대한골절학회지제 17 권, 제 3 호, 2004 년 7 월 Journal of the Korean Fracture Society Vol. 17, No. 3, July, 2004 도수정복및 K- 강선내고정술을이용한 Mason 제 2 형요골두골절의치료 권병기 이송 안동기 박준성 차상규 서울성심병원정형외과 목적 : Mason 분류제 2형요골두골절에대하여 C-arm guide 하에 K-강선을이용한도수정복술및내고정술시행후기능적및방사선학적으로임상적결과를분석하고자하였다. 대상및방법 : 2001 년 3월부터 2003년 10월까지 Mason 분류제 2형요골두골절로내원한환자중 C-arm guide 하에도수정복후 K-강선을내고정술을시행받은 7례를대상으로하였으며, 평균연령은 38세 (5세 ~57 세 ) 였고, 평균추시기간은 20개월 (5개월 ~36개월 ) 이었다. 이들 7례를대상으로최종추시시방사선학적평가와기능적평가로써 Broberg 와 Morrey 의 functional rating system에따라우수 (Excellent), 양호 (Good), 보통 (Fair) 및불량 (Poor) 으로분류하여결과를판정하였다. 결과 : 최종추시결과주관절의운동범위는굴곡구축평균 1.4 도 ( 범위 : 0도 ~10 도 ), 후속굴곡평균 146.4 도 (140도 ~150도 ) 였으며, 전완부의회외전평균 74.2 도 (70 도 ~80 도 ), 회내전평균 75도 (70 도 ~80 도 ) 였다. 기능적평가결과우수 6례및양호 1례였으며, 불량에해당하는예는없었다. 방사선학적평가상전례에서골유합소견을관찰되었으며, 유합까지의기간은평균 5주 ( 범위 : 4주 ~6주 ) 였으며, 전례에서심각한합병증등은발생하지않았다. 결론 : Mason 분류제 2형요골두골절의치료에있어서 C-arm guide하에 K-강선을이용한골절편정복술및내고정술은합병증발생없이만족할만한결과를얻을수있는유용한방법이라사료된다. 색인단어 : 요골두골절, 도수적정복, K-강선, 내고정술 The Treatment of Mason Type II Radial Head Fractures using Closed Reduction and K-wire Fixation Byung Ki Kwon, M.D., Song Lee, M.D., Dong Ki Ahn, M.D., Joon Seong Park, M.D., Sang Kyu Cha, M.D. Department of Orthopedic Surgery, Seoul Sacred Heart General Hospital, Seoul, Korea Purpose: To analyze the clinical results of the treatment of Mason type II radial head fractures using closed reduction and K-wire internal fixation under C-arm guide by radiologically and functionally. Materials and Methods: Between March 2001 and October 2003, 7 patients with Mason type II radial head fracture were treated by closed reduction and internal fixation using K-wires under C-arm guide. The average age of the patients was 38 (5 to 57) years old, and average duration of follow up was 20 (5 to 36) months. At last follow up, we evaluated the radiological results and functional results by classifying excellent, good, fair and poor according to functional rating system of Broberg and Morrey. Results: The range of motion of the elbow at last follow up, average flexion contracture was 1.4 (0 to 10) degrees, further average flexion was 146.4 (140 to 150) degrees, average supination was 74.2 (70 to 80) degrees and average pronation was 75 (70 to 80) degrees. In the functional results, 6 cases were excellent and 1 case was good. In the radiological evaluations, the average time of union was 5 (4 to 6) weeks after the operation and no serious complication was occurred in any cases. Conclusion: In the treatment of Mason type II radial head fracures, closed reduction and K-wire internal fixation under C-arm guide was an effective method of treatment with satisfactory results and no complications. Key Words: Radius head fracture, Closed reduction, K-wire, Internal fixation 통신저자 : 권병기서울특별시동대문구청량리동 40-12 서울성심병원정형외과 Tel : 02-966-1616 Fax : 02-968-2394 E-mail : sshosp331@hanmail.net Address reprint requests to : Byung Ki Kwon, M.D. Department of Orthopedic Surgery, Seoul Sacred Heart General Hospital 40-12 Chungryangri-dong, Dongdaemoon-gu, Seoul 130-011, Korea Tel : 82-2-966-1616 Fax : 82-2-968-2394 E-mail : sshosp331@hanmail.net 277
