ISSN 1225-1682 (Print) ISSN 2287-9293 (Online) 대한골절학회지제 27 권, 제 3 호, 2014 년 7 월 J Korean Fract Soc 2014;27(3):222-226 http://dx.doi.org/10.12671/jkfs.2014.27.3.222 Case Report 거골외측돌기골절과동반된비골건탈구 - 증례보고 - 황연수 조성준 김광열 김형천 김동선 왈레스기념침례병원정형외과 Peroneus Tendon Dislocation Associated with Fracture of Lateral Process of Talus - A Case Report - Youn-Soo Hwang, M.D., Sung-Jun Jo, M.D., Kwang-Yeol Kim, M.D., Hyung-Chun Kim, M.D., Dong-Seon Kim, M.D. Department of Orthopaedic Surgery, Wallace Memorial Baptist Hospital, Busan, Korea Traumatic peroneal tendon dislocation in association with fracture of the lateral process of the talus is a rare injury, which is difficult to diagnose. As a result, early detection is often delayed, which in turn leads to ankle pain and dysfunction. We treated a patient by open reduction and screw fixation in fracture of the lateral process of talus and primary repair of the superior peroneal retinaculum. We report this case with a brief review of the literature. Key Words: Talus, Peroneus tendon, Talus fracture, Peroneus tendon dislocation, Primary repair of superior peroneal retinaculum 거골의외측돌기의골절은스노보드를탈때수상할수있는흔하지않은골절로 von Knoch 등 1) 은단순방사선학적검사상외측돌기의 V 형태의소실 (V-sign) 로골절을진단할수있다고기술하였다. 비골건탈구는주로스포츠손상과관련하여발생하며단순족관절염좌로오진후부적절한치료로인하여후에재발성탈구를일으키게된다. 2) 또한비골건의탈구가동반된골절의경우골절의정복과치료에집중하게되므로수술시야에서우연히발 Received November 1, 2013 Revised March 31, 2014 Accepted March 31, 2014 Address reprint requests to: Sung-Jun Cho, M.D. Department of Orthopaedic Surgery, Wallace Memorial Baptist Hospital, 200 Geumdan-ro, Geumjeong-gu, Busan 609-728, Korea Tel: 82-51-580-1422ㆍFax: 82-51-583-2568 E-mail: alexander01@naver.com Financial support: None. Conflict of interest: None. 견되는경우를제외하고비골건의탈구를놓치는경우도있다. 2,3) 비골건의탈구와동반된거골의외측돌기골절은매우드문골절로서저자들은문헌고찰과함께보고하는바이다. 증례보고 49 세남자환자가약 3 m 높이지붕에서낙상후좌측족관절의동통과부종을주소로내원하였다. 내원당일시행한이학적검사상족관절내측부및외측부의압통및부종이심하였고, 족관절의후외측부위에압통이있었다. 족부방사선사진및컴퓨터단층촬영검사결과거골외측돌기골절과종골재거돌기의견열골절이발견되었다 (Fig. 1, 2). 수상후내측부및후외측부위통증이지속되어복합인대손상확인을위해시행한자기공명검사의 T2 조영영상에서삼각형의섬유연골 (fibrous ridge) 형태가 Copyright c 2014 The Korean Fracture Society. All rights reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 222
