骨科英文书籍精读（263）｜股骨干骨折多发伤的治疗方案
我们正在精读国外经典骨科书籍《Apley’s System of Orthopaedics and Fractures》，想要对于骨科英文形成系统认识，为以后无障碍阅读英文文献打下基础，请持续关注。
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Definitive treatment
The patient with multiple injuries
The association of femoral shaft fractures with other injuries, including head, chest, abdominal and pelvic trauma, increases the potential for developing fat embolism, ARDS and multi-organ failure. The risk of systemic complications can be significantly reduced by early stabilization of the fracture, usually by a locked intramedullary nail.
However, surgery to introduce a reamed intramedullary nail may produce untoward effects in those with severe chest injuries, especially when carried out within 24 hours of the fracture. It is thought the trauma of surgery and blood loss induces inflammatory changes that may increase both morbidity and mortality – this phenomenon is called ‘the second hit’, referring to a second episode of trauma, albeit surgical, on the patient. Consequently, in the multiplyinjured patient, particularly one with severe chest trauma, prompt stabilization with an external fixator may be wise; the fixator can be exchanged for an intramedullary nail when the patient’s condition stabilizes. The timing of this second procedure is problematic. Some guidance can be sought from measurement of circulating levels of interleukin-6, a pro-inflammatory cytokine (Pape, van Griensven et al. 2001); when the levels start to decrease, it should be safe to perform ‘second hit’ interventions. Clinically this occurs around 5–7 days after admission, but this window is by no means applicable to all patients nor is it conclusive at this time.
Performing the exchange to an intramedullary nail also carries the risk of transferring contaminants from pin sites to the intramedullary nail; the earlier the operation is performed, the lower the risk. In the patient who spends a protracted period in the intensive care unit, it may be safer to use external fixation as definitive treatment, perhaps with a return to theatre later to allow insertion of new pins to increase the stability of the construct.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
fat embolism脂肪栓塞
a reamed intramedullary nail扩髓髓内钉
ream /riːm/（用工具使孔）扩大
untoward /ʌnˈtɔːrd/adj. 不幸的；麻烦的；倔强的；困难的
untoward effects不利作用
morbidity and mortality发病率和死亡率
albeit /ˌɔːlˈbiːɪt/conj. 虽然，尽管
Consequently, /ˈkɑːnsɪkwentli/adv. 因此；结果；所以
problematic /ˌprɑːbləˈmætɪk/adj. 有疑问的；不确定的
Some guidance can be sought from measurement of circulating levels of interleukin-6, a pro-inflammatory cytokine.可以通过测量白细胞介素-6(一种促炎症细胞因子)的循环水平来寻求一些指导。
but this window is by no means applicable to all patients nor is it conclusive at this time.但这一时间窗并不适用于所有患者，也不是决定性的。
by no means决不；并没有
conclusive /kənˈkluːsɪv/adj. 决定性的；最后的；确实的；确定性的
definitive treatment根治方案；权威疗法；确定性治疗
百度翻译：
确定性治疗
多处受伤的病人
股骨干骨折与其他损伤（包括头部、胸部、腹部和骨盆创伤）相关，增加了发生脂肪栓塞、ARDS和多器官衰竭的可能性。早期稳定骨折，通常使用带锁髓内钉，可显著降低全身并发症的风险。
然而，手术引入扩髓髓髓内钉可能会对严重胸部损伤的患者产生不良影响，尤其是在骨折后24小时内进行。人们认为，手术创伤和失血会引起炎症改变，可能增加发病率和死亡率——这种现象被称为“第二次打击”，指的是患者遭受第二次创伤（尽管是手术创伤）。因此，对于多发伤患者，尤其是严重胸部创伤患者，及时用外固定架固定是明智的；当患者病情稳定后，可以用内固定架替换髓内钉。第二次手术的时机是有问题的。可以通过测量白细胞介素-6（一种860促炎细胞因子）的循环水平来寻求一些指导（Pape，van Griensven等人，2001）；当水平开始下降时，进行“二次打击”干预应该是安全的。临床上，这种情况发生在入院后5-7天左右，但这一时间窗并不适用于所有患者，也不是决定性的。
对髓内钉进行交换也有将污染物从钉位转移到髓内钉的风险；手术越早，风险越低。对于在重症监护室待了很长一段时间的患者，使用外固定作为最终治疗可能会更安全，也许稍后返回（手术室？？？），以便插入新的固定针以增加结构的稳定性。