Review Article doi:http://dx.doi.org/10.5397/cise.2012.15.1.43 대한견 주관절학회지제15권제1호 Clinics in Shoulder and Elbow Volume 15, Number 1, June, 2012 쇄골골절치료의최근경향 서울대학교의과대학정형외과학교실, 분당서울대학교병원관절센터 오주한 최혜연 Recent Treatment Options for the Clavicle Fracture Joo Han Oh, M.D., Ph.D., Hye Yeun Choi, M.D. Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Korea Purpose: We sought to determine the appropriate management modality for clavicle fracture through the review of current literature. Materials and Method: This article provides an overview of the knowledge regarding clavicular fracture in adults, including epidemiology, classification, surgical indication, current technique, and results. We also addressed recent debates: the range of the surgical indication for mid-clavicular fracture and the introduction of anatomically precontoured plate as a new treatment modality. Result and Conclusion: Nonsurgical treatment has been regarded as the first choice in the management of clavicle fractures. Quite recently, mounting evidence has shown that adverse outcomes, after a nonsurgical treatment, such as nonunion and malunion, were more prevalent than previously assumed. Accordingly, the indications for surgical fixation appear to be broadening. However, given that the ideal treatment option remains to be determined, the appropriate treatment of clavicle fractures should be tailored based on careful assessment of individual patient s data and preference. Key Words: Clavicle fracture, Treatment, Indication, Technique 서론대부분쇄골골절의치료원칙은보존적치료였다. 약간의단축이나중첩등은기능적으로큰지장을주지않으며, 정확한해부학적정복이꼭필요하지않다고생각되었다. 하지만최근보고들에서보존적치료시 우리가일반적으로생각하는것보다많은불유합이존재하며그기능도비수술적치료에비해나쁜것으로알려지고있는반면, 수술적치료는이전에비해좋은결과를보이고있어수술적치료의적응증이확대되어가는추세이다. 이에쇄골골절은개개인에따라세심한진단과개별화된치료가필요한골절로서저자들은 통신저자 : 최혜연경기도성남시분당구구미로 166 분당서울대학교병원정형외과 Tel: 031) 787-6255, Fax: 031) 787-4056, E-mail: hoho@nate.com 접수일 : 2012 년 5 월 9 일 43
대한견 주관절학회지제 15 권제 1 호 쇄골골절치료의최신지견과최근도입된 anatomically pre-shaped clavicle plate에대해소개하고자한다. 본 론 쇄골골절의 epidemiology 쇄골골절은성인골절의 2~5% 를차지하는비교적흔한골절중하나로 shoulder girdle 손상중에 35-44% 를차지하며 1-7) 년간 10 만명당 29 명에서 64 명의환자가발생한다. 1,3,8) 쇄골골절은30대이하젊은남성과70세이상노인에서 bimodal incidence를보인다 (Fig. 1). 젊은사람에서는주로간부의골절을보이며, 스포츠활동중직접손상을받아생기는경우가많고, 노인의경우여성이약간우세하며, 저에너지손상으로일상생활중넘어지면서발생하는경우가많으며, 골다공증과연관성이있을것으로생각된다. 3,9) 중간부위에서약 69~82% 가골절되며, 외측부위에서약 21~28%, 내측부위에서약 2~3% 정도발생한다. 2,3,9,10) 쇄골골절의분류 Allen 10) 은 1967년해부학적위치에따라중간부분을 type I, 외측부분은 type II, 내측부분은 type III 로기술하였으나분쇄, 단축정도를반영하지않아서예후나치료방침에도움을받을수없었다. Neer는외측쇄골골절을다시세분하여오구쇄골인대 (coracoclavicular ligament) 의외측에골절이있어인대손상이없는안정적인제 1형과오구쇄골인대의내측 Fig. 1. The incidence of clavicular fracture in relation to age and sex cohort (from Robinson CM. Fractures of the clavicle in the acult. Epidemiology and classification. J Bone Joint Surg Br.1998;80:480). 