Peroneus Tendon Dislocation Associated with Fracture of Lateral Process of Talus 223 Fig. 1. Preoperative anteroposterior and lateral radiograph showing fracture of the lateral process of talus. Fig. 2. Preoperative computed tomography showing fragment of the talar lateral process. 붕괴되면서비골건의주변으로조영증가된소견 (Fig. 3) 이관찰되었으나, 탈구된소견은저명하게관찰되지않았다. 수술소견상족관절외과골후하부에 J shape 의피부절개후거골외측부위의골절을확인하였고, 그상방부위에비골홈 (peroneal groove) 으로부터탈구된비골건및완전파열된상비골건지대를관찰할수있어서피부절개를연장하여관찰하였다. 비골건은연속성이유지된채로파열된상비골건지대부분을통하여장비골건및단비골건이전방으로탈구되어있는급성손상양상을보였다 (Fig. 4). 수술은거골외측돌기에대해정복및 AO Headless compression screw (HCS; Synthes, Solothurn, Switzerland) 와 Kirschner wire 를이용한내고정술을시행하고, 비 골건을해부학적위치로정복후파열된상비골건지대를비흡수성봉합사로단순봉합하였다 (Fig. 5). 수술후 4 주간단하지부목으로고정하였고, 수술후 4 주부터부분체중부하를시작하여 6 주부터전체중부하를시행하였다. 수술 3 개월째추시결과골절의유합을얻을수있었고, 수술 8 개월째추시결과건측과비교하여족관절의운동범위제한은없었다. 비골건의탈구는관찰되지않았으며만족할만한임상학적결과를얻을수있었다. 고 찰 거골의외측돌기의골절은단순족관절염좌로오인될
224 Youn-Soo Hwang, et al. 수있고, 다른거골부의손상은동반되지않는경우가많다. 1) 손상기전으로는내번된발이심하게배굴되며외측돌기에압박력및전단력이작용할때발생하며, 드물게외회전및외번이원인이될수있고, 외측거종인대 (lateral talocalcaneal ligament) 의외측돌기부착점에서발생한견열골절이원인이될수도있다. 4-6) 거골외측돌기의골절양상에따라 Hawkins 5) 는 3종류로분류하였는데, 본증례의경우골절선이거비관절면에서거골하골절로연장되는경우로제1형에해당되었다. 여러저자들은골절편의크기가 1 cm 이상이거나 2 mm 이상의전위가있을때관혈적정복및내고정술이필요하다 5-7) 고하였다. Fig. 3. Preoperative magnetic resonance imaging showing increased signal of peroneus tendon (arrow). 비골건은단비골건과장비골건으로구분되며, 표재비골건지대와비골사이의구에의해생성된섬유골성터널을통과하여외과의후방과족근골을주행후다섯번째중족골거친면및첫번째중족골기저부에각각부착된다. 두개의비골지대에의해견고하게고정되어있고, 주로족부의회내운동, 족저굴곡및내번에대한균형을유지하여족관절의안정화에기여한다. 탈구기전으로는내번된족부에갑작스런족배굴곡이가해질때비골건과족저굴곡건의반사적수축에의해발생되거나, 비골과의외측부위에견열골절이동반되면서발생된다. 8) 드물게는선천적또는후천적상비골건지대의이완, 비골과후방구의해부학적이상이원인이되기도한다. 8,9) 본증례에서는상비골건지대가비골부착부위에서떨어진후장비골건및단비골건이전방으로탈구되어있는양상으로형태학적분류상 Oden s classification II형에해당되었다. 낙상으로인한복합손상으로정확한수상기전의확인이어려웠으나, 낙상당시족관절이내번된상태에서배굴된힘이가해졌다고생각된다. 골절과동반된비골건탈구의경우연부조직의전반적인부종과동통, 피하출혈로인해진단을더욱어렵게한다. 정복되지못한비골건탈구는족부내번에대한저항을힘들게하여지면이고르지않은곳을보행시불편함을일으키거나활액막염을유발하여만성적인족관절외측부위동통을일으킨다. 따라서거골외측돌기골절과동반된비골건탈구는수상당시발견이중요하며세심한관찰및이학적검사가필요하다. 이런손상이동반될경우족관절외과후방부위에부종및압통, 외번시통증이있는지를주의깊게관찰해야한다. 또한컴퓨터단층촬영검사와자기공명검사를통해골절양상및복합인대손상을파악하 Fig. 4. Intraoperative finding shows peroneus tendon reduction and dislocation.
