대한견 주관절학회지제 10 권제 1 호 J. of Korean Shoulder and Elbow Society Volume 10, Number 1, June, 2007 회전근개의손상환자에서외상성과퇴행성의감별 조선대학교의과대학정형외과학교실, 서남대학교의과대학정형외과학교실 윤태현 문영래 * 김정호 Discriminate between Traumatic and Degenerative Rotator Cuff Lesion in Rotator Cuff Injury Patient Te Hyun Youn, M.D., Young Lae Moon, M.D.*, Jeoung Ho Kim, M.D. Department of Orthopaedic surgery, Chosun University Hospital, Gwang Ju,Korea, Department of Orthopedic Surgery, Seonam University, Gwangju, Korea 서론최근회전근개의외상관련손상이많이보고되고있으나실제로는교통사고, 산업장손상, 개인보험과연관되어보상반응으로외상을주장하는경우가많아주의가요구된다. 심한회전근개손상환자에서나이가많고견관절의퇴행변화가있는경우원인을파악하여외상성손상과퇴행성손상으로분류하는것은매우어려울때가많다. 본장에서는이를파악하는데도움이되는병력및검사소견과타문헌의예를알아보고자한다. 회전근개파열의종류에따른결정인자회전근개손상에대하여결정을내리기위하여필요한지식은회전근개에대한해부학, 역학, 병인, 연령증가에따른회전근개파열의빈도 9), 병리손상기전, 생리학등에대한것이있으며결정을내리기위한검사로는병력청취, 진찰검사, 단순방사선검사, MRI, 초음파소견, 수술소견등이있다. 병력청취외상성회전근개부분손상의경우응급실등에서는별증상호소가없어초진검사시간과될수있고시간이경과한후지속적인또는간헐적인견관절통증을평가하는과정에서진단될수있어주의를요한다. 외상성손상의기전에는견관절전방탈구, 외회전손상, 외전-외회전손상, 교통사고등이있으며이에따라서수상당시직접혹은간접외상또는복합적인손상및추락또는견인손상등의기전에대한병력을잘청취하여야하며수상당시에통증이있었는지여부또는외상이전 통신저자 : 문영래 * 광주광역시동구서석동 588 조선대병원정형외과학교실 Tel: 062) 220-3147, Fax: 062) 226-3379, E-Mail: orthoped@chosun.ac.kr 10
윤태현외 : 회전근개의손상환자에서외상성과퇴행성의감별 부터견관절통증이나기능약화등이존재하였는지있었다면얼마나지속되었는지를확인하여야한다. 무엇보다중요한것은손상기전과실제병변과일치하는지를평가하는것이다. 진찰검사회전근개질환이의심되는경우에가장먼저충돌징후검사법이널리쓰이며극상근의근력은 empty can 검사법, 극하근의근력은 hornblower 검사법, 상완낙하징후, 견갑하근은 lift off 검사법, 복부압박검사법등이유용하게사용된다. 또한손상된근육자체삼각근의위축여부및만성불안정증이동반되었는지도평가하여야한다. Milgram 등 8) 에의하면나이가들어갈수록회전근개는 maximal stress와최대응력이약해지면서퇴행및외상성파열의가능성이커진다고하였으며 Hashomoto 등 4) 에의하면만성파열의병리소견으로지방변성과혈관침식, 교원섬유의감소및배열의불규칙, 초자양변화 Fig. 1. () Fresh rotator cuff tear margin is filled with healthy fibrous tissue (Stain, hematoxylin and eosin; original magnification, 40). () Chronic retractive case shows fatty infiltration and disorganization in the proximal part of the tendon that is distributed from the middle to deep layer (Stain, hematoxylin and eosin; original magnification, 100). Fig. 2. () Simple radiogram reveals calcification of supraspinatus tendon () Magnetic resonance image reveals low signal intensity as calcification of supraspinatus tendon. 11
대한견 주관절학회지제 10 권제 1 호 (hyaline degeneration), 지방변성, 연골형이형성등을보인다고하였다 (Fig. 1). 단순방사선촬영단순방사선촬영은충돌현상을초래하는골격의변화를찾는방법으로써탈구를평가하며대결절에미란이나작은골낭종이보이기도하며견봉돌기골극이나석회침착또는상완골두의상방전위그리고병이진행되면견쇄관절의관절염 등이나타날수있다 (Fig. 2, 3). 자기공명영상회전근개자체의상태를보는자기공명영상검사에서만성손상을의미하는소견은대결절의부종 6) 과오구견봉인대의비대및퇴화, 견갑하근의퇴축및이두박근의탈구, 견봉하부의골변화, 갈고리형견봉, 견봉의전하방경사, 견봉상완관절염변화특히하방부의골극형성과견봉쇄골관 Fig. 5. ssessment for normal rotator cuff muscle volume () or atrophy () is best accomplished on oblique sagittal T1 weighted image. Fig. 3. Simple radiogram showing upward migration of humeral head upward migration and spur change at acromion and greater tuberosity. Fig. 4. cormioclavicular joint arthrosis is evidence of chronic overhead activity. 12
윤태현외 : 회전근개의손상환자에서외상성과퇴행성의감별 절증등이있으며외상성회전근개손상을의미하는소견으로는위축이없는견갑하근, 이두박근은잘보존되어있지만대결절골절과부착부에결손이보일수있다 10). 견갑하근파열은외상성에의한경우가약 70% 정도로보고되고있다 3). 그러나 퇴행변화에의한손상도적지않은데견갑하근상부의파열이오면서오구상완인대의이완이오고후속적으로상완이두근의장두의불안정성이나아탈구가발생하게된다. 또한, 견갑하근퇴행의또다른원인으로오구돌기의충돌이영향을미치기도한다 2,3,5) (Fig. 4-9). 수술소견 Fig. 6. Magnetic resonance image of 55-year-old-male patient reveals subacromial enthesopathy with rotator cuff tear. 수술시관찰되는육안적소견으로외상성손상과퇴행성손상을구분할수있는데이두박근의장건은급성손상에서수상으로인해병리적변화를일으키게되는데퇴행성손상환자와비교해서보다더이두박근구에서탈구를잘보이나퇴행성손상에서는부분이나완전파열양상을더욱흔하게보인다 (Fig. 10) 4). 활액막염은양측에서고루관찰될수있어두그룹간의차이를구별하는 Fig. 7. oth illustration () and magnetic resonance imaging () reveals hooked acromion, it is source of ischemia and mechanical impingement 13
