YAGODYCHNY AREA [regio glutea (PNA), regio glutaea (JNA, BNA); synonym: sciatic area,
nates clunes]. Borders of a rump pass from above on an ileal crest, from below — on a buttock fold (in the presence of two folds — on lower), medially — on the broken line, I connect -
Russian cabbage soup an upper back ileal awn to lateral edge of a tailbone, and further down to a buttock fold, lateralno — in a straight line, the femur connecting an upper front awn to a big spit. Main reference points I. lakes are an ileal crest (crista iliaca), an upper back ileal awn (spina iliaca posterior sup.), sciatic hillock (tuber ischiadicum), big spit (trochanter major), buttock fold (plica natium glutaea).
Skin I. the lake it is connected by numerous connective tissue tyazha with a superficial fascia owing to what hypodermic cellulose has a cellular structure. In it there pass the nerves innervating skin of a rump: upper buttock, or upper branches of buttocks (subitem of clunium sup.), departing from back branches of lumbar nerves; average buttock, or average branches of buttocks (subitem of clunium med.), departing from back branches of sacral nerves; lower buttock, or lower nerves of buttocks (subitem of clunium inf.), the hips which are branches of a back cutaneous nerve.
The superficial fascia divides hypodermic cellulose into two layers; sometimes the superficial fascia has several leaves. Between leaves of a superficial fascia the fatty pillow (corpus adi-posum) is located; between a deep leaf of a superficial fascia and a muscular fascia the fatty layer proceeding to the lumbar area is located. Own fascia of gluteuses has 3 leaves. Structure of its superficial leaf variously: over a free part of an average gluteus it is thickened, reminds an aponeurosis, and over an upper half of a big gluteus represents a thin friable plate. The connective tissue layers passing through thickness of a big gluteus (m. gluteus maximus), this leaf is connected with an average leaf, to-ry covers a big gluteus from within. Growing together at the edges of a big gluteus, both leaves of a fascia create a case for the first muscular layer of a rump. The third, deep leaf of own fascia forms a similar case for an average gluteus (m. gluteus medius). Fascia of a pear-shaped muscle (t. piriformis) covers this muscle with a sinew in the form of a friable connective tissue case. Thin and friable are same a fascia of an internal locking muscle (m. obtura-torius int.) and twin muscles (vol. of gemelli). The fascia of a square muscle of a hip (m. quadratus femoris) is a little more expressed, than listed to a fascia. The described muscles together with their fastion form the second muscular layer of a rump (tsvetn. tab., Art. 400, fig. 1).
Most deeply the small gluteus (m. gluteus minimus) and an outside locking muscle are located (m. obturatorius ext.), creating the third layer of muscles. Fascial cases of these muscles are poorly expressed. There are bones and a linking of a rump more deeply (tsvetn. the tab., Art. 400, fig. 2), an ischium, a wing and a body of an ileal bone, a sacral hillock - naya a sheaf (lig. sacrotuberale), sacral and awned sheaf (lig. sacrospi-nale) and the capsule of a hip joint (see).
Between fastion, separate muscles and groups of muscles kletchatochny spaces and cracks of a rump are located. The most expressed space is under a big gluteus (interfascial kletchatochny space). Its upper bound is the line of division of own fascia I. the lake on leaves, lower — the fascial spur connecting bottom edge of a big gluteus to fastion of back group of muscles of a hip and a big adductor. This space is connected on the course of buttock arteries and veins with cellulose of a basin, on the course of a sexual (pudental) neurovascular bunch — with cellulose of an ischiorectal pole, on the course of a sciatic nerve — with intermuscular intervals of a back surface of a hip.
Under an average gluteus the deep interfascial kletchatochny space is located. As its upper bound serves the line of an attachment of fastion of average and small gluteuses to an ileal bone. Connection of the specified fastion with a case of a pear-shaped muscle makes its internal border, and the conjunction with a fascia of a pressure-telya of a wide fascia of a hip (m. tensor fasciae latae) is outside; the lower bound is presented by the line of an union of fastion of average and small gluteuses.
Under a small gluteus there is a kletchatochny crack limited in front to a back surface of an ileal bone and the capsule of a hip joint. One more kletchatochny crack is located between group of tazovertelny muscles (mm. piriformis obturatorii, gemelli, quadratus femoris) and capsule of a hip joint.
