= Review Article = 대한정형외과스포츠의학회지제 9 권제 1 호 2010 J Korean Orthop Soc Sports Med 2010; 9(1): 16-21 만성구획증후군및스트레스골절 최창혁 백승훈 장일웅 대구가톨릭대학교의과대학정형외과학교실 최근스포츠활동증가로인한하지의과사용증후군인만성구획증후군및스트레스골절의빈도가늘어가고있다. 만성구획증후군은운동중근육의부피증가와이로인한구획압증가로야기된가역적인허혈상태로, 보존적치료로호전되지않는경우근막절개술등의수술적치료를고려할수있다. 스트레스골절은정상적인골에비정상적인스트레스가가해져서발생하는피로골절과비정상적인골에정상적인스트레스에의해서발생하는부전골절로분류할수있으며, 대부분의스트레스골절은하지, 특히경골부에호발한다. 운동선수에서피로골절은훈련방법의변화에기인할수있고진단은일차적으로단순방사선촬영을시행하며, 자기공명영상을통해확진할수있다. 대부분의경우휴식및단기간의고정등을통한보존적치료만으로증상의호전및운동복귀가가능하나, 경골의신연부에발생한경우수술적치료를요할수도있다. 색인단어 : 스포츠손상, 과사용증후군, 만성구획증후군, 피로골절, 근막절개술 서론 달리기는최근가장많이관심을받는운동중의하나로, 과사용으로인한운동유발하지통증의빈도또한증가하고있는실정이다. 경골과관련된스트레스손상은운동후하지통증의 75% 를차지하며, 만성구획증후군 (chronic compartment syndrome), 스트레스골절 (stress fracture), 경부목 (shin splint, medial tibial stress syndrome) 및가자미근증후군 (soleus syndrome) 등의양상으로나타나게된다 2,3,11, 22). 본론 1. 만성구획증후군 만성구획증후군은간과되는경향이있으며혈관검사에이상이없는젊은사람이파행을보일경우의심해볼수있는질환이다. 1) 원인주로장거리달리기를과하게하는경우주로발생하며, 농구, 축구, 육체미운동등하지에지속적인충격을받는운동선수에서도발생할수있고, 둔상 (blunt trauma), 정맥부전및종양의증식에의해서도발생할수있다. 만성구획증후군은전통신저자 : 최창혁대구광역시남구대명4동대구가톨릭대학교병원정형외과 TEL: 053) 650-4276 FAX: 053) 650-4272 E-mail: chchoi@cu.ac.kr 방과후방심부하퇴구획에주로발생하며, 이는운동시근막에가해지는만성적인신연력이근막의순응도 (compliance) 를변화시켜운동시변화하는근의부피의변화에잘적응하지못해발생하는것으로알려져있다. 2) 증상파행 (claudication), 이상감각, 운동후근육긴장감등을호소하며, 이는국소적인신경근육압박및허혈에의한다. 구획압의증가는근육비후, 근막의두께및탄력의변화에의한근막순응도이상, 근막반흔 (myofascial scarring), 정맥고혈압 (venous hypertension) 및외상후연부조직염증등에의해유발된다. 장거리달리기선수나자전거, 크로스컨츄리스키선수등에서호발하며, 운동시증가하는통증과이상감각으로운동을지속할수없다. 슬와동맥증후군 (popliteal arterial syndrome) 과달리자세에관계없이통증이지속되며, 급성구획증후군 (acute compartment syndrome) 과는달리증상이심해지면구획압증가를유발하는행동을피하게되어영구적인신경및근육손상은드물다. 근육의종창이발생할수있는데이는근탈장 (muscle hernia) 과의감별점으로써중요한소견이다 1,5). 3) 진단휴식시증상이없는만성구획증후군환자의구획압은약 85% 에서 15 mmhg 이상증가되어있으나 25 mmhg이상까지증가하는경우는드물다. 반면급성구획증후군환자는대개 40 mmhg이상까지증가하며, 정상인은심한활동후기준치의 3~4배까지증가하기도하나 50 mmhg이상까지는증가하지는않으며, 휴식후수분이내에정상범위로회복된다. 만성 16
만성구획증후군및스트레스골절 17 구획증후군환자는운동후구획압이 100 mmhg까지증가할수있으며, 이러한압력이유지되면근육과신경에손상을유발하게된다. 진단은병력으로도가능하나, 구획압측정이중요하며운동전압력이 15 mmhg를넘거나, 운동 1분후구획압이 30 mmhg이상, 5분후 20 mmhg이상이면확진할수있다 22). 전외측및천부후방구획의압력은쉽고안전하게측정할수있으나, 심부후방구획압을측정하는경우피하맹검측정은신경혈관손상의위험이있으므로유의해야한다. 보이지않았다고보고하였다. Fronek 등 7) 은 18명의만성구획증후군환자중근탈장이정상인 (5% 이하 ) 에비해높은빈도 (39%) 로발견되었고, 보존적치료를시행한 5명은모두운동으로복귀할수없었던반면, 수술적치료를시행한 13명중 12명 (92%) 는통증완화및운동으로의복귀가가능하였다고보고하였다. 2. 피로골절 4) 치료피로골절, 건염, 골막염등의운동손상 (exertional injury) 과달리만성구획증후군은보존적치료로근본적인치료는힘들다. 안정, 소염제와물리치료등으로일시적인증상호전을기대할수있으나, 과도한신체활동재개시증상이재발하게된다 24). 외과적인근막절개술 (fasciotomy) 이가장효과적인치료법으로, 이는영구적으로구획내압력을감소시킬수있다. 가장흔히시행되는방법은피하근막절개술 (subcutaneous fasciotomy) 이며, 최근에는개방성근막절제술 (open fasciectomy) 이보다안전하고효과적인방법으로인정되고있다 5). 개방성근막절제술 (open fasciectomy): 근육구획의종축을따라피부를절개하며, 이는시야를확보하여혈관결찰, 근막절제와추가적인피하근막절개 (fasciectomy combined with extended subcutaneous fasciotomy) 를효과적으로시행할수있다 (Fig. 1). 