Bone pelvis and perineum. The structure of the female pelvis

TAZ [pelvis(PNA, JNA)] - a bony ring formed by two pelvic bones, the sacrum and the coccyx. The thorax serves as a support for the torso and lower extremities and is the seat of a number of internal organs.

Comparative anatomy

In fish and pinnipeds, the thorax is formed by two bones that are not connected to the spine. In birds it is open in front, and in the back the pelvic bones connect to the spine. In four-legged mammals, the T. is small in size and elongated in the anteroposterior direction. As the transition to upright posture occurs, T. becomes shorter and wider. In humans, the anteroposterior and transverse dimensions of the upper aperture of the T. are almost identical.

Anatomy

The pelvic bones are connected to each other in front by the pubic symphysis (see), and in the back with the sacrum (see Spine) using the sacroiliac joints (see Sacroiliac joint). The coccyx (see), connected to the top of the sacrum, complements the bone ring that forms the pelvis. The pelvic bone (os coxae) is formed as a result of the fusion of three bones: the ilium (os ilium), the ischium (os ishii) and the pubis (os pubis). This fusion is located in the area of ​​the acetabulum.

External landmarks of T. are the iliac crests, sacrum, coccyx, pubic symphysis, and ischial tuberosities.

The border line (linea terminalis) on the inner surface of the bony pelvic ring, formed by the promontory (promontorium), arcuate lines (lineae arcuatae), ridges of the pubic bones (pecten ossis pubis) and the upper edge of the pubic symphysis, conventionally divides the pelvis into large and small (pelvis major et pelvis minor). Big T. is located above the boundary line and is limited from behind by the body of Ly, from the side and below by the inner surfaces of the wings iliac bones; it is open at the top and front. Small T. has the appearance of a wide short canal (cavity) of a cylindrical shape, the walls of which are formed by the pelvic bones, sacrum and coccyx. The border of the upper (inlet) opening of the small T. - the upper aperture of the pelvis (apertura pelvis sup.) runs along the boundary line, the lower (outlet) opening - the lower aperture of the pelvis (apertura pelvis inf.) runs in front along the lower edge of the pubic symphysis, on the side - along the ischial tuberosities, the lower edge of the branches of the ischial bones and the sacrotuberous ligaments, and behind - along the coccyx. The upper opening connects the cavities of the large and small T., and the lower one is closed by the muscles and fascia of the perineum (see Perineum).

The anterior wall of the cavity of the small T. is short and formed by the posterior surface of the pubic symphysis and its ligaments, the anterior part of the lateral wall is occupied by the obturator foramen (foramen obturatum), which is closed by the obturator membrane (membrana obturatoria), and the posterior part of the lateral wall represents the space between the ischium and sacrum. This space is divided by the sacrotuberous and sacrospinous ligaments into the greater and lesser sciatic foramina (foramina ischiadica majus et minus), through which muscles, vessels and nerves pass. Over the obturator groove of the upper branch of the pubic bone, the obturator membrane is thrown over in the form of a bridge, resulting in the formation of the obturator canal (canalis obturatorius), into which the obturator artery, vein and nerve pass. The posterior wall of the cavity of the small T. is the longest and is formed by the pelvic surface of the sacrum and coccyx.

When the body is in a vertical position, the T. is located at an angle to the horizontal plane. The angle between the horizontal plane and the plane of entry into the small T. is called the angle of inclination of the T. (inclinatio pelvis), the value of which ranges from 55° to 75° (on average 60°); it varies depending on posture* body position, gender and age, for example, in newborns this angle is greater than in adults.

Domestic bone walls large and small T. are covered with muscles and fascia (Fig. 1). On the inner surface of the large pelvis there is an iliac psoas(m. iliopsoas), on the lateral wall of the small T. - the internal obturator muscle (m. obturatorius internus), in the posterior part of the lateral wall and partially on the posterior wall the piriformis muscle (m. piriformis) begins. The obturator internus and piriformis muscles are covered by the parietal fascia of the pelvis (fascia pelvis parietalis), and the iliopsoas muscle is covered by the iliac fascia (fascia iliaca).

The cavity of the greater T. is the lower part of the abdominal cavity, which contains the cecum, sigmoid colon and loops small intestine. In the cavity of the small T. there are the rectum and bladder with the pelvic part of the ureters, in men - the prostate gland, seminal vesicles, vas deferens, in women - the ovaries, fallopian tubes, uterus, vagina (see color table to article Bladder, Fig. 1, 2; color table for the Uterus station, Fig. 2). The cavity of the greater T. also contains the common and external iliac arteries and veins, their branches, branches of the lumbar plexus, and the common and external iliac lymph nodes. nodes. In the small T. there are internal iliac arteries and veins, their branches, internal iliac lymph nodes, venous plexuses (sacral, rectal, vesical, prostatic, uterine, vaginal), sacral plexus, upper and lower hypogastric plexuses. n. With. The muscles of the lower limb, back, abdomen and perineum are attached to the bones of the pelvis.

The soft tissues that cover the bony base of the large and small pelvis from the outside belong to the gluteal region, the thigh area and the perineum.

The shape and size of T. depend on age and gender. V of a newborn T. has the shape of a funnel (compressed from the sides, the wings of the ilium are located almost vertically), to some extent resembling the pelvis of mammals.

The female pelvis, compared to the male pelvis, has a number of anatomical features (Fig. 2). The T. of a newborn girl is lower and wider due to an increase in the transverse size of the entrance to the pelvis. During this period, most of the pelvic bones consist of cartilaginous tissue located between the ossification nuclei, and the pelvic bones are separated by cartilaginous layers. At the 8th year of life in girls, cartilaginous tissue in the area of ​​​​the junction of the branches of the pubic and ischial bones is replaced by bone tissue. By the age of 14-16, the fusion of the ilium, ischium and pubis into one pelvic bone is gradually completed, and final ossification occurs only by the age of 25. The differences between female T. and male ones clearly appear during puberty (see) and become most pronounced in adulthood. Female bones

T. are thinner, smoother and less massive than the bones of the male T. The female T. is lower, wider and larger in volume. The sacrum in women is wider and not as strongly concave as in men; the promontory of the base of the sacrum (sacral promontory) protrudes less forward in women than in men; The pubic symphysis of the female T. is shorter and wider. The entrance to the small T. in women is wider, transversely oval in shape, with a notch in the area of ​​the sacral promontory. The cavity of the small T. in women is larger, its outlines approaching a cylinder curved anteriorly. These features are of utmost importance during childbirth (see).

In obstetrics, it is customary to distinguish 4 planes of the small T.: the plane of the entrance to the small T., the plane of the wide part of the cavity of the small T., the plane of the narrow part of the cavity of the small T., the plane of the exit of the T. (Fig. 3).

