【医学英语第7期】临床篇之骨科学（一）

发布时间：2021/12/2 11:43:46

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本期为骨科疾病的第一讲，骨科学又称矫形外科学（Orthopedics同时有此两种释义）。是医学的一个专业或学科，专门研究骨骼肌肉系统的解剖、生理与病理，运用药物、手术及物理方法保持和发展这一系统的正常形态与功能，以及治疗这一系统的伤病。本期主要讨论股骨颈骨折和膝盖疼痛这两种常见骨科疾病。

股骨颈骨折常发生于老年人，随着人的寿命延长，其发病率日渐增高，尤其随着人口老龄化，已成为严重的社会问题。其临床治疗中存在骨折不愈合和股骨头缺血坏死两个主要难题。

膝盖疼痛多为慢性病变，导致膝盖疼痛的原因有很多，比如关节劳损，韧带拉伤关节炎，风湿病等都会出现膝盖疼痛的情况。

案例分析

Case 1：A 72-year-old woman with a history of osteoporosis presents to her physician after falling 2 days earlier on a slippery sidewalk, landing on her left side. Since the fall, she has been unable to walk because of severe pain in her left hip. The pain is worse when she tries to move it. When asked to walk for assessment of her gait, she refuses, saying that it is too painful. Physical examination reveals normal vitals, extreme pain with both external and internal rotation of the hip, and tenderness over the anterolateral portion of the left lip.

案例1：72岁女性因滑倒至左侧髋部着地受伤，伤后因左髋部疼痛严重而无法行走。检查步态因过于疼痛而遭拒。体检显示生命体征正常，髋部外旋内旋均极度疼痛，左髋部前外侧触痛明显。

1. What is the most likely diagnosis?

The most common cause (MCC) causes of lateral hip paining elderly patients include osteoarthritis, bursitis, metastases, and femoral fracture. In this patient, the sudden onset of pain after the fall and inability to walk strongly suggest a fracture of the neck of the femur.

股骨颈骨折

诊断特点：老年近期有外伤史，伤后即无法行走，髋部内外旋疼痛，强烈提示本疾病。

2. What is a potential complication of this condition?

Fracture of the neck may disrupt blood supply to the head of the femur. The major arterial supply to the head of the femur is the medial and lateral circumflex femoral arteries and the artery of the ligament of the head of the femur. Disruption of the blood supply may cause avascular necrosis of the femoral head.

股骨颈骨折并发症

骨折易造成股骨头血供受损，股骨头主要血供为旋股内侧和外侧动脉，以及股骨头韧带动脉。故血供受损可能会导致非血管性坏死。

3. Six weeks later, repeat X-ray shows a callus. What does the callus indicate about the patient’s stage of healing?

Bone healing is often divided into 3 stages:

a.Inflammatory phase: a hematoma forms at the site of fracture to help deliver the buildings blocks of new bone formation. Reabsorption occurs at the edges of bone, which is why fractures are more likely to be seen on X-ray days after the injury.

b.Reparative phase: new blood vessels that supply nutrients to the cartilage begin to form at the fracture site, followed by callus formation. The osteoprogenitor cells that form the callus derive from the inner surface of the periosteum, not from the marrow or the epiphyseal plate. The patient is in this stage of healing.

c.Remodeling phase: the endochondral callus becomes ossified and bone undergoes structural remodeling (a process that is much slower in elders than in children) 

骨折愈合三个阶段：

1.炎症期：血肿形成→骨边缘出现重吸收→X-ray常见表现

2.修复期：新生血管在骨折部位形成→出现骨胼胝（骨痂）→骨祖细胞来源于骨膜内表面，而非来源于骨骺板 （根据题干可知患者目前处于此阶段）

3.重构期：软骨内骨痂骨化，骨结构重构（老年人远慢于儿童）

Case 2: A 19-year-old woman athlete comes to the emergency department with her coach after injuring her left knee during sports practice. She says she hear a “pop” when she made a quick turn and then developed a sharp pain on the lateral side of her knee and her leg “collapsed”.

案例2：19岁运动员在运动中左膝受伤，主诉在急速转动时听到膝盖内爆裂声，随后出现膝外侧锐痛，感觉左腿无法运动。

1. What are the two main intracapsular ligaments in the knee?

The anterior cruciate ligament extends from the anterior intercondylar area of the tibial plateau and traverses superior and lateral to the medial surface of the lateral femoral condyle. 

The posterior cruciate ligament extends from the posterior intercondylar area of the tibial plateau and traverses superior and medial to the lateral surface of the medial condyle of the femur.

膝关节韧带断裂

诊断：特殊职业或运动+外伤史+查体及影像学检查

膝关节主要韧带：前交叉韧带从胫骨平台前髁间区向外延伸，穿过股骨外侧髁上外侧至股骨外侧髁内表面。后交叉韧带从胫骨平台后髁间区延伸，穿过股骨内侧髁外侧表面的上内侧。

2. What is the role of the meniscus?

The half-moon-shaped meniscus is cartilage that is found between the femur and tibia. The meniscus absorbs the impact load of the joint and is involved in stability. 

半月板作用：半月状的半月板为股骨和胫骨之间的软骨组织，主要作用为吸收压力+稳定关节

3. Which ligament of the knee is most often injured?

The medial collateral ligament is weaker than the anterior or the posterior cruciate ligaments, so medial collateral ligament injuries are more common. Anterior cruciate ligaments tears are much more common than posterior. 

常见韧带损伤：内副韧带最为薄弱，故最易损伤；前交叉韧带比后交叉韧带更易损伤。

4. What is the terrible or unhappy triad?

This is a common contact-sport injury to the knee that occurs when lateral trauma is applied to the knee joint while the foot is fixed to the ground. Subsequently, the medial collateral ligament, lateral meniscus, and anterior cruciate ligament are damaged.

膝关节三联征：运动员常见的身体接触项目的膝关节损伤，主要因足部着地时受到侧面创伤。表现为内副韧带+外侧半月板+前交叉韧带同时受损。

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