대한고관절학회지제 19 권제 3 호 Vol. 19, No. 3, September, 2007 외상성고관절후방탈구에동반된대퇴골두골절의치료 김정호 이상홍 문영래 김동휘 송근상 조선대학교의과대학정형외과학교실 목적 : 대퇴골두골절이동반된후방탈구환자의 Pipkin 분류에따른치료결과및합병증등을알아보고자하였다. 대상및방법 : 대퇴골두골절을동반한후방탈구중 Thompson-Epstein Ⅴ형 10예를대상으로하였으며, Pipkin 분류상 Ⅰ형 5예, Ⅲ형 1예, Ⅳ형 4예이었고, 남자가 7예, 여자가 3예였다. 수상당시평균연령은약 38세 (19~72) 였으며, 수상원인은교통사고가 9예, 낙상이 1예이었고, 추시기간은평균 33개월 (13~79) 이었다. 골절의정복은 9예에서 6시간이내, 1예에서 12시간이내에시행되었다. 정복후안정성이확인되면골격견인술을이용한보존적치료, 불안정성및골절의형태에따른수술적치료방법을선택하였으며환자의이학적검사및방사선사진, C-T, MRI 등을통하여합병증을조사하였다. 결과 : Pipkin Ⅰ형은 4예에서보존적치료, 1예에서나사못을이용한수술적치료를시행하였고, Ⅲ형은일차적인공고관절치환술, Ⅳ형 4예중 2예는금속판고정술, 나머지 2예는골격견인술을이용한보존적치료를시행하였다. 모든예에서골유합은얻었으며, Ⅳ형에서경도의외상성관절염과대퇴골두하방골편의무혈성괴사증이각각 1예씩발생하였다. 결론 : 수상당시의손상정도가예후에영향을미치는것으로사료되었다. 색인단어 : 대퇴골두골절, 고관절후방탈구, Pipkin 분류 서 외상성고관절후방탈구는정형외과적응급상황으로써, 전체외상성탈구의약 5% 를차지하고있으며, 이중대퇴골두의골절을동반하는경우가약 7% 를차지하고있다 1,2). 이는최근급증하는교통사고로인하여그빈도가증가하고있으며대퇴골두의무혈성괴사, 외상성관절염등후유증을초래할수있어장기간에걸친추시관찰이필요하다. 이논문의목적은외상성고관절후방탈구환자중 Thompson-Epstein 13) V 형에해당하는 10 예를대상으로하였고, 이를다시 Pipkin 10) 분류에따라분류하여이에대해각각의치료결과와합병증등을알아보고자하였다. 론 대상및방법 성별및연령분포를보면수상당시연령은최소 19 세 통신저자 : 이상홍광주광역시동구서석동 588 번지조선대학교병원정형외과 TEL: 82-62-220-3147 FX: 82-62-226-3379 E-mail: shalee@chosun.ac.kr 에서 72 세로평균 38 세였으며, 총 10 예중남자가 7 명, 여자가 3 명이였다. 평균추시기간은 33 개월로서최소 13 개월부터최대 79 개월까지였다. 골절의원인으로는교통사고가 9 예로대부분을차지하고있었고, 1 예에서만추락사고의의한수상이었다. 교통사고중차량내부에탑승한상태에서발생한경우가 8 예, 오토바이탑승중발생한교통사고가 1 예였다. 동반손상은 Pipkin 1 형 2 예에서동측의경비골골절 1 예와두부손상 1 예가있었으며 Pipkin 4 형 2 예에서편측의상완골골절 1 예와 1 예의복부손상이동반되었다. 골절의분류는골반의전후, 측면단순방사선사진및 CT 를통해서골절양상을파악한후 Thompson-Epstein V 형을 Pipkin 분류에따라나누었으며, 1 형이 5 예, 3 형이 1 예, 4 형이 4 예였다. 정복시기는타병원에서정복후전원된 6 예와본원에서시행한 3 예에서 6 시간이내에이루어졌으며, 나머지 1 예에서는 12 시간이내에정복이이루어졌다. 모두도수정복술을시행했으며, 8 예에서 llis 방법으로, 2 예에서는 Stimpson 방법을통하여정복하였다. 치료방법은정복후안정성이확인되었던 6 예에서골격견인술을이용한보존적치료를시행하였으며, 나머지 4 예에서는수술적치료를시행하였다. 평가방법은수상및내원시골반의전후, 측면단순방사선사진및컴퓨터단층촬영을통해서골절양상을파악한후정복및치료를시행한뒤, 컴퓨터단층촬영과자기공명영상을통해서 176
외상성고관절후방탈구에동반된대퇴골두골절의치료 수술후상태와합병증등을파악하고 Epstein criteria 4.5) 에따라서임상적, 방사선학적평가를시행하였다. 동통이없고정상운동범위를보이며정상적인대퇴골두와비구관계및관절간격을보이는경우를우수, 동통은없으나정상범위의 75% 의운동범위와정상적인대퇴골두와비구관계를보이며미량의관절간격협소및골극을보이는경우를양호, 중등도의동통및운동범위소실및정상적인대퇴골두와비구관계를보이나중등도의관절간격소실과골극및연골하골이생성되는경우를보통, 심한동통및현저한운동범위의제한과현저한관절간격소실및대퇴골두음영증가, 골두변형및심한골극형성시불량으로평가하였다. 결 Pipkin 1 형의경우 4 예에서평균 6 주간의골격견인술을이용한보존적치료를시행하였고 (Fig. 1) 전예에서우수의임상적결과를얻었으며, 1 예에서불완전정복으로대퇴골두골절부에나사못고정술을시행하여양호한 과 결과를얻었다. 3 형의경우에는대퇴경부골절과동반한골두의분쇄골절이심해예후가불량할것으로사료되어 1 차적인인공관절전치환술을시행하였다 (Fig. 2). 4 형의경우에는 2 예에서비교적정복이양호하여골격견인술을통한보존적치료를약 8 주간시행하여각각우수와보통의임상적결과를보였으며, 2 예에서 Kocher- Langenbeck 의후방도달법을이용하여대퇴골두의골절편의제거및비구골절에대한금속판과나사못고정술을시행하였고양호의임상적소견을보였다 (Fig. 3). Epstein criteria 에의하여방사선학적평가결과우수가 4 예, 양호가 4 예, 보통이 2 예였는데 Pipkin 4 형에서수술적치료를시행하였던 1 예와보존적치료를시행하였던 1 예에서보통의결과를보였으며 3 예에서방사선적결과보다임상적결과가우수한소견을보였다 (Table 1). 추시중관찰된합병증으로 Pipkin 4 형에서외상성관절염이 1 예, 대퇴골두골절편의무혈성괴사가 1 예가발생하였으며 (Fig. 4), Pipkin 1 형에서도수정복전일시적인신경마비가 1 예있었으나정복후소실되는소견이관찰되었다. C D Fig. 1. (, ) 31-year-old male sustained Pipkin type I fracture of hip. (C, D) He was treated conservatively and the radiograph and MRI taken at 17 months shows complete healing of the fracture. 177