The plane of entry into the lesser T. passes through the upper edge of the pubic symphysis, the arcuate lines, and the sacral promontory. The direct size of the entrance is the obstetric, or true, conjugate (conjugata vera) - the distance between the sacral promontory and the most protruding point on the inner surface of the pubic symphysis is 11 cm. There is also an anatomical conjugate (conjugata anatomica) - the distance between the sacral promontory and the middle of the upper edge pubic symphysis, equal to 11.5 cm. The transverse size of the entrance - the distance between the most distant points of the arcuate lines - is equal to 13 cm. There are two oblique sizes: the right oblique - from the right sacroiliac joint to the left iliopubic eminence and the left oblique - from the left sacroiliac joint to the right iliopubic eminence; both are 12 cm.

The plane of the wide part of the small T. has the following boundaries: in front - the middle of the inner surface of the pubic symphysis, on the sides - the middle of the acetabulum, in the back - the junction of the S1 and S2 vertebrae. There are direct dimensions of the wide part of the small T. - the distance from the middle of the posterior surface of the pubic symphysis to the junction of the S2 and S2 vertebrae - equal to 12.5 cm, and transverse - the distance between the internal surfaces of the acetabulum, equal to 12.5 cm. There are no oblique dimensions, because in this part T. does not have a continuous bone ring.

The plane of the narrow part of the small T. is limited in front by the lower edge of the pubic symphysis, on the sides by the ischial spines, and behind by the sacrococcygeal joint and has straight and transverse dimensions. The direct dimension (from the lower edge of the pubic symphysis to the sacrococcygeal joint) is 11 cm, the transverse dimension (the distance between the ischial spines) is 10.5 cm.

The plane of exit of the small T. is limited in front by the lower edge of the pubic symphysis, on the sides by the ischial tuberosities, and behind by the apex of the coccyx and has straight and transverse dimensions. The straight size (from the lower edge of the pubic symphysis to the apex of the coccyx) is 9.5 cm; when the fetus passes through the small T., the coccyx deviates by 1.5 - 2 cm and the direct size increases to 11.5 cm. The transverse size (the distance between the inner surfaces of the ischial tuberosities) is 11 cm.

Thus, the largest dimension at the entrance to the small T. is transverse. In the wide part of the cavity of the small T., the straight and transverse dimensions are equal, and the largest dimension is the conventionally accepted oblique dimension. In the narrow part of the cavity and at the exit of the small T. the straight dimensions are larger than the transverse ones. Since the pubic symphysis is much shorter than the sacrum and coccyx, the T. planes converge anteriorly and fan out posteriorly. If you connect the midpoints of the straight dimensions of all T. planes, you will get not a straight line, but a concave anterior (towards the pubic symphysis) line, the edges are called the pelvic axis.

In addition to the indicated planes, there are parallel planes of the small T. according to Godge (see Fig. 6 to the article Roda, vol. 22, art. 333). The first - terminal - corresponds to the plane of entry into the small T. The second plane - main - passes through the lower edge of the pubic symphysis; it is called the main one, because at this level the continuous bony ring of the pelvis ends. The third plane - the spinal plane - passes through the ischial spines. The fourth plane - the exit plane - passes through the tailbone bent anteriorly.

To judge the size of a small T., it is important to measure the diagonal conjugate - the distance between the lower edge of the pubic symphysis and the sacral promontory, which is more than 12 cm.

In a standing position, the upper edge of the woman's pubic symphysis is projected below the sacral promontory; the true conjugate forms an angle of inclination T. with the horizontal plane, which is normally approximately 60°, but can vary depending on the duration of pregnancy.

X-ray anatomy

For rentgenol. studying T. produce survey radiographs in direct (posterior and anterior), lateral and oblique projections. In addition, targeted radiographs are additionally performed to examine a specific part of the pelvic bones. Most often done straight overview shot T. bones with the patient lying on his back with his legs extended. The cassette is located transversely in the plane of the imaging table. The central X-ray beam is directed perpendicular to the cassette along the midline of the body at the level of the superior anterior iliac spines. In this projection, an image of all the bones of the T., the sacrum and 2-3 lower lumbar vertebrae is obtained (Fig. 4). If the subject is positioned correctly in the image, the obturator foramina have the same shape, and the boundary line is clearly defined.

This line smoothly, without step-like deformations, passes from one half of the pelvis to the other.

Lateral projection photographs are taken with the patient lying on his side. In this case, the center of the X-ray beam is directed towards the lower anterior iliac spine.

Oblique projection photographs are taken with the patient tilted from a lateral position anteriorly or posteriorly. In this case, not only the wing of the ilium is clearly visible, but also the posterior edge of the acetabulum.

The pubic symphysis is examined in a straight anterior or straight posterior projection. The shape of the slit of the pubic symphysis is variable, its width ranges from 0.5 to 1.0 cm. The upper edges of the pubic bones forming the symphysis are at the same level, the boundary line smoothly passes from bone to bone. The surfaces of the bones adjacent to the pubic symphysis have clear and even outlines.

Sometimes, to study the pubic symphysis, photographs are taken in an axial projection (with the patient sitting in a sitting position with legs extended or lowered and the torso tilted back; the central beam of radiation is directed from top to bottom, i.e., along the posterior surface of the pubic symphysis).

Examination methods

Patients are examined by inspection, palpation, and measuring the size of the pelvis. According to indications, X-ray research methods are used, in particular X-ray pelvimetry (see Pelvimetry). In obstetrics, pelvic measurement is of greatest importance (see Obstetric examination).

Pathology

T.'s pathology includes malformations, injuries and diseases.

Developmental defects are observed more often in the posterior part of the pelvic ring: dermoid cysts (see Dermoid) and epidermoid cysts (see), transverse clefts, nonunion of the arches of the sacral vertebrae (see Spina bifida), underdevelopment and even complete absence sacrum and coccyx (see Sacral region).

In the anterior part of the pelvic ring, malformations are relatively rare. More often this is the absence of the pubic symphysis; the supporting and dynamic functions of T. are, as a rule, preserved.

The pelvic bones are affected by dyschondroplasia (see Chondrodystrophy) and marble disease (see). Osteo-poikilia (see) is much less common.

Damage T. can be open or closed. There are injuries to soft tissues and bones of T., injuries to the pelvic organs. Fractures of the pelvic bones can be combined with injuries to other parts of the skeleton or internal organs.

In Shiba, the soft tissues surrounding the pelvic ring may be accompanied by bruising, skin detachment and the formation of slowly resolving and easily infected deep intermuscular hematomas (see). Treatment is often conservative (rest, local hypothermia, and subsequently resorption therapy). In case of skin detachment and hematoma formation, they resort to puncture. In case of suppuration of the hematoma, it is indicated surgery. With a significant bruise of the perineal area (kick, fall on the edge of a hard body, etc.), subcutaneous damage to the membranous part of the urethra is possible (see).

