대한골절학회지제24권, 제3호, 2011년 7월 Journal of the Korean Fracture Society Vol. 24, No. 3, July, 2011 증례보고 족관절탈구후후경골건감돈과장족무지굴건이탈에동반된 Checkrein 변형 - 증례보고 - 배서영ㆍ정형진ㆍ김만영 인제대학교상계백병원정형외과 20 세남자환자가우측족관절탈구로원위경비관절고정과외고정술을시행받았는데, 외고정기와원위경비나사못을제거한후첨족및 checkrein 변형이진행하여내원하였다. 단순방사선검사상우측족관절의내측관절간격과원위경비관절간격이넓어져있었고, 자기공명영상검사에서는후경골건이원위경비관절안으로감돈되어장족무지굴건의활주를방해하는소견이확인되었다. 이에장족무지굴건연장술과감돈된후경골건절제및장족지굴건이전술을시행하여치료하였는데, 이는흔하지않은증례로판단되어문헌고찰과함께보고하는바이다. 색인단어 : 족관절, 탈구, Checkrein 변형, 후경골건감돈 Checkrein Deformity by Incarcerated Posterior Tibial Tendon and Displaced Flexor Hallucis Longus Tendon following Ankle Dislocation A Case Report Su-Young Bae, M.D., Ph.D., Hyung-Jin Chung, M.D., Ph.D., Man-Young Kim, M.D. Department of Orthopaedic Surgery, Sanggye Paik Hospital, Inje University, Seoul, Korea We report a case of 20 year-old man who had unusual equinus and checkrein deformity following dislocation of his right ankle joint. He had been treated with distal tibiofibular screw fixation and external fixation. After removal of external fixator, he had suffered from progressive deformity of foot and ankle. Widening of distal tibiofibular joint and medial clear space was found on radiograph and it was revealed that posterior tibial tendon had been dislocated and incarcerated into the distal tibiofibular joint on MRI. We corrected the deformity with excision of incarcerated posterior tibial tendon, adhesiolysis and lengthening of flexor hallucis longus tendon, reconstruction of deltoid ligament and flexor digitorum longus tendon transfer. Key Words: Ankle, Dislocation, Checkrein deformity, Posterior tibial tendon incarceration 족관절을족저굴곡한상태에서는족지가신전되지만족관절을배굴할수록족지의굴곡변형이심해지는 checkrein 5) 변형은대부분의경우하지골절후골절부위에서장족무지굴건이반흔조직이나가골에의해유착되거나구획증후군에의해장족무지굴건이위축되는경우에발생하 며 1,4), 종골골절후에장족무지굴건의유착에의해발생하기도한다 1). 본교실에서는족관절탈구후첨족변형과함께발생한 checkrein 변형이장족무지굴건이비골구에감돈된후경골건에의해포착되어발생한예를경험하여이를보고하고자한다. 통신저자 : 배서영서울시노원구상계 6, 7 동 761-1 인제대학교상계백병원정형외과족부ㆍ족관절센터 Tel:02-950-1399, 1032 ㆍ Fax:02-950-1398 E-mail:sybae99@gmail.com 접수 : 2011. 3. 2 심사 ( 수정 ): 2011. 4. 8 게재확정 : 2011. 4. 28 Address reprint requests to:su-young Bae, M.D., Ph.D. Foot & Ankle Center, Department of Orthopaedic Surgery, Sanggye Paik Hospital, Inje University, 761-1, Sanggye 6,7-dong, Nowon-gu, Seoul 139-707, Korea Tel:82-2-950-1399, 1032 ㆍ Fax:82-2-950-1398 E-mail:sybae99@gmail.com 271
272 배서영, 정형진, 김만영 증례보고 20 세남자환자가우측족관절의첨족변형및부종과통증, 족부의 checkrein 변형으로정상보행이불가함을주소로내원하였다 (Fig. 1, 2). 이환자는내원약 7 개월전에골절을동반하지않은족관절탈구 (Fig. 3) 로타원에서족관절의관혈적정복과원위경비관절고정술및외고정술을시행받았고 (Fig. 4) 외고정장치와원위경비골고정나사못제거이후에첨족과 checkrein 변형이점차진행하여정상보행이불가능해졌다고호소하였다. 1. 신체검사 환자는족관절약 15 도족저굴곡상태에서수동적능동적으로족배굴곡이불가하였고족저굴곡은가능하였다. 족무지의 checkrein 변형은족관절 15 도족저굴곡상태에서도약 10 도의족저굴곡상태였으며수동적족배굴곡이불 가하였다. 2. 방사선검사 단순방사선검사에서는원위경비관절의뚜렷한이개와내측관절간격이넓어져있는것을확인할수있었다 (Fig. 2). 신체검사에서 checkrein 변형이뚜렷하고경골내과와거골사이간극이벌어져있어내측관절간격에장족무지굴건이감돈된것을의심하고자기공명영상검사를시행하였으나자기공명영상검사에서는경골의비골구후연으로후경골건이감돈되어장족무지굴건을전위시킨소견이관찰되었다 (Fig. 5). 3. 수술방법및수술소견 자기공명영상결과를근거로후경골건의비골구감돈으로판단되어수술적치료를시행하였다. 우측족관절내 Fig. 1. Equinus of right ankle and flexion deformity of interphalangeal joint of great toe. Fig. 2. (A) Anteroposterior view of right ankle shows widening of tibiofibular space and medial clear space. (B) Lateral view shows equinus and flexion deformity of great toe.
