CSE REPORT J Korean Fract Soc 2019;32(2):97-101 ISSN 1225-1682 (Print) ㆍ ISSN 2287-9293 (Online) https://doi.org/10.12671/jkfs.2019.32.2.97 쇄골간부불유합의골고정술시행후발생한진행성상완신경총마비 - 증례보고 - 진홍기ㆍ박기봉ㆍ조형래ㆍ강정일ㆍ이완석 좋은삼선병원정형외과 Progressive rachial Plexus Palsy after Fixation of Clavicle Shaft Nonunion - Case Report - Hong-Ki Jin, M.D., Ki ong Park, M.D., Hyung Lae Cho, M.D., Jung-Il Kang, M.D., Wan Seok Lee, M.D. Department of Orthopedic Surgery, Good Samsun Hospital, usan, Korea Received November 21, 2018 Revised January 2, 2019 ccepted January 17, 2019 Correspondence to: Hong-Ki Jin, M.D. Department of Orthopedic Surgery, Good Samsun Hospital, 326 Gayadaero, Sasang-gu, usan 47007, Korea Tel: +82-51-310-9289 Fax: +82-51-310-9348 E-mail: hongiroom@naver.com The brachial plexus palsy is a rare complication of a clavicle fracture, occurring in 0.5% to 9.0% of cases. This condition is caused by excessive callus formation, which can be recovered by a spur resection and surgical fixation. In contrast, only seven cases have been reported after surgical reduction and fixation. case of progressive brachial plexus palsy was observed after fixation of the displaced nonunion of a clavicle fracture. The symptom were improved after removing the implant. Key Words: Clavicle fracture, Nonunion, rachial plexus neuropathy, Thoracic outlet syndrome Financial support: None. Conflict of interests: None. 상완신경총마비는신경및혈관의압박으로발생가능한흉곽출구증후군의일환으로쇄골골절후 0.3%-6.0% 로드물게발생한다. 1) 이러한압박증상은수상직후골절된쇄골골편에의한직접손상으로발생하거나불유합, 부정유합시과도한가골형성으로지연성으로발생될수있다. 2) 하지만수술후발생한경우는드물며특히지연성으로골고정술수술직후에발생한경우는해외에서 2예보고되어있다. 3) 저자들은쇄골불유합의골고정술직후진행성으로발생한상완신경총마비를경험하였고내고정물제거후회복되는결과 를얻었기에문헌고찰과함께보고하는바이다. 증례보고 40세남자환자로운동시우측쇄골의통증과견관절의불편감을주소로내원하였다. 과거력상 1년 8개월전보행자교통사고로타병원에서최초진단시우측쇄골간부의골절이관찰되었으나동반손상으로두개내경막하출혈및지주막하출혈이있었으며의식저하및자발호흡이불가능한상 Copyright 2019 The Korean Fracture Society. ll rights reserved. This is an Open ccess article distributed under the terms of the Creative Commons ttribution 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. www.jkfs.or.kr 97
