骨科英文书籍精读（99）｜肱骨髁上骨折（3）
Complications
EARLY
Vascular injury
The great danger of supracondylar fracture is injury to the brachial artery, which, before the introduction of percutaneous pinning, was reported as occurring in over 5 percent of cases. Nowadays the incidence is probably less than 1 percent. Peripheral ischaemia may be immediate and severe, or the pulse may fail to return after reduction.
More commonly the injury is complicated by forearm oedema and a mounting compartment syndrome which leads to necrosis of the muscle and nerves without causing peripheral gangrene. Undue pain plus one positive sign (pain on passive extension of the fingers, a tense and tender forearm, an absent pulse, blunted sensation or reduced capillary return on pressing the finger pulp) demands urgent action. The flexed elbow must be extended and all dressings removed. If the circulation does not promptly improve, then angiography (on the operating table if it saves time) is carried out, the vessel repaired or grafted and a forearm fasciotomy performed. If angiography is not available, or would cause much delay, then Doppler imaging should be used. In extreme cases, operative exploration would be justified on clinical criteria alone.
Nerve injury
The radial nerve, median nerve (particularly the anterior interosseous branch) or the ulnar nerve may be injured. Tests for nerve function are described in Chapter 11. Fortunately loss of function is usually temporary and recovery can be expected in 3 to 4 months. If there is no recovery the nerve should be explored. However, if a nerve, documented as intact prior to manipulation, is then found to have failed after manipulation, then entrapment in the fracture is suspected and immediate exploration should be arranged.
The ulnar nerve may be damaged by careless pinning. If the injury is recognized, and the pin removed, recovery will usually follow.
LATE
Malunion
Malunion is common. However, backward or sideways shifts are gradually smoothed out by modelling during growth and they seldom give rise to visible deformity of the elbow. Forward or backward tilt may limit flexion or extension, but consequent disability is slight.
Uncorrected sideways tilt (angulation) and rotation are much more important and may lead to varus (or rarely valgus) deformity of the elbow; this is permanent and will not improve with growth (Fig. 24.32). The fracture is extra-physeal and so physeal damage should not be blamed for the deformity; usually it is faulty reduction which is responsible. Cubitus varus is disfiguring and cubitus valgus may cause late ulnar palsy. If deformity is marked, it will need correction by supracondylar osteotomy usually once the child approaches skeletal maturity.
Elbow stiffness and myositis ossifficans
Stiffness is an ever-present risk with elbow injuries. Extension in particular may take months to return. It must not be hurried. Passive movement (which includes carrying weights) or forced movement is prohibited – this will only make matters worse and may contribute to the development of myositis ossificans. As it is, myositis ossificans is extremely rare, and should remain so if rehabilitation is properly supervised.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
oedema /ɪˈdiːmə/n. [病理] 水肿
peripheral /pəˈrɪfərəl/adj. 外围的；次要的；（神经）末梢区域的n. 外部设备
gangrene /ˈɡæŋɡriːn/n. [外科] 坏疽
vt. 使生坏疽vi. 生坏疽；腐败
angiography/ændʒɪ'ɑgrəfi/n. [特医] 血管造影术；血管照相术；血管学；[特医] 血管造影法
fasciotomy /fæʃi'ɔtəmi/n. [外科] 筋膜切开术
document /ˈdɑːkjumənt/n. 文件，公文；[计] 文档；证件vt. 记录，记载
permanent/ˈpɜːrmənənt/adj. 永久的，永恒的；不变的n. 烫发（等于permanent wave）
Cubitus varus is disfiguring and cubitus valgus may cause late ulnar palsy.肘内翻可造成畸形，肘外翻可导致尺神经麻痹.
Cubitus/'kju:bitəs/n. [昆] 肘脉；[解剖] 前臂，尺骨
If deformity is marked, it will need correction by supracondylar osteotomy usually once the child approaches skeletal maturity.如果畸形明显，通常在儿童接近骨骼成熟时，需要通过髁上截骨术矫正。
ever-present/'evə,prezənt/adj. 经常存在的；始终存在的
As it is,实际上；事实上；既然如此
百度翻译：
早期并发症
血管损伤
髁上骨折的最大危险是肱动脉损伤，据报道，在采用经皮穿针治疗前，有超过5%的病例发生这种损伤。现在发病率可能不到1%。周围性缺血可能是立即和严重的，或脉搏可能无法恢复后减少。
更常见的情况是，前臂水肿和一种可导致肌肉和神经坏死而不引起周围坏疽的隆起室综合征。过度疼痛加上一个积极的迹象（手指被动伸展疼痛，前臂紧张和柔软，脉搏消失，感觉迟钝或按压指腹时毛细血管回流减少）需要紧急行动。弯曲的弯头必须伸出，所有的敷料都要去掉。如果循环不能迅速改善，则进行血管造影（如果节省时间，可在手术台上进行），修复或移植血管，并进行前臂筋膜切开术。如果血管造影不可用，或会造成很大的延迟，则应使用多普勒成像。在极端情况下，仅凭临床标准就可以证明手术探查是合理的。
神经损伤
桡神经、正中神经（尤其是骨间前支）或尺神经可能受到损伤。神经功能测试在第11章中描述。幸运的是，功能丧失通常是暂时的，预计3至4个月后恢复。如果没有恢复，就应该探查神经。然而，如果在操作前记录为完整的神经，在操作后被发现失败，则怀疑骨折中有卡压，应立即安排探查。
不小心的固定可能会损伤尺神经。如果损伤被识别出来，并且拔下了别针，通常会恢复。
晚期并发症
畸形愈合
畸形愈合很常见。然而，在生长过程中，向后或侧移通过建模逐渐平滑，它们很少导致明显的肘关节畸形。向前或向后倾斜可能会限制屈曲或伸展，但随后的残疾是轻微的。
未矫正的侧倾（成角）和旋转更为重要，可能导致肘内翻（或很少外翻）畸形；这是永久性的，不会随着生长而改善（图24.32）。骨折是一种额外的骨痂，所以畸形不应归咎于骨痂的损伤，通常是由于复位不当造成的。肘内翻畸形，肘外翻可引起迟发性尺神经麻痹。如果畸形明显，通常在孩子接近骨骼成熟时需要通过髁上截骨术矫正。
肘关节僵硬与骨化性肌炎
僵硬是肘关节受伤的一个经常存在的风险。特别是延期可能需要几个月才能恢复。不能着急。禁止被动运动（包括负重）或强迫运动-这只会使情况变得更糟，并可能导致骨化性肌炎的发生。骨化性肌炎是极为罕见的，如果康复得到适当的监督，这种情况应该一直存在。