骨科英文书籍精读（37）｜骨折晚期并发症之畸形愈合
MALUNION
When the fragments join in an unsatisfactory position (unacceptable angulation, rotation or shortening) the fracture is said to be malunited. Causes are failure to reduce a fracture adequately, failure to hold reduction while healing proceeds, or gradual collapse of comminuted or osteoporotic bone.
Clinical features
The deformity is usually obvious, but sometimes the true extent of malunion is apparent only on x-ray. Rotational deformity of the femur, tibia, humerus or forearm may be missed unless the limb is compared
with its opposite fellow. Rotational deformity of a metacarpal fracture is detected by asking the patient to flatten the fingers onto the palm and seeing whether the normal regular fan-shaped appearance is reproduced (Chapter 26).
X-rays are essential to check the position of the fracture while it is uniting. This is particularly important during the first 3 weeks, when the situation may change without warning. At this stage it is sometimes difficult to decide what constitutes ‘malunion’; acceptable norms differ from one site to another and these are discussed under the individual fractures.
Treatment
Incipient malunion may call for treatment even before the fracture has fully united; the decision on the need for re-manipulation or correction may be extremely difficult. A few guidelines are offered:
1. In adults, fractures should be reduced as near to the anatomical position as possible. Angulation of more than 10–15 degrees in a long bone or a noticeable rotational deformity may need correction by remanipulation, or by osteotomy and fixation.
2. In children, angular deformities near the bone ends (and especially if the deformity is in the same plane as that of movement of the nearby joint) will usually remodel with time; rotational deformities will not.
3. In the lower limb, shortening of more than 2.0 cm is seldom acceptable to the patient and a limb length equalizing procedure may be indicated.
4. The patient’s expectations (often prompted by cosmesis) may be quite different from the surgeon’s; they are not to be ignored.
5. Early discussion with the patient, and a guided view of the x-rays, will help in deciding the need for treatment and may prevent later misunderstanding.
6. Very little is known of the long-term effects of small angular deformities on joint function. However, it seems likely that malalignment of more than 15 degrees in any plane may cause asymmetrical loading of the joint above or below and the late development of secondary osteoarthritis; this applies particularly to the large weightbearing joints.
---from 《Apley’s System of Orthopaedics and Fractures》P718-720
重点词汇整理：
MALUNION/mæ'lju:njən/n. 畸形愈合
osteoporotic 骨质疏松的
osteoporosis /ˌɑːstioʊpəˈroʊsɪs/
n. [外科] 骨质疏松症
Rotational deformity 旋转畸形
metacarpal fracture 掌骨骨折
/ˌmetəˈkɑːrpl/n. 掌骨adj. 掌部的
Incipient /ɪnˈsɪpiənt/adj. 初期的；初始的；起初的；发端的
anatomical position解剖位置
reduced to the anatomical position 解剖复位
remanipulation 重新操作
osteotomy /,ɑstɪ'ɑtəmi/n. 截骨术，骨切开术
remodel /ˌriːˈmɑːdl/vt. 塑形；改造；改变；改型
cosmesis美容术
asymmetrical/,esɪ'mɛtrɪkl/adj. 非对称的；不匀称的，不对等的
symmetrical /sɪˈmetrɪkl/adj. 匀称的，对称的
百度翻译：
畸形愈合
当碎片在不满意的位置（不可接受的角度，旋转或缩短）连接时，骨折被称为不愈合。其原因是未能充分减少骨折，未能在愈合过程中保持复位，或骨质疏松性骨逐渐塌陷。
临床特征
畸形通常很明显，但有时畸形愈合的真正程度只有在x光片上才明显。股骨、胫骨、肱骨或前臂的旋转畸形可能会丢失，除非对肢体进行比较
和它的对手。掌骨骨折的旋转畸形是通过让患者将手指平放在手掌上，观察是否再现了正常的规则扇形外观来检测的（第26章）。
X射线是在裂缝接合时检查裂缝位置的必要手段。这在头3周尤为重要，因为在这3周，局势可能会毫无征兆地发生变化。在这个阶段，有时很难确定什么是“畸形愈合”；可接受的标准在不同的部位有所不同，这些在个别骨折下讨论。
治疗
即使在骨折完全愈合之前，早期的畸形愈合也可能需要治疗；决定是否需要再次手术或矫正可能非常困难。提供了一些指导原则：
一。在成人中，骨折应尽量减少到接近解剖位置。长骨的角度超过10-15度或明显的旋转畸形可能需要通过再操作或截骨术和固定进行矫正。
2。在儿童中，骨末端附近的角畸形（特别是如果畸形与附近关节的运动在同一平面上）通常会随着时间的推移而重塑，而旋转畸形则不会。
三。在下肢，短缩超过2.0cm对患者来说是不可接受的，可能需要进行肢体长度均衡的手术。
四。病人的期望（通常是由美容引起的）可能与外科医生的期望大不相同；它们不可忽视。
5个。尽早与患者讨论，并在x光片引导下观察，将有助于确定治疗的必要性，并可能防止以后的误解。
6。很少有人知道小角度变形对关节功能的长期影响。然而，任何平面上超过15度的不对齐都可能导致关节上下不对称负荷和继发性骨关节炎的晚期发展；这尤其适用于大型承重关节。