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대한골절학회지제21권, 제2호, 2008년 4월 Journal of the Korean Fractrure Society Vol. 21, No. 2, April, 2008 종설 소아대퇴골골절의최소침습적금속판고정술 - 11 세환아의대퇴골골절에서 (Minimally Invasive Plate Osteosynthesis in Pediatric Femoral Fractures - What is an Optimal Treatment in a Femoral Fracture of 11 Years-old) 오창욱 경북대학교의과대학정형외과학교실 소아의대퇴골골절은견인술, 고수상석고고정등의보존적인치료가주로이용되어왔으나, 최근학동기의소아에서는환아의빠른학교로의복귀나가족의사회적복귀를위해수술적치료의이용이증가되고있는추세이다 7,10). 수술적치료방법중에서, 유연성골수정, 금속판내고정술, 외고정장치, 교합성골수정등의수술적치료까지다양한방법이이용되고있으며 2,5,6,24), 방법의선택은환자의나이, 골절의위치와형태, 술자의선호등에따라다르다. 각각의고정법은장, 단점이있으나, 수술적방법선택의중요한기준은빠른골의치유를도모할수있어야하며, 운동및보행을조기에허용하고, 또한합병증이작은내고정물이우선되어야한다 5). 본종설은 11 세소아의대퇴골골절 (Fig. 1) 에서의수술적치료를할때고려할점과저자가선호하는최소침습적금속판고정술에대해소개하고자한다. 선택가능한치료 1. 유연성골수정 (Flexible nail) 6 세이상의소아대퇴골골절에서가장많이선호되는유연성골수정은골절부의추가적인손상은주지않으면서, 빠른골의치유및재형성을유도하며, 성장판이나대퇴골두에영향을주지않는장점이있다 5,8,13,17). 하지만, 경험이적은의사가수술할경우, 적지않은수에서문제점과합병증을가져올수있으며, 유연성골수정의시술후가 Fig. 1. A femoral shaft fracture with a butterfly fragment in 11 years-old girl. 통신저자 : 오창욱대구광역시중구동인동 2 가 101 번지경북대학교의과대학정형외과학교실 Tel:053-420-5630 ㆍ Fax:053-422-6605 E-mail:cwoh@knu.ac.kr Address reprint requests to:chang-wug Oh, M.D. Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, 101, Dongin-dong 2-ga, Jung-gu, Daegu 700-422, Korea Tel:82-53-420-5630ㆍFax:82-53-422-6605 E-mail:cwoh@knu.ac.kr 169

170 오창욱 장많은문제점은슬관절부에남아있는골수정의돌출 (Fig. 2) 로인한통증또는자극이되겠다. 또한가는골수정을쓰거나, 양측의골수정의굵기가다른경우, 3 점고정이적절히이루어지지않는등의원칙적인고정을하지않을경우정복의소실을가져올수있다. 본증례와같이 10 세이상이고, 체중이 50 kg 가넘는경우에는유연성골수정을시행한다면, 기본적인생역학적안정성이매우작으므로, 정복의소실가능성이많다는보고가있다 (Fig. 3). Narayanan 등 15) 은분쇄가있거나체중이많은환자에서유연성골수정을시행할경우부정정렬의빈도가많다고보고한바있다. 그외에도, 근위부또는원위부의골절, 분쇄가있는골절, 두부손상등으로제어되지않는강직 (uncontrolled rigidity) 이있 는경우등은유연성골수정만으로는안정적인고정을얻을수없으며, 추가적인석고고정이필요한것이현실이다 5,14,25). 이는환자의조기운동이나관절의강직을유발할수있으므로이상적인치료라고하기힘들다. 2. 외고정장치 (External fixation) 과거, 외고정장치는조기체중부하와보행이가능한장점때문에많이이용되어왔는데, 분쇄가심하거나근위 Fig. 2. When flexible nails are remained too long distally, they will protrude the skin and soft tissue (arrow) and it provokes the infection and knee stiffness. Fig. 3. Although the femoral fracture was well reduced by flexible nails (left), the nails were bent and varus deformity occurred because the patient had a weight-bearing too early (right). Fig. 4. After the rigid interlocking nailing of femoral shaft fracture in an adolescent, an osteonecrosis of the femoral head occurred (arrow). This picture was from the courtesy of Dr. Byun Young-Soo in Daegu Fatima Hospital.