김정호 이상홍 문영래 김동휘 송근상 고 고관절탈구와동반된대퇴골두골절은비교적흔하지않은골절로써고관절탈구에서약 7% 를차지하고있으며정형외과적으로심각한합병증을유발할수있는응급상황으로써이에대한정확하고빠른정복및방사선학적평가가요구된다. 손상기전은교통사고로인한계기판손상이나추락사고등으로고관절이 60 도이하의굴곡및내전, 내회전상태에서발생한다고하였는데저자들의경우도교통사고 9 예와추락사고 1 예를보였다. 방사선학적평가는단순방사선촬영, 컴퓨터단층촬영및자기공명영상이유용하며특히고관절정복전, 정복후에컴퓨터단층촬영을통해골절양상파악및수술시행여부에대해판단할수있고, 자기공명영상을통하여추시평가함으로써대퇴골두무혈성괴사등의심각한합병증을발견할수있다. Pipkin 10) 은 Thompson-Epstein 분류 V 형의후방탈구및골절을다시대퇴골두골절양상에따라 4 가지형태로분류하였으며 Marchetti 등 9), Stannard 등 11) 찰 은이중 4 형이제일많다고하였으나, 저자의경우에는 1 형이 5 예, 4 형이 4 예순이었다. Stannard 등 11) 은조기의도수정복의시간및조기의안정화, 골절의해부학적정복과견고한고정등이좋은결과를획득하는데필수적이요소라고하였고조기정복술이 24 시간을경과하여정복한것보다더좋은결과를보인다고하여정복시간과예후와의연관성에대하여보고하고있다. 반면 Marchetti 등 9) 은대퇴탈구의정복을 6 시간이내와이후를비교분석하여결과상에유의한차이점은없었다고보고하고있다. 저자들도최대한빠른시간내에정확한해부학적정복을시행하기위하여노력하였으며타병원에서전원시에도정복후내원한경우가많아 9 예에서 6 시간이내에, 나머지 1 예에서도 12 시간이내에정복을시행할수있었다. 저자들은전례에서일차적으로도수정복술을시행하였으며 8 예에서는 llis 방법, 나머지 2 예에서 Stimpson 방법을통하여정복하였다. 정복을시행한후의정확성은관절면의간격이건측과 2 mm 이상의차이가있을때와 Shenton 씨선의파열로판단하여해부학적정복의실패 C D Fig. 2. (, ) 33-year-old female sustained Pipkin type III fracture of hip. (C) Femoral head was fractured with communition. (D) She was treated with total hip arthroplasty and the radiograph taken 13 months postoperatively shows stable fixation of cup and stem. 178
외상성고관절후방탈구에동반된대퇴골두골절의치료 C D Fig. 3. (, ) 46-year-old male sustained Pipkin type IV fracture of hip. (C, D) He was treated with open reduction and internal fixation and the radiograph and MRI taken 24 months postoperatively shows complete healing of the fracture. Table 1. Case analysis. case ge Sex Type of Injury Reduction Follow-up Treatment Complication Clinical Radiographic (year) fracture mechanism time (hour) (Month) method result result 1 33 F 3 *T 02 14 primary TH Excellent Good 2 39 M 4 0T 01 20 Conservative Tx. VN Fair Fair 3 46 M 4 0T 11 26 OR & IF c plate Osteoarthritis Good Fair 4 72 M 1 0T 02 79 Conservative Tx. Excellent Excellent 5 33 M 4 0T 01 62 Conservative Tx. Excellent Good 6 19 M 1 0T 04 17 Conservative Tx. Excellent Excellent 7 52 F 4 Fall down 02 27 OR & IF c plate Good Good 8 25 M 1 0T 02 13 OR & IF c screw Good Good 9 35 F 1 0T 05 38 Conservative Tx. Transient sciatic nerve injury Excellent Excellent 10 31 M 1 0T 02 39 Conservative Tx. Excellent Excellent *T: traffic accident, TH: total hip arthroplasty, Tx: treatment, OR & IF: open reduction and internal fixation, VN: avascular necrosis. 179