Journal of the Korean Fracture Society Vol. 32, No. 2, pril 2019 태로두개내혈종제거및감압술을응급으로시행하였고쇄골골절에대해서는전위가심하지않아보존적치료를시행하였다고확인되었다. 1년 8개월경과관찰기간동안골절부는전위가증가되면서불유합이발생하였다 (Fig. 1). 본원내원후시행한단순방사선검사상우측쇄골골절부는전위가동반된불유합소견이관찰되었고, 컴퓨터단층촬영상불유합부위를중심으로근위및원위골편의하방으로가골이형성되어있었으나 (Fig. 1), 흉곽출구증후군의증상은관찰되지않았다. 이학적검사상쇄골불유합부위의전위로인하여골절상부의피부가돌출된상태였으며견관절전방거상시건측과비교하여견갑부운동이상증이관찰되었다. 견관절운동시통증과함께전방거상 130도, 외회전 50도, 내회전제3 요추높이로관절운동범위의제한이있었다. 환자는지속되는통증과운동범위제한및미관상의문제로전위된쇄골의교정수술을희망하였다. 수술은불유합및단축을교정하는해부학적복원을목표로골절부위하방의골극을제거한뒤단축된길이만큼의자가골반골지주골을이식하고관혈적정복및내고정술을시행하였다. 수술직후특별한신경학적증상은없었으나술후 2일째동측상완의저린감과수지의감각저하를호소하였고, 술후 3일째수지및수근부의근력저하를호소하였다. 증상은진행되어술후 5일째시행한이학적검사상우측수지, 수근부, 주관절의신전및굴곡근력이도수근력측정상 2단계로감소되었으나쇄골하동맥에대한애드손검사 (dson test) 는정상으로관찰되었고양측상완에서혈압과맥박은차이없이정상적으로측정되었다. 근력저하는지속적으로악화되어술후 7일에수지, 수근 부, 주관절, 견관절의신전및굴곡근력이 0단계의완전한마비증상이관찰되었으나우측상완을제외한다른부위의신경학적증상은관찰되지않았다. 마비의원인으로상완신경총의직접손상, 혈종에의한압박등을고려하여시행한우측견관절및경추부의자기공명영상검사에서상완신경총에서는정상적인연속성이관찰되었으며쇄골수술부위주변에국한된고신호강도만관찰되었고상완신경총주변으로압박을일으킬수있는혈종등의소견은없었다 (Fig. 2). 경추부자기공명영상에서도신경압박소견은관찰되지않았다 (Fig. 2). 수술 14일에시행한근전도검사에서신경전도검사상척골신경, 정중신경, 요골신경모두에서잠시 (latency) 와신경전도속도 (nerve conduction velocity) 는정상범위였으나진폭 (amplitude) 의감소가관찰되어축삭손상 (axonal injury) 을시사하는소견이관찰되었고, 침근전도검사상상완이두근, 삼각근, 상완삼두근, 요측수근신건, 요측수근굴근, 단무지외전근, 척측수근굴근, 제 1 배측골간근에서탈신경 (denervation) 을시사하는비정상자발전위 (abnormal spontaneous activity) 가관찰되어 whole brachial plexus lesion 또는 whole arm type의상완신경총병증 (brachial plexopathy) 으로진단되었다. 수술후뚜렷하게진행하는마비증상과이를뒷받침하는근전도검사소견을종합하여전위되었던쇄골이골고정술을시행한후정복되면서압박에의해발생한진행성상완신경총마비로판단하고골고정술후 15일에감압을위한내고정물제거수술을시행하였다. 수술장소견에서기구제거와동시에쇄골내측골편이외측에대하여 16 mm의상방전위가발생하면서수술전상태로재전위되었다 (Fig. 3). 기구 C Fig. 1. Distance from the 1st rib to the clavicle of the non-union side changed from 41.2 mm (, preoperative) to 28.5 mm (, postoperative). fter implant removal (C) displacement recurred and the distance increased to 42.1 mm. Three-dimensional computed tomography shows that bony spur alone coraco-clavicular ligament () was completely removed (, C). The level of the scapular spine migrated 24.6 mm upward after fixation () and returned to the preoperative state after implant removal (C). 98
Progressive rachial Plexus Palsy after Fixation of Clavicle Shaft Nonunion Hong-Ki Jin, et al. Fig. 2. () Postoperative thoracic outlet magnetic resonance imaging (MRI) shows normal brachial plexus continuity witout hematoma. () Cervical spine MRI shows cervical disc degeneration without both disc herniation or spinal cord lesion. Fig. 3. () Normal contour of the clavicle was recovered after a strut bone graft and fixation. () 16 mm step off of the medial clavicle fragment occurred immediately after removing the plate. 