骨科英文书籍精读（53）｜骨骺损伤（2）
X-rays
The physis itself is radiolucent and the epiphysis may be incompletely ossified; this makes it hard to tell whether the bone end is damaged or deformed. The younger the child, the smaller the ‘visible’ part of the epiphysis and thus the more difficult it is to make the diagnosis; comparison with the normal side is a great help. Telltale features are widening of the physeal ‘gap’, incongruity of the joint or tilting of the epiphyseal axis. If there is marked displacement the diagnosis is obvious, but even a type 4 fracture may at first be so little displaced that the fracture line is hard to see; if there is the faintest suspicion of a physeal fracture, a repeat x-ray after 4 or 5 days is essential.Types 5 and 6 injuries are usually diagnosed only in retrospect.
Treatment
Undisplaced fractures may be treated by splinting the part in a cast or a close-fitting plaster slab for 2–4 weeks (depending on the site of injury and the age of the child). However, with undisplaced types 3 and 4 fractures, a check x-ray after 4 days and again at about 10 days is mandatory in order not to miss late displacement.
Displaced fractures should be reduced as soon as possible. With types 1 and 2 this can usually be done closed; the part is then splinted securely for 3–6 weeks. Types 3 and 4 fractures demand perfect anatomical reduction. An attempt can be made to achieve this by gentle manipulation under general anaesthesia; if this is successful, the limb is held in a cast for 4–8 weeks (the longer periods for type 4 injuries). If a type 3 or 4 fracture cannot be reduced accurately by closed manipulation, immediate open reduction and internal fixation with smooth K-wires is essential. The limb is then splinted for 4–6 weeks, but it takes that long again before the child is ready to resume unrestricted activities.
Complications
Types 1 and 2 injuries, if properly reduced, have an excellent prognosis and bone growth is not adversely affected. Exceptions to this rule are injuries around the knee involving the distal femoral or proximal tibial physis; both growth plates are undulating in shape, so a transverse fracture plane may actually pass through more than just the hypertrophic zone but also damage the proliferative zone. Complications such as malunion or non-union may also occur if the diagnosis is missed and the fracture remains unreduced (e.g. fracture separation of the medial humeral epicondyle).
Types 3 and 4 injuries may result in premature fusion of part of the growth plate or asymmetrical growth of the bone end. Types 5 and 6 fractures cause premature fusion and retardation of growth. The size
and position of the bony bridge across the physis can be assessed by tomography or magnetic resonance imaging (MRI). If the bridge is relatively small (less than one-third the width of the physis) it can be
excised and replaced by a fat graft, with some prospect of preventing or diminishing the growth disturbance (Langenskiold, 1975; 1981). However, if the bone bridge is more extensive the operation is contraindicated as it can end up doing more harm than good.
Established deformity, whether from asymmetrical growth or from malunion of a displaced fracture (e.g. a valgus elbow due to proximal displacement of a lateral humeral condylar fracture) should be treated by corrective osteotomy. If further growth is abnormal, the osteotomy may have to be repeated.
