BASIN [pelvis (PNA, JNA)] — the bone ring formed by two haunch bones, a sacrum and a tailbone. T. serves as a support for a trunk and the lower extremities and is a receptacle of a number of internals.
A comparative anatomy
At fishes and pinniped T. it is formed by two bones which are not tied with a backbone. At birds it is open in front, and behind haunch bones connect to a backbone. At four-footed mammal T. the small sizes, it is extended in the perednezadny direction. In process of transition to bipedalism of T. becomes shorter and wider. The person has perednezadny and cross sizes of an upper aperture of T. almost identical.
Haunch bones connect with each other in front a pubic symphysis (see), and behind to a sacrum (see the Backbone) by means of sacroiliac joints (see. Sacroiliac eustav). Tailbone (see), having connected to a top of a sacrum, supplements the bone ring creating a basin. The haunch bone (os coxae) is formed as a result of an union of three bones: ileal (os ilium), sciatic (os ishii) and pubic (os pubis). This union is in area of an acetabular hollow (acetabulum).
Outside reference points of T. ileal crests, a sacrum, a tailbone, a pubic symphysis, sciatic hillocks are.
The ambit (linea terminalis) on an inner surface of a bone pelvic ring formed by the cape (promontorium), the arc-shaped lines (lineae arcuatae), crests of pubic bones (pecten ossis pubis) and the upper edge of a pubic symphysis conditionally divides T. on big and small (pelvis major et pelvis minor). In big T. it is located up from an ambit and is limited behind bodied Ly, sideways and from below by inner surfaces of wings of ileal bones; from above and in front it is open. Small T. has an appearance of the wide short channel (cavity) of a cylindrical form, walls to-rogo are formed by haunch bones, a sacrum and a tailbone. Border of an upper (entrance) opening small T. — upper aperture of a basin (apertura pelvis sup.) passes on an ambit, the lower (day off) opening — the lower aperture of a basin (apertura pelvis inf.) passes in front on bottom edge of a pubic symphysis, sideways — on sciatic hillocks, bottom edge of branches of ischiums and a sacral hillock - nym to sheaves, and behind — on a tailbone. The upper opening connects cavities big and small T., and lower — it is closed by muscles and fastion of a crotch (see the Crotch).
Front wall of a cavity small T. short is also formed by a back surface of a pubic symphysis and its sheaves, the forefront of a lateral wall is busy with a locking opening (foramen obturatum), a cut is closed by a locking membrane (membrana obturatoria), and the tail of a lateral wall represents an interval between an ischium and a sacrum. This interval is divided a cross-tsovo-bugornoy and sacral ostistoys by sheaves into big and small sciatic openings (foramina ischiadica majus et minus), through to-rye there pass muscles, vessels and nerves. Over a locking furrow of an upper branch of a pubic bone the locking membrane is thrown in the form of the bridge therefore the locking channel (canalis obturatorius) is formed, to Krom there go a locking artery, a vein and a nerve. Back wall of a cavity small T. the longest is also formed by a pelvic surface of a sacrum and a tailbone.
At vertical position of a body of T. it is located at an angle to the horizontal plane. A corner between the horizontal plane and the plane of an entrance in small T. call a tilt angle of T. (inclinatio pelvis), size to-rogo makes from 55 ° to 75 ° (on average 60 °); it changes depending on a bearing * provisions of a body, gender and age, napr, newborns have this corner more, than at adults.
Internal bone walls big and small T. are covered with muscles and fastion (fig. 1). On an inner surface of a big basin the iliolumbar muscle (m. iliopsoas), on a lateral wall small is located with T. — the internal locking muscle (m. obturatorius internus), in back department of a lateral wall and partially on a back wall begins a pear-shaped muscle (m. piriformis). Internal locking and pear-shaped muscles are covered with a parietal fascia of a basin (fascia pelvis parietalis), and an iliolumbar muscle — an ileal fascia (fascia iliaca).
Cavity big T. is a lower part of an abdominal cavity, in Krom there are a caecum, a sigmoid gut and loops of a small bowel. In a cavity small T. the rectum and a bladder with a pelvic part of ureters are located, men have a prostate, seed bubbles, a deferent duct, women have ovaries, uterine tubes, a uterus, a vagina (see tsvetn. the tab. to St. Bladder , fig. 1, 2; tsvetn. the tab. to St. Uterus , fig. 2). In a cavity big T. also general and наруя^-ные pass ileal arteries and veins, their branches, branches of a lumbar texture, the general are located and outside ileal limf. nodes. In small T. there are internal ileal arteries and veins, their branches, internal ileal limf, nodes, veniplexes (sacral, pryamokishechny, vesical, prostatic, uterine, vulval), a sacriplex, top and bottom hypogastric textures of century of N of page. Muscles of the lower extremity, a back, a stomach and a crotch are attached to pelvic bones.
The soft tissues covering a bone basis of a big and small pelvis outside belong to a rump, area of a hip and a crotch.
Form and sizes T. depend on age and a floor. V newborn of T. has the form of a funnel (it is squeezed from sides, wings of ileal bones are located almost vertically), in a nek-swarm of degree reminding a basin of mammals.
