대한수부외과학회지제 12 권제 1 호 The Journal of the Korean Society for Surgery of the Hand VOLUME 12, NUMBER 1, March 2007 제 5 중수골경부골절의관혈적정복 연세대학교의과대학정형외과학교실 Open Reduction for the 5th Metacarpal Neck Fracture Ho-Jung Kang, M.D., Sung-Hoon Jung, M.D., Yoon-Jin Choi, M.D., Chang-Wook Han, M.D., Soo-Bong Hahn, M.D. Department of Orthopaedic Surgery, Yongdong Severance Hospital, Yonsei University, College of Medicine, Seoul, Korea Purpose: To evaluate the treatment results of open surgery in the 5th metacarpal neck fracture by retrospective analysis. Materials and Methods: From March 1996 to May 2004, 15 patients who underwent open surgery due to the 5th metacarpal neck fracture were retrospectively reviewed with radiographic and functional analysis. We used the visual analog satisfaction score (0~10) to assess the patient s subjective satisfaction and the assessment categories including pain, limitation of motion, hand deformity, and function. Patients gave each assessment category 10 points as the best score, and we analyzed the results with a total of 40 points. For open reduction, posterolateral approach was used with the 5th extensor tendon retracted to the ulna or radial side, and then fracture site reduction was done. Results: There were malunion in 4 cases, rotational deformity in 2 cases, redisplacement after closed reduction in 6 cases, displaced intraarticular fracture in 2 cases, and open fracture in 1 case. Patient subjective satisfaction score was an average of 34.6 points (29~38 points). Average dorsal angulation was 50.2 (41 ~ 72 ) in the preoperative oblique radiographs and 18.4 (15 ~ 41 ) at the last follow up. Conclusion: Open surgery should be recommanded for the treatment of the 5th metacarpal neck fracture in cases of malunion, rotational deformity, unstable and redisplaced fracture, displaced intrarticular fracture, and displaced growth plate injury. 통신저자 : 정성훈서울특별시강남구도곡동 146-92 영동세브란스병원정형외과학교실 TEL: 02-2019-3410, FAX: 02-573-5393 E-mail: shjdoc@naver.com Key Words: The fifth metacarpal, Neck fracture, Open reduction 서 론 제 5 중수골경부골절은흔한수부손상의하나로주먹을쥔상태에서중수골두부위로다른물체를가격할때발생하므로권투선수골절 (boxer s fracture) 이라고불리기도하며, 전체수부골절의 20% 를차지할정도로흔한수부골손상이다 1. 많은문헌에서제 5 중수골경부골절의치료에있어보존적치료만으로도우수한치료결과를얻었음을발표하였으나실제로수상당시방사선필름상골절부의각형성및분쇄정도에따른치료결과비교가부족하고허용가능한배측전위각도여전히논란이되고있다 2-8. 이들은골절부각형성이 70도까지보존적치료가가능하며치료후기능적결과 (functional result) 상정상과차이가없다고하였으나, 다른실험결과에서는골절부각형성이 30도이상이되면관절을가로지르는근육, 건의작용효율에영향을주어중수지간관절굴곡기능에장애가있음이밝혀졌다 9,10. 골절부각형성교정이안되었을경우외관상으로는수배부중수수지관절마디 (knuckle) 의함몰이나중수골의골두가수장부쪽으로돌출하여티눈이생길수있고기능적으로는굴곡구축, 굴곡제한, 그리고신전지연등이발 11
