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대한정형외과학회지 : 제 43 권제 3 호 2008 J Korean Orthop Assoc 2008; 43: 359-365 Weber B 형외과골절과동반된원위경비인대결합손상 박시영ㆍ박상원ㆍ한승범ㆍ정웅교ㆍ최근석ㆍ이순혁 고려대학교의과대학안암병원정형외과학교실 Syndesmosis Injury Associated with the Weber Type B Lateral Malleolar Fracture Si Young Park, M.D., Sang Won Park, M.D., Seung Beom Hahn, M.D., Woong Kyo Jung, M.D., Keun Seok Choi, M.D., and Soon Hyuck Lee, M.D. Department of Orthopedic Surgery, Korea University College of Medicine, Anam Hospital, Seoul, Korea Purpose: We evaluated the syndesmosis instability associated with Weber type B lateral malleolar fractures. Materials and Methods: Eighty one Weber type B lateral malleolar fractures were evaluated and classified according to the radiologic criteria. Syndesmosis instability was checked with a hook test during operation. The radiological and clinical results were assessed. Results: Twenty two cases were associated with a widening of the distal tibiofibular distance. Sixteen (73%) had syndesmosis instability confirmed with a hook test and were fixed with a syndesmotic screw. Eight (66%) out of 12 Wagstaffe fractures were fixed with a syndesmotic screw due to the instability. The distal tibiofibular distance was 7.4±2.4 mm, 4.6±1.9 mm and 4.9±1.9 mm preoperatively, postoperatively, and at the final follow up, respectively. All cases achieved union and good clinical results with more than 85 on the AOFAS score were obtained. Conclusion: Weber type B lateral malleolar fractures can be associated with a syndesmosis injury. An intraoperative hook test should be carried out for accurate diagnosis. Considerable attention needs to be paid to Wagsteffe fractures, because of the high probability of combining syndesmosis instability. Key Words: Ankle, Syndesmosis, Fracture, Instability 서론외과는족근관절의안정성을유지하는데필수적인해부학적인구조로서, 골절이발생한경우적절히치료되지않으면추후족근관절전체의불안정성을유발하여결국심한퇴행성변화를유발하게되어심한기능적인손실이온다 20). 특히 Weber B형외과골절은족근관절골절중가장흔히발생되는골절로서흔히외회전력에의하여발생하며해부학적인정복과적절한고정이필수적으로필요하며, 또한동반하여발생할수있는원위경비인대결합의손상여부에도주의하여치료하여야좋은결 과를보일수있다 11,21). 원위경비인대결합은족근관절의기능과안정성에중요한역할을하며족근관절골절과동반한경우원위경비인대결합의손상유무는치료및예후에중요한영향을미치지만이를정확히진단하기에는많은어려움이있다 1). 수술이필요한원위경비인대결합의파열은족근관절의 Weber C형외과골절에서흔히동반하고, Weber B형외과골절에서는골절의위치와골절유발역학에따르면그가능성이적다고알려지고있으나 2,9), 인대결합의파열및불안정성의동반의가능성이있고 통신저자 : 이순혁서울특별시성북구안암동 5 가 126-1 고려대학교의과대학안암병원정형외과학교실 TEL: 02-920-5905 ㆍ FAX: 02-924-2471 E-mail: soonlee@kumc.or.kr Address reprint requests to Soon Hyuck Lee, M.D. Department of Orthopaedic Surgery, Anam Hospital, Korea University College of Medicine, 126-1, Anamdong, Sungbookgu, Seoul 136-705, Korea Tel: +82.2-920-5905, Fax: +82.2-924-2471 E-mail: soonlee@kumc.or.kr 359

