骨科英文书籍精读（383）｜距骨骨折的治疗
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Treatment
The general principles set out on page 920 should be observed.
UNDISPLACED FRACTURES
A split below-knee plaster is applied and, when the swelling has subsided, is replaced by a complete cast with the foot plantarflexed. Weightbearing is not permitted for the first 4 weeks; thereafter, the plaster is removed, the fracture position is checked by x-ray, a new cast is applied and weightbearing is gradually introduced. Further plaster changes or use of an adjustable splintage boot will allow the foot to be brought up, slowly, to plantigrade; physiotherapy is commenced. At 8–12 weeks the splintage is discarded and function is regained by normal use.
DISPLACED FRACTURES OF THE NECK
Even the slightest displacement makes it a type II fracture, which needs to be reduced. If the skin is tight, reduction becomes urgent because of the risk of skin necrosis. Reduction must be perfect: (1) in order to ensure that the subtalar joint is mechanically sound; 2) to lessen the chance – or at any rate lessen the effects – of avascular necrosis.
With type II fractures, closed manipulation under general anaesthesia can be tried first. Traction is applied with the ankle in plantarflexion; the foot is then steered into inversion or eversion to correct the displacement shown on the x-ray. The reduction is checked by x-ray; nothing short of 'anatomic’ is acceptable. A below-knee cast is applied (with the foot still in equinus) and this is retained, non-weightbearing, for 4 weeks. Cast changes after that will allow the foot to be gradually brought up to plantigrade; however, weightbearing is not permitted until there is evidence of union (8–12 weeks).
If closed reduction fails (which it often does), open reduction is essential; indeed, some would say that all type II fractures should be managed by open reduction and internal fixation without attempting closed treatment. Through an anteromedial incision the fracture is exposed and manipulated into position. Wider access can be obtained by pre-drilling and then osteotomizing the medial malleolus; after the talar fracture has been reduced, the malleolar fragment is fixed back in position with a screw. The position is checked by x-ray and the fracture is then fixed with two K-wires or a lag screw. Postoperatively a belowknee cast is applied; weightbearing is not permitted until there are signs of union (8–12 weeks).
Type III fracture–dislocations need urgent open reduction and internal fixation. The approach will depend on the fracture pattern and position of displaced fragments. Osteotomy of the medial malleolus might help; the malleolus is pre-drilled for screw fixation and osteotomized and retracted distally without injuring the deltoid ligament. This wide exposure is essential to permit removal of small fragments from the ankle joint and perfect reduction of the displaced talar body under direct vision; even then, it is difficult! The position is checked by x-ray and the fracture is then fixed securely with screws. If there is the slightest doubt about the condition of the skin, the wound is left open and delayed primary closure carried out 5 days later. Postoperatively the foot is splinted and elevated until the swelling subsides; a below-knee cast or splintage boot is then applied, following the same routine as for type II injuries.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
foot plantarflexed 脚掌跖屈
plantigrade /ˈplæntəˌɡreɪd/adj. 踯行的；踯行类的n. 跖行动物
commence /kəˈmens/v. 开始；着手
in order to ensure that the subtalar joint is mechanically sound;为了确保距下关节在机械上是健全的.
sound 合理的；无损的;健全的
inversion or eversion内翻或外翻
nothing short of 'anatomic’ is acceptable.除了“解剖复位”外，什么都不能接受。
不符合 "解剖复位 "的情况是不能接受的
short of缺乏；不足；除…以外
Wider access can be obtained by pre-drilling and then osteotomizing the medial malleolus;内踝预钻孔后截骨可获得较宽的通路;
Osteotomy /ˌɒstɪˈɑːtəmi/
n. 截骨术，骨切开术
Osteotomize截骨 v.
deltoid ligament. 三角韧带
DeepL翻译（仅供参考，建议自己翻译）：
治疗方法
应遵守第920页规定的一般原则。
未移位的骨折
使用膝下分块石膏，当肿胀消退后，用完整的石膏代替，脚掌跖屈。头4周不允许负重；此后，去除石膏，通过X线检查骨折位置，打上新的石膏，逐渐开始负重。进一步更换石膏或使用可调节的夹板靴，可以使足部缓慢上升，达到跖步状态；开始进行物理治疗。在8-12周时，夹板被丢弃，功能通过正常使用得到恢复。
颈部移位的骨折
即使是最轻微的移位，也属于II型骨折，需要进行缩减。如果皮肤很紧，由于有皮肤坏死的危险，缩小就变得很紧急。减轻必须是完美的。(1)为了确保距下关节在机械上是健全的；(2)为了减少血管坏死的机会--或至少是减少影响--。
对于II型骨折，可以首先尝试在全麻下进行封闭式操作。踝关节处于跖屈状态时进行牵引；然后引导足部内翻或外翻，以纠正X线片上显示的位移。通过X线检查减少的情况；不符合 "解剖学 "的情况是不能接受的。使用膝下石膏（脚仍处于等长状态），并保持非负重状态，持续4周。此后，石膏的更换将使足部逐渐恢复到跖骨状态；然而，在有证据表明结合之前（8-12周）不允许负重。
如果闭合复位失败（经常如此），则必须进行开放复位；事实上，有人会说，所有的II型骨折都应该通过开放复位和内固定来处理，而不必尝试闭合治疗。通过前内侧切口，骨折被暴露出来并被操纵到合适的位置。通过预先钻孔，然后对内侧大腿骨进行截骨，可以获得更宽的通道；在距骨骨折缩小后，用螺钉将大腿骨碎片固定在位置上。通过X线检查位置，然后用两根K线或一个滞后螺钉固定骨折。术后使用膝下石膏，在出现结合迹象之前（8-12周）不允许负重。
III型骨折-脱位需要紧急开放复位和内固定。方法取决于骨折模式和移位的碎片的位置。内侧大腿骨的截骨可能会有帮助；大腿骨要预先钻孔，以便用螺钉固定，截骨后向远端牵拉，不伤及三角韧带。这种广泛的暴露是必不可少的，以便能够从踝关节中取出小碎片，并在直视下完美地缩小移位的距骨体；即使这样，也是很困难的 通过X射线检查位置，然后用螺钉牢固地固定骨折。如果对皮肤状况有丝毫的怀疑，伤口将保持开放，并在5天后进行延迟的初级封闭。术后，脚被夹板固定并抬高，直到肿胀消退；然后使用膝下石膏或复古靴，与II型损伤的常规治疗相同。