骨科英文书籍精读（325）｜股四头肌肌腱损伤
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RUPTURE OF QUADRICEPS TENDON
The patient is usually elderly, may have a history of diabetes or rheumatoid disease, or may have been treated with corticosteroids. Occasionally acute rupture is seen in a young athlete. The typical injury is followed by tearing pain and giving way of the knee.
There is bruising and local tenderness; sometimes a gap can be felt proximal to the patella. Active knee extension is either impossible (suggesting a complete rupture) or weak (partial rupture). The diagnosis can be confirmed by MRI.
Treatment
Partial tears
Non-operative treatment will suffice: a plaster cylinder is applied for 6 weeks, followed by physiotherapy that concentrates on restoring knee flexion and quadriceps strength.
Complete tears
Early operation is needed, or else the ruptured fibres will retract and repair will be more difficult. End-to-end suturing can be reinforced by turning down a partial-thickness triangular flap of quadriceps tendon proximal to the repair (Scuderi). If the tendon has been avulsed from the proximal pole of the patella, it should be re-attached to a trough created at that site using pull-through sutures. Postoperatively the knee is held in extension in hinged brace. Early supervised movement through the brace is important to prevent adhesions; limits to the amount of flexion can be controlled through the brace and increased as the repair heals over the next 12 weeks (Fig. 30.13).
'Chronic’ ruptures (usually the result of delayed presentations or missed diagnoses) are difficult to repair because the ends have retracted. The gap can often be made smaller by closing the medial and lateral ends, and the remaining central gap is then covered by a full-thickness V-flap turned down from the proximal quadriceps tendon (Codivilla). A pullout or cerclage wire protects the repair.
The results of acute repairs are good, with most patients regaining full power, a good range of movement and little or no extensor lag. Late repairs are less predictable.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
rheumatoid /ˌruːmətɔɪd/adj. 类风湿病的
corticosteroids /,kɔ:tikəus'tirɔid/n. [生化] 皮质类固醇，类固醇；激素，皮质甾类
giving way of the knee膝关节畸形
concentrates on restoring knee flexion and quadriceps strength.集中精力恢复膝关节屈曲和股四头肌的力量。
a partial-thickness triangular flap of quadriceps tendon 股四头肌腱部分增厚的三角皮瓣
cerclage wire 环扎钢丝
cerclage /sə:'klædʒ/n. （折骨端）环扎术
lag. /læɡ/n. 落后；迟延；防护套；囚犯；桶板vt. 给......保温vi. 滞后；缓缓而行；蹒跚adj. 最后的
有道翻译（仅供参考，建议自己翻译）：
股四头肌腱断裂
患者通常年事已高，可能有糖尿病或类风湿病史，或曾用糖皮质激素治疗。偶尔在年轻运动员身上也能看到尖锐的错误。典型的损伤是随之而来的撕裂疼痛和膝关节变形。有瘀伤和局部压痛;有时在髌骨近端可感到缝隙。主动膝关节伸展要么是不可能的(提示完全破裂)，要么是微弱的(部分破裂)。MRI可证实诊断。
治疗
部分的撕裂
非手术治疗就足够了:用石膏筒敷6周，然后进行物理治疗，主要是恢复膝关节屈曲和股四头肌的力量。
完整的撕裂
早期手术是必要的，否则破裂的纤维会缩回，修复会更加困难。端到端缝合可以通过将修复端四头肌腱近端部分厚度的三角皮瓣(Scuderi)下折来加强。如果肌腱已从髌骨近端撕脱，应使用拉穿缝合将其重新连接到该部位创建的槽上。术后用铰链式支具伸展固定膝关节。早期在监督下通过支具移动对防止粘连非常重要;可以通过支具控制屈曲量的限制，并在接下来的12周修复愈合时增加屈曲量(图30.13)。
“慢性”断裂(通常是延迟表现或误诊的结果)很难修复，因为其末端已经缩回。通常可以通过闭合内侧和外侧端来缩小间隙，然后用从近端股四头肌腱(Codivilla)向下的全层v形皮瓣覆盖剩余的中央间隙。拔出或环扎线保护修复。
急性修复的结果很好，大多数患者恢复了全部力量，活动范围良好，很少或没有伸肌滞后。迟来的修理是不可预测的。