360 박시영ㆍ박상원ㆍ한승범외 3 인 이의동반여부를정확히진단하여치료하는것이무엇보다도중요하다고할수있다. 본연구에서는 Weber B형외과골절로수술적인치료를시행받고최소 1년이상추시관찰이가능하였던환자에서원위경비인대결합의손상과의연관성을알아보고그진단및치료의결과에대해알아보려고하였다. 대상및방법 1998년 1월부터 2005년 12월까지본원에서 Weber B형외과골절로수술을시행받은 86명의환자중최소 1년이상추시관찰이가능하였던 81명의환자를대상으로후향적연구를시행하였다. 남자는 45명, 여자는 36명이었고평균연령은 37.6 세 (19-68세) 였고추시기간은평균 2.4년 (1-5 년 ) 이었다. 수상시촬영된방사선검사를통하여족근관절전후면방사선검사및격자상촬영영상을시행하여골절의양상을분류하였고, 원위비골의견열골절 (Wagstaffe 골절 ) 22) 의동반여부를확인하였으며, 족근관절전후면방사선검사에서경골비골간간격을측정하여 5 mm 이상인경우원위경비인대결합의손상을동반한것이라진단하였다 18). 원위경비골간격은저자 3인이측정하여그평균값을기록하였다. 수술은 Weber B형외과골절에서동반한내과골절및외과골절에대해해부학적인정복과내고정술을제1 저자에의해시행되었으며특히외과골절에대하여금속판고정술을시행후이동영상증폭기하에서훅을이용하여비골을측방으로견인하여원위경비인대결합의손상여부및술후불안정성에대하여검사한후 2 mm 이상의전위가발생한경우불안정성이동반하였다고진단하였고 13) 3.5 mm 피질골나사를이용하여원위경비골간나사못고정술을시행하였다. 수술후 8주간의단하지캐스트고정후나사못제거술시행후정상보행운동을허용하였다. 수술후 1개월, 3개월, 6개월, 1년에주기적으로추시관찰을시행하였으며, 방사선학적인평가는골절의정복정도를 Cedell 등의방법 4,7) 으로평가하였고, 최종추시시유합여부를판독하고, 원위경비골간격을측정하여수술직후와비교하였다. 또한관절운동의범위를측정하여반대편과비교하였고, 임상적인평가는 AOFAS ankle-hindfoot scale 12) 에따라설문과이학적검사를통해통증 (40점 ), 기능 (50점 ) 정렬 (10점 ) 등의 항목으로점수화하였다. 통계학적인분석은윈도우응용 SPSS 통계분석프로그램10 (SPSS10.0, Chicago, IL, USA) 을이용하여 paired t-test를이용하여술전및술후원위경비골간격과관절운동정도를정상측과비교분석하였고, student t-test 를이용하여나사못고정을시행하지않은환자군과나사못고정술을시행한환자군사이의족근관절운동정도및 AOFAS ankle-hindfoot scale 의차이를비교분석하였다. Linear regression analysis 를이용하여최종추시시의원위경비골간격의측정정도와관절운동의정도및 AOFAS ankle-hindfoot scale 을이용한임상적인결과와의상관관계를알아보았다. 결과는 p값이 0.05 미만인경우에의미있다고해석하였다. 결과총 81명의 Weber B형외과골절환자에서술전방사선사진상에서원위경비골간격이 5 mm 이상을보여원위경비인대결합의손상이의심되는경우는 22예 (27%) 에서있었고, 해부학적인정복술및내고정술이후에훅을이용하여외과의견인검사를시행하여원위경비인대결합의불안정성을보인경우는 14예, 술전방사선검사상에서원위경비골간격이 5 mm 이하인경우에도내고정술후외과의견인검사상 2 mm 이상의이개를보여불안정성이동반한다고진단한경우가 2예있어, 총 16 예 (20%) 의환자에있어내고정술후원위경비인대결 Table 1. Characteristics of Study Cohort (N=81) Unstable Group Stable group (16) (65) Ages, yrs (mean, SD, years) 34.3±18 39.8±21 Sex (Male/Female) 11/5 34/31 Fracture characteristic Lateral malleolar fracture 3 13 Bimalleolar fracture 12 44 Trimalleolar fracture 1 8 Wagstaffe fracture 8 4 Reduction status Good 14 60 Moderate 2 5 Poor 0 0 Distance* (mean, SD, mm) Preoperative status 7.4±2.4 Postoperative status 4.6±1.9 Final follow up status 4.9±1.9 *: Distal tibiofibular distance on radiologic anterolateral view.

