骨科英文书籍精读（338）｜胫骨平台骨折的治疗（1）
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Treatment
Treatment by traction is simple and often produces a well-functioning knee, but residual angulation is not uncommon (Apley, 1979). On the other hand, obsessional surgery to restore the shattered surface may
produce a good x-ray appearance – and a stiff knee, especially if the operation is followed by prolonged immobilization (Fig. 30.19).
Type 1 fractures
Undisplaced type 1 fractures can be treated conservatively. The haemarthrosis is aspirated and a compression bandage is applied. The limb is rested on a continuous passive motion (CPM) machine and knee movements are begun. As soon as the acute pain and swelling have subsided (usually within 1 week), a hinged cast-brace is fitted and the patient is allowed up; however, weightbearing is not allowed for another 3 weeks. Thereafter, partial weightbearing is permitted but full weightbearing is delayed until the fracture has healed (usually around 8 weeks).
Displaced fractures should be treated by open reduction and internal fixation.
The condylar surface is examined and trapped fragments are released or removed. The aim is for an accurate reduction; two lag screws or a buttress plate are usually sufficient for fixation.
Type 2 fractures
If depression is slight (less than 5 mm) and the knee is not unstable, or if the patient is old and frail or osteoporotic, the fracture is treated closed with the aim of regaining mobility and function rather than anatomical restitution. After aspiration and compression bandaging, skeletal traction is applied via a threaded pin passed through the tibia 7 cm below the fracture. An attempt is made to squeeze the condyle into shape; the knee is then flexed and extended several times to 'mould’ the upper tibia on the opposing femoral condyle. The leg is cradled on pillows and, with 5 kg traction in place, active exercises are carried out every day. As soon as the fracture is 'sticky’ (usually at 3–4 weeks), the traction pin is removed, a hinged cast-brace is applied and the patient is allowed up on crutches. Full weightbearing is deferred for another 6 weeks.
In younger patients, and more so in those with a central depression of more than 5 mm, open reduction with elevation of the plateau and internal fixation is often preferred. A midline incision offers good exposure – together with a limited transverse arthrotomy beneath the lateral meniscus; the joint is seen to allow a check on the quality of reduction. Bone graft or a similar substitute is needed to support the elevated fragments. Small 3.5 mm screws placed in parallel just beneath the subchondral bone hold up the elevated fragments well (these are sometimes referred to as 'raft’ screws, describing the arrangement of parallel screws, Fig. 30.20).
Alternatively cannulated screws can be used. The wedge of lateral condyle is then fixed with a buttress plate – newer designs of contoured and angle-stable plates (using screws that lock into the plate) are available but are not always necessary – and early knee movement is encouraged after surgery (Fig. 30.21). A CPM machine can help with the regime of passive exercise to complement the active work; at 2 weeks the patient is allowed up in a cast-brace, which is retained until the fracture has united.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
shattered /ˈʃætərd/adj. 破碎的；极度疲劳的
shattered surface破碎的关节面
continuous passive motion (CPM) machine连续被动运动(CPM)机器
trapped fragments被困的片段（滞留的骨碎片）
trap /træp/n. （捕捉动物的）陷阱，捕捉器；圈套vt. 使……陷入险境或困境；绊住；捕捉
anatomical restitution解剖复位
restitution /ˌrestɪˈtuːʃn/n. 恢复；赔偿；归还
threaded pin 螺纹针
/θred/n. 线；螺纹；思路；衣服；线状物；玻璃纤维；路线vt. 穿过；穿线于；使交织vi. 通过；穿透过
threat /θret/n. 威胁，恐吓；凶兆
squeeze /skwiːz/v. 挤；紧握；勒索
cradled on pillows 放在枕头上
cradle /ˈkreɪdl/n. 摇篮；发源地；发祥地；支船架vt. 抚育；把...搁在支架上；把...放在摇篮内
midline incision正中切口
midline /ˈmɪdˌlaɪn/n. 中线；中间线
transverse arthrotomy 横关节切开术
'raft’ screws, describing the arrangement of parallel screws“竹筏”螺钉，用来描述平行螺钉的排列方式
raft/ræft/n. 筏；救生艇；（美）大量vt. 筏运；制成筏
Alternatively cannulated screws can be used.也可以使用空心螺钉
Alternatively /ɔːlˈtɜːrnətɪvli/adv. 要不，或者；非此即彼；二者择一地；作为一种选择
buttress plate支撑钢板
/ˈbʌtrəs/n. 扶壁；山边扶壁状凸出部分；支持力量v. 支持；用扶壁支撑（建筑物等）
contour /ˈkɑːntʊr/n. 轮廓；等高线；周线；电路；概要vt. 画轮廓；画等高线
A CPM machine can help with the regime of passive exercise to complement the active workCPM机器可以帮助被动锻炼的制度，以补充主动工作。
regime /reɪˈʒiːm/n. 政权，政体；社会制度；管理体制
有道翻译（仅供参考，建议自己翻译）：
治疗
牵引治疗很简单，通常能产生功能良好的膝关节，但残余成角并不少见（Apley，1979）。另一方面，强迫症手术修复破碎的表面可能
产生良好的x光外观-和僵硬的膝盖，特别是如果手术后长时间固定（图30.19）。
1型骨折
未移位的1型骨折可以保守治疗。吸出血肿并用绷带压迫。肢体在持续被动运动（CPM）机器上休息，膝盖开始运动。一旦急性疼痛和肿胀消退（通常在1周内），安装铰链式石膏支架，允许患者起身；但是，3周内不允许负重。此后，允许部分负重，但延迟完全负重，直到骨折愈合（通常约8周）。
移位骨折应采用切开复位内固定治疗。
检查髁突表面，释放或移除截留的碎片。目的是精确复位；两个拉力螺钉或一个支撑钢板通常足以固定。
2型骨折
如果凹陷轻微（小于5毫米），膝关节不稳定，或者患者年老体弱或骨质疏松，骨折闭合治疗的目的是恢复活动能力和功能，而不是解剖恢复。抽吸和加压包扎后，通过穿过骨折下方7 cm胫骨的螺纹钉进行骨骼牵引。尝试将髁状突挤压成形；然后将膝盖弯曲并伸展几次，以在相对的股骨髁上“塑造”上胫骨。腿放在枕头上，在5公斤的牵引力下，每天进行积极的锻炼。一旦骨折“粘滞”（通常在3-4周），牵引销被移除，一个铰链铸造支架被应用，病人被允许拄着拐杖。完全负重推迟6周。
对于较年轻的患者，尤其是中央凹陷大于5mm的患者，通常首选切开复位加高原抬高和内固定。中线切口提供良好的暴露-加上外侧半月板下方有限的横向关节切开术；可以看到关节以检查复位质量。需要骨移植或类似的替代物来支撑升高的碎片。平行放置在软骨下骨下方的3.5 mm小螺钉能很好地支撑升高的碎片（这些螺钉有时被称为“筏式”螺钉，描述平行螺钉的排列，图30.20）。
或者可以使用空心螺钉。然后用支撑板固定外侧髁的楔块-可以使用轮廓稳定和角度稳定的新型钢板（使用锁定在钢板中的螺钉），但并不总是必要的-并且鼓励术后早期膝关节运动（图30.21）。CPM机器可以帮助被动运动，以补充主动工作；2周时，允许患者使用石膏支撑，直到骨折愈合。