骨科英文书籍精读（291）｜股骨远端骨折的治疗
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Treatment
Non-operative If the fracture is only slightly displaced and extra-articular, or if it reduces easily with the knee in flexion, it can be treated quite satisfactorily by traction through the proximal tibia; the limb is cradled on a Thomas’ splint with a knee flexion piece and movements are encouraged. If the distal fragment is displaced by gastrocnemius pull, a second pin above the knee, and vertical traction, will correct this. At 4–6 weeks, when the fracture is beginning to unite, traction can be replaced by a cast-brace and the patient allowed up and partially weightbearing with crutches. Nonoperative treatment should be considered as an option if the patient is young or the facilities and skill to treat by internal fixation are absent. Elderly patients tend not do as well with the 6 weeks of enforced recumbency.
Surgery
Operative treatment with internal fixation can enable accurate fracture reduction, especially of the joint surface, and early movement. If the necessary facilities and skill are available, this is the treatment of choice. For the elderly, early mobilization is so important that internal fixation is almost obligatory. Sometimes the hold on osteoporotic bone is poor (despite modern implant designs) or the patient may be old and frail, making early mobilization difficult or risky, but nursing in bed is made easier and knee movements can be started sooner.
Several different devices are available:
1. Locked intramedullary nails which are introduced retrograde through the intercondylar notch – these are suitable for the type A and simpler type C fractures.
2. Plates that are applied to the lateral surface of the femur: traditional angled blade-plates or 95 degree condylar screw-plates. They are suitable for type A and the simpler type C fractures. For severely comminuted type C fractures, the newer plate designs with locking screws appear to offer an advantage over other implants; they provide adequate stability, even in the presence of osteoporotic bone, but (as with compression plates) unprotected weightbearing is best avoided until union is assured.
3. Simple lag screws – these suffice for type B fractures and are inserted in parallel, with the screw heads buried within the articular cartilage to avoid abrading the opposing joint surface. They are also used to hold the femoral condyles together in type C fractures before intramedullary nails or lateral plates are used to hold the main supracondylar break (Figure 29.33).
Knee movements are started soon after operation, if wound healing allows. This limits adhesions forming within the knee joint.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
/əˈbreɪd/
vt. 擦伤；磨损
vi. 经受磨损；受擦伤
百度翻译：
治疗
非手术性如果骨折只是轻微移位和关节外，或者如果在屈膝时骨折很容易缩小，则可以通过胫骨近端的牵引进行治疗；将肢体托起在带有膝关节屈曲块的托马斯夹板上，并鼓励活动。如果远端骨折被腓肠肌牵拉断开，膝盖上方的第二个销钉和垂直牵引将纠正这种情况。在4-6周，当骨折开始愈合时，牵引可以用石膏支架代替，患者可以用拐杖站立并部分负重。如果患者年轻或缺乏内固定治疗的设备和技能，应考虑非手术治疗。老年患者在6周的强制卧姿中往往表现不佳。
手术治疗
手术治疗加内固定可使骨折准确复位，尤其是关节面，并能早期活动。如果有必要的设施和技能，这是治疗的选择。对于老年人来说，早期活动非常重要，内固定几乎是强制性的。有时，对骨质疏松骨的保持力很差（尽管有现代的植入物设计），或者患者可能年老体弱，使早期活动困难或有风险，但在床上护理更容易，膝关节活动可以更快开始。
有几种不同的设备可供选择：
1、经髁间切口逆行引入的交锁髓内钉适用于A型和C型骨折。
2、应用于股骨外表面的钢板：传统的斜刃钢板或95度髁螺钉钢板。适用于A型和较简单的C型骨折。对于严重粉碎性C型骨折，较新的带锁定螺钉的钢板设计似乎比其他植入物更具优势；即使在骨质疏松的情况下，它们也能提供足够的稳定性，但是（与加压钢板一样）在确保愈合之前，最好避免无保护的负重。
3、简单的拉力螺钉-这些螺钉足以治疗B型骨折，并平行插入，螺钉头埋入关节软骨内，以避免磨损相对的关节面。在使用髓内钉或侧板固定主髁上骨折之前，它们还用于将C型骨折中的股骨髁固定在一起（图29.33）。
如果伤口愈合允许的话，术后很快就会开始膝关节活动。这限制了膝关节内形成的粘连。