骨科英文书籍精读（245）｜股骨转子间骨折
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INTERTROCHANTERIC FRACTURES
Intertrochanteric fractures are, by definition, extracapsular. As with femoral neck fractures, they are common in elderly, osteoporotic people; most of the patients are women in the 8th decade. However, in contrast to intracapsular fractures, extracapsular trochanteric fractures unite quite easily and seldom cause avascular necrosis.
Mechanism of injury
The fracture is caused either by a fall directly onto the greater trochanter or by an indirect twisting injury. The crack runs up between the lesser and greater trochanter and the proximal fragment tends to displace in varus.
Pathological anatomy
Intertrochanteric fractures are divided into stable and unstable varieties. In essence, unstable fractures are those where:
1. there is poor contact between the fracture fragments, as in four-part intertrochanteric types (greater and lesser trochanter, proximal and distal femoral fragments), or if the posteromedial cortex is comminuted.
2. the fracture pattern is such that forces of weightbearing continually displace the fragments further, as in those with a reverse oblique pattern or with a subtrochanteric extension.
3. osteoporosis leading to poor quality grip by the fixation implants.
The importance of fracture pattern is detailed in the classification by Kyle (1994) which distinguishes four basic patterns that reflect increasing instability and increasing difficulty at reduction and fixation (Figure 29.11).
Clinical features
The patient is usually old and is unable to stand. The leg is shorter and more externally rotated than with a transcervical fracture (because the fracture is extracapsular) and the patient cannot lift his or her leg.
X-ray
Undisplaced, stable fractures may show no more than a thin crack along the intertrochanteric line; indeed, there is often doubt as to whether the bone is fractured and the diagnosis may have to be confirmed by scintigraphy or MRI.
More often the fracture is displaced and there may be considerable comminution. The lesser and greater trochanters may be identifiable as separate fragments and this calls for caution; surgery is technically more difficult and, even with modern implants, stable fixation may be hindered because of poor bone quality.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
extracapsular/,ekstrə'kæpsjulə/adj. 囊外的
intracapsular囊内的
Intertrochanteric/,intətrəkən'terik/adj. （股骨）粗隆间的；转子间 的
In essence/ɪn ˈesns/本质上；其实；大体上
/ˈesns/n. 本质，实质；精华；香精
grip/ɡrɪp/n. 紧握；柄；支配；握拍方式；拍柄绷带vt. 紧握；夹紧vi. 抓住
transcervical fracture股骨颈骨折
cervical /ˈsɜːrvɪkl/adj. 颈的；子宫颈的
hinder/ˈhɪndər/vt. 阻碍；打扰adj. 后面的vi. 成为阻碍
百度翻译：
股骨转子间骨折
根据定义，股骨转子间骨折是囊外骨折。与股骨颈骨折一样，老年骨质疏松症患者中也很常见；大多数患者是80年代的女性。然而，与囊内骨折相比，囊外转子骨折很容易合并，很少引起缺血性坏死。
损伤机制
骨折的原因要么是直接摔在大转子上，要么是间接扭伤。裂缝在小转子和大转子之间向上延伸，近端碎片倾向于内翻。
病理解剖学
股骨转子间骨折分为稳定型和不稳定型。本质上，不稳定骨折是指：
1、骨折碎片之间接触不良，如四部分转子间型（大转子和小转子、股骨近端和远端碎片），或后内侧皮质粉碎。
2、骨折模式是指负重的力量不断地使骨折块进一步移位，如反向倾斜模式或股骨转子下延伸的骨折。
3、骨质疏松导致植入物固定质量差。
骨折类型的重要性在Kyle（1994）的分类中有详细说明，该分类区分了四种基本类型，它们反映了越来越不稳定和越来越难复位和固定（图29.11）。
临床特征
病人通常年纪大了，不能站立。与经颈骨折相比（因为骨折是沟外骨折），患者的腿较短，且更易外旋，因此无法抬起腿。
X射线
未移位、稳定的骨折沿股骨粗隆间线可能只显示一条细裂纹；事实上，常常怀疑骨头是否骨折，诊断可能需要通过闪烁扫描或MRI来证实。
更多的时候骨折移位，可能有相当大的粉碎。小转子和大转子可能是分离的碎片，这需要谨慎；手术在技术上更加困难，即使使用现代植入物，稳定的固定也可能因为较差的骨质量而受到阻碍。