165 pissn : 1226-2102, eissn : 2005-8918 Case Report J Korean Orthop Assoc 2014; 49: 165-171 http://dx.doi.org/10.4055/jkoa.2014.49.2.165 www.jkoa.org 민경대 황석하 * 김준범 조상혁 이병일 순천향대학교의과대학정형외과학교실, * 성애병원정형외과 Treatment of Scapula Fractures of the Inferior Angle Causing Pseudowinging Scapula Kyoung-Dae Min, M.D., Seok-Ha Hwang, M.D.*, Jun-Bum Kim, M.D., Sang-Hyuck Cho, M.D., and Byung-Ill Lee, M.D. Department of Orthopedic Surgery, Soonchunhyang University College of Medicine, *Department of Orthopepic Surgery, Sungae Hospital, Seoul, Korea Nonoperative treatment of r body fractures has shown good clinical results. Although fractures of the inferior angle, particularly with oblique lines from the medial proximal to lateral distally, are very rare, we believe that such a fracture pattern would be regarded as an avulsion fracture of the serratus anterior muscle requiring surgery. We have experienced three cases demonstrating pseudowinging of the due to displacement of the inferior angle fracture of the. Surgical repair or plating showed satisfactory clinical results. Through these cases, we describe the cause of winging and the problems resulting from an avulsion fracture of the serratus anterior muscle with a review of the relevant literature and explain the reason that an operation is needed for this fracture pattern. Key words:, serratus anterior muscle, winging, avulsion fracture 견갑골체부골절은드물게발생하는골절이지만보존적치료로 양호한임상결과를얻을수있기때문에대부분의경우보존적 치료를시행하고있다. 1) 이중장흉신경이나척추부신경과같은 신경의손상없이견갑골골절로익상견갑이발생한보고는매우 드물다. 2-6) 그러나견갑골하각부골절에서는해부학적특수성으 로익상견갑이발생하기쉬운데, 이경우전거근의견인력에의 해골편에전위가발생할가능성이높아보존적치료로양호한 임상결과를얻을수있는지의문스럽다. 저자들은견갑골하각부에서골절선이견갑골내측을근위부 로시작해서외측을원위부로향하는하내측사선골절 3 예를경 험하였다. 전체예에서신경손상은없었으나통증이동반된익상 Received November 25, 2013 Revised December 11, 2013 Accepted January 8, 2014 Correspondence to: Seok-Ha Hwang, M.D. Department of Orthopedic Surgery, Sungae Hospital, 22 Yeouidaebang-ro 53-gil, Yeongdeungpo-gu, Seoul 150-960, Korea TEL: +82-2-840-7233 FAX: +82-2-840-7755 E-mail: hwangseokha@naver.com 견갑소견과기능적장애를확인하였으며수술적치료로만족할만한임상적결과를얻었다. 이에견갑골하각부하내측사선골절을수술적치료가필요한전거근견열골절로이해할필요가있다고판단하여이를문헌고찰과함께보고하고자한다. 증례보고 1. 증례 1 특별한과거력이없는신체건강한 41세남자가 12개월전교통사고후, 단순방사선촬영상우측하부견갑골골절이있다고진단받은후보조기를이용한보존적치료를해오다활동시에지속되는견관절후방통증과외전시탄발음을주소로내원하였다. 환자는우측손을전방으로올릴때와우측손으로벽을미는동작을할때심한통증을겪었으며, 우측견갑골하방에압통과이동성종물을호소하였다. 이학적검사상견관절운동범위는모든범위에서가능하였으나, 후면에서관찰시견갑골하각부의부분 The Journal of the Korean Orthopaedic Association Volume 49 Number 2 2014 Copyright 2014 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
