骨科英文书籍精读（48）｜骨折晚期并发症之应力性骨折（2）
Clinical features
There may be a history of unaccustomed and repetitive activity or one of a strenuous physical exercise programme. A common sequence of events is: pain after exercise – pain during exercise – pain without exercise. Occasionally the patient presents only after the fracture has healed and may then complain of a lump (the callus).
The patient is usually healthy. The affected site may be swollen or red. It is sometimes warm and usually tender; the callus may be palpable. ‘Springing’ the bone (attempting to bend it) is often painful.
Imaging
X-RAY
Early on, the fracture is difficult to detect, but radioscintigraphy will show increased activity at the painful spot. Plain x-rays taken a few weeks later may show a small transverse defect in the cortex and/or localized periosteal new-bone formation. These appearances have, at times, been mistaken for those of an osteosarcoma, a horrifying trap for the unwary. Compression stress fractures (especially of the femoral neck and upper tibia) may show as a hazy transverse band of sclerosis with (in the tibia) peripheral callus.
Another typical picture is that of a small osteoarticular fracture – most commonly of the dome of the medial femoral condyle at the knee or the upper surface of the talus at the ankle. Later, ischaemic necrosis of the detached fragment may render the lesion even more obvious.
MRI
The earliest changes, particularly in ‘spontaneous’ undisplaced osteoarticular fractures, are revealed by MRI. This investigation should be requested in older patients (possibly with osteoporosis) complaining of sudden onset of pain over the anteromedial part of the
knee.
Diagnosis
Many disorders, including osteomyelitis, scurvy and battered baby syndrome, may be confused with stress fractures. The great danger, however, is a mistaken diagnosis of osteosarcoma; scanning shows increased uptake in both conditions and even biopsy may be misleading.
Treatment
Most stress fractures need no treatment other than an elastic bandage and avoidance of the painful activity until the lesion heals; surprisingly, this can take many months and the forced inactivity is not easily accepted by the hard-driving athlete or dancer.
An important exception is stress fracture of the femoral neck. This should be suspected in all elderly people who complain of pain in the hip for which no obvious cause can be found. If the diagnosis is con-firmed by bone scan, the femoral neck should be internally fixed with screws as a prophylactic measure.
---from 《Apley’s System of Orthopaedics and Fractures》P724
重点词汇整理：
unaccustomed/ˌʌnəˈkʌstəmd/adj. 不习惯的；奇怪的
lump /lʌmp/n. 块，块状；肿块；瘤；很多；笨人adj. 成团的；总共的vt. 混在一起；使成块状；忍耐；笨重地移动vi. 结块adv. 很；非常
periosteal/,peri'ɔstiəl/adj. 骨膜的
periostea/,perɪ'ɒstɪə/骨膜（ periosteum的名词复数 ）
horrifying trap for the unwary对粗心的人来说是可怕的陷阱
/ˈhɔːrɪfaɪɪŋ/adj. 令人极其震惊的（或厌恶的、恐惧的）v. 惊吓，（使）惊骇
unwary/ʌnˈweri/adj. 粗心的；不警惕的；不谨慎的
show as a hazy transverse band of sclerosis with (in the tibia) peripheral callus.表现为(胫骨)周围愈伤组织硬化的模糊横带。
hazy /ˈheɪzi/adj. 朦胧的；模糊的；有薄雾的
sclerosis /skləˈroʊsɪs/n. [病理] 硬化，[医] 硬化症；细胞壁硬化
render 致使；提供，回报；
undisplaced 无移位的
sudden onset of pain突然发作性疼痛
anteromedial 前内侧的
onset /ˈɑːnset/n. 开始，着手；发作；攻击，进攻
Many disorders, including osteomyelitis, scurvy and battered baby syndrome, may be confused with stress fractures. 许多疾病，包括骨髓炎、坏血病和婴儿受伤综合症，可能会与应力性骨折混淆。
biopsy /ˈbaɪɑːpsi/n. 活组织检查；活组织切片检查；切片检查法
elastic bandage 弹性绷带；橡胶绷带
elastic /ɪˈlæstɪk/n. 松紧带；橡皮圈adj. 有弹性的；灵活的；易伸缩的
hard-driving athlete or dancer. 努力的运动员或舞者
prophylactic measure.预防措施。
prophylactic /ˌproʊfəˈlæktɪk/adj. 预防性的，预防疾病的n. 预防性药物（或器具、措施）；预防法；避孕用具
百度翻译：
临床特征
可能有不习惯的重复性活动或剧烈的体育锻炼项目。常见的事件顺序是：运动后疼痛-运动中疼痛-不运动时疼痛。偶尔，病人只有在骨折愈合后才会出现，然后可能会抱怨有肿块（骨痂）。
病人通常是健康的。受影响的部位可能肿胀或发红。它有时是温暖的，通常是柔软的；可以触摸到老茧。“弹跳”骨头（试图弯曲它）通常是痛苦的。
成像
X射线
早期，骨折很难被发现，但放射造影显示疼痛部位的活动性增强。几周后的x线平片可能显示皮质有一个小的横向缺陷和/或局限性的骨膜新生骨形成。这些症状有时被误认为是骨肉瘤，是粗心大意者的可怕陷阱。压缩应力性骨折（尤其是股骨颈和胫骨上部）可能表现为（胫骨）周围骨痂模糊的硬化横带。
另一个典型的图像是一个小的骨关节骨折-最常见的是膝关节内侧股骨髁圆顶或踝关节距骨上表面。随后，分离片段的缺血坏死可能使病变更加明显。
磁共振成像
最早的变化，特别是在“自发”的无移位骨关节骨折，是由核磁共振显示。在老年患者（可能患有骨质疏松症）中，应要求进行这项调查，因为他们抱怨
膝盖。
诊断
许多疾病，包括骨髓炎、坏血病和婴儿受虐综合症，可能与应力性骨折混淆。然而，最大的危险是对骨肉瘤的错误诊断；扫描显示在这两种情况下摄取增加，甚至活检可能会误导。
治疗
大多数应力性骨折不需要治疗，只需使用弹性绷带，避免疼痛活动，直到损伤愈合；令人惊讶的是，这可能需要很多个月的时间，而且强迫不活动不容易被硬朗的运动员或舞者接受。
一个重要的例外是股骨颈应力性骨折。所有抱怨髋部疼痛但找不到明显原因的老年人都应该怀疑这一点。如果骨扫描确诊，股骨颈应用螺钉内固定作为预防措施。