骨科英文书籍精读（373）｜踝部骨折的治疗(2)
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DISPLACED FRACTURES
Reduction of these joint disruptions is a prerequisite to all further treatment; knowledge of the causal mechanism (and this is where the Lauge-Hansen classification is useful) helps to guide the method of closed reduction. Although internal fixation is usually performed to stabilize the reduction, not all such fractures require surgery.
Displaced Weber type A fractures
The medial malleolar fracture is nearly vertical and after closed reduction it often remains unstable; internal fixation of the malleolar fragment with one or two screws directed almost parallel to the ankle joint is advisable. A perfect reduction should be aimed for, with accurate restoration of the tibial articular surface. Loose bone fragments are removed. The lateral malleolar fracture, unless it is already perfectly reduced and stable, should be fixed with a plate and screws or tension-band wiring. Postoperatively a 'walking cast’ or removable splintage boot is applied for 6 weeks; the advantage of removable splintage is that early physiotherapy can be commenced.
Displaced Weber type B fractures
The most common fracture pattern is a spiral fracture of the fibula and an oblique fracture of the medial malleolus. The causal mechanism is external rotation of the ankle when the foot is caught in a supinated position. Closed reduction therefore needs traction (to disimpact the fracture) and then internal rotation of the foot. If closed reduction succeeds, a cast is applied, following the same routine as for undisplaced fractures. Failure of closed reduction (sometimes a torn medial ligament is caught in between the talus and medial malleolus) or late redisplacement calls for operative treatment.
Type B fractures may also be caused by abduction; often the lateral aspect of the fibula is comminuted and the fracture line more horizontal. Despite accurate reduction (the ankle is adducted and the foot supinated), these injuries are unstable and often poorly controlled in a cast; internal fixation is therefore preferred.
Displaced Weber type C fractures
The fibular fracture is well above the syndesmosis and frequently there are associated medial and posterior malleolar fragments. An isolated type C fibular fracture should raise strong suspicions of major ligament damage to the syndesmosis and medial side of the joint. Almost all type C fractures are unstable and will need open reduction and internal fixation. The first step is to reduce the fibula, restoring its length and alignment; the fracture is then stabilized using a plate and screws.
If there is a medial fracture, this also is fixed. The syndesmosis is then checked, using a hook to pull the fibula laterally. If the joint opens out, it means that the ligaments are torn; the syndesmosis is stabilized by inserting a transverse screw across from the fibula into the tibia (the ankle should be held in 10 degrees of dorsiflexion when the screw is inserted).
Fracture subluxations more than 1 or 2 weeks old may prove difficult to reduce because of clot organization in the syndesmosis. Granulation tissue should be removed from the syndesmosis and transverse tibiofibular fixation secured.
Postoperative management
After open reduction and fixation of ankle fractures, movements should be regained before applying a below-knee plaster cast, or removable support boot. The patient is then allowed partial weightbearing with crutches; the support is retained until the fractures have consolidated (anything from 6–12 weeks).
Management of the syndesmosis- or diastasis-screw remains controversial. Some advocate removal of the screw when the syndesmosis has healed, and before weightbearing has commenced (6 weeks is too early, 10 weeks is probably more appropriate). Others are happy to allow early weightbearing with the screw still in place, accepting that the screw may break (especially if four cortices are engaged).
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
a prerequisite to all further treatment是所有进一步治疗的先决条件
prerequisite /ˌpriːˈrekwəzɪt/n. 先决条件adj. 首要必备的
causal mechanism因果机制
causal/ˈkɔːzl/adj. 因果关系的；有原因的n. 表示原因的连词
accurate restoration of the tibial articular surface胫骨关节面精确复位
the advantage of removable splintage is that early physiotherapy can be commenced.可移动夹板的优点是可以早期开始物理治疗。
supinated position. 旋后位
cortices
有道翻译（仅供参考，建议自己翻译）：
移位骨折
减少这些联合干扰是所有进一步治疗的先决条件；对因果机制的了解（Lauge-Hansen分类在这方面很有用）有助于指导闭合复位法。虽然内固定通常用于稳定复位，但并非所有骨折都需要手术。
移位韦伯A型骨折内踝骨折近垂直，闭合复位后常不稳定；建议用一个或两个几乎平行于踝关节的螺钉对踝关节进行内固定。一个完美的复位应以精确的胫骨关节面恢复为目标。松动的骨头碎片被移除。外踝骨折，除非已经完全复位和稳定，应该用钢板和螺钉或张力带固定。术后应用“步行石膏”或可拆卸夹板靴6周；可移动夹板的优点是可以开始早期理疗。
移位的韦伯B型骨折最常见的骨折类型是腓骨螺旋形骨折和内踝斜形骨折。其发病机制是当脚处于旋后位时脚踝的外旋。因此，闭合复位需要牵引（解除骨折），然后足部内旋。如果闭合复位成功，则按照与未移位骨折相同的程序进行铸型。闭合复位失败（有时距骨和内踝之间的内侧韧带撕裂）或晚期再安置需要手术治疗。
B型骨折也可由外展引起；腓骨的侧面常被粉碎，骨折线更为水平。尽管准确率降低（踝关节内收，足底旋后），但这些损伤是不稳定的，并且在铸型中通常控制不好；因此，首选内固定。
移位的韦伯C型骨折腓骨骨折远高于联合，常伴有内踝和后踝骨折。一个孤立的C型腓骨骨折应引起强烈的怀疑，主要韧带损伤的联合和内侧的关节。几乎所有的C型骨折都是不稳定的，需要切开复位内固定。第一步是缩小腓骨，恢复腓骨的长度和排列；然后用钢板和螺钉固定骨折。
如果有内侧骨折，这也是固定的。然后用钩子将腓骨侧向牵引，检查联合。如果关节张开，说明韧带撕裂；通过将横向螺钉从腓骨插入胫骨（螺钉插入时踝关节应保持背屈10度）来稳定联合。
超过1周或2周的骨折半脱位可能很难复位，因为联合处有血栓组织。结缔组织中的肉芽组织应切除，并固定胫腓骨横向固定。
术后处理踝关节骨折切开复位固定后，应在应用膝下石膏或可拆卸支撑靴前恢复活动。然后允许患者用拐杖部分负重；支撑物保留到骨折愈合（6-12周）。
联合或分离螺钉的处理仍有争议。有些人主张在韧带愈合时，在负重开始前（6周太早，10周可能更合适）取出螺钉。其他人则乐于在螺钉固定的情况下进行早期负重，接受螺钉可能断裂的事实（尤其是如果四个皮质接合）。
开放性骨折
踝关节开放性骨折带来了特殊的问题。如果骨折在早期没有复位和稳定，可能无法恢复解剖结构。因此，即使存在开放性伤口，只要软组织没有受到太严重的损伤，伤口没有受到污染，不稳定的损伤也应该通过内固定治疗。如果椎间固定风险太大，可以使用外固定器，通常作为临时跨越选择。其他方面的处理遵循第23章概述的原则。