374 pissn : , eissn : Original Article J Korean Orthop Assoc 2014; 49:

374 pissn : 1226-2102, eissn : 2005-8918 Original Article J Korean Orthop Assoc 2014; 49: 374-380 http://dx.doi.org/10.4055/jkoa.2014.49.5.374 www.jkoa.org Hook 금속판을이용한쇄골원위부불안정성골절의치료결과분석 전호승 우영균 황석하 서승표 강서구 이준경 성애병원정형외과 Analysis of Treatment Results of Unstable Distal Clavicle Fractures Using Hook Plate Ho-Seung Jeon, M.D., Young-Kyun Woo, M.D., Seok-Ha Hwang, M.D., Seung-Pyo Suh, M.D., Seo-Goo Kang, M.D., and Joon-Kyung Lee, M.D. Department of Orthopedic Surgery, Sung-Ae Hospital, Seoul, Korea Purpose: The purpose of this study is to analyze the treatment results and complications in unstable distal clavicle fractures which were treated with a Hook plate, and, in particular, to compare the functional results before and after removal of the Hook plate. Materials and Methods: We examined 20 cases in 20 patients who underwent removal of Hook plates after bony union was obtained in an unstable fracture of the distal clavicle (Neer type II) from March 2009 to December 2012. The average follow-up period after initial surgery was 12 months (8-20 months). Plates were removed at 18 weeks (ranged from 10-36 weeks) after initial fixation. University of California at Los Angeles (UCLA) and Korean Shoulder Scoring System (KSS) scores were used for clinical functional evaluation, and plain radiographs were used for radiological evaluation. Results: In radiological evaluation, bony union was obtained at an average of 11.4 weeks (ranged from 8-14 weeks) in all of the 20 patients. All of the 20 patients showed limited range of motion, mild pain, and discomfort of the shoulder before removal of the Hook plate, and all of the 20 patients showed better results in UCLA and KSS score after removal of the plate, when compared to before removal. Stress fracture as a major complication, was united completely with a figure of 8 bandage and deep wound infection was resolved after repeated debridement and antibiotic treatment with satisfactory functional results. Conclusion: Hook plate in treatment of unstable fracture of the distal clavicle is considered to be a useful method because rigid fixation can be obtained. However, there are some complications, such as limited range of motion, pain, and discomfort of the shoulder joint, before removal of the Hook plate. Therefore, we think that removal of the Hook plate as soon as possible if bony union is obtained would be desirable. Key words: clavicle, unstable fracture, Hook plate 서론 쇄골은우리몸에서가장흔히골절되는장관골중하나로그중 Received January 24, 2014 Revised April 11, 2014 Accepted July 1, 2014 Correspondence to: Seok-Ha Hwang, M.D. Department of Orthopedic Surgery, Sung-Ae 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 쇄골원위부골절은보존적치료시불유합이약 30% 에서발생하여수술적인치료가필요한경우가많다. 1,2) 특히 Neer type II의골절은근위골편의불안정성으로인하여보존적치료시불유합의가능성이높으며원위골편의크기가작거나분쇄가있는경우견고한고정이어렵다고알려져있다. 3-5) 불안정성쇄골원위부골절의수술적치료방법으로는여러형태의금속판을이용한고정술, 오구- 쇄골나사못고정술, K-강선고정술, 골수강내강선고정술, Phemister 술식등다양한방법이있다. 6-9) 그중 Hook The Journal of the Korean Orthopaedic Association Volume 49 Number 5 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.

