骨科英文书籍精读（341）｜胫骨平台骨折的复位原则
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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Principles in reduction and fixation
Traction is used to achieve reduction; many of the fragments that have
soft-tissue attachments will reduce spontaneously (ligamentotaxis). This is done by applying bone distractors across the knee joint or by traction on a traction table.
If open reduction is needed or intended, the operation should be carefully planned. High-quality imaging is needed to define the fracture pattern accurately. The difficulty of fixing plateau fractures should not be underestimated; operative treatment should be undertaken only if the full range of implants and the necessary expertise are available.
The standard approach to the lateral part of the joint is through a longitudinal parapatellar incision. The aim is to preserve the meniscus while fully exposing the fractured plateau; this is best done by entering the joint through a transverse capsular incision beneath the meniscus. If exposure of the medial compartment is needed, a separate posteromedial incision and approach is made. Dividing the patellar ligament in a Z-fashion – whilst giving good access across the entire joint – limits the extent of knee flexion exercises after surgery, even if the ligament is repaired.
A single large fragment may be re-positioned and held with lag screws and washers; a buttress plate is added for security. Comminuted, depressed fractures must be elevated by pushing the fragmented mass upwards from below; the osteoarticular surface is then supported by packing the subchondral area with cortico-cancellous grafts (obtained from the iliac crest) and held in place by inserting 'raft’ screws and a suitably contoured buttress plate. Unless it is torn, the meniscus should be preserved and sutured back in place when the capsule is repaired.
Displaced fractures with splits in both the sagittal and the coronal plane may be impossible to reduce and fix through the anterior approach; a second, posteromedial or posterolateral approach is the answer.
Extensive exposure and manipulation of highly comminuted fractures can sometimes be selfdefeating. These injuries may be better treated by percutaneous manipulation of the fragments (under traction) and circular-frame external fixation.
Stability is all-important; no matter which method is used, fixation must be secure enough to permit early joint movement. There is little point in ending up with a pleasing x-ray and a stiff knee.
Postoperatively the limb is elevated and splinted until swelling subsides; movements are begun as soon as possible and active exercises are encouraged. The patient is allowed up as swelling subsides, and at the end of 6 weeks the patient can partial weightbear with crutches; full weightbearing is resumed when healing is complete, usually after 12–16 weeks.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
limits the extent of knee flexion exercises after surgery, even if the ligament is repaired.限制手术后膝关节屈曲运动的范围，即使韧带已修复。
lag screws and washers拉力螺钉和垫圈
washer /ˈwɑːʃər/n. [机] 垫圈；洗涤器；洗衣人
buttress plate支撑钢板
iliac crest 髂嵴
contoured /ˈkɑːntʊrd/adj. 波状外形的
sagittal and the coronal plane 矢状面和冠状面
Extensive exposure and manipulation of highly comminuted fractures can sometimes be selfdefeating. 过度暴露和操作高度粉碎性骨折有时会弄巧成拙。
selfdefeating弄巧成拙；自取其辱
circular-frame external fixation.环形支架外固定
There is little point in ending up with a pleasing x-ray and a stiff knee.用一张漂亮的x光片和僵硬的膝盖来结束没有什么意义。
resume /rɪˈzuːm/vt. （中断后）重新开始，继续n. （文章、讲话等的）梗概，摘要；个人简历，履历
有道翻译（仅供参考，建议自己翻译）：
复位固定原则
牵引是用来实现减少；许多碎片软组织附着物会自发减少（韧带断裂）。这是通过在膝关节上施加骨牵引器或在牵引台上牵引来实现的。
如果需要或打算进行切开复位，应仔细计划手术。为了准确地确定骨折类型，需要高质量的成像。不应低估固定平台骨折的难度；只有在具备全套植入物和必要的专业知识的情况下才能进行手术治疗。
关节外侧部的标准入路是通过髌旁纵切口。目的是在完全暴露骨折平台的同时保留半月板；最好通过半月板下方的横囊切口进入关节。如果需要暴露内侧隔室，则进行单独的后内侧切口和入路。以Z形方式分割髌骨韧带-同时使整个关节有良好的通路-限制了术后膝关节屈曲练习的范围，即使韧带得到修复。
单个大碎片可以重新定位，并用拉力螺钉和垫圈固定；为了安全起见，增加了一个支撑板。粉碎、凹陷的骨折必须通过从下方向上推动碎块来抬高；然后用皮质松质骨移植物（取自髂骨嵴）填充软骨下区域来支撑骨关节面，并通过插入“筏”螺钉和适当轮廓的支撑钢板固定到位。除非被撕裂，半月板应该被保留，并在修复关节囊时缝合回原位。
移位的骨折在矢状面和冠状面上都有裂痕，可能无法通过前入路复位和固定；第二种方法是后内侧或后外侧入路。
对高度粉碎性骨折的广泛暴露和操作有时会弄巧成拙。这些损伤可以通过经皮操作碎片（牵引下）和环形框架外固定来更好地治疗。
稳定性是非常重要的；无论使用哪种方法，固定必须足够安全，以允许早期关节活动。最后拍一张令人愉快的x光片和一个僵硬的膝盖没有什么意义。
术后肢体抬高并用夹板固定，直到肿胀消退；尽快开始运动，鼓励积极锻炼。当肿胀消退时，允许患者起身，6周结束时，患者可以用拐杖部分负重；痊愈后，通常在12-16周后恢复完全负重。