166 민경대 황석하 김준범외 2 인 함몰이관찰되며, 전방거상시견갑골의내측경계가후방으로돌출되는익상견갑의형태를보였다 (Fig. 1A). 우측견갑골측면을촬영한단순방사선촬영소견상견갑골하각부에서분리된골편이전외측을향하여늑골쪽으로전위되어있었고 (Fig. 1B), 컴퓨터단층촬영소견상견갑골하각부에경계부위가완만한골편의전외방전위가확인되어견갑부하각골절부가불유합된것으로판단되었다 (Fig. 1C). 신경전기생리학적검사는특이소견을보이지않았다. 골절편은전거근의견인으로통증과기능장애를동반한익상견을야기하고, 불유합된골절편은더이상의보존적치료로유합되기어려워보여수술적치료를실시하기로결정하였다. 견갑골하각부를중심으로 10 cm 가량사면으로절개하고광배근과승모근사이로견갑골하내측연에도달한후전외측으로전위된하각부골절편주변으로형성된점액낭과비후된섬유성조직을제거하니전거근은골절편늑골면에부착되어있었으며, 견 갑골내측연에서대능형근은파열되어있는소견을보이고있었다. 골절편경계부일부를마멸하여출혈을확인한후정복하였으며두개의잠김압박금속판 (locking compression plate [LCP] 2.4 straight, Synthes, Bettlach, Switzerland; LCP condylar plate, 2.4, Synthes) 를이용하여골절편을고정하였다. 이후자가골이식을시행하고하각부와골절편에각각천공을하여 FiberWire (Arthrex, Naples, FL, USA) 를이용한골편봉합을통해추가적인고정을하였다 (Fig. 1D). 수술후견관절외전보조기로고정한상태에서간헐적으로진자운동 (pendulum exercise) 과 90도이하의수동적관절운동을조심스럽게시행하였다. 술후 6주에촬영한단순방사선사진에서골절편이잘유지되고있음을확인후 (Fig. 1E), 능동적관절운동을시행하여가능한범위까지늘려나갔다. 술후 3개월외래추시에서관절운동은모든범위에서통증없이가능하였고, 운동시탄발음과익상견갑소견도없어졌다 (Fig. 1F). 술후 24개월째최종추시에서수상전과같은일상생활을하 Figure 1. (A) On physical examination, a 41-year-old driver who suffered a traffic accident; image shows right winging of the at posttraumatic one year. (B) Scapula lateral view shows the bony fragment, which is separated from the inferior border of the and displaced by the serratus anterior muscle. (C) Image of 3-dimensional-computed tomography can check for a blunted fracture margin, suggesting nonunion. (D) Intraoperative image shows the surgical technique used to reduce and hold the fracture with a double plate and surgical repair. (E) At postoperative six weeks, lateral radiograph of the right shows a well reducted state of the bony fragment. (F) At postoperative three months, there is no winging of the on elevation of the arm and no crepitus on abduction.
167 고있어만족할만한임상적결과를보였다. 2. 증례 2 39세남자환자로 3 m 높이언덕에서떨어지면서발생한좌측견갑부통증을주소로내원하였다. 내원시좌측하각부에압통을호소하였으며견갑골하내측이돌출된익상견갑소견을확인할수있었다. 단순방사선사진과컴퓨터단층촬영소견상좌측견갑골하각부에내측연을근위부로시작해서외측연을원위부로하는사선골절과골절편이하각부전외측으로전위된소견을확인할수있었다 (Fig. 2A, 2B). 익상견갑의원인을확인하기위해시행한신경전기생리학적검사는이상소견이없었다. 전위된골절편으로인해익상견갑이발생하였고기능적장애 가예상되었기때문에수술적치료를하기로결정하였다. 견갑골하각부중심으로사면절개하여광배근과승모근사이로견갑골하내측연을확인후주변혈종을제거하고살펴보니전외측으로전위된골편을확인할수있었다. 대능형근과대원형근은견갑골에부착되어있었으며전위된골편에부착되어있는전거근을확인할수있었다. 금속판을이용하여고정하기에는골절편이작고두께가얇아골편과하각부에각각 5곳을천공한후 FiberWire (Arthrex) 를통과시켜봉합하는방법으로골편고정술을시행하였다. 수술후견관절외전보조기를착용시켜고정하였다. 술후 3개월째시행한단순방사선사진과컴퓨터단층촬영에서유합된골편을확인할수있었으며 (Fig. 2C, 2D), 관절운동은모든범위에서통증없이가능하였고익상견갑은보이지않았다. 술후 18개 Figure 2. (A, B) Scapula lateral view and image of 3-dimensional-computed tomography show the inferior border fracture of the and anterolateral displacement of the bony fragment. (C, D) At postoperative three months, lateral radiograph and image of 3-dimensional-computed tomography of the left confirm good alignment of the inferior angle of the. Figure 3. (A) On initial examination, a 55-year-old man who fell from a height of 2 m; photography shows dominant winging of the right in leaning with his arms on the wall. (B) Scapula lateral view shows anterolateral displacement of the bony fragment with the inferior border fracture of the. (C) At postoperative three months, image of 3-dimensional-computed tomography of the right confirms acceptable alignment of the inferior angle of the.