족관절탈구후후경골건감돈과장족무지굴건이탈에동반된 Checkrein 변형 273 Fig. 3. Immediate post-traumatic radiographs of other clinic show that talus was displaced into distal tibiofibular space. Fig. 4. (A) For initial treatment, open reduction and external fixation of ankle joint was done and a syndesmotic screw was inserted at other clinic. (B) Follow-up X-ray with the external fixator removed 2 months later. 과 5 cm 상방에서내과후방을지나주상골지점까지피부절개를가하고, 유착된연부조직을박리하여후경골건을확인후근위로박리하여그심부에서장족무지굴건과장족지굴건을확인하였다. 후경골건은근위로갈수록제경로를이탈하여족관절후연으로유착되어있었으며, 경골의비골구후연과비골사이에감돈된상태로섬유성반흔조직으로변성되어있었다 (Fig. 6). 이섬유화되고비후된반흔조직은장족무지굴건을후방및내측으로전위시키면서그활막과유착되어있었다. 이변성된후경골건을제거하고장족지굴건및장족무지굴건의유착을박리한후장족무지굴건의연속성이유지됨과활주를확인하였으나 checkrein 변형과첨족변형은교정되지않았다. 이에장족무지굴근의섬유화에따른변화로추정하였으며, 장족무지굴건을족관절중립위에서족무지의 60 도배굴이가능하도록연장하였다. 이때장족무지굴건에 Z 형절제를가한후에도족관절의수동적배굴이중립위까지되지않아경피적아킬레스건연장술과후방관절막절제를추가로시행하였다.
274 배서영, 정형진, 김만영 삼각인대완전파열과함께후경골건이손상되어내측을지지하는구조가없는상태를교정하기위하여후경골건을절제한원위부를내과와거골체를통과시킨후고정하여삼각인대의재건을시행하였고후경골건의기능보완을위하여장족지굴건을족저부중간지점에서절단하여주상골로이전하였으며 8), 원위경비관절이개에대하여족관절 외측에추가적인수직절개를통해반흔조직제거후원위경비관절을재정복하고 3 개의유관나사를이용해원위경비관절을고정하였다 (Fig. 7). 수술후일주일뒤부터조심스럽게수동적관절운동시작하였으며, 수술후 3 개월째유관나사를제거하고전체중부하를시행하였다. 수술후약 1 년뒤원위경비관절의이개와족관절내측관절간격이넓어진소견은관찰되지않았으며, 환자는평지의정상보행과가벼운달리기가가능한상태였다. 그러나족관절의관절간격협소가관찰되어외상성관절염진행에대하여장기추시가필요한상태이다 (Fig. 8). 고 찰 Fig. 5. Ankle MRI shows incarceration of posterior tibial tendon into the fibular groove of distal tibia (white arrows) and displaced flexor hallucis longus tendon (black arrows). 족부의 checkrein 변형이외상후에생기는기전은여러가지로설명되지만아직논란이있다. 장족무지굴건의유착에의한것이가장흔하다고알려져있고, 원위경골또는비골의골절후가골형성혹은족부의근육및건의구축에의해서도발생한다고알려져있다 1,4,5). 장족지굴건이동반이환되는경우도있으며보통굴근지대주위에서건단축과함께유착소견을보인다 6). 족부 checkrein 변형은흔히외상에의한원위경골골절합병증으로발생하지만만성염증, 종양, 골절후발생한족부구획증후군에의해서도발생할수있다 6). 수술적치료로는손상부위의유착을박리하거나장족무지굴건의이완술이주로시행되며, 대부분임상결과가좋다고알려져있다 4,7,9). 본증례는족관절탈구후에발생한첨족과 checkrein 변형으로, 족관절을최대족저굴곡한상태에서는족무지가중립위에달하지만족관절의점진적배굴에따라족무지의굴곡변형이심해지는 checkrein 변형의일반적임상소견을보였다. 하지만장족무지굴건의기능적단축의원인이골절부위의가골이나반흔조직에유착또는장족무 Fig. 6. (A) Posterior tibial tendon was displaced into the posterolateral aspect of the ankle joint. (B) Continuity of flexor hallucis longus tendon was intact (freer under the tendon).