278 권병기, 이송, 안동기, 박준성, 차상규 서 요골두는척골근위부와관절하여주로전완의회내전및회외전운동에관여하면서상완골의소두와관절하여주관절의굴신운동에도관여한다. 이러한요골두골절의치료목적은동통없는정상관절운동과주관절의안정성을회복하는데있다. 비전이성요골두골절의치료에있어서보존적치료에는논란의여지가없으나, 전이성요골두골절치료의수술적방법에대하여는여러이견이많다 21). 요골두골절의수술적치료로는대개 Mason 분류 13) (Table 1) 제 2 형이상에서실시하며방법으로는골편절제술, 요골두제거술, 관혈적정복및내고정술과요골두의인공삽입물대치술등을들수있다. 그중요골두제거술은원위요척관절의불안정성, 수근관절및주관절의동통및퇴행성관절염, 관절의불안정성, 이소성골형성등의많은문제점을유발할수있고 11,12,17), 또한관혈적정복술및내고정술이나인공삽입물대치술은골절부의개방과조작에따른연부조직의손상으로인한합병증이발생할수있어치료에있어서고려해야할사항이다. 이에저자들은 Mason 분류 13) 제 2형요골두골절로내원한환자 7례에대해서경피적으로 K-강선을삽입하여골절정복및내고정술을시행하고최종추시시임상적결과를문헌고찰과함께보고하고자한다. 론 대상및방법 2001년 3월부터 2003년 10월까지 Mason 분류 13) 제 2형의요골두골절로내원한환자중경피적으로삽입한 K-강선을이용해골절정복및내고정술을시행한 7례를대상으로하였다. 성별로는남자 4례, 여자 3례였으며수술시연령은최소 5세, 최고 57세로평균 36.1세였다. 수상의원인으로는주관절신전상태에서추락사고가 5례, 교통사고에의한직접손상이 2례였다. 수상후수술까지의기간은대개 1일에서 3일이내였으며수술후평균추시기간은 20개월 (5개월 ~36개월 ) 이었다. 수술은환자를앙와위에서전신마취, 혹은상완신경총 Table 1. Mason classification Type 1- Nondisplaced or minimally displaced fracture of the radial head Type 2- Displaced fracture of the radial head Type 3- Comminuted fracture of the radial head Type 4- Radial head fracture associated with elbow dislocation (with or without coronoid Fracture) 차단술시행후 C-arm guide하에골절부를확인하고주관절혹은전완부의측면에서경피적으로 K-강선 1개를삽입하여 K-강선을요골두의골절선사이로전진시켜서골절편사이에위치하게한후, 이 K-강선을조작하여골절정복을시도하였다. 골절부가해부학적정복이되면골절편사이에삽입한 K-강선을드릴로전진시켜서반대쪽피질골까지고정하고필요한경우 1개의 K-강선을추가적으로경피적으로삽입하여골절편을고정하였다. 수술직후주관절을 90도굴곡및중립회전위상태에서장상지석고고정을하고 4주후석고붕대와내고정된 K-강선을제거한후 2주간착탈이가능한장상지부목 (removable long arm splint) 을착용하게하여수동적관절운동을실시하였다. 수술후 6주부터동통이없는한도내에서능동적관절운동및근력운동을점차적으로증가시켰다. 이들에대해서최종추시시방사선학적으로골유합여부를판단하였고, 기능적평가로는 Broberg와 Morrey의 functional rating system 3) 을따라우수 (Excellent), 양호 (Good), 보통 (Fair) 및불량 (Poor) 으로분류하여임상적결과를판정하였다 (Table 2). Table 2. Functional Rating Index (Modified After B.F. Morrey et al.) Variable Motion Degree of extension (0.2 arc) Degree of pronation (0.1 arc) Degree of supination (0.1 arc) Point Value 27 6 7 Strength Normal 20 Mild loss (appreciated but not limitng, 80% of opposite side) 13 Moderate loss (limits some activity, 50% of opposite) 5 Severe loss (limits every day tasks, disabling) 0 Stability Normal 5 Mild loss (perceived by patient, no limitation) 4 Moderate loss (limits some activity 2 Severe loss (limits everyday tasks) 0 Pain Normal 35 Mild (With activity, no medication) 28 Moderate (with or after activity) 15 Severe (at rest, constant medication, disabling) 0 (The translation of tital score to qualitiative groups was as follows: 95 to 100 points, excellant; 80 to 94 points, good; 60 to 79 points, fair; and zero to 59 points, poor.)
