177 pissn : 1226-2102, eissn : 2005-8918 Case Report J Korean Orthop Assoc 2019; 54: 177-181 https://doi.org/10.4055/jkoa.2019.54.2.177 www.jkoa.org 오인된심부정맥혈전증에대하여항응고제투여후발생한급성구획증후군 황석하 전호승 우영균 임성태 성애병원정형외과 Acute Compartment Syndrome after Anticoagulant Therapy to Misdiagnosed Deep Vein Thrombosis Seok-Ha Hwang, M.D., Ho-Seung Jeon, M.D., Young-Kyun Woo, M.D., and Seong-Tae Lim, M.D. Department of Orthopedic Surgery, Sung-Ae Hospital, Seoul, Korea Acute compartment syndrome, which is an orthopedic emergency, induces irreversible tissue necrosis by increasing the compartment pressure. In serious cases, this event may result in functional impairment, loss of the lower limb, and death by renal failure. When the patient initially presents with pain and swelling that are similar to deep vein thrombosis, a differential diagnosis between the two diseases is very critical. The authors encountered a case of acute compartment syndrome after anticoagulant therapy in a patient presenting with painful swelling of the left leg following a massage that was initially misdiagnosed as deep vein thrombosis. A fasciotomy was performed on this case with satisfactory results. This paper reports this case with a review of the relevant literature. Key words: compartment syndrome, deep vein thrombosis, anticoagulant therapy, fasciotomy 급성구획증후군은정형외과영역에서중대한응급질환중하 나로, 1) 구획내의압력이증가함으로써관류압을떨어뜨리고, 이 로인해조직에저산소혈증이발생하여돌이킬수없는조직의 손상및괴사가발생한다고알려져있다. 2) 급성구획증후군은기 능적장애, 하지의손실, 심할경우신기능저하를유발하여사망 까지이를수있으므로, 정확한조기진단및치료가매우중요하 다고알려져있다. 3,4) 저자들은항혈소판제제를복용중인환자에서마사지후생긴 단순근육내출혈을심부정맥혈전증으로오인하였고항응고제 투여후급성구획증후군으로진행되었으나응급으로근막절개 Received October 7, 2017 Revised December 27, 2017 Accepted April 13, 2018 Correspondence to: Ho-Seung Jeon, M.D. Department of Orthopedic Surgery, Sung-Ae Hospital, 22 Yeouidaebang-ro 53-gil, Yeongdeungpo-gu, Seoul 07354, Korea TEL: +82-2-840-7231 FAX: +82-2-840-7755 E-mail: j9422hs@hanmail.net ORCID: https://orcid.org/0000-0002-0172-9923 술을시행하여만족스러운치료결과를얻었다. 아직까지는저자들과같은증례가국내에보고된바없기에, 문헌고찰과함께본증례를보고하고자한다. 증례보고 53세남자가내원당일경락마사지를받은뒤발생한좌측하퇴부통증및종창을주소로응급실에내원하였다 (Fig. 1). 환자는 1 년전발생한뇌경색후유증으로좌측하지의근육위축과하지부종이지속되었고, 혈전을예방하기위하여이니스트클로피도그렐정 75 mg (Inist Bio Pharmaceutical, Hwaseong, Korea) 을복용중이었다. 내원당시좌측하지말단의감각은정상이었고, 좌측하지전체의근력은등급 4로관찰되었다. 통증정도는시각통증등급 5점이었고, 압통과함께경도의종창소견으로건측과큰차이를보이지않고있었다. 당시응급실에서시행한혈액검사에서백혈구수는 12,130/ml, 크레아틴인산분해효소는 270 IU/L였 The Journal of the Korean Orthopaedic Association Volume 54 Number 2 2019 Copyright 2019 by The Korean Orthopaedic Association 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.
