骨科英文书籍精读（121）｜儿童前臂远端骨折（2）
Treatment
Physeal fractures are reduced, under anaesthesia, by pressure on the distal fragment. The arm is immobilized in a full-length cast with the wrist slightly flexed and ulnar deviated, and the elbow at 90 degrees. The cast is retained for 4 weeks. These fractures very rarely interfere with growth. Even if reduction is not absolutely perfect, further growth and modelling will obliterate any deformity. Patients seen more than 2
weeks after injury are best left untreated.
Buckle fractures require no more than 2 weeks in plaster, followed by another 2 weeks of restricted activity.
Greenstick fractures are usually easy to reduce – but apt to re-displace in the cast! Some degree of angulation can be accepted: in children under 10, up to 30 degrees and in children over 10, up 15 degrees. If the deformity is greater, the fracture is reduced by thumb pressure and the arm is immobilized with three-point fixation in a full-length cast with the wrist and forearm in neutral and the elbow flexed 90 degrees. The cast is changed and the fracture re-x-rayed at 2 weeks; if it has re-displaced a further manipulation can be carried out. The cast is finally discarded after 6 weeks.
Complete fractures can be embarrassingly difficult to reduce – especially if the ulna is intact. The fracture is manipulated in much the same way as a Colles’ fracture; the reduction is checked by x-ray and a fulllength cast is applied with the wrist neutral and the forearm supinated. After 2 weeks, a check x-ray is obtained; the cast is kept on for 6 weeks. If the fracture slips, especially if the ulna is intact, it should be stabilized with a percutaneous K-wire.
Complications
EARLY
Forearm swelling and threatened compartment syndrome
This dire combination can be prevented by avoiding over-forceful or repeated manipulations, splitting the plaster, elevating the arm for the first 24–48 hours and encouraging exercises.
LATE
Malunion
This late sequel is uncommon in children under 10 years of age. Deformity of as much as 30 degrees will straighten out with further growth and remodelling over the next 5 years. This should be
carefully explained to the worried parents.
Radio-ulnar discrepancy
Premature fusion of the radial epiphysis may result in bone length disparity and subluxation of the radio-ulnar joint. If this is troublesome, the radius can be lengthened and, if the child is near to skeletal maturity, the ulnar physis fused surgically.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
deviate /ˈdiːvieɪt/vi. 脱离；越轨vt. 使偏离
ulnar deviated尺偏
obliterate/əˈblɪtəreɪt/vt. 消灭；涂去；冲刷；忘掉
Patients seen more than 2
weeks after injury are best left untreated. 伤后2周以上的病人最好不治疗。
restricted activity.限制活动。
carried out.实施贯彻（carry out 的过去式和过去分词）
sequel /ˈsiːkwəl/. 续集；结局；继续；后果
result in 导致，结果是
troublesome, /ˈtrʌblsəm/adj. 麻烦的；讨厌的；使人苦恼的
lengthen /ˈleŋθən/vt. 使延长；加长vi. 延长；变长
百度翻译：
治疗
在麻醉下，通过对远端骨块施加压力，可以减少骺端骨折。手臂固定在全长石膏上，手腕轻微弯曲，尺骨偏斜，肘部呈90度。cast保留4周。这些骨折很少与生长相干涉。即使复位不是绝对完美的，进一步的生长和造型将消除任何畸形。受伤后超过2周的病人最好不要治疗。
扣状骨折需要不超过2周的石膏，然后再限制活动2周。
绿枝骨折通常很容易复位，但在石膏中容易再移位！一定程度的角度是可以接受的：10岁以下的儿童，30度以下，10岁以上的儿童15度以上。如果变形量较大，则用拇指按压骨折，用三点固定法固定手臂，手腕和前臂保持中立，肘部弯曲90度。术后2周内，髋关节发生改变，骨折复位，可进行进一步的手法治疗。六个星期后，演员最后被淘汰。
完全性骨折很难复位，尤其是尺骨完整的情况下。骨折的处理方法与Colles骨折的处理方法非常相似，复位情况通过x射线检查，并在腕关节中立、前臂旋后的情况下进行全长石膏固定。2周后，检查x光片，石膏保持6周。如果骨折滑脱，尤其是尺骨完整的话，应该用经皮K形钢丝固定。
早期并发症
前臂肿胀和威胁性筋膜室综合征
这种可怕的组合可以通过避免强力或反复的操作，劈开推动者，在第一个24-48小时抬高手臂和鼓励性的锻炼来防止。
晚期并发症
畸形愈合
这种晚期的后遗症在10岁以下的儿童中并不常见。高达30度的畸形将在未来5年内随着进一步的生长和建模而矫正。这一点应该向忧心忡忡的父母作出解释。
尺桡骨差异
桡骨骨骺过早融合可导致骨长度不一致和桡尺关节半脱位。如果这是麻烦的，可以延长桡骨，如果孩子接近于腕骨成熟期，则可以手术融合尺骨。