ORIGINAL ARTICLE pissn 1598-3889 eissn 2234-0998 J Korean Soc Surg Hand 2015;20(1):15-22. http://dx.doi.org/10.12790/jkssh.2015.20.1.15 JOURNAL OF THE KOREAN SOCIETY FOR SURGERY OF THE HAND Efficacy of External Fixation and Transfixation Pinning of Distal Radioulnar Joint in Distal Radius Fracture Sang-Pil Yoon, Kyung-Sub Song, Su-Keon Lee, Sang-Youn Lim, Young-Tae Lee, Seung-Hwan Lee Department of Orthopaedic Surgery, Kwang-Myeong Sung-Ae Hospital, Seoul, Korea Received: February 24, 2015 Revised: [1] March 10, 2015 [2] March 18, 2015 Accepted: March 19, 2015 Correspondence to: Seung-Hwan Lee Department of Orthopaedic Surgery, Kwang-Myeong Sung-Ae Hospital, #36 Digital-ro, Gwangmyeong 423-711, Korea TEL: +82-2-2680-7699 FAX: +82-2-2680-7755 E-mail: java5885@gmail.com This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/bync/3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Purpose: The purpose of this study is to evaluate efficacy of percutaneous pinning of distal radioulnar joint in patient with distal radius fracture. Methods: Thirty-eight patients who underwent percutaneous pinning and external fixation for distal radius fracture were included in this study. Radiologic and clinical outcomes were compared between the patients who underwent percutaneous pinning on the radius only (PD group) and the patients with supplementary pinning on distal radioulnar joint (DRU group) after percutaneous pinning on the radius. External fixation was performed in all patients. Results: Twenty-three patients were PD group and fifteen patients were DRU group. Radial height and radial inclination was significantly higher in DRU group. There was no significant difference in ulnar variance, volar tilt and articular step off between two groups. Among the clinical outcome, there was no significant difference in range of motion between two groups but grip strength was significantly larger in DRU group. Conclusion: Percutaneous pinning with K-wires on distal radioulnar joint in distal radius fracture can be a useful procedure for prevention of radial shortening without loss of range of motion of the wrist. Keywords: Distal radius frature, Percutaneous pinning, Distal radioulnar joint 서론 원위요골골절은상지에서발생하는가장흔한골절중하나로기대수명의연장과스포츠활동의증가로그수가증가하고있다 1,2. 전위된원위요골의불안정성골절에서치료의원칙은해부학적정복과단단한고정으로알려져있다. 도수정복및 K- 강선고정술과외고정기를이용하는방법은불안정원위요골골절의수술적치료의한방법으로오래전부터흔히사용되었다 3-8. 외고정술은경피적핀고정술과함께사용 될경우관혈적정복술과별다른차이가없이좋은결과를얻을수있으며 9, 술기가비교적간단하고외부에서추가적인조작이가능하다는장점을가지고있다. 따라서외고정기구를이용한수술적치료는아직까지도여러손상에서적용되고있다. 그러나견인및인대신연만으로는수장경사의유지및관절내골절의정복이불가능하다는점이문제점으로제시되고있다 10. 본연구에서는전위된원위요골의불안정성골절환자에서외고정술및핀고정술을이용한수술적치료에서원위요척관절핀고정술의임상적및방사선학적결과를분석 Copyright c 2015. The Korean Society for Surgery of the Hand http://www.jkssh.org/ 15