Weber B 형외과골절과동반된원위경비인대결합손상 361 Table 2. Algorism of the Diagnosis and Treatment of Ankle Diastasis *: Distal tibiofibular distance on the radiologic anterolateral view. 합의불안정성을진단하고원위경비골간나사못고정술을시행하였다 (Table 1, 2). 원위비골의견열골절소위 Wagsteffe 골절을동반한경우 (Fig. 1) 는총 12예에서있었고이중방사선학적으로원위경비인대결합의손상을의심케하는경우는 10 예였고, 고정술후외과의견인검사에서불안정성을보여나사못고정술을시행한경우는 8예 (66%) 있었다 (Table 3). 전례에서양호한정복양상을보였고, 내고정술후원위경비인대결합의불안정성을보인 16예에서원위경비골간간격은수술전 7.4±2.4 mm, 술후 4.6±1.9 mm, 최종추시시 4.9±1.9 mm였다. 최종추시시전례에서완전한골유합을얻을수있었 Fig. 1. Weber type B fracture with a syndesmosis instability. (A) Preoperative ankle radiograph shows a Weber type B ankle fracture with an avulsion fragment of the distal fibula by the anterior tibiofibular ligament. The preoperative distal tibiofibular clear space was measured to be 6.5 mm. (B) Preoperative ankle MRI shows a rupture of the intramembranous ligament between the distal tibia and fibula (arrow). (C) Ruptured anterior tibiofibular ligament (arrow) was detected during surgery. (D) Postoperative radiograph show internal fixation of the ankle fracture and syndesmosis screw fixation.

362 박시영ㆍ박상원ㆍ한승범외 3 인 으며, 2예의나사못의파열, 1예의원위경비골간이소성골화가발생하였으나족근관절의운동범위나임상적인결과에는영향을미치지않았다. 원위경비골간불안정성으로나사못고정술후최종추시시족근관절의운동범위는굴곡이 23±7 o 으로건측에비해감소된소견보였으나 (p<0.05) 신전에는특이한차이를보이지않았다. 나사못고정술을시행한환자에서최종추시시 AOFAS ankle-hindfoot scale 를측정하였을때전례에서 85점이상으로좋은결과를보였다. 나사못고정술을시행하지않은환자군과의비교에서는족근관절의굴곡정도가통계학적으로의미있게 (p<0.05) 감소되어있었으나, 임상적인결과분석인 AOFAS anklehindfoot scale 에서는특이한차이를보이지않았다 (Table 4). 또한통계학적인검사상최종추시시의원위경비골간간격의정도와관절운동의정도및임상적인결과와는특이한상관관계를보이지않았다 (p>0.05). Table 3. Results of the Wagsteffe Fracture *: Avulsion distal fibular fracture by the anterior tibiofibular ligament, : distal tibiofibular distance on the radiologic anterolateral view. 고찰원위경비인대결합은전경비인대, 후경비인대, 골간인대, 하횡인대로이루어지고전경비인대가약 35% 의안정성을제공하고골간인대가약 22% 를후경비인대가약 33% 를하횡인대가약 9% 의안정성을제공하며, 족근관절의안전성을유지하고회전운동이이루어지게한다 17). 사체연구에서전경비인대의파열시경비골을 4 mm까지분리시킬수있고, 골간인대가추가로파열되는경우 1 cm까지도분리된다고한다 3). 원위경비인대결합의손상의발생기전은주로외전력에의하여손상이발생되는데 Lauge Hansen 분류에서는주로회내외회전형, 회내외전형, 간혹회외외회전력에의해서발생할수있으며, Weber 분류에서는 C형에서동반을많이하고 B형에서는동반여부에논란이있다 2,9). 원위경비인대결합의손상은동반되었다고하여도이를반드시치료해야하는것이아니고수술적인치료의적응및나사못고정술의필요성에는많은논란의여지는있으나대개상위비골골절과동반하여족근관절내측손상이동반된경우, 내과골절을고정한후비골의외측전위가발생한경우이거나, 내측손상이삼각인대파열과동반하여비골골절이관절면의약 3 cm 상부에위치한경우등으로알려져있다 15). 