骨科英文书籍精读（357）｜胫腓骨骨折术后晚期并发症
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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Delayed union
High-energy fractures are slow to unite and liable to non-union or fatigue failure if a nail has been used. If there is insufficient contact at the fracture site, either through bone loss or comminution, 'prophylactic’ bone grafting as soon as the soft tissues have healed is recommended (Watson, 1994). If there is a failure of union to progress on x-ray by 6 months, secondary intervention should be considered. The first nail is removed, the canal reamed and a larger nail reinserted. If the fibula has united before the tibia, it should be osteotomized so as to allow better apposition and compression of the tibial fragments.
Non-union
This may follow bone loss or deep infection, but a common cause is faulty treatment. Either the risks and consequences of delayed union have not been recognized, or splintage has been discontinued too soon, or the patient with a recently united fracture has walked with a stiff equinus ankle.
Hypertrophic non-union can be treated by intramedullary nailing (or exchange nailing) or compression plating. Atrophic non-union needs bone grafting in addition. If the fibula has united, a small segment should be excised so as to permit compression of the tibial fragments. Intractable cases will respond to nothing except radical Ilizarov techniques (Fig. 30.32).
Joint stiffness
Prolonged cast immobilization is liable to cause stiffness of the ankle and foot, which may persist for 12 months or longer in spite of active exercises. This can be avoided by changing to a functional brace as soon as it is safe to do so, usually by 4–6 weeks.
Osteoporosis
Osteoporosis of the distal fragment is so common with all forms of treatment as to be regarded as a 'normal’ consequence of tibial fractures. Axial loading of the tibia is important and weightbearing should be re-established as soon as possible. After prolonged external fixation, special care should be taken to prevent a distal stress fracture.
Regional complex pain syndrome
With distal third fractures, this is not uncommon. Exercises should be encouraged throughout the period of treatment. The management of the established condition is discussed in Chapter 10.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
fatigue /fəˈtiːɡ/n. 疲劳，疲乏；杂役vt. 使疲劳；使心智衰弱vi. 疲劳adj. 疲劳的
prophylactic/ˌproʊfəˈlæktɪk/adj. 预防性的，预防疾病的n. 预防性药物（或器具、措施）；预防法；避孕用具
splintage/'splintidʒ/n. [医] 夹板固定
equinus. 马蹄足（一种发育性畸形）
Hypertrophic non-union增生性骨不连
Hypertrophic /,haipə'trɔfik/adj. 肥厚的；过度膨胀的
Atrophic non-union萎缩性骨不连
Intractable cases will respond to nothing except radical Ilizarov techniques对于顽固性病例，除了彻底的伊扎罗夫技术外，什么都不会有反应
Intractable/ɪnˈtræktəbl/adj. 棘手的；难治的；倔强的；不听话的
有道翻译（仅供参考，建议自己翻译）：
延迟愈合
高能量骨折愈合缓慢，如果使用了钉子，容易发生不愈合或疲劳破坏。如果骨折部位接触不足，无论是骨丢失还是粉碎，建议在软组织愈合后立即进行预防性植骨（Watson，1994）。如果在6个月前x光片上不能愈合，应考虑二次介入治疗。第一个钉子被移除，椎管被扩孔，一个更大的钉子被重新插入。如果腓骨在胫骨之前已愈合，则应进行截骨，以便更好地对胫骨碎片进行并置和压缩。
不愈合
这可能是骨丢失或深部感染引起的，但常见的原因是治疗不当。要么是骨折延迟愈合的风险和后果尚未被认识到，要么是夹板固定术中断得太快，要么是最近合并骨折的患者行走时出现了马蹄关节僵硬。
肥大性骨不连可用髓内钉（或交锁钉）或加压钢板治疗。萎缩性骨不连需加植骨。如果腓骨已愈合，应切除一小段，以便压缩胫骨碎片。除了激进的Ilizarov技术（图30.32），难治性病例不会有任何反应。
关节僵硬
长时间的石膏固定容易导致踝关节和足部僵硬，尽管进行了积极的锻炼，这种僵硬可能会持续12个月或更长时间。在安全的情况下尽快更换功能性支撑可以避免这种情况，通常是4-6周。
骨质疏松症
远端骨折的骨质疏松症在各种治疗方式中都很常见，被认为是胫骨骨折的“正常”后果。胫骨的轴向负荷很重要，应尽快恢复负重。延长外固定时间后，应特别注意防止远端应力性骨折。
局部复杂疼痛综合征
对于第三远端骨折，这并不少见。治疗期间应鼓励锻炼。第10章讨论了对既定条件的管理。