ORIGINAL ARTICLE pissn 1598-3889 eissn 2234-0998 J Korean Soc Surg Hand 2015;20(3):104-109. http://dx.doi.org/10.12790/jkssh.2015.20.3.104 JOURNAL OF THE KOREAN SOCIETY FOR SURGERY OF THE HAND Effect of Different Splints on Displacement after Closed Reduction of the Distal Radius Fractures: A Comparison of Short Arm Double Splint and Sugar-Tong Splint Jae Hoon Lee 1, Se Hyuck Hong 1, Young Joon Kim 2, Jong Hun Back 2, Jung Suck Lee 1 1 Department of Orthopedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea 2 Department of Orthopedic Surgery, Kyung Hee Medical Center, Seoul, Korea Received: June 17, 2015 Revised: [1] July 30, 2015 [2] August 15, 2015 Accepted: August 16, 2015 Correspondence to: Jae Hoon Lee Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, 892 Dongnam-ro, Gangdong-gu, Seoul 05278, Korea TEL: +82-2-440-6153 FAX: +82-2-440-7497 E-mail: ljhos69@naver.com This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/bync/3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Purpose: This study was to compare short arm double splint allowing forearm rotation with sugar tong splint in terms of loss of reduction and incidence of shoulder stiffness after closed reduction of the distal radius factures. Methods: From June 2012 to February 2013, we retrospectively reviewed patients with distal radius fractures applied short arm double splint or sugar tong splint after closed reduction. Patients with more than 18 years old, acceptable reduction in X-ray and followed up at least 4 weeks were enrolled. Short arm double splint (SD) group was applied in 47 cases and sugar tong splint (ST) group was 34 cases. Gender, age and fracture types were not significantly different between two groups. The radiographic parameters were measured for palmar tilt, articular step-off, radial length, radial inclination, ulnar variance. The incidence and time of the reduction loss were also evaluated. In functional outcomes, the occurence of ipsilateral shoulder stiffness and the disabilities of the arm, shoulder and hand (DASH) score were evaluated with the medical records or telephone questionnaires at 6 months after initial trauma. Results: Loss of reduction was occured 16 cases in SD group (34%) and 10 cases in ST group (29.4%), which did not differ significantly between the groups (p=0.169). The DASH score and shoulder stiffness were not statistically different between two groups. Conclusion: There was no significant difference in loss of reduction after closed reduction of distal radius fractures and functional outcomes in both groups. Keywords: Distal radius fracture, Closed reduction, Short arm double splint, Sugar-tong splint 서론 원위요골골절은응급실로내원하는정형외과환자에서가 장흔한골절중하나이며고령의골다공증환자에서특히호발한다. 평균수명이증가함에따라원위요골골절의빈도는더욱증가하고있다 1-5. 원위요골골절의치료로는부목이나 104 http://www.jkssh.org/ Copyright c 2015. The Korean Society for Surgery of the Hand