The sacral and awned sheaf together with big sciatic cutting closes a big sciatic opening, in Krom the pear-shaped muscle is located. Over this muscle and under it (in nadgrushevidny and under - pear-shaped openings) there pass neurovascular bunches I. lake. Over - piriform opening is called also the channel; from within it is delimited from above by edge of big sciatic cutting, from below — a parietal layer of a pelvic fascia; outside — fastion of gluteuses. All muscular a fascia, concerning formation of the channel, are spliced with a fascia of the upper buttock sosudistonervny bunch located here.
Except kletchatochny spaces in I. lakes are available synovial bags. On an outside back surface of a big spit the trochanterian bag of a big gluteus lies (bursa trochanterica m. glutei maximi). On a back surface of a sciatic hillock the sciatic bag of a gluteus is located (bursa ischiadica m. glutei maximi). It is possible to find 2 or 3 buttock and femoral bags (bursae glutaeofemorales) which are located in the field of an attachment of a big gluteus less constantly; front trochanterian bag of an average gluteus (bursa trochanterica m. glutei medii ant.) is between a sinew of an average gluteus and a top of a big spit; back trochanterian bag of an average gluteus (bursa trochanterica m. glutei medii post.) — between sinews of average buttock and pear-shaped muscles. Bag of a pear-shaped muscle (bursa m. piriformis) lies below a sinew of a pear-shaped muscle between intertrochanteric space of a femur and a twin muscle; bag of an internal locking muscle (bursa m. obturatorii interni) — between a muscle and small sciatic cutting.
Upper buttock artery (and. glutea sup.) begins from an internal ileal artery, has a short trunk, to-ry prilezhit directly to a periosteum of an ileal bone, and is divided into final branches — superficial and deep; the last, in turn, is divided on top and bottom branches. A zone of blood supply of an artery are average and small gluteuses, an ileal bone, a napryagatel of a wide fascia of a hip, a hip joint. Lower buttock artery (. glutea inf.) together with the vein of the same name and the lower buttock nerve is located in the subpiriform opening limited from below sacral bugornoy to a ligament and an upper twin muscle, and from above — bottom edge of a pear-shaped muscle. The artery begins from a front trunk of an internal ileal artery and supplies with blood a big gluteus, a square muscle of a hip, a hip joint. Its branch (a. comitans n. ischiadici) on a small extent accompanies a sciatic nerve. Both main vessels of a rump widely anastomose the branches. Besides, the upper buttock artery anastomoses with the lateral artery which is bending around a femur (a. circumflexa femoris lat.), and the lower buttock artery — with the medial artery which is bending around a femur (a. circumflexa femoris med.), and back branch of a locking artery. Both upper, and lower buttock arteries are accompanied top and bottom by buttock veins, to-rye fall into an internal ileal vein.
Upper buttock nerve (n. gluteus sup.) and lower buttock nerve (item gluteus inf.) represent short branches of a sacriplex. The upper buttock nerve is located at an outside opening of the nadgrushevidny channel in front from vessels, and further — from top to bottom and lat-ralno. A zone of its innervation are average and small gluteuses, a napryagatel of a wide fascia of a hip and the capsule of a hip joint. The lower buttock nerve is in under piriform opening of a knutra in relation to the sciatic nerve occupying the most lateral zone of an opening and innervates a big gluteus.
The sexual (pudental) neurovascular bunch leaves a small pelvis and occupies an internal zone under - piriform opening. It includes an internal sexual artery (a. pudenda int.), vein of the same name and sexual nerve (n. pudendus). The nerve lies in the most medial site of subpiriform opening, vessels are located lateralny. Having rounded an ischium and a sacral and awned sheaf, the sexual neurovascular bunch is left by me. the lake also passes a pole in a sciatic prya-mrkishechnuyu. Back cutaneous nerve of a hip (n. cutaneus femoris post.), as a rule, is a branch of a sacriplex and is located near a sciatic nerve of a knutra from it; it innervates skin of a back surface of a hip (about its branches innervating skin of a rump see above); perineal branches of a back cutaneous nerve carry out an innervation of skin of a crotch and pudental area.
