The size of a woman's pelvis and its effect on childbirth. Features of the mechanism of labor in various forms of a narrow pelvis. What it is

/ // Forensic-medical examination. - 1963 - No. 4. — P. 18-25.

Department of Radiology and Medical Radiology (Head - I.I. Fedorov) Chernivtsi Medical Institute

Received by the editors 4/III 1963

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Age characteristics pelvic bones / Fedorov I.I. // Forensic-medical examination. - 1963. - No. 4. — P. 18-25.

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To determine the age of a person in forensic practice, features of the pelvic bones can be used.

To study the processes of ossification of the pelvis, we mainly used x-ray method, complementing it in in some cases anatomical and histological studies.

A total of 630 were examined healthy people(from birth to 25 years), 48 anatomical preparations of the pelvic bones, 40 anatomical preparations of growth zones and 51 histological sections from anatomical preparations of growth zones.

Ilium by the time of birth, it is clearly differentiated radiographically into the body and wing. Its upper edge is arched and has smooth contours, the anterior edge is close to straight, the posterior edge in the area of ​​the posterior superior spine almost touches the lateral edge of the sacrum. The inferior posterior spine and the greater sciatic notch are well defined. The lower edge is angled downward, its sides are straight and smooth (Fig. 1).

By the end of the first year of life, unevenness of the upper edge of the bone is revealed. In children 2-3 years old, this unevenness takes the form of a clearly defined jaggedness or “saw” (see Fig. 5, 1). It is most clearly detected at the age of 13-16. By the age of 19-25, with the onset of ridge synostosis with ilium, the unevenness disappears.

Rice. 1. X-ray of the pelvis of a newborn girl.

Microscopic examination revealed that the irregularities represent a zone of preparatory calcification of cartilage with uneven resorption and replacement bone tissue.

The lower anterior spine develops from an accessory ossification nucleus, detected on radiographs from 12-14 years of age. Synostosis of the inferior spine with the ilium occurs in girls at 14-16 years of age, and in boys - at 15-18 years of age.

The accessory ossification nucleus of the iliac crest is first noted on radiographs of the pelvis of girls aged 13-15 years, and in boys aged 15-18 years (Table 1). In the first 2-3 years after its appearance, the crest core consists of several “ossification points” (Fig. 2), which later merge into one continuous, smoothly curved strip, wider in the middle third and gradually tapering towards the anterior and posterior edges of the ilium. , spreading to its anterior and posterior spines. The lower contour of the ridge can also be uneven.

Synostosis of the crest with the ilium begins from the anterior edge of the wing and gradually spreads to its middle and posterior thirds.

Synostosis of the ridge along its entire length was first noted at the age of 19. By the age of 22, synostosis of the iliac crest is observed in all men, while in women it is observed only at the age of 25 (Table 2). By the time the crest synostoses with the ilium, its formation is completed.

Ischium at the time of birth, on radiographs it is represented by one upper branch (see Fig. 1). The lower branch begins to form from 4-5 months of life and is not clearly expressed until the end of the year. At 2 years of age, the ischium is already represented by both developed branches.

Table 1

The period of appearance of additional ossification nuclei of the ilium, ischium and pubic bones

Rice. 2. X-ray of the pelvis of a 15-year-old girl.

1 - ossification nuclei of the iliac crest; 2 - apophysis of the ischium; 3 - accessory ossification nucleus of the anterior inferior iliac spine.

The ischium does not have an independent ossification point and is formed from the primary nucleus of the ischium. For the first time it begins to appear on radiographs from 7-8 months of age, but by the end of the first year of life it is still poorly expressed. By the age of 10-12 years, the ischium reaches a size of 10-15 mm, its apex has unclear contours and is rounded. By the age of 13-17 the top. the bones are already clearly contoured; In about half of those studied, it appears flat, as if cut off, while in the other half it is rounded.

The accessory ossification nucleus of the apophysis of the ischium first appears at 13-17 years of age in girls, and at 15-19 years of age in boys (see Table 1, Fig. 3). In the first 2-3 years after its appearance, the apophysis consists of multiple “ossification points”, which later, gradually lengthening, merge into one continuous strip, separated from the ischium by a barely noticeable clearing. Synostosis of the apophysis with the bone also begins with the upper branch and gradually spreads to the lower branch; complete synostosis in men is observed at 19-22 years of age, in women - 2-3 years later (Table 3). Synostosis with the lower branch of the pubic bone in isolated cases is observed at 3 years of age, regardless of gender. The area of ​​synostosis appears thickened in the form of a callus, the contours of the thickening are uneven and unclear, and the bone pattern is uniform. All this suggests that the process of synostosis is not yet completed. At 3-5 years of age, only incomplete synostosis is observed. Complete synostosis of the lower ramus of the ischium with the lower ramus of the pubic bone is observed in isolated cases in girls aged 6 years, and in boys aged 8 years. Synostosis does not always occur symmetrically on both sides. At the age of 12, synostosis is observed in all boys. The area of ​​synostosis in approximately half of all those studied, even after the final formation of the ischium, remains thickened in the form of a bone callus, but unlike the latter, the thickening has clear contours and a normal bone pattern.

table 2

Period of synostosis of the iliac crest

Rice. 3. X-ray of the symphysis region of a 19-year-old young man.
1 - apophysis of the ischium; 2 - apophysis of the lower branch of the pubic bone.