생할수있다. 따라서보존적치료혹은비관혈적수술방법만으로는만족할만한치료결과를얻지못하는경우가있을수있다. 저자들은제 5 중수골경부골절에대해관혈적수술치료를했던예들을후향적으로분석하여관혈적수술의치료결과에대해알아보고자하였다. 대상및방법 1996년 3월부터 2004년 5월까지제 5 중수골경부골절로본원정형외과에내원했던 101 예를대상으로후향적분석을시행하였다. 전체 101 예의환자들중수술적치료를받았던예가 52예, 보존적치료를받았던예가 49예였다. 수술적치료를받았던예들중, 경피적핀고정술을시행한 37예를제외하고관혈적정복을시행한 15예를대상으로연구를진행하였다. 제 5 중수골경부골절로내원한환자분석대상에서는 3개이상의중수골골절이동반된다발성수부골절및압궤손상이있는경우와주요신경, 혈관및수부건손상이있는경우는제외시켰다. 관혈적수술치료는후외측접근을사용하여제 5 수지신전건을요골측이나척골측으로견인하였으며, 수상후 3주이상경과하여가골 (callus) 형성이많아골절부위의움직임이전혀없을경우에는골분쇄술 (osteoclasis) 후정복하여내고정을시행하였다. 고정방법으로는경피적강선고정 11 예, 미니나사고정 2예, 외고정장치 1예, 금속판및나사고정 1예가있었다. 수술후처치로는 3주간의부목고정후능동적관절운동을시작했으며 Kirschner 강선은수술후평균 4주에제거하였고 Orthofix 외고정장치는수술후 5주에제거하였다. 능동적관절운동은수술후 3주째시행하였는데하루 3회 10 분간중수지관절및수지관절굴곡-신전운동을하게하였다. 수술후 4주이후에는환자에게통증이심하지않는범위에서자유롭게운동을허용하였다. 입원및외래기록검토와수술전후및추시관찰시의방사선필름의검토, 계측을시행하였다. 입원및외래기록검토를통해환자의연령, 성별, 수상기전, 수술방법, 수술시간등을분석하였다. 추시관찰시임상적평가방법으로객관적평가로골절부압통여부, 수부변형, 관절운동범위, 파악력, 그리고기타합병증을, 주관적평가로환자의전반적만족도를검토하였다. 환자의만족도는전화질의및외래방문유도로환자의주관적관점에의해치료결과를통증, 관절운동장애, 수부변형, 기능에대한평가의항목으로나누어조사하였다. 환자자신의주관적인기능평가를위하여 visual analog satisfaction score (0~10) 를이용하였고, 각항목에대해최상의 점수로 10점을부여하여총 40점으로평가를시행하였다. 방사선학적은평가는전후면, 사면및측면촬영을기본으로검토하였으며후방각형성계측은 20 회내사면사진에서측정하였고, 수상당시의골절부각형성및분쇄정도, 수술직후의골절부각교정정도, 내고정물제거후와추시관찰상골유합및골절부교정각소실유무와그외의방사선적변화에대한검토및계측을시행하였다. 결과 전체 15예의평균연령은 29.7 세였고연령분포는 10세에서 61세였으며, 여자가 2명남자가 13명이었다. 손상기전은주먹을쥐고물체를가격하며다친예가 8예 (53.3%) 로가장많았고이외에물체에부딪히거나넘어지면서다친예가다음으로많았다. 주먹으로물체를가격하여골절이일어난경우는모든예가지배수의손상이었다. 관혈적수술을시행한경우는부정유합4예, 회전변형2예, 도수정복후재전위 6예, 전위된관절내골절 2예, 개방성골절 1예였다. 부정유합은수상후 6주가경과하고사면방사선사진에서배측경사각이 40 이상이거나회전변형이있어주먹을쥐었을때손가락이겹쳐지는변형이있는경우로정의하였고도수정복후재전위는 6주이내에도수정복을하였으나추시방사선상에서배측경사각이 40 이상이거나회전변형이보일경우로정의하였다. 회전변형으로따로 2예를분류한것은회전변형이있으면서배측경사각이허용범위안에있을경우에는방사선사진에서는보기힘들뿐만아니라석고고정시에도석고에가려져정확히평가하기가어렵고도수조작으로는정복이어렵기때문에따로분류하였다. 관절내골절의경우는골편이 2 mm 이상전위된관절내골절을관혈적으로정복하였다. 부정유합의경우는수술장에서바로관혈적으로골절부위에골분쇄술 (osteoclasis) 을시행하고정복한다음 2 mm 이상의중수골단축이있을경우에는자가장골이식술을함께시행하였다. 회전변형, 도수정복후재전위, 그리고관절내골절의경우는수술장에서먼저비관혈적정복술을시행했으나교정이되지않았을경우에관혈적정복술을시행하였다. 이환기간 ( 외상후수술까지의기간 ) 은 1일에서 8주까지로평균 25.7 일이었으며평균추시기간은 18개월 (12~24개월) 이었다. 최종추시시관절운동범위는개방성골절및부분적골소실로인해 Orthofix 외고정장치로치료했던 1예를제외하고는모두정상범위로만족할만한결과를보였다. 외고정장치로치료한예에서는제 5 중수수지관절이 15 의굴곡구 12