Jae Hoon Lee, et al. Effect of Different Splints on Displacement after Closed Reduction of the Distal Radius Fractures 석고붕대등을이용하는보존적치료와경피적핀고정술이나금속판을이용한관혈적정복및고정술과같은수술적치료가있다. 원위요골골절의보존적치료에서비관혈적정복후고정하는방법으로는여러종류의도구가사용되는데설탕집게부목 (sugar-tong splint), radial gutter splint 6, circumferential cast 7 등이대표적이다. 이중가장흔히사용되는설탕집게부목은주관절을포함하여고정함으로전완의회전을방지하여골절부의정복소실을줄이고자하는목적이있으나주관절을신전하지못하는불편감이있다 8. 저자들은주관절의원위부까지만고정을하여주관절굴신운동을허용하는 short arm double splint (Fig. 1) 를고안하였다. 이부목고정은고정기간동안편의성은증대될수있으나설탕집게부목에비해전완부회전을허용함으로고정력이불안정하여정복의유지및골절의유합에악영향을끼칠우려가있다. 하지만주관절과견관절의자유로운운동을허용하여보존적치료시발생할수있는견관절의동통및강직 8 을줄일수있을것으로생각하였다. 이에저자들은원위요골골절에대해성공적인도수정복을시행받은환자들중설탕집게부목을사용한군과 short arm double splint 를사용한군간에정복소실및견관절의강직정도에서차이가있는지분석하여 short arm double splint 의유용성을확인하고자하였다. 대상및방법 본원응급실을방문한원위요골골절환자를대상으로 2012년 6월부터 2012년 11 월까지도수정복후설탕집게부목을적용하였으며, 2012년 12월부터 2013년 2월까지 short arm double splint 를적용하였다. 전위성원위요골골절로내원하여성공적인도수정복을시행받고설탕집게부목 (ST 군 ) 또는 short arm double splint (SD군) 를적용한환자에서외래에서추시관찰한 18세이상의환자를대상으로후향적으 로조사하였다. 응급실에서수술을결정한경우, 개방성골절, 과거에동측이나반대측에원위요골골절을수상한병력이있는경우, 양측의동시손상인경우, 신경 혈관의손상이동반된경우는대상에서제외하였다. Association for Osteosynthesis/Association for the Study of Internal Fixation (AO/ASIF) 분류법을기준으로골절을분류하였고방사선검사상 radial length <7 mm, radial inclination <15, dorsal tilt >10, articular step-off >2 mm 중하나라도만족할경우 전위된골절 또는 정복의소실 로정의 (Table 1) 하였으며, 1회도수정복후방사선검사상전위가남아있는경우도수정복을 1회더시행하였다. 부목고정후환자는귀가하였고 1주간격으로최소한수상후 4주까지외래추시를하며방사선학적검사를시행하여 radial inclination, radial length, ulnar variance, palmar tilt, articular step-off를측정하여정복의소실유무를확인하였다. 정복의소실이일어난경우수술적치료를권하였으며정복의소실이발견된시기를정복이소실된시점으로판단하였다. 기능적평가를위해수상후 6개월에이환된상지에새로운견관절의동통또는강직의발생유무와 disabilities of the arm, shoulder and hand (DASH) score 9 를측정하였고, 외래로내원하지않은환자에대해서는전화설문을통해환자의 DASH score 및현재견관절의상태에대해문의하였다. 수상전에견관절의통증이나관절강직이없었던환자에서원위요골골절의치료과정에서견관절운동제한이나통증이발생한경우견관절강직또는통증이있었다고판단하였다. 1. 통계분석통계분석을위한프로그램으로 SPSS ver. 12.0 software (SPSS Inc., Chicago, IL, USA) 를사용하였다. 두군간에유의한차이가있는지알아보고자 Pearson 카이제곱검정을사용하였으며, 95% 의신뢰도를기준으로 p<0.05를통계적으로유의한수준으로판단하였다. 결과 2012 년 6 월부터 2013 년 2 월까지전위성원위요골골절로 Table 1. Definition of displacement or reduction loss Fig. 1. Photography of short arm double splint. Dorsal tilt >10 Articular step-off >2 mm Radial length <7 mm Radial inclination <15 http://www.jkssh.org/ 105