The female basin in comparison with men's has a number of anatomic features (fig. 2). T. is lower and wider than the newborn girl due to increase in cross sectional dimension of an entrance to a basin. During this period the most part of haunch bones consists of the cartilaginous tissue which is located between kernels of ossification, and haunch bones are divided by cartilaginous layers. On the 8th year of life at girls cartilaginous tissue in a zone of connection of branches of pubic and sciatic bones is replaced with a bone tissue. By 14 — 16 years merge of ileal, sciatic and pubic bones in one haunch bone gradually comes to the end, and final ossification occurs only by 25 years. Distinguish I women's T. from men's clearly are shown during puberty (see) also become the most expressed at mature age. Bones women's
T. thinner, smooth and less massive, than bones men's T. Zhensky T. lower, more widely and more in volume. The sacrum at women is wider and is not so strongly bent, as at men; the cape of the basis of a sacrum (the sacral cape) at women acts less forward, than at men; pubic symphysis women's T. well and more widely. An entrance in small T. at women is wider, a cross and oval form, with dredging in the field of the sacral cape. Cavity small T. at women is more extensive, on the outlines approaches the cylinder bent kpered. These features are essential at childbirth (see).
In obstetrics it is accepted to allocate 4 planes small to T.: the plane of an entrance in small T., plane of a wide part of a cavity small T., plane of a narrow part of a cavity small T., plane of an exit of T. (fig. 3).
The plane of an entrance in small T. passes through the upper edge of a pubic symphysis, the arc-shaped lines and the sacral cape. The direct size of an entrance — obstetric, or true, a conjugate (conjugata vera) — distance between a sacral mysokhm and the most acting point on an inner surface of a pubic symphysis, is equal to 11 cm. Distinguish also anatomic conjugate (conjugata anatomica) — distance between the sacral cape and the middle of the upper edge of a pubic symphysis, equal 11,5 cm. Cross sectional dimension of an entrance — distance between the most remote points of the arc-shaped lines — is equal to 13 cm. Slanting sizes two: right a braid — from the right sacroiliac joint to an eminence left ileal pubic and left a braid — from the left sacroiliac joint to the right ileal and pubic eminence; both are equal to 12 cm.
Plane of a wide part small T. has the following borders: in front — the middle of an inner surface of a pubic symphysis, from sides — the middle of acetabular hollows, behind — the conjunction of S1 and S2 of vertebrae. Distinguish the direct size of a wide part small T. — distance from the middle of a back surface of a pubic symphysis to the conjunction of S2 and S2 of vertebrae — equal 12,5 cm, and cross — distance between inner surfaces of acetabular hollows, equal 12,5 cm. There are no slanting sizes since in this part T. has no continuous bone ring.
Plane of a narrow part small T. it is limited in front to bottom edge of a pubic symphysis, from sides — sciatic awns, behind — a sacrococcygeal joint and has the direct and cross sizes. The direct size (from bottom edge of a pubic symphysis to a sacrococcygeal joint) is equal to 11 cm, cross (distance between sciatic awns) is equal to 10.5 cm.
Plane of an exit small T. it is limited in front to bottom edge of a pubic symphysis, on each side sciatic hillocks, behind — a top of a tailbone and has the direct and cross sizes. The direct size (from bottom edge of a pubic symphysis to a top of a tailbone) is equal to 9,5 cm; during the passing of a fruit through small T. the tailbone deviates on 1,5 — 2 cm and the direct size increases to 11.5 cm. Cross sectional dimension (distance between inner surfaces of sciatic hillocks) is equal to 11 cm
Thus, the largest size in an entrance in small to T. is cross. In a wide part of a cavity small T. the direct and cross sizes are equal, and the largest size is conditionally accepted slanting size. In a narrow part of a cavity and at the exit small T. the direct sizes there are more cross. Since the pubic symphysis is much shorter, than a sacrum with a tailbone, the planes T. meet in the direction of a kpereda and fanlikely kzad disperse. If to connect the middle of the direct sizes of all planes T., it will turn out not the direct, but bent kpereda (to a pubic symphysis) the line, edges is called a wire axis of a basin.
Except the specified planes, distinguish the parallel planes small T. across Godzhu (see fig. 6 to St. Childbirth, t. 22, Art. 333). The first — terminal — corresponds to the plane of an entrance in small T. The second plane — main — passes through bottom edge of a pubic symphysis; it is called main since at this level the continuous bone ring of a basin comes to an end. The third plane — spinal — passes through sciatic awns. The fourth plane — output — passes through the tailbone which is turned in kpered.
For judgment of the sizes small T. measurement of a diagonal conjugate — distance between bottom edge of a pubic symphysis and the sacral cape matters, a cut it is more than 12 cm.
In a standing position the upper edge of a pubic symphysis of the woman is projected below the sacral cape; the true conjugate forms a tilt angle of T with the horizontal plane., to-ry it is normal equal about 60 °, but can change depending on duration of gestation.