도수정복및 K- 강선내고정술을이용한 Mason 제 2 형요골두골절의치료 279 Table 3. Patient data Case Sex/Age Injury mechanism Follow up Flex/Ext * Sup/Pron Strength Stability Pain Result 1 M/57 Fall down 8 140/10 70/75 Normal Normal Mild Good 2 F/52 Fall down 12 145/0 75/70 Normal Normal Normal Excellent 3 F/35 Fall down 5 150/0 75/80 Normal Mild Normal Excellent 4 M/5 Direct 21 145/0 75/75 Normal Normal Normal Excellent 5 M/23 Direct 29 145/0 70/75 Normal Normal Normal Excellent 6 F/56 Fall down 36 145/0 70/75 Normal Normal Normal Excellent 7 M/25 Fall down 29 150/5 80/75 Normal Normal Normal Excellent * Flexion/Exention, Supination/Pronation Motion, strength, stability, pain, and score are depicted in points Table 4. Elbow evaluation result Mean motionz Extension 1.4 degrees Fexion 146.4 degrees Pronation 75 degrees Supination 74.2 degrees Motion 39.7 Strength 20 Stability 4.8 Pain 33.2 Elbow score 97.5 Motion, strength, stability, pain, and score are depicted in points 결과최종추시결과주관절의운동범위는굴곡구축평균 1.4도 ( 범위 : 0도 ~10도 ), 후속굴곡평균 146.4도 (140도 ~150 도 ) 였으며, 전완부의회외전평균 74.2도 (70도 ~80도 ), 회내전평균 75도 (70도 ~80도 ) 였다 (Table 3, 4). 술후관절의기능평가를위해운동범위, 근력, 관절안정성, 동통에근거한 Broberg와 Morrey의 functional rating system 3) 을적용한결과 6례가우수, 1례가양호였으며, 불량에해당하는예는없었다. 단순방사선검사상골진 (callus) 이나타나고, 골절선이소실되기시작하는소견을골유합으로판정하였는데, 유합까지의기간은평균 5주 ( 범위 : 4주 ~6주 ) 였다. 1례에서경도의동통과주관절운동제한의소견을보였으나, 심한동통을동반한관절운동장애, 불유합, 이소성석회화및불안정성등과같은심각한합병증으로요골두절제술을시행한례는없었다. 증례증례 1 35세여자환자로낙상시주관절과신전상태에서땅을짚은후요골두의 Mason분류 13) 제 2형의골절이발생하였다 (Fig. 1A). 수상 1일후상완신경총차단술하에서 C-arm guide하에 K-강선을이용해서골절편을해부학적으로정복한후 2개의 K-강선을사용하여내고정을시행하였으며 (Fig. 2B), 술후 4주간장상지석고붕대를착용하였다. 수술후 5개월추시관찰에서방사선소견상골유합은견고하였고 (Fig. 1C), 통증은없었다. 관절운동범위는굴곡구축 0도, 후속굴곡 150도, 회내전 75도및회외전 80도로정상이었으며, 관절불안정성및근력약화소견없는상태로 Broberg 와 Morrey의 functional rating system 3) 분류상결과평가는우수였다. 증례 2 57세남자환자로낙상시주관절과신전상태에서땅을짚은후부분적분쇄소견을보이는요골두골절로내원하였다 (Fig. 2A). 수상 1일후전신마취하에도수정복을한후 1개의 K-강선을이용하여내고정을시행하였다 (Fig. 2B). 수술 8개월후추시관찰에서방사선소견상견고한골유합을관찰할수있었으나 (Fig. 2C), 심한활동시간헐적인동통을호소하였다. 관절운동범위는굴곡구축 10도, 후속굴곡 140도, 회내전 75도및회외전 70도였으며 Broberg 와 Morrey의 functional rating system 3) 분류상평가는양호였다. 고찰요골두는척골절흔내에위치하며척골과함께전완부의회외전및회내전, 운동시에상완골소두와관절하면서주관절의안정성에매우중요한역할을한다. Schwab 등 18)
