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Treatment
The general principles set out on page 920 should be observed.
UNDISPLACED FRACTURES
A split below-knee plaster is applied and, when the swelling has subsided, is replaced by a complete cast with the foot plantarflexed. Weightbearing is not permitted for the first 4 weeks; thereafter, the plaster is removed, the fracture position is checked by x-ray, a new cast is applied and weightbearing is gradually introduced. Further plaster changes or use of an adjustable splintage boot will allow the foot to be brought up, slowly, to plantigrade; physiotherapy is commenced. At 8–12 weeks the splintage is discarded and function is regained by normal use.
DISPLACED FRACTURES OF THE NECK
Even the slightest displacement makes it a type II fracture, which needs to be reduced. If the skin is tight, reduction becomes urgent because of the risk of skin necrosis. Reduction must be perfect: (1) in order to ensure that the subtalar joint is mechanically sound; 2) to lessen the chance – or at any rate lessen the effects – of avascular necrosis.
With type II fractures, closed manipulation under general anaesthesia can be tried first. Traction is applied with the ankle in plantarflexion; the foot is then steered into inversion or eversion to correct the displacement shown on the x-ray. The reduction is checked by x-ray; nothing short of 『anatomic』 is acceptable. A below-knee cast is applied (with the foot still in equinus) and this is retained, non-weightbearing, for 4 weeks. Cast changes after that will allow the foot to be gradually brought up to plantigrade; however, weightbearing is not permitted until there is evidence of union (8–12 weeks).
If closed reduction fails (which it often does), open reduction is essential; indeed, some would say that all type II fractures should be managed by open reduction and internal fixation without attempting closed treatment. Through an anteromedial incision the fracture is exposed and manipulated into position. Wider access can be obtained by pre-drilling and then osteotomizing the medial malleolus; after the talar fracture has been reduced, the malleolar fragment is fixed back in position with a screw. The position is checked by x-ray and the fracture is then fixed with two K-wires or a lag screw. Postoperatively a belowknee cast is applied; weightbearing is not permitted until there are signs of union (8–12 weeks).
Type III fracture–dislocations need urgent open reduction and internal fixation. The approach will depend on the fracture pattern and position of displaced fragments. Osteotomy of the medial malleolus might help; the malleolus is pre-drilled for screw fixation and osteotomized and retracted distally without injuring the deltoid ligament. This wide exposure is essential to permit removal of small fragments from the ankle joint and perfect reduction of the displaced talar body under direct vision; even then, it is difficult! The position is checked by x-ray and the fracture is then fixed securely with screws. If there is the slightest doubt about the condition of the skin, the wound is left open and delayed primary closure carried out 5 days later. Postoperatively the foot is splinted and elevated until the swelling subsides; a below-knee cast or splintage boot is then applied, following the same routine as for type II injuries.
---from 《Apley’s System of Orthopaedics and Fractures》
重點詞彙整理：
foot plantarflexed 腳掌蹠屈
plantigrade /ˈplæntəˌɡreɪd/adj. 躑行的；躑行類的n. 蹠行動物
commence /kəˈmens/v. 開始；著手
in order to ensure that the subtalar joint is mechanically sound;為了確保距下關節在機械上是健全的.
sound 合理的；無損的;健全的
inversion or eversion內翻或外翻
nothing short of 『anatomic』 is acceptable.除了「解剖復位」外，什麼都不能接受。
不符合 "解剖復位 "的情況是不能接受的
short of缺乏；不足；除…以外
Wider access can be obtained by pre-drilling and then osteotomizing the medial malleolus;內踝預鑽孔後截骨可獲得較寬的通路;
Osteotomy /ˌɒstɪˈɑːtəmi/
n. 截骨術，骨切開術
Osteotomize截骨 v.
deltoid ligament. 三角韌帶
DeepL翻譯（僅供參考，建議自己翻譯）：
治療方法
應遵守第920頁規定的一般原則。
未移位的骨折
使用膝下分塊石膏，當腫脹消退後，用完整的石膏代替，腳掌蹠屈。頭4周不允許負重；此後，去除石膏，通過X線檢查骨折位置，打上新的石膏，逐漸開始負重。進一步更換石膏或使用可調節的夾板靴，可以使足部緩慢上升，達到蹠步狀態；開始進行物理治療。在8-12周時，夾板被丟棄，功能通過正常使用得到恢復。
頸部移位的骨折
即使是最輕微的移位，也屬於II型骨折，需要進行縮減。如果皮膚很緊，由於有皮膚壞死的危險，縮小就變得很緊急。減輕必須是完美的。(1)為了確保距下關節在機械上是健全的；(2)為了減少血管壞死的機會--或至少是減少影響--。
對於II型骨折，可以首先嘗試在全麻下進行封閉式操作。踝關節處於蹠屈狀態時進行牽引；然後引導足部內翻或外翻，以糾正X線片上顯示的位移。通過X線檢查減少的情況；不符合 "解剖學 "的情況是不能接受的。使用膝下石膏（腳仍處於等長狀態），並保持非負重狀態，持續4周。此後，石膏的更換將使足部逐漸恢復到蹠骨狀態；然而，在有證據表明結合之前（8-12周）不允許負重。
如果閉合復位失敗（經常如此），則必須進行開放復位；事實上，有人會說，所有的II型骨折都應該通過開放復位和內固定來處理，而不必嘗試閉合治療。通過前內側切口，骨折被暴露出來並被操縱到合適的位置。通過預先鑽孔，然後對內側大腿骨進行截骨，可以獲得更寬的通道；在距骨骨折縮小後，用螺釘將大腿骨碎片固定在位置上。通過X線檢查位置，然後用兩根K線或一個滯後螺釘固定骨折。術後使用膝下石膏，在出現結合跡象之前（8-12周）不允許負重。
III型骨折-脫位需要緊急開放復位和內固定。方法取決於骨折模式和移位的碎片的位置。內側大腿骨的截骨可能會有幫助；大腿骨要預先鑽孔，以便用螺釘固定，截骨後向遠端牽拉，不傷及三角韌帶。這種廣泛的暴露是必不可少的，以便能夠從踝關節中取出小碎片，並在直視下完美地縮小移位的距骨體；即使這樣，也是很困難的 通過X射線檢查位置，然後用螺釘牢固地固定骨折。如果對皮膚狀況有絲毫的懷疑，傷口將保持開放，並在5天後進行延遲的初級封閉。術後，腳被夾板固定並抬高，直到腫脹消退；然後使用膝下石膏或復古靴，與II型損傷的常規治療相同。
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