The prognosis for uncomplicated T. injury is favorable.

Soft tissue injuries are more often observed in the gluteal region (see) and perineum (see), and can be combined with injuries to internal organs. Of particular danger in this case are the development of anaerobic infection (see) and damage to the gluteal vessels. Treatment is surgical; it consists of surgical treatment of the wound (see) and careful hemostasis. If hemostasis is difficult, which is possible, for example, when the gluteal vessels or their branches are injured, ligation of the internal iliac or gluteal artery is resorted to. To ligate the internal iliac artery, the skin, aponeurosis and transverse abdominal fascia are dissected using a midline incision in the anterior abdominal wall from the pubic symphysis upward. The peritoneum along with the ureter is pushed back in a stupid way upward and medially, after which the psoas major muscle with the adjacent common, external and internal iliac arteries is exposed. A Deschamps needle is placed under the internal iliac artery and a ligature is applied.

Ligation of the gluteal artery is performed with the patient in the prone position. A horseshoe-shaped incision in the posterior part of the iliac crest is used to dissect the skin, gluteus maximus and medius muscles, and the periosteum of the ilium. The myocutaneous-muscular-periosteal flap is peeled down using a rasp, exposing the upper edge of the greater sciatic foramen. By dissecting the periosteum, the gluteal artery is exposed in the flap. Sometimes, when an artery is injured in this area, its proximal end may go into the pelvic cavity. In this case, the upper edge of the greater sciatic notch is resected.

The prognosis is determined by the severity of the injury and the timeliness of treatment.

T.'s fractures are usually severe damage to the musculoskeletal system. They occur mainly in car accidents and falls from heights. Fractures of individual T. bones are possible due to a direct blow or sudden muscle tension (avulsion fractures of the iliac spine, ischial tuberosity). In 25-45% of cases, T. bone fractures are combined with damage to other bones or internal organs.

According to the classification of A. V. Kaplan, there are 4 main types of fractures of the T. bones: marginal fractures, fractures of the pelvic bones without breaking the continuity of the pelvic ring, with breaking its continuity, and fractures of the acetabulum.

Edge fractures include avulsions of the iliac spines, fractures of the iliac wing, coccyx and sacrum below the sacroiliac joint (Fig. 5); to fractures of the bones of the pelvic ring without breaking its continuity - a unilateral or bilateral fracture of the pubic bone, a unilateral or bilateral fracture of the ischium, a fracture of the pubis on one side and the ischium on the other (Fig. 6); to fractures of the pelvic ring with a violation of its continuity in the anterior section - one- and bilateral fractures of both branches of the pubic bone, one- and two-sided fractures of the pubis and ischium (Fig. 7, a), in the posterior section - a longitudinal fracture of the ilium (Fig. 7.6), as well as ruptures of joints - the pubic symphysis and rupture of the sacroiliac joint, joint fractures of the anterior and posterior sections - one- and two-sided vertical fractures of the Malgenya type (see Malgenya fractures]), diagonal fracture, various combinations bone fractures (Fig. 7, c) and ruptures of synostoses of the anterior and posterior parts of the pelvis. The group of fractures of the acetabulum includes a fracture of the edge of the acetabulum, including with a dislocation of the hip, an isolated fracture of the bottom of the acetabulum and Y-shaped cartilage in children, a fracture of the acetabulum in combination with a fracture of other parts of the T.

In addition, there are injuries that disrupt the continuity of only one (anterior or posterior) section of the pelvic ring, and injuries that disrupt the continuity of the pelvic ring simultaneously in both sections.

Symptoms of T. fractures depend on the nature of the fracture and the presence of associated injuries. With marginal fractures, the condition of patients is usually quite satisfactory. With avulsions of the iliac spine and fractures of the iliac wing (Duvernay fracture), swelling and local pain in the area of ​​damage are noted, as well as dysfunction of the corresponding lower limb. With an avulsion fracture of the iliac spine, in some cases, a “backward” symptom is observed, described in 1931 by L. I. Lozinsky: increased pain in the area of ​​the fracture when trying to actively bend the hip; When moving backwards and pulling up the limb (“backward”), the pain is less pronounced. Fractures of the coccyx and sacrum below the articulation are diagnosed on the basis of local pain, which intensifies when walking and sitting; a rectal examination can determine patol. mobility of the distal coccyx and its displacement. Fractures of the ischial tuberosity also manifest as local pain, which intensifies with active extension of the lower limb.

Fractures anterior section T., especially with a violation of the continuity of the pelvic ring, may be accompanied by a deterioration in the general condition of the victim. Patients often take forced situation with the hip and knee joints bent and the lower limbs apart - “frog pose” (Volkovich’s symptom). In case of damage to the anterior semi-ring of the T., pain is observed in the area of ​​the fracture, which intensifies with palpation and compression of the bones of the T., as well as during vaginal and rectal examination. With fractures of the horizontal branch of the pubic bone, active flexion in the hip joint is difficult. In some cases, a symptom of a “stuck heel” is observed - the victim cannot lift his outstretched leg. With fractures near the pubic symphysis, active adduction of the limb is more impaired due to tension in the adductor muscles of the thigh attached to this area. Dysfunction of the lower extremities is one of the constant symptoms of fractures of the anterior half-ring of the T.

On the 2-3rd day after the injury, bruises may appear in the surrounding tissues: for fractures of the pubic bone - above the inguinal (pupart) ligament, for fractures of the sciatic bone - in the perineal area. With ruptures of the pubic symphysis, retraction in this area is determined during palpation and vaginal examination. Ruptures of the pubic symphysis are usually combined with a fracture of the T. bones or damage to the sacroiliac ligaments.

Isolated injuries to the bones of the posterior section of the pelvic ring with a violation of its continuity are extremely rare; simultaneous injuries to its anterior and posterior sections are more often observed. Patients are often in a state of traumatic shock caused by massive trauma and blood loss. Due to the anatomical features of the blood supply to the bones of T. and the richly developed network of choroid plexuses in the pelvic region, bleeding from pelvic fractures is usually prolonged and profuse. The formation of massive (up to 2-3 l) retroperitoneal hematomas is possible. Stopped bleeding can resume with the slightest movements of the patient, shifting, or insufficiently careful examination. Retroperitoneal hematoma due to irritation by blood of the parietal layer of the peritoneum often creates a picture of an acute abdomen. With low-lying hematomas, symptoms of damage may be observed urinary tract.