375 Hook 금속판을이용한쇄골골절의치료결과 금속판을이용한고정술은원위골편의크기가작은골절에서도안정적인고정력을제공할수있으며, 조기관절운동이가능한장점이있어최근많이사용되고있다. 3,6-9) 하지만, 수술후견관절운동범위의감소, 견봉하통증및견봉하골미란등의합병증도보고되고있다. 10-13) 이에저자들은불안정성쇄골윈위부골절에서 Hook 금속판을이용하여골유합을얻은후금속판제거술을시행한환자군을대상으로치료결과및합병증들을분석하고, 금속판제거전과후의임상적기능평가를서로비교하고자하였다. 대상및방법 1. 연구대상 2009 년 3월부터 2012 년 12월까지방사선사진상 Neer type II의쇄골원위부불안정성골절에대해 Hook 금속판 (locking compression plate clavicle hook plate; Synthes, Oberdorf, Switzerland) 을이용하여수술한환자들 27명중금속판제거술을시행한 20명 20예를대상으로하였다. 평균연령은 52세 (27-74 세 ) 였으며우측이 9 예, 좌측이 11예였다. 수술후평균추시기간은 12개월 (8-20 개월 ) 이었다. 손상원인으로는교통사고가 5예, 추락사고가 3예, 실족사고가 12예였으며, 동측상지에동반골절이나신경손상은모든예에서관찰되지않았다. 골절양상은오구- 쇄골인대내측이골절되었으나오구- 쇄골인대가파열되지않은경우 (IIA) 가 7예, 원추양인대는파열되고승모양인대만이원위골편에부착되어있는경우 (IIB) 가 13예였다. 임상적기능평가로 University of California at Los Angeles (UCLA) 점수, Korean Shoulder Scoring System (KSS) 점수를이용하였으며, 방사선학적평가는단순방사선사진을이용하였다. 견관절운동시 Hook 와상완골골두사이에충돌이일어나지않는것을확인하였다. 이후삼각근과승모근을봉합한후피부봉합을하였으며오구- 쇄골인대에대한봉합술이나재건술은시행하지않았다 (Fig. 1). 수술후외전보조기를착용하였으며술후일주일부터진자운동을시작하였다. 수술후 2주부터는능동적관절운동을허용하였다. 금속판제거술은방사선학적으로골유합을확인한후가능한한조기에시행하였다. 금속판제거시에견봉- 쇄골관절을노출시키거나관절낭또는주위의재생된인대에손상을가하지않게하기위하여이전절개선의내측 2/3 길이만절개하여금속나사를제거하고견봉하공간에손상이가지않도록주의하면서금속판을들어올려금속판을제거하였다. 3. 평가방법수술후의평가를위해서쇄골의전후방및두경사 (cephalic tilt) 2. 수술방법전신마취하에서환자를해변의자자세로위치시킨후골절선을중심으로쇄골의외측 1/3 부위에서견봉- 쇄골관절후방으로쇄골의주행방향을따라피부절개를가하였다. 피하지방아래삼각근과승모근의근막을박리하여골절부위를노출시켰다. 골절을정복한뒤 K-강선이나정복겸자로일시적으로정복을유지한후에 Hook 금속판을삽입하였다. 영상증폭장치를사용하여건측의쇄골외측단의높이를기준으로정복된환측의높이를확인하고견봉의하연에 Hook 가위치할수있도록가장적합한깊이의 Hook 를가진금속판을선택하였다. 나사못을이용하여골절의내측부터고정을시행하였고, 골절부위에견고한고정력을줄수있도록근위부에최소한 2개이상의나사못을삽입하였으며원위골편의크기가큰경우에는나사못을이용한고정을시행하였으나원위골편의크기가작고분쇄가심한경우에는나사못을삽입하지않았다. 고정후영상증폭장치를사용하여 Figure 1. (A) Neer type IIB fracture of the clavicle in a 53-year-old man is seen. (B) The distal clavicular fracture is stabilized with a Hook plate. (C) At postoperative three months, radiograph shows union of the fracture.

