대한수부외과학회지제 13 권제 1 호 The Journal of the Korean Society for Surgery of the Hand VOLUME 13, NUMBER 1, March 2008 경북대학교의과대학정형외과학교실, 대구파티마병원정형외과 1 전인호 신동주 1 손영헌 이병우 김풍택 Volar Dislocation of the Distal Radioulnar Joint Associated With Radial Shaft Malunion In-Ho Jeon, M.D., Dong-Ju Shin, M.D. 1, Young-Hon Son, M.D., Byung-Woo Lee, M.D., Poong-Taek Kim, M.D. Department of Orthopedic Surgery, Kyungpook National University Hospital, Fatima Hospital 1, Daegu, Korea. Purpose: We report four cases of adolescent recurrent volar instability of the DRUJ associated with radial shaft malunion. Materials and Methods: Four patients between the age 14 and 22 years presented recurrent volar ulnar head dislocation with painful clunk. All patients had radial shaft fracture at an average age of 11 years (range:9-13 years) and all were male. Two patients had been treated conservatively with long arm cast, one with open reduction/internal fixation and another one had no formal treatment. Patients complained the volar dislocation of ulnar head in pronation and the reduction of ulnar head in supination with clunk. Plain radiographs showed malunion of the radial shaft with an average volar angulation of 11 degrees and the arthritic deformity of the distal radioulnar joint. CT scans in supination demonstrated the disruption of the distal radioulnar joint. Corrective osteotomy of the radius was performed in three patients. We evaluated the preoperative and postoperative pain and grip power (Mayo wrist score) and 통신저자 : 김풍택대구광역시중구삼덕동 2가 50 경북대학교의과대학정형외과학교실 TEL: 053-420-5632, FAX: 053-422-6605 E-mail: ptkim@knu.ac.kr radiographic outcome. Mean follow-up period was 18months (range: 6~25 months). Results: Redislocation of the ulnar head and painful clunk disappeared after corrective osteotomy. Radiographs showed anterior bowing of radial shaft decreased to 3.3 degrees and bone union was achieved in 3 months postoperatively. Mayo modified wrist scores improved from 76.1 points to 86.5 points at the time of the last follow up. Conclusion: Corrective osteotomy should be considered in volar instability of the DRUJ associated with radial shaft malunion to restore unstable DRUJ Key Words: Radial malunion, DRUJ instability, Corrective osteotomy 서 론 요골간부골절의부정유합은미용적변형과운동범위의제한, 손목관절의불안정성또는동통을유발할수있다. 이들중에서전완의회외전시원위요척관절의장측전방불안정성을보이는경우는보고가드물다. 원위요척관절을안정화시키는연부조직구조물로는삼각섬유연골복합체의요척인대, 척수근신근과척수근신근의건초, 방형회내근, 골간막이있으며 S자절흔과같은골성구조도원위요척관절의안정에중요한역할을한다. 이들구조물중결함이생기면불안정성을유발할수있으며 Bowers 1 의제4 형불안전성에서볼수있듯이관절외결함도원위요척관절의불안정성을유발할수있다. 부정유합으로치유된요골간부의중간과원위 1/3 부분의골절은요골간부의선천적인요측휨이사라짐에따라원위요척골관절의장측불안정성을가져올수야기할수있다 1. 요골의정상휨의소실, 요골과척골사이의공간의소실, 회전부정정렬은모두 20