178 Seok-Ha Hwang, et al. 으며, 그외에다른특별한이상소견은보이지않았다. 컴퓨터단층촬영정맥조영술에서후경골정맥과슬와정맥의혈행의감소소견및소량의근육내출혈소견을보였으나 (Fig. 2), 일반외과전문의가심부정맥혈전증으로오인하여환자를일반외과로입원시켜크렉산주 (enoxaparin sodium; Sanofi Winthrop Industrie, Madison-Alford, France) 0.8 ml를피하주사로 1일 2회투여하였다. 3일뒤환자는초기에시각통증등급 5점에서 8점으로점점심해지는극심한통증을호소하였고, 종창, 창백, 이상감각및족관 절배측굴곡의근력등급이 2로감소하였다. 급성구획증후군을의심하여환자를정형외과로전과받아수술적치료를시행하기위해다른원인들과감별하고자촬영한자기공명영상에서하퇴부후방근위 1/3 부위에위치한표재후방구획내의비복근과가자미근사이에형성된 20 cm 길이의거대혈종이주변의혈관을심하게압박하는소견이뚜렷하게보였다 (Fig. 3). 그리고임상적인증상 (5P 징후 ) 이뚜렷한경우에구획압측정없이증상만으로도급성구획증후군을진단하고근막절개술을시행할수있다는알고리즘 (Fig. 4) 5) 에따라구획압측정없이근막절개술과혈종제거술을시행하였다 (Fig. 5). 수술장에서도표재후방구획내의비복근과가자미근사이의거대혈종이관찰되었고, 주변으로파열된혈관은보이지않았으며, 근육의괴사소견은관찰되지않았다. 근막절개술시행후환자의족관절배측굴곡의근력등급은 4 로호전되었고, 수술후 5일째에재출혈또는혈종의재발소견이없는것을확인하여지연일차봉합술을시행하고수술후 3주째에는봉합사를제거하였으며, 목발보행이가능한상태로퇴원하였다. 1년원격추시에서특별한합병증이없었고, 목발없이보행이가능하였다. 고찰 Figure 1. Initial photograph of both lower legs. There was no significant difference in the swelling in both legs. 구획증후군은통증 (pain), 창백 (pallor), 이상감각 (paresthesia), 마비 (paralysis), 무맥 (pulselessness) 등의 5P 징후 를특징으로하며, Whitesides 방법이나휴대용구획압측정기를통해구획압을측정하여 30 mmhg 이상으로측정될경우혹은 5P 징후 가뚜렷 A B C Figure 2. Axial images (A, B) and 3-dimensional reconstruction image (C) of computed tomography venogram show a poorly visible posterior tibial and popliteal vein (thick short white arrows) with a heterogeneous density of subcutaneous soft tissue, small amount of intramuscular hemorrhage, and edema of the deep soft tissue (long thin white arrows).
179 Acute Compartment Syndrome after Anticoagulant Therapy to Misdiagnosed Deep Vein Thrombosis A B Figure 3. T2-weighted magnetic resonance axial image (A) and sagittal image (B) show multiloculated fluid collection, suggesting an extensive large hematoma compressing the adjacent vessels between the soleus and gastrocnemius muscle. Suspected compartmental syndrome Unequivocally positive clinical findings >30 mmhg* Clinical diagnosis made Patient not alert/unreliable polytrauma victim inconclusive clinical findings Compartmental pressure measurement Fasciotomy <30 mmhg* Continuous compartmental pressure monitoring and serial clinical evaluation >30 mmhg* <30 mmhg* *In patients with hypotension, compartmental syndromes may occur at pressures less than 30 mmhg. Currently we use 25 mmhg as the critical pressure in these patients. Figure 4. Algorithm for the diagnosis and treatment of acute compartment syndrome of lower leg after tibial fracture. Cited from the article of Bourne and Rorabeck (Clin Orthop Relat Res. 1989;240:97-104). 5) 한경우에는구획압측정없이도근막절개술의적응증이된다고알려져있다. 5) 그중에서도가장중요한것은손상정도보다훨씬심하게호소하는통증으로근육의괴사때문에오는통증이다. 침범된부위의근육을수동적으로신전시킬때통증이악화된다. 하지만 Ackermann 등 6) 은구획증후군에서통증이처음에는심하지않았으나수일에걸쳐심해졌던증례를보고한바있으며, 본증례에서도초기에통증의정도가시각통증등급 5점이었고, 종창의정도도건측과비교하여뚜렷한차이를보이지않아조기진단에어려움이있었다고생각된다. 심부정맥혈전증은열감, 발적, 통증및종창이중요한임상적특징이며창백, 표재성정맥의확장등의소견을보이기도한다. 7) 또한정확한진단을하는데있어, 임상증상이다양하기때문에위험요소로서환자의과거력을특히중요하게고려해야한다고알려져있다. 하지만이러한증상들가운데초기증상으로통증과종창만나타날경우에는본증례와같이구획증후군의증상과매우유사하게나타날수있어초기에두질환의감별이매우어려울수있다. Lopez 등 8) 은족저굴곡근의파열로인하여발생한심하지않은급성증상을보이는증례를심부정맥혈전증으로오인하였다고보고한바있다. 본증례에서도입원당시에통증은시각통증등급 5점으로매우높지않았고, 경도의종창을보이고있었으며, 이상감각, 마비등의증상들은보이지않았기에구획증후군으로진단하기가어려운상태였다고생각된다. 또한 Hiraga 등 9) 은본증례처럼뇌경색의과거력이있는환자에서항응고제의사용이근육내출혈을일으킬수있다고보고하였다. 그리고컴퓨터단층촬영정맥조영술에서후경골정맥과슬와정맥의혈류저
