骨科英文书籍精读（98）｜肱骨髁上骨折（2）
Treatment
If there is even a suspicion of a fracture, the elbow is gently splinted in 30 degrees of flexion to prevent movement and possible neurovascular injury during the x-ray examination.
TYPE I: UNDISPLACED FRACTURE
The elbow is immobilized at 90 degrees and neutral rotation in a lightweight splint or cast and the arm is supported by a sling. It is essential to obtain an x-ray 5–7 days later to check that there has been no displacement. The splint is retained for 3 weeks and supervised movement is then allowed.
The capitulum normally angles forward about 30 degrees; if the capitulum is in a straight line with the humerus on the lateral x-ray, it will still remodel.
Even with Type I fractures, care must be taken to recognise any medial tilt of the distal fragment on the anteroposterior x-ray, otherwise cubitus varus can result. Measure Baumann’s angle.
TYPE II A: POSTERIORLY ANGULATED FRACTURE –MILD
In these cases swelling is usually not severe and the risk of vascular injury is low. If the posterior cortices are in continuity, the fracture can be reduced under general anaesthesia by the following step-wise manoeuvre: (1) traction for 2–3 minutes in the length of the arm with counter-traction above the elbow;(2) correction of any sideways tilt or shift and rotation (in comparison with the other arm); (3) gradual flexion of the elbow to 120 degrees, and pronation of the forearm, while maintaining traction and exerting finger pressure behind the distal fragment to correct posterior tilt. Then feel the pulse and check the capillary return – if the distal circulation is suspect, immediately relax the amount of elbow flexion until it improves. X-rays are taken to confirm reduction, checking carefully to see that there is no varus or valgus angulation and no rotational deformity. The anteroposterior view is confusing and unreliable with the elbow flexed, but the important features can be inferred by noting Baumann’s angle. Again, subtle medial tilt and rotation of the distal fragment must be recognised. If the acutely flexed position cannot be maintained without disturbing the circulation, or if the reduction is unstable, (and most of these fractures are unstable!) the fracture should be fixed with percutaneous crossed K-wires (take care not to skewer the ulnar nerve!). Following reduction, the arm is held in a collar and cuff; the circulation should be checked repeatedly during the first 24 hours. An x-ray is obtained after 3–5 days to confirm that the fracture has not slipped. The splint is retained for 3 weeks, after which movements are begun.
TYPES II B AND III: ANGULATED AND MALROTATED OR POSTERIORLY DISPLACED
These are usually associated with severe swelling, are difficult to reduce and are often unstable; moreover, there is a considerable risk of neurovascular injury or circulatory compromise due to swelling. The fracture should be reduced under general anaesthesia as soon as possible, by the method described above, and then held with percutaneous crossed K-wires; this obviates the necessity to hold the elbow acutely flexed.
Smooth wires should be used (this lessens the risk of physeal injury) and great care should be taken not to injure the ulnar, radial and median nerves. Postoperative management is the same as for Type II A.
OPEN REDUCTION
This is sometimes necessary for (1) a fracture which simply cannot be reduced closed; (2) an open fracture; or (3) a fracture associated with vascular damage. The fracture is exposed (preferably through two ncisions, one on each side of the elbow), the haematoma is evacuated and the fracture is reduced and held by two crossed K-wires.
CONTINUOUS TRACTION
Traction through a screw in the olecranon, with the arm held overhead, can be used (1) if the fracture is severely displaced and cannot be reduced by manipulation; (2) if, with the elbow flexed 100 degrees, the pulse is obliterated and image intensification is not available to allow pinning and then straightening of the elbow; or (3) for severe open injuries or multiple injuries of the limb. Once the swelling subsides, a further attempt can be made at closed reduction.
TREATMENT OF ANTERIORLY DISPLACED FRACTURES
This is a rare injury (less than 5 percent of supracondylar fractures). However, ‘posterior’ fractures are sometimes inadvertently converted to ‘anterior’ ones by excessive traction and manipulation.