376 전호승 우영균 황석하외 3 인 방사선사진을이용한골유합및금속물의위치, 견봉하골침식등을관찰하였다. 방사선학적결과는수술직후, 수술후 1, 2, 4주, 그리고골유합시점까지 1개월간격으로정기적으로촬영하여가골이골절부의상하모두연결되거나가골형성이없는경우는골절선이없어지고골소주가골절부를통과하는소견이보이는시기를골유합으로정의하여골유합기간을분석하였다. 골유합을정확히판단하기어려운경우컴퓨터단층촬영을이용하여유합여부를확인하였다. 임상적기능평가는최종추시시의 UCLA 점수와 KSS 점수를사용하였고, UCLA 점수는우수 (34-35 점 ), 양호 (29-33 점 ), 불량 (<28 점 ) 으로나누어평가하였다. 그리고술후합병증들에대하여확인하였다. 결과 1. 방사선학적결과모든환자에서수술후평균 11.4 주 (8-14 주 ) 에방사선학적골유합을확인할수있었으며, 금속판제거술은방사선학적으로골유합을확인한후평균 18주 (10-36 주 ) 이후에시행하였다 (Table 1). 단순방사선사진상견봉하골미란은 9예에서발생하였으며, 평균 2.8 mm (1.8-4.8 mm) 로그중 2예에서견봉부위의압통을호소하였고, 금속판을제거한후호전되었다. 7예에서는견봉부위의압통이없었고, 견봉하골미란이없이견봉하통증을보이는사례도있어저자들은견봉하골미란과증상과는큰연관성이없다고판단하였다 (Fig. 2). 2. 임상적기능평가결과 UCLA 점수기준에의한평가는우수 6예, 양호 13예, 불량 1예였으며, 평균 30.3 점 (26-35 점 ) 을보였다. KSS 점수는평균 75.6 점 (56-88점 ) 이었다. 골유합판정시평균견관절운동범위는전방거상 150 도 (120-180 도 ), 외전 126 도 (90-170 도 ), 외회전 65도 (45-80 도 ) 로모든환자에서수상전에비해전반적인견관절운동범위감소를보였다. 그외에 20예의환자중 18예에서운동시견봉하통증을호소하였으며, 20예모두에서견관절운동시불편감을호소하였다. 금속판제거술후최종추시는금속판제거후평균 2주에시행하였으며, UCLA 점수기준에의한평가는우수 15예, 양호 5예였고, 평균 33.2 점 (29-35 점 ) 을보였다 (Fig. 3). KSS 점수는평균 82.0 점 (62-93 점 ) 이었다 (Fig. 4). 평균견관절운동범위는전방거상 Table 1. Patient Demographics and Results Case No. Sex/age (yr) Fracture type (Neer) Side Fracture union (wk) Plate removal (wk) Before plate removal After plate removal UCLA KSS UCLA KSS 1 Female/72 IIA Right 14 16 29 73 31 80 2 Male/25 IIB Right 8 12 35 88 35 93 3 Male/72 IIA Left 8 10 26 56 29 62 4 Male/53 IIB Left 14 36 29 74 30 82 5 M/65 IIB Left 14 22 29 73 34 81 6 M/64 IIA Left 8 11 30 79 34 85 7 Female/74 IIB Right 14 22 27 60 29 66 8 Male/53 IIB Right 12 24 30 79 34 85 9 Male/28 IIB Left 12 18 34 83 35 89 10 Male/68 IIB Left 16 24 29 77 34 83 11 Female/73 IIB Right 12 16 29 65 30 74 12 Male/43 IIA Right 12 20 30 79 34 85 13 Male/49 IIB Right 10 16 29 76 34 83 14 Female/27 IIB Left 10 16 34 82 35 88 15 Male/42 IIB Left 10 16 34 80 35 86 16 Male/47 IIA Left 12 20 29 72 34 79 17 Male/49 IIB Left 10 12 29 77 34 83 18 Male/68 IIA Right 12 16 29 76 34 82 19 Male/35 IIA Right 10 16 31 79 34 85 20 Male/28 IIB Left 10 24 34 83 35 89 UCLA, University of California at Los Angeles shoulder score; KSS, Korean Shoulder Scoring System.