전완부와수근관절의기능악화를가져올수있다 2-6. 전방휨이발생하고이로인해회외전시원위요척관절에서요골의원위부분이후방으로이동하는결과를초래한다. 부정유합에이은연부조직안정성의파열은점진적으로진행되고마침내원위요척관절의심각한불안정성을가져온다. Bowers 1 는정확한교정절골술은형태적인삼각섬유연골복합체의재건없이손목관절을재안정화할수있다고하였다. 하지만세부적인수술적수기와결과에대해서는알려진바가거의없다. 저자들은요골간부부정유합과관련된원위요척관절의재발성전방불안정성을교정절골술로치료한 3례와치료를거부한 1례를기술한다. 연구대상및방법 2005년 7월부터 2007년 1월까지요골간부의각변형에기인한원위요척관절의만성적불안정성이있는 4명의환자를대상으로하였다 (Table 1). 전례에 서남성이었고요골골절당시의평균나이는 11세 ( 범위 : 9~13세 ) 였다. 3례에서낙상으로수상하였고 1 례는보행자교통사고였다. 골절부위는 1례에서전완의근위 1/3, 2례에서중간부, 1례에서윈위 1/3 부분이었다. 골절당시치료로는보존적요법이 2례, 관혈적정복및내고정술을 1례에서시행하였고, 간과된골절이 1례였다. 환자들은회외전시척골두의전방탈구, 회내전시탄발음과함께정복되는증상을호소하였고, 단순방사선촬영상요골간부의부정유합이관찰되었다 (Fig. 1, 2). 전례에서요골의전방각변형 ( 평균 11도 ) 이관찰되었고, 원위요척관절의변형은존재하지않았다. 원위요척관절컴퓨터단층촬영상회외전시정상적인척골두를기준으로하여, 원위요골이후방으로아탈구되는현상이관찰되었다 (Fig. 3). 수술을거부한 1례를제외한 3례에대해수술전후의동통, 악력등기능적평가 (Mayo 수근관절지수 ) 7 와방사선결과를분석하였다. 평균추시기간은 18개월 ( 범위 :6~25개월) 이었다. Table 1. Details of preoperative demographics of the patients with unstable DRUJ. case sex age Age at Time from the time of Fracture Injury to fracture of radius Osteotomy (years) Deformity Ulnar head Grip ROM (anterior subluxation power F/E P/S bowing) into (kg) Mayo score 1 M 17 12 diaphysis 5 12.8 volar 80/80 80/70 24/35 78 2 M 22 12 diaphysis 100 14.4 volar 80/70 080/100 28/38 75 3 M 14 09 metaphysis, diaphysis 5 13.0 volar 80/75 90/90 28/31 85 4 M 20 13 diaphysis - 02.0 volar 75/70 80/75 26/31 79 Fig. 1. (A, B) Preoperative photographs showed volar prominence of ulnar head at supination, which relocated at pronation. 21
전인호 신동주 손영헌 이병우 김풍택 수술방법 4례중 3례에서원위요척관절의안정성을위해요골간부부정유합에대해교정절골술을시행하였다 (Fig. 4). 절골위치는원위요척관절을좀더쉽게조절하기위해서부정유합된부의의요골대신에원위간부에서시행하였다. 앙와위에서공기지혈대를사용한후원위요골을 Lister 결절에서부터근위부 10 cm까지세로방향의절개선을통해후방으로노출 시켰다. 단무지신근을외측으로당기고나머지신근들은내측으로당긴후절골은수근관절의근위부 5 cm에서시행하였다. 장골에서채취한골을 12도의교정각으로절골한틈으로넣고미리배측으로휘어놓은 small LC-DCP plate (Synthes) 와부가적인 Kirschner wires 를원위요척골관절면에적합하도록술중방사선학적계측으로고정하였다. 나머지 1례는 volar Henry s approach를통하여요골간부를노출시키고부정유합된곳에서폐쇄설 Fig. 2. Preoperative radiographs of the left forearm and wrist, (A, B) anteroposterior and lateral view, showing anterior bowing of the radius, and (C) lateral view in supination showing dorsal subluxation of the distal radius. Fig. 3. (A, B) Preoperative CT scan on DRUJ at pronation (A) and supination (B) showing the disruption of the DRUJ integrity at supination and dorsal subluxation of the distal radius. 22