원위경비인대결합의손상및불안정성의진단에는여러가지진찰소견및방사선학적측정방법등이알려져있으나, 골절을동반한환자에있어사용하기에는많은어려움을가지고있고, 수술전에원위경비골사이의이개를진단할뿐동반한골절의내고정술을시행한경우원위경비인대결합의불안정성의잔존여부는예측할수없어원위경비골간나사못고정술의적응방법으로사용하기어렵다고생각된다. 또한초음파검사, 관절경검사및자기공명검사등을 Table 4. Clinical Results of Syndesmosis Fixation Unstable group* (16) Stable group** (65) Range of motion ( o ) Dorsiflexion (injured/uninjured) 23±11/31±7 (p<0.05) # 28±7/30±6 (p>0.05) # p<0.05 ## Platarflexion (injured/uninjured) 39±8/42±6 (p>0.05) # 40±6/43±5 (p>0.05) # Ns ## AOFAS ankle-hindfoot scale 92.2±6.5 93.4±8.1 Ns ## Over 90 14 52 80-90 2 13 Less 80 0 0 # : paired t-test for an analysis of the final range of motion between the injured ankle and normal ankle of each patient, ## : student t-test for an analysis of the final range of motion between the two groups.

Weber B 형외과골절과동반된원위경비인대결합손상 363 이용하여전경비인대의파열및골간인대의파열을진단할수있으나고가의검사이고골절을동반한경우사용하기어려운점등이문제로생각된다 5,6,10,14,16). Kennedy 등은 Weber C형외과골절에서동반된인대결합손상에대해나사못고정술을시행한경우와시행하지않은경우에서로임상적방사선학적으로큰차이를보이지않았다고보고하여나사못고정술의필요성에대해의문을제기하였으나 9), Weening 등은원위경비인대결합의불안정성을정확히진단하여이개가발생하는경우나사못고정을하는것은좋은임상적인결과를보인다고하였고 23), 본연구에서도원위비골을견인검사를통해이개를진단후나사못고정한경우원위경비인대결합의손상을동반하지않은 Weber B형외과골절의결과비교하여족근관절의굴곡운동에감소를보였으나, AOFAS ankle-hindfoot scale 을통한임상적인결과에서는좋은결과를얻었다고생각되어, 불안정성을보인경우에는나사못고정술을시행하여야한다고생각된다. Weber B형외과골절은족근관절골절중가장흔한경우이고대개회외외회전형골절에서발생되며, 이경우이론적으로전경비인대의파열은동반되나, 내고정술을시행하는경우에는원위경비골의불안정성을유발하지않는것으로알려져있다. 즉전경비인대의파열은골절의하부에위치하여골절된내과및외과의내고정술을시행하는경우원위경비골의이개가발생하지않는것으로알려져왔다 15). 하지만그상부에위치한골간인대의파열이동반되는경우에는내고정술을시행하여도원위경비골사이에불안정성이계속남게되어이를진단하고치료하지않으면불안정성에의해많은문제가발생할수있다고생각된다. 최근의자기공명영상을이용하여 Weber B형족근골절에서전경비인대및골간인대의파열이발생함을보여주는보고가있고 16), 또한원위비골의견열골절, 소위 Wagstaffe 골절이동반되는경우족근관절의불안정성이동반되는경우가많다고보고되고있다 19). 본연구에서술전방사선검사에서원위경비골간격의측정에의한원위경비인대결합의불안정성의예측은 63% 에서보였고, 또한이개가보이지않았던 2명의환자에서도불안정성을보여원위경비골간간격의이개만으로는족근관절의골절을동반한경우인대결합의손상, 특히골간인대의손상여부를진단하는 데정확한정보를주지못한다고생각된다. 본연구에서는 Weber B형의외과골절환자에있어내고정술을시행후훅을이용하여외측으로견인검사를시행하여그불안정성을측정하여예상외로외과의골절이관절면과같은높이에있는 Weber B형골절에서도내고정술후약 20% 라는상대적으로많은환자에서불안정성을관찰할수있었으며, 이에나사못고정술을시행함으로써좋은임상적방사선학적인결과를얻을수있었다. 또한원위비골의견열골절을동반한 12예중고정술후불안정성을 66% 에서보여박등의연구 19) 와비슷한결과를얻을수있었다. 본연구는상대적으로적은수의환자에서최소 1년이상의추시관찰을시행하여연구를시행하여, 외상성관절염의발생은관찰할수없었으나추후많은수의환자를대상으로하는장기간의연구가필요할것으로생각된다. 