The differential diagnosis of retroperitoneal hematoma and intra-abdominal bleeding often seems very difficult. The Joyce symptom observed with the latter (a shift in the boundaries of dullness of percussion sound in the lateral parts of the abdominal cavity when the patient’s position changes) is often impossible to identify due to the severity of the victim’s condition. In these cases, objective research methods are used (laparocentesis, laparoscopy, contrast urethrocystography). Upon examination, the forced position of the patient attracts attention. In case of fractures of the bones of the T. with displacement, asymmetry of the pelvic ring is determined, the limb on the side of the injury is rotated outward, appears shortened due to the displacement of the lateral fragment of the T. upward. Palpation reveals pain in the area of ​​the fractures, which intensifies with attempts to compress (Verney's symptom) or spread (Larrey's symptom) the wings of the iliac bones. Possible bloating, dullness of percussion sound, lack of peristalsis, and even the presence of symptoms of peritoneal irritation caused by retroperitoneal hematoma. The nature of the damage is clarified with x-ray examination. research. With rotational displacement of half of the pelvis (usually external rotation), the size of the iliac wing increases on the radiograph, the obturator foramen decreases, and its configuration changes (see Sacroiliac joint).

The incidence of acetabular injuries is approx. 7% of all T fractures. Symptoms depend on the location of the fracture. With fractures of the bottom of the cavity without displacement of the fragments, pain in the joint area is noted, but patients can sometimes even walk. In case of fractures of the roof of the acetabulum, complicated by hip dislocation (usually posterior), the limb takes on a characteristic position. Rentgenol is of decisive importance in the diagnosis of this pathology. examination (see Hip joint).

Fractures of T. bones are often accompanied by damage to the pelvic organs, especially the urinary tract (see Urethra, Bladder, Rectum).

Fractures of the coccyx and sacrum - see Coccyx, Sacral region.

To avoid displacement of fragments and damage to the pelvic organs, transportation of a victim with a fracture of the T. bones should be carried out on a rigid stretcher or board. The patient's limbs are bent at the hip and knee joints. IN popliteal areas lay the roller. Before transportation, it is advisable to perform intra-pelvic anesthesia. In the hospital, it is necessary to avoid unnecessary shifting of patients.

Treatment of severe injuries to T. often has to begin with anti-shock measures. Of particular importance are infusion therapy to compensate for blood loss and intrapelvic novocaine anesthesia according to Shkolnikov. With the patient in the supine position, 2 cm inward from the superior anterior iliac spine, an injection needle 14-16 cm long is injected novocaine solution, moving the needle from front to back to a depth of 12-14 cm to the internal iliac fossa. For a unilateral fracture on the injured side, 300-400 ml is injected into it, for a bilateral fracture - 250-300 ml on each side of 0.25% novocaine solution. To prevent complications associated with the administration of large doses of novocaine, 1. or 1% ephedrine solution or 1 ml of 10% caffeine solution is added to it. Usually, a single intrapelvic anesthesia is sufficient.

For fractures of the ilium, after intrapelvic anesthesia, the patient is placed for 3-4 weeks on a board with a bolster in the popliteal areas. For avulsion fractures of the iliac spine with severe diastasis, open reduction or osteosynthesis with a screw may be required. Patients with pelvic ring fractures are treated in a similar manner without disrupting its continuity.

In case of fractures of the bones of the anterior part of the pelvic ring with a violation of its continuity, in most cases, treatment is also carried out by positioning on a backboard with a roller in the popliteal areas. When bone fragments are displaced, traction on the tuberosity is recommended. tibia with small loads (3-4 kg) with limbs apart. In case of severe deformation of the anterior semi-ring of T. with a rupture of the pubic symphysis, surgical intervention may be required (stabilization of the anterior semi-ring). Walking is allowed after 6 weeks. Working capacity is restored after 2.5-3 months.

The most difficult treatment is for patients with simultaneous damage to the bones of the anterior and posterior sections of the pelvic ring. In case of fractures of the bones of the T., accompanied by ruptures of the ligaments of the pubic and sacroiliac joints without displacement of the lateral fragment of the T. (rupture of the ligaments of the sacroiliac joint is radiologically diagnosed in this case by an indirect sign - diastasis of the pubic symphysis), the patient is suspended on a hammock with a load of 5 -8 kg, squeezing T. in the frontal plane. In case of ruptures of the syndesmosis with a displacement of half of the T. upward, the displacement is first eliminated by skeletal traction along the axis of the thigh with a load of 10-12 kg and only after repositioning the T. is tightened with a hammock. In case of fractures with a violation of the continuity of both parts of the pelvic ring, internal rotation of the lateral fragment is also possible. Therefore, before lowering the next ftoc, it is necessary to carry out derotation (simultaneously or by traction by the wing of the ilium). Due to the danger of secondary rotational displacement, the hammock should not compress the T. in the frontal plane. Considering that the posterior section of the T. bears the main static load, bed rest must be observed for at least 3 months. When fractures do not heal, the stability of the pelvic ring is disrupted. In these cases, surgical intervention is indicated (see Sacroiliac joint, Malgenya fractures). The ability to work with this type of damage to T. is usually restored within a period of 6 to 10 months. Often there is a need to temporarily transfer patients to disability.

In case of combined injuries to T., reposition is postponed until the general condition of the victim improves. This problem arises especially acutely with concomitant severe traumatic brain injury (see) or massive damage to the chest (see Chest), since the reposition of pelvic fragments requires an elevated position of the foot end of the bed. With a concomitant fracture of the femur, reposition of the displaced lateral fragment of the pelvis can only be accomplished by traction on the ilium.

For acetabular fractures, conservative treatment is indicated in most cases. Thus, for fractures of the bottom (fossa) of the acetabulum without protrusion of the femoral head and displacement of bone fragments, unloading traction along the axis of the femur is used. When the head of the femur is protruded, traction along the axis of the femoral neck is often required to remove it. However, this, as a rule, does not ensure the reposition of fragments of the acetabulum, as a result of which the phenomena of deforming arthrosis with pronounced pain syndrome and dysfunction of the joint. Surgical reposition of fragments of the floor of the acetabulum also usually does not relieve the patient from the development of deforming arthrosis (see). Thus, with severe damage to the floor of the acetabulum full recovery ability to work often does not occur and patients need to be transferred to disability. To restore the weight-bearing ability of the limb, endoprosthetics or arthrodesis (s. Hip joint) may be required.

The results of treatment of marginal fractures of the acetabulum are more favorable. For uncomplicated injuries, unloading traction is used. Often, a fracture of the edge of the acetabulum is combined with a dislocation of the femoral head. Usually, in this case, a significant fragment of the postero-superior edge of the cavity is broken out, which cannot be reduced in a closed way, and therefore open reduction of the fragment of the roof of the cavity with fixation with screws is required.