근막절개술에비해침습적인시술이나재활기간의차이없이재원기간, 초기합병증및후기재발률등을효과적으로줄일수있는장점이있다. Turnipseed 등 22) 은 109례의개방성근막절제술과 100례의피하근막절개술을시행한후, 개방성근막절제술에서적은초기합병증 ( 각각 6% 및 11%) 과후기재발율 ( 각각 2% 및 11%) 을보였으며, 근력및지구력의경우유의한차이를 스트레스와관련된골손상은스포츠손상환자의 10% 에달하며, 스트레스골절은피로골절 (fatigue fracture) 과부전골절 (insufficiency fracture) 로분류할수있다. 은정상적인골조직에과다한스트레스가가해졌을때발생하며, 부전골절은비정상적인 (mineral deficient or abnormally inelastic) 골조직에가해진정상적인스트레스에의해서발생하게된다. 1) 발생빈도스트레스골절은주로운동선수나군인들에게발생하며, 일반운동선수에서의발생빈도는 1% 미만이나, 달리기선수의경우 20% 까지발생할수있으며, 특히최근의달리기열풍에따른장년층에서의발생가능성을유의해야한다. 달리기의경우호발부위는체중부하를받는하지의골조직이며, Boden 등 3) 은경골 (49.1%), 족근골 (25.3%), 중족골 (8.8%) 및골반골의순서로발생하고, 17% 에서양측성으로발생한다고하였다. 2) 병태생리 (pathophysiology) 과거스트레스골절을반복적인부하에의한골조직의손상으로이해하였으나, 생리적인응력 (strain) 에서도골절이발생하면서빠른재형성소견도관찰되어, 최근에는기계적인자극외에골관류실조 (impaired bone perfusion) 를스트레스골절의주된요인으로설명하고있다. Gaeta 등 9) 은증상이없는운동선수에서도골소실이관찰되는반면, 경부목 (shin splint) A Fig. 1. (A) Fascia overlying the intramuscular septum should be preserved so as to protect the superficial peroneal nerve from direct trauma or scar entrapment. (B) Skin incision should be placed posterior to the saphenous vein and nerve. (L: lateral compartment, A: anterior compartment, DP: deep posterior compartment, SP: superficial posterior compartment) B
18 최창혁 백승훈 장일웅 환자에서는경골피질의변화를공히보인바골재형성이증상의원인이된다고하였다. Otter 등 17) 은반복적인자극이간헐적인허혈을초래하며, 이로인한골재형성은골의약화및스트레스골절을유발한다고하였다. 그외정맥혈의순환장애, 모세혈관의반력으로인한미세손상, 세포외기질 (extracellular matrix) 의직접손상등이혈관신생 (angiogenesis) 을유발하기도한다 10). 따라서스트레스골절의원인으로골재형성과혈관신생은외부의충격자체보다변화된골관류에의해유발되는것으로알려지고있다. 3) 손상의생역학스트레스골절은뼈의국소부위에스트레스가누적되어부분혹은불완전한골절이생기는것이다. 가해지는스트레스는근육의수축이나하지가지면에닿는충격에의해발생하며, 응력은이러한힘이뼈를변형시키는정도를말한다. 응력-변형률반응 (stress-strain response) 은힘의방향, 뼈의모양, 미세구조및밀도에따라결정된다. 대부분의일상활동에서는힘이가해지지않으면뼈는제위치로회복되나, 가해진힘이커지면탄성범위 (elastic range) 및소성범위 (plastic range) 를거쳐골의변형이커지게되고최종적으로골절이유발된다. 뼈에가해지는힘은압박 (compression), 신연 (tension), 굴곡 (bending), 회전 (rotation) 및전단력 (torsion and shear force) 으로분류할수있으며, 근피로 (muscle fatigue), 과부하 (overload) 및재형성의복합적인기전에의해피로골절이유발된다. (1) 근피로뼈는신장력보다압박력에강한반면, 근육은뼈에가해지는신장력을완화시키는효과가있어 21), 근육의작용은피로골절을방지하는효과가있다. 따라서근피로가발생하면신장력에대한저항이감소되고이는충격완화효과 (shock absorption function) 를감소시켜피로골절을유발할수있다 18). (2) 과부하정상적인상태에서스트레스가가해지면뼈에비해근육의강화가조기에이루어져, 뼈에대한상대적으로과한근력의불균형이피로골절을유발할수있다. (3) 재형성정상적인상태에서뼈에가해지는스트레스는파골세포의작용 (osteoclastic activity) 을통해층판골 (lamellar bone) 을흡수하여보다조밀하고강한골로대치하는재형성을야기한다. 과한자극이반복되면재형성이촉진되며, 이는골흡수와재형성의불균형을유발하여골약화와함께골절을유발한다 21). 4) 위험요소 (Risk factors) 25) (1) 훈련요소 (training factors) ⅰ. 훈련의변화 (Alteration of training) 피로골절은새로운운동방법의시행, 기존훈련프로그램의변화, 훈련강도, 기간및횟수의증가등을통해발생할수있다 12). ⅱ. 신발및훈련환경 (Footwear and training surface) 부적합한신발이나딱딱한바닥은적절한충격완화를얻을수없으며, 특히피로한상태에서는골조직이충격을더욱많이받게된다. Table 1. Radiologic grading system for stress injuries: the correlation between histology, radiography, bone scintigraphy and MR imaging. Stress reaction Grade 1 Grade2 Grade3 Grade4 Histology Periosteal bone & cortical tunneling Cortical resorption Extensive tunneling & reaction Microfractures Radiography: Cortical bone Cortical