J Korean Soc Surg Hand Vol. 20, No. 3, September 2015 내원한환자중보존적치료를시행한환자는총 94 명이었으며추시기간중추적소실된 13명을제외하고 short arm double splint 를적용한군 (SD군) 은 47 명, 설탕집게부목을적용한군 (ST군) 은 34 명이었다. 성별, 연령및초기방사선학적평가척도 (radial inclination, radial length, ulnar variance, palmar tilt, articular step-off) 에서유의한차이는없었다 (Table 2). AO/ASIF 분류상 SD 군은 A형이 35예, B형이 9예, C형이 3예였으며, ST군은 A형이 25예, B형이 5예, C 형이 4예였다. 추시기간중정복소실은 SD군에서 16예 (34.0%) 발생하였으며 ST군에서는 10예 (29.4%) 발생하였고 두군간정복소실률에서유의한차이는발견되지않았다 (p=0.169). AO/ASIF 분류별로정복소실은 SD group 에서 A 형은 10예 (28.6%), B형은 9예 (44.4%), C형은 2예 (66.7%) 였고 ST group 에서는 A형 4예 (16.0%), B형 4예 (80.0%), C형에서 2예 (50.0%) 발생하였다 (Table 3). 두군에서관절내골절여부 (A, B, C형사이 ) 및골절분쇄 (A2와 A3, C1과 C2) 여부에따른정복소실율의차이는보이지않았다. SD군은수상후 1 주에서 1주간격으로각각 5예, 3예, 4예, 4예의정복소실이새로발생하였고, ST군에서는각각 5예, 2예, 1예, 2예가발생하였다 (Table 4). 보존적치료중수술적치료로전환한경우 Table 2. Demographics Characteristic SD group (47) ST group (34) p-value Female 39 (83.0) 24 (70.6) 0.178 Mean age (yr) 64.0 (±12.3) 57.5 (±14.5) 0.437 Radial inclination ( ) 18.0 (±6.0) 19.0 (±5.4) 0.448 Radial length (mm) 6.9 (±3.2) 8.7 (±3.0) 0.643 Ulnar variance (mm) 2.6 (±2.8) 3.1 (±3.2) 0.345 Palmar tilt ( ) -11.9 (±13.3) -9.4 (±16.1) 0.350 Step-off (mm) 0.04 (±0.2) 0.12 (±0.5) 0.076 SD, short arm double splint; ST, sugar-tong splint. Table 3. Association for Osteosynthesis/Association for the Study of Internal Fixation classification SD group (47) ST group (34) N Reduction loss, n (%) N Reduction loss, n (%) A1 0 10 (28.6) 0 4 (16.0) A2 15 19 A3 20 6 Total 35 25 B1 2 4 (44.4) 2 4 (80.0) B2 5 3 B3 2 0 Total 9 5 C1 2 2 (66.7) 2 2 (50.0) C2 1 2 C3 0 0 Total 3 4 SD, short arm double splint; ST, sugar-tong splint. Table 4. Time of reduction loss Variable Reduction loss,n(%) PT1wk PT2wk PT3wk PT4wk SD group (47) 16 (34.0) 5 3 4 4 ST group (34) 10 (29.4) 5 2 1 2 p-value 0.169 - - - PT, post-trauma; SD, short arm double splint; ST, sugar-tong splint. 106 http://www.jkssh.org/
Jae Hoon Lee, et al. Effect of Different Splints on Displacement after Closed Reduction of the Distal Radius Fractures 는 SD 군에서 10예, ST군에서 7예였다. 수상후 2주이내에수술이시행된경우는 SD군에서 9예, ST군에서 5예였고 SD군중 1예는수상후 4주에, ST군중 2예는수상후 3주에수술이시행되었다. 수상후 6개월에조사한 DASH score 는 SD군에서평균 35.5±4.3점, ST군에서는평균 36.2±6.0점으로두군간유의한차이는발견되지않았다 (p=0.563). 수상후수술을 2주이내에시행한군과 2주이후에수술을시행한군사이의 DASH score 의차이는없었다. 수상후 6개월에수상측견관절의동통이나강직을호소한환자는 SD군에서 37예중 8 예 (17%), ST군에서 27예중 4예 (14.8%) 로통계적으로유의한차이를보이지않았다 (Table 5). 고찰 원위요골골절의보존적치료와수술적치료의방사선학적, 임상적결과를비교하거나 10-12 보존적치료중부목과석고붕대를비교한연구 7 는보고된바가있으나보존적치료중설탕집게부목과 short arm double splint 를비교한연구는아직까지보고된바가없다. 저자들은본연구를통해두종류의고정방법에따른결과에차이가있는지알아보고자하였으며도수정복및부목고정후 4주이상추시관찰을하였고정복의소실이일어난비율은 ST군에서 29.4%, SD군에서 34.0% 로두군간유의한차이가없었다 (p=0.169). Short arm double splint 의경우전완의수장측과배측에 2개의부목을대고부목이주관절의원위부에서끝나도록제작을하여전완의회전운동및주관절굴곡신전운동이가능하도록하였다. 1개의부목을 U자형태로전완의수장측과배측을지나면서주관절을둘러싸서제작하는설탕집게부목은제작과정이상대적으로쉽고도수정복후비교적단기간에제작할수있어서도수정복과부목적용사이에일어날수있는정복의소실을최소화하고전완의회전운동을제한하여추시기간중정복의소실이 short arm double splint 에비해적게일어날것으로생각하였으나본연구에서는두군간에유의한차이가없었다. 이는실제적으로부목제작을자주접하게되는정형외과의사의입장에서는 short arm double splint 를 제작하는것이설탕집게부목과비교하여크게복잡하거나시간이오래소요되지는않으며환자에게전완의회전운동을허용하는것이골절의전위를악화시키거나정복을소실하는데큰영향을미치지않는다는것을의미한다. Grafstein 등 7 은원위요골골절의보존적치료로석고붕대와부목을비교하였고정복소실률이나기능적평가상통계적으로유의한차이가없었고이를토대로어떠한방법으로고정을하든결과에큰차이가없으므로각각의의사가익숙하고선호하는방법을사용할것을권장하였다. 