Features of combat injuries, staged treatment. Among gunshot wounds of T., there are wounds of soft tissues of the pelvic and gluteal regions, wounds of soft tissues and bones without damage to T.’s organs, and wounds with damage to the pelvic organs. The last type of injury includes intraperitoneal injuries Bladder and rectum and extraperitoneal wounds of the bladder, rectum, posterior urethra and prostate gland.

Wounds can be tangential, through and blind; the latter are more common. Among gunshot wounds of T.'s bones, there are: marginal and isolated fractures without breaking the continuity of the pelvic ring; fracture with disruption of the continuity of the pelvic ring; "fractures of the bones of the acetabulum area; fractures with damage to the anterior and posterior sections of the acetabulum. Often injuries of the acetabulum are accompanied by damage to the hip joint.

According to the experience of the Great Patriotic War, T. bone injuries without damage to internal organs were noted in 61.3% of all pelvic wounds; T. bone injuries with extra- and intraperitoneal damage to T. organs amounted to 19.1%; T. bone injuries combined with injury to the abdominal organs along the half - 9.6% of cases, and with damage large vessels and nerve trunks - in 4.3%.

When examining a wounded person, the presence of entry and exit wound holes is determined. Based on the location and direction of the wound channel, damage to bones, pelvic organs, and blood vessels can be suspected. Palpation and careful lateral or anteroposterior compression of T. causes pain in the area of ​​fractures. A digital examination of the rectum allows not only to determine its damage (blood remains on the finger), but often also to determine a fracture and displacement of bone fragments. Wounded people with a fracture of the pubic bones cannot lift a straight leg (symptom of a “stuck heel”) due to increased pain in the area of ​​​​the injury. In case of injuries to T., it is necessary to exclude damage to the pelvis hip joint. Damage to the pelvic organs, large vessels and nerve trunks should be established or excluded. Final diagnosis a gunshot fracture of the T. bones is established after radiography of the entire T. (Fig. 8).

Gunshot fractures of T. bones are often accompanied by shock (see), significant blood loss (see), inf. complications (extra- and intrapelvic phlegmon, abscesses and osteomyelitis), often anaerobic infection, as well as urinary, fecal and purulent leaks (see Streaks, Urinary leakage). . Injuries to large vessels of T. (external and internal iliac arteries) are accompanied by external and cavitary bleeding and can lead to death. With interstitial bleeding with the formation of pulsating hematomas, blood loss is slower.

When providing first medical care(see First aid) a protective bandage is applied, analgesics are administered, the wounded person is carefully carried out on a shield (stretcher), a duffel bag or an overcoat roll in the form of a roller is placed under the legs bent at the knee joints.

When providing first aid (see), bandages are monitored and corrected, transport immobilization is improved, and analgesics are administered.

When providing first aid (see), measures are taken to prevent shock, control bleeding and prevent wound infection. All wounded are administered antibiotics, antitetanus serum and adsorbed tetanus toxoid, and immobilization is improved. If the bladder is full and the urethra is damaged, a suprapubic capillary puncture is performed.

At the stage of providing qualified medical care (see) during medical triage (see Medical triage), three groups of victims are distinguished: those wounded in soft tissue; wounded with gunshot fractures of T. bones without damage to internal organs and threatening bleeding; wounded with gunshot fractures of T. bones, complicated by bleeding and damage to internal organs. In the first and second groups, measures are taken to prepare for evacuation, bandages are corrected or changed, painkillers or cardiovascular drugs are administered. If there is simultaneous damage to the bones of T., the hip joint or thigh, transport immobilization is carried out (see) with a Dieterichs splint, reinforced with plaster rings (see Splinting). The wounded of the first group are evacuated to general surgical hospitals, the second - to specialized hospitals for those wounded in the extremities. The wounded of the third group are provided with life-saving assistance. Especially often there is a need for final stop bleeding from the gluteal arteries. If ligation is unsuccessful, ligation of the internal iliac artery is performed in the wound (see above). Interstitial bleeding and the formation of large retroperitoneal hematomas in T. are observed when the branches of the internal iliac artery are affected. In such cases, bleeding after emptying the hematoma during primary surgical treatment of the wound (see) is stopped by ligating the internal iliac artery if its bleeding branch cannot be found. In case of damage to the bladder, urethra and rectum, the necessary surgical interventions are performed. The wounded with damage to the pelvic organs are evacuated to a specialized hospital, where the diagnosis is clarified using intravenous urography (see), cystoscopy (see) and cystography (see), fistulography (see) and the necessary treatment is carried out according to indications. Events.

Diseases. Inflammatory processes can be localized in soft tissues, located superficially or in deep layers, and also affect the pelvic organs. There may be sinter abscesses (see Sinter abscess), descending into the T.'s cavity from the overlying sections (see Psoitis). Diagnosis of superficial ulcers and phlegmons (see) is not particularly difficult. They flow with high temperature and pronounced local phenomena. Swelling abscesses, phlegmons of the pelvic tissue, on the contrary, long time.may remain unrecognized. Their course is more severe and is accompanied by dysfunction of the pelvic organs. Treatment - surgical intervention in combination with targeted antibacterial therapy. It is advisable to open deep phlegmons and edemas using wide access, allowing one to approach the sciatic foramen, where abscesses emerging from the T cavity are usually located. For phlegmons of the pelvic tissue, early drainage is indicated.

Osteomyelitis of bones of T. is divided into hematogenous and post-traumatic (see, Osteomyelitis). The latter is more often a consequence of gunshot and open fractures (see). Somewhat less frequently, it occurs when the pelvic organs are damaged and urinary leaks form (see Urinary leakage). The development of the process is manifested by symptoms of intoxication and sepsis (see). Swelling and tissue infiltration increase, and the amount of purulent discharge increases. X-ray signs of osteomyelitis are revealed only after 3-5 weeks. With the formation of fistulas, the appearance of rentgenol. symptoms makes diagnosis easier. Fistulography and transosseous venography are informative (see). Each localization of osteomyelitis is characterized by a predominant location of purulent leaks, which are divided into primary (when pus breaks out of the bone) and secondary, formed after the breakthrough of primary ulcers. With osteomyelitis of the pubic bone, prevesical edema is formed primarily, and preperitoneal, perineal, scrotal, and femoral edema is formed secondarily. With osteomyelitis of the ischium, primary leaks can be localized in the ischiorectal fossa, tissue of the perineum, gluteal region and thigh. When the ilium is damaged, primary leaks usually form on its inner and outer surfaces, and secondary ones can be of different locations. With osteomyelitis of the sacrum, primary leaks are more often observed on its anterior surface. In the complex to treat. measures for osteomyelitis T. the leading place is occupied by early surgical intervention in the form of wide resection of the affected bones and drainage of leaks.

The prognosis depends on the underlying disease and timely treatment of its complications.