Fig. 4. Corrective osteotomy of shaft malunion of radius. (A) Radius was exposed dorsally through a longitudinal incision. (B) Prebended 5-hole plate was used to fix the osteotomy. Table 2. Status of patients after corrective osteotomy. case F/U Osteotomy Angulation after ROM Grip power (Mo) site operation F/E P/S (kg) Mayo score 1 24 Meta-diaphyseal junction 1 70/80 80/75 29/35 90 2 13 Malunion level 7 80/90 80/90 34/38 89 3 7 Meta-diaphyseal junction 2 80/80 80/80 30/31 90 절골부의유합이확인되었을때자유로운운동을허락하였다. 결 과 Fig. 5. Through volar Henry approach, shaft of radius was exposed and closed wedge osteotomy at the level of malunion was conducted 상절골술을시행하고골이식없이 6-hole LCP (Synthes) 를고정하였다 (Fig. 5). 영상증폭장치로전완의회전과수근관절의운동동안에원위요척관절의안정성을확인하였다 (Fig. 6). 수술후단상지석고붕대를 6주간시행하였고석고붕대를제거한후에는무거운물건을들지않도록하고능동적수근관절운동을장려하였다. 단순방사선사진은 1개월간격으로시행하였으며, 방사선학적으로 교정절골술을시행후전례에서원위요척관절의재발성탈구는모두교정되었다 (Table 2). 수근관절부동통이있었던 2명의환자는술후동통이사라졌고, 이들중한명은술전제 4, 5수지에저린감을호소하였는데술후저린감이사라졌다. Mayo 수근관절지수는술전평균 79.3 점에서술후 89.7점으로향상되었다. 요골의전방각변형은평균 3.3 도로감소하였으며모두 3개월이내에절골부위의유합을얻었다. 최종추시까지재탈구나전완부회전운동제한은관찰되지않았다 (Fig. 7). 3명의환자모두더이상의치료를요구하지않았고, 수술전의직장으로복귀하였다. 고찰 원위요척관절의안정성은배측과장측의요척인대, 척골측부인대, meniscal homologue, 관절 23
전인호 신동주 손영헌 이병우 김풍택 Fig. 6. (A, B) Stability of DRUJ was ckecked during passive rotation of forearm under fluoroscopy. Fig. 7. (A, B) Anteroposterior and lateral radiographs of the left forearm 7 months after corrective osteotomy showed correction of the volar instability of the DRUJ. 판, 척수근신근의건초를포함하는삼각섬유연골복합체에의해얻어진다. 원위요척관절의불안정성의병태생리중드물게전완부의골절과연관되어일어나며저자들은요골간부골절의부정유합에서발생된척골골두의장측탈구 4례를보고하였다. 원위요척관절의불안성은성장기골격의재생능력을가진 15세이전에잘발생한다 8. 저자들의증례모두에서수상후 12개월이상경과하였고평균나이가 11세인청소년기에발생하였다. 골간막의구축이있을지라도전완의회전범위는심각하게줄어들지않았다. 전완의회전의회복은골격길이의보존과축성정렬과회전정렬의유지에달려있다 2,9-11. Dameron 12 는원위요척관절의탈구는전방또는후방으로모두일어날수있다고보고하였으며, 척골이후방으로탈구될경우축성부하와함께전완을회외전하면정복이용이하고, 전방으로탈구된다면전완을회내전하면정복이된다고하였다. 본증례에서는요골간부의전방각형성으로인해전완부회전시원위요골이정상적인척골두와의관계를소실하고후방으로탈구되는현상이발생한것이다. Bower 는이런현상을원위요척관절불안정성중관절외원인제 4형으로분류하고기술하였다 1. 요골간부골절의부정유합이나전완부동시골절의부정유합은원위요척관절의불안정성을일으킬수있다. 이런한문제점은전완부의근위부에서골절이발생하였을때더흔히일어난다 4,6,13,14. 저자들은전완의근위 1/3 지점에서 1례, 중간부에서 2례, 1례에서는간단-간부에서의골절이부정유합과원위요척 24
관절의불안정성이발생하였다. 부정유합의중등도에서 4명의환자중 3명이 12.8 도에서 14.4 도의요골간부장측각변성을보였지만 1명은단지 2도의장측각변성으로원위요척골관절의불안정성을보였다. 요골간부부정유합에동반된원위요척관절의전방불안정성의치료는이견이있다. Bowers 1 는연부조직재건없이부정유합부위에서의교정절골술로원위요척관절을안정화할수있다고하였다. Maki 등 15 은 3례의수장근이나요수굴근을이용하여인대재건술과동반한교정절골술을시행하고교정절골술이반드시필요하지는않다고하였다. Oda 등 16 은요골간부부정유합에동반된원위요척관절의전방불안정성을가진 3례에서원위요척관절의요척인대의재건없이부정유합부위대신원위간부에개방쐐기절골술을시행하여좋은결과를얻었다. Blackburn 17 등은 drill osteoclasis를사용하여 12명의환자중 10명환자에서좋은결과를보고하였고, 이술식이어린이에게서개방절골술의대안이라고하였다. 그러나 closed osteoclasis는수상후 4~5 주정도의조기부정유합에적응이될수있고이때는병변이재생할수있을만한충분한여력이있다. Trousdale와 Linscheid 8 는수상후 12개월이지난 9 명의환자를원위요척골관절의불안정성과관련된전완부부정유합에대해교정절골술로치료하여안정된수근관절은보였지만그중 6명은전완부의운동범위가감소하였다. 저자들은 3례에서요골각변형을절골술과금속판고정으로한번만에교정하여추가적인재건술없이원위요척골관절의안정성을획득하였으며, 전완부회전운동제한을보이지않았다. 