骨科英文书籍精读（267）｜股骨干骨折髓内钉治疗
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Intramedullary nailing
Intramedullary nailing is the method of choice for most femoral shaft fractures. However, it should not be attempted unless the appropriate facilities and expertise are available. The basic implant system consists of an intramedullary nail (in a range of sizes) which is perforated near each end so that locking screws can be inserted transversely at the proximal and distal ends; this controls rotation and length, and ensures stability even for subtrochanteric and distal third fractures (Figure 29.25).
These important details should be remembered when using locked intramedullary nails:
1. Reamed nails have a lower need for revision surgery when compared to unreamed nails.
2. Select a nail that is approximately the size of the medullary isthmus so that it fills the canal reasonably well (after reaming) and adds to stability – small diameter nails are quicker to insert but more frequently lead to the need for revision surgery.
3. Consider alternative means of fracture fixation if the isthmus is so narrow that a large amount of canal reaming will have to be done in order to fit the smallest diameter nail available.
4. Use a nail of sufficient length to fully span the canal.
5. Antegrade insertion (through either the piriformis fossa or the tip of the greater trochanter, depending on the design of nail) or retrograde insertion (through the intercondylar notch distally) are equally suitable techniques to use; there is a small incidence of hip and thigh pain with antegrade nails, whereas there is a small problem with knee pain with retrograde nails. Retrograde insertion of intramedullary nails is particularly useful for: obese patients; when there are bilateral femoral shaft fractures (as the procedure can be performed without the need for a fracture table and the added time for setting up for each side); when there is a tibial shaft fracture on the same side; and if there is a femoral neck fracture more proximally, as screws can be inserted to hold this fracture without being impeded by the nail.
Stability is improved by using interlocking screws; all locking holes in the nail should be used. Often there is enough shared stability between the nail and fracture ends to allow some weightbearing early on. The fracture usually heals within 20 weeks and the complication rate is low; sometimes malunion (more likely malrotation) or delayed union (from leaving the fracture site over-distracted) occurs.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
expertise/ˌekspɜːrˈtiːz/n. 专门知识；专门技术；专家的意见
medullary isthmus骨髓腔最狭窄处
isthmus /ˈɪsməs/n. 地峡；管峡
piriformis fossa 梨状窝
retrograde /ˈretrəɡreɪd/adj. 倒退的；退化的；次序颠倒的vt. 使倒退vi. 逆行；倒退；退步adv. 倒退地；向后地
retrograde insertion逆行置入
intercondylar notch髁间窝
/nɑːtʃ/n. 刻痕，凹口；等级；峡谷
antegrade前进的；顺行的
obese patients肥胖患者
/oʊˈbiːs/adj. 肥胖的，过胖的
obesity /oʊˈbiːsəti/n. 肥大，肥胖
being impeded by the nail. 被钉子阻碍。
distract /dɪˈstrækt/vt. 转移；分心
百度翻译：
髓内钉
髓内钉是治疗大多数股骨干骨折的首选方法。但是，除非有适当的设施和专门知识，否则不应尝试这样做。基本的植入系统包括髓内钉（大小不等），髓内钉在每一端附近穿孔，以便锁定螺钉可以横向插入近端和远端；这控制了旋转和长度，并确保了稳定性，即使是转子下和远端第三骨折（图29.25）。
使用带锁髓内钉时应记住以下重要细节：
1、与未扩髓的指甲相比，扩髓的指甲对翻修手术的需求较低。
2、选择一个大约与髓峡部大小的钉子，这样它可以很好地填充椎管（扩孔后）并增加稳定性——小直径钉子插入更快，但更频繁地导致需要翻修手术。
3、如果峡部太窄，需要进行大量的椎管扩孔以适应最小直径的髓内钉，可以考虑其他的骨折固定方法。
4、使用足够长的钉子完全跨过运河。
5、顺行插入（通过梨状窝或大转子尖，取决于指甲的设计）或逆行插入（通过髁间切迹远端）同样适合使用；顺行钉的髋关节和大腿疼痛发生率很低，而膝关节则有小问题指甲逆行疼痛。逆行插入髓内钉对以下患者特别有用：肥胖患者；双侧股骨干骨折时（因为该手术无需骨折表和为每侧增加设置时间即可进行）；同侧胫骨骨干骨折时；如果股骨颈骨折在更近的位置，可以插入螺钉来固定骨折而不受钉的阻碍。
使用联锁螺钉可提高稳定性；应使用钉子上的所有锁定孔。通常情况下，指甲和骨折端之间有足够的共同稳定性，以允许早期负重。骨折通常在20周内愈合，并发症发生率较低；有时会发生畸形愈合（更可能是旋转不良）或延迟愈合（由于过度分散骨折部位）。