---from 《Apley’s System of Orthopaedics and Fractures》P729-730
重点词汇整理：
radiolucent /,redio'lʊsənt/adj. 射线可透过的
Telltale /ˈtelteɪl/n. 迹象；指示器；搬弄是非者adj. 报警的；泄密的；搬弄是非的
incongruity /ˌɪnkənˈɡruːəti/n. 不协调；不一致；不适宜
tilting /tɪlt/n. 倾卸台v. 使倾斜（tilt的ing形式）adj. [航][气象] 倾斜；倾卸
faintest /'feintist/adj. 一点也不的（用于否定句，加强语气）；极小的
slab/slæb/n. 厚板，平板；混凝土路面；厚片vt. 把…分成厚片；用石板铺
mandatory /ˈmændətɔːri/n. 受托者（等于mandatary）adj. 强制的；托管的；命令的
securely /sɪˈkjʊrli/adv. 安全地；牢固地；安心地；有把握地
anatomical reduction解剖复位 /ˌænəˈtɑːmɪkl/adj. 解剖的；解剖学的；结构上的
unrestricted /ˌʌnrɪˈstrɪktɪd/adj. 自由的；无限制的；不受束缚的
adversely /ədˈvɜːrsli,ˈædvɜːrsli/adv. 不利地；逆地；反对地
undulating /ˈʌndʒəleɪtɪŋ/adj. 波状的；波浪起伏的v. 使波动（undulate的ing形式）；使成波浪形
medial humeral epicondyle内侧肱骨上髁
asymmetrical growth 不对称生长/,esɪ'mɛtrɪkl/adj. 非对称的；不匀称的，不对等的
retardation/ˌriːtɑːrˈdeɪʃn/n. 阻滞；迟延；妨碍
extensive /ɪkˈstensɪv/adj. 广泛的；大量的；广阔的
contraindicate/ˌkɑːntrəˈɪndɪkeɪt/v. 禁忌（某种疗法或药物）；显示（治疗或处置）不当
valgus/'vælɡəs/n. 外翻足的人；外翻足adj. 外翻的
谷歌翻译：
X线检查
骨骺本身是放射透明的，骨骺可能不完全骨化，这使得很难判断骨端是受损还是变形。孩子越小，骨骺的“可见”部分就越小，因此诊断就越困难；与正常侧进行比较会有很大帮助。能说明问题的特征是骨骺“间隙”扩大、关节不协调或骨骺轴线倾斜。如果有明显的移位，诊断很明显，但即使是4型骨折，一开始也可能移位很小，很难看到骨折线；如果有最微弱的骺骨骨折的怀疑，4或5天后重复拍一次x光是必要的。5型和6型损伤通常只有在事后才能诊断出来。
治疗
未移位的骨折可以用石膏夹板或石膏板固定2-4周(取决于受伤部位和儿童的年龄)。然而，对于未移位的3型和4型骨折，为了不遗漏晚期移位，必须在4天后检查X光，并在大约10天再检查一次。
移位骨折应尽快复位。对于类型1和类型2，这通常可以闭合完成；然后将该部分牢固地夹板固定3-6周。3型和4型骨折需要完美的解剖复位。可以尝试在全身麻醉下通过轻柔的手法来实现这一点；如果成功，肢体将固定在石膏上4-8周(4型损伤的时间较长)。如果3型或4型骨折不能通过闭合操作准确复位，立即切开复位，用光滑的克氏针内固定是必不可少的。然后用夹板固定四肢4-6周，但又需要这么长时间，孩子才能准备好恢复不受限制的活动。
并发症
如果复位得当，1型和2型损伤预后良好，骨生长不会受到不良影响。这条规则的例外是涉及股骨远端或胫骨近端骨骺的膝关节周围的损伤；两个生长板都是波浪形的，因此横向骨折平面实际上可能不仅穿过肥大区，而且还会破坏增殖区。如果漏诊而骨折仍未复位(如肱骨内侧上髁骨折分离)，也可能发生畸形愈合或骨不连等并发症。
3型和4型损伤可能导致部分生长板过早融合或骨端不对称生长。5型和6型骨折会导致过早融合和生长迟缓。横跨骨骺的骨桥的大小和位置可以通过断层扫描或磁共振成像(MRI)进行评估。如果桥相对较小(小于骨骺宽度的三分之一)，可以切除它，用脂肪移植物取代，有一定的前景可以防止或减少生长障碍(Langenskiold，1975；1981)。然而，如果骨桥范围更广，手术是禁忌的，因为它最终可能弊大于利。
已确定的畸形，无论是由于不对称生长还是移位骨折的畸形愈合(例如，肱骨外侧髁骨折近端移位导致的外翻肘)，都应该采用矫正性截骨治疗。如果进一步生长不正常，可能需要重复截骨。