결론 Weber B형족근관절골절은원위경비인대결합파열이동반될수있으며외과골절의내고정후동반된골간인대의파열에의하여불안정성을유발할수있어이를진단하기위하여내고정술후외과의견인검사를반드시시행하여야하며, 특히원위비골의견열골절이있는경우는더욱불안정성을동반할가능성이높으므로주의깊은진단및치료가필요하다고생각된다. 참고문헌 1. Amendola A: Controversies in diagnosis and management of syndesmosis injuries of the ankle. Foot Ankle, 13: 44-50, 1992. 2. Boden SD, Labropoulos PA, McCowin P, Lestini WF, Hurwitz SR: Mechanical considerations for the syndesmosis screw. A cadaver study. J Bone Joint Surg Am, 71: 1548-1555, 1989. 3. Bonnin JG: Injury to the ligaments of the ankle. J Bone Joint Surg Br, 47: 609-611, 1965. 4. Cedell CA: Supination-outward rotation injuries of the ankle. A clinical and roentgenological study with special reference to the operative treatment. Acta Orthop Scand, Suppl 110: 3+, 1967. 5. Gardner MJ, Demetrakopoulos D, Briggs SM, Helfet

364 박시영ㆍ박상원ㆍ한승범외 3 인 DL, Lorich DG: The ability of the Lauge-Hansen classification to predict ligament injury and mechanism in ankle fractures: an MRI study. J Orthop Trauma, 20: 267-272, 2006. 6. Jenkinson RJ, Sanders DW, Macleod MD, Domonkos A, Lydestadt J: Intraoperative diagnosis of syndesmosis injuries in external rotation ankle fractures. J Orthop Trauma, 19: 604-609, 2005. 7. Joy G, Patzakis MJ, Harvey JP Jr: Precise evaluation of the reduction of severe ankle fractures. J Bone Joint Surg Am, 56: 979-993, 1974. 8. Katznelson A, Lin E, Militiano J: Ruptures of the ligaments about the tibio-fibular syndesmosis. Injury, 15: 170-172, 1983. 9. Kennedy JG, Soffe KE, Dalla Vedova P, et al: Evaluation of the syndesmotic screw in low Weber C ankle fractures. J Orthop Trauma, 14: 359-366, 2000. 10. Kerr R, Forrester DM, Kingston S: Magnetic resonance imaging of foot and ankle trauma. Orthop Clin North Am, 21: 591-601, 1990. 11. Kim SK, Oh JK: One or two lag screws for fixation of Danis-Weber type B fractures of the ankle. J Trauma, 46: 1039-1044, 1999. 12. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M: Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int, 15: 349-353, 1994. 13. Klossner O: Late results of operative and non-operative treatment of severe ankle fractures. A clinical study. Acta Chir Scand Suppl, Suppl 293: S1-S93, 1962. 