骨科英文书籍精读（363）｜踝关节侧韧带急性损伤
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ACUTE INJURY OF LATERAL LIGAMENTS
Clinical features
A history of a twisting injury followed by pain and swelling could suggest anything from a minor sprain to a fracture. If the patient is able to walk, and bruising is only faint and slow to appear, it is probably a sprain; if bruising is marked and the patient unable to put any weight on the foot, this suggests a more severe injury. Tenderness is maximal just distal and slightly anterior to the lateral malleolus. The slightest attempt at passive inversion of the ankle is extremely painful. It is impossible to test for abnormal mobility without using local or general anaesthesia.
With all ankle injuries it is essential to examine the entire leg and foot; undisplaced fractures of the fibula or the tarsal bones, or even the fifth metatarsal bone are easily missed and injuries of the distal tibiofibular joint and the peroneal tendon sheath cause features that mimic those of a lateral ligament strain.
Imaging
About 15 per cent of ankle sprains reaching the Emergency Department are associated with an ankle fracture. This complication can be excluded by obtaining an x-ray, but there are doubts as to whether all
patients with ankle injuries should be subjected to x-ray examination. Almost 2 decades ago The Ottawa Ankle Rules were developed to assist in making this decision. X-ray examination is called for if there is:
(1) pain around the malleolus; (2) inability to take weight on the ankle immediately after the injury; (3) inability to take four steps in the Emergency Department; (4) bone tenderness at the posterior edge or tip of the medial or lateral malleolus or the base of the fifth metatarsal bone.
If x-ray examination is considered necessary, anteroposterior, lateral and 'mortise’ (30-degree oblique) views of the ankle should be obtained. Localized soft tissue swelling and, in some cases, a small avulsion fracture of the tip of the lateral malleolus or the anterolateral surface of the talus may be the only corroborative signs of a lateral ligament injury. However, it is important to exclude other injuries, such as an undisplaced fibular fracture or diastasis of the tibiofibular syndesmosis. If tenderness extends onto the foot, or if swelling is so severe that the area cannot be properly examined, additional x-rays of the foot are essential.
Persistent inability to weightbear over 1 week or longer should call for re-examination and review of all the initial 'negative’ x-rays. For patients who have had persistent pain, swelling, instability and impaired function over 6 weeks or longer, despite appropriate early treatment, magnetic resonance imaging (MRI) or computed tomography (CT) will be required to assess the extent of soft tissue injury or subtle bony changes.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
faint /feɪnt/adj. 模糊的；头晕的；虚弱的；[医] 衰弱的vi. 昏倒；变得微弱；变得没气力n. [中医] 昏厥，昏倒
anaesthesia /ˌænəsˈθiːʒə/n. 麻醉；麻木；感觉缺失（等于anesthesia）
tendon sheath 腱鞘
sheath /ʃiːθ/n. 鞘；护套；叶鞘；女子紧身服装
mimic /ˈmɪmɪk/vt. 模仿，摹拟adj. 模仿的，模拟的；假装的
diastasis of the tibiofibular syndesmosis.胫腓联合分离。
diastasis /dai'æstəsis/n. 脱骱；心休息期
subtle bony changes.微妙的骨的变化。
subtle/ˈsʌtl/adj. 微妙的；精细的；敏感的；狡猾的；稀薄的
有道翻译（仅供参考，建议自己翻译）：
急性外侧韧带损伤
临床特征
扭转损伤后疼痛和肿胀的病史可以说明任何东西，从轻微扭伤到骨折。如果患者能够走路，瘀伤只会出现微弱和缓慢，那可能是扭伤；如果有瘀伤的痕迹，患者不能在脚上施加任何重量，这意味着会造成更严重的伤害。触痛最大的是在踝外侧，稍前。踝关节被动翻转的一点点尝试都是非常痛苦的。不使用局部或全身麻醉，就不可能检测异常活动性。
所有踝关节损伤都必须检查整个腿部和脚；腓骨或跗骨，甚至第五跖骨的未裂骨折很容易丢失，胫腓远端关节和腓腱鞘的损伤会导致类似侧韧带应变的特征。
影像
到达急诊部的踝关节扭伤中，约15%与踝关节骨折有关。通过获得x光可以排除这种并发症，但对于是否全部存在疑问
踝关节损伤患者应接受x线检查。近20年前，渥太华踝关节规则是为了协助作出这一决定。如果有以下情况，则要求进行X光检查：
（1） 踝关节周围疼痛(2） 伤后不能立即对脚踝进行负重(3） 应急部门不能采取四个步骤(4） 踝内侧或外侧的后缘或尖端或第五跖骨基部的骨压痛。
如果认为有必要进行x光检查，则应获得踝关节的后、外侧和“榫”（30度斜视）视图。局限性软组织肿胀，在某些情况下，外踝尖端或距骨前外侧表面的小撕脱性骨折可能是外侧韧带损伤的唯一确证。然而，排除其他损伤，如未裂腓骨骨折或胫腓联合脱臼是很重要的。如果脚部有压痛，或者肿胀严重到不能正确检查部位，则必须额外对脚进行x光检查。
持续无法承受超过1周或更长时间的体重，应要求重新检查和审查所有最初的“阴性”x光片。对于6周或更长时间持续疼痛、肿胀、不稳定和功能受损的患者，尽管有适当的早期治疗，但仍需进行磁共振成像（MRI）或CT（CT）评估软组织损伤或细微骨病变的程度。