Absorbent vessels I. lakes take away a lymph in superficial inguinal limf, nodes (nodi lymphatici inguinales superficiales). Deep limf, vessels are located on the course of veins Ya. lake. On them the lymph flows in parietal nodes of a basin (see). On the course of buttock vessels there are top and bottom buttock nodes (nn. lymphatici glu-teales sup. et inf.).
Pathology. To pathology I. lakes refer damages, inflammatory diseases, tumors. Rare species of pathology I. the lake is an entereshiocele.
Damages. Distinguish the closed and open damages I. lake. The closed damages — bruises (see) arise at blow or falling. At the same time there are damages of hypodermic cellulose, muscles and vessels, character and degree to-rykh depend at most influences and the areas of damage. As a rule, bruises are followed by formation of the extensive hypodermic, subfascial and intermuscular hematomas (see) sometimes causing peeling of skin or hypodermic cellulose. At long crush of soft tissues I. the lake, especially in combination with crush of tissues of the lower extremities, can develop traumatic toxicosis (see). If at a bruise buttock arteries are injured, there are extensive interstitial hemorrhages extending on interfascial spaces in a cavity of a small pelvis and to a hip up to a popliteal space. Similar hemorrhages can lead to considerable blood loss.
Sometimes the hematoma and the fabrics impregnated with blood can be sacculated with formation of the traumatic cyst filled with gemolizirovanny blood (see the Hematoma). At adjournment of salts of calcium the traumatic ossifying miositis develops in the muscles injured and impregnated with blood, to-ry with firmness breaks function of muscles (see the Miositis). The expressed dysfunctions of muscles I. lakes at a traumatic ossifying miositis are the indication to surgery — excision of ossifitsiro-bathing fabrics.
Injuries of buttock arteries and open damages I. lakes most often arise at fighting gunshot wounds. In peace time the avulsive, kolotorezany wounds resulting from falling or an injury meet. At the same time sometimes there are a bruise, a partial or complete separation of a sciatic nerve (see) that is clinically shown by paresis and paralyzes. Especially hard the combined damages I proceed. the lake and bodies of a small pelvis, and also the wounds getting through fabrics of a rump into a pelvic cavity. In these cases the wound of a bladder which is followed by uric zateka in a rump is possible (see. Uric flowed), and also the wound of a rectum (see) leading to bystry development is purulent - putrefactive phlegmon of a small pelvis and a rump (see Taz, damages).
To fighting damages I. lakes carry gunshot wounds, to-rye can be tangent, blind and getting. Nonperforating wounds in this area, both bullet, and fragmental, meet more often than at wounds of other areas. At gunshot wounds I. the island damage top and bottom buttock arteries, followed by plentiful outside bleeding is possible. At the long and narrow wound channel bleeding from dot wound openings happens insignificant in this connection damage of vessels can be unnoticed. In these cases, as well as at hypodermic ruptures of arteries, conditions for formation of the holding apart or pulsing hematomas are created. Diagnosis of wounds of buttock arteries is complicated. In the beginning owing to treatment blood of surrounding fabrics forms diffuse infiltrate. Usually the pulsation of a hematoma can be found only in 5 — 12 days after wound since the bleeding point is covered with a massive layer I year muscles. At a prelum a hematoma of a sciatic nerve there is pain, edges at development of a wound fever accrues. In these cases quite often mistakenly take the pulsing hematoma for purulent infiltrate. At nonperforating wounds I. the lake a large splinter can put pressure upon a sciatic nerve that sometimes leads to development of painful shock (see). By experience of the Great Patriotic War gunshot wounds of buttock arteries made 0,4 — 4% of all wounds of blood vessels. The upper buttock artery (67,8%) was more often injured. At 76,1% of wounded of injury of buttock arteries were the reason of secondary bleedings, at 23,9% the pulsing hematomas and aneurisms were observed. Gunshot wounds of a sciatic nerve on frequency took the second place after wound of a beam nerve and made 14,9% in relation to all wounds of nervous trunks. Damages of a sciatic nerve are sometimes combined with wounds of buttock arteries. The isolated wounds of a sciatic nerve in itself do not threaten life, but sharply reduce probability of return of the wounded to a system.
Gunshot wounds and open damages I. lakes in addition to a possibility of injury of her arteries and nervous trunks constitute big danger because of development of infectious complications, especially mephitic gangrene (see). A large number of a fatty tissue and muscular tissue, and also their rather bad blood supply cause a heavy current of a mephitic gangrene and purulent complications, to-rye are followed by formation of numerous zatek and a consecutive putrefactive infection. It quite often leads to development of sepsis (see).
