骨科英文书籍精读（379）｜足部损伤的处理原则
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PRINCIPLES IN MANAGING INJURIES OF THE FOOT
Injuries of the foot are apt to be followed by residual symptoms and loss of function, which seem out of proportion to the initial trauma. Severe injuries affect the foot as a whole, whatever the particular bone that might be fractured. A global approach is therefore essential in dealing with these injuries, the objective being a return to full weightbearing without pain, with an appropriate propulsive gait.
Identification of these injuries is particularly challenging in the patient with multiple trauma, where the more subtle foot injuries might be missed as the lifethreatening truncal injuries and limb-threatening long bone injuries distract attention from the more subtle injuries to the foot, which may nonetheless impair eventual function.
Clinical assessment
The entire foot should be examined systematically, no matter that the injury may appear to be localized to one spot. Multiple fractures, or combinations of fractures and dislocations, are easily missed. The circulation and nerve supply must be carefully assessed; a well-reduced fracture is a useless achievement if the foot becomes ischaemic or insensitive. Similarly, attention must be paid to the soft tissues and functional movement of the foot; the stiff, painful foot is impaired for propulsion, and maybe even for stance.
Fractures and dislocations may cause tenting of the skin; this is always a bad sign because there is a risk of skin necrosis if reduction is delayed.
Imaging
Imaging routinely begins with anteroposterior, lateral and oblique x-rays of the foot. If a fracture of the talus or calcaneum, or fracture–dislocation of the midtarsal joints is suspected then special views may be helpful, but a more rewarding approach is to carry out a CT scan of the foot.
CT is especially useful for evaluating fractures of the calcaneum, and MRI is helpful in diagnosing osteochondral fractures of the talus. Familiarity with the talocalcaneal anatomy is essential if fractures of the hindfoot are to be diagnosed properly.
Treatment
Swelling is always a problem. Not only does it make clinical examination difficult, but more importantly it may lead to definitive treatment being delayed; fractures and dislocations are more difficult to reduce in a swollen foot. The principles are:
· realign and splint the foot, keep it elevated and apply Cryo-Cuff or ice-packs and intermittent pneumatic compression foot pumps;
· make the diagnosis, defining the extent of injury;
· start definitive treatment as soon as the fracture pattern is properly defined and swelling permits.
In the rehabilitation phase, if the foot has to be immobilized, exercise those joints that can be left free. Start weightbearing as soon as the patient will tolerate it, provided this will not jeopardize the reduction. If a removable splint will fit the purpose, use it so that non-weightbearing exercises can be started as soon as possible. Prolonged immobilization predisposes to stiffness, impaired function, localized osteoporosis and complex regional pain syndrome.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
propulsive /prəu'pʌlsiv/adj. 推进的；有推进力的
subtle foot injuries轻微的足部损伤
subtle /ˈsʌtl/adj. 微妙的；精细的；敏感的；狡猾的；稀薄的
truncal injuries躯干损伤
/'trʌŋkəl/adj. 树干的；躯干的
distract attention分散注意力；转移注意力 /dɪˈstrækt/vt. 转移；分心
ischaemic（局部）缺血的
painful foot is impaired for propulsion, and maybe even for stance. 疼痛的脚会影响推进力，甚至可能影响站立。
Fractures and dislocations may cause tenting of the skin;骨折和脱位可能导致皮肤帐篷状;（顶皮肤）
midtarsal跗骨间的
tarsal/'tɑ:səl/adj. 跗骨的；眼睑软骨的n. 跗骨
anatomy /əˈnætəmi/n. 解剖；解剖学；剖析；骨骼
hindfoot 后足
hind /haɪnd/adj. 后部的n. 雌鹿
definitive treatment根治方案；权威疗法；确定性治疗
intermittent pneumatic compression foot pumps;
间歇式气动压缩脚部泵;
intermittent /ˌɪntərˈmɪtənt/adj. 间歇的；断断续续的；间歇性
defining the extent of injury;界定损害程度;
define/dɪˈfaɪn/vt. 定义；使明确；规定
definite /ˈdefɪnət/adj. 一定的；确切的
rehabilitation phase康复阶段
rehabilitation /ˌriːəˌbɪlɪˈteɪʃn/；n. 复原；康复
Start weightbearing as soon as the patient will tolerate it, provided this will not jeopardize the reduction.一旦病人能忍受，就开始负重，前提是这样做不会危及复位。
jeopardize /ˈdʒepərdaɪz/vt. 危害；使陷危地；使受危困
Prolonged immobilization predisposes to stiffness, impaired function, localized osteoporosis and complex regional pain syndrome.
长期固定容易导致僵硬、功能受损、局部骨质疏松症和复杂的局部疼痛综合征。
有道翻译（仅供参考，建议自己翻译）：
脚外伤的管理原则
脚部损伤后容易出现残留症状和功能丧失，这似乎与最初的创伤不相称。严重的损伤会影响整个脚，无论哪种特定的骨头可能骨折。因此，在处理这些损伤时，全球的方法是必不可少的，目标是恢复完全负重而无疼痛，并采取适当的推进步态。
在多发伤患者中，这些损伤的识别尤其具有挑战性，因为危及生命的躯干损伤和威胁长骨损伤的肢体会分散注意力，从而分散注意力，使注意力从更微妙的脚损伤转移，但这可能损害最终功能。
临床评估
无论损伤似乎局限于一个部位，都应系统地检查整个脚部。多处骨折，或骨折和位错的组合，很容易被遗漏。必须仔细评估循环和神经供应；如果脚变得缺血或麻木，骨折的程度很好就没有用了。同样，必须注意脚的软组织和功能运动；僵硬的、疼痛的脚由于推进而受损，甚至可能是为了站立。
骨折和脱位可能导致皮肤的张力；这总是一个坏信号，因为如果减少延迟，有皮肤坏死的危险。
成像
影像学通常从前倾、外侧和斜视的足部x光开始。如果怀疑距骨或跟骨骨折或骨折-跗骨关节脱位，则特殊的观点可能会有帮助，但更有益的方法是对脚进行CT扫描。
CT对跟骨骨折的诊断尤为有用，MRI对诊断距骨软骨骨折有一定的帮助。如果要正确诊断后脚骨折，熟悉距骨解剖是必不可少的。
治疗
肿胀总是个问题。不仅使临床检查困难，更重要的是它可能导致最终治疗延迟；肿胀的脚更难减少骨折和脱位。原则是：
·重新调整和夹板脚，保持脚部升高，并使用冷冻袖口或冰袋和间歇气动压缩脚泵；
·作出诊断，确定损伤程度；
·一旦骨折部位定义正确，且允许肿胀，立即开始最终治疗。
在康复阶段，如果脚必须固定，那么就可以自由地锻炼那些关节。只要患者能容忍，就立即开始负重，前提是这不会危及减重。如果可拆卸夹板符合此目的，请使用它，以便尽快开始非负重练习。长期固定容易导致僵硬、功能受损、局部骨质疏松和复杂区域疼痛综合征。