For rentgenol. studying of T. make survey roentgenograms in straight lines (back and front), side and slanting projections. Besides, in addition carry out aim roentgenograms for a research of a certain department of haunch bones. Most often do a direct survey picture of bones of T. in position of the patient lying on spin with the extended legs. The cartridge is located cross in the plane of a snimochny table. The central bunch of x-ray emission is sent perpendicularly to the cartridge on the centerline of a body at the level of upper front ileal awns. In this projection receive the image of all bones of T., sacrum and 2 — 3 lower lumbar vertebrae (fig. 4). At the correct laying investigated in a picture locking openings have the identical form, the ambit accurately is defined.
This line smoothly, without stupeneobrazny deformations, passes from one half of a basin to another.
Pictures in a side projection make in position of the patient lying on one side. At the same time the center of a bunch of x-ray emission is directed to the lower front ileal awn.
Pictures in a slanting projection do at an inclination of the patient of edgewise position of a kpereda or a kzada. At the same time not only the wing of an ileal bone, but also the rear edge of an acetabular hollow well comes to light.
The pubic symphysis is investigated in a direct lobby or a direct back projection. The form of a crack of a pubic symphysis is variable, its width fluctuates ranging from 0,5 to 1,0 cm. The upper edges of the pubic bones forming a symphysis are at one level, the ambit smoothly passes from a bone to a bone. The surfaces of the bones adjoining a pubic symphysis have accurate and equal outlines.
Sometimes make pictures in an axial projection for a research of a pubic symphysis (in position of the patient sitting with the extended or lowered legs and rejected back by a trunk; the central bunch of radiation is directed from top to down, i.e. along a back surface of a pubic symphysis).
Methods of inspection
carry out Inspection of patients by survey, palpations, measurements of the sizes of a basin. According to indications apply radiological methods of a research, in particular a rentgenopelvimetriya (see. Pelvimetriya ). In obstetrics the greatest value has measurement of a basin (see. Obstetric research ).
Pathology of T. includes defects of its development, damage and disease.
Malformations are observed more often in back department of a pelvic ring: dermoid cysts (see the Dermoid) and epidermoid cysts (see), cross crevices, failure of union of arches of sacral vertebrae (see Spina bifida), an underdevelopment and even total absence of a sacrum and tailbone (see. Sacral area).
In front department of a pelvic ring malformations are rather rare. This lack of a pubic symphysis is more often; basic and dynamic functions T. at the same time are, as a rule, kept.
Pelvic bones are surprised at a dyschondroplasia (see the Chondrodystrophia) and a marble disease (see). Much less often the osteopoikilosis meets (see).
Damages T. can be open and closed. Allocate damages of soft tissues and bones of T., damages of pelvic bodies. Changes of pelvic bones can be combined with damages of other parts of a skeleton or internals.
At a shiba of the soft tissues surrounding a pelvic ring can be followed by bruises, amotio of skin and formation of slowly resolving and easily infected deep intermuscular hematomas (see). Treatment more often conservative (rest, local hypothermia, and further resorptional therapy). At amotio of skin and formation of a hematoma resort to its puncture. In case of suppuration of a hematoma an operative measure is shown. At a considerable bruise of area of a crotch (kick, falling on edge of a solid, etc.) perhaps hypodermic damage of a webby part of an urethra (see).
The forecast at an uncomplicated bruise of T. favorable.
Wounds of soft tissues are more often observed in a rump (see) and crotches (see), can be combined with internal injuries. Special danger is constituted at the same time development of a mephitic gangrene (see) and damage of buttock vessels. Treatment operational; it consists in surgical treatment of a wound (see) and careful hemostasis. If the hemostasis is complicated that is possible, e.g., at wound of buttock vessels or their branches, resort the CU to bandaging of an internal ileal or buttock artery. For bandaging of an internal ileal artery midsection of a front abdominal wall from a pubic symphysis up cut skin, an aponeurosis and a cross fascia of a stomach. The peritoneum together with an ureter is removed in the stupid way up and medially then the big lumbar muscle with adjacent general, outside and internal ileal arteries is bared. Under an internal ileal artery bring Deshan's needle and impose a ligature.
Bandaging of a buttock artery is made in position of the patient on a stomach. A horseshoe section in back department of a crest of an ileal bone cut skin, big and average gluteuses, a periosteum of an ileal bone. The skin and muscular and periosteal rag the raspatory is otslaivat down, baring the upper edge of a big sciatic opening. Cutting a periosteum, bare a buttock artery in a rag. At wound of an artery in this area its proximal end can sometimes go to a pelvic cavity. In this case resect the upper edge of big sciatic cutting.
The forecast is defined by weight of wound and timeliness of the carried-out treatment.
Changes of T. usually are heavy damage of a musculoskeletal system. They arise preferential at road incidents and falling from height. Fractures of separate bones of T. are possible owing to direct blow or a sharp muscle tension (avulsion fractures of an ileal awn, a sciatic hillock). In 25 — 45% of cases fractures of bones of T. are combined with injuries of other bones or internals.