에골절이있거나오구쇄골인대의부착부에골절이있어인대손상이있고불안정한제 2형, 견봉쇄골관절 (acromioclavicular joint) 의관절면 (intraarticular) 골절의제 3형으로분류하였다. 11) Rockwood는제 2형골절을원추양인대 (conoid ligament) 가원위골편에모두붙어있는 IIA, 원추양인대가파열된 IIB 로세분하였고, 11) Craig가이를더욱보완한분류를제안하였다 (Fig. 2). 12) Robinson등은예후적요소를감안한 Edinburgh classification (Fig.3) 을제안하였다. 3) 우선골절부위에따라내측을 type I, 중간을 type II, 외측을 type III라하고, 골절전위 100% 이하를 subgroup A, 100% 이상을 subgroup B로정하였으며, type I, type III 골절은관절면침범여부에따라침범이없을시 subgroup 1, 있을시 subgroup 2로, type II는골절의분쇄또는 wedge 여부에따라단순또는 wedge type 은 subgroup 1, 분쇄또는 segmental type 은 subgroup 2로분류하였다. 3) 외측부분골절의불유합에대해서는 Craig 분류가, 중간부분골절에대해서는 Edinburgh classification 이가장예후를잘반영하는것으로보고되었다. 13) 쇄골간부골절의치료수술적또는비수술적치료의결정지금까지쇄골골절의치료는대부분보존적치료를우선하였으며, 전위가적은골절을보존적으로치료하는데이의가없을것이다. 전위가있는골절을비수술적으로치료해왔던이유는크게 3가지로나눌수있다. 우선대부분의연구에서불유합 (nonunion) 비율을 1% 미만으로보고하였다. 9,14,19) 둘째, 1960년대 Neer 16) 와 Raw 18) 에의해시행된두개의대규모후향적연구 (retrospective study) 에서수술적치료의불유합빈도가비수술적치료에서보다 3배가량높았다. 셋째, 비수술적치료후환자의만족도가높은것으로나타났다. 14,15,17) 하지만지난 10 여년간연구에서비수술적치료시불유합빈도가더높고, 기능적결과도더좋지않다는보고가늘어난반면수술적치료의결과는향상되었다. 20,22) 최근 2144명을대상으로한대규모 metaanalysis에서수술적치료를시행한경우불유합비율은 2.2%, 보존적치료후에는 5.9% 라하였고, 특히전위가있는골절일경우는 15.1% 로높게보고하였다. 23) Canadian Orthopaedic Trauma Society의 multicenter trial에서도비수술적치료군에서불유합, 부정유합빈도가더높고, 기능소실이더많으며, 유합에더오랜시간이걸림을보고하였다. 20) McKee 44
오주한 : 쇄골골절치료의최근경향 Fig. 2. Distal clavicular fracture classification (from Jeray KJ. Acute midshaft clavicular fracture, J Am Acad Orthop Surg. 2007;15:239-48). 등은주로젊고활동적인남성환자군에서전위골절의경우비수술적치료가수술적치료에비해불유합과증상있는부정유합이유의하게많다고보고하였다. 24) 불유합, 부정유합등뿐만아니라, 기능적인면이나환자만족도에서도나쁜결과를보고하였다. McKee는전위된분쇄상골절에서 20% 의높은불유합비율을보일뿐아니라어깨의 strength와 endurance의 deficit을보였다하였다. 3,21) Nowak 등은전향적인장기간추적관찰연구에서비수술적치료후 6개월째불유합의빈도는 7% 정도이지만, 46% 의환자가 9~10년후에도완전히회복됐다고느끼지못하며, 특히 9% 환자는쉬는자세에서도동통이있고, 29% 의환자는활동중동통이있으며, 27% 의환자는외관상의문제를호소하였다고한다. 52명에대해시행한후향적연구에서는 2 cm 이상단축된경우유의하게불유합이나증상이있는부정유합이더많고좋지않은임상적결과를보인다하였으며, 52명중 16 명 (31%) 에서치료결과에대 해불만족을보였다고발표하였다. 25) 한편비수술적으로치료한 868명을추적관찰한연구와 1000명을대상으로한역학연구에서불유합, 부정유합의고위험군을노인, 여성, 피질골의중첩이없는경우 ( 간부두께이상전위된경우 ), 분쇄골절, 2 cm 이상단축인경우로보고하였다. 이같은사실을종합하여볼때개방형골절, 신경혈관의손상이동반되었을때, 다발성손상, 부유견관절, 피부의 tenting 등일반적인적응증이외에도, 나이많은여성, 전위된분쇄골절의경우수술적치료를고려할수있겠다또한젊고활동적인환자에서단축이 1.5 cm 내지 2 cm 이상이거나심한외관상의문제가있을경우, 더좋은기능적결과를빠른시간내에얻어일상생활및스포츠활동으로의복귀를원하는경우는상대적인적응증으로고려할수있겠다. 앞으로는좀더명확한진단과충분한환자와의의견교환을통해수술적치료와비수술적치료중적절한치료방침을결 45
대한견 주관절학회지제 15 권제 1 호 정하도록하여야할것이다. 고정방법의선택 : 금속판 vs 골수강내핀중간부분쇄골골절의치료에는금속판을이용한내고정술또는핀을이용한골수강내고정술이많이쓰인다. Plate 를이용한수술은바로강력한고정이가능하고동통이빨리완화되며재활이빠르고심각한단축을극복할수있다는장점이있다. 12) 반면 plate가피부바로밑에위치하여튀어나와있고, 수술시피부절개가커외관상문제의소지가있다. 또일반적으로 plate를쇄골상방에위치시키며, 생역학적연구에서도상방에고정시가장단단한고정력을보인다고하나, 이경우쇄골아래쪽의신경혈관구조가다칠위험성이있다. 이에전방, 하방에 plate를적용하기도한다. 합병증으로는감염, hardware failure, hypertrophic scar, implant loosening, 불유합, 금속판제거후재골절등 12,28,29) 이보고된바있다. 최근에는 dynamic compression 또는 locking plate를많이사용하고있으며 reconstruction plate는골절부위에서변형되어불유합, 부정유합의원인이되기쉬워선호되지않고있다 (Fig. 4). 