striations, gray cortex sign New bone formation True fracture line Radiography: Cancellous bone Blurring of trabecular margins, faint sclerotic Sclerotic band True fracture line densities Scintigraphy Amorphous lesion in the bone marrow Mildly increased activity in the cortical region Moderately increased cortical activity Wide fusiform lesion with highly increased activity in the corticomedullary region Wide extensive lesion with intensely increased activity in the transcorticomedullary region MR imagin Ill-defined zone of bone marrow edema (T2W) Mild periosteal edema (T2W) Moderate to severe periosteal edema and G2 on both T1W & T2W G3 with low signal fracture line bone marrow edema (T2W)
만성구획증후군및스트레스골절 19 (2) 하지의생역학 (Lower extremity biomechanics) ⅰ. 회내족 (Pronated foot) 후족부외반위치에서의회내족 (Pronated foot with hindfoot valgus position) 은족관절외과에스트레스가증가한다. 또한보행시중간입각기 (midstance phase) 와족지들림 (toe-off) 을통해제 1중족골의과가동및과신전이유발되어, 제 2 혹은제3 중족골의스트레스가증가하게된다 12). ⅱ. 요족 (Cavus foot) 요족은제 1중족골의경성굴곡을통해스트레스가증가하며, 종자골복합체 (sesamoid complex), 소중족골 (lesser metatarsal) 및종골등에스트레스골절을유발할수있다 12). ⅲ. 내반정렬 (Varus alignment) 내반슬 (Genu varum), Blount 병 (tibia vara), 거골하내반 (subtalar varus), 전족부내반 (forefoot varus) 등은하지의스트레스골절을유발할수있으며, 이중 49% 은경골에서발생한다 13). ⅳ. 사지부동 (Limb length discrepancy) 짧은하지는달리기를할때안정성을증가시키기위해외회전하며, 보폭은커진다 (overstriding). 결과적으로발에가해지는스트레스가증가하게되며, 스트레스골절의위험성이증가하게된다 12). (3) 전신요소 (systemic factors) ⅰ. 골밀도 (Bone mineral density, BMD) 골밀도는 35세까지증가후감소하며, 초경전 (premenarcheal) 연령에서골밀도증가및운동유발골재형성이가장크다 16). Lauder 등 14) 은체질량지수 (body mass index), 골밀도와스트레스골절사이에강한상관관계가있다고하였으며, 특히여성에서저체중과골밀도의저하를피로골절의위험요소로지적하였다. 또한운동을통해골밀도증가를기대할수는있으나, 지나치게강한운동은스트레스골절을더욱조장한다고하였다. 이들은주당운동시간이늘어나면골밀도의점진적인증가를볼수있으나, 여성에서는골절의빈도가증가할수있어, 주당5시간이하의운동을한경우12% 가증가한반면, 10시간이상운동을한경우 50% 까지증가한다고하였다. 골밀도를감소시키는다른요소로백인, 보행이상을유발하는상황이나관절치환술등의시술이있다. ⅱ. 여성스트레스골절은여성에서호발하며 3), 여성운동선수삼주징 (female athlete triad), 즉식이이상 (eating disorder), 무월경 (amenorrhea), 골다공증 (osteoporosis) 으로인한에스트로겐결핍은골밀도감소및스트레스골절의위험도를증가시킨다 14,16). 5) 진단운동시악화되고, 휴식시소실되는통증이특징이다 4,6,9). 단순방사선촬영상초기에는골변화를확인하기힘들므로, 의 심될경우 DEXA (dual energy X-ray absorptiometry) 를이용하여국소적인골밀도의감소나, MRI를이용하여골수혹은골막부종 (bone marrow or periosteal edema) 을확인할수있다. 통증의원인은골재형성에의한것으로알려지고있으며, CT 및 MRI는스트레스유발피질골재형성 (stressinduced cortical bone remodeling) 을확인하는데유용하다 1,8,9,15,20) (Table 1). 6) 치료경골부위에발생하는대부분의스트레스골절은압박부 (compression side) 에발생하며, 휴식, 활동조절, 보조기, 그리고저강도의초음파자극치료등을포함한약 6~8주간의보존적치료후운동복귀가가능하다. 그러나약 4.6% 의빈도로발생하는경골의중간전방신연부 (tension side) 에발생하는스트레스골절및제1족지의종자골, 제5족지의중족골및주상골의스트레스골절은불유합의가능성이높아수술적치료를요할수있다. Varmer 등 23) 은운동선수에서발생한만성경골중간전방부골절 11예에서확공성골수정을시행후임상적및방사선적골유합을각각 2.7개월및 3개월에얻었으며, 4개월후운동복귀가가능하였다고하였다. 결론 최근스포츠활동증가의증가및이로인한하지의과사용증후군인만성구획증후군및스트레스골절의빈도가늘어가고있다. 만성구획증후군은운동중근육의부피증가와이로인한구획압증가로야기된가역적인허혈상태로, 보존적치료로호전되지않는경우근막절개술등의수술적치료를고려할수있다. 스트레스골절은하지, 특히경골부에호발하며진단은일차적으로단순방사선촬영을시행하고, 자기공명영상을통해확진할수있다. 