骨科英文书籍精读（395）｜跗骨-跖骨损伤
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TARSO-METATARSAL INJURIES
The five tarso-metatarsal (TMT) joints form a structural complex that is held intact partly by the interdigitating joints and partly by the strong ligaments that bind the metatarsal bones to each other and to the tarsal bones of the midfoot.
An appreciation of the anatomy across the TMT joints is important in understanding these injuries. The second metatarsal base is set into a recess formed by the medial, intermediate and lateral cuneiforms. There is no ligament between the first and second metatarsal bases, but the plantar ligament between second metatarsal base and medial cuneiform is short and thick. In the coronal plane, the second metatarsal base forms the apex or keystone in the arch.
Dislocation is rare, but important not to miss; twisting and crushing injuries are the usual causes, with the foot buckling or twisting at the midfoot–forefoot junction. The term Lisfranc injury is often used for the disruptions that occur at the midfoot–forefoot junction. Classifying these by direction of forefoot dislocation is, however, pointless – it is neither a guide to treatment nor an indication of outcome. These are often high-energy injuries with extensive damage to the whole region of the foot, and simply to assess the direction of metatarsal displacement is to miss the complexity of the injury pattern.
Clinical features
TMT dislocation or fracture–dislocation should always be suspected in patients with pain and swelling of the foot after high-velocity car accidents and falls. Unfortunately about 20–30 per cent of these injuries are initially missed. Only with severe injury is there an obvious deformity.
X-rays may be difficult to interpret; something looks wrong but it is often difficult to tell what. A systematic method for examining the foot x-rays can help to improve the pick-up rate for these injuries. Concentrate on the second and fourth metatarsals in the oblique views: the medial edge of the second should be in line with the medial edge of the second cuneiform, and the medial edge of the fourth should line up with the medial side of the cuboid. A true lateral may show the dorsal displacement of the second metatarsal base. If a fracture–dislocation is suspected (the displacement may reduce spontaneously and not be immediately detectable), stress views may reveal the abnormality, but a CT scan is a more efficient way of showing the extent of injury.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
a structural complex结构复合体
interdigitate/ˌɪntərˈdɪdʒɪˌteɪt/v. （如双手紧握时十指交叉似的）相互交错
digitate/ˈdɪdʒɪˌteɪt/adj. （复叶）掌状的
interdigitating joints相互咬合的关节
The second metatarsal base is set into a recess formed by the medial, intermediate and lateral cuneiforms.第二跖骨基底位于由内侧、中间和外侧楔形骨形成的隐窝内。
plantar ligament 跖侧（足底）韧带
apex or keystone in the arch顶点或拱顶
velocity/vəˈlɑːsəti/n. 【物】速度
high-velocity car accidents 高速车祸
the displacement may reduce spontaneously and not be immediately detectable位移可能会自动复位，不能立即检测到
DeepL翻译（仅供参考，建议自己翻译）：
跗骨-跖骨损伤
五个跗骨-跖骨（TMT）关节形成一个结构复合体，部分由相互咬合的关节保持完整，部分由强大的韧带将跖骨相互结合，并与中足的跗骨结合。
足中部的跗骨。
了解TMT关节的解剖结构对于理解这些损伤是很重要的。第二跖骨基底设置在由内侧、中间和外侧楔形骨形成的凹陷中。第一和第二跖骨基底之间没有韧带，但第二跖骨基底和内侧楔形肌之间的跖骨韧带短而厚。在冠状面，第二跖骨基底形成拱门的顶点或基石。
脱位是罕见的，但重要的是不要错过；扭曲和挤压伤是通常的原因，脚在足中部-足前部交界处屈曲或扭曲。Lisfranc损伤一词常被用于发生在中足-前足交界处的破坏。然而，按前足脱位的方向来分类是毫无意义的，它既不是治疗的指南，也不是结果的标志。这些通常是高能量的损伤，对整个足部区域有广泛的损伤，简单地评估跖骨移位的方向是忽略了损伤模式的复杂性。
临床特征
在高速车祸和跌倒后出现脚部疼痛和肿胀的病人，应始终怀疑TMT脱位或骨折脱位。不幸的是，约有20%-30%的此类损伤最初被漏掉。只有在严重受伤的情况下才会出现明显的畸形。
X光片可能很难解释；有些东西看起来不对劲，但往往很难说是什么。采用系统的方法检查足部X射线可以帮助提高这些损伤的检出率。在斜切面上集中观察第二和第四跖骨：第二跖骨的内侧边缘应与第二楔形的内侧边缘一致，第四跖骨的内侧边缘应与立方体的内侧一致。真正的侧位可显示第二跖骨基底的背侧移位。如果怀疑有骨折-脱位（移位可能会自发减少而不能立即发现），应力视图可能会显示异常，但CT扫描是显示损伤程度的更有效方法。