12) Intramedullary pin fixation 방법 (Fig. 5) 의경우수술절개가작아미용적인면에서더우수하고, 골막박리, 연부조직의박리가적다는장점이있다. 하지만생역학적연구에서 plate가좀더강력한 construct 임을보여주었다. 30) failure load에는골수내 pin 고정술도우수한결과를보였지만 rotational stiffness는부족하였다. 30) 또한 smooth한 pin의경우골절부위에서압박력이부족할수있고, pin이 migration 될가능성이있다. 31) 분쇄가있을경우단축이발생할수있으며, 일반적으로유합후에는수술적제거가필요하다는단점이있다. 다양한종류의 pin fixation의결과합병증이 25.8% 에서 50% 까지보고되었는데, 32) implant breakage, skin breakdown, temporary brachial plexus palsy, 불유합, 단축등이다. 12,13) 하지만최근 IM pin fixation 과 plating을비교한 randomized trial은두군사이유사한수술후결과를보여주었으며, 33,34) Lee 등은 pin fixation에서약간우세한결과를보인다고하였다. 35) Duan 등의 meta-analysis는 function score, 불유합결과에서는 Fig. 4. Reconstruction plate fixation. Fig. 3. The Edinburgh classification of clavicular fractures (from Robinson CM. Fractures of the clavicle in the acult. Epidemiology and classification. J Bone Joint Surg Br.1998;80:480). Fig. 5. Intramedullary pin fixation. 46
오주한 : 쇄골골절치료의최근경향 유사하고 symptomatic hardware만 plate군에서더많은결과를보여주었다. 36) 또한 simple wedge type 에서두군을비교한연구결과에서도유의한차이가없다하였다. 32) Pre-contoured anatomical plate Pre-contoured anatomical plate는해부학적형태에잘맞도록설계되어수술시 contouring 할필요가없어수술시간을줄여주고, plate fatigue fracture 를줄일수있다. 37) 200 구의 cadaveric study에서 plate가정확한위치에서조금만외측으로벗어나도잘맞지않을수있고, 백인여성의쇄골에는해부학적모양이좀맞지않는다 37) 고하였지만분쇄골절에서골절정복의틀을제공하는역할로사용할수도있으며, low profile, beveled edges 형태는수술후 hardware prominence 적어금속판제거를위한재수술을줄일수있다. 단단한고정력과강도가생역학적연구에서증명되었으며, 이에빠른재활도가능하다. 38) 또한 titanium composition은 modulus of elasticity가뼈와유사하여 stress shielding을줄여준다 (Fig. 6). 이처럼기존금속판과골수강내 pin 고정술의단점을보완한것으로좋은결과를보일것으로기대되지만, 이를기존치료방법과비교한임상적결과를보여주는연구는많지않다. 52명을대상으로한후향적연구에서 non-contoured plate group은 14명중 9명에서 (64.3%) pre-contoured plate group은 28 명중 9명에서 (32.1%) 튀어나온금속판에대한불만을토로하였고, 이중각각 3명, 3명 (21.4%, 10.1%) 이 hardware 제거수술을하였다. 수술적치료후 ROM 과기능에관한주관적인 score는두군에서유사하여예상대로수술적치료후 prominent implant로인한재수술의빈도가낮음을확인하였다. 38) Fig. 6. Precontoured anatomical plate fixation. 외측쇄골골절의치료대부분의외측쇄골골절은전위가적거나전위가없는관절외골절 (Edinburgh type 3A) 로비수술적치료가선호된다. 전위가있는경우 (Edinburgh type 3B) 불유합이 22% 내지 50% 에달하지만 5,7,39,40) 비수술적치료를선호하는의사도있는데, 특히노인에서활동이적은경우그러하다. 이경우비수술적치료후증상이있는불유합은 14% 로낮으며, 7) 대부분불유합의경우기능적결과가비교적좋은편이라고볼수있기때문이다. 5-7,39,41) 하지만대부분의경우에는동통과어깨기능에부정적영향을주는불유합을막기위해수술적치료를선택한다. 수술적치료후에는 95% 에서 100% 의유합률을보인다고한다. 42) 불유합의위험성이나이와전위정도가증가함에따라증가하는것으로보고한저자들도있다. 6,7) 내고정물의선택매우다양한수술적치료방법이제안되고있지만어느하나가일반적으로받아들여지지는않고있으며, 각각의장단점이있다. K-wire fixation의경우약 50% 에서 migration 된다는보고도있으며, 그럴경우예측불허의심각한합병증이발생할수있어추천되지않고있다. 6,43,44) Coracoclavicular screw의경우오구돌기의좁은형태로인하여수술방법이어렵고, screw cutout이나 loosening 등의합병증이발생할수있으며종종어깨관절의운동을제한하여유합후에는제거해야하는등의단점이있지만골절유합과어깨기능회복에좋다는보고가있다. 12,38) Plate 또는 hook plate도널리사용되고있다. Plate 는외측골편이적어도 screw 2개, 이상적으로는 3개이상고정할수있을만큼큰경우에만고정력을얻을수있다. Hook plate는 offset이있는 lateral hook이견봉의하, 후방에위치하여외측골편이나사못을고정할수없을만큼작을때사용할수있다. 45) 하지만관절강직또는견봉쇄골관절의골관절염이발생할수있다는우려가있다. 43,46,47) 이에 3개월에내고정물제거가권장되고있다. 또한정확하게위치하지못하면충분한고정력을얻지못할수있다 (Fig. 7). Suture and sling technique 중 coracoclavicular sling with Dacron graft material 방법은오구쇄골인대를재건하는목적이외에골절부위의 stabilization, 다른 fixation technique을 reinforce하는역할도하여좋은결과를보고하였다. 48,51) 작은골절편을동반하였을때 Endobutton 이나 transarticular PDS banding 49,50) 을사용하여손상된오구쇄골인 47
