骨科英文书籍精读（69）｜肩关节前脱位并发症（2）
LATE
Shoulder stiffness
Prolonged immobilization may lead to stiffness of the shoulder, especially in patients over the age of 40. There is loss of lateral rotation, which automatically limits abduction. Active exercises will usually loosen the joint. They are practised vigorously, bearing in mind that full abduction is not possible until lateral rotation has been regained. Manipulation under anaesthesia or arthroscopic capsular release is advised only if progress has halted and at least 6 months have elapsed since injury.
Unreduced dislocation
Surprisingly, a dislocation of the shoulder sometimes remains undiagnosed. This is more likely if the patient is either unconscious or very old. Closed reduction is worth attempting up to 6 weeks after injury; manipulation later may fracture the bone or tear vessels or nerves. Operative reduction is indicated after 6 weeks only in the young, because it is difficult, dangerous and followed by prolonged stiffness. An anterior approach is used, and the vessels and nerves are carefully identified before the dislocation is reduced. ‘Active neglect’ summarizes the treatment of unreduced dislocation in the elderly. The dislocation is disregarded and gentle active movements are encouraged. Moderately good function is often regained.
Recurrent dislocation
If an anterior dislocation tears the shoulder capsule, repair occurs spontaneously following reduction and the dislocation may not recur; but if the glenoid labrum is detached, or the capsule is stripped off the front of the neck of the glenoid, repair is less likely and recurrence is more common. Detachment of the labrum occurs particularly in young patients, and, if at injury a bony defect has been gouged out of the posterolateral aspect of the humeral head, recurrence is even more likely. In older patients, especially if there is a rotator cuff tear or greater tuberosity fracture, recurrent dislocation is unlikely. The period of post-operative immobilization makes no difference.
The history is diagnostic. The patient complains that the shoulder dislocates with relatively trivial everyday actions. Often he can reduce the dislocation himself. Any doubt as to diagnosis is quickly resolved by the apprehension test: if the patient’s arm is passively placed behind the coronal plane in a position of abduction and lateral rotation, his immediate resistance and apprehension are pathognomonic. An anteroposterior x-ray with the shoulder medially rotated may show an indentation in the back of the humeral head (the Hill–Sachs lesion).
Even more common, but less readily diagnosed, is recurrent subluxation. The management of both types of instability is dealt with in Chapter 13.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
Prolonged immobilization 长期制动
lateral rotation旋外 侧旋 外旋
full abduction is not possible until lateral rotation has been regained.完全外展是不可能的，直到外旋功能得到恢复。
halt /hɔːlt/n. 停止；（英）小火车站；跛，瘸；（口令）立定adj. 跛的，瘸的
elapse/ɪˈlæps/n. 流逝；时间的过去vi. 消逝；时间过去
This is more likely if the patient is either unconscious or very old. 如果病人已经失去意识或年纪很大，这种情况更有可能发生。
capsule关节囊
Detachment /dɪˈtætʃmənt/n. 分离，拆开；超然；分遣；分遣队
gouge /ɡaʊdʒ/n. 沟；圆凿；以圆凿刨
n. (Gouge)人名；(英)古奇；(法)古热vt. 用半圆凿子挖；欺骗
The period of post-operative immobilization makes no difference.术后固定时间无差异。
relatively trivial 相对简单的
Any doubt as to diagnosis任何关于诊断的疑问
coronal plane 冠状平面
immediate resistance直接的阻力
pathognomonic./pə,θɑgnə'mɑnɪk/adj. 特殊（病征）的；能确定诊断的
subluxation /,sʌblʌk'seiʃən/n. [外科] 半脱位；不全脱位
dealt /delt/v. 处理（deal的过去式和过去分词）
百度翻译：
晚期并发症
肩部僵硬
长时间的固定可能会导致肩关节僵硬，尤其是40岁以上的患者。会失去侧向旋转，这会自动限制外展。积极运动通常会使关节松弛。他们被大力练习，记住在恢复侧向旋转之前不可能完全外展。在麻醉下操作或关节镜下的囊膜松解术只有在进展停止且受伤后至少6个月后才建议使用。
未复位脱位
令人惊讶的是，肩关节脱位有时仍然没有被诊断出来。如果患者失去知觉或年纪很大，则更可能出现这种情况。闭合复位在受伤后6周内是值得尝试的；以后的操作可能会骨折或撕裂血管或神经。手术复位仅适用于年轻人6周后，因为手术难度大、危险性大，并且伴有长期僵硬。前路入路，在脱位复位前仔细辨认血管和神经。“主动忽视”总结了老年人未复位脱位的治疗方法。不考虑错位，鼓励温和的主动运动。适度良好的功能通常会恢复。
复发性脱位
如果前脱位撕裂了肩关节囊，复位后会自发修复，脱位可能不会复发；但是如果盂唇分离，或者肩胛盂颈前部的包膜被剥离，修复的可能性较小，复发的可能性更大。唇脱离尤其发生在年轻患者，而且，如果受伤，骨缺损
从肱骨头后外侧挖出，复发的可能性更大。在老年患者中，尤其是肩袖撕裂或大粗隆骨折时，不太可能再发生脱位。术后固定时间无明显差异。
历史是诊断性的。患者抱怨肩膀脱臼与相对琐碎的日常行动。通常他能自己减少错位。对于诊断的任何疑问都可以通过恐惧测试迅速解决：如果患者的手臂被动地放在冠状面后面，处于外展和侧向旋转的位置，那么他的直接抵抗和恐惧是病理学的。肩内侧旋转的前后位x光片可能显示肱骨头后部有凹陷（Hill-Sachs病变）。
更常见但不易诊断的是复发性半脱位。第13章讨论了两种不稳定的管理。