Peroneus Tendon Dislocation Associated with Fracture of Lateral Process of Talus 225 Fig. 5. Postoperative anteroposterior and lateral radiograph. The fracture was reduced and stabilized using a Headless compression screw and Kirschner wire. 는데도움이된다고생각한다. 비골건의급성손상시수술적치료방법으로는비골건지대를직접봉합하거나골에고정기구를이용하여봉합하는술식이이용되고있다. 10) 저자들은거골외측돌기골절과동시에진단된비골건의급성탈구에대해외측돌기에대해서 Headless compression screw와 Kirschner wire 를이용한내고정술을시행하였고, 탈구된비골건의정복후파열된상비골건지대를비흡수성봉합사로단순봉합하였다. 거골외측돌기골절과급성외상성비골건탈구가동반된손상은매우드문경우이며국내에서는아직까지문헌상보고된증례가없다. 술전충분한이학적검사및영상검사, 술중주위손상확인을통해임상적으로좋은결과를거둘수있었기때문에이에대해보고하는바이다. References 1) von Knoch F, Reckord U, von Knoch M, Sommer C: Fracture of the lateral process of the talus in snowboarders. J Bone Joint Surg Br, 89: 772-777, 2007. 2) Arrowsmith SR, Fleming LL, Allman FL: Traumatic dislocations of the peroneal tendons. Am J Sports Med, 11: 142-146, 1983. 3) Rosenfeld P: Acute and chronic peroneal tendon dislocations. Foot Ankle Clin, 12: 643-657, 2007. 4) Funk JR, Srinivasan SC, Crandall JR: Snowboarder's talus fractures experimentally produced by eversion and dorsiflexion. Am J Sports Med, 31: 921-928, 2003. 5) Hawkins LG: Fracture of the lateral process of the talus. J Bone Joint Surg Am, 47: 1170-1175, 1965. 6) Boon AJ, Smith J, Zobitz ME, Amrami KM: Snowboarder's talus fracture. Mechanism of injury. Am J Sports Med, 29: 333-338, 2001. 7) Berkowitz MJ, Kim DH: Process and tubercle fractures of the hindfoot. J Am Acad Orthop Surg, 13: 492-502, 2005. 8) DuVries HL: Surgery of the foot. St. Louis, C. V. Mosby: 253-355, 1959. 9) Eckert WR, Davis EA Jr: Acute rupture of the peroneal retinaculum. J Bone Joint Surg Am, 58: 670-672, 1976. 10) Safran MR, O'Malley D Jr, Fu FH: Peroneal tendon subluxation in athletes: new exam technique, case reports, and review. Med Sci Sports Exerc, 31: S487-S492, 1999.
ISSN 1225-1682 (Print) ISSN 2287-9293 (Online) 대한골절학회지제 27 권, 제 3 호, 2014 년 7 월 J Korean Fract Soc 2014;27(3):222-226 http://dx.doi.org/10.12671/jkfs.2014.27.3.222 Case Report 거골외측돌기골절과동반된비골건탈구 - 증례보고 - 황연수 조성준 김광열 김형천 김동선 왈레스기념침례병원정형외과 거골의외측돌기골절과외상성비골건탈구가동반된손상은매우드문경우이고진단이어렵다. 이로인해조기진단이지연되어족관절통증및변형을초래할수있다. 저자들은골절에대한내고정술시행과함께비골건을해부학적위치로정복하고파열된상비골건지대를봉합한후임상적으로좋은결과를거둘수있었기에문헌고찰과함께이에대해보고하는바이다. 색인단어 : 거골, 비골건, 거골골절, 비골건탈구, 상비골건지대봉합 접수일 2013. 11. 1 수정일 2014. 3. 31 게재확정 2014. 3. 31 교신저자조성준부산시금정구금단로 200, 왈레스기념침례병원정형외과교실 Tel 051-580-1422, Fax 051-583-2568, E-mail alexander01@naver.com Copyright c 2014 The Korean Fracture Society. All rights reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 226