With T. bone tuberculosis, the focus most often occurs in the area of ​​the hip, sacroiliac joints and pubic symphysis (see Extrapulmonary tuberculosis, tuberculosis of bones and joints).

Pronounced changes in T.'s bones are observed in the puerperal form of osteomalacia (see). The bones of the pelvic ring are pressed into the T.'s cavity, the distance between the iliac bones is reduced. The sacrum is pressed down by the spine and takes on a more horizontal position, the sacral promontory protrudes forward, the pubic symphysis protrudes anteriorly, the ischial tuberosities are brought closer together, the obturator foramina are located in the sagittal plane and the entrance to the T. takes on a Y-shape. Severe osteoporosis is characteristic (see).

Changes in T.'s bones are characteristic of ankylosing spondylitis (see ankylosing spondylitis). A special place among the early symptoms is occupied by sacroiliitis, which is considered pathognomonic for this disease.

Damage to T.'s bones is observed in 30% of cases of bone echinococcosis (see Echinococcus). Characterized by dull pain in the T. area, an increase in the affected parts in volume, patol. fractures. The process continues for years, but sometimes a more rapid course is observed, reminiscent of osteomyelitis. X-ray reveals a cellular structure of the affected area or a cavity with a clear boundary from healthy bone. Treatment boils down to early radical resection of the affected area of ​​bone. Relapses are possible. Associated infection often leads to the development of sepsis (see).

Corrective operations (osteotomies of the ilium) are performed for dysplasia of the hip joint (see Hip joint). For T. bone fractures, various types of osteosynthesis are performed (see) using screws, plates, etc.

Bibliography: Bodyazhina V.I. and Zhmakin K.I. Obstetrics, p. 115, M., 1979; Bystritsky M.I. Fractures of the pelvic bones, L., 1960; G o s t e v V. S. Retroperitoneal hemorrhages in closed fractures of the pelvic bones, Vestn. chir., t. 106, no. 2, p. 49, 1971, bibliogr.; o n e, Ligation of the internal iliac arteries in severe pelvic injuries, ibid., t. 108, no. 3, p. 99, 1972, bibliogr.; Drachun P. S. Surgical treatment of old and chronic ruptures of the symphysis pubis, Orthop. and traumat., No. I, p. 67, 1972, bibliogr.; Jordania I. F. Textbook of obstetrics, p. 37, M., 1964; Ivanitsky M. F. Human Anatomy, vol. 1, p. 170, M., 1965; Kaplan A.V. Damage to bones and joints, p. 284, M., 1979; K a r a l i n A.N. and Hamito in R.K. Restoration of working capacity in patients with pelvic bone fractures, Orthop. and traumat., No. 8, p. 25, 1971; Lagunova I. G. X-ray anatomy of the skeleton, p. 291, M., 1981; Landa M.I. Damage and complications associated with pelvic fractures, Orthop. and traumat., No. 8, p. 8, 1963; L yu b o - sh i ts N. A. Closed fractures pelvic bones in children, M., 1968, bibliogr.; Multi-volume guide to obstetrics and gynecology, ed. L. S. Persianinova, vol. 1, p. 296, M., 1961; Nadein A.P. Essays on purulent surgery of the male pelvis, L., 1960, bibliogr.; Nagy D. X-ray anatomy, trans. from Hungarian, p. 113, 350, Budapest, 1961; Nesterov-ska Ya V.I. Bones of the lower extremities and their connections, in the book: Clinical. X-ray anat., ed. G. Yu. Koval, p. 244, Kyiv, 1975; Nikitin G. D., M i t goni N. K. and Gryaznukhin E. G. Multiple and combined bone fractures, e. 172, L., 1976; Experience of Soviet medicine in the Great Patriotic War of 1941 - 1945, vol. 13, p. 131, M., 1955; Essays on military field surgery, ed. Yu. G. Shaposhnikova, p. 173, M., 1977; Petrovsky B.V. and Lapkina E.A. Gunshot injuries to the pelvic bones, Surgery, No. 8, p. 68, 1946; Injuries and diseases of the pelvic bones, ed. M. V. Volkova, M., 1969; Pozharisky V. F. Resuscitation for severe skeletal injuries, M., 1972; Revenko T. A., Chirakh S. X. and Babosha V. A. Combined injuries of the pelvic bones, bladder and urethra, Kyiv, 1978; Reinberg S. A. X-ray diagnosis of diseases of bones and joints, book. 1, p. 108, M., 1964; Selivanov V.P. and Voronya research assistant and Yu.P. Osteomyelitis of the pelvis, M., 1975, bibliogr.; Watson-Jones R. Fractures and joint injuries, trans. from English, p. 599, M., 1972; U s t i m e n-k about E. M. Traumatic ruptures of the bladder, M., 1978; Shkolnikov L. G., S e l i v a n about in V. P. and Tsodyks V. M. Damage to the pelvis and pelvic organs, M., 1966, bibliogr.; Anson V. J. a. M with V and at S. V. Surgical anatomy, Philadelphia, 1971; With r e at s-sel I. et Schnepp I. Fractures trans-cotyloidiennes du bassin, P., 1961; Fr i e-d e b o 1 d G. Schwere Frakture des Beckens und der Zeitpunkt, ihrer Verso-rung, Mschr. Unfallheilk., S. 408, 1971; Ka m i n a P. Anatomie gynecologique et obstetricale, P., 1979; K o s s a k o w-ski J. S., Zach ar j asiewicz I. e. K orszynski M. ZJamania mied-nicy powiklane uszkodzeniem pecnerza lub cewki moczowej, Wiad. lek., t. 25, s. 237, 1972; P i 1 1 e t J. Anatomie du petit bassin, P., 1967; Sobotta J.u. In e-c h e r H. Atlas der Anatomie des Menschen, Bd 1, Munchen, 1972; Sullivan C. R. Fractures of the pelvis, Postgrad. Med., v. 39, p. 45, 1966; Textbook of obstetrics and gynecology, ed. by D. N. Danforth, N. Y., 1971.

V. M. Tsodyks; E. I. Borzyak (an., comparative anatomy), M. K. Klimova (rent.), S. S. Tkachenko (military), E. A. Chernukha (female pelvis).

Pelvis I (pelvis)

a bony ring formed by two symmetrical pelvic bones, the sacrum and coccyx, forming the sacroiliac and pubic bones. The pelvis forms the lower extremities, is a support for the torso, forms, resting on the heads of the femurs. The joints of the pelvic bones are characterized by great strength and low mobility.

The sacroiliac joint is a paired flat, stiff joint, formed by the ear-shaped surfaces of the sacrum and iliac bones. The sacrospinous and sacrotuberous are connected to pelvic bone, close the greater and lesser sciatic notches, forming the greater and lesser sciatic foramina.

