적관찰중 1명의환자에서흉골골절정복고정술후 8개월이경과한다음인공고정물을제거하였는데, 인공고정물제거후에도유합상태가비교적양호하게유지되었을뿐만아니라전흉벽의통증이많이감소하였고자세의유지혹은일상활동의제한도거의없었다. IV. 고찰흉골의수술적고정술은과거에거의주목을받지못했는데, 이것은흉골골절의발생빈도가낮을뿐만아니라흉골골절중에서수술적교정의대상이될수있는골절편의전위나전흉벽의동요흉을동반한경우가매우적기때문으로생각된다. 뿐만아니라본연구에서보면수술적교정이필요한심한흉골골절의절반이상이다른부위의골절이나동반손상없이단독으로발생하였고흉강내장기손상도심혈관계손상이아닌혈흉, 기흉등의폐혹은흉막의손상이었다. 이러한결과는골절편의전위혹은전흉벽의동요흉등을동반한심한흉골골절환자에서치명 적인심혈관계손상보다는폐혹은흉막의손상이잘동반되고수술후에도폐렴, 무기폐, 흉막삼출, 호흡부전증후군등의호흡기합병증이더흔하게나타나므로호흡기치료가매우중요하다는것을의미한다. 흉골의전위골절은외상후초기에진단되지못할경우가관절증 (pseudoarthrosis), 폐환기장애, 전흉벽변형등의합병증이발생할수있으므로조기에진단하고치료하는것이환자의삶의질향상에중요한역할을하게된다. 예를들면흉골골절의합병증으로가관절증이발생한경우흔히심한통증을동반하면서활동의제한을초래할수있고, 흉골골절후오랜시간이지난다음발생한전흉벽변형에대한만기교정은수술적관점에서매우복잡한문제를야기시킬수있다. 흉골전위골절에대한정복고정술의방법은보존적치료로흉부척추의과신전을이용한비관혈적정복술이있고수술적치료로는 8자형철사접합, 금속판을이용한내고정술등이있다.(9-11) 일반적으로보존적인치료로정복되지않는심한전위골절에대해수술적정복고정술이시행되는데, 흉골골절에대한다양한수술방법들이개발되고경험이축적되면서심한흉골골절환자에서수술적정복고정술은안전하고효과적인치료방법으로이용되고있다. 저자들의경우에도흉골골절에대한치료방법의변화를보면, 2008년이전에는거의모든흉골골절환자에서보존적치료가시행되었지만그이후에는심한흉골골절의경우수술적정복고정술이초기치료로시행되고있다. 수술적정복고정술의방법으로는다분절골절에서특수한핀 (Steinmann pin) 을이용하여골절편을고정하는방법, 전위골절에서골절편의위아래를철사로묶어고정하는철사접합 (wiring), 금속판과나사를이용하는고정법등이보고되었다.(12-14) 특히골절편이심하게어긋난경우에금속판을이용한고정법이철사를이용한 8자형고정술에비해더단단하게고정할수있으므로최근에는외상으로인한흉골전위골절은물론이고정중흉골절개후흉골의만성불유합환자에서도금속판 Table 2. Comparison between longitudinal plate and T-shaped plate group (n=11) L*-group (n=7) T -group (n=4) p-value Sternal fracture 0.000 Isolated 5 (71.4%) 0 (000.0%) Combined injuries 2 (28.6%) 4 (100.0%) Postoperative complication NS Yes 1 (14.3%) 1 (025.0%) No 6 (85.7%) 3 (075.0%) Surgical fixation of fracture 0.000 Complete 4 (57.1%) 4 (100.0%) Incomplete 3 (42.9%) 0 (000.0%) *Longitudinal plate T-shaped plate 178
김영진외 : 흉골전위골절에대한수술적정복고정술의결과 과나사를이용한고정법이많이시행되고있다. 금속판을이용한고정법은골절편을단단하고정확하게맞출수있어정상유합이가능하게할수있을뿐만아니라종격동연부조직의박리를최소화하여중요장기의손상이나흉골의부행혈관차단등의위험성을감소시킬수있다는장점이있다. 더나아가전위를동반한심한흉골골절환자에서수술적정복고정술은환자의통증을감소시키고폐기능을향상시키며가관절증및전흉벽기형을방지할수있을것이라생각된다. 본연구에서금속판을이용한수술방법을비교한결과티타늄 T자형금속판을이용한내고정술이티타늄일자형금속판을이용한경우에비해유합이더잘유지되는것을확인할수있었다. 이러한결과는 T자형금속판이장력과압박에모두잘견딜수있는구조로되어있어골절편의전위를진행시키려는힘에저항하여골절편의유합을정상적으로유지하는것이가능하기때문이다.(15) 실제로흉골의볼록한전면이장력에노출되면오목한후면에는압박이증가하게되는데, 전위골절전면에부착된고정물중에서 T자형금속판이일자형금속판에비해굴곡력을더잘이겨낼수있기때문에흉골후면의골절편또한압박이적어져서골절편의유합을보다잘유지할수있는것이다. V. 