On A. V. Kaplan's classification, allocate 4 main types of fractures of bones of T.: regional changes, changes of pelvic bones without disturbance of a continuity of a pelvic ring, with disturbance of its continuity and changes of an acetabular hollow.
Separations of ileal awns, fractures of a wing of an ileal bone, tailbone and sacrum below a sacroiliac joint (fig. 5) belong to regional changes; to fractures of bones of a pelvic ring without disturbance of its continuity — one - or a bilateral fracture of a pubic bone, one - or a bilateral change of an ischium, a fracture of a pubic bone on the one hand and sciatic about other (fig. 6); to changes of a pelvic ring with disturbance of its continuity in front department — one - and bilateral changes of both branches of a pubic bone, one - and bilateral fractures of pubic and sciatic bones (fig. 7, a), in back department — a longitudinal fracture of an ileal bone (fig. 7,6), and also ruptures of joints — a pubic symphysis and a rupture of a sacroiliac joint, joint changes of front and back departments — one - and a bilateral vertical change like Malgenya (see Maljgenya changes]), a diagonal change, various combinations of fractures of bones (fig. 7, c) and ruptures of synostoses of front and back departments of a basin. The group of changes of an acetabular hollow includes a change of edge of a hollow, including with dislocation of a hip, the isolated change of a bottom of a hollow and a Y-shaped cartilage at children, a change of a hollow in combination with a change of other departments of T.
Besides, allocate the damages breaking a continuity only one (front or back) department of a pelvic ring, and the damages breaking a continuity of a pelvic ring at the same time in both departments.
Symptomatology at changes of T. depends on the nature of a fracture and existence of the accompanying damages. At regional changes a condition of patients usually quite satisfactory. At separations of an ileal awn and fractures of a wing of an ileal bone (a change of Dyu-verneya) note a swelling and local morbidity in a zone of damage, and also dysfunction of the corresponding lower extremity. At an avulsion fracture of an ileal awn in some cases the symptom of «backward stroke» described in 1931 by L. I. Lozinsky is observed: strengthening of pains in the field of a change in attempt to actively bend a hip; at the movement back and pulling up of an extremity («backward stroke») pain is less expressed. Changes of a tailbone and sacrum below a joint are diagnosed on the basis of the local morbidity amplifying during the walking and in a sitting position; at a rectal research it is possible to define patol. mobility of distal department of a tailbone and its shift. Changes of a sciatic hillock are also shown by the local morbidity amplifying at active extension of the lower extremity.
Changes of front department of T., in particular with disturbance of a continuity of a pelvic ring, can be followed by deterioration in the general condition of the victim. Patients quite often accept forced situation with the bent in hip and knee joints and divorced lower extremities — «a pose of a frog» (Volkovich's symptom). At damages of a front half ring of T. the pains in the field of a change amplifying at a palpation and a prelum of bones of T are noted., and also at a vaginal and rectal research. At changes of a horizontal branch of a pubic bone active bending in a hip joint is complicated. In some cases the symptom of «the stuck heel» is observed — the victim cannot raise the extended leg. At changes near a pubic symphysis active reduction of an extremity owing to tension of the adductors of a hip which are attached in this area is more broken. Dysfunction of the lower extremities is one of constant symptoms at fractures of bones of a front half ring of T.
On 2 — the 3rd days after an injury can appear bruises in surrounding fabrics: at fractures of a pubic bone — over an inguinal (pupartovy) sheaf, at changes sciatic — in a crotch. At ruptures of a pubic symphysis retraction in this area is defined during a palpation and a vaginal research. Ruptures of a pubic symphysis are combined usually with a fracture of bones of T. or injury of sacroiliac ligaments.
The isolated injuries of bones of back department of a pelvic ring meet disturbance of its continuity extremely seldom, simultaneous damages of its front and back departments are more often observed. Patients quite often are in a condition of the traumatic shock caused by a massive injury and blood loss. Due to the anatomic features of blood supply of bones of T. and richly developed network of vascular textures of pelvic area bleeding at changes of a basin usually happens long and plentiful. Formation massive (to 2 — 3 l) retroperitoneal hematomas is possible. The stopped bleeding can renew at the most insignificant movements of the patient, a rearrangement, insufficiently careful research. The retroperitoneal hematoma owing to irritation blood of a parietal layer of a peritoneum quite often creates a picture of an acute abdomen. At low located hematomas symptoms of injury of urinary tract can be observed.
Quite often differential diagnosis of a retroperitoneal hematoma and intra belly bleeding is represented very difficult. Joyce's symptom which is observed at the last (shift of borders of a dullness in side departments of an abdominal cavity at change of position of the patient) cannot often be revealed because of weight of a condition of the victim. In these cases use objective methods of a research (a laparocentesis, a laparoscopy, a contrast uretrotsistografiya). At survey forced position of the patient attracts attention. At fractures of bones of T. asymmetry of a pelvic ring, an extremity on the party of damage of a rotirovan of a knaruzha decides on shift, it seems to the T shortened at the expense of the shift of a lateral fragment. up. Palpatorno comes to light the morbidity in the field of changes amplifying in attempts of a prelum (Verneuil's symptom) or cultivations (Larrey's symptom) of wings of ileal bones. Abdominal distention, a dullness, lack of a vermicular movement and even existence of the symptoms of irritation of a peritoneum caused by a retroperitoneal hematoma is possible. The nature of damage is specified at rentgenol. research. At the rotational shift of a half of a basin (outside rotation is more often) on the roentgenogram the size of a wing of an ileal bone increases, the locking opening decreases, its configuration changes (see. Sacroiliac joint).