J Korean Soc Surg Hand Vol. 20, No. 1, March 2015 하고자하였다. 대상및방법 2013년 3월부터 2014년 2월까지본원에서전위된원위요골의불안정한골절로수술받고 3개월이상추시가가능했던 38명의환자를대상으로하였다. 수술적치료의적응증은외래나응급실에서정복술후에도, 원위요골의배측경사 (dorsal tilt) 가 20 이상, 요골단축이 3 mm 이상, 또는관절면의부조화가 2 mm 이상인환자로하였다. 척골두에골절이동반되어원위요척관절핀고정시에핀 이요골을지지할수없는경우는연구대상에서제외하였다. 마취후에영상증폭장치하에서도수정복후에도관절면의부조화가 2 mm 이상이거나골절의정복이되지않고단축이나배측경사가지속되는경우에는관혈적정복술및전방금속판내고정술을시행하였으며, 역시대상에서제외하였다. 골절유형에따른임상적, 방사선학적결과의차이를최소화하기위해 AO 분류 B2, 3형골절로연구대상을한정하였다. AO 분류 A, C형의원위요골골절에대해서는역시마취하에비관혈적정복술후에만족할만한정복을얻은경우에는핀고정술및외고정술을시행하였으며, 정복이되지않는경우에는관혈적정복술및전방금속판고정 Fig. 1. Radiographs of 52-year-old male patient. (A) Preoperative radiograph shows 1.72 mm radial shortening and 25 dorsal tilting. (B) Preoperative computed tomography scan shows intra-articular fracture. (C) External fixation and K-wire fixation was done. Radial shortening decreased to 1 mm and volar tilting recovered to 10.2. (D) Twelve-week follow-up radiograph shows 3.9 mm radial shortening and 9.4 volar tilting. 16 http://www.jkssh.org/
Sang-Pil Yoon, et al. Efficacy of External Fixation and Transfixation Pinning of Distal Radioulnar Joint in Distal Radius Fracture 술을시행하였다. 수술방법의선택은무작위로외고정술및요골에만경피적핀고정술만을시행후외고정을시행하거나 (Fig. 1), 요골에핀고정술후에추가적으로원위요척관절에핀고정을시행후외고정을시행하였다 (Fig. 2). 요골에경피적핀고정술을받은환자가 23명 (pinning on distal radius only [PD] 그룹 ), 추가적인경피적원위요척관절핀고정술을시행한환자가 15 명이었다 (pinning on distal radioulnar joint [DRU] 그룹 ). 환자의평균연령은 63.7세였다. AO 분류상 PD 그룹에는 B2형골절이 12예, B3 형골절이 11 예있었다. DRU 그룹에는 B2형골절이 8예, B3형골절이 7 예있었다. 1. 방사선학적계측및임상적결과수술전, 수술직후, 수술후 3개월째에수근관절전후면, 측면방사선촬영을실시하였다. 시행한방사선사진상요골높이 (radial height), 요골경사 (radial inclination), 요골의수장측경사 (volar tilt), 척골에대한상대적인요골단축정도 (ulnar variance) 를측정하였다. 임상적결과는술후 3개월추시때의손목관절의운동범위를각도기 (goniometer) 를이 Fig. 2. Radiographs of 54-year-old female patient. (A) Preoperative radiograph shows 0.2 mm radial shortening and 23 dorsal tilting. (B) Preoperative computed tomography scan shows intra-articular fracture. (C) External fixation and percutaneous pinning with K-wire on distal radioulnar joint was done. Radial shortening decreased to 0 mm and volar tilting recovered to 8.4. (D) Twelve-week follow-up radiograph shows 0.5 mm radial shortening and 7.5 volar tilting. http://www.jkssh.org/ 17
