骨科英文书籍精读（343）｜胫骨近端骨骺骨折分离
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FRACTURE-SEPARATION OF PROXIMAL TIBIAL EPIPHYSIS
This uncommon injury is usually caused by a severe hyperextension and valgus strain. The epiphysis displaces forwards and laterally, often taking a small fragment of the metaphysis with it (a Salter–Harris type 2 injury). There is a risk of popliteal artery damage where the vessel is stretched across the step at the back of the tibia.
Clinical features
The knee is tensely swollen and extremely tender. If the epiphysis is displaced, there may be a valgus or hyperextension deformity. All movements are resisted. The swelling may extend into the calf and a careful watch for compartment syndrome, particularly if the fracture was caused by hyperextension, is important.
X-ray
Salter–Harris type 1 and 2 injuries may be undisplaced and difficult to define on x-ray; a few small bone fragments near the epiphysis may be the only clue. In the more serious injuries the entire upper tibial epiphysis may be tilted forwards or sideways. The fracture is categorized by the direction of displacement, so there are hyperextension, flexion, varus or valgus types.
Treatment
Under anaesthesia, closed manipulative reduction can usually be achieved. The direction of tilt may suggest the mechanism of injury; the fragment can be reduced by gentle traction and manipulation in a direction opposite to that of the fracturing force. Fixation using smooth K-wires or screws may be needed if the fracture is unstable. Occasionally, when the entire tibial epiphysis cannot be accurately reduced by closed manipulation, it is repositioned at operation and held
by a screw (Figure 30.25). The rare Salter–Harris type 3 or 4 fractures also may need open reduction and fixation.
Following reduction, whether closed or open, a long-leg cast is applied. For the usual hyperextension injury the knee is held flexed at 30 degrees; for the less common flexion and varus injuries the knee is kept straight. The cast is worn for 6–8 weeks, with partial weightbearing from the outset. Knee movement quickly returns when the cast is removed.
Complications
Epiphyseal fractures in young children sometimes result in angular deformity of the proximal tibia. This may later require operative correction.
With the higher grades of injury there is a risk of complete growth arrest at the proximal tibia. If the predicted leg length discrepancy is greater than 2.5 cm, tibial lengthening (or epiphyseodesis of the opposite limb) may be needed.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
There is a risk of popliteal artery damage where the vessel is stretched across the step at the back of the tibia.
由于腘动脉横跨过胫骨后面的台阶，所以，有损伤腘动脉的风险。
The swelling may extend into the calf and a careful watch for compartment syndrome, 肿胀可能会延伸到小腿，要仔细观察有无筋膜室综合征，
calf /kæf/n. [解剖] 腓肠，小腿；小牛；
epiphyseodesis 骺骨干固定术
有道翻译（仅供参考，建议自己翻译）：
胫骨近端骨骺骨折分离
这种罕见的损伤通常是由严重的过度伸展和外翻引起的。骨骺向前和侧向移位，常伴有干骺端的小碎片（Salter-Harris 2型损伤）。如果血管在胫骨后面的台阶上伸展，则存在腘动脉损伤的风险。
临床特征
膝盖紧张地肿胀，非常柔软。如果骨骺移位，可能有外翻或过度伸展畸形。所有的动作都被阻止了。肿胀可能延伸到小腿，仔细观察骨筋膜室综合征，特别是如果骨折是由过度伸展引起的，这一点很重要。
X射线
Salter–Harris 1型和2型损伤可能未发生移位，在x光片上很难确定；骨骺附近的一些895小块骨头可能是唯一的线索。在较严重的损伤中，整个胫骨上骨骺可能向前或侧向倾斜。骨折按移位方向分为过伸型、屈曲型、内翻型和外翻型。
治疗
在麻醉下，通常可以实现闭合手法复位。倾斜的方向可能暗示了损伤的机制；通过轻轻的牵引和操作，可以在与破裂力相反的方向上减少碎片。如果骨折不稳定，可能需要使用光滑的K形钢丝或螺钉固定。有时，当闭合手法不能精确复位整个胫骨骨骺时，在手术中重新定位并固定
通过螺钉（图30.25）。罕见的Salter-Harris 3型或4型骨折也可能需要切开复位固定。
复位后，无论闭合还是开放，都要进行长腿石膏。对于通常的过度伸展损伤，膝盖保持30度弯曲；对于不太常见的弯曲和内翻损伤，膝盖保持笔直。石膏从一开始就有部分负重，需要佩戴6-8周。移除石膏后，膝盖移动会迅速恢复。
并发症
儿童骨骺骨折有时会导致胫骨近端角畸形。这以后可能需要手术矫正。
损伤等级越高，胫骨近端有完全生长停滞的危险。如果预测的腿长差异大于2.5cm，可能需要胫骨延长（或对侧肢体骨骺固定）。