Table 3

Period of synostosis of the apophysis of the ischium

Rice. 4. X-ray of an anatomical specimen of the pubic bones in the symphysis region of a 13-year-old boy.
1 - the serration (“saw”) of the pubic bones is clearly visible.

The final formation of the ischium in men ends at 19-22 years, in women - at 21-25 years.

pubic bone at the time of birth, on the radiographs of all those studied, it was represented by one upper branch, located obliquely (see Fig. 1).

The lower branch begins to form from the 2nd month of life. In all 6-8 month old children, the lower branch is already clearly expressed. The contours of the upper branch in the area of ​​the symphysis and acetabulum in the first 1-2 years are smooth and rounded. At the 3rd year, uneven contours are revealed, which by 4-6 years takes on the appearance of a “saw” or waviness and histologically represents a zone of calcification of cartilage with its uneven resorption and replacement by bone tissue; here the growth of the upper branch of the pubic bone occurs in length.

Table 4

The wavy contours are more clearly visible at the age of 13-16, during the most rapid bone growth (Fig. 4); it disappears in girls at the 13-15th year of life, in boys - at the 15-18th year. With the disappearance of the undulation, the growth of the superior branch of the pubic bone stops. The anterior tubercle of the obturator foramen is formed by the primary ossification nucleus of the superior ramus of the pubis. Radiologically, the tubercle first begins to appear at 7-9 years of age. From 13-16 years of age, it is visible in approximately 25% of those studied. The accessory ossification nucleus of the apophysis of the lower branch appears at 19-22 years of age (see Table 1). In the first 1-2 years after appearance, the apophysis consists of several “ossification points”, which later merge into one narrow strip (see Fig. 3). Synostosis of the apophysis with the lower branch and the formation of the pubic bone are observed in men 22-23 years old, in women 22-25 years old (Table 4).

acetabulum at the time of birth and in the first months of a child’s life, it consists of cartilaginous tissue and is represented by a wide clearing limited by the ilium, ischium and pubic bones (see Fig. 1). The contours of these bones in the area of ​​the acetabulum are smooth until 6-7 months of life. From 8-9 months there is a slight unevenness of the upper contour of the acetabulum, and from 3 years of age - unevenness of the acetabulum in the area of ​​the anterior and posterior contour, which by 4-6 years takes on the appearance of waviness (Fig. 5, 3). Histological studies of G.P. Nazarishvili and our team showed that the uneven contours of the cavity are due to uneven growth of bone substance due to articular cartilage. The wavy contours are most pronounced during puberty, when the most intensive growth of the pelvic bones is noted. With the onset of synostosis of the bones forming the acetabulum and the cessation of their growth, the waviness of the contours disappears.

Rice. 5. X-ray of the pelvis of a 4-year-old boy.

1 - unevenness of the upper edge of the ilium; 2 - thickening of the area of ​​synostosis of the lower branches; 3-irregularity of the contours of the acetabulum; 4 - “figure of a tear”; 5 - “crescent figure”.

In 7-8 month old children, above the upper contour of the acetabulum, in the area of ​​its roof, a compaction of bone substance with very delicate short transversely located bone beams appears. In the majority of children studied, at the age of one year, the layer of compaction of the bone substance above the roof is 0.5 cm, and in some cases reaches 1 cm. By the age of 18-19 years, the thickness of the roof of the acetabulum is 4-6 cm, regardless of gender.

The compact bone substance of the acetabulum fossa first begins to appear on radiographs in children at 2 years of age in the form of a gentle spherical shadow. At the same time, the compact bone substance of the medial surface of the body of the ischium begins to appear in the form of a straight vertical strip. Both described stripes run almost parallel to each other. At 3 years of age, a third short, smoothly rounded strip of compact bone substance appears at the lower edge of the acetabulum notch, closing the lower ends of the two strips described above. From the moment of their fusion, a radiographic formation of the acetabulum is created in the form of a “tear-shaped figure” (A. Köhler, V.S. Maykova-Stroganova). From the age of 4-5 years of life, the “tear figure” is observed in all those studied (see Fig. 5, 4).

In 2-year-old children, along the lower part of the posterior edge of the acetabulum, a “crescent figure” begins to appear in the form of a gentle, smoothly rounded short shadow, convexly facing outward. At the age of 3, the “crescent figure” is observed in half of the studied, and from 5-6 years old - in all (see Fig. 5, 5).

Rice. 6. X-ray of the pelvis of a 14-year-old boy.

By the age of 7-9 years, the “acetabulum bones”, located between the ilium and pubic bones, begin to be identified for the first time. The shape of the bones is irregular, elongated, size 2-4 mm in width and 10-12 mm in length. More often one or two such bones are visible symmetrically on both sides, less often on one side. At the age of 10-12 years, “acetabulum bones” are observed in almost all children. By the time of synostosis, their shape remains irregular, elongated, their size increases to 3-6 mm in width and up to 10-15 mm in length.

Table 5

With the completion of synostosis of the bones forming the acetabulum, the “ossicles of the acetabulum” are not detected.

At the age of 12-13, a third additional bone formation appears - the “epiphysis of the acetabulum.” By the time of synostosis of the bones forming the acetabulum, this bone is observed in the majority of those studied (Fig. 6).