제 5 중수골경부골절의관혈적정복 축및 65 의굴곡제한을보였으며최종추시상배측각형성이 41 였다. 방사선사진상각변형은술전사면사진에서중수골경부의배측후방각이평균 50.2 (41 ~72 ) 에서최종추시시평균 18.4 (15 ~41 ) 로회복되었다. 평균수술시간은마취시간을포함하여 60.4분 (45~75분) 이었다. 방사선사진상모든예에서골유합이이루어졌으며, 유합시기는평균 6주 3 일 ( 최단 30일, 최장 91일 ) 이었다 (Table 1). 수술후환자의주관적만족도는평균 34.6점 (29~38) 이었는데외관상중수골두함몰에대해서는크게불편감을호소하지않았다. 술후합병증으로는핀삽입부의일시적천부감염이 1예있었으나경구용항생제치료와핀제거로모두치유되었고, 굴곡제한을보인 1예를제외하고는수부의파악력에장애를호소하는환자는없었다. 증례 2 29세남환으로주먹으로가격후, 발생한제 5 중수골경부나선형골절에대해도수정복및석고붕대고정시행하였지만, 정복소실되어수상후 1주째본원에내원하였다. 수술장에서도수정복을시도했으나전위된각이교정이되지않아개방적수술방법을택했다. 후외측접근으로관혈적정복시행후미니나사고정을시행하였으며수술 6개월후추시방사선사진상골유합된소견을보였다 (Fig. 3). 증례 1 14세남환으로주먹으로벽을친후, 7주간간과되었다가회전변형및운동장애를주소로내원하였다 (Fig. 1). 사면방사선사진에서후방각형성 54 를보였다. 후외측접근으로골분쇄술및골이식술시행후 K-강선을이용하여고정을시행하였고, 강선고정상태에서파악시키면서회전변형의교정을확인하였다. 수술후 5주 3일째 K-강선을제거하였고, 추시중골유합및중수수지관절의운동범위는정상소견을보였다 (Fig. 2). Fig. 1. Preoperative photograph shows rotational deformity of 5 th finger at 7 weeks after initial trauma. Table 1. Perioperative data Age/Sex D*/Non-D Injury Time Satisfaction Indications for Internal Mechanism to surgery fixation score open reduction 01 M/29 D Fight 1 wk Mini screw 38 Redisplacement 02 M/14 D Fall 7 wks K-wire 29 Malunion 03 M/18 N Fall 4 wks K-wire 36 Redisplacement 04 M/24 D Fight 8 wks K-wire 37 Malunion 05 M/14 D Fight 2 wks K-wire 37 Intraarticular fx 06 M/50 D Fall 3 wks K-wire 36 Rotation 07 M/34 D Work related 2 wks K-wire 31 Rotation 08 F/10 D Fall 4 wks K-wire 35 Redisplacement 09 F/27 D Fight 3 wks Mini screw 36 Redisplacement 10 M/31 D Fight 6 wks K-wire 37 Malunion 11 M/12 D Fight 2 wks K-wire 35 Intraarticular fx 12 M/39 D Work related 1 day E/F 32 Open fx 13 M/61 N Fall 6 wks K-wire 30 Malunion 14 M/41 D Fight 4 wks Mini plate 36 Redisplacement 15 M/42 D Fight 5 wks K-wire 35 Redisplacement D*: dominant hand, Non-D : non-dominant hand, E/F : external fixation 13
Fig. 2. Preoperative radiograph shows malunited 5 th metacarpal neck fracture at 7 weeks after initial trauma. Dorsal angulation was 54. Acceptable alignment was achieved after osteoclasis and internal fixation. Follow up radiograph shows satisfactory union at postoperative 2 years. Fig. 3. Preoperative radiograph shows angulation of 5 th metacarpal neck by reduction loss at 1 weeks after initial trauma. Acceptable alignment was achieved after open reduction and mini screw fixation. Follow up radiograph shows satisfactory union at postoperative 6 months. 고찰 주먹을쥔상태에서물체를가격할때주로발생하는제 5 중수골경부골절은수부에발생하는흔한골 절인데, 이로인해수부의파악력감소, 너클소실등다양한합병증이나타날수있기때문에청년층이나직업적으로손을많이사용하고스포츠를즐기는현대인들은적절한치료를시행하는것이중요하다 11-14. 제 14
