骨科英文书籍精读（81）｜肱骨干骨折（2）
OPERATIVE TREATMENT
Patients often find the hanging cast uncomfortable, tedious and frustrating; they can feel the fragments moving and that is sometimes quite distressing. The temptation is to ‘do something’, and the ‘something’ usually means an operation. It is well to remember (a) that the complication rate after internal fixation of the humerus is high and (b) that the great majority of humeral fractures unite with non-operative treatment. (c) There is no good evidence that the union rate is higher with fixation (and the rate may be lower if there is distraction with nailing or periosteal stripping with plating). There are, nevertheless, some well defined indications for surgery:
· severe multiple injuries
· an open fracture
· segmental fractures
· displaced intra-articular extension of the fracture
· a pathological fracture
· a ‘floating elbow’ (simultaneous unstable humeral and forearm fractures)
· radial nerve palsy after manipulation
· non-union
· problems with nursing care in a dependent person.
Fixation can be achieved with either (1) a compression plate and screws, (2) an interlocking intramedullary nail or semi-flexible pins, or (3) an external fixator.
Plating permits excellent reduction and fixation, and has the added advantage that it does not interfere with shoulder or elbow function. However, it requires wide dissection and the radial nerve must be protected. Too much periosteal stripping or inadequate fixation will probably increase the risk of non-union.
Antegrade nailing is performed with a rigid interlocking nail inserted through the rotator cuff under fluoroscopic control. It requires minimal dissection but has the disadvantage that it causes rotator cuff problems in a significant proportion of cases (the reported incidence ranges from 5–40 percent). The nail can also distract the fracture which will inhibit union; if this happens, exchange nailing and bone grafting of the fracture may be needed.
Retrograde nailing with multiple flexible rods is not entirely stable. Retrograde nailing with an interlocking nail is suitable for some fractures of the middle third.
External fixation may be the best option for highenergy segmental fractures and open fractures. However, great care must be taken in placing the pins as the radial nerve is vulnerable.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
tedious /ˈtiːdiəs/adj. 沉闷的；冗长乏味的
temptation /tempˈteɪʃn/n. 引诱；诱惑物
distraction /dɪˈstrækʃn/n. 注意力分散；消遣；心烦意乱
defined indications for surgery明确的手术指征
simultaneous /ˌsaɪmlˈteɪniəs/n. 同时译员adj. 同时的；联立的；同时发生的
palsy/ˈpɔːlzi/n. 麻痹，麻痹状态；中风vt. 麻痹；使瘫痪
dissection /dɪˈsekʃn,daɪˈsekʃn/n. 解剖，切开；解剖体；详细查究
Antegrade 前进的;顺行的
fluoroscopic /'flu（:）ərəskɔpik/adj. 荧光镜的；荧光检查法的
Retrograde /ˈretrəɡreɪd/adj. 倒退的；退化的；次序颠倒的vt. 使倒退
adv. 倒退地；向后地vi. 逆行；倒退；退步
vulnerable./ˈvʌlnərəbl/adj. 易受攻击的，易受…的攻击；易受伤害的；有弱点的
百度翻译：
手术治疗
患者经常发现悬挂的演员不舒服，乏味和令人沮丧；他们可以感觉到碎片在移动，有时会非常痛苦。诱惑是“做一些事情”，而“某些事情”通常意味着一种手术。最好记住（a）肱骨内固定术后并发症发生率高，（b）绝大多数肱骨骨折与非手术治疗相结合。（c） 没有充分的证据表明固定时愈合率更高（如果用钉子或电镀骨膜剥离分散，则愈合率可能更低）。然而，有一些明确的手术指征：
·严重多处受伤
·开放式骨折
·节段性骨折
·骨折的关节内移位
·病理性骨折
·一个“浮动肘”（同时不稳定的肱骨和前臂骨折）
·操作后桡神经麻痹
·不结合
·受抚养人的护理问题。
可以用（1）压缩板和螺钉，（2）互锁髓内钉或半柔性销，或（3）外固定器来实现固定。
电镀可实现出色的复位和固定，并具有不会干扰肩部或肘部功能的额外优势。然而，它需要广泛的解剖，并且必须保护桡神经。过多的骨膜剥离或固定不充分可能会增加不愈合的风险。
顺行钉是在透视控制下通过肩袖插入刚性锁定钉进行的。它需要最少的解剖，但缺点是在很大一部分病例中会引起肩袖问题（报告的发病率在5%至40%之间）。指甲还可以分散骨折，这将抑制愈合；如果发生这种情况，可能需要交换钉和骨折的骨移植。
带有多个柔性杆的逆行钉并不完全稳定。带有互锁钉的逆行钉适用于中间三分之一的一些骨折。
外固定可能是高能量节段性骨折和开放性骨折的最佳选择。然而，由于桡神经脆弱，必须非常小心地放置销钉。