도수정복및고정후 1주일간격으로추시관찰하면서수상후몇주에정복의소실이잘발생하는지조사하였다. SD군과 ST군모두수상후 4주까지는비교적비슷한빈도로정복의소실이발생하였고 5주이후에는정복의소실은발생하지않았다. 위의결과를토대로수상후 4주까지는특별히주의를기울여야할것으로생각되지만보다정확한분석을위해충분한증례수의확보가전제되어야할것이다. 원위요골골절의분류로는 20개가넘는분류법이사용되고있으나본저자들은관찰자간신뢰도가높다고평가되는 AO/ASIF 분류법을기준으로골절을분류하였다 13. A형 (A2, A3) 이두군다과반수이상차지하였으며통계적유의성은없었으나 A형에서 C형으로갈수록, 즉골절의복잡성이증가할수록정복소실률이증가하는경향을보였다. 따라서처음골절을정복하기전에골절의정도를 AO/ASIF 분류법에의해파악을한후보존적치료를하더라도추후정복소실및수술로의이행가능성에대해예측을한후이에대한설명및대비가있어야할것으로생각된다. 본연구에서는치료후기능적평가의척도로 DASH score 를사용하였다. 두군간정복의소실률에서차이가없었던것과마찬가지로 DASH score 도유의한차이를보이지않았다 (p=0.563). 보존적으로치료한경우골절부의유합이이루어진이후에도동측견관절의동통및강직을호소하는경우 8 가종종있으므로기능적평가중에서도견관절의기능에초점을맞추어연구를진행하였다. 의무기록또는전화설문을통해수상전과비교하여수상한상지에새로운견관절의동통또는강직이발생하였는지조사하였고그결과두군간의유의 Table 5. Functional assessment Variable SD group ST group p-value DASH score 35.5±4.3 36.2±6.0 0.563 Shoulder pain/stiffness 8 (17) 4 (14.8) 0.753 Values are presented as mean±standard deviation or number (%). SD, short arm double splint; ST, sugar-tong splint; DASH, disabilities of the arm, shoulder and hand. http://www.jkssh.org/ 107
J Korean Soc Surg Hand Vol. 20, No. 3, September 2015 한차이를보이지않았다. 본연구의제한점으로는먼저증례수가많지않아검정력분석을시행하지못한점이있다. 아직초기보고단계로더많은증례수가확보되어야하겠으며수상후몇주째에정복의소실이가장잘발생하는지, 몇주가지나야정복의소실률이감소하는지추가적인연구가필요할것으로생각된다. 또한정복의소실률을좌우하는인자중부목의종류외에환자의나이, 골다공증의유무등에대한고려가있어야하겠다. 또한견관절의정확한평가를위해서는문진외에견관절에대한객관적이고구체적인영상학적검사및이학적검사가필요할것으로생각된다. 결론 본연구를통해원위요골골절의보존적치료로사용하는 short arm double splint 와설탕집게부목은추시기간중정복소실및기능평가에서유의한차이를보이지않았으므로골절의치료에대해서는어떠한부목을사용하여도무방하다고할수있다. REFERENCES 1. Thompson PW, Taylor J, Dawson A. The annual incidence and seasonal variation of fractures of the distal radius in men and women over 25 years in Dorset, UK. Injury. 2004;35:462-6. 2. Cummings SR, Black DM, Rubin SM. Lifetime risks of hip, Colles', or vertebral fracture and coronary heart disease among white postmenopausal women. Arch Intern Med. 1989;149:2445-8. 3. Solgaard S, Petersen VS. Epidemiology of distal radius fractures. Acta Orthop Scand. 1985;56:391-3. 4. O'Neill TW, Cooper C, Finn JD, et al. Incidence of distal forearm fracture in British men and women. Osteoporos Int. 2001;12:555-8. 5. Singer BR, McLauchlan GJ, Robinson CM, Christie J. Epidemiology of fractures in 15,000 adults: the influence of age and gender. J Bone Joint Surg Br. 1998;80:243-8. 6. Bong MR, Egol KA, Leibman M, Koval KJ. A comparison of immediate postreduction splinting constructs for controlling initial displacement of fractures of the distal radius: a prospective randomized study of long-arm versus short-arm splinting. J Hand Surg Am. 2006;31: 766-70. 7. Grafstein E, Stenstrom R, Christenson J, et al. A prospective randomized controlled trial comparing circumferential casting and splinting in displaced Colles fractures. CJEM. 2010;12:192-200. 