제거후 3일째상완의저림증상이감소되었으나근력의회복은관찰되지않았다. 7일에수근부신전이도수근력측정상 1단계로처음으로관찰되었고 10일에수지신전이회복 2 주에주관절굴곡및신전이 3단계까지회복되었다. 4주에견관절외전이 3단계까지회복되고술후 8주에상완의모든근력이수술전정상근력상태까지회복되었다. 고정술전과비교하여견관절운동범위의차이는없었으나운동시견관절통증은 visual analogue scale 상 5에서 3으로감소되었고견갑부운동이상증에대한재활치료를시행하였다. 고찰 쇄골은견관절이기능하고충분한운동범위를가질수있도록연결하고흉곽으로부터의거리를유지해주며외측은모양은얇고편평하며내측으로갈수록삼각형의두꺼운구조로하부의혈관과신경을보호한다. 중간 1/3 부위의골절이 80% 로가장흔하게발생하며이전에는주로비수술적인방법으로치료를시행하였으나불유합, 단축등의합병증발생이높다는보고들이제시되면서수술적치료의비율이증가하고있다. 하지만아직보존적치료에대한수술적치료의우수성에대한근거는부족하다. 4) 수술의적응증은심한분 쇄골절이있는경우, 2 cm 이상의전위, 인대의동반손상, 불유합, 개방성골절, 그리고혈관이나신경의압박소견이있는경우등이다. 5) 쇄골골절후발생하는흉곽출구증후군은 0.5% 로드물게보고되는합병증이다. 1965 년부터 2013 년까지 427건이보고되었고이중수술후발생한경우는 7건에불과하다. 3,6) 5예는수술후점진적으로과도한가골이생성되면서발생한것으로가골의압박으로인하여신경학적증상과혈역학적증상이함께동반되어관찰되었다. 반면골절수술직후진행성으로발생한상완신경총마비에대한보고는 2예뿐이다. 3) 국내에서는쇄골골절의보존적치료후발생한 2예의증례보고가있었으나수술후발생한경우에대한보고는없었다. 7) 쇄골골절은드물게신경마비, 급격한출혈, 혈전색전증등의합병증이동반한다. 신경및혈관손상은쇄골내측부직후방에위치한혈관과상완신경총이골편에의한직접손상, 불유합, 부정유합및가골형성등으로인하여발생하며수상직후에나타나기보다는골절부에과도한가골형성으로인하여쇄골내측 1/3과 1번늑골사이의늑쇄공간 (costclavicular space) 이감소되면서압박되어발생하게된다. 이러한공간의감소는견관절을후방전위하면서외전시키는 wright position 에서약 50% 까지감소된다. 8) 상완신경총마 99
Journal of the Korean Fracture Society Vol. 32, No. 2, pril 2019 비의원인을진단하는데단순방사선사진은제한되므로자기공명영상검사를시행하여직접손상유무와압박의원인정도를확인하고신경전도검사와근전도검사를시행하는것이진단과치료결정에도움을줄수있다. 9) 본증례의특징으로는첫째, 수상직후나불유합으로진행하면서상완신경총마비가발생한것이아니라불유합으로시행한골고정술직후발생했으며둘째, 증상이수술후 2일째부터시작되어마비가지속적으로진행되었다는점, 셋째로혈관의압박소견없이신경마비만발생했으며특정신경이아닌전상완신경총마비가발생했다는점이다. 쇄골골절후비수술적치료의과정에서발생한상완신경총마비는형성된가골을절제하는감압술과불유합부위의고정을시행하여대부분좋은결과를보고하였고골절수술후발생한 2예에서는각각내고정물제거술및유착된신경의박리를시행한후회복하였다고보고하였다. 3,10) 본증례에서는골고정술시행시이전에생성된가골을제거하였음에도전상완신경총의마비가발생하였다. 저자들은첫째로상방전위된쇄골 (Fig. 1) 로인하여증가된늑쇄공간에연부조직생성및유착등으로공간점유병변이발생한상태에서내측쇄골편이정복되며하방전위됨에따라 (Fig. 1) 늑쇄공간의상대적인공간감소가발생하였고, 둘째로방사선에서수술전견갑골상연이 5번째늑골에위치하였다가수술후쇄골이정복됨에따라 4번째늑골로 24.6 mm 상승되어 (Fig. 1) 쇄골의하단-제 1번늑골상연-견갑골상연으로구성되는늑쇄공간감소를유발했을것으로추정하였다. 이에의인성으로내측쇄골에의한직접및간접신경압박이발생한것으로판단하여신경에대한탐색이나유착박리없이내고정물제거술만시행하였다. 내고정물제거와동시에내측쇄골골편은외측에대하여 16 mm 상방전위가되면술전불유합상태로재전위되었다 (Fig. 3). 쇄골골절후불유합환자에서견갑부운동이상증이동반된경우에시행하는정복및골고정술은늑쇄공간감소를유발할수있으므로수술후신경학적증상발생에대한세밀한관찰과진행성상완신경총마비시적극적인진단과회복을위한내고정물제거및감압술이필요할것으로생각된다. 요약 쇄골골절후발생하는상완신경총마비는 0.5%-9.0% 정도로드물게발생한다. 