Treatment of the closed damages I. lake conservative: bed
rest, anesthetics; at extensive hemorrhages with the preventive purpose appoint antibiotics. In the first
2 — 3 days locally apply cold, in the subsequent carry out physical therapy (UVCh, a diathermy). At traumatic amotio of skin or hypodermic cellulose apply a compressing bandage, delete the liquid which accumulated under skin by means of a puncture. In case of unsuccessfulness of a puncture make a section of skin and delete liquid. Impractical skin and hypodermic cellulose are excised with the subsequent substitution of defect a free skin transplant. At the closed injury of an artery which is characterized by quickly accruing hematoma, deterioration in the general state, decrease in a hemoglobin content in blood make operation with the purpose of a stop of bleeding. In case of open damage carry out surgical treatment of a wound (see), and sew the damaged sciatic nerve (see. Nervous seam, Sciatic nerve).
At surgical treatment of a wound considerable difficulties are presented by a stop of bleeding. Bandaging of buttock arteries in a wound for the purpose of a final stop of bleeding is technically difficult and connected with an additional injury. It is not possible to take a short trunk of the arteries branching in a basin a styptic clip even after a wide section on the course of fibers of a big gluteus. Therefore in need of a stop of bleeding it is more reasonable to begin it with extra peritoneal bandaging internal ileal areteriya. Operation is carried out under anesthetic. Before bandaging of an internal ileal artery a wound I. lakes carefully tampon. Use quick access across Shev-kunenko: the arc-shaped section is carried out from the end of the XI edge down also by kpered to an upper front ileal awn, and from the last — a knutra. The peritoneum is otslaivat in the stupid way; the internal ileal artery located on 1 cm of a knutra from an outside ileal artery is tied up two silk ligatures. Collateral circulation is recovered through an anastomosis of branches of a femoral artery with top and bottom buttock arteries and with a locking artery. Bandaging on an extent, as a rule, provides a final stop of bleeding from buttock arteries. Even if bleeding proceeds from the peripheral end of a buttock artery due to opening of a collateral blood-groove, it during the bandaging decreases so that it is possible to continue search of the bleeding vessel in I. the lake without risk to lose the patient on the operating table from the proceeding bleeding. In this case the section offered by A. G. Radziyev-sky for approach to the damaged sciatic nerve is more convenient for a final stop of bleeding, at Krom the big gluteus is crossed on the outer edge and turn off its knutr. Upon termination of operation sew a gluteus, beginning from below. The most frequent complication in the postoperative period is suppuration of a wound.
The principles of stage treatment of wounded with damages I. the lake is same, as at assistance to wounded with damages of a basin and pelvic bodies (see Taz). First aid consists in imposing of an aseptic compressing bandage on a wound and administration of anesthetics. During the rendering the pre-medical help (see) control and correct bandages, enter anesthetics. Transportation of the victim is carried out on a stretcher. The first medical assistance consists in holding actions for prevention of shock (see) and fight against bleeding (see). Bleeding is stopped by a hard tamponade of a wound (see the Tamponade), at the same time imposing of temporary seams on skin over a tampon is possible, to-ry is subject to removal not later than in 24 hours, and at emergence of symptoms of an infection — even earlier. During the rendering the qualified surgical help after sorting medical (see) all wounded in I. lakes divide into the following groups: the wounded with the proceeding bleeding who are subject to an urgent operative measure; wounded in state of shock without symptoms of bleeding, the Crimea carry out antishock therapy; wounded in the soft tissues which are not demanding performing urgent surgery, the Crimea make primary surgical treatment of a wound and operation on vessels in case of their damage. The specialized help includes operative measures concerning the developed infectious complications, traumatic aneurisms of buttock arteries and damages of a sciatic nerve. Quite often it is necessary to operate in connection with late bleeding from a buttock artery, damage a cut often remains not distinguished at the previous stages of evacuation.