제 5 중수골경부골절의관혈적정복 5 중수골은형태상다른중수골에비해가늘고, 위치상주위조직의보호가약하여비교적쉽게골절이발생하는것으로알려져있다 15. 대부분보존적치료로좋은결과를얻을수있으나어느정도의각형성을허용할것인지에대해서는여전히논란이있다 4-8,16,17. 그러나후방각형성이심한상태에서도수정복이이루어지지않을때수부기능장애의합병증을예방하기위해수술적치료를적극적으로고려해야하는경우도있다. 이러한경우수술적치료법으로는도수정복및경피적핀삽입술, 도수정복및외고정장치술, 관혈적정복및내고정술등이있으며, 가장일반적인수술적치료법인도수정복및경피적핀삽입술을통해대부분만족스러운결과를얻을수있다 7,17-19. 그러나특수한상황에서는비관혈적정복에의해만족스러운결과를기대하기힘들수있는데, 이러한경우에관혈적정복이필요하지만관혈적수술의임상적유용성이나적응증및치료결과에대한문헌보고는아직미비한실정이다. Smith 와 Peimer 20 는 30도이상의교정되지않는배측각형성은배측횡절개를통하여관혈적정복을할것을권유하였고 King 21 은불안정한중수골경부골절에서관혈적정복후금속판과나사로고정할것을권유하였다. Thurston 22 은 35도에서 60도까지의배측각형성과주먹을쥘때손바닥쪽으로의중수골두돌출에의한불편함을호소한 10례의환자에서 Pivot 절골술을사용하여만족스러운결과를얻었음을보고하였다. 이상의보고들은관혈적정복술을시행하였으나주로그수술술기에관한보고들로그정확한적응증에대한언급이부족하였고그대상환자의수도제한적이었다. 따라서본연구에서는관혈적수술치료를시행했던증례들을후향적으로분석하여치료결과및적응증을알아보고자하였다. 본연구에서관혈적수술의적응증으로생각한것은부정유합, 회전변형, 도수정복후재전위, 전위된관절내골절, 개방성골절등이었고보존적치료및비관혈적정복시에허용기준으로삼은배측경사각은 40 였으며회전변형의기준은중수수지관절을굴곡했을때제 5 수지가제 4 수지에겹쳐지는변형이있는경우로하였다. 부정유합이나회전변형의측면에서보면제 5 중수골경부골절은일반적으로보존적치료를사용하기때문에보존적치료에의한합병증즉, 부정유합이나회전변형등이흔하게발생할수있다. 이러한합병증들이조기에발견되고치료된다면재도수정복이나비관혈적정복술및내고정술만으로치료되어질수있으나석고고정으로인해서방사선사진판독이어렵고회전변형여부를알수있는검사를하기도어렵기때문에부정유합이나 회전변형이수상후 1~2 주이상경과한뒤에발견되는경우가많으며수술장에서도비관혈적정복술이실패할가능성이높다. 본연구에서는이러한경우에관혈적수술치료를시행함으로써술후환자만족도측면이나술후방사선소견등의관점에서좋은결과를얻을수있었다. 또한관절내골절이나불안정골절및재전위골절의경우에는반드시관혈적수술이필요하지는않지만, 도수정복만으로만족스러운결과를얻을수없다면가능한조기에관혈적수술을시행하는방법도술후좋은결과를얻을수있음을보여주었다. 본연구에서도수상 6주이내의골절은수술장에서일단비관혈적정복술을시도했으나모두실패하였다. 그리고불안정성전위골절의경우에주의할점은적절한내고정의방법을선택하는것인데, 분쇄가심한골절이나골분쇄술후골결손이있는경우핀고정만으로는안정적고정을얻지못할수있기때문에수술소견에따라서제 4, 5 중수골을함께고정하거나골이식등의추가가필요할수도있다. 마지막으로전위된성장판골절의경우관혈적수술의적응증이될수있는데성장판손상시도수정복만으로치료했을경우추후성장장애에의한길이차이로인해추가적인수술이필요할수있기때문에인위적인성장판의추가적손상을고려하더라도비관혈적방법으로정확한정복을할수없다면조기에관혈적수술치료를염두해두어야할것이다. 결론 제 5 중수골경부골절의치료에있어서부정유합, 회전변형, 불안정및재전위골절, 전위된관절내골절, 전위된성장판골절등의경우에비관혈적치료로만족할만한결과를얻을수없다고판단될경우에는관혈적수술치료로도좋은결과를얻을수있을것으로사료된다. 참고문헌 01) Hunter JM, Cowen NJ. Fifth metacarpal fractures in a compensation clinic population. J Bone Joint Surg Am. 1970;52:1159-65. 02) Jahss SA. Fractures of the metacarpals: A new method of reduction and immobilization. J Bone Joint Surg Am. 1938;20:178-86. 03) Stern PJ. Fractures of the Metacarpal and Phalanges. In: Green DP. editor. Green s Operative Hand Surgery. 5th ed. New York: Churchill Livingstone; 2005. p281-5. 04) Braakman M, Oderwald EE, Haentjens MHHJ. Functional 15
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