There are large and small pelvises. The border between them is , which is drawn through (promontorium), the arcuate line, the ridges of the pubic bones and the upper edge of the pubic symphysis. The opening thus limited forms the upper aperture of the pelvis. The large pelvis is much wider than the small one. It contains the organs of the lower abdominal cavity.

The small pelvis is a short bony canal in which the bladder and internal genital organs are located. The anterior wall of the pelvis is very short (superior rami of the pubic bones, pubic symphysis); the lateral walls are formed by the internal surfaces of the pelvic bones below the boundary line and the obturator membrane, the sacrotuberous and sacrospinous ligaments, the greater and lesser sciatic foramina; the posterior wall is the longest, formed by the sacrum and coccyx. The inferior aperture of the pelvis, or of the small pelvis, has diamond shape; it is limited by the sacrotuberous ligaments, the ischial buffs, the branches of the ischial bones, the lower branches of the pubic bones, and the arcuate pubis. The lower opening of the pelvis is closed by muscles and fascia, which form the genitourinary diaphragm and the pelvic diaphragm (see Perineum).

The iliopsoas, piriformis and obturator internus begin on the walls of the pelvis and attach to the proximal end of the femur. Gluteal muscles(major, middle and small), gemelli, obturator externus, quadratus femoris and tensor fascia lata muscles begin on outer surface pelvis and are attached to the proximal end of the femur.

Sex differences in the structure of the pelvis are revealed at the age of about 10 years. The female pelvis is wider and shorter ( rice. 1 ), the wings of the ilium are turned to the sides, the small pelvis has the shape of a transverse oval, the shape of the pelvic cavity is cylindrical, the angle between the lower branches of the pubic bones is obtuse or straight (equal to 90-100°), has the shape of an arch. The male pelvis is narrower and higher, the wings of the ilium are more vertical, the promontory protrudes forward, the shape of the pelvic cavity is cone-shaped, the lower branches of the pubic bones form an angle of 70-75°.

In obstetric practice, the small pelvis is divided into 4 sections by conventional planes (classical planes), which fan out from the pubic symphysis to the sacrum. There is also a system of parallel planes according to Godju. In clinical practice, the following sizes of the female pelvis are most often used ( rice. 2, 3 ): distantia spinarum - the distance between the anterior superior iliac spines is 25-26 cm; distantia cristarum - the greatest distance between the iliac crests is 28-29 cm; distantia trochanterica - the distance between the greater trochanters is 30-31 cm; true, or obstetric, - the distance between the posterior edge of the pubic symphysis and the promontory is 11 cm. To determine the obstetric conjugate, it is necessary from the external direct size (the distance from the pubic symphysis to the recess between the last lumbar and first sacral vertebra) equal to 20-21 cm, subtract 9 cm- a distance equal to the thickness of the tissues and the spinal column.

The pelvic bones have a number of palpable projections that serve as important landmarks. The iliac crest is defined throughout its entire length, with the exception of the posterior section. In front it is determined by the anterior superior, and behind it - by the posterior superior iliac spine. palpable above the gluteal fold, the coccyx is in the upper part of the intergluteal fold.

The blood supply to the walls of the pelvis and internal organs is carried out by the branches of the internal iliac artery. At the level of the greater sciatic foramen, it is divided into two trunks: anterior and posterior. The internal pudendal, all visceral and parietal arteries (obturator, inferior gluteal) depart from the anterior trunk; the parietal arteries (lateral sacral, superior gluteal and iliopsoas) depart from the posterior trunk.

Research methods include inspection, palpation, and determination of the size of the pelvis. clarified using x-ray examination.

Pathology. Developmental defects are more often observed in the posterior part of the pelvic ring: non-fusion of the arches of the sacral vertebrae, underdevelopment or complete absence of the sacrum and coccyx. In the anterior section of T. there may be no pubic symphysis.

Damage pelvis can be closed or open. Possible lesions include soft tissue, pelvic bones and pelvic organs. Often there is a combination with damage to other parts of the skeleton or internal organs.

Soft tissue bruises may be accompanied by hemorrhages, intermuscular hematomas and skin detachment. often conservative. When the hematoma suppurates, it is indicated.

Injury to the gluteal region often leads to damage to the gluteal vessels. Surgical treatment - . If it is difficult in the wound, then they resort to ligation of the gluteal or internal iliac artery using extraperitoneal access.

Pelvic fractures occur mainly in car accidents or falls from a great height. Fractures of individual bones are possible due to direct impact or muscle strain (avulsions). In accordance with the classification of A.V. Kaplan, there are 4 main types of pelvic bone fractures: marginal fractures of the pelvic ring bones without breaking its continuity, with breaking its continuity, and fractures of the acetabulum. Marginal fractures include avulsion fractures of the iliac spines and ischial tuberosity, fractures of the iliac wing of the coccyx and sacrum below the sacroiliac joint ( rice. 4 ); to fractures of the bones of the pelvic ring without breaking its continuity - unilateral or bilateral fractures of the pubic or ischial bones, diagonal of the pubic and ischial bones ( rice. 5 ); to fractures with disruption of the continuity of the pelvic ring in the anterior section - unilateral and bilateral fractures of the pubic and ischial bones ( rice. 6 ), in the posterior section - a vertical fracture of the sacrum or ilium ( rice. 7 ); to simultaneous damage to the anterior posterior sections of the pelvic ring - vertical fractures on one side (Malgenya type), one- and two-sided diagonal fractures, i.e. vertical fractures in the anterior and posterior sections on opposite sides, ligaments of the pubic and sacroiliac joints, various combinations of bone fractures and ruptures of the pelvic joints ( rice. 8 ). The group of fractures of the acetabulum includes fractures of its bottom and U-shaped cartilage in children, fractures of the edge of the acetabulum and transacetabular fractures of the ilium (see Hip joint).

Symptoms depend on the location of the fracture and its severity. With marginal fractures, the general condition often remains satisfactory. In case of fractures of the spine and wing of the ilium, the ischial tuberosity, local dysfunction of the corresponding lower limb is noted. Fractures of the sacrum and coccyx are diagnosed based on the complaint of local pain, which intensifies when walking and sitting. A rectal examination can also reveal pathological mobility of the coccyx. Fractures of the anterior part of the pelvic ring, especially with a violation of its continuity, may be accompanied by a deterioration in the general condition of the victim. The patient's position is often forced with the lower limbs bent and spread apart (the so-called frog position), they are disturbed. in the area of ​​the fracture increases with load on the anterior pelvic ring, and in women, during vaginal examination. In cases of rupture of the pubic symphysis, it is determined by palpation and vaginal examination.