The main method of treatment of a mephitic gangrene of a rump is operation which consists in a wide section of a wound, opening of muscular fascial cases, excision of nekrotizirovanny fabrics, removal of foreign bodys and freely lying bone fragments, opening of the blind pockets and deepenings going aside from a wound with leaving of a wound widely open. At emergence of a mephitic gangrene, except an operative measure, administration of antigangrenous serum and antibacterial agents, of great importance timely performing oksibaro-therapy is, edges allows to improve results of treatment considerably (see. Hyperbaric oxygenation).
Inflammatory diseases I. lakes are a consequence of the wounds opened and the closed damages, suppuration of the formed hematomas more often, distribution of inflammatory process of a small pelvis through big and small sciatic openings, and also results from the natechnik who are going down along a backbone and at purulent processes in a hip joint and synovial bags, especially at their punctures. Abscess (see) and phlegmon (see) I. lakes can develop as a result of purulent diseases of skin (see the Furuncle, the Anthrax), to-rye are often observed in this area because of the expressed hypodermic cellulose and bad blood supply of skin, and also at metastatic hit of contagiums at sepsis. Besides, purulent processes in I. lakes can arise in connection with injections of medicines that is, as a rule, caused by disturbances of an asepsis and antiseptics.
Depending on depth abscesses and phlegmons I. lakes can be hypodermic, subfascial and intermuscular; phlegmon can have infiltrative, is purulent-infilt-rativny also necrotic character. A streptococcus, proteas, pyocyanic and intestinal sticks happen contagiums more often pathogenic staphylococcus. The factors promoting development of a purulent inflammation are associated diseases, the raised bleeding of fabrics, decrease in protective forces of an organism in connection with the postponed disease or advanced age of the patient.
The RUMP 427
At post-injection inflammatory processes at first can be observed an aseptic necrosis with disorganization of interstitial substance of connecting fabric, destruction of collagenic and muscle fibers as a result of reaction of fabric to administration of hypertonic medicinal salt solutions (magnesium sulfate, analginum, etc.). In case of accession of an infection the aseptic necrosis can pass into a purulent inflammation.
Diagnosis of superficial purulent processes usually does not represent work since is followed by typical changes of an integument. At intermuscular and sub-fascial purulent processes of change of skin are absent and it is not always possible to define the fluctuation observed at abscess. Therefore at a swelling and morbidity in I. the lake and the phenomena of the general intoxication characteristic of purulent process, quite often for identification of deeply lying abscesses resort to diagnostic punctures a fine long needle with anesthesia of fabrics solution of novocaine.
Treatment of inflammatory diseases I. lake, as a rule, operational. Only in initial stages of post-injection infiltrates when there are no signs of purulent process, use of such conservative actions as heat, physical therapy (UVCh, a diathermy), reception of antibacterial drugs is possible, under influence to-rykh infiltrate often resolves. At hypodermic abscesses and superficial phlegmons make skin cuts in a softening range of fabrics or the most expressed inflammatory changes. At the same time it is necessary to remember that hypodermic cellulose has a cellular structure and for division of the available trabeculas and identification of pockets and zatek it is necessary to carry out audit of an abscess cavity a finger. Opening of abscesses is made under a local anesthesia, at operational treatment of phlegmons apply an anesthesia. After evacuation of pus and a fabric detritis the wound is washed out antiseptic solutions and drained. At abscesses suture on a wound with its obligatory drainage is admissible. At the same time use drainage tubes with side openings for the subsequent bathing of the wound solutions of antiseptic and antibacterial agents.
