骨科英文书籍精读（246）｜股骨转子间骨折的治疗
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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Treatment
Intertrochanteric fractures are almost always treated by early internal fixation – not because they fail to unite with conservative treatment (they unite quite readily), but (a) to obtain the best possible position and (b) to get the patient up and walking as soon as possible and thereby reduce the complications associated with prolonged recumbency. Non-operative treatment may be appropriate for a small group who are too ill to undergo anaesthesia; traction in bed until there is sufficient reduction of pain to allow mobilization can yield reasonable results but much depends on the quality of nursing care and physical therapy (Kaplan, Miyamoto et al. 2008).
Fracture reduction at surgery is performed on a fracture table that provides slight traction and internal rotation; the position is checked by x-ray and the fracture is fixed with an angled device – preferably a sliding screw in conjunction with a plate or intramedullary nail. Positioning the screw is important if it is to be prevented from cutting out of the osteoporotic bone. It should pass up the femoral neck to end within the centre of the femoral head, with the tip resting about 5 mm from the subchondral bone plate. A ‘tip-apex’ distance is described to identify a ‘sweet-spot’ for positioning this sliding screw: if within 25 mm, there is a lower risk of the screw cutting out of the femoral head (Figure 29.13). The side plate should be long enough to accommodate at least 4 screws below the fracture line. A small lesser trochanteric fragment may be ‘caught’ with additional screws.
With the less common ‘reversed oblique’ fracture (where the fracture line runs downwards obliquely from medial to lateral cortex) there is a tendency for the distal fragment to shift medially under the proximal fragment as the hip screw slides in the barrel; often the screws from the slide plate lose their purchase from the femoral shaft. In these cases a 95 degree screw-plate device or an intramedullary device with a hip screw gives more stable fixation.
If closed reduction fails to achieve a satisfactory position, open reduction and manipulation of the fragments will be necessary. A large posteromedial fragment (often including the lesser trochanter) may need additional fixation. The addition of bone grafts may hasten union of the medial cortex. On the occasion that anatomical reduction proves impossible, a valgus osteotomy may be needed to allow the proximal fragment to abut securely against the femoral shaft (Dimon and Hughston 1967) (Figure 29.14 c,d).
Postoperatively, exercises are started on the day after operation and the patient allowed up and partial weightbearing as soon as possible.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
recumbency /ri'kʌmbənsi/n. 斜靠着；躺着；休息
undergo anaesthesia接受麻醉
/ˌʌndərˈɡoʊ/vt. 经历，经受；忍受
sweet-spot甜蜜点；最有效点；最佳击球位置
sliding screw:滑动螺钉
accommodate /əˈkɑːmədeɪt/vt. 容纳；使适应；供应；调解vi. 适应；调解
less common不常见的
manipulation /məˌnɪpjuˈleɪʃn/n. 操纵；操作；处理；篡改
hasten /ˈheɪsn/vt. 加速；使赶紧；催促vi. 赶快；急忙
anatomical reduction 解剖复位
abut /əˈbʌt/vt. 邻接；毗邻；紧靠vi. 邻接；毗邻；紧靠
valgus /vælɡəs/n. 外翻足的人；外翻足adj. 外翻的
varus /'vεərəs/n. 内翻足；弓形腿
百度翻译：
治疗
股骨粗隆间骨折几乎都是通过早期内固定治疗的，而不是因为保守治疗不能愈合（很容易愈合），但是（a）获得尽可能好的姿势和（b）让患者尽快起来行走，从而减少与长期卧姿相关的并发症。非手术治疗可能适用于病得太重而无法接受麻醉的一小群人；在床上牵引直到疼痛得到充分缓解，以便能够进行活动，可以产生合理的结果，但在很大程度上取决于护理和物理治疗的质量（Kaplan，Miyamoto等人，2008）。
手术中的骨折复位是在提供轻微牵引和内旋转的骨折台上进行的；通过x光检查骨折的位置，并用有角度的装置固定骨折-最好是滑动螺钉和钢板或髓内钉。如果要防止螺钉从骨质疏松的骨头中切出，那么螺钉的定位是很重要的。它应该通过股骨颈到达股骨头中心，尖端离软骨下骨板大约5毫米。描述了“尖端-顶点”距离，以确定滑动螺钉定位的“最佳点”：如果在25 mm范围内，螺钉从股骨头切出的风险较低（图29.13）。侧板的长度应足以容纳骨折线以下至少4个螺钉。小转子碎片可能会被额外的螺钉“夹住”。
对于不太常见的“反斜”骨折（骨折线从内侧到外侧皮质倾斜向下），当髋螺钉在套筒内滑动时，远侧骨折块有向近侧骨折块下方内侧移动的趋势；通常滑板上的螺钉从股骨干处丢失。在这些情况下，95度螺钉钢板装置或带髋螺钉的髓内装置提供更稳定的固定。
如果闭合复位未能达到满意的位置，则需要切开复位和操纵碎片。大的后内侧骨折（通常包括小转子）可能需要额外的固定。骨移植物的加入可能加速内侧皮质的愈合。在解剖复位证明不可能的情况下，可能需要进行外翻截骨术，以使近端碎片牢固地紧靠股骨干（Dimon和Hughston，1967年）（图29.14 c，d）。
术后于术后第二天开始运动，患者应尽快起身负重。