Frequency of damages of an acetabular hollow makes apprx. 7% of all changes of T. Simptomatik depends on localization of a change. At changes of a bottom of a hollow without the shift of fragments morbidity in a joint is noted, but patients can even sometimes go. At the changes of a roof of an acetabular hollow complicated by dislocation of a hip (is more often back), the extremity adopts the characteristic provision. Crucial importance in diagnosis of this pathology has rentgenol. a research (see. Hip joint).
Fractures of bones of T. quite often are followed by damages of pelvic bodies, especially urinary tract (see the Urethra, the Bladder, the Rectum).
Transportation of the victim with a fracture of bones of T. in order to avoid the shift of fragments and damage of pelvic bodies it has to be carried out on a rigid stretcher or a board. To the patient bend extremities in hip and knee joints. To subnodal areas stack the roller. Before transportation it is reasonable to carry out intra-pelvic anesthesia. In a hospital it is necessary to avoid an excessive rearrangement of patients.
Treatment of heavy damages of T. quite often it is necessary to begin with holding antishock actions. Are of particular importance infusional therapy for compensation of blood loss and vnutritazo-vy novocainic anesthesia across Shkolnikov. In position of the patient on spin otstupya on 2 cm of a knutra from an upper front ileal awn a syringe needle 14 — 16 cm long enter solution of novocaine, advancing a needle in the direction in front back on depth of 12 — 14 cm to an internal ileal pole. At a unilateral change on the party of damage enter 300 — 400 ml into it, at bilateral — on 250 — 300 ml from each party of 0,25% of solution of novocaine. For prevention of the complications connected with introduction of high doses of novocaine add to it 1.il1% of solution of ephedrine or 1 ml of 10% of solution of caffeine. Usually rather single carrying out intra pelvic anesthesia.
At fractures of an ileal bone after carrying out intra pelvic anesthesia of the patient stack on 3 — 4 weeks on a board with the roller in subnodal areas. At avulsion fractures of an ileal awn with the expressed diastases open reposition or an osteosynthesis the screw can be required. Similarly carry out treatment of patients with changes of a pelvic ring without disturbance of its continuity.
At fractures of bones of front department of a pelvic ring with disturbance of its continuity in most cases treatment by situation on a board with the roller in subnodal areas is also performed. At the shift of bone fragments recommend extension for tuberosity of tibial bones with small loads (3 — 4 kg) at divorced extremities. At the expressed deformation of a front half ring of T. with a rupture of a pubic symphysis an operative measure (stabilization of a front half ring) can be required. Allow to go in 6 weeks. Working capacity is recovered in 2,5 — 3 months.
Treatment of patients with simultaneous injury of bones of front and back departments of a pelvic ring is the most difficult. At fractures of bones of T., the linking of pubic and sacroiliac connections which is followed by gaps without the shift of a lateral fragment of T. (the rupture of ligaments of sacroiliac joint radiological is diagnosed in this case on an indirect sign — a diastase of a pubic symphysis), the patient is suspended on a gamachka with a load on 5 — 8 kg, squeezing T. in the frontal plane. At ruptures of syndesmoses with the shift of a half of T. up in the beginning eliminate shift by skeletal traction on an axis of a hip with a load of 10 — 12 kg and only after reposition of T. pull together with a gamachok. At changes with disturbance of a continuity of both departments of a pelvic ring it is possible as well internal rotation of a lateral fragment. Therefore before bringing down ftocled-it needs to be carried out a derotation (in one step or extension for a wing of an ileal bone). Due to the danger of secondary rotational shift the gamachok shall not squeeze T. in the frontal plane. Considering that back department of T. bears the main static load, the bed rest shall be observed not less than 3 months. At failure of union of changes stability of a pelvic ring is broken. In these cases an operative measure is shown (see. Sacroiliac joint, Malgenya changes ). Working capacity at this type of damages of T. it is recovered usually in terms from 6 to 10 months. Quite often there is a need for temporary transfer of patients on disability.
At the combined damages of T. reposition is postponed until improvement of the general condition of the victim. Especially sharply this problem arises at the accompanying severe craniocereberal injury (see) or massive injury of a thorax (see. Breast ), as reposition of fragments of a basin requires the sublime provision of the foot end of a bed. At the accompanying fracture of a femur reposition of the displaced lateral fragment of a basin can be carried out only by extension for an ileal bone.