14. Lee HS, Park SS, Kim JW, et al: Diagnostic value of ultrasonography for acute tear of tibiofibular syndesmosis in ankle. J Korean Foot Ankle Soc, 8: 1-6, 2004. 15. Leeds HC, Ehrlich MG: Instability of the distal tibiofibular syndesmosis after bimalleolar and trimalleolar ankle fractures. J Bone Joint Surg Am, 66: 490-503, 1984. 16. Nielson JH, Sallis JG, Potter HG, Helfet DL, Lorich DG: Correlation of interosseous membrane tears to the level of the fibular fracture. J Orthop Trauma, 18: 68-74, 2004. 17. Ogilvie-Harris DJ, Reed SC: Disruption of the ankle syndesmosis: diagnosis and treatment by arthroscopic surgery. Arthroscopy, 10: 561-568, 1994. 18. Ostrum RF, De Meo P, Subramanian R: A critical analysis of the anterior-posterior radiographic anatomy of the ankle syndesmosis. Foot Ankle Int, 16: 128-131, 1995. 19. Park JW, Kim SK, Hong JS, Park JH: Anterior tibiofibular ligament avulsion fracture in weber type B lateral malleolar fracture. J Trauma, 52: 655-659, 2002. 20. Pettrone FA, Gail M, Pee D, Fitzpatrick T, Van Herpe LB: Quantitative criteria for prediction of the results after displaced fracture of the ankle. J Bone Joint Surg Am, 65: 667-677, 1983. 21. Quigley TB: A simple aid to the reduction of abductionexternal rotation fractures of the ankle. Am J Surg, 97: 488-493, 1959. 22. Wagstaffe W: An unusual form of fracture of the fibula. Cited by St Thomas Hosp Rep, 6: 43, 1875. 23. Weening B, Bhandari M: Predictors of functional outcome following transsyndesmotic screw fixation of ankle fractures. J Orthop Trauma, 19: 102-108, 2005.

Weber B 형외과골절과동반된원위경비인대결합손상 365 = 국문초록 = 목적 : Weber B 형외과골절에서원위경비인대결합의손상과의연관성을알아보고그진단및치료의결과에대해알아보려고하였다. 대상및방법 : 최소 1 년이상관찰이가능하였던 81 명의 Weber B 형외과골절로수술받은환자를대상으로후향적으로원위경비골간격을측정하였고, 술중외과의견인검사를시행하여불안정성여부를판단하였다. 최종추시시원위경비골간격을측정하였고, 족근관절운동의정도와 AOFAS ankle-hindfoot scale 을이용하여분석하였다. 결과 : 원위경비인대파열을의심할수있었던경우는총 22 예였고, 이중 16 예 (73%) 에서불안정성이있어나사못고정술을시행하였다. 12 예의비골견열골절중 8 예 (66%) 에서불안정성을보여나사못고정술을시행하였다. 경비골간격은술전 7.4±2.4 mm, 술후 4.6±1.9 mm, 최종추시시 4.9±1.9 mm 였다. 전례에서골유합을얻을수있었고 AOFAS score 상 85 점이상의좋은임상적인결과를얻을수있었다. 결론 : Weber B 형족근관절골절은원위경비인대결합파열이동반될수있으며외과골절의내고정후동반된골간인대의파열에의하여불안정성을유발할수있어이를진단하기위하여내고정술후외과의견인검사를반드시시행하여야하며, 특히원위비골의견열골절이있는경우에서는더욱불안정성을동반할가능성이높으므로주의깊은진단및치료가필요하다고생각된다. 색인단어 : 족근관절, 원위경비인대결합, 골절, 불안정성