骨科英文书籍精读（371）｜踝部骨折(2)
我们正在精读国外经典骨科书籍《Apley’s System of Orthopaedics and Fractures》，想要对于骨科英文形成系统认识，为以后无障碍阅读英文文献打下基础，请持续关注。
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Clinical features
Ankle fractures are seen in skiers, footballers and climbers; an older group includes women with postmenopausal osteoporosis.
A history of a severe twisting injury, followed by intense pain and inability to stand on the leg suggests something more serious than a simple sprain. The ankle is swollen and deformity may be obvious. The site of tenderness is important; if both the medial and lateral sides are tender, a double injury (bony or ligamentous) must be suspected.
X-ray
At least three views are needed: anteroposterior, lateral and a 30-degree oblique 'mortise’ view. The level of the fibular fracture is often best seen in the lateral view; diastasis may not be appreciated without the mortise view. Further x-rays may be needed to exclude a proximal fibular fracture.
From a careful study of the x-rays it should be possible to reconstruct the mechanism of injury. The four most common patterns are shown in Figure 31.5.
Treatment
Swelling is usually rapid and severe, particularly in the higher energy injuries. If the injury is not dealt with within a few hours, definitive treatment may have to be deferred for several days while the leg is elevated so that the swelling can subside; this can be hastened by using a foot pump (which also reduces the risk of deep-vein thrombosis).
Fractures are visible on x-ray; ligaments are not.
Always look for clues to the invisible ligament injury – widening of the tibiofibular space, asymmetry of the talotibial space, widening of the medial joint space, or tilting of the talus – before deciding on a course of action.
Like other intra-articular injuries, ankle fractures must be accurately reduced and held if later mechanical dysfunction is to be prevented. Persistent displacement of the talus, or a step in the articular surface, leads to increased stress and predisposes to secondary osteoarthritis.
In assessing the accuracy of reduction, four objectives must be met: (1) the fibula must be restored to its full length; (2) the talus must sit squarely in the mortise, with the talar and tibial articular surfaces parallel; (3) the medial joint space must be restored to its normal width, i.e. the same width as the tibio-talar space (about 4 mm); (4) oblique x-rays must show that there is no tibiofibular diastasis.
Ankle fractures are often unstable. Whatever the method of reduction and fixation, the position must be checked by x-ray during the period of healing.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
postmenopausal osteoporosis绝经后骨质疏松症
suspect /səˈspekt/v. 怀疑；猜想n. 嫌疑犯adj. 靠不住的；可疑的
diastasis may not be appreciated without the mortise view. 如果没有踝穴视图，可能无法鉴别分离。
appreciate /əˈpriːʃieɪt/vt. 欣赏；感激；领会；鉴别vi. 增值；涨价
definitive treatment根治方案
/dɪˈfɪnətɪv/adj. 最后的；最佳的；最权威的
deep-vein thrombosis深静脉血栓形成
asymmetry of the talotibial space距胫骨间隙不对称
asymmetry /ˌeɪˈsɪmətri/n. 不对称
predisposes to secondary osteoarthritis易患继发性骨关节炎
predispose/ˌpriːdɪˈspoʊz/vt. 预先处置；使…偏向于；容易... ...
squarely /ˈskwerli/adv. 直角地；诚实地；正好；干脆地；正当地
有道翻译（仅供参考，建议自己翻译）：
临床特征
踝关节骨折见于滑雪者、足球运动员和攀岩者；老年组包括绝经后骨质疏松症妇女。
严重的扭伤史，伴随着剧烈的疼痛和无法站在腿上表明比单纯的扭伤更严重。脚踝肿胀，畸形明显。温柔的部位很重要；如果内侧和外侧都有压痛，必须怀疑是双重损伤（骨性或韧带性）。
X射线
至少需要三个视图：前后视图、侧视图和30度倾斜“榫眼”视图。腓骨骨折的水平通常最好在侧位观察；如果没有榫眼视图，可能无法欣赏分离。可能需要进一步的x光片来排除近端腓骨骨折。
通过仔细研究x光片，可以重建损伤机制。四种最常见的模式如图31.5所示。
治疗
肿胀通常是迅速和严重的，尤其是在高能量损伤。如果伤在几个小时内没有得到处理，那么当腿抬高时，最终的治疗可能不得不推迟几天，以便肿胀可以消退；这可以通过使用足底泵来加速（这也降低了深静脉血栓形成的风险）。
x线可见骨折；韧带不是。
在决定行动方案之前，一定要寻找隐形韧带损伤的线索——胫腓骨间隙增宽、距胫间隙不对称、内侧关节间隙增宽或距骨倾斜。
与其他关节内损伤一样，踝关节骨折必须准确复位和固定，才能防止后期的机械功能障碍。距骨持续移位，或关节面有台阶，
导致压力增加，易患继发性骨关节炎。
在评估复位的准确性时，必须达到四个目标：（1）腓骨必须完全恢复(2） 距骨必须垂直于榫眼，距骨和胫骨关节面平行(3） 内侧关节间隙必须恢复到正常宽度，即与胫距间隙相同的宽度（约4mm）(4） 斜位x线必须显示没有胫腓骨分离。
踝关节骨折通常是不稳定的。无论采用哪种复位固定方法，在愈合过程中都必须进行x线检查。