At changes of an acetabular hollow conservative treatment is in most cases shown. So, at changes of a bottom (pole) of an acetabular hollow without protrusion of a head of a femur and shift of bone fragments resort to unloading extension on an axis of a hip. At a protrusion of a head of a femur quite often its extraction requires extension on an axis of a neck of a hip. However it, as a rule, does not provide reposition of fragments of an acetabular hollow therefore in the subsequent the phenomena of the deforming arthrosis with the expressed pain syndrome and dysfunction of a joint develop. Operational reposition of fragments of a bottom of an acetabular hollow also usually does not save the patient from development of the phenomena of the deforming arthrosis (see). Thus, at rough damages of a bottom of an acetabular hollow of a complete recovery of working capacity often does not come and patients need transfer into disability. For recovery of an oporosposobnost of an extremity endoprosthesis replacement or an artificial ankylosis can be required (the SI. Hip joint).
Results of treatment of regional changes of an acetabular hollow are more favorable. At uncomplicated damages apply unloading extension. Quite often the change of edge of an acetabular hollow is combined with dislocation of a head of a femur. Usually at the same time the considerable fragment of posterosuperior edge of a hollow is broken out, to-ry it is not possible to reponirovat in the closed way in this connection open reposition of a fragment of a roof of a hollow with fixing by screws is required.
Features of fighting damages, stage treatment. Among gunshot wounds there is a T. distinguish wounds of soft tissues of pelvic and buttock areas, wounds of soft tissues and bones without damage of bodies of T. and wounds with damage of pelvic bodies. The last type of wound includes intraperitoneal wounds of a bladder and rectum and extra peritoneal wounds of a bladder, rectum, back urethra and prostate.
Wounds can be tangent, through and blind; the last meet more often. Among gunshot wounds of bones there is a T. distinguish: the regional and isolated changes without disturbance of a continuity of a pelvic ring; a change with disturbance of a continuity of a pelvic ring; 'fractures of bones of area of an acetabular hollow; changes with damage of front and back departments of T. Neredko of wound of T. are followed by damage of a hip joint.
By experience of the Great Patriotic War of wound of bones of T. without internal injury wounds of bones of T are noted in 61,3% of all wounds of a basin. with out of - and intraperitoneal damage of bodies of T. made 19,1%, injuries of bones of T., combined with wound of bodies belly on l of OST — 9,6% of cases, and with damage of large vessels and nervous trunks — in 4,3%.
At inspection of the wounded establish existence of entrance and output wound openings. On localization and the direction of the wound channel it is possible to suspect injury of bones, pelvic bodies, and also vessels. Palpation and careful side or perednezadny prelum of T. causes pain in the field of changes. The manual research of a rectum allows not only to establish its damage (on a finger there is blood), but quite often and to define a change and shift of bone fragments. Wounded with a fracture of pubic bones cannot raise the straightened leg (a symptom of «the stuck heel») because of strengthening of pains in the field of damage. At wounds of T. it is necessary to exclude damage of a hip joint. It is necessary to establish or exclude damage of pelvic bodies, large vessels and nervous trunks. Final diagnosis of a fire fracture of bones of T. establish after a X-ray analysis of only A T. (fig. 8).
Fire fractures of bones of T. often are followed by shock (see), considerable blood loss (see), inf. complications (out of - and intra pelvic phlegmons, abscesses and osteomyelitis), quite often mephitic gangrene, and also uric, fecal and purulent zateka (see. Flow, Uric flowed). . Wounds of large vessels of T. (outside and internal ileal arteries) are followed by outside and band bleeding and can lead to death. At interstitial bleeding with formation of the pulsing hematomas blood loss slower.
At first aid (see. First aid) apply a protective bandage, enter analgetics, carefully take out the wounded on a board (stretcher), under the legs bent in knee joints place a carryall or a roll of an overcoat in the form of the roller.
During the rendering the pre-medical help (see) control and correct bandages, improve a transport immobilization, enter analgetics.
During the rendering the first medical assistance (see) hold events for prevention of shock, fight against bleeding and the prevention of a wound fever. All wounded enter antibiotics, antitetanic serum and the adsorbed tetanic anatoxin, improve an immobilization. At overflow of a bladder in case of injury of an urethra carry out a suprapubic capillary puncture.
At a stage of rendering the qualified medical care (see) at medical sorting (see Sorting medical) allocate three groups of victims: wounded in soft tissues; wounded with fire fractures of bones of T. without internal injury and the menacing bleeding; wounded with fire fractures of bones of T., complicated by bleeding and an internal injury. In the first and second group hold events for preparation for evacuation, correct or change bandages, enter anesthetics or cardiovascular means. At simultaneous injury of bones of T., a hip joint or a hip carry out a transport immobilization (see) Diterikhs's tire strengthened by plaster rings (see. Splintage ), Wounded of the first group are evacuated in all-surgical hospital, the second — in specialized hospital for wounded in extremities. Wounded of the third group are given help according to vital indications. Especially often there is a need for a final stop of bleeding from buttock arteries. At unsuccessfulness of bandaging them in a wound carry out bandaging of an internal ileal artery (see above). Interstitial bleeding and formation of big retroperitoneal hematomas in T. it is observed at defeat of branches of an internal ileal artery. In similar cases bleeding after emptying of a hematoma during primary surgical treatment of a wound (see) is stopped, tying up an internal ileal artery if it is not possible to find its bleeding branch. At injury of a bladder, urethra and rectum perform necessary surgeries. Wounded with damage of pelvic bodies tsistoskopiya (see) and tsistografiya evacuate in specialized hospital where specify the diagnosis by means of intravenous urography (see), (see), fistulografiya (see) and carry out according to indications necessary to lay down. actions.