족관절탈구후후경골건감돈과장족무지굴건이탈에동반된 Checkrein 변형 275 Fig. 7. Intra-operative ankle X-ray (AP and lateral views). Fig. 8. Follow-up standing ankle radiograph. 지굴근의구획증후군에의한것이아니라후경골건의감돈과시간이지나면서발생한후경골건과장족무지굴건의유착에의해발생한변형이었다. 후경골건이비골구후연에감돈됨으로써경비관절의이개를유발하면서동시에내측관절간격도점차넓어지게되었고, 90 도로감돈된후경골건의섬유화된반흔조직이장족무지굴근과건의경로를이탈시키고유착을초래했다. 후경골건은족관절의탈구시에감돈되어관절의정복을방해할수있는구조물인데본증례에서는정복을방해할뿐아니라지연성변형을유발하는한원인이될수있음을보여준다 3). 본증례에대한수술적치료과정에서후경골건과장족무지굴건의유착유리술만으로변형이교정되지않아, 장족무지굴건과아킬레스건연장술을시행하였고, 손상된족관절내측삼각인대를후경골건을이용하여재건하였다. 이후후경골건의기능보완을위하여장족지굴건이식술을시행하였다. 족부의 checkrein 변형에대한수술적치료결과는대체로우수한편이나약 25% 정도에서재발할수있다는보고도있는데 6), 본증례는수술후약 1년까지변형의재발없이정상보행이가능하였다. 그러나수술후방사선사진에서족관절간격의협소가관찰되어외상성관절염의발생여부에대한장기적인추시관리가필요할것으로판단된다. 족관절의골절혹은탈구시정복을방해할수있는구조물인후경골건이 2) 원위경비관절에감돈되어족관절탈구의수술적치료후에도족관절의첨족과족부의 checkrein 변형을초래하였음을이학적검사와 MRI 검사등으로진단하였고, 수술적치료로변형을교정할수있었다. 이에저자들은족관절의골절또는탈구의수술적치료후에도지연성 checkrein 변형의발생가능성을염두에두고세심한추적관찰이필요하리라고생각한다. 참고문헌 1) Carr JB: Complication of calcaneus fractures entrapment of the flexor hallucis longus: report of two cases. J Orthop Trauma, 4: 166-168, 1990. 2) De Zwart DF, Davidson JS: Rupture of the posterior tibial tendon associated with fractures of the ankle. A report of two cases. J Bone Joint Surg Am, 65: 260-262, 1983. 3) Ermis MN, Yagmurlu MF, Kilinc AS, Karakas ES: Irreducible fracture dislocation of the ankle caused by tibialis posterior tendon interposition. J Foot Ankle Surg, 49: 166-171, 2010. 4) Feeney MS, Williams RL, Stephens MM: Selective lengthening of the proximal flexor tendon in the management of acquired claw toes. J Bone Joint Surg Br, 83:
276 배서영, 정형진, 김만영 335-338, 2001. 5) Jahss MH: Disorders of the foot and ankle. Vol. 2. 2nd ed. Philadelphia, WB Saunders: 1471-1477, 1991. 6) Kwon H, Kim DW, Kim DJ, Sohn CS, Song JM, Rah SK: Checkrein deformity of the lesser toes following comminuted fracture of calcaneus: a case report. J Korean Fracture Soc, 11: 806-810, 1998. 7) Lee HS, Kim JS, Park SS, Lee DH, Park JM, Wapner KL: Treatment of checkrein deformity of the hallux. J Bone Joint Surg Br, 90: 1055-1058, 2008. 8) Myerson M, Corrigan J: Treatment of posterior tibialis tendon dysfunction with flexor digitorum longus tendon transfer and calcaneal osteotomy. Orthopedics, 19: 383-388, 1996. 9) Sanhudo JA, Lompa PA: Checkrein deformity--flexor hallucis tethering: two case reports. Foot Ankle Int, 23: 799-800, 2002.