대한견 주관절학회지제 15 권제 1 호 대나견봉쇄골인대를재건해주는방법도사용되고있다. 이러한방법들은강력하지는않지만안정적인고정이가능하여빠른재활이가능하고, implant 제거를위한재수술이필요없다는장점이있다. 48-51) 최근관절경적고정술도소개되었다. 52) 이러한방법들을전반적으로비교분석한임상적결과에대한보고는없는실정이다. Anatomically pre-contoured plate 외측골절편에많은수의다양한방향의고정된각도의나사못 (multiple, divergent, fixed angled) 고정을할수있어특히외측골편이작거나골다공증이심할때, pullout strength를증가시켜줄것으로생각된다. 또한쇄골에서견봉으로건너가는 bridge 역할을하지않기때문에견봉쇄골관절의 motion이보존된다 (Fig. 8). 42) Jaron R 등은수술후높은 union rate (94%) 와적은합병증, 좋은기능적결과를보고하였다. 42) 하지만임상적결과에대해거의보고가없다. 내측쇄골골절의치료내측부분의쇄골골절은거의대부분보존적치료를시행한다. 이골절은매우드문형태로보통전위가거의없고, sternoclavicular joint를대부분침범하지않는다. 1,3) 수술적치료는 mediastinal structure가 compromise 될위험성이있을경우에만시행한다. 이경우응급으로일단도수정복을시행하고, 도수정복이실패하였을경우관혈적정복을시도한다. 관혈적정복시내고정물은 mediastinal migration 가능성이있기때문에조심해야할필요가있다. 특히 k-wire는 breakage와 migration이쉬우므로위험하다. 따라서 modified hooked Balser plate나 interosseous wires 또는 sutures를사용한다. 53-55) 하지만 hardware removal 위한재수술이필요하고, 이방법들에대한임상적결과보고가뒷받침되지않고있다. 결 전위가없는쇄골골절에대해서는비수술적치료가 treatment of choice이다. 하지만전위가있는중간부분의골절에대해서는이러한오래된믿음이깨어지고있으며, 기존의수술적응증이외에젊고활동적이며빠른복귀를원하는전위가심한환자에서또는불유합의위험이높은전위가심한환자에서수술적치료를고려해볼수있겠다. 이러한골절의수술방법으로최근 plate fixation과 IM pin fixation이비슷한결과를보이는것으로보고되고있으며, anatomically pre-contoured plate는이들의단점을보완한방법으로좋은결과를보일것으로생각되나, 이를뒷받침할임상적결과보고가더필요하다. 외측부분및내측부분의골절은전위가적을경우비수술적치료를하고, 외측부분의경우오구쇄골인대의손상및전위가심할경우수술적치료가필요할수있으나수술방법은다양한방법이혼용되고있으며, 내측부분의골절로 mediastinal structure compromise 가발생한위험성이있을경우에는수술적치료를할수있다. 론 REFERENCES 1) Nordqvist A, Petersson C. The incidence of fractures of the clavicle. Clin Orthop Relat Res. 1994:127-32. 2) Postacchini F, Gumina S, De Santis P, Albo F. Epidemiology of clavicle fractures. J Shoulder Elbow Surg. 2002;11:452-6. 3) Robinson CM. Fractures of the clavicle in the adult. Epidemiology and classification. J Bone Joint Surg Br. 1998;80:476-84. Fig. 7. Hook plate fixation. Fig. 8. Precontoured anatomical plate fixation of distal clavicular fracture. 48
오주한 : 쇄골골절치료의최근경향 4) Smekal V, Oberladstaetter J, Struve P, Krappinger D. Shaft fractures of the clavicle: current concepts. Arch Orthop Trauma Surg. 2009;129:807-15. 5) Rokito AS, Zuckerman JD, Shaari JM, Eisenberg DP, Cuomo F, Gallagher MA. A comparison of nonoperative and operative treatment of type II distal clavicle fractures. Bull Hosp Jt Dis. 2002;61:32-9. 6) Kona J, Bosse MJ, Staeheli JW, Rosseau RL. Type II distal clavicle fractures: a retrospective review of surgical treatment. J Orthop Trauma. 1990;4:115-20. 