骨科英文书籍精读（132）｜腕舟骨骨折（4）
Complications
Avascular necrosis
The proximal fragment may die, especially with proximal pole fractures, and then at 2–3 months it appears dense on x-ray. Although revascularization and union are theoretically possible, they take years and meanwhile the wrist collapses and arthritis develops. Bone grafting, as for delayed union, may be successful, in which case the bone, though abnormal, is structurally intact. If the wrist becomes painful, the dead fragment can be excised. However, the wrist tends to collapse after this procedure; a better option would be to remove the entire proximal row of carpal bones or else to remove the scaphoid and fuse the proximal to the distal row (four-corner fusion: capitate–hamate–triquetrum–lunate).
Non-union
By 3 months it may be obvious that the fracture will not unite. Bone grafting should be attempted, especially in the younger, more vigorous type of patient, because this probably reduces the chance of later, symptomatic osteoarthritis. Two types of graft are used. If the scaphoid has folded into a flexed ‘humpback’ shape, then it is approached from the front and a wedge of cortico-cancellous iliac crest graft is inserted to restore the shape of the bone. The graft is fixed with a buried screw and/or K-wires. If the scaphoid has not collapsed, the graft is inserted into a trough carved into the front of the scaphoid and again stabilized with a screw or wires. If these techniques fail to achieve union then the options are a vascularized bone graft, scaphoidectomy with proximal-to-distal-row (four-corner) fusion, proximal row carpectomy or radio-carpal arthrodesis.
In older patients, and those who are completely asymptomatic, non-union may be left untreated. Sometimes a patient is seen for the first time with a ‘sprain’, but x-rays show an old, un-united fracture with sclerosed edges; 3–4 weeks in plaster may suffice to make him or her comfortable once again, and no further treatment is required.
Osteoarthritis
Non-union or avascular necrosis may lead to secondary osteoarthritis of the wrist. If the arthritis is localized to the distal pole, excising the radial styloid may help. As the arthritis progresses, changes appear in the scapho-capitate joint then the capitate-lunate joint. The lunate-radius joint is never affected, thus allowing salvage procedures – either
proximal row carpectomy or four-corner fusion.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
theoretically possible理论上可行
theoretically /ˌθiːəˈretɪkli/adv. 理论地；理论上
capitate–hamate–triquetrum–lunate
头状骨，钩状骨，三角骨，月骨
vigorous/ˈvɪɡərəs/adj. 有力的；精力充沛的
a wedge of cortico-cancellous iliac crest graft 楔形骨皮质松质髂骨移植物
cancellous /kænsələs/adj. 多孔的；罗眼状的
iliac /ˈɪliˌæk/adj. 髂的；肠骨的；回肠的
crest /krest/n. [物] 波峰；冠；山顶；顶饰vi. 到达绝顶；形成浪峰
buried screw 埋头钉
trough /trɔːf/n. 水槽；饲料槽；低谷期；低气压；波谷
a vascularized bone graft,带血管蒂的骨移植，
carpectomy腕骨切除术
arthrodesis /ɑ:'θrɔdəsis/关节固定术 关节融合术
asymptomatic /ˌeɪsɪmptəˈmætɪk/adj. 无症状的
suffice /səˈfaɪs/vt. 使满足；足够…用；合格vi. 足够；有能力
salvage/ˈsælvɪdʒ/n. 打捞；海上救助；抢救财货；救难的奖金vt. 抢救；海上救助
百度翻译：
难题
缺血性坏死
近端骨折可能会死亡，尤其是近端极骨折，然后在2-3个月时，在x光片上表现为致密。虽然血管重建和愈合在理论上是可能的，但它们需要数年的时间，同时手腕塌陷，关节炎发展。对于延迟愈合，骨移植可能是成功的，在这种情况下，骨虽然异常，但结构完整。如果手腕疼痛，可以切除死亡的碎片。然而，腕关节在这个手术后容易塌陷；一个更好的选择是移除整个近端的腕骨行，或者移除舟骨并融合远端行的近端（四角融合：头状-钩状-三叉-月骨）。
不愈合
到3个月时，骨折可能明显不愈合。应尝试植骨，尤其是在年轻、精力旺盛的患者中，因为这可能会减少以后出现症状性骨关节炎的几率。有两种类型的移植物。如果舟状骨折叠成弯曲的驼背形，则从前面接近舟状骨，并插入皮质松质髂嵴楔状植骨块以恢复骨的形状。移植物用埋入式螺钉和/或K-线固定。如果舟状骨没有塌陷，将移植物插入舟骨前部的槽中，再用螺丝钉或金属丝固定。如果这些技术不能实现愈合，则可选择血管化骨移植、舟状骨切除加近端至远端行（四角）融合、近排腕关节切除术或放射性腕关节融合术。
对于老年患者，以及那些完全没有症状的患者，骨不连可能得不到治疗。有时患者第一次出现“扭伤”，但x光片显示陈旧、不愈合的骨折，边缘硬化；用石膏敷3-4周就足以使他或她再次感到舒适，无需进一步治疗。
骨关节炎
不愈合或缺血性坏死可导致继发性腕关节炎。如果关节炎局限于远端，切除桡骨茎突可能会有所帮助。随着关节炎的发展，肩胛骨-头状关节和头-月骨关节发生变化。月骨-桡骨关节不会受到影响，因此允许进行补救程序-或者近排腕骨切除或四角融合术。