骨科英文书籍精读（7）｜视、触、动、射
Look 视
Swelling, bruising and deformity may be obvious, but the important point is whether the skin is intact; if the skin is broken and the wound communicates with the fracture, the injury is ‘open’ (‘compound’). Note also the posture of the distal extremity and the colour of the skin (for tell-tale signs of nerve or vessel damage).
Feel 触
The injured part is gently palpated for localized tenderness. Some fractures would be missed if not specifically looked for, e.g. the classical sign (indeed the only clinical sign!) of a fractured scaphoid is tenderness on pressure precisely in the anatomical snuff-box. The common and characteristic associated injuries should also be felt for, even if the patient does not complain of them. For example, an isolated fracture of the proximal fibula should always alert to the likelihood of an associated fracture or ligament injury of the ankle, and
in high-energy injuries always examine the spine and pelvis. Vascular and peripheral nerve abnormalities should be tested for both before and after treatment.
Move 动
Crepitus and abnormal movement may be present, but why inflict pain when x-rays are available? It is more important to ask if the patient can move the joints distal to the injury.
X-RAY 射线
X-ray examination is mandatory. Remember the rule of twos:
· Two views – A fracture or a dislocation may not be seen on a single x-ray film, and at least two views (anteroposterior and lateral) must be taken.
· Two joints – In the forearm or leg, one bone may be fractured and angulated. Angulation, however, is impossible unless the other bone is also broken, or a joint dislocated. The joints above and below the fracture must both be included on the x-ray films.
· Two limbs – In children, the appearance of immature epiphyses may confuse the diagnosis of a fracture; x-rays of the uninjured limb are needed for comparison.
· Two injuries – Severe force often causes injuries at more than one level. Thus, with fractures of the calcaneum or femur it is important to also x-ray the pelvis and spine.
·Two occasions– Some fractures are notoriously difficult to detect soon after injury, but another x-ray examination a week or two later may show the lesion. Common examples are undisplaced fractures of the distal end of the clavicle, scaphoid, femoral neck and lateral malleolus, and also stress fractures and physeal injuries wherever they occur.
X-ray examination must be ‘adequate’ (a,b) Two films of the same tibia: the fracture may be ‘invisible’ in oneview and perfectly plain in a view at right angles to that. (c,d) More than one occasion: A fractured scaphoid may not be obvious on the day of injury, but clearly seen 2 weeks later. (e,f) Two joints: The first x-ray (e) did not include the elbow.This was, in fact, a Monteggia fracture – the head of the radius is dislocated; (f) shows the dislocated radiohumeral joint.(g,h) Two limbs: Sometimes the abnormality can be appreciated only by comparision with the normal side; in this case there is a fracture of the lateral condyle on the left side (h).
---from 《Apley’s System of Orthopaedics and Fractures》P693
重点词汇整理：
Note also the posture of the distal extremity and the colour of the skin (for tell-tale signs of nerve or vessel damage).