결론 요골간부의부정유합은원위요척관절의불안정성의원인이되며, 부정유합된요골의교정절골술은정상원위요척관절을보존하는동시에불안정성의관절외적인근본원인을교정함으로써원위요척관절을안정화시키는술식이다. 참고문헌 01) Bowers WH. Instability of the distal radioulnar articulation. Hand Clin. 1991;7:311-27. 02) Creasman C, Zaleske DJ, Ehrlich MG. Analyzing forearm fractures in children. The more subtle signs of impending problems. Clin Orthop Relat Res. 1984;88:40-53. 03) Evans EM. Rotational deformity in the treatment of fractures of both bones of the forearm. J Bone Joint Surg Am. 1945;27:373-9. 04) Matthews LS, Kaufer H, Garver DF, Sonstegard DA. The effect on supination-pronation of angular malalignment of fractures of both bones of the forearm. An experimental study. J Bone joint Surg Am. 1982;64:14-7. 05) Rang M. Children s Fractures. Philadelphia: JB Lippincott; 1974. p124-40. 06) Roberts JA. Angulation of the radius in children s fractures. J Bone joint Surg Br. 1986;68:751-4. 07) Cooney WP, Bussey R, Dobyns JH, Linscheid RL. Difficult wrist fractures. Perilunate fracture-dislocations of the wrist. Clin Orthop Relat Res. 1987;214:136-47. 08) Trousdale RT, Linscheid RL. Operative treatment of malunited fractures of the forearm. J Bone Joint Surg Am. 1995;77:894-902. 09) Fuller DI, McCullough CJ. Malunited fractures of the forearm in children. J Bone Joint Surg Br. 1982;64:364-7. 10) Hughston JC. Fractures of the forearm in children. J Bone Joint Surg Am. 1982;44:1678-93. 11) Schemitsch EH, Richards RR. The effect of malunion on functional outcome after plate fixation of fractures of both hones of the forearm in adults. J Bone Joint Surg Am. 1992;74:1068-78. 12) Dameron TB Jr. Traumatic dislocation of the distal radioulnar joint. Clin Orthop Relat Res. 1972;83:55-63. 13) Tarr RR, Garfinkel AI, Sarmiento A. The effects of angular and rotational deformities of both bones of the forearm: an in vitro study. J Bone Joint Surg Am. 1984;66:65-70. 14) Weinberg AM, Pietsch IT, Krefft M, Pape HC, van Griensven M, Helm MB et al. Pronation and supination of the forearm: with special reference to the humero-ulnar articulation. Unfallchirurg. 2001;104:404-9. 15) Maki Y, Yoshizu T, Tsubokawa N. Volar dislocation of distal radioulnar joint caused secondarily after conservatively treated forearm fracture. J Jpn Soc Surg Hand. 2001;18:25-8. 16) Oda T, Wada T, Isogai S, Iba K, Aoki M, Yamashita T. Corrective osteotomy for volar instability of the distal radioulnar Joint associated with radial shaft malunion. J Hand Surg Br. 2007;32:573-7. 17) Blackburn N, Ziv I, Rang M. Correction of the malunited forearm fracture. Clin Orthop Relat Res. 1984;188:54-7. 25