Synostosis of the bones forming the acetabulum is observed in isolated cases on radiographs of the pelvis of 13-year-old girls. At the age of 14, synostosis is observed in the majority of girls; at the age of 15, in all girls. Synostosis of these bones in young men begins accordingly 2-3 years later (Table 5). By the age of 18-19 years, the acetabulum appears radiographically to be fully formed.

conclusions

1. The pubic bone has an apophysis of the lower branch, the additional ossification nucleus of which appears at 19-22 years of age, regardless of gender. Synostosis of the apophysis with the lower branch occurs at 22-23 years in men, and at 22-25 years in women.
2. Accessory nuclei of ossification of the iliac crest and apophysis of the ischium appear in girls at 13-15 years of age, in boys - at 15-18 years of age. Synostosis of these apophyses, according to our observations, occurs in men at 19-22 years of age, in women - at 19-25 years of age. However, this issue can be finally resolved only by studying a significantly larger number of observations of individuals aged 22-25 years.
3. Synostosis of the lower branches of the ischium and pubic bones is observed in girls aged 6-12 years, in boys - 8-15 years, incomplete synostosis - from 3 years of age, regardless of gender.
4. The accessory ossification nucleus of the anterior inferior iliac spine appears at 12-14 years of age, regardless of gender. Its synostosis with the ilium occurs in girls at 14-16 years old, in boys - at 15-18 years old.
5. Synostosis of the bones forming the acetabulum occurs in girls at 13-15 years old, in boys - at 15-17 years old.

1. Sacroiliac joint- a tight joint formed by the ear-shaped articular surfaces of the sacrum and ilium. Blood supply from aa. lumbalis, iliolumbalis et sacrales laterales. Innervation: branches of the lumbar and sacral plexuses.

2. Pubic symphysis connects both pubic bones to each other. Between the surfaces of these bones facing each other there is a fibrocartilaginous plate in which the synovial cleft is located.

3.Sacrotuberous and sacrospinous ligaments-strong interosseous ligaments connecting the sacrum with the pelvic bone on each side: the first - with the ischial tuberosity, the second - with the adjacent spine. The described ligaments transform the greater and lesser sciatic notches into the greater and lesser sciatic foramina.

4. Obturator membrane- a fibrous plate that covers the obturator foramen of the pelvis. Attaching to the edges of the obturator groove pubic bone, it turns this groove into the obturator canal.

Pelvis as a whole

Both pelvic bones form the pelvis, which serves to connect the torso with the free lower limbs. The bony ring of the pelvis is divided into two sections: upper- big basin, and the lower, narrower one - the small pelvis. Below, the pelvic cavity ends with the inferior pelvic aperture, the ischial tuberosities, and the coccyx.

The bones of the female pelvis are generally thinner and smoother than those of men. Wings iliac bones in women they are more turned to the sides. The entrance to the female pelvis has a transverse oval shape and is wider; the female sacrum is relatively wider and at the same time flatter. The tailbone protrudes forward less. The pelvic cavity in its outline approaches a cylinder. The female pelvis is low, but wider and more capacious.

Sex differences:

The female pelvis is lower and wider, while the male pelvis is higher and narrower. The wings of the ilium in women are turned to the sides, while in men they are located more vertically. In men, the pelvic cavity narrows downward. In the area of ​​the superior aperture, the promontory of the sacrum sharply protrudes forward, the pelvic cavity is narrowed by closely located ischial spines and tuberosities, the symphysis is narrow, high, the exit from the small pelvis is also limited by the protruding coccyx. In general, the pelvic cavity in men seems compressed from the sides

Age features:

The pelvis of a newborn is much less developed than the chest, abdomen and head. The promontory of the sacrum is absent and the shape of the pelvis resembles a funnel with an upper diameter of 2.7 cm. The sacrum is located 1 cm above the entrance to the pelvis. By 3 years of life, the border line (linea terminalis) is compared to the cape. The anteroposterior dimension is larger than the transverse one. Only by the end of the 2nd year does the transverse size become larger. Until puberty, the pelvis grows slowly.

In older people, the number of bone plates in the spongy substance of the pelvic bones decreases and cavities appear. Bones become lighter and more fragile. The cartilage of the pubic fusion partially atrophies and loses elasticity.

13. Hip joint. Structure, shape, movements in the joint and muscles acting on it

The hip joint is formed by the acetabulum, which includes the head of the femur. A fibrocartilaginous rim runs along the entire edge of the acetabulum. The hip joint has two intra-articular ligaments: the transverse acetabular ligament, the ligament of the head, and the ligament of the femoral head. The hip joint is cup-shaped and allows movement around three axes: frontal, sagittal and vertical. Circular motion is also possible. The external ligaments are located according to the three main axes: three longitudinal ligaments - iliofemoral, pubofemoral, ischiofemoral - perpendicular to the frontal and sagittal axes, and circular, perpendicular to the vertical axis.

Lead:

o Gluteus maximus

o Gluteus minimus

o Gluteus medius

Adductor muscles of the thigh (adduction)

o adductor longus muscle.

o adductor brevis muscle.

o adductor magnus muscle.

o thin muscle,

Anterior group - flexors

o quadriceps femoris muscle.

o sartorius muscle

Posterior thigh muscles (extensors)

o semitendinosus muscle.

o semimembranosus muscle.

o biceps femoris muscle

o popliteus muscle.