J Korean Soc Surg Hand Vol. 20, No. 1, March 2015 용하여측정하였고, 파악력 (grip strength) 를 Jamar 악력계 (dynamometer) 를이용하여측정하였다. 모든환자에서이중에너지방사선흡수계측 (dual-energy X-Ray absorptiometry) 를시행하여요추부의골밀도를측정하였다. 2. 수술방법전신마취나상완신경총마취하에영상증폭장치를보면서도수정복을시행하여관절내골절간격이정복되는것을확인한후 1.6-2.4 mm의 K- 강선을삽입하였다. 강선삽입시에는요골의경상돌기위에 11번수술칼로 5 mm 정도절개를가한뒤끝이둔한기구로골막까지보이게하여신전건이나표재성요골신경에손상이가지않도록하였다. 요골의경상돌기에서약 2-3 mm 근위부에강선을삽입하였다. 요골경상돌기에는골절부의분쇄정도에따라 1개또는 2개의 K-강선을삽입하였다. PD 그룹에서는 23명의환자중 4예에서 1개의 K-강선을사용하였고, DRU 그룹에서는 15명의환자중 3예에서 1개의 K- 강선을사용하였다. 나머지환자에서는모두 2개의 K-강선을사용하였다. 원위요척관절핀고정술의경우척골의경상돌기하단에서시작하여원위요척관절을통과하여요골의연골하골을지지하며삽입하였다. 수술후 4주후외래에서 K-강선을제거하고, 6주째외고정기를제거한후물리치료와재활치료를시행하였다. 추시는수술후 2주, 4주, 6주, 3개월에추시하였다. 3. 통계학적방법통계는 PD 그룹과 DRU 그룹간의방사선학적및임상적결과를 paired t-test를이용하여비교분석하였다. 통계프로그램은 PASW ver. 18.0 (SPSS Inc., Chicago, IL, USA) 을사용하였다. 결과 PD 그룹의평균연령은 63.1 (±8.6) 세였고, DRU 그룹의평균연령은 64.5 (±8.7) 세로두군간에통계학적인차이는없었다. 요추부골밀도는 PD 그룹에서 T점수가 -3.13 (± 0.91) 이었으며, DRU 그룹에서 -2.62 (±0.58) 로두군간에유의한차이를보이지않았다 (Table 1). 수술전방사선학적결과는비관혈적정복술후에석고부목을유지한상태에서시행한방사선사진에서측정하였다. PD 그룹에서는요골높이가 7.23 (±1.92) mm, DRU 그룹에서 7.43 (±2.03) mm로나타났다. 요골경사각 (radial inclination) 의경우 PD 그룹에서 15.42 (±3.23 ), DRU 그룹에서 14.95 (±2.72 ) 로나타났다. 척골변위 (ulnar variance) 는 PD 그룹에서 0.34 (±0.23) mm, DRU 그룹에서 0.29 (± 0.12 )mm로나타났다. 수장측경사의경우 PD 그룹에서 11.23 (±4.78 ), DRU 그룹에서 10.43 (±3.78 ) 로나타났다. 관절면부조화 (articular step off) 에서는 PD 그룹에서 1.34 (±0.45 )mm, DRU 그룹에서 1.41 (±0.37) mm로나타났다 (Table 1). 수술후방사선학적결과에서는요골높이 (radial height) 가 PD 그룹에서 10.52 (±1.81) mm, DRU 그룹에서 12.20 (± 2.15) mm로 DRU 그룹에서유의하게큰것으로나타났다 (p=0.013). 요골경사각 (radial inclination) 의경우 PD 그룹에서 19.91 (±4.98 ), DRU 그룹에서 22.80 (±2.62 ) 로역시 DRU 그룹에서유의하게높은것으로나타났다 (p=0.026). 수술후척골변위 (ulnar variance) 는 PD 그룹에서 0.13 (±1.10) mm, DRU 그룹에서 0.20 (±1.27) mm로두군간에통계학적인차이는없었다. 수술후수장측경사는 PD 그룹에서 9.00 (±4.52 ), DRU 그룹에서 9.67 (±3.42 ) 로두군간에통계학적인차이는없었다. 관절면부조화 (articular step off) 에서는 PD 그룹에서 0.04 (±0.21) mm, DRU 그룹 Table 1. Radiologic outcomes of PD group and DRU group Outcome All (n=38) Preoperative Postoperative PD group DRU group PD group DRU group p-value* Lumbar BMD (T-score) -2.93 (±0.83) - - -3.13 (±0.91) -2.62 (±0.58) 0.063 Radial height (mm) 11.18 (±2.09) 7.23 (±1.92) 07.43 (±2.03) 10.52 (±1.81) 12.20 (±2.15) 0.013 Radial inclination ( ) 21.05 (±4.41) 15.42 (±3.23) 14.95 (±2.72) 