대부분의경우휴식및단기간의고정등을통한보존적치료만으로증상의호전및운동복귀가가능하나, 경골의신연부에발생한경우수술적치료를요할수도있다. 참고문헌 01. Bergman AG and Fredericson M: MR imaging of stress reactions, muscle injuries, and other overuse injuries in runners. Mafn Reson Imaging Clin N Am, 7:151-174, 1999. 02. Bhatt R, Lauder I, Finlay DB, Allen MJ, et al.: Correlation of bone scintigraphy and histological findings in medial tibial syndrome. Br J Sports Med, 34:49-53, 2000. 03. Boden BP and Osbahr DC: High-risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg, 8:344-
20 최창혁 백승훈 장일웅 353, 2000. 04. Brukner P, Bennell K, Matheson G: Stress fractures. Carlton, Victoria, Australia: Blackwell Science, 1999. 05. Detmer DE, Sharpe K, Sufit R, Girdley F: Chronic compartment syndrome: diagnosis, management, and outcomes. Am J Sports Med, 13:162-170, 1985. 06. Epperley T, Fields KB: Epidemiology of running injuries. In: O Connor F, Wilder R, editors. The textbook of running medicine. New York: McGraw-Hill:1-10, 2001. 07. Fronek J, Mubarak SJ, Hargens AR, et al.: Management of chronic exertional anterior compartment syndrome of the lower extremity. Clin Ortho relat Res, 220:217-227, 1987. 08. Gaeta M, Minutoli F, Scribano E, et al.: CT and MR imaging findings in athletes with early tibial stress injuries: Comparison with bone scintigraphy findings and emphasis on cortical abnormalities. Radiology, 235:553-561, 2005. 09. Gaeta M, Minutoli F, Vinci S, et al.: High-resolution CT grading of tibial stress reactions in distance runners. AJR, 187:789-793, 2006. 10. Globus RK, Plouet J, Gospodarowicz D: Cultured bovine bone cells synthesize basic fi broblast growth factor and store it in their extracellular matrix. Endocrinology, 124:1539-1547, 1989. 11. Gore R, Mallory R, Sullenberger L: Bilateral lower extremity compartment syndrome and anterior tibial stress fractures following an army physical fitness test. Medscape J Med, 10:82, 2008. 12. Haverstock BD: Stress fractures of the foot and ankle. Clin Podiatr Med Surg, 18:273-284, 2001. 13. Krivickas LS: Anatomical factors associated with overuse sports injuries. Sports Med, 24:132-146, 1997. 14. Lauder TD, Dixit S, Pezzin LE, et al.: The relation between stress fractures and bone mineral density: evidence from active-duty army women. Arch Phys Med Rehabil, 81:73-79, 2000. 15. Moran DS, Evans RK, Hadad E: Imaging of lower extremity stress fracture injuries. Sports Med, 38:345-356, 2008. 16. Morris FL, Naughton GA, Gibbs JL et al.: Prospective ten-month exercise intervention in premenarcheal girls; positive effects on bone and lean mass. J Bone Miner Res, 12:1453-1462, 1997. 17. Otter MW, Qin YX, Rubin CT et al.: Does bone perfusion/reperfusion initiate bone remodeling and the stress fracture syndrome? Med hypotheses, 53:363-368, 1999. 