The fracture is reduced by pulling on the forearm with the elbow semiflexed, applying thumb pressure over the front of the distal fragment and then extending the elbow fully. Crossed percutaneous pins are used if unstable. A posterior slab is bandaged on and retained for 3 weeks. Thereafter, the child is allowed to regain flexion gradually.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
supervised /'sʊpɚvaɪz/v. 监督（supervise的过去式和过去分词）；指导adj. 有监督的
tilt倾斜
cubitus varus 肘内翻/'kju:bitəs/n. [昆] 肘脉；[解剖] 前臂，尺骨
/'kju:bitəs/
n. [昆] 肘脉；[解剖] 前臂，尺骨
/prəu'neiʃən/
pronationn. 手掌向下；（手足的）内转;旋前
percutaneous /ˌpɜːrkjuːˈteɪniəs/adj. 经皮的；经由皮肤的
skewer /ˈskjuːər/n. 烤肉叉子；串肉扦；针vt. 刺穿；串住；讽刺
obviate /ˈɑːbvieɪt/vt. 排除；避免；消除
百度翻译：
治疗
如果有骨折的嫌疑，肘关节要用夹板轻轻地夹住30度的弯曲度，以防止在x光检查中移动和可能的神经血管损伤。
Ⅰ型：不移位骨折
肘关节固定在90度，中性旋转，用轻型夹板或石膏固定，手臂由吊索支撑。必须在5-7天后进行x光检查，以确保没有移位。夹板保留3周，然后允许在监督下移动。
小头通常向前倾斜约30度；如果在侧位x线片上小头与肱骨成一条直线，它仍将重塑。
对肘内翻型骨折，除此之外，任何一种骨折都要注意内倾角。测量鲍曼角。
II A型：后Y角骨折-轻度
在这些情况下，肿胀通常不严重，血管损伤的风险也很低。如果后皮质连续，在全身麻醉下，可通过以下逐步操作减少骨折：（1）在肘部上方反向牵引的情况下，手臂长度牵引2-3分钟；（2）纠正任何侧倾或移位和旋转（与另一只手臂相比）；（3）逐渐弯曲肘关节向120度，前臂内翻，同时保持牵引力，并对远端骨折片施加手指压力，以纠正后倾。然后感觉脉搏，检查毛细血管回流情况——如果怀疑远端循环，立即放松肘关节的弯曲度，直到改善为止。X光片确认复位，仔细检查是否有内翻或外翻成角，无旋转畸形。肘关节弯曲时的前后观是令人困惑和不可靠的，但重要的特征可以通过注意鲍曼角来推断。再次，必须认识到远端碎片的轻微内侧倾斜和旋转。如果不能在不干扰循环的情况下保持剧烈弯曲的位置，或者如果复位不稳定（这些骨折大多不稳定！）骨折应用经皮交叉K-线固定（注意不要刺伤尺神经！）。复位后，手臂用衣领和袖口固定；在最初的24小时内，应反复检查循环。3-5天后进行x光检查，以确认骨折没有滑脱。夹板保留3周，之后开始活动。
II型B和III型：成角、旋转不良或后移
这些症状通常伴有严重的肿胀，很难减轻，而且往往不稳定；此外，由于肿胀，有相当大的神经血管损伤或循环系统受损的风险。骨折应在全身麻醉下尽快复位，采用上述方法，然后用经皮交叉K形钢丝固定；这样就避免了手肘剧烈弯曲的必要性。
应使用光滑的金属丝（这样可以降低皮损的风险），并且应特别注意不要损伤尺神经、桡神经和正中神经。术后处理同ⅡA型。
开放式还原
对于（1）无法闭合复位的骨折；（2）开放性骨折；或（3）与血管损伤相关的骨折，这有时是必要的。骨折暴露（最好通过两个切口，肘部两侧各一个），血肿排出，骨折复位并用两根交叉的K形钢丝固定。
连续牵引
通过尺骨鹰嘴内的螺钉牵引，手臂举过头顶，可用于（1）如果骨折严重移位，无法通过手法复位；（2）如果肘部弯曲100度，脉搏消失，影像增强无法进行钉扎然后伸直肘部；（三）肢体严重开放性损伤或多发伤。一旦肿胀消退，可以进一步尝试闭合复位。
前移位骨折的治疗
这是一种罕见的损伤（不到5%的髁上骨折）。然而，由于过度的牵引和操作，“后”骨折有时会无意中转变为“前”骨折。
通过在肘关节半屈的情况下拉动前臂，在远端骨折块前部施加拇指压力，然后完全伸展肘关节，从而减少骨折。如果不稳定，可使用交叉经皮穿刺针。后板用绷带包扎并保留3周。此后，允许孩子逐渐恢复屈曲。