19.91 (±4.98) 22.80 (±2.62) 0.026 Ulnar variance (mm) 00.00 (±1.16) 00.34 (±0.23) 00.29 (±0.12) 00.13 (±1.10) 00.20 (±1.27) 0.399 Volar tilt ( ) 09.26 (±4.09) 11.23 (±4.78) 10.43 (±3.78) 09.00 (±4.52) 09.67 (±3.42) 0.629 Articular step off (mm) 00.13 (±0.34) 01.34 (±0.45) 01.41 (±0.37) 00.04 (±0.21) 00.27 (±0.46) 0.093 PD, pinning on distal radius only; DRU, supplementary pinning on distal radioulnar joint; BMD, bone mineral density. *A p-value by t-test between postoperative radiologic outcomes of PD group and DRU group. 18 http://www.jkssh.org/
Sang-Pil Yoon, et al. Efficacy of External Fixation and Transfixation Pinning of Distal Radioulnar Joint in Distal Radius Fracture Table 2. Clinical outcomes of PD group and DRU group Outcome PD group (postoperative) DRU group (postoperative) p-value Age (yr) 63.1 (±8.6) 64.5 (±8.7) 0.627 Flexion ( ) 68.26 (±6.11) 71.60 (±6.14) 0.109 Extension ( ) 53.61 (±3.87) 53.33 (±7.94) 0.902 Pronation ( ) 53.87 (±5.88) 56.27 (±5.27) 0.209 Supination ( ) 53.04 (±5.12) 53.80 (±7.79) 0.719 Grip streng (lb) 44.26 (±3.62) 54.20 (±5.87) 0.001 PD, pinning on distal radius only; DRU, supplementary pinning on distal radioulnar joint. 에서 0.27 (±0.46) mm로역시두군간에통계학적인차이는보이지않았다 (Table 1). 임상적결과에서두그룹간에손목관절의운동범위중굴곡, 신전, 회내전그리고회외전에는유의한차이를보이지않았다 (Table 2). 그러나수부의파악력 (grip strength) 에서는 PD 그룹에서 44.26 (±3.62) lb, DRU 그룹에서 54.20 (± 5.87) lb 로 DRU 그룹에서유의하게좋은결과를나타내었다 (p=0.001) (Table 2). 고찰 전위된요골골절의치료에서해부학적복원이좋은결과를가져온다는것은많은연구에서보고되고있다 11-14. 2 mm 이상의관절면의전위나불일치는추후퇴행성관절염을초래할가능성이높은것으로알려져있다 15,16. 또한요골단축이 6 mm 이상이되면척수근충돌 (ulnocarpal impingement), 원위요척관절의통증, 회내전과회외전의감소등이발생할수있다 17-19. Kazuki 등 20 은배측경사정도에따른관절의운동범위와수근관절의정렬 (carpal alignment) 변화를연구하여, 10 이하의배측경사에서는관절의운동범위와수근관절의정렬에미치는영향이적은것으로보고하였다. 또한요골의경사각이변할경우에도수부의파악력과주상-월상관절의부하에좋지않은영향을미치는것으로보고되었다 21,22. 일반적으로 2 mm 이상의관절면의부조화, 20 이상의배측경사, 그리고 5 mm 이상의요골단축은정복하는것이바람직하다 11,23,24. 본연구의이론적배경은불안정원위요골골절을대상으로한연구를참고하였다. 불안정원위요골골절에서의수술적치료법으로는도수정복후경피적핀고정술또는외고정기고정술이나두가지방법의병용, 그리고관혈적방법으로금속판을이용한방법등이이용되고있다. 최근들어금속판고정술과핀고정술두수술간에임상적인결과에유의한차 이가없다는연구들이보고되고있어 25, 경피적핀고정술및외고정술도원위요골골절에우수한치료방침이라할수있다. 본연구에서는금속강선을이용한비관혈적인방법중보조적인경피적원위요척관절핀고정술의효과를검토해보고자하였다. 본연구에서는방사선학적결과에서원위요척관절에핀고정을시행하였던환자군이요골에만핀고정을시행한환자군에비하여요골높이및요골경사각이유의하게큰것으로나타났다. 원위요척관절의 K-강선을이용한핀고정은불안정한원위요골골편을상대적으로안정된척골에고정시켜줌으로써요골에만핀고정을시행한경우보다요골의단축을방지하였던것으로생각된다. 본연구에서는수술후 4주째에 K-강선을제거하였으며, 6 주째에외고정기를제거하였다. 원위요척관절에대한핀고정을시행하였으나, 외고정기제거후에두군간에회내및회외운동범위에유의한차이는없었다. 