소아대퇴골골절의최소침습적금속판고정술 - 11 세환아의대퇴골골절에서 171 또는원위부골절의경우일반적인고정법이고정력이떨어지고, 골절정복의유지가힘들며, 성장판의손상이가능성이있으므로좋은대안으로많이이용되어왔다. 하지만, 일반적인단순골절에서의사용은핀감염, 재골절, 사두고근의구축, 보기싫은흉터등의합병증발생이적지않아최근이용빈도가줄어들고있다. 재골절은외고정장치의강성도가너무높아충분한간접가골의형성이이루어지지않아발생하는최대의단점으로여겨지고있다 23). 3. 교합성골수정 (Interlocking intramedullary nail) 성인의대퇴골간부골절에흔히이용되는교합성골수정은뛰어난강성도와비관혈적정복이가능하여조기운동및보행이가능하고, 부정유합의가능성이작고, 골유합률이매우높은장점이있다 9). 이는청소년기의소아에서도적용이가능하며, 이론적으로는가장이상적인치료가될것이다. 하지만, 성인에서와같이이상와 (piriformis fossa) 에서골수정을삽입할경우대퇴골두로의혈류차단 Fig. 5. These are the sequence of operatingprocedure in the suggested patient of Fig. 1. After the temporary reduction of femoral fracture with flexible nails, the plate was introduced through the submuscular tunnel. Then, the locking screws were fixed at the proximal and distal sides of the plate. The fracture site was not open to preserve the biology. The flexible nail makes an easier reduction of fracture, which facilitates the minimally invasive plate osteosynthesis (MIPO) procedure.

172 오창욱 에따른무혈성괴사 (avascular necrosis) (Fig. 4) 가발생할수있는데 19), 이는가장위험한합병증임에분명하다. 또한대퇴대전자부의조기골단판유합에따른외반고 (coxa valga) 와하지단축의위험성이따르게된다 3,21). 최소침습적금속판고정술 (minimally invasive plate osteosynthesis) 또는근육하금속판고정술 (submuscular plating) 최근골절치료에서각광을받고있는최소침습적금속판고정술은성인의골절중골수정이적용되기힘든장관골의골간단부의골절이나분쇄골절에이용되고있는생물학적고정법 (biologic fixation) 이다 1,16,20). 과거에행해진관혈적정복술은술기가쉬워다발성골절환자에서적용이추천되고있으나 12), 연부조직과골막의손상이많아혈액의손실이많고, 감염의위험성이높으며, 대퇴골의과다성장이많았으며, 금속판을제거후에재골절이일어날수있는단점들이많아지양되어온것이사실이다 4,22,26). 이와는달리최소침습적금속판고정술은골절부를개방치않으므로감염의가능성이낮고, 풍부한간접가골을형성하므로강도가좋은간접적가골 (indirect callus) 의형성과빠른골유합을유도하며, 골절의유합후금속판을제거시에발생할수있는재골절이예방되는것이큰장점들이다 11). 같은비관혈적고정방법인유연성골수정을사용한치료법은제시된증례처럼나이가많거나체중이많은환자에서의안정적인고정의유지가힘들다는것이단점인데, 최소침습적금속판고정술은고정력이충분하므로정복의소실을염려할필요가없고, 조기운동이가능한장점이있다. 또한, 분쇄가있거나, 근위또는원위부에골절이존재하여외고정장치외에는다른고정법이마땅치않을경우에본치료법이좋은선택이될수있다. 전술한바와같이청소년기의대퇴골골절은교합성골수정으로고정시에가장이상적인생역학적지지를주는것이장점이나, 대퇴골두무혈성괴사가발생할수있으므로이를배제할수있는본방법이좋은대체방법이되겠다. 특히최근에개발된잠김압박금속판을사용하다면그강성도가교합성골수정에가장근접하므로과거의압박금속판을사용할때보다우수한장점이있다. 최소침습적금속판고정술의단점은골절부를개방치않고고정을하므로그고정법이어렵고, 수술시간이많이걸리며, 이에따른방사선노출의가능성이높다는것이다. 즉, 수술법을익히는배움곡선 (learning curve) 이큰것이경험이적은의사들에게선호되지않은이유중의하나이며, 이는골절의정복에어려움이많음에따른것이다. 이에대한보완으로저자는 1 2 개의유연성골수정을이용하여임시적정복을한후에금속판을고정하는것을권유한다 18). 이는특히골절의위치가근위부또는원위부에위치하여정복과그유지가힘들거나, 분쇄가심하여정렬을얻기가힘들때, 더좋은선택이될수있다. Fig. 6. In postoperative films (left), a satisfactory reduction was achieved. The patient had a solid union, on 1 year follow-up films (right).

