骨科英文书籍精读（256）｜股骨转子下骨折的治疗
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Treatment
Traction may help to reduce blood loss and pain. It is an interim measure until the patient, especially if elderly and with multiple medical problems, is stabilized and prepared for surgery.
Open reduction and internal fixation is the treatment of choice. Two main types of implant are used for fracture fixation: (a) an intramedullary nail with a proximal interlocking screw that can be directed into the femoral head or placed in the standard manner, and (b) a 95 degree hip screw-and-plate device. Both implants are suitable but there are circumstances where one may be preferable:
1. Intramedullary nails are generally stronger and can tolerate stresses for longer if healing is slow; this may be the case if the fracture is very comminuted or unstable, or if one suspects that operative dissection may have compromised bone viability.
2. An intramedullary nail is also preferable for a pathological fracture; a full-length nail should be used as there may be tumour deposits in the distal part of the femur.
Key points to bear in mind when operating on these fractures are: (a) an anatomic reduction will provide the greatest surface area of contact between the fragments and reduce stresses on the implant; with intramedullary nails this has to be achieved before reaming is commenced; (b) as little soft-tissue dissection as possible to accomplish reduction should be performed; and (c) it is important that the integrity of the medial cortex (around the lesser trochanter) be established, particularly if a hip screw-and-plate device is used.
Proximal interlocking screws with intramedullary nails should be directed into the femoral head if the fracture pattern extends above the lesser trochanter. If the fracture enters the piriformis fossa, then an intramedullary nail designed to be inserted at the tip of the greater trochanter is better; alternatively a 95 degree hip screw-and-plate device can be used.
Postoperatively the patient is allowed partial weightbearing (with crutches) until union is secure. It is rarely feasible to impose significant weightbearing restrictions on the elderly and it would be better to choose a stronger implant (and ensure a nearanatomic reduction of the fracture) so that early loading can be tolerated.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
interim measure暂行办法; 临时措施
interim/ˈɪntərɪm/n. 过渡时期，中间时期；暂定adj. 临时的，暂时的；中间的；间歇的
there are circumstances where one may be preferable但在某些情况下，其中一种可能更可取.
if one suspects that operative dissection may have compromised bone viability如果有人推测切开复位可能损害骨活力
dissection/dɪˈsekʃn,daɪˈsekʃn/n. 解剖，切开；解剖体；详细查究
a full-length nail should be used as there may be tumour deposits in the distal part of the femur.由于股骨远端可能有肿瘤沉积，应使用全长髓内钉。
ream/riːm/v. 欺骗；（用工具使孔）扩大
commence /kəˈmens/v. 开始；着手
piriformis fossa,：梨状肌窝,
alternatively a 95 degree hip screw-and-plate device can be used. 也可以使用95度髋螺钉-钢板装置。
百度翻译：
治疗
牵引可能有助于减少失血和疼痛。这是一个临时措施，直到病人，特别是老年人和多个医疗问题，是稳定和准备手术。
切开复位内固定是治疗的首选方法。两种主要类型的植入物用于骨折固定：（a）带近端交锁螺钉的髓内钉，可直接插入股骨头或以标准方式放置，（b）95度髋螺钉和钢板装置。两种植入物都是合适的，但在某些情况下，其中一种可能更可取：
1、如果愈合缓慢，髓内钉通常更坚固，可以承受更长的应力；如果骨折非常粉碎或不稳定，或者怀疑手术解剖可能损害了骨的生存能力，则可能出现这种情况。
2、病理性骨折最好使用髓内钉；股骨远端可能有肿瘤沉积，应使用全长髓内钉。
在对这些骨折进行手术时要记住的要点是：（a）解剖复位将提供碎片之间最大的接触表面积，并减少植入物上的应力；对于髓内钉，这必须在开始扩孔之前实现；（b） 应尽可能少地进行软组织解剖以完成复位；以及（c）建立内侧皮质（小转子周围）的完整性非常重要，尤其是在使用髋螺钉和钢板装置的情况下。如果骨折延伸到小转子以上，带髓内钉的近端交锁螺钉应直接插入股骨头。如果骨折进入梨状窝，则最好在大转子尖端插入髓内钉；或者可以使用95度髋螺钉和钢板装置。
术后允许患者部分负重（用拐杖），直到愈合。对老年人施加明显的负重限制几乎是不可行的，最好选择一个更坚固的植入物（并确保骨折接近解剖复位），以便能够容忍早期负重。