骨科英文书籍精读（378）｜儿童踝关节骨折的治疗和并发症
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Treatment
Salter–Harris types 1 and 2 injuries are treated closed. If it is displaced, the fracture is gently reduced under general anaesthesia; the limb is immobilized in a fulllength cast for 3 weeks and then in a below-knee walking cast for a further 3 weeks. Occasionally, surgery is needed to extract a periosteal flap, which prevents an adequate reduction.
Type 3 or 4 fractures, if undisplaced, can be treated in the same manner, but the ankle must be re-x-rayed after 5 days to ensure that the fragments have not slipped. Displaced fractures can sometimes be reduced closed by reversing the forces that produced the injury. However, unless reduction is near-perfect, the fracture should be reduced open and fixed with interfragmentary screws, which are inserted parallel to the physis. Postoperatively the leg is immobilized in a below-knee cast for 6 weeks.
Tillaux fractures are treated in the same way as type 3 fractures. Triplane fractures, if undisplaced, can be managed closed but require vigilant monitoring for late displacement. Displaced fractures must be reduced and fixed.
Complications
Malunion
Imperfect reduction may result in angular deformity of the ankle – usually valgus. In children under 10 years old, mild deformities may be accommodated by further growth and modelling. In older children the deformity should be corrected by a supramalleolar closing-wedge osteotomy.
Asymmetrical growth
Fractures through the epiphysis (Salter–Harris type 3 or 4) may result in localized fusion of the physis. The bony bridge is usually in the medial half of the growth plate; the lateral half goes on growing and the distal tibia gradually veers into varus. MRI and CT are helpful in showing precisely where physeal arrest has occurred. If the bony bridge is small (less than 30 per cent of the physeal width) it can be excised and replaced by a pad of fat in the hope that physeal growth may be restored. If more than half of the physis is involved, or the child is near the end of the growth period, a supramalleolar closing-wedge osteotomy is indicated.
Shortening
Early physeal closure occurs in about 2 per cent of children with distal tibial injuries. Fortunately the resulting limb length discrepancy is usually mild. If it promises to be more than 2 cm and the child is young enough, proximal tibial epiphysiodesis in the opposite limb may restore equality. If the discrepancy is marked, or the child near the end of the growth period, leg lengthening is indicated.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
extract /ˈekstrækt/v. 提取，提炼；索取，设法得到；选取，摘录；取出，拔出；推断出，引申出；开（方），求（根）n. 摘录，引文；榨出物，汁
interfragmentary screws骨折块间螺钉
vigilant/ˈvɪdʒɪlənt/adj. 警惕的；警醒的；注意的；警戒的
valgus/vælɡəs/n. 外翻足的人；外翻足adj. 外翻的
varus /'vεərəs/n. 内翻足；弓形腿
supramalleolar踝上
Asymmetrical /,esɪ'metrɪkl/adj. 非对称的；不匀称的，不对等的
veer /vɪr/vi. 转向；改变观点；风向顺时针转；调转船尾向上风vt. 使转向；使顺风；使船尾向上风n. 转向；方向的转变
discrepancy /dɪˈskrepənsi/n. 不符；矛盾；相差
limb length discrepancy 肢体长度差异
epiphysiodesis骺骨阻滞术
restore equality恢复平等
有道翻译（仅供参考，建议自己翻译）：
治疗
Salter–Harris 1型和2型损伤闭合治疗。如果骨折移位，在全麻下轻轻复位；四肢固定在全长石膏内3周，然后固定在膝盖以下再步行3周。有时，需要手术取出骨膜瓣，以充分复位。
3型或4型骨折，如果没有移位，可以用同样的方法进行治疗，但踝关节必须在5天后重新进行x光检查，以确保碎片没有滑落。移位的骨折有时可以通过逆转产生损伤的力来减少或闭合。但是，除非复位接近完美，否则骨折应切开复位，并用与物理体平行插入的碎块间螺钉固定。术后将腿固定在膝下石膏内6周。
tilaux骨折的治疗方法与3型骨折相同。三平面骨折，如果没有移位，可以闭合治疗，但需要警惕监测晚期移位。移位的骨折必须复位固定。
并发症
畸形愈合
不完全复位可能导致踝关节角畸形-通常是外翻。对于10岁以下的儿童，轻微的畸形可以通过进一步的生长和建模来适应。对于年龄较大的儿童，应通过踝上闭合楔形截骨术矫正畸形。
不对称增长
骨骺骨折（Salter–Harris 3型或4型）可导致局部融合。骨桥通常位于生长板的内半部；外侧半部继续生长，胫骨远端逐渐变为内翻。MRI和CT有助于准确显示physeal阻滞的发生部位。如果骨桥很小（小于海豹宽度的30%），可以切除它，用脂肪垫代替，希望海豹可以恢复生长。如果超过一半的体格受累，或者孩子接近生长末期，则需要进行踝上闭合楔形截骨术。
缩短
在胫骨远端损伤的儿童中，约有2%的儿童发生早期physeal闭合。幸运的是，由此产生的肢体长度差异通常是轻微的。如果保证大于2cm且孩子足够年轻，则对侧肢体胫骨近端骨骺发育可恢复等长。如果差异明显，或儿童接近生长期结束时，则表示腿部延长。