대부분보존치료후골절부의치유과정에서형성된과도한가골에의해발생하며가골의제거와 불유합에대한수술적고정으로회복된좋은결과들이보고되어있다. 반면수술후발생한경우는드물며국내외에 7건이보고되어있다. 저자들은쇄골골절후전위된불유합환자에대하여골고정술을시행하고발생한진행성상완신경총마비를경험하였다. 내고정물제거를시행하고호전되는결과를얻어보고하는바이다. 색인단어 : 쇄골골절, 불유합, 상완신경총마비, 흉곽출구증후군 ORCID 진홍기, https://orcid.org/0000-0002-4638-2185 박기봉, https://orcid.org/0000-0002-2978-8300 조형래, https://orcid.org/0000-0001-7935-5055 강정일, https://orcid.org/0000-0003-3860-7396 이완석, https://orcid.org/0000-0002-9879-3947 References 1. Rumball KM, Da Silva VF, Preston DN, Carruthers CC: rachial-plexus injury after clavicular fracture: case report and literature review. Can J Surg, 34: 264-266, 1991. 2. Hill JM, McGuire MH, Crosby L: Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J one Joint Surg r, 79: 537-539, 1997. 3. Rosati M, ndreani L, Poggetti, Zampa V, Parchi P, Lisanti M: Progressive brachial plexus palsy after osteosynthesis of an inveterate clavicular fracture. J Orthop Case Rep, 3: 18-21, 2013. 4. Woltz S, Krijnen P, Schipper I: Plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures: a meta-analysis of randomized controlled trials. J one Joint Surg m, 99: 1051-1057, 2017. 5. Song SW, Lee HS, Woo YK, Rhee SK, Kim YY: Treatment of clavide fracture: operative vs non-operative. J Korean Fract Soc, 13: 544-549, 2000. 6. Clitherow HDS, ain GI: Major neurovascular complications of clavicle fracture surgery. Shoulder Elbow, 7: 3-12, 2015. 7. Lee WS, Chung WY, Jeon TS, Kim YS, Kim NH: Delayed brachial plexus palsy due to clavicular fracture. J Korean Soc Fract, 16: 230-234, 2003. 8. Tanaka Y, oki M, Izumi T, Fujimiya M, Yamashita T, Imai T: Measurement of subclavicular pressure on the subclavian artery and brachial plexus in the costoclavicular space during provocative positioning for thoracic outlet syndrome. J Orthop Sci, 15: 118-124, 2010. 9. Connolly JF, Dehne R: Nonunion of the clavicle and thoracic 100
Progressive rachial Plexus Palsy after Fixation of Clavicle Shaft Nonunion Hong-Ki Jin, et al. outlet syndrome. J Trauma, 29: 1127-1132; discussion 1132-1133, 1989. 10. Jeyaseelan L, Singh VK, Ghosh S, Sinisi M, Fox M: Iatropathic brachial plexus injury: a complication of delayed fixation of clavicle fractures. one Joint J, 95: 106-110, 2013. 101