骨科英文书籍精读（179）｜手外伤（18）
AMPUTATION
Indications
A finger is amputated only if it remains painful or unhealed, or if it is a nuisance (i.e. the patient cannot bend it, straighten it or feel with it), and then only if repair is impossible or uneconomic.
Technique
In the finger-tip, the aim is a mobile digit covered by healthy skin with normal sensation. This can be achieved by local advancement flaps or neurovascular island flaps, or by bone shortening (‘terminalization’). A cross-finger flap is fairly straight forward and provides good skin cover, but sensation is limited and a flexion contracture can develop in the donor finger. The final choice depends on the patient’s requirements and the surgeon’s skill.
In the thumb every millimetre is worth preserving; even a stiff or deformed thumb is worth keeping.
The middle and ring fingers should not be amputated through the knuckle joint because cosmetically this is unsatisfactory and small objects will fall through the gap (‘incontinence of grip’). If the proximal phalanx can be left, the appearance is still abnormal but function is better. The extensor tendon must never be sutured to the flexor tendon; this will act as a tether on the common belly of flexor digitorum profundus and prevent the other digits from flexing fully (the ‘Quadriga effect’). If the middle phalanx is amputated distal to the flexor digitorum superficialis insertion, the profundus tendon continues to pull, but now through the lumbrical, making the proximal interphalangeal joint paradoxically extend rather than flex. This irritating anomaly is avoided by suturing the superficialis stump to the flexor sheath or by dividing the lumbrical.
For more proximal injuries, the entire finger with most of its metacarpal may be amputated; the hand is weakened but the appearance is usually satisfactory. If the middle ray is amputated through the metacarpal, the index finger may ‘scissor’ across it in flexion; this can be overcome by dividing the adjacent index metacarpal and transposing it to the stump of the middle metacarpal.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
nuisance /ˈnuːsns/n. 讨厌的人；损害；麻烦事；讨厌的东西
In the thumb every millimetre is worth preserving; even a stiff or deformed thumb is worth keeping.在拇指中，每一毫米都值得保存;即使是僵硬或变形的拇指也值得保留。
knuckle /ˈnʌkl/n. 关节；指关节；指节；膝关节；肘vi. 开始认真工作vt. 用指关节敲打
cosmetically/kɔz'metikli/adv. 从美容方面，通过化妆
small objects小物体
lumbrical, /'lʌmbrikəl/n. 蚓状肌adj. 蚓状肌的
paradoxically/ˌpærəˈdɑːksɪkli/adv. 自相矛盾地；似是而非地；反常地
irritating /ˈɪrɪteɪtɪŋ/adj. 刺激的；气人的；使愤怒的；烦人的，使人恼火的vt. 刺激；激怒；使烦恼；使发炎，使不适；使不耐烦；使（身体某部分）疼痛（irritate 的现在分词）
百度翻译：
截肢
适应症
只有当手指仍然疼痛或未愈合，或是令人讨厌（即患者无法弯曲、伸直或感觉不到），并且只有在修复不可能或不经济的情况下，才可截肢。
技术
在指尖，目标是一个移动的手指手指覆盖着正常感觉的健康皮肤。这可以通过局部推进皮瓣或神经血管岛状皮瓣，或通过骨缩短（“末端化”）来实现。交叉指皮瓣是相当直的，提供了良好的皮肤覆盖，但感觉是有限的，一个屈曲挛缩可以在供体手指发展。最终的选择取决于病人的要求和外科医生的技能。
拇指的每一毫米都值得保存，即使是僵硬或变形的拇指也值得保存。
中指和无名指不应通过指关节截肢，因为从美容角度来看，这是不满意的，小物体会从缝隙中掉落（“握力失禁”）。如果能保留近端pha lanx，外观仍不正常，但功能较好。伸肌肌腱决不能与屈肌腱缝合；这将作为趾深屈肌共同腹部的系带，并阻止其他手指完全屈曲（“四边形效应”）。如果中指骨在指浅屈肌止点的远端截肢，深肌腱继续牵拉，但现在穿过腰骶，使近端指间关节反常地延伸而不是弯曲。这种刺激性异常可通过将浅表残端缝合到屈肌鞘上或将腰背分开来避免。
对于更近端的损伤，整个手指及其掌骨的大部分可以被截肢；手虽然虚弱，但外观通常是令人满意的。如果中间射线通过掌骨截肢，食指可能在屈曲时“剪”过它；这可以通过分割相邻的食指掌骨并将其移到中间掌骨的残端来克服。