To fix an imperfectly reduced fracture is to risk failure. If a stage III or IV fracture cannot be reduced closed, and the patient is under 60 years of age, open reduction through an anterolateral approach is advisable. However, in older patients (and certainly in those over 70) this may not be justified; if two careful attempts at closed reduction fail, prosthetic replacement is preferable. Some may even argue that prosthetic replacement is always a preferable option for this older group as it carries a much lower risk of needing revision surgery.
Once the fracture is reduced, it is held with cannulated screws or a sliding screw and side-plate which attaches to the femoral shaft. A lateral incision is used to expose the upper femur. When using cannulated screws, guide wires –– inserted under fluoroscopic control – are used to ensure correct placement of the fixing device. Usually three cannulated screws will suffice; they should lie parallel and extend to within 5 mm of the subchondral bone plate. It is usual to start with an inferior screw that skirts the inferior cortex of the neck but remains centred in the lateral x-ray view. This screw should be inserted through the lateral cortex of the femur at a level proximal to the lesser trochanter lest a stress riser is created and produces a subtrochanteric fracture. Two further screws are inserted more proximally, this time centred in the femoral neck on the anteroposterior x-ray but straddling the anterior and posterior margins of the femoral neck on the lateral x-ray (Figure 29.8). If a sliding screw is used, the femoral neck will first have to be reamed; a temporary guidewire should always
be introduced before reaming so as to prevent the femoral head from rotating with the reamer and tearing the remaining soft-tissue attachments. Once the sliding screw is fixed, the guidewire is replaced by a single screw to reduce the risk of femoral head rotation during fracture healing – this screw must be parallel to the sliding screw or else impaction of the fracture will not occur!
From the first day patients should sit up in bed or in a chair. They are taught breathing exercises, and encouraged to help themselves and to begin walking (with crutches or a walker) as soon as possible. To delay weightbearing may be theoretically appropriate but is rarely practicable.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
anterolateral approach前外侧入路
prosthetic replacement假体置换
/prɑːsˈθetɪk/adj. 假体的
advisable，preferable 这两个词均可以表示“可取的”
cannulated screws 空心螺钉
/'kænjulit, -leit/adj. 筒状的（等于cannular）vt. 插管
sliding screw滑动螺钉
suffice/səˈfaɪs/vt. 使满足；足够…用；合格vi. 足够；有能力
subchondral bone软骨下骨
inferior /ɪnˈfɪriər/n. 下级；次品adj. 差的；自卑的；下级的，下等的
trochanter /tro'kæntər/n. [解剖] 转子；粗隆；昆虫的转节
lest /lest/conj. 唯恐，以免；（引出产生某种情感的原因）唯恐，担心
straddle英 /ˈstrædl/ 美 /ˈstrædl/vi. 跨坐；两腿叉开坐vt. 叉开(腿)；骑，跨；跨立于；跨越n. 跨坐；横跨
theoretically appropriate理论上适当
百度翻译：
修复不完全复位的骨折有失败的风险。如果III期或IV期骨折不能闭合复位，且患者年龄在60岁以下，建议通过前外侧入路切开复位。然而，对于老年患者（当然也包括70岁以上的患者），这可能是不合理的；如果两次仔细的闭合复位尝试失败，假体置换是更好的选择。有些人甚至认为，对于老年人来说，假体置换总是一个更好的选择，因为它需要翻修手术的风险要低得多。
骨折复位后，用空心螺钉或滑动螺钉和附在股骨干上的侧板固定。侧切口暴露股骨上部。当使用空心螺钉时，使用导线（在透视控制下插入）来确保固定装置的正确放置。通常三个空心螺钉就足够了；它们应该平行排列，并延伸到软骨下骨板的5毫米以内。通常情况下，从一个下侧螺钉开始，该螺钉绕过颈部下缘，但仍保持在侧位x光片的中心位置。该螺钉应插入股骨外侧皮质，靠近小转子，以免产生应力升高，导致转子下骨折。另外两个螺钉较近端插入，这一次在前后位x光片上位于股骨颈中心，但在侧位x光片上横跨股骨颈的前后缘（图29.8）。如果使用滑动螺钉，股骨颈必须首先扩孔；应始终使用临时导丝
在扩孔前引入，以防止股骨头随扩孔器旋转而撕裂剩余的软组织附着物。滑动螺钉固定后，导丝由一个螺钉代替，以降低骨折愈合过程中股骨头旋转的风险-该螺钉必须与滑动螺钉平行，否则不会发生骨折嵌顿！
从第一天起，病人应该坐在床上或椅子上。他们被教导呼吸练习，并鼓励他们帮助自己，尽快开始走路（用拐杖或助行器）。延迟负重在理论上可能是适当的，但很少可行。
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