骨科英文书籍精读（387）｜跟骨骨折的病理
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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Pathological anatomy
Based largely on the work of Palmer (1948) and Essex-Lopresti (1952), it has been customary to divide calcaneal fractures into extra-articular fractures (those involving the various calcaneal processes or the body posterior to the talocalcaneal joint) and intraarticular fractures (those that split the talocalcaneal articular facet).
EXTRA-ARTICULAR FRACTURES
These account for 25 per cent of calcaneal injuries. They usually follow fairly simple patterns, with shearing or avulsion of the anterior process, the sustentaculum tali, the tuberosity or the inferomedial process. Fractures of the posterior (extra-articular) part of the body are caused by compression. Extra-articular fractures are usually easy to manage and have a good prognosis.
INTRA-ARTICULAR FRACTURES
These injuries are much more complex and unpredictable in their outcome. They are best understood by imagining the impact of the talus cleaving the bone from above to produce a primary fracture line that runs obliquely across the posterior articular facet and the body from posteromedial to anterolateral. Where it splits, the posterior articular facet depends upon the position of the foot at impact: if the heel is in valgus (abducted), the fracture is in the lateral part of the facet; if the heel is in varus (adducted), the fracture is more medial.
The upward displacement of the body of the calcaneum produces one of the classic x-ray signs of a 'depressed’ fracture: flattening of the angle subtended by the posterior articular surface and the upper surface of the body posterior to the joint (Böhler’s angle).
The advent of CT, and the trend towards operative reduction and fixation of displaced calcaneal fractures, have sharpened our understanding of these complex injuries. There are two important ways of assessing or classifying these injuries that are of relevance to the treating surgeon (and the patient). The work of Sanders and Gregory (1995) has helped to define the intra-articular fracture pattern and the associated outcome and prognosis. Knowledge of the variations in fracture pattern, particularly in relation to the lateral wall of the calcaneum (Eastwood et al., 1993) has improved our understanding of the anatomy that is likely to be encountered at operation, approaching from an extended L-shaped incision; the lateral joint fragment may sometimes be trapped within the body of the calcaneum and can only be reduced if the lateral wall of the body is osteotomized so as to gain access to it (Eastwood et al., 1993).
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
talocalcaneal joint距跟关节
sustentaculum tali,载距突
inferomedial process下内侧突
sharpened our understanding of these complex injuries加深了我们对这些复杂损伤的理解
DeepL翻译（仅供参考，建议自己翻译）：
主要基于Palmer(1948)和Essex-Lopresti(1952)的工作，习惯上将小腿骨骨折分为关节外骨折（涉及各种小腿骨突或距骨关节后的身体）和关节内骨折（那些分裂距骨关节面的骨折）。
关节外骨折
这类骨折占小腿骨损伤的25%。它们通常遵循相当简单的模式，包括前突、跗关节、结节或内侧突的剪切或撕脱。身体后部（关节外）的骨折是由压缩引起的。关节外骨折通常容易处理，预后良好。
关节内骨折
这些损伤要复杂得多，其结果也不可预测。对它们最好的理解是，想象一下距骨的冲击力从上面劈开骨头，产生一条主要的骨折线，从后内侧到前外侧斜着穿过后关节面和身体。后关节面裂开的位置取决于撞击时脚的位置：如果脚跟处于外翻状态（内收），骨折就在关节面的外侧；如果脚跟处于内翻状态（外收），骨折就在内侧。
小腿骨体的上移产生了 "凹陷性 "骨折的典型X线征象之一：后关节面和关节后的骨体上表面所对的角度变平（Böhler角）。
CT的出现，以及对移位的小腿骨骨折进行手术复位和固定的趋势，使我们对这些复杂的损伤有了更清晰的认识。对这些损伤的评估或分类有两种重要的方法，对治疗的外科医生（和病人）是有意义的。Sanders和Gregory(1995)的工作有助于定义关节内骨折模式以及相关的结果和预后。对骨折模式变化的了解，特别是与小腿侧壁有关的变化（Eastwood等，1993），提高了我们对手术中可能遇到的解剖结构的理解，从一个扩展的L形切口进入；侧方关节碎片有时可能被困在小腿骨体内，只有对骨体侧壁进行截骨，以获得接触它的机会，才可以减少骨折（Eastwood等，1993）。