骨科英文书籍精读（377）｜儿童踝关节骨折
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ANKLE FRACTURES IN CHILDREN
Physeal injuries are quite common in children and almost a third of these occur around the ankle.
Mechanism of injury
The foot is fixed to the ground or trapped in a crevice and the leg twists to one or the other side. The tibial (or fibular) physis is wrenched apart, usually resulting in a Salter–Harris type 1 or 2 fracture. With severe external rotation or abduction the fibula may also fracture more proximally. The tibial metaphyseal spike may come off posteriorly, laterally or posteromedially; its position is determined by the mechanism of injury and suggests the method of reduction. With adduction injuries the tip of the fibula may be avulsed.
Type 3 and 4 fractures are uncommon. They are due to a supination–adduction force. The epiphysis is split vertically and one piece of the epiphysis (usually the medial part) may be displaced.
Two unusual injuries of the growing ankle are the Tillaux fracture and the notorious triplane fracture. The Tillaux fracture is an avulsion of a fragment of tibia by the anterior tibiofibular ligament; in the child or adolescent this fragment is the lateral part of the epiphysis and the injury is therefore a Salter–Harris type 3 fracture.
The triplane fracture occurs on the medial side of the tibia and is a combination of Salter–Harris types 2 and 3 injuries. Fracture lines appear in the coronal, sagittal and transverse planes. Injury to the physis may result in either asymmetrical growth or arrested growth.
Clinical features
Following a sprain the ankle is painful, swollen, bruised and acutely tender. There may be an obvious deformity, but sometimes the injury looks deceptively mild.
Imaging
Undisplaced physeal fractures – especially those in the distal fibula – are easily missed. Even a hint of physeal widening should be regarded with great suspicion and the child x-rayed again after 1 week. In an infant the state of the physis can sometimes only be guessed at, but a few weeks after injury there may be extensive periosteal new bone formation.
In triplane fractures the tibial epiphysis may be split in one plane and the metaphysis in another, thus making it difficult to see both fractures in the same x-ray. CT scans are particularly helpful in these and other type 3 injuries.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
Physeal生长的;骺板
Physeal injuries骺板损伤
crevice/ˈkrevɪs/n. 裂缝；裂隙
wrench /rentʃ/n. 扳手，扳钳；扭伤；痛苦；歪曲；猛扭vt. 扭伤；
metaphyseal干骺端的
adduction内收
abduction外展
supination–adduction 旋后内收
coronal, sagittal and transverse planes冠状面，矢状面和横切面
asymmetrical growth or arrested growth.不对称生长或生长停滞
asymmetrical /,esɪ'metrɪkl/adj. 非对称的；不匀称的，不对等的
deceptively /dɪˈseptɪvli/adv. 看似；
hint /hɪnt/n. 暗示；线索vt. 暗示；示意
epiphysis /i'pifisis/n. 骺；脑上体；松果体
有道翻译（仅供参考，建议自己翻译）：
儿童踝关节骨折
Physeal损伤在儿童中很常见，其中近三分之一发生在脚踝周围。
损伤机制
脚固定在地上或陷在缝隙中，腿向一侧或另一侧扭曲。胫骨（或腓骨）被扭开，通常导致Salter-Harris 1型或2型骨折。严重的外旋或外展也可能导致腓骨近端骨折。胫骨干骺突可从后、侧或后内侧脱落；其位置由损伤机制决定，并建议复位方法。内收伤可导致腓骨尖撕脱。
3型和4型骨折并不常见。他们是由于旋后-内收力。骨骺垂直分裂，一块骨骺（通常是内侧部分）可能移位。
两个不寻常的受伤的增长踝关节是蒂劳克斯骨折和臭名昭著的三平面骨折。蒂劳克斯骨折是胫骨前胫腓韧带撕裂伤；在儿童或青少年中，该骨折块是骨骺的外侧部分，因此损伤为Salter-Harris 3型骨折。
三平面骨折发生在胫骨内侧，是Salter-Harris 2型和3型损伤的组合。骨折线出现在冠状面、矢状面和横切面。身体损伤可能导致不对称生长或生长停滞。
临床特征
扭伤后脚踝疼痛，肿胀，瘀伤和剧烈疼痛。可能有明显的畸形，但有时损伤看起来似乎很轻微。
成像
未移位的physeal骨折——尤其是腓骨远端的骨折——很容易被遗漏。即使是肺动脉瘤扩大的迹象也应引起高度怀疑，孩子在1周后再次接受x光检查。婴儿的身体状况有时只能猜测，但在受伤后几周，可能会有广泛的骨膜新骨形成。
在三平面骨折中，胫骨骨骺可能在一个平面上分裂，干骺端在另一个平面上分裂，因此很难在同一张x光片上同时看到两处骨折。CT扫描对这些和其他3型损伤尤其有用。