7) Robinson CM, Court-Brown CM, McQueen MM, Wakefield AE. Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. J Bone Joint Surg Am. 2004;86-A:1359-65. 8) Nowak J, Mallmin H, Larsson S. The aetiology and epidemiology of clavicular fractures. A prospective study during a two-year period in Uppsala, Sweden. Injury. 2000;31:353-8. 9) Stanley D, Trowbridge EA, Norris SH. The mechanism of clavicular fracture. A clinical and biomechanical analysis. J Bone Joint Surg Br. 1988;70:461-4. 10) Allman FL, Jr. Fractures and ligamentous injuries of the clavicle and its articulation. J Bone Joint Surg Am. 1967;49:774-84. 11) Neer CS, 2nd. Fractures of the distal third of the clavicle. Clin Orthop Relat Res. 1968;58:43-50. 12) Khan LA, Bradnock TJ, Scott C, Robinson CM. Fractures of the clavicle. J Bone Joint Surg Am. 2009;91:447-60. 13) van der Meijden OA, Gaskill TR, Millett PJ. Treatment of clavicle fractures: current concepts review. J Shoulder Elbow Surg. 2012;21:423-9. 14) Andersen K, Jensen PO, Lauritzen J. Treatment of clavicular fractures. Figure-of-eight bandage versus a simple sling. Acta Orthop Scand. 1987;58:71-4. 15) Eskola A, Vainionpaa S, Myllynen P, Patiala H, Rokkanen P. Outcome of clavicular fracture in 89 patients. Arch Orthop Trauma Surg. 1986;105:337-8. 16) Neer CS, 2nd. Nonunion of the clavicle. J Am Med Assoc. 1960;172:1006-11. 17) Nordqvist A, Petersson CJ, Redlund-Johnell I. Midclavicle fractures in adults: end result study after conservative treatment. J Orthop Trauma. 1998;12:572-6. 18) Rowe CR. An atlas of anatomy and treatment of midclavicular fractures. Clin Orthop Relat Res. 1968;58:29-42. 19) Sankarankutty M, Turner BW. Fractures of the clavicle. Injury. 1975;7:101-6. 20) Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. J Bone Joint Surg Am. 2007;89:1-10. 21) McKee MD, Pedersen EM, Jones C, Stephen DJ, Kreder HJ, Schemitsch EH, Wild LM, Potter J. Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg Am. 2006;88:35-40. 22) McKee MD, Wild LM, Schemitsch EH. Midshaft malunions of the clavicle. J Bone Joint Surg Am. 2003;85-A:790-7. 23) Zlowodzki M, Zelle BA, Cole PA, Jeray K, McKee MD. Treatment of acute midshaft clavicle fractures: systematic review of 2144 fractures: on behalf of the Evidence-Based Orthopaedic Trauma Working Group. J Orthop Trauma. 2005;19:504-7. 24) McKee RC, Whelan DB, Schemitsch EH, McKee MD. Operative Versus Nonoperative Care of Displaced Midshaft Clavicular Fractures: A Meta-Analysis of Randomized Clinical Trials. J Bone Joint Surg Am. 2012. 25) Hill JM, McGuire MH, Crosby LA. Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br. 1997;79:537-9. 26) Collinge C, Devinney S, Herscovici D, DiPasquale T, Sanders R. Anterior-inferior plate fixation of middlethird fractures and nonunions of the clavicle. J Orthop Trauma. 