이는단일 K-강선을이용한핀고정을시행하였으며, 조기에 K-강선을제거함으로써원위요척관절에대한손상을최소화할수있었던결과로사료된다. 또한요골이단축을방지함으로써수부파악력 (grip strength) 을보존할수있었던것으로생각된다. 도수정복및금속강선고정술은상대적으로비침습적이고시술시간이짧으며비용적인측면에서도장점이있으나상대적으로고정력에서떨어지고골유합이이루어지는동안정복의소실과그에따른기능감소가단점으로지적되고있다 26. 하지만 Glickel 등 27 은도수정복후경피적금속강선고정술의장기추시연구에서우수한방사선학적및임상적결과를보고하였고, Rozental 등 28 은 45 명의불안정원위요골골절환자를대상으로시행한전향적연구에서수장부잠김압박금속판내고정술과도수정복후금속강선고정술간의임상적결과를비교한결과수술후 6주까지는임상적결과가금속판내고정술환자에서우수하나그후서서히차이가줄어들어 1년추시에서는의미있는차이를보이지않았다고보고하면서, 수술후초기의임상결과를바탕으로빠른기능적복귀 http://www.jkssh.org/ 19
J Korean Soc Surg Hand Vol. 20, No. 1, March 2015 가필요한환자에서관혈적방법을추천하였다. Kreder 등 9 은 179명의관절을침범한전위된원위요골골절환자를대상으로금속판내고정술과도수정복후금속강선및외고정기고정술을비교한무작위연구에서수술후첫 2년동안은비관혈적인치료를받은환자에서관혈적치료를받은경우보다일상생활로의복귀나기능적측면에서더우수한결과를보였고수술후 1년이후에는기능적결과의변화가없으므로 1년이상의추시는필요없다고하였다. 본연구에서는이와같이비관혈적인치료인도수정복후핀고정술및외고정기고정술의장점을극대화시키고자보조적인경피적원위요척관절핀고정술을추가로시행하였고그결과기존의금속강선및외고정기고정술의방법보다임상적으로는수부의파악력의세기가우수하였고, 방사선적으로는요골높이와요골경사각의회복이우월하였다. 본연구의한계는추시기간이 3개월로짧았기때문에장기적으로외상후관절염등에대한연구가필요할것이다. 결론 원위요골골절의외고정과경피적핀고정술을시행한결과비교에서방사선학적으로요골에만핀고정을시행한환자에비해요골과원위요척관절에핀고정을시행한환자군에서요골높이 (radial height) 와요골경사 (radial inclination) 가유의하게큰것으로나타났다. 임상적으로는수부파악력이요골과원위요척관절에핀고정을시행한환자군에서유의하게큰것으로나타났다. 불안정원위요골골절의수술적치료에서경피적원위요척관절핀고정술은수근관절의움직임제한없이요골단축을방지할수유용한술식이될수있을것으로생각된다. REFERENCES 1. Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am. 2001;26:908-15. 2. Park C, Ha YC, Jang S, Jang S, Yoon HK, Lee YK. The incidence and residual lifetime risk of osteoporosisrelated fractures in Korea. J Bone Miner Metab. 2011; 29:744-51. 3. Azzopardi T, Ehrendorfer S, Coulton T, Abela M. Unstable extra-articular fractures of the distal radius: a prospective, randomised study of immobilisation in a cast versus supplementary percutaneous pinning. J Bone Joint Surg Br. 2005;87:837-40. 4. Cooney WP 3rd, Linscheid RL, Dobyns JH. External pin fixation for unstable Colles' fractures. J Bone Joint Surg Am. 1979;61:840-5. 5. Fitoussi F, Ip WY, Chow SP. Treatment of displaced intra-articular fractures of the distal end of the radius with plates. J Bone Joint Surg Am. 1997;79:1303-12. 6. Handoll HH, Madhok R. Surgical interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev. 2003;(3):CD003209. 7. Horne G. A prospective randomized trial of external fixation and plaster cast immobilization in the treatment of distal radius fractures. J Orthop Trauma. 1991;5:246. 8. Kapoor H, Agarwal A, Dhaon BK. Displaced intra-articular fractures of distal radius: a comparative evaluation of results following closed reduction, external fixation and open reduction with internal fixation. Injury. 