168 민경대 황석하 김준범외 2 인 월째최종추시시특별한문제없이생활이가능한상태로만족할만한임상적결과를얻었다. 3. 증례 3 55세남자환자로작업도중 2 m 높이사다리에서떨어지면서발생한우측견갑부와좌측흉곽통증을주소로내원하였다. 우측견갑골하각부에부종으로익상겹갑은명확하지않았으나양팔을앞으로전방거상하여벽을미는동작을취하니우측견갑골하내측이돌출되는익상견갑소견을확인할수있었다 (Fig. 3A). 단순방사선촬영소견상좌측제4, 5번늑골골절과함께우측견갑골하각부에내측연이근위부로향하는브이 (V) 형태의하각부골절을확인할수있었다 (Fig. 3B). 신경전기생리학적검사는정상이였다. 견갑골하각부중심으로사면절개하여견갑골하내측연에도달하여혈종을제거하니전외측으로전위된골편전면부에전거근이부착되어있었고대원형근, 대능형근, 광배근이부분적으로골편에부착되어있었으나명확한근파열소견은관찰되지않았다. 하각골편의외측연은 2.0 cm 정도되어잠김압박금속판 (LCP 2.4 straight, Synthes) 을이용한고정을시행후나머지부분은뼈에구멍을만들어골편을봉합하여고정하였다. 술후 3 개월째시행한컴퓨터단층촬영소견에서골편은정복된상태로잘유지되고있었고 (Fig. 3C), 술후 12개월째외래추시에서통증없이전범위근력운동이가능하였으며익상견갑소견은나타나지않았다. 고찰 익상견갑이장흉신경의손상에따른전거근의기능적장애로발생한다는사실은널리알려져있으나전거근을포함한근육손상이나견갑골의골절에의해익상견갑이발생했다는보고는드물다. 2-6) 전거근은상지거상시와견갑대 (shoulder girdle) 가전방으로움직이는경우견갑골의내측연과하각부를흉곽에고정하는역할과견관절의원회전 (circumduction) 이가능하도록견갑골의회전과견인에관여하는고유기능을하는근육으로, 첫번째부터 8-9 번째늑골외측에서기시해서견갑골전내측면에부착한다. 2,6-9) 그런데전거근의하부를이루는근육군은 5-6 번째늑골부터 8-9 번째늑골외측에서기시해서견갑골하각부전내측면에부채모양으로수렴하는궤도를이루며부착하는해부학적인특성으로견갑골하각부에전거근에의한흉곽으로의견연력이집중된다. 2,6,9) 따라서견갑골하각부골절시견갑골체부는체부에작용하는전거근의근력약화로익상견갑이발생하기쉽다. 견갑골골절이전체골절의 1% 도안되는빈도로발생하는드문골절이고견갑골하각부골절은몇몇보고밖에없을정도로적기때문에수상기전을정확히파악하는것은어렵다 (Table 1). 1-4,6,10) 그러나일반적으로견갑골골절이고에너지손상에서발 생하는데반해견갑골하각부골절은하각부에직접적인충격 (direct blow, blunt trauma) 이가해지거나, 수부나주관절등에충격이가해지면서발생하는전거근의강력한수축력에의한손상으로발생하기쉽다. 3,4,6,10) 본증례들의수상기전도고에너지손상이라기보다는견갑골하부에직접적인충격이나팔을바닥에짚으면서전거근에강력한수축력을일으키는간접적인손상으로견갑골하각부골절이발생한것으로추측되었으며고에너지손상에서보이는심각한동반손상도보이지않았다. 견갑골하각부골절이고에너지손상이아닌직접적인충격이나간접적인손상으로도발생하는것은하각부에집중적으로부착하는전거근의견인력이하각부골절을일으키는힘으로작용하기때문으로보인다. 따라서전거근견열골절로발생한견갑골하각부골절편은전거근에의해전외측으로전위될가능성이높기때문에보존적치료로유합되지않을가능성이높을것으로생각된다. 특히전거근하부를이루는근육군이견갑골하각부에집중적으로부착하는해부학적인특성으로인해본증례들과같이내측에서근위부로올라간양상의하각부사선골절일경우골절편에전거근에의한견인력이더욱집중되기때문에전위될가능성이높을것으로판단된다. Gaffney 7) 와 Otoshi 등 8) 은전거근의견열손상이있는경우라도견갑골골절을동반하지않은경우에서익상견갑을보이지않았다고보고했고, Franco 등 10) 은전거근견열골절로보이는흉곽쪽으로휘어진견갑골하각부골절환자에서익상견갑소견은나타나지않았다고보고했다. 그러나 Hayes 와 Zehr 2), Mansha 등 6) 은내측에서근위부로올라간사선모양의견갑골하각부골절을보고하였는데, 모두에서견갑골하각부골절편이전외측으로전위되면서익상견갑소견을보였다고하였다. 저자들이보고한증례들도모두이와유사한견갑골하각부하내측사선골절을보이는경우였으며, 대능형근파열이동반된증례 1에서견갑골내측연이전반적으로돌출된익상견갑소견을보였으며나머지증례들에서도익상견갑변형을확인할수있었다. 견갑골체부골절은대부분보존적치료로좋은결과를보고하고있으나전위가심하거나견열골절인경우수술적치료를고려해야하고견갑골의오구돌기, 관절와하부, 견봉등에견열골절이발생한경우에도수술적치료가필요할수있다고보고하고있다. 1,3,6) Heyse-Moore 와 Stoker, 3) Brindle 과 Coen 4) 은익상견갑을보이는견갑골하각부골절의경우도보존적치료로양호한치료결과를얻었다고보고하였다. 그러나본증례들과같은양상을보이는견갑골하각부골절의경우전거근에의해골편이전외측으로전위되기쉽고이로인해견갑골은하향회전 (downward rotation) 되면서익상견갑소견을보인다면보존적치료를통한골유합을얻기힘들다고여겨진다. 더구나견갑골하각부골절편에부정유합이나불유합이발생하면견갑골에작용하는전거근의기능이약해지면서기능상장애및통증이지속되며익상견갑의