Blood supply: from the retearticulare, formed by the branches of the medial and lateral circumflex femoral artery (from a. profundafemoris) and the obturator artery. The acetabular branch departs from the latter to the head of the femur. Venous outflow occurs into the deep veins of the thigh and pelvis - v. profunda femoris, v. femoralis, v. iliaca interna.

Innervated from nn. obturatonus, femoralis et ischiadicus.

The weight of the fetus and the size of the pelvis of a pregnant woman are two inseparable concepts. The structure and size of the pelvis are crucial for the course and outcome of childbirth. Deviations in the structure of the pelvis, especially a decrease in its size, complicate the course of labor or present insurmountable obstacles to it. The examination plan for a pregnant woman must include measuring the pelvis. This procedure is often performed at the first visit to every woman who contacts an obstetrician-gynecologist in connection with the onset of a desired pregnancy. The bony pelvis and the soft tissues lining it constitute the birth canal through which the baby is born. The doctor and his patient need to know whether the birth canal is too small for the baby. This circumstance determines the possibility of childbirth through natural birth canal. The results of the pelvic examination are entered into medical documents. So that you can figure out for yourself what is written on your exchange card, we will tell you in detail what the doctor does when measuring a pregnant woman’s pelvis. The pelvis is examined by inspection, palpation and measurement. To determine the size of the pelvis with a “pelvis gauge” (the pelvis gauge has the shape of a compass equipped with a scale on which centimeter and half-centimeter divisions are marked; there are buttons at the ends of the branches of the pelvis gauge; they are applied to the places between which the distance is to be measured), the external values ​​described below are measured, according to which approximately judge the size and shape of the small pelvis.

An anatomically narrow pelvis is a pelvis in which all or at least one of the dimensions is shortened by 2 cm (the dimensions in question are listed above). An anatomically narrow pelvis is not always an obstacle to childbirth. The outcome of childbirth depends not only on its size, but also on the nature of labor, the weight of the fetus and the ability of the fetal head to change. If labor is good, then with a small degree of pelvic narrowing, childbirth usually ends safely for the mother and fetus. In addition to the anatomically narrow pelvis, the concept of a clinically narrow pelvis is distinguished. A narrow pelvis can be quite functional, but even a normal-sized pelvis can be narrow for a large fetus. Diagnosis of an anatomically narrow pelvis is based on its measurement with a pelvimeter, magnetic resonance imaging or ultrasound pelviometry; the question of whether a given pelvis is functionally narrow is decided during childbirth by assessing the nature of labor, the advancement of the head, and so on. With a narrow pelvis, pay attention to the shape of the abdomen: a pointed abdomen in primiparas and saggy in those who have given birth.

There is such a classification of pelvic sizes:

• gynecoid pelvis (normal pelvis female type);
• android pelvis (male type);
• anthropoid pelvis (inherent in primates, but also observed in humans, its main feature is an increase in the size of the direct entrance to the pelvis and its predominance over the transverse one);
• platypeloid pelvis (flat). In practice, classifications are usually used that take into account the shape and degree of narrowing.

Frequently occurring forms of a narrow pelvis: uniformly narrowed pelvis: all dimensions (straight, transverse and oblique) are reduced by the same amount, most often by 2 cm. This type of narrow pelvis is observed in women short stature, the right physique. The pelvis has correct form a normal, well-developed pelvis, but all its dimensions are reduced. Features of the biomechanism of childbirth: the biomechanism of childbirth resembles the usual one, however, labor proceeds more slowly, extension of the head is difficult due to the narrow pubic angle, internal rotation of the shoulders is also difficult.

The weight of the fetus also affects the outcome of childbirth; The pelvis is already smaller than the normal size for delivery, but if the fetus is large, then delivery tactics should be reconsidered. Transversely narrowed pelvis: characterized by a decrease in the transverse dimensions of the pelvis by 0.5 - 1 cm or more with a normal (or increased) size of the true conjugate. The shape of the pelvic inlet is round or longitudinally oval instead of transversely oval, inherent normal pelvis female type. With transverse narrowing of the pelvis, flattening of the sacrum is often observed.

Features of the biomechanism of childbirth: excessive flexion is observed, maybe long standing heads in straight size. Extension of the head at the exit from the pelvic cavity is difficult and a perineal rupture is likely. In this case, and if the fetus is large, then delivery must be completed by cesarean section. Flat pelvis: it has shortened straight dimensions with the usual values ​​of transverse and oblique dimensions. With a simple flat pelvis, all direct dimensions are narrowed, while the rest have normal values. Features of the biomechanism of labor: clinical inconsistency may occur. If the head goes down, then due to wide sizes exit, a very fast “assault” course of labor is possible. To increase the direct size of the entrance, the Wolcher position is recommended (with horizontal position the torso and legs are lowered down from the edge of the delivery bed).

In the case of diagnosing a narrow pelvis, it is necessary to analyze risk factors for other types of pathology, for example, miscarriage. A pregnant woman and a woman in labor are led by a doctor who, together with the woman, chooses the delivery tactics. With a narrow pelvis, early hospitalization is indicated at 38 weeks of pregnancy. In the presence of the 1st degree of narrowing, childbirth is possible through the natural birth canal, provided that the fetus is not large and labor is good, as well as the absence of other pathology. With the 2nd degree of narrowing, childbirth is possible only with an extremely premature fetus. In the case of the 3rd and 4th degree of narrowing, a cesarean section is performed as planned. With the 4th degree of narrowing of the pelvis, problems arise even with performing an abortion and fertilization surgery. With a narrow pelvis, anomalies of position or insertion often occur. Complications of childbirth in the case of a narrow pelvis are: weakness of labor, premature rupture of water, fetal hypoxia, maternal birth trauma (perineal ruptures, cervical ruptures, etc.), fetal birth trauma, postpartum hemorrhage and so on.

