骨科英文书籍精读（66）｜肩关节前脱位（2）
Treatment
Various methods of reduction have been described, some of them now of no more than historical interest. In a patient who has had previous dislocations, simple traction on the arm may be successful. Usually, sedation and occasionally general anaesthesia is required.
With Stimson’s technique, the patient is left prone with the arm hanging over the side of the bed. After 15 or 20 minutes the shoulder may reduce.
In the Hippocratic method, gently increasing traction is applied to the arm with the shoulder in slight abduction, while an assistant applies firm countertraction to the body (a towel slung around the patient’s chest, under the axilla, is helpful).
With Kocher’s method, the elbow is bent to 90° and held close to the body; no traction should be applied. The arm is slowly rotated 75 degrees laterally, then the point of the elbow is lifted forwards, and finally the arm is rotated medially. This technique carries the risk of nerve, vessel and bone injury and is not recommended.
Another technique has the patient sitting on a reduction chair and with gentle traction of the arm over the back of the padded chair the dislocation is reduced.
An x-ray is taken to confirm reduction and exclude a fracture. When the patient is fully awake, active abduction is gently tested to exclude an axillary nerve injury and rotator cuff tear. The median, radial, ulnar
and musculocutaneous nerves are also tested and the pulse is felt.
The arm is rested in a sling for about three weeks in those under 30 years of age (who are most prone to recurrence) and for only a week in those over 30 (who are most prone to stiffness). Then movements are begun, but combined abduction and lateral rotation must be avoided for at least 3 weeks. Throughout this period, elbow and finger movements are practised every day.
There has been some interest in the use of external rotation splints, based on the theory that this would reduce the Bankart lesion into a better position for healing. However a recent Cochrane review has concluded that there is insufficient evidence to inform on the choices for conservative treatment and that further trials are needed to compare different types and duration of immobilization.
Young athletes who dislocate their shoulder traumatically and who continue to pursue their sports (particularly contact sports) are at a much higher risk of re-dislocation in the future. With increasing advances and techniques of arthroscopy and arthroscopic anterior stabilization surgery, some are now advocating early surgery in this group of patients to repair the Bankart lesion of the anterior labrum. However a consensus on early surgery has still not been reached.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
some of them now of no more than historical interest.其中一些现在只有历史价值。
sedation /sɪˈdeɪʃn/n. 镇静；镇静作用；镇静状态
prone /proʊn/adj. 俯卧的；有…倾向的，易于…的
countertraction对抗牵引
padded chair 有坐垫的椅子
An x-ray is taken to confirm reduction and exclude a fracture. 进行x光检查以确认复位并排除骨折。
rotator cuff tear肩袖撕裂
musculocutaneous nerve肌皮神经
Throughout /θruːˈaʊt/prep. 自始至终；遍及adv. 自始至终；遍及
duration of immobilization.固定的时间。
consensus /kənˈsensəs/n. 一致；舆论；合意
reach a consensus 达成一致意见
百度翻译：
治疗
已经描述了各种还原方法，其中一些现在只不过是历史意义上的。对于曾经有过脱臼的病人，简单的手臂牵引可能是成功的。通常情况下，需要镇静和偶尔全身麻醉。
根据Stimson的技术，病人可以俯卧，手臂悬在床边。15或20分钟后，肩部可能会减少。
在希波克拉底法中，轻微外展时，用肩膀轻轻地增加手臂的牵引力，而助手则对身体施加有力的反牵引力（在腋下，将毛巾挂在患者胸前会有帮助）。
采用Kocher方法，肘部弯曲至90°并紧贴身体；不应施加牵引力。手臂缓慢地横向旋转75度，然后肘关节向前抬起，最后手臂向内旋转。这种技术有神经、血管和骨损伤的风险，不推荐使用。
另一种方法是让患者坐在复位椅上，用手臂轻轻地牵引软垫椅的背部，从而减少脱位。
x光检查确认复位并排除骨折。当病人完全清醒时，轻轻检查主动外展以排除腋神经损伤和肩袖撕裂。正中、桡骨、尺骨肌肉皮神经也会被测试，脉搏也会被感觉到。
30岁以下的人（最容易复发）的手臂用吊带固定大约3周，30岁以上的人（最容易僵硬）只休息一周。然后开始活动，但至少3周内必须避免外展和侧向旋转。在这期间，每天都要练习手肘和手指的动作。
有人对使用外旋夹板有一些兴趣，基于这样的理论，这将减少班卡特损伤到一个更好的位置愈合。然而，最近的一项Cochrane综述得出结论，没有足够的证据来说明保守治疗的选择，还需要进一步的试验来比较不同类型和固定时间。
年轻的运动员，如果肩关节受到创伤而脱臼，并且继续从事体育运动（特别是接触性运动），将来再脱位的风险要高得多。随着关节镜和关节镜下前路稳定手术技术的不断进步，有人主张早期手术修复前唇Bankart病变。然而，对于早期手术还没有达成共识。