169 Table 1. Summary of Literature Reporting on Fracture of the Inferior Angle of the Scapula Source (year) (Age [yr]/sex/side) Hayes and Zehr 2) (1981) (25/M/right) Heyse-Moore and Stoker 3) (1982) (13/F/left) Injury mechanism Concomitant inury NA Cerebral contusion Fracture pattern Inferior angle Fx. /c Direct trauma No Fx. of inferior angle Brindle and Coen 4) (1998) (17/M/right) Franco et al. 10) (2004) (47/M/left) Indirect trauma (violent contraction) Indirect trauma (repetitive contraction) No Fx. of inferior angle No Fx. at the lower angle /c deflection of the fragment towards the chest wall No winging Mansha et al. 6) (2010) (31/M/right) Direct trauma No Inferior angle Fx. /c Case 1 (41/M/right) Direct trauma No Inferior angle Fx. /c Case 2 (39/M/left) Indirect trauma (falling on an outstretched arm) Case 3 (55/M/right) Indirect trauma (falling on an outstretched arm) No Inferior angle Fx. /c Left 4th, 5th rib Fx. Inferior angle Fx. /c M, male; F, female; NA, not available; Fx., fracture; /c, with; Cons., conservative treatment. Treatment Time to surgery Follow-up Clinical outcome Operative 9 months 12 months Functional recovery /c Cons. 4.5 months Functional recovery, prominence at the lower angle Cons. 6 months Functional recovery /c Cons. 12 months Light pain in arm abduction movement Operative 24 months 3.5 months Functional range of motion /c no pain, no winging Operative 12 months 24 months Functional recovery /c Operative 5 days 18 months Functional recovery /c Operative 5 days 12 months Functional recovery /c Radiologic outcome NA Slipping of the fractured fragment NA
170 민경대 황석하 김준범외 2 인 호전을기대하기어려울것이다. Hayes 와 Zehr 2) 는이와같은골절환자에서 7개월간의보존적치료에도익상견갑변형이지속되고근력약화및통증이호전되지않아골편제거술및견연된전거근을부착부에봉합하였으며, Mansha 등 6) 도견갑골하각부하내측골절환자에서 2년간의보존적치료에도지속되는근력약화및통증과익상견갑소견으로골편의수술적봉합술을시행했다고보고하였다. Franco 등 10) 은견갑골하각부골절환자에서보존적치료후 1년추시에서골편이더전위되면서견관절외전시통증이지속되었다고보고하였다. 증례 1의경우도 1년간의보존적치료에도불구하고관절운동시탄발음을동반한통증과기능적장애가지속되어금속판을이용한고정술을시행한경우였다. 물론전거근견열골절시수술적치료를통해더나은임상적결과를얻을수있는지확인하기위해서는더많은증례를통한비교연구가필요하리라생각된다. 결론적으로외상으로발생한견갑골하각부골절이하내측사선골절양상인경우는전거근의강력한수축이작용한견열골절로이해하여야할것으로보인다. 