A clinically narrow pelvis can occur even with normal pelvic sizes due to the presence of a large fetus, anomaly of head insertion, post-maturity, etc. With normal pelvic sizes and the average height of a woman, a fetus with an estimated weight of 4000 g or more is considered large. Risk factors for the formation of clinical inconsistency can be identified in advance. However, the final diagnosis is made already in the 1st stage of labor.

Thus, we can confidently say that determining the weight of the fetus, the size of the woman’s pelvis and their compliance is very important for delivery tactics. Therefore, when registering for pregnancy, you must: - consult a doctor about the size of your pelvis; - if these measurements were not carried out in the early stages of pregnancy, then ask the doctor to take them starting from the 35th week of pregnancy; - starting from 35–36 weeks of pregnancy, it is necessary to determine the estimated weight of the fetus (according to the above calculations); - controlling your weight and calculating the expected weight of the fetus; - it is necessary to consult with a doctor about the diet and rules of behavior for a successful birth; - from 37–40 (41–42 with prolonged pregnancy), it is necessary to determine and monitor the weight of the fetus to select labor management tactics.

In a newborn, the pelvis is funnel-shaped. The wings of the ilium are located vertically and are slightly S-shaped. The iliac fossae are only outlined, the line of entry into the small pelvis is weakly contoured. The small pelvis is underdeveloped, the entrance to it is narrow, longitudinally oval in shape. At puberty, the bodies of the ilium, pubis and ischium fuse into a single pelvic bone. As the child begins to stand on his feet and walk, the position of the pelvis changes. The angle of inclination of the pelvis decreases and reaches 45° in early childhood. The iliac fossae deepen, the line of entry into the small pelvis becomes clearly defined, transversely oval in shape. The pelvic cavity is approaching cylindrical.

The levator ani muscle in a newborn has not yet been differentiated into its main parts and is a thin muscular plate. In newborn boys, the rectovesical fossa is relatively deeper than in subsequent age periods. In girls, in the pelvic cavity the vesicouterine fossa is relatively small and occupies a higher position than the rectouterine fossa, with which the left lateral canal and the left mesenteric sinus of the abdominal cavity directly communicate.

In newborns bladder fusiform or pear-shaped, lies high and, when filled more than half, extends beyond the boundary line of the pelvis. As the child grows, the bubble becomes more rounded. In young children, the ureters are adjacent to the bladder for a greater extent than in adults. The internal opening of the urethra often lies at the level of the upper edge of the symphysis.

Developmental defects genitourinary organs

Undescended testicle

The process of descent of the testicles into the scrotum begins in the 6th month of uterine life and usually ends by the time the child is born. However, according to various reasons one testicle (monorchidism) or both (cryptorchidism) may be delayed in its path. The most common places where they stop is the abdominal cavity or inguinal canal. Sometimes there is ectopia of the testicles in the perineum, thigh, and pubis.

Operations for an undescended testicle are performed at the age of over 2 years, since before this period there are cases of late self-descension of the testicle. The testicle is lowered into the prepared bed in the empty half of the scrotum using a long thick silk ligature, both ends of which are passed on a needle (from the bed side) through the bottom of the scrotum outward. The ends of the ligature are fixed on a gauze roller. To hold the testicle in a retracted position, the ends of the ligature are tied to a rubber ring attached to a plaster splint applied to the lower limb for a period of 2–3 weeks.

Malformations of the urethra

Epispadias – absence of the upper wall of the urethra:

1. epispadias of the head;

2. epispadias of the penis;

3. total epispadias, when a completely open urethra is combined with splitting of the symphysis.

The last two types of epispadias are usually accompanied by urinary incontinence. In girls, epispadias can be expressed as clefting of the urethra, clitoris and labia minora.

For epispadias, surgery is performed at 5–6 years of age. It involves the creation of a normal urethra, and in cases accompanied by urinary incontinence, the restoration of the bladder sphincter.

Hypospadias is the presence of an external opening of the urethra on the lower surface of the penis:

1. hypospadias of the head;

2. hypospadias of the trunk;

3. hypospadias of the scrotum.

For hypospadias, the operation is performed at 1.5–2 years and solves two problems: straightening the penis and forming the missing distal segment of the urethra. To solve the first problem, the rudimentary urethra and fibrous tissue are excised, followed by plastic closure of the resulting defect. At the second stage of the urethroplasty operation, different ways: using local tissues (skin of the penis and scrotum) using the free plastic method and the method of using the Filatov stem. Phimosis is a narrowness of the opening of the foreskin. As the child grows, a number of complications may develop: difficulty urinating, inflammation of the inner layer of the foreskin and glans, paraphimosis. Fusion of the labia minora is the development of loose adhesions between their edges, almost completely covering the entrance to the vagina, with the exception of small area in the upper section through which urine is excreted.

Features of the rectum in newborns and children

The rectum of newborns is filled with meconium. In children of the first years of life, it is thin-walled and relatively long: its division into anal and ampullary parts is not always clearly visible. The mucous membrane is weakly fixed, which explains its relatively easy loss.