280 권병기, 이송, 안동기, 박준성, 차상규 A A B B Fig. 1. (A) Thirty-five year-old female patient sustained Mason type II radial head fracture. (B) Immediate postoperative radiograph shows reduced fracture fragment, which was fixed with 2 K-wires. (C) Radiograph at postoperative 5 months shows anatomically healed radial head. C Fig. 2. (A) graph of 57 year-old male patient shows comminuted radial head fracture. (B) Fracture fragments were reduced and fixed with one K-wire. (C) Radiograph of postoperative 8 months shows well heald radial head. C 은외반부하 (Valgus stress) 에저항하는구조물로요골두의중요성에대해언급한바있으며, Morrey 등 16) 은요골두를외반력에저항하는중요구조라하여, 내측측부인대에이어 secondary stabilizer라고하였다. 종적인안정성에대하여 Halls와 Travill 9) 은완관절에가해진종적부하를견디는골성구조물의역할에대해요상완관절이 40%, 척상완관절이 60% 의부하를담당한다고하였다. 따라서요골두골절시에는주관절의관절운동과안정성에장애가발생하여심
도수정복및 K- 강선내고정술을이용한 Mason 제 2 형요골두골절의치료 281 각한관절기능장애를초래할수있다. 성인의요골두골절은모든주관절손상의약 20% 를차지하며 4), 수상기전은주관절을신전한상태에서종적하중이요골두에가해질때가장많이발생하는것으로알려져있다 1,4). 전위가있는요골두골절의경우관절불안정성및동통을동반한운동장애등의합병증의발생이높으므로수술적치료를요하며, 수술방법으로는요골두의관혈적정복및내고정술, 골편제거술, 요골두절제술, 요골두인공성형치환술등으로나눌수있다. 1897년 Helfrich가요골근위단의골절을처음으로분류하여치료를시작하였고, Schwartz와 Young 19) 은요골두절제술을골절치료의한방법으로제안하였으며, Grossman 8), Hammond 10) 및 Sever 20) 은회내전, 회외전등의운동제한을방지하기위한방편으로골절편의단순제거술을권장하기도하였다. 전위가심하고분쇄상인요골두골절에서요골두제거술은주관절의운동강도나운동범위에는많은지장을초래하지만널리사용되어왔다 1). 1954년 Mason 13) 이골절의전이와분쇄양상에따라분류를하였고, 치료에있어서, 제 1형골절은보존적치료를시행하고조기관절운동을시행하고, Mason 제 2, 3형골절은요골두절제술과다양한내고정물을이용한관혈적정복술및내고정술이시행되어져왔으나, 요골두절제술은요골단축, 관절운동장애및완관절증상등술후여러가지합병증을유발할수있다. 이에많은저자들은내고정술이더좋은결과를나타낸다고보고하였고 2,5,6,7,11), 대체적으로 Mason 제 3형보다제 2형에서더좋은결과를보고하고있으며이때사용되어진내고정물로는 K-강선, 흡수성나사못, Herbert 나사못, AO의압박나사못및금속판등이다 14,15). 흡수성나사못사용시골흡수, 내고정물에의한활액막염등의합병증발생이보고되었고 2), 금속고정물을이용한관혈적정복술및내고정술또한관절운동장애, 수술시신경손상, 이소성골형성, 부정유합, 불유합, 고정의소실및무혈성괴사등의합병증을유발할수있다 21). 이에저자들은관혈적정복술에서발생할수있는합병증을최소화하면서, 가능한요골두를해부학적정복을얻고자하였으며, K-강선을경피적으로골절편사이에삽입하여 K-강선을통해골절편을직접조작함으로써정확한정복과안정적인고정이가능하였고, 주관절을개방해서골절부를조작함으로써발생할수있는연부조직의합병증을피할수있었으며, 전례에서최종추시시만족할만한골유합소견과기능적으로도정상에가까운임상적결과를얻었다. 또한관혈적정복술후가장심각한합병증인이소성골형성및신경손상을포함한다른중요합병증발생이없었고, 연부조직의손상이없었으므로관절운동과근력의회복이조기에가능하였으며, 관헐적정복술에비해수술시간이짧 으며수술부위를개방하지않기때문에마취방법에있어서상완신경총차단술만으로도충분히가능하여환자가반드시입원할필요가없었다. 하지만 Mason 제 3형이상의분쇄골절에서시행한예는없으나이러한수기만으로는좋은결과를얻기힘들것으로예상된다. 결론 Mason 제 2형의요골두골절의치료에있어서 C-arm guide하에 K-강선을이용한골절부정복술및내고정술은관혈적정복술에비해간단하면서도합병증발생을최소화하면서만족할만한결과를얻을수있는유용한방법이라사료된다. 참고문헌 1) Adler JB and Shaftan GW: Radial head fractures. Is excision necessary? J Trauma, 4: 115, 1964. 2) Baek GH, Sohn YJ, Lee CK and Chung MS: Bioabsorbable Implant Fixation for the Treatment of Radial Head and Neck Fractures. J Korean Fracture Soc, 11: 70-77, 1998. 