Isolated injuries to the posterior pelvic ring are rare. More often, simultaneous damage to the anterior and posterior sections is observed. General state patients with such an injury are usually severe, which is due to significant blood loss and the formation of extensive retroperitoneal hematomas (up to 2-3 l). Differentiating the latter with intra-abdominal bleeding is difficult and requires the use of ultrasound, laparoscopy, abdominal lavage, and laparotomy. In displaced fractures, for example, in a unilateral vertical fracture of the pelvic ring (Malgaigne type), the pelvic ring is revealed, on the side of the injury it is rotated outward, it seems shortened due to the upward displacement of the lateral fragment of the pelvis. However, a comparative measurement of the length of the legs shows that they are the same. There may be bloating, lack of peristalsis, and even the presence of symptoms of peritoneal irritation caused by a retroperitoneal hematoma. pelvic injuries are determined by x-ray examination.

To avoid displacement of fragments and secondary damage to the pelvic organs, transportation of victims should be carried out on a rigid stretcher or a board with bent lower limbs (a roller in the popliteal area). Before transportation, it is advisable to carry out an intrapelvic blockade according to Shkolnikov (see Novocaine blockade).

In case of marginal fractures and injuries of the anterior part of the pelvic ring (even with a violation of its continuity), as a rule, conservative treatment is used. Prescribed for 4-6 weeks. bed rest (for fractures of the iliac wing and the anterior half-ring, a cushion is placed in the popliteal areas). recovers in 2.5-3 months.

The most difficult treatment is for patients with simultaneous damage to the anterior and posterior sections of the pelvic ring. Infusion therapy according to Shkolnikov is of particular importance. In case of pelvic fractures (or ruptures of the ligaments of its joints) with displacement of the lateral fragment, its internal rotation and length are first eliminated using skeletal traction performed directly behind or behind the epicondyles of the femur, and after reposition the gas is tightened with a special belt. Considering that the posterior part of the pelvic ring acts as a support, bed rest is prescribed for at least 3 months. Working capacity is restored within 6 to 10 months. Often there is a need for a temporary transfer to . For non-union of fractures, especially the posterior part of the pelvic ring, it is indicated surgical treatment(see Sacroiliac joint).

Treatment of acetabular floor fractures is usually conservative. Surgical intervention is usually used for marginal fractures (see Hip joint). Any damage to the acetabulum can cause post-traumatic coxarthrosis (see Coxarthrosis).

Diseases. Inflammatory processes can be localized in superficial soft tissues or in deep layers. Drip abscesses are possible (see Natechnik (Natechnik)), descending from the overlying sections (see Psoitis). The diagnosis of superficial ulcers and phlegmon (Phlegmon) is not difficult. Abscesses and phlegmons of the pelvic tissue, on the contrary, may remain unrecognized for a long time. Treatment is surgical.

Osteomyelitis of the pelvic bones is most often a consequence of gunshot and open fractures, but can also develop hematogenously (see Osteomyelitis). Manifested by symptoms of sepsis. In the complex of therapeutic measures, the leading place is occupied by early surgical intervention - wide affected bones and swelling.

With tuberculosis of the pelvic bones, the focus most often occurs in the area of ​​the hip, sacroiliac joint and pubic symphysis (see Extrapulmonary tuberculosis (Extrapulmonary tuberculosis), bones and joints).

Lesions of the pelvic bones are observed in Echinococcosis E. Characterized by dull pain, an increase in the affected parts in volume, and pathological fractures. Surgical treatment is resection of the affected area. Relapses are possible.

Actinomycosis of the pelvic bones is rare. The process begins acutely, accompanied by high body temperature, sharp pains. Subsequently they appear with scanty discharge. Treatment is carried out with iodine preparations, actinolysate, and less commonly, radiotherapy is used.

Operations. Surgical approaches to the pelvic bones and its joints are varied. Greatest practical significance They have drainage of the pelvic tissue according to Buyalsky-McWhorter for purulent and urinary leaks, to the outer parts of the ilium for osteomyelitis, to the ischium and pubic symphysis, Chaklin’s intrapelvic access. In case of pelvic fractures with displacement of fragments, they are repositioned and. Hemipelviectomy is used for pelvic tumors; it can be total (in the pubic symphysis and sacroiliac joint) and subtotal (resection of the ilium and pubic bones).

Bibliography: Human Anatomy, ed. M.R. Sapina, vol. 1, p. 140, vol. 2, p. 411, M., 1986; Bodyazhina V.I. Zhmakia K.N. and Kiryushenkov A.P. , With. 100, 299, M., 1986; Korzh A.A., Kulish N.I. and Moiseeva K.N. Surgical treatment of pelvic diseases, Kyiv, 1985, bibliogr.; Kaplan A.V. bones and joints, p. 331, M., 1979; Lyuboshits N.A. Closed fractures of the pelvic bones in children, M., 1968, bibliogr.; Nagy D. X-ray, trans. from Hungarian, p. 350, Budapest, 1961; Nikitin G.D. and Gryaznukhin E.G. Multiple fractures and associated injuries, p. 228, L., 1983; Revenko T.A., Chirakh S.X. and Babosh V.A. Combined injuries of the pelvic bones, bladder and urethra, Kyiv, 1978; Selivanov V.P. and Voronyansky Yu.P. Osteomyelitis of the pelvis, M., 1975, bibliogr.; Trubnikov V.F., Kovalev S.I. and Chaichenko V.P. Treatment of patients with pelvic injuries, Orthop. and traumat., No. 1, p. 7, 1984, bibliogr.; Trubnikov V.F. and others. On the classification of pelvic injuries, Vestn. hir., No. 5, p. 5, 1983; Ustimenko E.M. Traumatic ruptures of the bladder, M., 1978; Frauchi V.X. Topographic anatomy and surgical abdomen and pelvis, p. 627, Kazan, 1966; Cherkes-Zade D.I. Causes and classification of post-traumatic pelvic deformities, Orthop. and traumat., No. 4, p. 52, 1981, bibliogr.; aka, Treatment of chronic pelvic injuries, Alma-Ata, 1986, bibliogr.; Shkolnikov L.G., Selivanov V.P. and Tsodyks V.I. Damage to the pelvis and pelvic organs, M., 1966, bibliogr.

Rice. 3. Dimensions of the female pelvis on a sagittal cut: 1 - anatomical conjugate; 2 - true (gynecological) conjugate; 3 - straight incision (outlet from the pelvis); 4 - diagonal conjugate; 60° - pelvic tilt angle.

view of the male (left) and female (right) pelvis: a - front view; b - top view; the bones of the female pelvis are thinner and smoother, the female pelvis is lower, wider, its cavity has a larger volume">

Rice. 1. Appearance of the male (left) and female (right) pelvis: a - front view; b - top view; the bones of the female pelvis are thinner and smoother, the female pelvis is lower, wider, and its cavity has a larger volume.