Developmental defects

1. anal atresia;

2. rectal atresia;

3. atresia of the rectum and anus.

The outlet of the rectum can open into the bladder, into the urethra, into the vagina under the hymen, into the vestibule of the vagina, and also into the scrotum area. The first three types of atresia belong to the group of internal, and the last two - to the group of external.

With atresia anus newborns are subject to urgent surgery. The rectum is mobilized so that it extends 1–2 cm beyond the skin of the perineum. The rectum is opened in the transverse direction, its wall is sutured along the entire circumference to the muscles of the perineum, and the edges of the intestinal mucosa are fixed without tension to the skin of the perineum.

With rectal atresia, if its blind end is located above 5–7 cm from the skin of the perineum, it is not always possible to isolate and reduce the intestine through the perineal route. In these cases, the perineal wound is sutured and a fecal fistula is placed on upper section sigmoid colon. The sigma reduction operation is usually performed at about one year of age. If the newborn is in good general condition and there are no other developmental defects, a one-stage operation is performed using a combined peritoneal-perineal method. The intestine brought into the perineal area is opened, and its mucous membrane is sutured without tension to the edges of the skin. The intestinal wall is fixed to the perineal muscles with separate sutures.

Lecture No. 11. Topographic anatomy of the upper limb

Scapular region

The boundaries of the region correspond to the scapula.

Layer-by-layer topography

1. The skin is thick and inactive.

2. Subcutaneous tissue is poorly expressed.

3. Superficial fascia is dense

4. The proper fascia is thin and covers the trapezius and latissimus dorsi muscles. The deep layer of the proper fascia is dense, attached to the edges of the supra- and infraspinatus fossa and, together with the scapula, forms bone-fibrous containers for the muscles of the same name.

5. On the anterior (costal) surface of the scapula there is the subscapularis muscle and the tissue space.

The blood supply to the formations of the region is carried out by the suprascapular and subscapular arteries, and the transverse artery of the neck. The main nerves of the region are nn.suprascapularis et subscapularis.

Deltoid region

The boundaries of the area correspond to the deltoid muscle.

The skin is dense and inactive. The subcutaneous tissue and superficial fascia are followed by the fascia proper, which forms the sheath of the deltoid muscle and gives off spurs into its thickness. Under the muscle there is a subdeltoid cellular space in which the main neurovascular bundle of the region is located (a.circumflexa humeri posterior, anastomosing with a.circumflexa humeri anterior, veins of the same name and p.axillaris), muscle tendons and a synovial bursa.

Subclavian region

Region boundaries:

1. upper – collarbone;

2. lower - a horizontal line drawn through the third rib (in women - the upper edge of the mammary gland);

3. medial – edge of the sternum;

4. lateral – the anterior edge of the deltoid muscle.

Layer-by-layer topography

1. The skin of the subclavian region is thin and mobile.

2. Subcutaneous tissue is well developed and has a cellular structure. It contains cutaneous nerves (nn. supraclaviculares) from the cervical plexus, as well as the anterior and lateral branches of the intercostal nerves.

3. The superficial fascia is thin; in women, downward from the collarbone, it thickens and forms a ligament that supports the mammary gland.

4 The fascia itself forms a sheath for the large pectoral muscle and gives off septa into its thickness, which determines the isolated nature of purulent processes in the muscle. Between the pectoralis major muscle and the fascia clavipectoralis, which covers the pectoralis minor muscle, there is a superficial subpectoral tissue space where phlegmon can be localized. Pus penetrates under the pectoralis major muscle along the vessels and nerves that perforate its own fascia.

5. Fascia clavipectoralis attaches to the clavicle, coracoid process, ribs and forms sheaths for the subclavian and pectoralis minor muscles. At the lower edge of the pectoralis major muscle, it fuses with the fascia of the axillary fossa, forming a lig. suspensorium axillae. Under the pectoralis minor muscle there is a deep subpectoral cellular space. In the subclavian region, three triangles are distinguished, which are projected onto the anterior wall of the axilla (see below).

Axillary area

Region boundaries:

1. anterior – lower edge of the pectoralis major muscle;

2. posterior - the lower edge of the latissimus dorsi and teres major muscles;

3. medial - a line running along the IV rib and connecting the edges of the above muscles on the chest;

4. lateral - a line connecting the edges of the pectoralis major muscle and the latissimus dorsi muscle on the shoulder.

When the limb is abducted, the area looks like a hole or depression. After removing the skin, subcutaneous fat and fascia, the fossa turns into a cavity.

Layer-by-layer topography

1. The skin of the area is thin, mobile, covered with hair, contains a large number of apocrine sweat and sebaceous glands, during inflammation of which boils and hidradenitis can develop.

2. Subcutaneous tissue is poorly developed and is located in layers.

3. Superficial fascia is practically absent.

4. The fascia proper in the center of the region is thin and has numerous slits through which cutaneous vessels and nerves pass. At the edges of the cavity, it thickens and passes into the fascia that covers the muscles of the walls of the cavity and then passes into the fascia of the shoulder. After removing the native fascia, the muscles that bound the axilla are identified, which has the shape of a truncated quadrangular pyramid with the base facing downwards.

The walls of the armpit:

1. anterior - pectoralis major and minor muscles;

2. posterior - subscapularis, latissimus dorsi and teres major;

3. medial - the outer surface of the chest wall (up to the 4th rib) with the serratus anterior muscle;

4. lateral - medial surface humerus with the short head of the biceps muscle and the coracobrachialis muscle.