377 Hook 금속판을이용한쇄골골절의치료결과 Figure 4. Korean Shoulder Scoring System (KSS) score. SD: standard deviation. Figure 2. (A) Neer type IIA fracture of the distal clavicle in a 68-yearold man is seen. (B) Immediate postoperative radiograph shows normal cortical surface of acromion. (C) At postoperative three months, radiograph shows subacromial erosion around the tip of the Hook plate. Figure 5. (A) Fracture of the clavicle through the most medial screw hole of the Hook plate is seen. (B) At six months of follow-up, union of the fracture is seen. Figure 3. University of California at Los Angeles (UCLA) score. SD: standard deviation. 165 도 (140-180 도 ), 외전 151 도 (120-180 도 ), 외회전 70 도 (50-80 도 ) 로모든환자에서금속판제거술후견관절운동범위증가를보 였으며, 견봉하통증을호소하였던 18 예모두에서증상의소실을 보였다. 3. 합병증관혈적정복술후금속판나사못구멍을통한스트레스골절이 1 예, 수술부위에발생한심부감염이 1예가있었다. 스트레스골절이발생한 1예는 8자붕대를이용한보존적치료를통해골유합을얻었고 (Fig. 5), 심부감염이발생한 1예는세척술, 변연절제술및항생제투여등으로완치되었다. 금속판제거술후에발생한합병증은없었다. 고찰 쇄골원위부골절은드물지않은견관절의골절로흔히 Neer 분류법에의하여분류되는데, 이중 type II의골절은오구- 쇄골인

378 전호승 우영균 황석하외 3 인 대내측이나인대손상이동반된골절로, 승모근에의해골절근위부가상방으로견인되기때문에골절부의불안정성이발생하여보존적치료로는불유합의가능성이높아여러연구에의해수술적치료가필요한것으로알려져왔다. 14-16) Neer 2) 는보존적치료로 50% 의불유합을보고하였으며, 보존적치료방법으로는골유합이되더라도유합기간이길고이러한긴유합기간과연부조직손상으로견관절유착과기능장애의합병증을유발할수있기때문에조기에수술을하라고주장하였다. 이러한쇄골원위부골절의수술적고정방법에대해서는다양한방법이소개되었으나절대적으로우위의결과를보이는치료방법은없다고알려져있다. 7,17,18) Hook 금속판을이용한내고정술은분쇄가심하거나쇄골외측단의골편이작은 Neer type IIB 골절에서도 Hook 의견봉하고정으로안정적인고정을할수있고, 잠김나사못의고정으로회전및각변형에안정성을도모할수있으며 Hook 의견봉하고정으로인해수직면에대해서도안정성을가진다고알려져있다. 7) 따라서저자들은불안정성쇄골원위부골절의수술적치료로 Hook 금속판을이용한내고정술을시행하여골편에안정감을줄수있는충분한고정력을얻고, 빠른재활운동으로관절강직을줄이고자하였다. K-강선을이용한고정에대해 Fann 등 19) 은 32예중모든예에서합병증없이골유합을얻었다고하였지만, Kona 등 20) 은 13예중 5예의감염과 6예의불유합이있었다고보고하였다. Craig 21) 는 Knowles 핀을이용한관혈적골수강내고정술에대해 K-강선고정방법에비해고정기간이더짧고정복이용이하며강선의이동이더적다고보고하였으나, 견봉- 쇄골관절손상으로인한관절염을유발하는단점이있다고하였다. Flinkkilä 등 22) 은견봉-쇄골탈구와불안정한쇄골원위부골절에서 K-강선을이용한고정과 Hook 금속판을이용한고정술을비교한결과골유합과기능적인측면에서는큰차이가없었으나 K-강선을이용한고정에서정복소실, 감염, 불유합이발생하여 Hook 금속판을이용한고정을추천하였고, 금속판에의한견봉의손상이나회전근개의손상은없었다고하였다. Faraj 와 Ketzer 12) 은 Hook 금속판을이용하여치료한 7예의견봉- 쇄골탈구와 3예의쇄골원위부골절에대하여술후 12주이내에일상작업과가벼운스포츠로복귀할수있었고금속판의제거는필요하지않다고하였다. 본연구에서는 20예의불안정성쇄골원위부골절에서모두골유합을얻을수있었으며, 나사못의이완이나고정실패등은관찰되지않았다. 하지만이러한 Hook 금속판의좋은결과들에반해여러합병증들이보고되고있으며, 이는주로 Hook 금속판의디자인중가장핵심적인부분인 Hook 와관련된것들이다. 