180 Seok-Ha Hwang, et al. A B Figure 5. (A) Extensive hematoma in the posterior compartment between the soleus and gastrocnemius muscles after fasciotomy can be seen. (B) After removing the hematoma of the posterior compartment, markedly swollen muscles were observed. 하소견이관찰되었고, 주변으로소량이지만근육내출혈소견이관찰되었으나이를간과하고심부정맥혈전증으로오인하였다. 그뒤심부정맥혈전증의치료를위해항응고제인크렉산주를 3 일간투여하면서출혈성경향이더욱심해져혈종의크기가크게증가하였고, 이로인하여증상이악화되었다고생각된다. 두질환의감별을위해서는심부정맥혈전증에서는 D-dimer 검사가선별검사로이용될수있으며, 도플러초음파가 97% 의민감도와 94% 의특이도를가지고있어진단검사로서유용하다. 7) 이외에도컴퓨터단층촬영정맥조영술도많이이용이되나특이도는 93%, 민감도는 71% 정도로정확도가떨어져확진검사로는도플러초음파가가장유용하다고볼수있다. 10) 한편, 구획증후군을진단하기위해서는자기공명영상으로해당구획의손상및종창을확인하는것이진단에도움이된다고하지만아직까지도구획압측정이가장신뢰할만한표준검사로알려져있다. 본증례와같이경미한외상으로인한구획증후군은초기에심부정맥혈전증과임상증상이매우유사하게나타날수있기때문에감별진단이어려울수있다. 따라서통증및종창의임상증상만을보이는환자에있어서는두가지질환을모두의심해야하며, 자세한병력청취, 자기공명영상, 도플러초음파등의다양한진단방법들을이용하여두가지질환을조기에감별하는것이극도로중요하다고생각되는바이다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES C. Acute lower-leg compartment syndrome. Orthopedics. 2013;36:619-24. 2. Von Keudell AG, Weaver MJ, Appleton PT, et al. Diagnosis and treatment of acute extremity compartment syndrome. Lancet. 2015;386:1299-310. 3. Oh CW, Lee HJ. Acute compartment syndrome after trauma. J Korean Fract Soc. 2010;23:399-403. 4. Fulkerson E, Razi A, Tejwani N. Review: acute compartment syndrome of the foot. Foot Ankle Int. 2003;24:180-7. 5. Bourne RB, Rorabeck CH. Compartment syndromes of the lower leg. Clin Orthop Relat Res. 1989;240:97-104. 6. Ackermann PW, Labruto F, Weiss RJ, Jansson KÅ. Increasing thigh pain: acute compartment syndrome! BMJ Case Rep. 2010;2010. pii: bcr12.2009.2513. 7. Bonner L, Johnson J. Deep vein thrombosis: diagnosis and treatment. Nurs Stand. 2014;28:51-8; quiz 60. 8. Lopez GJ, Hoffman RS, Davenport M. Plantaris rupture: a mimic of deep venous thrombosis. J Emerg Med. 2011;40:e27-30. 9. Hiraga A, Nakagawa Y, Kamitsukasa I, Suzuki T, Kuwabara S. Muscle haematoma due to antithrombotic treatment for ischaemic stroke. J Clin Neurosci. 2015;22:1160-3. 10. Peterson DA, Kazerooni EA, Wakefield TW, et al. Computed tomographic venography is specific but not sensitive for diagnosis of acute lower-extremity deep venous thrombosis in patients with suspected pulmonary embolus. J Vasc Surg. 2001;34:798-804. 1. Mauser N, Gissel H, Henderson C, Hao J, Hak D, Mauffrey
181 pissn : 1226-2102, eissn : 2005-8918 Case Report J Korean Orthop Assoc 2019; 54: 177-181 https://doi.org/10.4055/jkoa.2019.54.2.177 www.jkoa.org 오인된심부정맥혈전증에대하여항응고제투여후발생한급성구획증후군 황석하 전호승 우영균 임성태 성애병원정형외과 급성구획증후군은정형외과적응급질환이며, 구획내의압력이증가하여비가역적인조직의괴사를유발한다. 이것은기능적장애, 하지의손실및심할경우신기능저하를유발하여사망까지이를수있다. 환자가초기에통증과종창을호소하는경우심부정맥혈전증과유사하여두질환간의감별이매우중요하다고알려져있다. 저자들은마사지후좌측하퇴부의통증과종창을보이는환자를심부정맥혈전증으로오인하였고항응고제를투여하여발생한급성구획증후군에근막절개술을시행하였고만족스러운치료결과를얻었으며, 문헌고찰과함께본증례를보고하고자한다. 색인단어 : 구획증후군, 심부정맥혈전증, 항응고제, 근막절개술 접수일 2017 년 10 월 7 일수정일 2017 년 12 월 27 일게재확정일 2018 년 4 월 13 일책임저자전호승 07354, 서울시영등포구여의대방로 53 길 22, 성애병원정형외과 TEL 02-840-7231, FAX 02-840-7755, E-mail j9422hs@hanmail.net, ORCID https://orcid.org/0000-0002-0172-9923 대한정형외과학회지 : 제 54 권제 2 호 2019 Copyright 2019 by The Korean Orthopaedic Association 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.