The contents of the armpit are:

1. loose fatty tissue;

2. a. axillaris with branches;

3. v. axillaris with tributaries;

4. Brachial plexus with nerves extending from it;

5. lymph nodes and vessels.

Anterior wall of the axilla

On the anterior wall of the armpit there are three triangles:

1. trig, clavipectorale (refers to the subclavian region) - limited by the clavicle, the upper edge of the pectoralis minor muscle, the base of the triangle faces the sternum;

2. trig, pectorale – corresponds to the contours of the pectoralis minor muscle;

3. trig, subpectoral – limited by the lower edges of the pectoralis minor and major muscles; the base of the triangle faces the deltoid muscle.

In accordance with the triangles, 3 sections are distinguished: a. axillaris. The 1st section belongs to the subclavian region, the 2nd and 3rd sections to the axillary region.

In trig, clavipectorale, the subclavian vein occupies an anteromedial position, bundles brachial plexus– lateral, the artery is located between the vein and the plexus bundles. The axillary artery gives off: a. thoracica suprema, a. thora-coacromialis. In trig, pectorale, the axillary vein maintains an anteromedial position. The axillary artery is located posteriorly and laterally. The brachial plexus is divided into lateral, posterior and medial bundles adjacent to the artery. In this section, a. departs from the axillary artery. thoracica lateralis.

In the trig, subpectoral vein lies medial to the artery. The nerves of the upper limb are formed from the bundles of the brachial plexus, surrounding the artery on all sides. In front of the artery is the median nerve, formed by two roots from the lateral and medial bundles of the brachial plexus. Posterior to the artery are the radial and axillary nerves from the posterior bundle of the brachial plexus. Outside the artery is the musculocutaneous nerve from the lateral bundle of the brachial plexus.

On the medial side, the branches of the medial bundle of the brachial plexus are adjacent to the artery: the ulnar nerve, the medial cutaneous nerve of the forearm, the medial cutaneous nerve of the shoulder.

From the axillary artery within this triangle depart: a. subscapularis is the largest branch, a. circumflexa humeri anterior and a. circumflexa humeri posterior. These branches participate in the formation of collateral pathways, anastomosing with the suprascapular artery and the transverse artery of the neck. This is the main intersystem bypass of the blood circulation during dressing a. axillaris. It is advisable to ligate the latter above the level of origin of the subscapular artery.

Posterior wall of the axilla

In the posterior wall of the armpit, two openings are formed through which blood vessels and nerves pass.

The four-way opening is limited by:

1. from above – by the edge of the subscapularis muscle;

2. from below – by the tendon of the latissimus dorsi muscle;

3. medially - the long head of the triceps muscle;

4. laterally – surgical neck humerus.

The axillary nerve and the posterior circumflex artery pass through this hole. The axillary nerve crosses an unreinforced portion of the shoulder joint capsule, which makes it possible for it to be compressed during shoulder dislocations. In case of fractures of the surgical neck of the humerus, the nerve may be damaged by a bone fragment and grow into the callus.

The three-way opening is limited by:

1. from above – the subscapularis muscle;

2. from below – by the edge of the latissimus dorsi tendon;

3 outside – by the tendon of the long head of the triceps muscle.

The artery that goes around the scapula passes through this hole.

Purulent processes localized in the subfascial cellular space of the armpit can spread:

1. on the back surface of the body in the scapular region through a three-sided opening;

2. into the subdeltoid space - through the quadrilateral foramen;

3. along the main neurovascular bundle in the proximal direction to the neck and in anterior mediastinum, in the distal – on the shoulder, forearm, hand;

4. through the fascia clavipectoralis along the vessels into the subpectoral space;

5. into the prescapular gap between m. subscapularis and the chest wall.

The lymph nodes in the armpit are located in the form of 5 groups connected to each other by lymphatic vessels.

1. Nodes on the lateral wall of the axilla.

2. Nodes on the medial wall of the axilla along a. thoracica lateralis. One (or several nodes) is located along the outer edge of the pectoralis major muscle on level III ribs and is called the sentinel node of Zorgius, since metastases in breast cancer are often found here.

3. Nodes on the posterior wall of the cavity, along the subscapular vessels.

4. Nodes in the center of the axillary fossa above and below the fascia proper.

5. Nodes in the trigonum clavipectorale, along the axillary vein.

Shoulder joint

The shoulder joint is formed by the head of the humerus and the glenoid cavity of the scapula. The articular capsule is attached along the edge of the scapula and along the anatomical neck of the shoulder. The joint capsule is free and forms a number of inversions (pockets): axillary, subscapular, intertubercular. The last volvulus is the synovial sheath of the tendon of the long head of the biceps brachii muscle. Inversions increase the volume of the joint cavity, thereby increasing the range of motion in the joint. At the same time they are weak points joint capsules, where there may be breakthroughs of pus when it is inflamed into neighboring areas.

The shoulder joint is weakly strengthened by ligaments; it is mainly strengthened by muscles. The inferomedial portion of the joint capsule is not covered by muscles, so dislocations most often occur in the axillary fossa.

Near the joint there are bursae: subdeltoid, subacromial, subcoracoid and subscapularis bursa (communicates with the joint cavity). These bags are shock absorbers during movements and are located between the bone (joint) on the one hand, and the muscle (tendon) on the other.