9,23-25) Renger 등 24) 은 Hook 금속판의고정술후 44명의환자중 30명 (68%) 의환자에서견관절운동시의통증과견봉의긁히는느낌및견관절의운 동제한이있었다고하였다. ElMaraghy 등 26) 은 Hook 금속판을이용한사체연구에서 15예중 9예에서극상건과 Hook 기저부의접촉이있었다고보고하였다. 따라서전형적인견봉하충돌증후군의병변인견봉전연보다 Hook 금속판의 Hook 가후방에위치하더라도 Hook 에의한충돌증후군이발생할수있다고하였다. Chaudry 와 Waseem 27) 은낮은깊이의 Hook 를가진금속판을사용하여견봉하구조물과의충돌을줄일수있다고하였다. 하지만 ElMaraghy 등 26) 은사체연구에서 15 mm 깊이의 Hook 금속판을사용한 4개의사체모두에서극상건과의접촉이관찰되어낮은깊이의 Hook 를사용한다고하더라도견봉하구조물과의충돌을완전히배제할수는없다고하였다. 저자들역시 Hook 로인한충돌은최소화하고골절편의고정력은높이기위해견봉의하연에위치할수있는최대한낮은깊이의 Hook 를가진 Hook 금속판을사용하였으나술후재활과정에서견관절의운동범위의감소및견봉하통증이나타나는것을확인하였다. 이는금속판 Hook 와견봉하구조물의충돌로인해발생하는것으로판단되어저자들은골유합이확인된후가능한한조기에금속판제거술을시행하였고, 제거술후견관절운동범위가회복되고견관절통증이호전되는것을확인할수있었다. 금속판제거시기는방사선학적으로골유합이확인된후가능한빨리제거하는것을원칙으로하였으나수술후정기적으로내원하지않았던 1예에서는수술후 36주만에제거술을시행하였다. 수술후금속판내측나사못구멍을통한골절이 1예발생하였으나이는수술후발생한 2차례의경미한직접적외상으로인한스트레스골절로판단하여보존적치료를통하여골유합을얻었다. 본연구의한계점으로는금속판제거술을시행하지않은비교대상군이없다는점, 연구대상에포함된환자의수가적었다는점, 장기추시가이루어지지못한점, 술후처치및재활과정에대한비교분석이이루어지지않은점이있지만, Hook 금속판을이용한불안정성쇄골원위부골절의치료와관련하여금속판제거전과제거후의임상적기능평가를처음으로비교한연구라는점에서의의가있다고생각한다. 결론 쇄골원위부불안정성골절의치료에서 Hook 금속판을이용한수술법은해부학적정복과견고한고정력을얻을수있으므로유용한치료방법중하나로생각되나수술후견관절운동범위의감소및견관절의동통이나불편감등의합병증이있을수있으므로골유합이확인되면가능한한조기에 Hook 금속판을제거하는것이바람직할것으로생각된다.

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380 pissn : 1226-2102, eissn : 2005-8918 Original Article J Korean Orthop Assoc 2014; 49: 374-380 http://dx.doi.org/10.4055/jkoa.2014.49.5.374 www.jkoa.org 전호승 우영균 황석하외 3 인 Hook 금속판을이용한쇄골원위부불안정성골절의치료결과분석 전호승 우영균 황석하 서승표 강서구 이준경 성애병원정형외과 목적 : 쇄골원위부불안정성골절을 Hook 금속판으로치료한결과및합병증을분석하고, 금속판제거전, 후의기능적결과를비교분석하였다. 대상및방법 : 2009 년 3월부터 2012 년 12월까지쇄골원위부불안정성골절 (Neer type II) 을 Hook 금속판으로수술후금속판을제거한 20예를분석하였다. 술후평균추시는 12개월 (8-20 개월 ), 금속판제거는술후평균 18주 (10-36 주 ) 였다. 임상적기능평가는 University of California at Los Angeles (UCLA) 와 Korean Shoulder Scoring System (KSS) 점수를, 방사선학적평가는단순방사선사진을이용하였다. 결과 : 방사선학적평가상 20예중 20예모두술후평균 11.4 주 (8-20 주 ) 에골유합을얻었다. 20예모두술후견관절운동감소, 동통등을보였고, 금속판제거후 20예모두제거전보다 UCLA 및 KSS 점수가향상되었다. 결론 : 쇄골원위부불안정성골절치료에서 Hook 금속판고정술은견고한고정력을얻을수있어유용한방법이나술후견관절운동감소, 동통등합병증이있어골유합시가능한한조기에 Hook 금속판을제거하는것이좋을것으로생각된다. 색인단어 : 쇄골, 불안정성골절, Hook 금속판 접수일 2014 년 1 월 24 일수정일 2014 년 4 월 11 일게재확정일 2014 년 7 월 1 일책임저자황석하서울시영등포구여의대방로 53 길 22, 성애병원정형외과 TEL 02-840-7233, FAX 02-840-7755, E-mail hwangseokha@naver.com 대한정형외과학회지 : 제 49 권제 5 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.