2006;20:680-6. 27) Iannotti MR, Crosby LA, Stafford P, Grayson G, Goulet R. Effects of plate location and selection on the stability of midshaft clavicle osteotomies: a biomechanical study. J Shoulder Elbow Surg. 2002;11:457-62. 28) Bostman O, Manninen M, Pihlajamaki H. Complications of plate fixation in fresh displaced midclavicular fractures. J Trauma. 1997;43:778-83. 29) Poigenfurst J, Rappold G, Fischer W. Plating of fresh clavicular fractures: results of 122 operations. Injury. 1992;23:237-41. 30) Golish SR, Oliviero JA, Francke EI, Miller MD. A biomechanical study of plate versus intramedullary devices for midshaft clavicle fixation. J Orthop Surg Res. 2008;3:28. 31) D ST, Day M, Dent C, Williams R, Evans R. Treatment of mid-shaft clavicle fractures: A comparative study. Int J Shoulder Surg. 2009;3:23-7. 32) Kleweno CP, Jawa A, Wells JH, O'Brien TG, Higgins LD, Harris MB, Warner JJ. Midshaft clavicular fractures: comparison of intramedullary pin and plate fixation. J Shoulder Elbow Surg. 2011;20:1114-7. 33) Ferran NA, Hodgson P, Vannet N, Williams R, Evans RO. Locked intramedullary fixation vs plating for displaced and shortened mid-shaft clavicle fractures: a randomized clinical trial. J Shoulder Elbow Surg. 2010;19:783-9. 34) Liu HH, Chang CH, Chia WT, Chen CH, Tarng YW, Wong CY. Comparison of plates versus intramedullary nails for fixation of displaced midshaft clavicular fractures. J Trauma. 2010;69:E82-7. 35) Lee YS, Lin CC, Huang CR, Chen CN, Liao WY. Operative treatment of midclavicular fractures in 62 elderly patients: knowles pin versus plate. Orthopedics. 49
대한견 주관절학회지제 15 권제 1 호 2007;30:959-64. 36) Duan X, Zhong G, Cen S, Huang F, Xiang Z. Plating versus intramedullary pin or conservative treatment for midshaft fracture of clavicle: a meta-analysis of randomized controlled trials. J Shoulder Elbow Surg. 2011;20:1008-15. 37) Huang JI, Toogood P, Chen MR, Wilber JH, Cooperman DR. Clavicular anatomy and the applicability of precontoured plates. J Bone Joint Surg Am. 2007; 89:2260-5. 38) VanBeek C, Boselli KJ, Cadet ER, Ahmad CS, Levine WN. Precontoured plating of clavicle fractures: decreased hardware-related complications? Clin Orthop Relat Res. 2011;469:3337-43. 39) Nordqvist A, Petersson C, Redlund-Johnell I. The natural course of lateral clavicle fracture. 15 (11-21) year follow-up of 110 cases. Acta Orthop Scand. 1993;64:87-91. 40) Robinson CM, Cairns DA. Primary nonoperative treatment of displaced lateral fractures of the clavicle. J Bone Joint Surg Am. 2004;86-A:778-82. 41) Deafenbaugh MK, Dugdale TW, Staeheli JW, Nielsen R. Nonoperative treatment of Neer type II distal clavicle fractures: a prospective study. Contemp Orthop. 1990;20:405-13. 