2000; 31:75-9. 9. Kreder HJ, Hanel DP, Agel J, et al. Indirect reduction and percutaneous fixation versus open reduction and internal fixation for displaced intra-articular fractures of the distal radius: a randomised, controlled trial. J Bone Joint Surg Br. 2005;87:829-36. 10. Bartosh RA, Saldana MJ. Intraarticular fractures of the distal radius: a cadaveric study to determine if ligamentotaxis restores radiopalmar tilt. J Hand Surg Am. 1990; 15:18-21. 11. Ark J, Jupiter JB. The rationale for precise management of distal radius fractures. Orthop Clin North Am. 1993; 24:205-10. 12. Howard PW, Stewart HD, Hind RE, Burke FD. External fixation or plaster for severely displaced comminuted Colles' fractures? A prospective study of anatomical and functional results. J Bone Joint Surg Br. 1989;71:68-73. 13. Jenkins NH, Jones DG, Johnson SR, Mintowt-Czyz WJ. External fixation of Colles' fractures. An anatomical study. J Bone Joint Surg Br. 1987;69:207-11. 14. McQueen M, Caspers J. Colles fracture: does the anatomical result affect the final function? J Bone Joint Surg Br. 1988;70:649-51. 15. Bradway JK, Amadio PC, Cooney WP. Open reduction and internal fixation of displaced, comminuted intraarticular fractures of the distal end of the radius. J Bone Joint Surg Am. 1989;71:839-47. 16. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg Am. 20 http://www.jkssh.org/
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J Korean Soc Surg Hand Vol. 20, No. 1, March 2015 원위요골골절에서외고정술및원위요척관절에대한핀고정술의효용성 윤상필 송경섭 이수건 임상윤 이영태 이승환광명성애병원정형외과 목적 : 원위요골골절환자의수술적치료에서 K-강선을이용한원위요척관절의핀고정의효용성을알아보고자하였다. 방법 : 원위요골골절에대해 K-강선을이용한핀고정과외고정을시행한 38명의환자를대상으로하였다. 원위요골에대해서만핀고정을시행한그룹 (pinning on distal radius only [PD] 그룹 ) 과원위요골과원위요척관절에핀고정을시행한그룹 (pinning on distal radioulnar [DRU] 그룹 ) 간에방사선학적결과와임상적결과를비교분석하였다. 모든환자에서외고정을시행하였다. 결과 : 23명의환자는 PD 그룹에속하였고, 15명의환자는 DRU 그룹에속하였다. 방사선학적계측상 DRU 그룹에서요골높이와요골경사각이유의하게큰것으로나타났다. 두군간에척골변위, 배측경사, 관절면의부조화에서통계학적인차이는없었다. 하지만임상적결과에서는 DRU 그룹에서수부에파악력이유의하게높은것으로나타났으며, 두군간에운동범위에서통계학적인차이는없었다. 결론 : 원위요골골절에서원위요척관절의핀고정술은요골단축을방지하기위해유용한술기로생각된다. 색인단어 : 원위요골골절, 핀고정, 원위요척관절 접수일 2015 년 2 월 24 일수정일 1 차 2015 년 3 월 10 일, 2 차 2015 년 3 월 18 일게재확정일 2015 년 3 월 19 일교신저자이승환경기도광명시디지털로 36 광명성애병원정형외과 TEL 02-680-7699 FAX 02-2680-7755 E-mail java5885@gmail.com 22 http://www.jkssh.org/