결론단순흉골골절혹은동반손상이있는환자에서골절편의전위가심하거나전흉벽동요흉이있는경우에 T자형티타늄금속판을이용한내고정술은여러가지합병증이발생할수있는보존적치료에비해더효과적인치료방법이다. 흉골골절에대한수술적정복고정술의단기적인교정효과는물론이고장기적으로기능적혹은미용적영역에대한평가및비용적측면에대한장점을보다확실하게알기위해서는앞으로다기관참여를통한전향적연구가필요할것으로사료된다. REFERENCES 01) Brookes JG, Dunn RJ, Rogers IR. Sternal fractures: A retrospective analysis of 272 cases. J Trauma 1993;35:46-54. 02) Helal B. Fractures of the manubrium sterni. J Bone Joint Surg Br 1964;46:602-7. 03) Potaris K, Gakidis J, Mihos P, Voutsinas V, Deligeorgis A, Pet V. Management of sternal fractures of 239 cases. Asian Cardiovasc Thorac Ann 2002;10:145-9. 04) Mayba II: Non-union of fractures of the sternum. J Bone Joint Surg Am 1985;67:1091-3. 05) Trinca GW, Doaley BJ. The effects of mandatory seat belt wearing on the mortality and pattern of injury of car occupants in motor vehicle crashes in Victoria. Med J Aust 1975;1:675-8. 06) Gouldman JW, Miller RS. Sternal fracture: a benign entity? Am Surg 1997;63:17-9. 07) Harley DP, Menal I. Cardiac and vascular sequelae of sternal fractures. J Trauma 1986;26:553-7. 08) Sadaba JR, Oswal D, Musch CM. Management of isolated sternal fractures: determining the risk of blunt cardiac injury. Ann R Coll Surg Engl 2000;82:162-6. 09) Hills MW, Delprado AM, Deane SA. Sternal fractures: Associated injuries and management. J Trauma 1993;35:55-60. 10) van Sterkenburg SM, Brutel de la Riviere A, Vermeulen FE. Sternal fixation with absorbable suture material. Eur J Cardio-thorac Surg 1990;4:345. 11) Athanassiadi K, Gerazounis M, Moustardas M, Metaxas E. Sternal fracture: retrospective analysis of 100 cases. World J Surg 2002;26:1243-6. 12) Molina JE. Evaluation and operative technique to repair isolated sternal fractures. J Thorac Cardiovasc Surg 2005;130:445-8. 13) Kitchens J, Richardson JD. Open fixation of sternal fracture. Surg Gynecol Obstet 1993;177:423-4. 14) Bonney S, Lenczner E, Harvey EJ. Sternal fractures Anterior plating rationale. J Trauma 2004;57:1344-6. 15) Al-Qudah Abdullah. Operative treatment of sternal fractures. Asian Cardiovasc Thorac Ann 2006;14:399-401. 179