骨科英文书籍精读（384）｜距骨骨折的治疗(2)
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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DISPLACED FRACTURES OF THE BODY
Fractures through the body of the talus are usually displaced or comminuted and involve the ankle and/or the talocalcaneal joint; occasionally the fragments are completely dislocated.
Minimal displacement can be accepted; a belowknee non-weightbearing cast is applied for 6–8 weeks; this is then replaced by a weightbearing cast for another 4 weeks.
Horizontal fractures that do not involve the ankle or subtalar joint are treated by closed reduction and cast immobilization (as earlier).
Displaced fractures with dislocation of the adjacent joints should be accurately reduced. In almost all cases open reduction and internal fixation will be needed. An osteotomy of the medial malleolus is useful for adequate exposure of the talus; the malleolus is predrilled before the osteotomy and fixed back into position after the talar fracture has been dealt with. The prognosis for these fractures is poor: there is a considerable incidence of malunion, joint incongruity, avascular necrosis and secondary osteoarthritis of the ankle or talocalcaneal joint.
DISPLACED FRACTURES OF THE HEAD
The main problem is injury to the talonavicular joint. If the fragments are large enough, open reduction and internal fixation with screws is the recommended treatment. If there is much comminution, it may be
better simply to excise the smaller fragments. Postoperative immobilization is the same as for other talar fractures.
FRACTURES OF THE TALAR PROCESSES
If the fragment is large enough, open reduction and fixation with K-wires or small screws is advisable. Tiny fragments are left but can be removed later if they become symptomatic.
OSTEOCHONDRAL FRACTURES
These small surface fractures of the dome of the talus usually occur with severe ankle sprains or subtalar dislocations. Most acute lesions can be treated by cast immobilization for 4–6 weeks. Occasionally a displaced fragment is large enough to warrant operative replacement and internal fixation – easier said than done! More often it is separated from its bed and is excised: the exposed bone is then drilled to encourage repair by fibrocartilage.
OPEN FRACTURES
Fractures of the talus are often associated with burst skin wounds. In some cases the fracture becomes 'open’ when stretched or tented skin starts sloughing. There is a high risk of infection in these wounds and
prophylactic antibiotics are advisable.
The injury is treated as an emergency. Under general anaesthesia, the wound is cleaned and debrided and all necrotic tissue is removed. The fracture is then dealt with as for closed injuries, except that the wound is left open and closed by delayed primary suture or skin grafting 5–7 days later, when swelling has subsided and it is certain that there is no infection.
Sometimes, in open injuries, the talus is completely detached and lying in the wound. After adequate debridement and cleansing, the talus should be replaced in the mortise and stabilized, if necessary with crossed K-wires. Later definitive fixation is then performed.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
adjacent /əˈdʒeɪsnt/adj. 邻近的，毗连的
The prognosis for these fractures is poor这些骨折的预后很差.
prognosis/prɑːɡˈnoʊsɪs/n. [医] 预后；预知
joint incongruity关节不协调
incongruity/ˌɪnkənˈɡruːəti/n. 不协调；不一致；不适宜
talonavicular joint.距舟关节
navicular /nəˈvɪkjələr/adj. [解剖] 舟状的，船状的n. 舟骨
comminution /,kɔmi'nju:ʃən/n. 粉碎；捣碎
comminuted /'kɑmə,njʊt/adj. 粉碎的v. 粉碎（comminute的过去分词）；使成粉末
symptomatic. /ˌsɪmptəˈmætɪk/adj. 有症状的；症候的
warrant /ˈwɔːrənt/n. 根据；证明；正当理由；委任状vt. 保证；担保；批准；辩解
easier said than done!说来容易做起来难
fibrocartilage /'faibrəu'kɑ:tilidʒ/n. [解剖] 纤维软骨
prophylactic antibiotics 预防性抗生素
prophylactic/ˌproʊfəˈlæktɪk/adj. 预防性的，预防疾病的n. 预防性药物（或器具、措施）；预防法；避孕用具
The fracture is then dealt with as for closed injuries,然后将骨折当作闭合性损伤来处理，
detach/dɪˈtætʃ/vt. 分离；派遣；使超然
Later definitive fixation is then performed.随后进行最终固定。
DeepL翻译（仅供参考，建议自己翻译）：
体部移位的骨折
贯穿距骨主体的骨折通常是移位或粉碎性的，涉及踝关节和/或距骨关节；偶尔碎片会完全脱位。
可以接受最小的移位；使用膝下非负重石膏6-8周；然后用负重石膏代替，再使用4周。
不涉及踝关节或胫骨下关节的水平骨折通过闭合复位和石膏固定治疗（如前）。
对伴有邻近关节脱位的移位性骨折应进行准确的复位。几乎在所有的情况下，都需要进行开放性复位和内固定。内侧大腿骨的截骨术对于充分暴露距骨是有用的；在截骨术前，大腿骨要预先钻孔，并在处理完距骨骨折后将其固定在原位。这些骨折的预后很差：有相当高的恶性融合、关节不协调、血管性坏死和踝关节或距骨关节的继发性骨关节炎的发生率。
头部移位的骨折
主要问题是对距骨关节的损伤。如果碎片足够大，建议采用开放复位和螺钉内固定的治疗方法。如果有很多粉碎性骨折，最好是将较小的碎片切除。
最好是简单地切除较小的碎片。术后的固定方法与其他距骨骨折的固定方法相同。
距骨突的骨折
如果碎片足够大，建议用K线或小螺钉进行开放复位和固定。微小的碎片会被留下，但如果它们变得有症状，可以在以后被切除。
骨软骨断裂
这些距骨圆顶的小表面骨折通常发生在严重的踝关节扭伤或胫骨脱位。大多数急性病变可以通过石膏固定4-6周来治疗。偶尔，移位的碎片大到需要手术置换和内固定--说起来容易做起来难。更多的情况是将其与床面分离并切除：然后在暴露的骨头上钻孔以促进纤维软骨的修复。
开放性骨折
距骨的骨折常常与皮肤破裂的伤口有关。在某些情况下，当拉伸或撕裂的皮肤开始脱落时，骨折就成为 "开放性"。这些伤口有很高的感染风险。
预防性抗生素是可取的。
损伤被当作紧急情况来处理。在全身麻醉的情况下，对伤口进行清洗和清创，并切除所有坏死的组织。然后像处理闭合性损伤一样处理骨折，只是伤口保持开放，5-7天后，当肿胀消退并且确定没有感染时，再通过延迟初级缝合或皮肤移植来关闭。
有时，在开放性损伤中，距骨完全脱离，躺在伤口中。在进行充分的清创和清洁后，应将距骨置入臼中，如有必要，用交叉的K线固定。然后再进行最终的固定。