42) Andersen JR, Willis MP, Nelson R, Mighell MA. Precontoured superior locked plating of distal clavicle fractures: a new strategy. Clin Orthop Relat Res. 2011;469:3344-50. 43) Flinkkila T, Ristiniemi J, Hyvonen P, Hamalainen M. Surgical treatment of unstable fractures of the distal clavicle: a comparative study of Kirschner wire and clavicular hook plate fixation. Acta Orthop Scand. 2002;73:50-3. 44) Lyons FA, Rockwood CA, Jr. Migration of pins used in operations on the shoulder. J Bone Joint Surg Am. 1990;72:1262-7. 45) Faraj AA, Ketzer B. The use of a hook-plate in the management of acromioclavicular injuries. Report of ten cases. Acta Orthop Belg. 2001;67:448-51. 46) Flinkkila T, Ristiniemi J, Lakovaara M, Hyvonen P, Leppilahti J. Hook-plate fixation of unstable lateral clavicle fractures: a report on 63 patients. Acta Orthop. 2006;77:644-9. 47) Mizue F, Shirai Y, Ito H. Surgical treatment of comminuted fractures of the distal clavicle using Wolter clavicular plates. J Nihon Med Sch. 2000;67:32-4. 48) Goldberg JA, Bruce WJ, Sonnabend DH, Walsh WR. Type 2 fractures of the distal clavicle: a new surgical technique. J Shoulder Elbow Surg. 1997;6:380-2. 49) Hessmann M, Kirchner R, Baumgaertel F, Gehling H, Gotzen L. Treatment of unstable distal clavicular fractures with and without lesions of the acromioclavicular joint. Injury. 1996;27:47-52. 50) Levy O. Simple, minimally invasive surgical technique for treatment of type 2 fractures of the distal clavicle. J Shoulder Elbow Surg. 2003;12:24-8. 51) Webber MC, Haines JF. The treatment of lateral clavicle fractures. Injury. 2000;31:175-9. 52) Checchia SL, Doneux PS, Miyazaki AN, Fregoneze M, Silva LA. Treatment of distal clavicle fractures using an arthroscopic technique. J Shoulder Elbow Surg. 2008;17:395-8. 53) Franck WM, Siassi RM, Hennig FF. Treatment of posterior epiphyseal disruption of the medial clavicle with a modified Balser plate. J Trauma. 2003;55:966-8. 54) Hanby CK, Pasque CB, Sullivan JA. Medial clavicle physis fracture with posterior displacement and vascular compromise: the value of three-dimensional computed tomography and duplex ultrasound. Orthopedics. 2003;26:81-4. 55) Lewonowski K, Bassett GS. Complete posterior sternoclavicular epiphyseal separation. A case report and review of the literature. Clin Orthop Relat Res. 1992:84-8. 50
오주한 : 쇄골골절치료의최근경향 초록 목적 : 쇄골골절의치료에관한광범위한자료검토를통해현시점에서의적절한쇄골골절치료방법을찾고자한다. 대상및방법 : 성인에서발생한쇄골골절과관련된전반적인내용, 즉쇄골골절의역학, 분류, 수술적응증, 최근도입된치료방법의현황및결과를문헌고찰을통해정리하였다. 또한, 쇄골중간부위골절의수술적응증의확대와, 새로운치료법의하나로주목받고있는 anatomically precontoured plate의도입을비롯한최신지견에대해살펴보았다. 결과및결론 : 지금까지쇄골골절은비수술적방법으로대부분치료되어왔다. 하지만최근들어기존에추산되었던것보다많은수의불유합, 부정유합발생이보고되면서수술적치료의적응증이점점확대되는추세이다. 하지만아직까지는쇄골골절에대한이상적인치료방침이확립되지않았음을고려할때, 환자개개인의임상정보와선호도를세심히고려한맞춤형치료가이루어져야하겠다. 색인단어 : 쇄골골절, 적응증, 치료방법 51