Diseases. Inflammatory processes can be localized in soft tissues, being located superficially or in deep layers, and also to strike pelvic bodies. The congestive abscesses (see Natechnik) which are going down in a cavity of T are possible. from overlying departments (see the Psoitis). Diagnosis of superficial abscesses and phlegmons (see) special complexity does not represent. They proceed with high temperature and the expressed local phenomena. Congestive abscesses, phlegmons of pelvic cellulose, on the contrary, .monut a long time to remain not distinguished. The current their heavier is also followed by dysfunction of pelvic bodies. To Lechentsa — an operative measure in combination with the directed antibacterial therapy. It is reasonable to make opening of deep phlegmons and zatek the broad accesses allowing to approach a sciatic opening where the abscesses leaving a cavity of T usually are located. At phlegmons of pelvic cellulose, early drainage is shown.
Osteomyelitis of bones of T. subdivide on hematogenous and posttraumatic (cm, Osteomyelitis). The last is a consequence of fire and open fractures more often (see). Slightly less often it arises at damage of pelvic bodies and formation of uric zatek (see. Uric flowed). Development of process is shown by symptoms of intoxication and sepsis (see). Hypostasis and infiltration of fabrics accrues, the quantity of purulent separated increases. Rentgenol. symptoms of osteomyelitis come to light only in 3 — 5 weeks. With formation of fistulas, emergence rentgenol. symptoms diagnosis becomes simpler. The fistulogra-fiya and a chreskostny flebografiya is informative (see). The preferential arrangement of purulent zatek is characteristic of each localization of osteomyelitis, to-rye subdivide on primary (at break of pus from a bone) and secondary, forming after break of primary abscesses. At osteomyelitis of a pubic bone prevesical initially forms became numb, for the second time — preperitoneal, perineal, scrotal, femoral. At osteomyelitis of an ischium primary flow can be localized in an ischiorectal pole, cellulose of a crotch, a rump and a hip. At damage of an ileal bone primary flow usually form on internal and outside its surfaces, and secondary can be various localization. At osteomyelitis of a sacrum primary flow are observed on its front surface more often. In a complex to lay down. actions at osteomyelitis of T. the leading place is taken by an early operative measure in the form of a wide resection of the affected bones and drainage of zatek.
The forecast depends on a basic disease and timeliness of treatment of its complications.
At tuberculosis of bones of T. most often the center arises in coxofemoral, sacroiliac joints and a pubic symphysis (see Tuberculosis vnelegoch-ny, a tuberculosis of bones and joints).
The expressed changes of bones of T. are observed at a puerperal form of osteomalacy (see). Bones of a pelvic ring are pressed into a cavity of T., the distance between ileal bones is reduced. The sacrum is crushed by a backbone down and accepts more horizontal position, the sacral cape is given forward, the pubic symphysis acts kpered, sciatic hillocks are pulled together, locking openings are located in the sagittal plane and an entrance to T. gets a Y-shaped form. Expressed is characteristic osteoporosis (see).
Changes of bones of T. are characteristic of Bekhterev's disease (see Bekhterev a disease). A specific place among early symptoms is held by the sacroileitis which is considered pathognomonic for this disease.
Damage of bones of T. it is observed in 30% of cases of an echinococcosis of bones (see the Echinococcus). Dull aches in the area T are characteristic., increase in the struck departments in volume, patol. changes. Process proceeds for years, but more rapid current reminding osteomyelitis is sometimes observed. Radiological the cellular structure of a zone of defeat or a cavity with accurate restriction from a healthy bone comes to light. Treatment comes down to an early radical resection of an affected area of a bone. A recurrence is possible. The joined infection often leads to development of sepsis (see).
Actinomycosis (see) bones of T. meets seldom. Damage of a bone happens in the contact way (from a periosteum), but not hematogenous. Process begins sharply, is followed by high temperature, sharp pains. In the subsequent fistulas with scanty separated develop. The diagnosis is confirmed bakterioskopiche-sk (druses an actinomyce are found). Treatment is carried out by drugs of iodine, aktinolizaty, apply a roentgenotherapy less often.
The forecast depends on a basic disease.
Tumors. Primary tumors of bones of T. on summary statistics occupy the fourth or fifth place among tumors of a skeleton. At adults tumors, coming from cartilaginous tissue are most often observed. According to M. V. Volkov (1968), in most cases they develop on a dysplastic basis.
The chondroma (see) is more often localized in the field of pubic or an ischium, an osteochondroma (see the Chondroma) the wing of an ileal bone, an osteoblastoclastoma (see) — pubic or ileal bones strikes more often. Treatment of these tumors — an operative measure — a resection within healthy fabrics.