김정호 이상홍 문영래 김동휘 송근상 나관절면정복의일치성 (congruency) 을얻지못한경우, 관절내골편에의한유리체가존재하는경우등을대퇴골두골절의수술적치료의적응증으로판단하였다 11). 대퇴골두골절의치료에있어서관혈적정복술을시행할것인지골절편의제거술을시행해야할지에대해서는논란이있다. utler 2) 는대퇴골두골절편이특히중앙와하부 (caudal to fovea) 양상일때 1/3 정도까지는제거할것을주장하였다. Swiontkowski 등 12) 은 Pipkin I 형의골절에있어서해부학적인도수정복이이루어지지않았을경우에관혈적정복술후골절편에대한내고정술이필요하다고주장하였다. Greenwald 과 Haynes 7) 는큰골절편이중앙와상부 (cephalad to fovea) 로존재하는경우에는비구연골과관절면이접촉하는부위이며체중부하에관여하기때문에견고한고정술이필요하다는데에동의하고있다. rumback 등 1) 은내고정물로써 Countersunk O screw, Herbert screw, ioabsorbable pin 등을권장하였고이를통해좋은결과를보고하였다. 저자들의경우 Pipkin 1 형에서도수정복후안정성확보및골편의완전정복의경우에대부분보존적치료를시행하였으며불완전정복된 1 예에서 Herbert screw 를이용해양호한고정을얻을수있었다. 고에너지손상을받은젊은환자에있어서는가능한한내고정술을일차치료로서고려하여야 하나분쇄가심한대퇴골두골절및탈구에서나고령의환자에있어서는고관절반치환술이나전치환술은매우유용한치료방법이다 8). 이는수술시간이짧고, 대퇴골두무혈성괴사를피할수있으며, 조기에기능적재활을할수있다는장점이있다. 저자들의 3 형증례에서대퇴경부골절을동반하면서대퇴골두의심한분쇄골절을동반하여일차적인공관절전치환술을시행하였다. Pipkin 4 형의경우대부분의저자들은비구골절의정복및고정후대퇴골두정복및고정을시행하는것을주장하였는데저자들도 2 예에서는작은대퇴골두하부골절편은제거하고비구부는금속판내고정술및나사못삽입술, 비교적비구부후연의골절편이적어관절안정성이유지되고대퇴골두의정복이양호한 2 예에서보존적치료를시행하였는데총 4 예중경도의외상성관절염과자기공명영상에서골두하부작은골절편의무혈성괴사가각각 1 예씩발생하여가장예후가불량하였다. 또한수술적방법으로써 Epstein 등 3-6) 은전방도달법의사용시후방탈구시손상된혈액공급이재손상됨으로써후방도달법의유용성을제기하였는데저자들의경우에도전예에서후방도달법을이용하여수술적치료를시행하였다. C D E Fig. 4. (, ) 39-year-old male sustained Pipkin type IV fracture of hip. (C, D,E) He was treated conservatively. The radiograph at 20 months shows good bone union of femoral head but the MRI demonstrate avascular necrosis. 180
외상성고관절후방탈구에동반된대퇴골두골절의치료 결 적은증례이지만, 수상당시의손상정도와조기정복, 골절의정확한해부학적정복및견고한고정이예후에영향을미치는것으로사료되었다. 론 REFERENCES 01) rumback RJ, Kenzora JE, Levitt LE, urgess R, Poka : Fractures of the femoral head. Proceedings of the hip Society 1986,St Louis,CV Mosby, pp181-206, 1987. 02) utler JE: Pipkin type II fractures of the femoral head. J one Joint Surg m, 63: 1292-1296, 1981. 03) Epstein HC: Posterior fracture dislocations of the hip. J one Joint Surg m, 56: 1103-1127, 1974. 04) Epstein HC: Posterior fracture dislocations of the hip: Comparison of open and closed methods of treatment in certain types. J one Joint Surg m, 43: 1079-1098, 1961. 05) Epstein HC: Traumatic dislocations of the hip, long term follow-up. Clin Orthop Relat Res, 92: 116-142, 1973. 06) Epstein HC, Wiss D, Cozen L: Posterior fracture dislocation of the hip with fractures of the femoral head. Clin Orthop Relat Res, 201: 9-17, 1985. 07) Greenwald S, Haynes DW: Weight bearing areas in the human hip joint. J one Joint Surg r, 54: 157-163, 1972. 08) Kozin SH, Kilessar DJ, Gaunche C, Marmar EC: ilateral femoral head fracture with posterior hip dislocation. Orthop Rev, (Suppl): 20-24, 1994. 09) Marchetti ME, Steinberg GG, Coumas JM: Intermediate term experience of Pipkin fracture dislocations of the hip. J Orthop Trauma, 10: 455-461, 1996. 