이경우전거근이작용하는해부학적특성으로인해익상견갑이발생하기쉽고, 전거근의견인력에전위된골절편이보존적치료로유합되기어렵기때문에기능적장애가남을가능성이높아수술적치료가필요할것으로판단된다. REFERENCES 1. Zlowodzki M, Bhandari M, Zelle BA, Kregor PJ, Cole PA. Treatment of fractures: systematic review of 520 fractures in 22 case series. J Orthop Trauma. 2006;20:230-3. 2. Hayes JM, Zehr DJ. Traumatic muscle avulsion causing winging of the. A case report. J Bone Joint Surg Am. 1981;63:495-7. 3. Heyse-Moore GH, Stoker DJ. Avulsion fractures of the. Skeletal Radiol. 1982;9:27-32. 4. Brindle TJ, Coen M. Scapular avulsion fracture of a high school wrestler. J Orthop Sports Phys Ther. 1998;27:444-7. 5. Bowen TR, Miller F. Greenstick fracture of the : a cause of r winging. J Orthop Trauma. 2006;20:147-9. 6. Mansha M, Middleton A, Rangan A. An unusual cause of r winging following trauma in an army personnel. J Shoulder Elbow Surg. 2010;19:e24-7. 7. Gaffney KM. Avulsion injury of the serratus anterior: a case history. Clin J Sport Med. 1997;7:134-6. 8. Otoshi K, Itoh Y, Tsujino A, Hasegawa M, Kikuchi S. Avulsion injury of the serratus anterior muscle in a high-school underhand pitcher: a case report. J Shoulder Elbow Surg. 2007;16:e45-7. 9. Hamada J, Igarashi E, Akita K, Mochizuki T. A cadaveric study of the serratus anterior muscle and the long thoracic nerve. J Shoulder Elbow Surg. 2008;17:790-4. 10. Franco M, Albano L, Blaimont A, Barrillon D, Bracco J. Spontaneous fracture of the lower angle of. Possible role of cough. Joint Bone Spine. 2004;71:580-2.
171 pissn : 1226-2102, eissn : 2005-8918 Case Report J Korean Orthop Assoc 2014; 49: 165-171 http://dx.doi.org/10.4055/jkoa.2014.49.2.165 www.jkoa.org 민경대 황석하 * 김준범 조상혁 이병일 순천향대학교의과대학정형외과학교실, * 성애병원정형외과 견갑골체부골절은대부분보존적치료를시행하고있으며양호한임상결과를보이는것으로알려져있다. 그러나견갑골하각부골절, 특히하각부골절선이내측에서근위부로올라간양상의사선골절은매우드물지만수술적치료를고려해야하는전거근의견열골절로생각된다. 저자들은견갑골하각부골절의전위로인해가성익상견갑변형을보인 3예의드문증례를경험하고관혈적정복과봉합사및금속판을이용한고정술을통하여만족할만한임상적결과를얻었는데, 본증례들과같은골절양상을보이는견갑골하각부골절이발생했을경우익상견갑이나타나는원인과전거근견열골절로인한문제점에대하여문헌고찰과함께살펴보고수술적치료의필요성을설명하고자한다. 색인단어 : 견갑골, 전거근, 익상견갑, 견열골절 접수일 2013 년 11 월 25 일수정일 2013 년 12 월 11 일게재확정일 2014 년 1 월 8 일책임저자황석하서울시영등포구여의대방로 53 길 22, 성애병원정형외과 TEL 02-840-7233, FAX 02-840-7755, E-mail hwangseokha@naver.com 대한정형외과학회지 : 제 49 권제 2 호 2014 Copyright 2014 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.