骨科英文书籍精读（365）｜踝关节复发性侧方不稳
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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RECURRENT LATERAL INSTABILITY
Recurrent sprains are potentially associated with added cartilage damage, and warrant careful investigation by MRI, arthroscopy and examination under anaesthesia.
Clinical features
The patient gives a history of a 'sprained ankle’ that never quite seems to recover and is followed by recurrent 'giving way’ or a feeling of instability when walking on uneven surfaces. This is said to occur in about 20 per cent of cases after acute lateral collateral ligament tears (Colville, 1994).
The ankle looks normal and passive movements are full, however stress tests for abnormal lateral ligament laxity may show either excessive talar tilting in the sagittal plane or anterior displacement (an anterior drawer sign) in the coronal plane. In the chronic phase these tests are painless and can be performed either manually or with the use of special mechanical stress devices. Both ankles are tested, so as to allow comparison of the abnormal with the normal side.
Talar tilt test
With the ankle held in the neutral position, the examiner stabilizes the tibia by grasping the leg with one hand above the ankle; the other hand is then used to force the heel into maximum inversion. The range of movement can be estimated clinically and compared with that of the normal ankle. The exact degree of talar tilt can also be measured by x-rays, which should be taken with the ankles in 30 degrees of internal rotation (mortise views); 15 degrees of talar tilt (or 5 degrees more than in the normal ankle) is regarded as abnormal. Inversion laxity suggests injury to both the calcaneofibular and anterior talofibular ligaments.
Anterior drawer test
The patient should be sitting with the knee flexed to 90 degrees and the ankle in 10 degrees of plantarflexion. The lower leg is stabilized with one hand while the other hand forces the patient’s heel forward under the tibia. In a positive test the talus can be felt sliding forwards and backwards. The position of the talus is verified by lateral x-rays; anterior displacement of 10 mm (or 5 mm more than on the normal side) indicates abnormal laxity of the anterior talofibular ligament. With an isolated tear of the anterior talofibular ligament, the anterior drawer test may be positive in the absence of abnormal talar tilt.
(Note: A positive anterior drawer test can sometimes be obtained in normal, asymptomatic individuals; the finding should always be considered in conjunction with other symptoms and signs).
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
warrant /ˈwɔːrənt/n. 根据；证明；正当理由；委任状vt. 保证；担保；批准；辩解
either excessive talar tilting in the sagittal plane or anterior displacement矢状面距骨过度倾斜或前移位
sagittal/ˈsædʒətəl/adj. 矢状的，前后向的；（位于）矢形面的；箭样的
exact degree 准确角度
exact /ɪɡˈzækt/adj. 准确的，精密的；精确的vt. 要求；强求；急需vi. 勒索钱财
plantarflexion跖曲
有道翻译（仅供参考，建议自己翻译）：
复发性侧不稳定
复发性扭伤可能与增加的软骨损伤有关，需要通过MRI、关节镜和麻醉检查进行仔细研究。
临床特征
患者有“踝关节扭伤”的病史，似乎从未完全恢复，然后在不平的路面上行走时会再次出现“让路”或不稳定的感觉。据说，急性侧副韧带撕裂后约有20%的病例会发生这种情况（Colville，1994）。
踝关节看起来正常，被动活动充分，但是异常侧韧带松弛的应力测试可能显示距骨在矢状面过度倾斜或冠状面前移位（前抽屉征）。在慢性期，这些测试是无痛的，可以手动进行，也可以使用特殊的机械应力装置。对两个脚踝进行测试，以便将异常侧与正常侧进行比较。
距骨倾斜试验
脚踝保持在中立位置，检查者用一只手抓住脚踝上方的腿来稳定胫骨；另一只手则是用来迫使脚跟最大程度地反转。活动范围可在临床上估计，并与正常踝关节的活动范围进行比较。距骨倾斜的确切程度也可以通过x光来测量，x光应在踝关节内旋转30度的情况下拍摄（榫眼视图）；距骨倾斜15度（或5
超过正常踝关节的度数）视为异常。内翻松弛提示跟骨腓骨和距腓骨前韧带损伤。
前抽屉试验
患者应坐着，膝盖弯曲90度，脚踝弯曲10度。一只手稳定小腿，另一只手将患者的脚后跟向前压到胫骨下方。在阳性测试中，距骨可以感觉到向前和向后滑动。距骨的位置是通过侧位x光来确定的；前移位10mm（或比正常侧多5mm）表明距腓前韧带异常松弛。对于距骨腓前韧带的孤立性撕裂，在距骨倾斜不异常的情况下，前抽屉试验可能是阳性的。
（注：在正常、无症状的个体中，前抽屉试验有时呈阳性；该发现应始终与其他症状和体征一起考虑）。