대한견 주관절학회지제 10 권제 1 호 Fig. 8. Compare with normal acromial sloping (), anteroinferiorly downsloping () is predisposing factor of chronic impingement and rotator cuff tear. Fig. 9. Subscpularis tear and biceps long head subluxation are showing in illustration () and axial magnetic resonance imaging. 데에는특이성이떨어지며파열의크기또한양측에서큰차이를보이지는않는다 1). 다른만성손상의소견으로는손상부주변이일어나있고, 겹으 로갈라지면서파열되는형태 (Fig. 11), 퇴축과위축 (Fig. 12), 견봉하부의비대나골변화 (Fig. 13) 등이있다 7). 특징적으로급성손상환자에서는 14
윤태현외 : 회전근개의손상환자에서외상성과퇴행성의감별 Fig. 10. iceps tendon fraying or tear is evidence of chronic rotator cuff injury. Fig. 11. rthroscopic finding reveals delaminated chronic rotator cuff tear. Fig. 12. Some chronic retractive tear showing atrophy and fatty degeneration. Fig. 13. Subacromial space reveals hypertrophy and morphologic change. 손상부위에서혈종을발견할수있는데퇴행성환자에서는발생되지않으므로이때는확진이가능하다. 결론외상성회전근개의손상과퇴행성회전근개의손상을구별하는데있어서건자체의변화와주변조직의변화, 그리고환자의연령과활동도등을고려하여야하리라사료되며손상기전과병적상태를비교하여판단하고환자의과거력과방사선적검사와수술소견등도함께종합하여진단의기준으로삼아야할것으로생각되나완전히만족할만한진단기준에대해서는더욱더연구가필요하리라생각된다. REFERENCES 01) raune C, Gramlich H, Habermeyer P: The macroscopic aspect of rotator cuff tears in traumatic and nontraumatic rupture cases. Unfallchirurg, 103: 462-467, 2000. 02)urkhart SS, rady PC: rthroscopic subscapularis repair: surgical tips and pearls to Z. rthroscopy, 22: 1014-1027, 2006. 03) Edwards T, Walch G, Nove-Josserand L, et al: rthroscopic debridement in the treatment of patients with isolated tears of the subscapularis. rthroscopy, 22: 941-946, 2006. 04) Hashimoto T, Nobuhara K, Hamada T: Pathologic evidence of degeneration as a primary cause of rotator cuff tear. Clin Orthop Relat Res, 415: 111-120, 2003. 05) Lo IK, urkhart SS: The etiology and assessment of subscapularis tendon tears: a case for 15
대한견 주관절학회지제 10 권제 1 호 subcoracoid impingement, the roller-wringer effect, and TUFF lesions of the subscapularis. rthroscopy, 19: 1142-1150, 2003. 06) McCauley TR, Disler DG, Tam MK: one marrow edema in the greater tuberosity of the humerus at MR imaging: association with rotator cuff tears and traumatic injury. Magn Reson Imaging, 18: 979-984, 2000. 07) Meyer DC, Lajtai G, von Rechenberg, Pfirrmann CW, Gerber C: Tendon retracts more than muscle in experimental chronic tears of the rotator cuff. J one Joint Surg r, 88: 1533-1538, 2006. 08) Milgrom C, Schaffler M, Gilbert Svan Holsbeeck M: Rotator-cuff changes in asymptomatic adults. The effect of age, hand dominance and gender. J one Joint Surg r, 77: 296-298, 1995. 09) Sorensen K, ak K, Krarup L, et al: cute rotator cuff tear: Do we miss the early diagnosis? prospective study showing a high incidence of rotator cuff tears after shoulder trauma. J Shoulder Elbow Surg, 16: 174-180, 2006. 10) Teefey S, Rubin D, Middleton WD, Hildebolt CF, Leibold R, Yamaguchi K: Detection and quantification of rotator cuff tears. Comparison of ultrasonographic, magnetic resonance imaging, and arthroscopic findings in seventyone consecutive cases. J one Joint Surg m, 86- : 708-716, 2004. 16