还要注意远端肢体的姿势和皮肤的颜色(神经或血管损伤的迹象)。
extremity /ɪkˈstreməti/n. 手足(肢体);极端；绝境；非常手段；
tell-tale signs 有迹象显示
tale /teɪl/n. 故事；传说；叙述；流言蜚语
The injured part is gently palpated for localized tenderness.轻轻触诊受伤部位，以确定局部压痛。
palpate /pælˈpeɪt/v. 触诊
tenderness/ˈtendərnəs/n.疼痛；亲切；柔软；敏感；棘手
the classical sign of a fractured scaphoid is tenderness on pressure precisely in the anatomical snuff-box.舟骨骨折的典型特征是解剖学上鼻烟壶处的压痛。
scaphoid /'skæfɔɪd/n. 舟状骨adj. 船状的，船形的
anatomical /ˌænəˈtɑːmɪkl/adj. 解剖的；解剖学的；结构上的
snuff-box鼻烟盒，鼻烟壶
snuff /snʌf/n. 鼻烟；烛花；灯花vt. 剪烛花；掐灭；消灭；嗅出vi. 扑灭；断气；嗅
Crepitus 捻发音；骨擦音
inflict /ɪnˈflɪkt/vt. 造成；使遭受（损伤、痛苦等）；给予（打击等）
mandatory/ˈmændətɔːri/adj. 强制的；托管的；命令的
anteroposterior and lateral前后和侧位（正侧位）
angulated. /'æŋgjə,let/v. 使成角形；向外倾斜
epiphyses 骨骺
comparison /kəmˈpærɪsn/n. 比较；对照；比喻；比较关系
with fractures of the calcaneum or femur it is important to also x-ray the pelvis and spine.跟骨或股骨骨折时，还需要对骨盆和脊柱进行x光检查。
Two occasions两期（前后对比）
notoriously /noʊˈtɔːriəsli/adv. 众所周知地；声名狼藉地；恶名昭彰地
lesion /ˈliːʒn/n. 损害；身体上的伤害；机能障碍
Common examples are undisplaced fractures of the distal end of the clavicle, scaphoid, femoral neck and lateral malleolus, and also stress fractures and physeal injuries wherever they occur.常见的例子有锁骨远端无移位性骨折、肩胛骨骨折、股骨颈骨折和外踝骨折，也有应力性骨折和骨骺损伤。
physeal 生长的；骨骺的
Monteggia fracture 孟氏骨折（尺骨骨折伴桡骨头脱位）
the head of the radius is dislocated;桡骨头脱位;
radiohumeral joint 肱桡关节
lateral condyle/'lætərəl'kɔndil/ 外侧髁；外髁
百度翻译：
视
肿胀、瘀伤和畸形可能很明显，但重要的一点是皮肤是否完好无损；如果皮肤破裂，伤口与骨折相通，则损伤为“开放性”（“复合性”）。还要注意远端肢体的姿势和皮肤的颜色（用于神经或血管损伤的信号）。
触
轻触受伤部位，看是否有局部疼痛。如果不特别注意一些骨折，例如经典征象（实际上是唯一的临床征象！）腕舟骨骨折的原因是解剖鼻烟壶内的压痛。即使病人没有抱怨，也应该感觉到常见的和有特点的相关伤害。例如，腓骨近端的孤立性骨折应始终注意踝关节相关骨折或韧带损伤的可能性，以及
在高能伤中，总是检查脊柱和骨盆。治疗前后均应检查血管和周围神经异常。
动
可能会出现皱纹和不正常的运动，但为什么当x光片可用时会造成疼痛？更重要的是询问患者是否能将关节移到损伤的远端。
X射线
必须进行X光检查。记住两个原则：
·两个视图-在一张x光片上可能看不到骨折或脱位，必须至少取两个视图（前后和外侧）。
·两个关节-在前臂或腿部，一根骨头可能骨折并成角。然而，除非另一块骨头也骨折或关节脱位，否则成角是不可能的。骨折上方和下方的关节都必须包括在x光片上。
·双肢-在儿童中，未损伤肢体的骨骺外观可能会混淆骨折的诊断；需要对未损伤肢体进行x光检查以进行比较。
·两人受伤-严重的力通常会导致一人以上的受伤。因此，对于calcaneum或股骨骨折，也必须对骨盆和脊柱进行x光检查。
·两种情况——有些骨折在受伤后很难立即发现，但一两周后的另一次x光检查可能会显示病变。常见的例子是锁骨远端、腕舟骨、股骨颈和外踝的无移位骨折，以及应力性骨折和physeal损伤。
X光检查必须“足够”（a，b）同一胫骨的五分之二：骨折在一个视图中是“看不见的”，在与之成直角的视图中是完全平坦的。（c，d）不止一次：舟骨骨折在受伤当天可能不明显，但在两周后清晰可见。（e，f）两个关节：第一次x光片（e）不包括肘部。事实上，这是一个孟氏骨折——桡骨头部脱臼；（f）显示肱桡骨关节脱臼。（g，h）双肢：有时只有与正常侧比较才能发现异常；在这种情况下，左侧的外侧髁骨折（h）。