18. Ross J: A review of lower limb overuse injuries during basic military training. Part 1: types of overuse injuries. Milit Med, 158:410-415, 1993. 19. Snyder RA, Koester MC, Dunn WR: Epidemiology of stress fractures. Clin Sports Med, 25:37-52, 2006. 20. Sofka CM: Imaging of stress fractures. Clin Sports Med, 25:53-62, 2006. 21. Spitz DJ, Newberg AH: Imaging of stress fractures in the athlete. Radiol Clin N Am, 40:313-331, 2002. 22. Turnipseed W, Detmer DE, Girdley: Chronic compartment syndrome. An Unusual cause for claudication, Ann Surg, 210:557-562, 1989. 23. Varner KE, Younas SA, Lintner DM, et al.: Chronic anterior midtibial stress fractures in athletes treated with reamed intrmedullary nailing. Am J Sports Med, 33:1071-1076, 2005. 24. Wiley JP, Clement DB, Doyle DL, Taunton JE: A primary care perspective chronic compartment syndrome of the leg. Physician and Sports Medicine, 15:111-120, 1987. 25. Yates B, White S: The incidence and risk factors in the development of medial tibial stress syndrome among naval recruits. Am J Sports Med, 32: 772-778, 2004.
만성구획증후군및스트레스골절 21 = ABSTRACT = Chronic Compartment Syndrome and Stress Fracture Chang-Hyuk Choi, M.D., Seung-Hoon Baek, M.D., Il-Woong Jang, M.D. Department of Orthopaedic Surgery, School of Medicine, Catholic University of Daegu, Daegu, Korea The prevalence of overuse syndrome in the lower extremity including chronic compartment syndrome and stress fracture is increasing with popularity of sports activities. Chronic compartment syndrome is defined as elevation of the interstitial pressure during exertional activities in a closed osseofascial compartment that results in microvascular compromise and operative procedures can be necessary if conservative treatments fail. Stress fracture can be classified as fatigue and insufficiency fracture; stress fracture occurs by repeated strain under abnormal conditions from the patient s activity whereas insufficiency fracture does by those from a process intrinsic to the bone. Most stress fractures occur in the lower extremity, most commonly in the tibial region. Fatigue fractures begin in athletes with the change in their training programs. The radiographic findings are usually diagnostic or at least strongly suggestive and MRI has proven to be a beneficial diagnostic tool for difficult diagnostic cases. Fatigue fractures are treated with a decrease in activity, but surgical procedure may be necessary in those in anterior cortex of the tibial diaphysis. Key Words: Sports injury, Overuse syndrome, Chronic compartment syndrome, Fatigue fracture, Fasciotomy Address reprint requests to Chang Hyuk Choi, M.D.,Ph.D. Department of Orthopedic Surgery, School of Medicine, Catholic University of Daegu, 3056-6 Daemyung-4 dong, Nam-gu, Daegu 705-718, Korea TEL: 82-53-650-4276, FAX: 82-53-650-4272, E-mail: chchoi@cu.ac.kr