骨科英文书籍精读（348）｜低能量胫腓骨骨折的处理（1）
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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Management
The main objectives are: (1) to limit soft-tissue damage and preserve (or restore, in the case of open fractures) skin cover; (2) to prevent – or at least recognize – a compartment syndrome; (3) to obtain and hold fracture alignment; (4) to start early weightbearing (loading promotes healing); (5) to start joint movements as soon as possible.
The first step is to gain a clear idea of the character of the injury – what some have called the 'fracturepersonality’ – which is a combination of the soft tissue condition and fracture pattern. Uncomminuted, spiral fractures with minimal soft-tissue damage (including open injuries like Gustilo I) are likely to heal with a minimum of trouble; they can be treated conservatively unless there is a definite indication for surgery (see later). Fractures associated with severe soft-tissue damage (whether open or closed) and unstable fracture patterns need much more careful attention if complications are to be avoided.
LOW-ENERGY FRACTURES
Most low-energy fractures, including Gustilo I injuries after attention to the wounds, can be treated by non-operative methods.
If the fracture is undisplaced or minimally displaced, a full-length cast from upper thigh to metatarsal necks is applied with the knee slightly flexed and the ankle at a right angle (Fig. 30.26). Displacement of the fibular fracture, unless it involves the ankle joint, is unimportant and can be ignored.
If the fracture is displaced, it is reduced under general anaesthesia with x-ray control. Apposition need not be complete but alignment must be near-perfect (no more than 7 degrees of angulation) and rotation absolutely perfect. A full-length cast is applied as for undisplaced fractures (note, however, that if placing the ankle at 0 degrees causes the fracture to displace, a few degrees of equinus are acceptable). The position is checked by x-ray; minor degrees of angulation can still be corrected by making a transverse cut in the plaster and wedging it into a better position.
The limb is elevated and the patient is kept under observation for 48–72 hours. If there is excessive swelling, the cast is split. Patients are usually allowed up (and home) on the second or third day, bearing minimal weight with the aid of crutches. The immediate application of plaster may be unwise if skin viability is doubtful, in which case a few days on skeletal traction is useful as a preliminary measure (Fig.30.27).
After 2 weeks the position is checked by x-ray. A change from an above- to a below-the-knee cast is possible around 4–6 weeks, when the fracture becomes 'sticky’. The cast is retained (or renewed if it becomes loose) until the fracture unites, which is around 8 weeks in children but seldom under 12 weeks in adults.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
loading promotes healing负重促进骨愈合
metatarsal /ˌmetəˈtɑːrsl/n. 跖骨adj. 跖骨的
Apposition need not be complete but alignment must be near-perfect and rotation absolutely perfect.对位不必完全，但对线必须接近完美，旋转必须完全纠正。
Apposition /ˌæpəˈzɪʃn/n. 并置，同格；同位语
equinus 马蹄足（一种发育性畸形）
wedging /ˈwedʒɪŋ/v. 楔入；挤进（wedge的ing形式）
viability /ˌvaɪəˈbɪləti/n. 生存能力，发育能力；可行性
preliminary measure初步措施
preliminary /prɪˈlɪmɪneri/adj. 初步的；开始的；预备的n. 初步行动；准备工作；预赛，预试
The cast is retained (or renewed if it becomes loose) until the fracture unites石膏会被保留(如果石膏松动则会进行更新)，直到骨折愈合
有道翻译（仅供参考，建议自己翻译）：
骨折处理
其主要目的是：（1）限制软组织损伤并保留（或恢复开放性骨折的皮肤覆盖物）；（2）预防或至少认识到骨筋膜室综合征；（3）获得并保持骨折对齐；（4）开始早期负重（负重促进愈合）；（5） 尽快开始关节活动。
第一步是对损伤的特征有一个清晰的认识，也就是一些人所说的“骨折人格”，它是软组织状况和骨折模式的结合。无损伤的螺旋形骨折，软组织损伤很小（包括Gustilo I等开放性损伤），愈合的麻烦很小；除非有明确的手术指征，否则可以保守治疗
（见下文）。如果要避免并发症，与严重软组织损伤（无论是开放性还是闭合性）和不稳定骨折模式相关的骨折需要更加小心。
低能损伤
大多数低能量骨折，包括GustiloⅠ型损伤后注意伤口，可采用非手术方法治疗。
如果骨折未发生移位或移位最小，则从大腿上部到跖骨颈部进行全长铸型，膝盖稍微弯曲，脚踝成直角（图30.26）。腓骨骨折的移位，除非它涉及踝关节，是不重要的，可以忽略不计。
如果骨折移位，在全身麻醉下用x射线控制复位。并置不需要完全，但对齐必须接近完美（不超过7度的角度）和旋转绝对完美。对于未移位的骨折，应用全长石膏（然而，注意，如果将踝部放置在0度位置导致骨折移位，则可以接受几度的马蹄骨）。通过x光检查位置；在石膏上做一个横向切口并将其楔入一个更好的位置，仍然可以纠正较小的角度。
抬高肢体，观察患者48-72小时。如果肿胀过度，铸型就会裂开。病人通常可以在第二天或第三天起床（回家），借助拐杖承受最小的重量。如果怀疑皮肤的通透性，立即施用膏药可能是不明智的，在这种情况下，几天的骨骼牵引是有用的初步措施（图30.27）。
两周后通过x光检查位置。4-6周左右，当骨折变得“粘滞”时，从膝上型到膝下型的改变是可能的。在骨折愈合之前，石膏被保留（或者如果它变松了就更新），儿童骨折愈合时间约为8周，而成人骨折愈合时间很少在12周以下。