骨科英文书籍精读（349）｜低能量胫腓骨骨折的处理（2）
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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Exercise
From the start, the patient is taught to exercise the muscles of the foot, ankle and knee. When he gets up, an overboot with a rocker sole is fitted and he is taught to walk correctly. When the plaster is removed, a crepe bandage or elasticated support is applied and the patient is told that he may either elevate and exercise the limb or walk correctly on it, but he must not let it dangle idly.
Functional bracing
With stable fractures the full-length cast may be changed after 4–6 weeks to a functional below-knee brace that is carefully moulded to bear upon the upper tibia and patellar tendon. This liberates the knee and allows full weightbearing (Sarmiento and Latta, 2006). A snug fit is important and the fastening straps will need to be tightened as the swelling subsides.
Indications for skeletal fixation
If follow-up x-rays show unsatisfactory fracture alignment, and wedging fails to correct this, the plaster is abandoned and the fracture is reduced and fixed at surgery. Indeed, many surgeons would hold that unstable fractures are better treated by skeletal fixation from the outset.
Closed intramedullary nailing
This is the method of choice for internal fixation. The fracture is reduced under x-ray control and image intensification. The proximal end of the tibia is exposed; a guide-wire is passed down the medullary canal and the canal is reamed. A nail of appropriate size and shape is then introduced from the proximal end across the fracture site. Transverse locking screws are inserted at the proximal and distal ends (Fig. 30.28). Postoperatively, partial weightbearing is started as soon as possible, progressing to full weightbearing when this is comfortable.
For diaphyseal fractures, union can be expected in over 95 per cent of cases. However, the method is less suitable for fractures near the bone ends.
Plate fixation
Plating is best for metaphyseal fractures that are unsuitable for nailing. It is also sometimes used for unstable tibial shaft fractures in children. Previously, the disadvantages of plate fixation included the need to expose the fracture site and, in so doing, stripping the soft tissues around the fracture. This may increase the risk of introducing infection and delaying union. Newer techniques of plating overcome these disadvantages. The plate is slid across the fracture through proximal and distal 'access incisions’ on the anterolateral aspect of the tibia and then fixed to the bone only at these levels. This method of 'submuscular’ plating preserves the soft tissues around the fracture site better than conventional open plating, and provides a relative stability that appears to hasten union. Even so, full weightbearing will need to be deferred until some callus formation is evident on xray, usually at 6–8 weeks.
External fixation
This is an alternative to closed nailing; it avoids exposure of the fracture site and allows further adjustments to be made if this should be needed. Partial weightbearing is permitted from the start and the external fixator can be replaced by a functional brace once there are signs of union (although, with modern fixators, this is usually unnecessary because fracture loading can be controlled and adjusted in the fixator).
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
crepe bandage弹力绷带
elasticated/ɪˈlæstɪkeɪtɪd/adj. 有松紧性的；织入橡皮筋的v. 有松紧地（elasticate的过去式）
dangle idly懒懒地摇摆
dangle /ˈdæŋɡl/v. （使）摇晃地悬挂着；提着；炫示；用……来诱惑（或激励）
idly /ˈaɪdli/adv. 无理由地，无目的地；
liberate/ˈlɪbəreɪt/vt. 解放；放出；释放;使获得自由
snug /snʌɡ/adj. 舒适的；温暖的；紧身的；隐藏的vt. 使变得温暖舒适；隐藏vi. 偎依；舒适地蜷伏n. 舒适温暖的地方；雅室
fastening strap缚带
ndeed, many surgeons would hold that unstable fractures are better treated by skeletal fixation from the outset.事实上，许多外科医生认为，不稳定骨折从一开始就通过外支架固定来治疗效果更好。
diaphyseal骨干的
diaphyseal fracture骨干骨折
Plating is best for metaphyseal fractures that are unsuitable for nailing.对于不适合髓内钉的干骺端骨折，最好采用钢板。
Previously, /ˈpriːviəsli/adv. 以前；预先；仓促地
This may increase the risk of introducing infection and delaying union. 这可能增加感染和延迟愈合的风险。
hasten union加速愈合
hasten /ˈheɪsn/vt. 加速；使赶紧；催促vi. 赶快；急忙
有道翻译（仅供参考，建议自己翻译）：
锻炼
从一开始，患者就被教导锻炼脚、脚踝和膝盖的肌肉。当他站起来，一个与摇杆鞋底过足是适合的，他被教导正确走路。当石膏被移除时，应用绉纱绷带或弹性支撑物，患者被告知他可以抬高和锻炼肢体或在其上正确行走，但他不能让肢体随意摆动。
功能性支撑
对于稳定的骨折，在4-6周后，可以将全长铸型改为功能性膝下支架，该支架经过精心塑形，以支撑胫骨和髌腱上部。这样可以解放膝盖，并允许完全负重（Sarmiento和Latta，2006）。舒适贴合非常重要，膨胀消退后需要拧紧紧固带。
骨骼固定适应症
如果随访的x光片显示骨折对中不满意，而楔入未能纠正，则放弃石膏，在手术时复位并固定骨折。事实上，许多外科医生认为，不稳定骨折最好从一开始就用骨骼固定治疗。
闭合髓内钉
这是内固定的首选方法。骨折在x线控制和影像增强下缩小。胫骨近端外露，一根导丝穿过髓管，髓管被扩孔。然后从骨折部位的近端引入合适大小和形状的钉子。在近端和远端插入横向锁定螺钉（图30.28）。术后，尽快开始部分负重，在舒适的情况下进行完全负重。
对于骨干骨折，95%以上的病例可以预期愈合。然而，这种方法不太适合骨端附近的骨折。
钢板固定
钢板是最好的干骺端骨折，不适合钉。有时也用于儿童胫骨不稳定骨折。以前，钢板固定的缺点包括需要暴露骨折部位，这样做，剥离骨折周围的软组织。这可能增加感染和延迟愈合的风险。较新的电镀技术克服了这些缺点。钢板通过胫骨前外侧的近端和远端“入路切口”滑动穿过骨折，然后仅在这些水平固定到骨上。这种“肌下”钢板的方法比传统的开放式钢板更好地保护了骨折部位周围的软组织，并提供了一种相对稳定的方法，似乎加速了愈合。即便如此，完全负重也需要推迟到X光片上有明显的骨痂形成，通常是6-8周。
外固定
这是闭合钉的一种替代方法；它避免了骨折部位的暴露，并允许在需要时进行进一步调整。从一开始就允许部分负重，一旦有愈合迹象，外固定架可以用功能性支架代替（尽管在现代固定架中，这通常是不必要的，因为骨折载荷可以在固定架中控制和调整）。