骨科英文书籍精读（36）｜骨折晚期并发症之骨不连
NON-UNION
In a minority of cases delayed union gradually turns into non-union that is it becomes apparent that the fracture will never unite without intervention. Movement can be elicited at the fracture site and pain
diminishes; the fracture gap becomes a type of pseudoarthrosis.
X-ray The fracture is clearly visible but the bone on either side of it may show either exuberant callus or atrophy. This contrasting appearance has led to nonunion being divided into hypertrophic and atrophic types. In hypertrophic non-union the bone ends are enlarged, suggesting that osteogenesis is still active but not quite capable of bridging the gap. In atrophic non-union, osteogenesis seems to have ceased. The bone ends are tapered or rounded with no suggestion of new bone formation.
Causes
When dealing with the problem of non-union, four questions must be addressed. They have given rise to the acronym CASS:
1. Contact – Was there sufficient contact between the fragments?
2. Alignment – Was the fracture adequately aligned, to reduce shear?
3. Stability – Was the fracture held with sufficient stability?
4. Stimulation – Was the fracture sufficiently ‘stimulated’? (e.g. by encouraging weightbearing).
There are, of course, also biological and patientrelated reasons that may lead to non-union: (1) poor soft tissues (from either the injury or surgery); (2)local infection; (3) associated drug abuse, anti-inflammatory or cytotoxic immunosuppressant medication and (4) non-compliance on the part of the patient.
Treatment
CONSERVATIVE
Non-union is occasionally symptomless, needing no treatment or, at most, a removable splint. Even if symptoms are present, operation is not the only answer; with hypertrophic non-union, functional bracing may be sufficient to induce union, but splintage often needs to be prolonged. Pulsed electromagnetic fields and low-frequency, pulsed ultrasound can also be used to stimulate union.
OPERATIVE
With hypertrophic non-union and in the absence of deformity, very rigid fixation alone (internal or external) may lead to union. With atrophic non-union, fixation alone is not enough. Fibrous tissue in the fracture gap, as well as the hard, sclerotic bone ends is excised and bone grafts are packed around the fracture. If there is significant ‘die-back’, this will require more extensive excision and the gap is then dealt with by bone advancement using the Ilizarov technique.
---from 《Apley’s System of Orthopaedics and Fractures》P6716-718
重点词汇整理：
elicit /ɪˈlɪsɪt/vt. 抽出，引出；引起
diminish/dɪˈmɪnɪʃ/vt. 使减少；使变小vi. 减少，缩小；变小
pseudoarthrosis假关节
pseudo/ˈsuːdoʊ/n. 伪君子；假冒的人adj. 冒充的，假的
arthrosis /ɑ:'θrəusis/n. [解剖] 关节；[外科] 关节病
exuberant /ɪɡˈzuːbərənt/adj. 精力充沛的，热情洋溢的；兴高采烈的；繁茂的，茂盛的；充满生气的，鲜艳的；充满活力和想象力的
atrophy/ˈætrəfi/n. 萎缩，萎缩症；发育停止vi. 萎缩；虚脱
hypertrophic and atrophic肥厚性和萎缩性
trophic /ˈtroʊfɪk/adj. 营养的；有关营养的
hyper-大，多
a-否定前缀
osteogenesis /,ɔstiəu'dʒenisis/n. [生理] 骨生成
tapered or rounded 锥形和圆形
tapered/'tepɚd/adj. 锥形的v. 逐渐变少（taper的过去式和过去分词）
suggestion细微的迹象；建议；示意；微量
acronym /ˈækrənɪm/
acro 最高；顶点；开头
anti-inflammatory or cytotoxic immunosuppressant medication抗炎或细胞毒性免疫抑制药物
non-compliance /,nɔnkəm'plaiəns/n. 不服从，不顺从
Pulsed electromagnetic fields and low-frequency, pulsed ultrasound can also be used to stimulate union.脉冲电磁场和低频、脉冲超声波也可以用来刺激愈合。
deformity /dɪˈfɔːrməti/n. 畸形；畸形的人或物；道德方面的缺陷
rigid fixation坚强内固定
Fibrous tissue 纤维组织/ˈfaɪbrəs/adj. 纤维的，纤维性的；纤维状的
sclerotic /skləˈrɑːtɪk/n. [解剖] 巩膜；硬化剂adj. 硬化的，僵硬的；巩膜的
bone advancement/transportment 骨搬运
百度翻译：
骨不连
在少数病例中，延迟愈合逐渐转变为不愈合，也就是说，很明显骨折在没有干预的情况下永远不会愈合。骨折处可引起活动和疼痛
减少；骨折间隙变为假关节病。
X光片骨折清晰可见，但骨折两侧的骨头可能显示出大量的骨痂或萎缩。这种反差的外观导致非愈合分为肥厚型和萎缩型。在肥大性骨不连中，骨末端增大，这表明成骨仍然活跃，但不能很好地弥合间隙。在萎缩性不愈合中，成骨作用似乎已经停止。骨端呈锥形或圆形，没有新骨形成的迹象。
致病因素
在处理不结盟问题时，必须解决四个问题。它们产生了首字母缩写CASS：
1、接触-碎片之间是否有足够的接触？
2、对齐-断裂是否充分对齐，以减少剪切？
3、稳定性-骨折是否有足够的稳定性？
4、刺激-骨折是否足够“刺激”？（例如鼓励负重）。
当然，也有可能导致不愈合的生物学和患者相关原因：（1）软组织不良（损伤或手术所致）；（2）局部感染；（3）相关药物滥用、抗炎或细胞毒性免疫抑制剂治疗；（4）患者不依从。
治疗
保守
不愈合有时是无症状的，不需要治疗，或最多，一个可移动夹板。即使出现症状，手术也不是唯一的解决办法；对于肥厚性不愈合，功能性支撑可能足以诱导愈合，但夹板期往往需要延长。脉冲电磁场和低频脉冲超声波也可用于刺激结合。
手术
对于肥大性不愈合和无畸形的情况，单独非常坚固的固定（内固定或外固定）可能导致愈合。对于萎缩性不愈合，光靠修复是不够的。骨折间隙中的纤维组织以及坚硬、硬化的骨端被切除，骨折周围填充了骨移植。如果有明显的“退行性变”，这将需要更广泛的切除，然后使用Ilizarov技术通过骨推进来处理间隙。