소아대퇴골골절의최소침습적금속판고정술 - 11 세환아의대퇴골골절에서 173 수술방법 본증례 (Fig. 5, 6) 는외측에나비골편을가진분쇄성골절이므로, 이는비관혈적정복을얻기가힘든골절형태이다. 금속판은골절부의분쇄부에대하여최소 3 배이상의충분한길이를선택하는것이필요하며, 가능한대퇴골의외연에맞도록미리적절히굽혀주는것이좋으며, 저자는최근개발된잠김압박금속판을선호한다. 2 개의유연성골수정을먼저원위부에서삽입하여임시적정복을하였는데, 이때하지의회전정렬및각정렬이적절한지를방사선투시경으로확인하는것이필요하다. 이는추후에이루어질최소침습적금속판고정술을보다쉽게행할수있도록하는전단계이며, 이미많은술자들이경험한유연성골수정의방법과다름이없으므로쉽게행할수있는기술이다. 이후, 원위부와근위부에각각약 3 cm 정도의피부절개를한다음, 근육하터널 (submuscular tunnel) 을만들고, 여기에준비된잠김압박금속판을삽입한다. 근육 하터널을통과한금속판을근위부와원위부절개를통하여 K- 강선으로임시고정을하는데, 이때금속판과골이적절하게위치하는지확인하는것이중요하다. 이후, 다른나사못구멍을통하여잠김나사못을고정하기시작하는데, 저자의경우각각 2 개의나사못을고정한후미리삽입되었던유연성골수정을제거한다. 이때근위부의나사못은가까운피질골만을고정하는것이좋은데, 이는유연성골수정이나사못에의해고정되어제거하지못할경우를예방하기위함이며, 잠김금속판을이용하는또다른장점이된다. 보통은근위부와원위부골편에각각 3 4 개의나사못을고정하며, 고정력을적절히고려하여일측만을고정한나사못은제거하고다시양측피질골을고정하는나사못으로교체할수도있다. 술후처치로는석고고정등은필요하지않으며, 동통이심하지않는한슬관절과고관절의적극적능동운동을권장한다. 체중부하및보행은추시촬영하는방사선사진의결과에따라결정하며, 저자의경우술후 1 개월에부 Fig. 7. A proximal femoral fracture in 7 years-old boy. In this fracture, the proximal fragment usually abducts and rotated externally. It makes the reduction very difficult. In the past, open reduction with the plate was commonly used. Fig. 8. With flexible nails, the reduction was achieved. Then, the plate was fixed in the MIPO method.

174 오창욱 Fig. 9. In postoperative films (left), a good alignment was achieved. The fracture united at 3 months postoperatively (right). 분체중부하, 이후충분한가골이형성되었을때전체중부하를허용한다. 요 소아의대퇴골골절은골절부를개방치않는생물학적치료가우선이며, 10 세이하의단순대퇴골골절은유연성골수정으로치료하는것이권유되고있다. 하지만, 골절의형태가분쇄가있거나, 골절의위치가근위또는원위부인경우 (Fig. 7 9), 체중이많은환아, 나이가 10 세이상의경우등은유연성골수정으로는술후안정성이부족하므로, 최소침습적금속판고정술이권유된다. 약 감사의글 본종설에일부사진을보내주신대구파티마병원의변영수과장님께감사드립니다. 참고문헌 1) Ağus H, Kalenderer O, Eryanilmaz G, Omeroğlu H: Biological internal fixation of comminuted femur shaft fractures by bridge plating in children. J Pediatr Orthop, 23: 184-189, 2003. 2) Aronson J, Tursky EA: External fixation of femur fractures in children. J Pediatr Orthop, 12: 157-163, 1992. 3) Beaty JH, Austin SM, Warner WC, Canale ST, Nichols L: Interlocking intramedullary nailing of femoral-shaft fractures in adolescents: preliminary results and complications. J Pediatr Orthop, 14: 178-183, 1994. 4) Caird MS, Mueller KA, Puryear A, Farley FA: Compression plating of pediatric femoral shaft fractures. J Pediatr Orthop, 23: 448-452, 2003. 5) Flynn JM, Hresko T, Reynolds RA, Blasier RD, Davidson R, Kasser J: Titanium elastic nails for pediatric femur fractures: a multicenter study of early results with analysis of complications. J Pediatr Orthop, 21: 4-8, 2001. 6) Galpin RD, Willis RB, Sabano N: Intramedullary nailing of pediatric femoral fractures. J Pediatr Orthop, 14: 184-189, 1994. 7) Greisberg J, Bliss MJ, Eberson CP, Solga P, d'amato C: Social and economic benefits of flexible intramedullary nails in the treatment of pediatric femoral shaft fractures. Orthopedics, 25: 1067-1070, 2002. 8) Heinrich SD, Drvaric DM, Darr K, MacEwen GD: The operative stabilization of pediatric diaphyseal femur fractures with flexible intramedullary nails: a prospective analysis. J Pediatr Orthop, 14: 501-507, 1994. 9) Herndon WA, Mahnken RF, Yngve DA, Sullivan JA: Management of femoral shaft fractures in the adolescent. J

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