8. Frykman G. Fracture of the distal radius including sequelae: shoulder-hand-finger syndrome, disturbance in the distal radio-ulnar joint and impairment of nerve function. A clinical and experimental study. Acta Orthop Scand. 1967:Suppl 108:3+. 9. Gummesson C, Atroshi I, Ekdahl C. The disabilities of the arm, shoulder and hand (DASH) outcome questionnaire: longitudinal construct validity and measuring self-rated health change after surgery. BMC Musculoskelet Disord. 2003;4:11. 10. Arora R, Gabl M, Gschwentner M, Deml C, Krappinger D, Lutz M. A comparative study of clinical and radiologic outcomes of unstable colles type distal radius fractures in patients older than 70 years: nonoperative treatment versus volar locking plating. J Orthop Trauma. 2009;23: 237-42. 11. Aktekin CN, Altay M, Gursoy Z, Aktekin LA, Ozturk AM, Tabak AY. Comparison between external fixation and cast treatment in the management of distal radius fractures in patients aged 65 years and older. J Hand Surg Am. 2010;35:736-42. 12. Diaz-Garcia RJ, Oda T, Shauver MJ, Chung KC. A systematic review of outcomes and complications of treating unstable distal radius fractures in the elderly. J Hand Surg Am. 2011;36:824-35.e2. 13. Kreder HJ, Hanel DP, McKee M, Jupiter J, McGillivary G, Swiontkowski MF. Consistency of AO fracture classification for the distal radius. J Bone Joint Surg Br. 1996; 78:726-31. 108 http://www.jkssh.org/
Jae Hoon Lee, et al. Effect of Different Splints on Displacement after Closed Reduction of the Distal Radius Fractures 원위요골골절도수정복후부목종류가골절전위에미치는영향 : Short Arm Double Splint 와 Sugar-Tong Splint 의비교 이재훈 1 홍세혁 1 김영준 2, 백종훈 2 이정석 1 1 강동경희대병원정형외과학교실, 2 경희대학병원정형외과학교실 목적 : 원위요골골절의도수정복후 sugar tong splint 를사용한군과전완의회전운동을허용하는 short arm double splint 를사용한군에서정복소실및견관절의강직정도를비교하였다. 방법 : 2012년 6월부터 2013년 2월까지전위성원위요골골절로내원하여도수정복및 sugar-tong splint 또는 short arm double splint 를적용하고성공적인정복을얻었던환자중최소 4주간외래에서추시관찰한 18세이상의환자를대상으로후향적으로조사하였다. 도수정복후 short arm double splint 를적용한군 (SD군) 은 47명, sugartong splint 를적용한군 (ST군) 은 34명이었으며, 두군간성별, 연령및골절형태는통계학적으로유의한차이가없었다. 방사선학적평가로추시시 palmar tilt, articular step-off, radial length, radial inclination, ulnar variance를측정하였고, 정복의소실유무와그시기에대해조사하였다. 기능적평가로수상후 6개월에의무기록및전화설문에서수상한상지의새로운견관절강직발생과 disabilities of the arm, shoulder and hand (DASH) score 를평가하였다. 결과 : 전정복소실의발생은 SD군에서 16예 (34%), ST군에서는 10예 (29.4%) 에서보여, 두군간유의한차이는없었다 (p=0.169). DASH score 및견관절강직및통증은두군간유의한차이를보이지않았다. 결론 : 두군에서원위요골골절정복후정복의소실및기능적결과에서유의한차이를보이지않았다. 색인단어 : 원위요골골절, 설탕집게부목, Short arm double splint, 도수정복 접수일 2015 년 6 월 17 일수정일 1 차 : 2015 년 7 월 30 일, 2 차 : 2015 년 8 월 15 일게재확정일 2015 년 8 월 16 일교신저자이재훈서울시강동구동남로 892 강동경희대병원정형외과학교실 TEL 02-440-6153 FAX 02-440-7497 E-mail ljhos69@naver.com http://www.jkssh.org/ 109