Operational treatment of deep abscesses and phlegmons I. lakes carry out under anesthetic. At the same time cuts should not be made through thickness of a gluteus. A distributional pattern of purulent zatek in I. the lake is defined by existence of the fascial spaces which are usually containing thick layers of friable connecting fabric and their bonds with the neighboring areas. This circumstance is decisive at the choice of quick access to the center of an inflammation. Inflammatory process can extend from I. the lake to the lumbar area and in the opposite direction. On the friable cellulose surrounding a sciatic nerve purulent flow, and at the combined wounds uric and fecal flow can get into intermuscular cellulose of a hip, a popliteal space, on a shin, sometimes reach foot. On the course of buttock arteries and veins purulent process can extend to cellulose of a basin, and on the course of a sexual (pudental) neurovascular bunch — in cellulose of an ischiorectal pole. Deep abscesses and phlegmons I. lakes of various origin drain by means of three cuts, to-rye often it is necessary to do at the same time. One of them will be out parallel to lateral edge of a sacrum, otstupya from it on 2 — 3 cm. The section is conducted through hypodermic cellulose, cross bunches of a big gluteus, hooks stretch it in different directions, cut fascial leaves, if necessary stratify bunches of an average gluteus; after broad opening of an abscess make its drainage. The second section is carried out parallel to the first on the outer edge I. lake. After a section of hypodermic cellulose cross bunches of a big gluteus and drain a wound. The third section up to 14 cm long is carried out on a hip on its back surface; below a buttock fold cut hypodermic cellulose and a wide fascia of a hip, reach the friable connecting fabric surrounding a sciatic nerve, get under a big gluteus and drain interfascial space. In need of limit disclosure of deep fabrics do a semi-lunar section by camber outside with cutting off and department of a rag of a big gluteus. Sometimes make additional cuts in an ischiorectal pole for ensuring outflow of pus at zateka from a rump. Treatment of a natechnik at diseases of a backbone or osteomyelitis (see) ischium consists in simultaneous removal of the main center in bones and a natechnik by his opening against the background of antibacterial and fortifying therapy.
The forecast at inflammatory diseases I. the lake depends on timely performing necessary treatment.
Prevention of post-injection inflammatory diseases I. the lake is based on careful observance of rules of an asepsis, antiseptics and technology of introduction to fabrics of medicines; the last should be entered only in a verkhnenaruzhny quadrant of a rump.
The entereshiocele meets seldom. It is observed preferential at elderly women, more often on the right. Depending on localization distinguish 3 types of hernias: leaving through a small sciatic opening, over a pear-shaped muscle and under it (see fig. 25 to St. Hernias, t. 6, Art. 517).
At the hernia leaving through a small sciatic opening, the hernial bag falls on the course of a sciatic nerve and can cause its prelum which is followed by pains; during the walking pain amplifies. The big hernial bag can reach the middle of a hip and even to go down below. At the hernia leaving over a pear-shaped muscle the pain arising in a zone on the upper bound and two lower thirds of the line drawn from a back upper ileal awn to a top of a big spit is characteristic. If the painful point is located
3 — 4 cm below than this level, it is possible to assume existence of the hernia leaving under a pear-shaped muscle. Treatment operational (see Hernias, an entereshiocele).
Tumors I. lakes meet quite seldom. From benign tumors lipomas are more often observed (see), the atheroma, fibroma (see), is more rare a myxoma (see), a neurofibroma (see) and teratomas (see), coming from than a sacrum and a tailbone. From malignant tumors there are myogenetic and synovial sarcomas (see) reaching sometimes the considerable sizes and also a neurosarcoma and a lymphosarcoma more often (see). Treatment of tumors I. lake operational. Malignant tumors of this area are usually located deeply, as a rule, intimately soldered to a sciatic nerve and buttock arteries, can burgeon in sciatic pryamokishechny cellulose, reaching a rectum. In this regard use wide quick access: the arc-shaped section of skin and hypodermic cellulose carry out on lateral border I. the lake and from below on a buttock fold. After assignment of a rag do an additional section in the vertical direction on the line, the corresponding projection of a sciatic nerve up and medially. After bandaging of buttock arteries the tumor is deleted with the uniform block together with gluteuses. The forecast depends on a form of a tumor and its wedge, stages.
Bibliogrvoyno-Yasenetsky V. F. Sketches of purulent surgery, L., 1956; Diagnosis and treatment of wounds, under the editorship of Yu. G. Shaposhnikov, M., 1984; Dolinin V. A. and Bisen-kov N. P. Wounds and injuries operations, L., 1982; Kovanov V. V. and Anikina T. I. Surgical anatomy of fastion and kletchatochny spaces of the person, M., &167; Kova
V. V. and Travin A. A. is new. Surgical anatomy of extremities of the person, page 251, M., 1983; The Multivolume guide to surgery, under the editorship of B. V. Petrovsky, t. 12, page 15, M., 1960; Experience of the Soviet medicine in the Great Patriotic War of 1941 — 1945, t. 14, M., 1952; Pods V. I., Gostishchev V. K. and Struchkov Yu. V. Guide to purulent surgery, M., 1984.
V. G. Mazurov, A. K. Revskoy, A. D. Timoshin (pathology); Y. F. Matyushin (An.).