3) Broberg MA and Morrey BF: Results of delayed excision of the radial head after fractures. J Bone Joint Surg, 68-A: 669-674, 1986 4) Browner BD, Jupiter JB, Levine AM and Trafton PG: Skeletal trauma, 2: 1125, 1992. 5) Bunker TD and Newman JH: The Herbert differential pitch bone screw in displaced radial head fractures. Injury, 16: 621-624, 1942. 6) Esser RD, Davis S and Taavao T: Fractures of radial head treated by intrnal fixation: late results in 26 cases. J Orthop Trauma, 9: 318-323, 1995. 7) Geel CW, Palmer AK and Ruedi T: Internal fixation of proximal radial head fractures. J Orthop Trauma, 4: 270-274, 1990. 8) Grossman J: Fracture of the head and neck of the radius. N Y J Med, 17: 472, 1923. 9) Halls AA and Travill A: Transmission of pressures across the elbow joint. Anat Rec, 150: 243-247, 1964. 10) Hammond R: Fracture of the head and neck of the radius. Ann Surg, 53: 207, 1910. 11) Kang HJ, Park MS, Shin SJ, Kang HS and Park BM: Operative Treatment of Radial Head Fracture of Mason type III. J Korean Fracture Soc, 12: 732-740, 1999. 12) King GJE, Evans DC and Kellam JF: Open reduction and
282 권병기, 이송, 안동기, 박준성, 차상규 internal fixation of radial head fractures. J Orthop Trauma, 5: 21-28, 1991. 13) Mason ML: Some observation on the fracture of the radius. J Bone Joint Surg, 42-A: 123-132, 1954. 14) McArthus RA: Herbert screw fixation of fracture of the head of radius. Clin Orthop, 224: 79-87, 1987. 15) Morrey BF: Current concepts in the treatment of fractures of the radial head, the olecranon, and the coronoid. Instructional course lectures. The Academy of American Orthopedic Surgeons, 22: 175-185, 1995. 16) Morrey BF, Tanaka S and An KN: Valgus stability of the elbow: A definition of primary and secondary constraints. Clin Orthop, 265: 187-195, 1991. 17) Ring D, Quintero J and Jupiter JB: Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg, 84-A: 1811-1815, 2002. 18) Schwab GH, Bennett JB, Woods GW and Tullos HS: Biomechanics of elbow instability: The role of the medial collateral ligament. Clin Orthop, 146: 42-52, 1980. 19) Schwartz RP and Young F: Treatment of fractures of the head and neck of the radial epiphysis in children. Surg Gynecol Obstet, 57: 528, 1933. 20) Server J: Fracture of the head and neck of the radius: A study of and results. JAMA, 84: 1551, 1925. 21) Shin DB, Lee YK, Ahn JY and Joo YK: Treatment Radial Head Fracture. J Korean Orthop Assoc, 29: 1835-1839, 1994.