Ewing's tumor (see Ewing a tumor) is found in a wing of an ileal bone more often. It causes the incremental pains amplifying at night. Treatment — beam and chemotherapy. The gemipelviek-tomiya was earlier widely applied, edges it was a little effective.
A chondrosarcoma (see) affects usually ileal bone. The true sizes of a tumor it is more, than revealed with the help rentgenol. researches. Pains at it irradiate in the lower extremity, symptoms of a prelum of internals are possible. Treatment — surgery — a gemipel-viektomiya.
Uniform classification of operations on bones of T. and its joints is not present.
Indications for operations are destructive processes owing to osteomyelitis (see), tuberculosis of bones of T., etc., tumors, nek-ry dystrophic processes, injuries, posttraumatic, inborn deformations
of T. Bolshinstvo of operations on T. it is characterized by considerable injury in this connection effective anesthesia (see the Anaesthesia) and specific maintaining the postoperative period is required (see).
Quick accesses to bones of T. and to its joints are various. Their use shall be strictly differentiated for a possibility of performance of intervention with the minimum injury.
Access of Shpren-gelya to outside departments of an ileal bone, intra pelvic access for Chaklin (see the Coxitis), access of Milcha to an ischium with a section in its projection, access Poko-tilov to a sacroiliac joint (see the Sacroileitis), etc. are most typical. Aim cuts, extent are more often applied and anatomic features to-rykh depending on features of operation widely vary.
Treat drainage of pelvic cellulose across Buyalsky the operative measures having the greatest practical value — IAC-at to an orter, resections of a pubic symphysis, an ischium, an ileal bone, a gemipelviekto-miya, stabilization of a pubic symphysis and a row other.
Drainage of pelvic cellulose across Buyalsky — IAC-at to an orter is carried out at purulent and uric zateka. In position of the patient on spin on an inner surface of a hip parallel to an inguinal fold, otstupya from it on 2 cm, make a section of skin and a fascia. Stupidly stratifying adductors of a hip, reach a locking opening of N T get through it into a cavity small., where enter a rubber drainage.
The resection of a pubic symphysis is shown at tumors and other destructive processes in pubic bones. In position of the patient on spin with arc-shaped cross section bare a front surface of a pubic symphysis, and by means of an additional section on the white line of a stomach — its back surface. Through a locking opening carry out Gigli's saw and carry out a resection within healthy fabrics, aiming not to injure femoral an artery and fade and also the lower epigastriß artery.
The resection of an ischium is carried out at tumors. The arc-shaped section of skin by camber of a knaruzha is done over a sciatic hillock then define edge of a big gluteus and cut it in transverse direction on 3 — 4 cm, baring thus a sciatic hillock. Take away, separating subperiostaln - oh, knaruzh of a muscle and a knutra a sheaf. Also subperiostalno take away knaruzh adductors of a hip and an outside locking muscle. At the same time the bottom edge of a locking opening is bared. All muscular array is taken away by knaruzh together with a sciatic nerve. At skeletonization of an inner surface of an ischium it is necessary to protect internal sexual vessels and a sexual nerve.
The resection of an ileal bone is carried out in position of the patient on spin with turn to the healthy party. The arc-shaped section behind bare an ileal bone. The exposure of an inner surface of an ileal bone can be carried out by cutting off of an ileal crest together with the muscles which are attached to it or by cutting off of the muscles fastening to it. The exposure of an inner surface is also carried out podnadkost-nichno.
Gemipelviektomiya can be total (an exarticulation in a pubic symphysis and a sacroiliac joint) and subtotal (a resection of ileal and pubic bones). Section of skin — on an ileal crest and on an inguinal fold with turn from top to bottom on 4 cm of a knaruzha from a pubic symphysis. Muscles separate from an ileal bone and together with a peritoneum take away them up. After a section of an inguinal sheaf (in a lower part of a wound) allocate and alloy femoral vessels and a nerve. All abdominal rag together with a peritoneum and vessels which are tied up out of a peritoneum is separated from an inner surface of an ileal bone in a cavity of a big basin, tie up a locking artery and cut the nerve of the same name. Make an osteotomy (see) pubic bone. Continuing a skin section of a kzada on a sciatic fold, remove a big gluteus, baring a back surface of an ileal bone. After a section of a pear-shaped muscle bare a sacriplex and a sciatic nerve, anesthetize them and cut. Through an upper pole of sciatic cutting carry out Gigli's saw for a section of an ileal bone.
Stabilization of a pubic symphysis is most often shown at posttraumatic or puerperal to a diastase. The osteosynthesis of a pubic symphysis is carried out by a wire seam and a metalwork or a bone transplant, and also the combined method.
Corrective operations (an osteotomy of an ileal bone) carry out at displaziya of a hip joint (see. Hip joint ). At fractures of bones of T. carry out different types osteosynthesis (see) by means of screws, plates, etc.
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V. M. Tsodyks; E. I. Borzyak (An., comparative anatomy), M. K. Klimova (rents.), S. S. Tkachenko (soldier.), E. A. Chernukh (female basin).