骨科英文书籍精读（117）｜桡骨远端骨折（2）
Treatment
UNDISPLACED FRACTURES
If the fracture is undisplaced (or only very slightly displaced), a dorsal splint is applied for a day or two until the swelling has resolved, then the cast is completed. An x-ray is taken at 10–14 days to ensure that the fracture has not slipped; if it has, surgery may be required; if not, the cast can usually be removed after four weeks to allow mobilization.
DISPLACED FRACTURES
Displaced fractures must be reduced under anaesthesia (haematoma block, Bier’s block or axillary block). The hand is grasped and traction is applied in the length of the bone (sometimes with extension of the wrist to disimpact the fragments); the distal fragment is then pushed into place by pressing on the dorsum while manipulating the wrist into flexion, ulnar deviation and pronation. The position is then checked by x-ray. If it is satisfactory, a dorsal plaster slab is applied, extending from just below the elbow to the metacarpal necks and two-thirds of the way round the circumference of the wrist. It is held in position by a crepe bandage. Extreme positions of flexion and ulnar deviation must be avoided; 20 degrees in each direction is adequate.
The arm is kept elevated for the next day or two; shoulder and finger exercises are started as soon as possible. If the fingers become swollen, cyanosed or painful, there should be no hesitation in splitting the bandage.
At 7–10 days fresh x-rays are taken; re-displacement is not uncommon and should be treated, if the patient’s functional demands are high, by re-manipulation and internal fixation. However, in some elderly patients with low functional demands, modest degrees of displacement should be accepted because (a) outcome in these patients is not so dependent upon anatomical perfection, and (b) fixation of the fragile bone can be very difficult.
The fracture unites in about 6 weeks and, even in the absence of radiological proof of union, the slab may safely be discarded and exercises begun.
IMPACTED OR COMMINUTED COLLES’ FRACTURES
With substantial impaction or comminution in osteoporotic bone, manipulation and plaster immobilization alone may be insufficient. The fracture can sometimes be reduced and held with percutaneous wires, but if impaction is severe even this may not be enough to maintain length; in that case, an external fixator is used to neutralize the compressive force of the 25 tendons crossing the wrist, and bone graft or bone substitute is placed into the gap. The fixator is attached to the distal radius and the second metacarpal shaft. It should be used only as a neutralizing device; too much distraction will lead to stiffness. The fixation is removed after 5–6 weeks and exercises begun.
Plate fixation is increasingly being used for some Colles’ fractures. The so-called ‘volar locking plate’ is applied to the front of the radius through the bed of flexor carpi radialis. The screws are fixed to the plate itself and are passed into the relatively stronger subchondral bone distally. These devices, which are flourishing in the orthopaedic marketplace, allow stable fixation and thus early mobilization of the forearm. Other devices, such as a locked intramedullary nail or crossed K-wires, are also suitable for the distal radius.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
ulnar deviation and pronation.尺偏和内翻。
pronation. /prəu'neiʃən/n. 手掌向下；（手足的）内转
deviation /ˌdiːviˈeɪʃn/n. 偏差；误差；背离
circumference /sərˈkʌmfərəns/n. 圆周；周长；胸围
crepe bandage弹力绷带
If the fingers become swollen, cyanosed or painful, there should be no hesitation in splitting the bandage.如果手指肿胀，发紫或疼痛，应该毫不犹豫地撕裂绷带。
split/splɪt/n. 劈开；裂缝vt. 分离；使分离；劈开
cyanosed /'saiənəust/adj. 发绀的；绀色的
The fracture unites in about 6 weeks and, even in the absence of radiological proof of union, the slab may safely be discarded and exercises begun.骨折在大约6周内愈合，即使在没有放射学证明愈合的情况下，也可以安全地丢弃骨板并开始练习。
osteoporotic骨质疏松的
neutralize/ˈnuːtrəlaɪz/vt. 抵销；使…中和；使…无效；使…中立vi. 中和；中立化；变无效
substitute/ˈsʌbstɪtuːt/n. 代用品；代替者vi. 替代
substantial /səbˈstænʃl/n. 本质；重要材料adj. 大量的；实质的；内容充实的
flexor carpi radialis] 桡侧腕屈肌
subchondral 软骨下的
The screws are fixed to the plate itself and are passed into the relatively stronger subchondral bone distally.螺钉固定在钢板上，并从远端进入相对较强的软骨下骨。
百度翻译：
治疗
不移位骨折
如果骨折没有移位（或只是非常轻微的移位），用背夹板固定一两天直到肿胀消除，然后就完成了石膏的铸造。在10-14天进行x光检查，以确保骨折没有滑脱；如果滑脱，可能需要手术；如果没有，通常可以在四周后取出石膏，以便活动。
移位骨折
移位骨折必须在麻醉下复位（血肿阻滞、比尔阻滞或腋窝阻滞）。手被抓住，并在骨头的长度上施加牵引力（有时会伸展手腕以消除碎片的冲击）；然后通过按压背部将远端碎片推到适当位置，同时操纵手腕进行屈曲、尺侧偏和旋前。然后用x射线检查位置。如果满意的话，可以使用背部石膏板，从肘部正下方延伸到掌骨颈部，并在腕部周围三分之二的范围内。它由绉布绷带固定。必须避免屈曲和尺骨偏斜的极端位置；每个方向20度就足够了。
手臂在接下来的一两天里保持抬高；肩关节和手指的运动要尽快开始。如果手指肿胀、发绀或疼痛，应毫不犹豫地撕开绷带。
在第7-10天进行新的x光检查；再移位并不少见，如果患者的功能要求很高，则应通过重新操作和内固定进行治疗。然而，在一些功能需求较低的老年患者中，应接受适度的移位，因为（a）这些患者不太依赖于解剖结构的完善，（b）脆弱骨的固定非常困难。
骨折在大约6周内愈合，即使没有愈合的放射学证据，钢板也可以安全地丢弃并开始训练。
撞击或粉碎性COLLES骨折
骨质疏松性骨实质性嵌顿或粉碎，单纯的手法和石膏固定可能是不够的。骨折可以减少几倍并用经皮钢丝固定，但如果嵌塞严重，甚至可能不足以维持长度；在这种情况下，使用外固定器中和穿过手腕的25根肌腱的压力，并将植骨或骨替代物放入间隙中。固定器固定在桡骨和第二掌骨轴上。它只能作为一个中和装置使用；太多的注意力分散会导致僵硬。固定在5-6周后移除，并开始运动。
钢板内固定越来越多地用于一些Colles骨折。所谓“掌侧锁定钢板”是通过桡侧腕屈肌床应用于桡骨前部。螺钉固定在钢板上，并通过远端相对较坚固的软骨下骨。这些器械在骨科市场上非常流行，可以稳定地固定，从而使前臂早期活动。其他器械，如带锁髓内钉或交叉K形钢丝，也适用于桡骨远端。