10) Pipkin G: Treatment of grade IV fracture dislocation of the hip. J one Joint Surg m, 39: 1027-1042, 1957. 11) Stannard JP, Harris HW, Volgas D, lonso JE: Functional Outcome of Patients With Femoral Head Fractures ssociated With Hip Dislocations. Clin Orthop Relat Res, 302: 36-41, 2000. 12) Swiontkowski MF, Thorpe M, Seiler JG, Hansen ST: Operative management of displaced femoral head fractures: Case-matched comparison of anterior versus posterior approaches for Pipkin I and Pipkin II fractures. J Orthop Trauma, 6: 437-442, 1992. 13) Thompson VP, and Epstein, HC: Traumatic dislocation of the hip: J one Joint Surg, 33: 746-778, 1951. 181
김정호 이상홍 문영래 김동휘 송근상 STRCT Treatment of Femoral Head Fracture with Traumatic Posterior Dislocation of the Hip Jeoung-Ho Kim, M.D., Sang-Hong Lee, M.D, Young-Lae Moon, M.D., Dong-Hui Kim, M.D. and Kun-Sang Song, M.D. Department of Orthopaedic Surgery, College of Medicine, Chosun University Puepose: To evaluate the treatment results and complication of a femoral head fracture with posterior dislocation of the hip according to the Pipkin classification. Materials and Methods: Ten cases of Thompson-Epstein type V femoral head fracture with a posterior dislocation of the hip were evaluated. ccording to the Pipkin classification, 5 cases were type I, 1 case was type III, and 4 cases were type IV. The average age at time of trauma was 38 (19~72) years, and the causes were traffic accidents in 9 cases and falls in 1 case. The average follow-up period was 33 (13~79) months. reduction of the fracture was performed within 6 hours in 9 cases and 12 hours in 1 case. When the stability was achieved after the reduction, the choice of further treatment was made from either conservative treatment while maintaining skeletal traction, or surgical treatment according to the fracture type and instability. The complications were evaluated by a physical examination, simple radiography, computed tomography (CT) and magnetic resonance imaging (MRI). Results: In Pipkin type I fractures, 4 cases were treated with conservative treatment and 1 case was treated with surgical treatment. One case of Pipkin type III fracture was treated with primary total hip arthroplasty. In Pipkin type IV fractures, 2 cases were treated surgically using a plate and 2 cases were treated with conservative treatment with skeletal traction. one union was achieved in all cases. One case of mild posttraumatic arthritis and 1 case of avascular necrosis was found, respectively in Pipkin type IV. Conclusion: The extent of the initial injury has an effect on the prognosis of a hip fracture and dislocation. Key Words: Femoral head fracture, Posterior dislocation of the hip, Pipkin type 182