Shoulder area

Shoulder limits:

1. upper – a circular line connecting the lower edges of the pectoralis major muscle and the latissimus dorsi muscle;

2. lower - a circular line drawn 4 cm above the epicondyles of the humerus.

Lines drawn vertically upward from the epicondyles divide the shoulder into anterior and posterior regions.

Anterior shoulder area

1. The skin is relatively thin and mobile, innervated by the branches of the nn. cutaneus brachii medialis and intercostobrachialis.

2. Subcutaneous tissue is well expressed.

3. The superficial fascia has the appearance of a thin plate. In the lower third of the shoulder, it forms cases for the saphenous veins and cutaneous nerves.

4. The fascia proper is well defined, with intermuscular septa extending from the lateral and medial sides to the humerus. In this case, two fascial beds are formed: anterior and posterior.

Under the fascia proper are the muscles of the anterior region of the shoulder: coracobrachialis muscle; two-headed and brachialis. These muscles are innervated by n. musculocutaneus.

The main neurovascular bundle, consisting of the brachial artery, median nerve and the brachial veins run in the medial groove of the shoulder. In the upper third of the shoulder, the median nerve usually lies lateral to the brachial artery. In the middle third of the shoulder it crosses the artery anteriorly. In the lower third of the shoulder n. medianus passes medial to the artery. The median nerve does not give off branches on the shoulder. The brachial artery in the upper third of the shoulder gives off a large branch - the deep artery of the shoulder, which, together with the radial nerve, goes into the posterior fascial bed. At the border of the upper and middle third of the shoulder, the superior ulnar collateral artery departs from the brachial artery.

Posterior and medial to the brachial artery, the ulnar nerve passes in the upper third of the shoulder. At the border of the middle and lower third of the shoulder, it pierces the medial intermuscular septum and passes into the posterior muscle bed. Laterally from the brachial artery, under the deep layer of the fascia propria, the musculocutaneous nerve passes.

Posterior shoulder

1. The skin on the back of the shoulder is slightly thicker than in anterior section, innervated by the branches of the axillary (n. cutaneus brachii lateralis) and radial (n. cutaneus brachii posterior) nerves.

2. Subcutaneous tissue is more pronounced than in the anterior region.

3. The superficial fascia is thin.

4. Under the fascia proper is the triceps muscle, innervated by the radial nerve. Deeper than the muscle is the neurovascular bundle of the posterior region of the shoulder, consisting of n. radialis, a. profunda brachii (from the brachial artery) and two veins.

In the middle third of the shoulder, the vessels and nerve are located between the triceps muscle and the groove on the humerus (canalis humeromuscularis). A fracture of the humerus along this canal may be accompanied by damage to the deep brachial artery with the development of bleeding and damage to the radial nerve, which is manifested by the symptom of “drop wrist.”

In the lower third of the shoulder, the radial nerve pierces the external intermuscular septum and passes into the anterior fascial bed, where it is located between the brachial and brachioradialis muscles. Here he is accompanied by a. collateral is radialis (one of the terminal branches of the deep brachial artery).

The spread of purulent leaks on the shoulder is determined by the structural features of the fascial sheaths:

1. in the upper third of the region along the radial and ulnar nerves, the anterior and posterior cases communicate with each other; the anterior bed along the main neurovascular bundle and the sheath of the biceps muscle communicates with the tissue of the axilla;

2. in lower section The anterior fascial sheath of the shoulder communicates with the subfascial tissue of the ulnar fossa.

Elbow area

Region boundaries:

1. at the top – a circular line drawn 4 cm above the epicondyles of the humerus;

2. below - a circular line drawn 4 cm below the epicondyles of the humerus.

Vertical lines drawn through the epicondyles, reg. The cubiti is divided into an anterior (antecubital fossa) and posterior ulnar region.

Anterior ulnar region

1. The skin is thin and mobile.

2. The degree of expression of subcutaneous tissue varies and depends on individual characteristics.

3. The superficial fascia is well developed, forms cases for the saphenous veins and divides the fiber into 2 layers. In the deep layer there are n. cutaneus antebrachii medialis and n. cutaneus antebrachii lateralis, as well as superficial veins ulnar region – vv. cephalica, basilica, mediana cubiti. By connecting with each other, the veins form various forms of anastomoses. These veins are used for puncture and catheterization for diagnostic and medicinal purposes. Next to v. basilica usually contains branches n. cutaneus antebrachii medialis. This may cause pain during venipuncture.

4. The fascia proper in the ulnar fossa covers 3 muscle groups: external, middle and internal, and gives off two intermuscular septa - medial and lateral.

* outer group of muscles – m. brachioradialis, t. supinator.

* medial muscle group – (from the outside to the inside): m. pronator teres, m. flexor carpi radialis, m. palmaris longus, m. flexor carpi ulnaris, m. flexor digitorum superficialis.

* middle muscle group - biceps muscle and its tendon, terminal bundles of the brachial muscle.

Between medial and medium groups The muscles of the ulnar fossa are determined by the sulcus cubitalis anterior medialis, where the brachial artery with two accompanying veins and the median nerve are located.

1–2 cm below the line connecting the epicondyles, the brachial artery divides into the radial and ulnar arteries. The radial artery then passes in the groove between the pronator teres and the brachioradialis muscle. The ulnar artery goes into the gap between the superficial and deep flexor digitorum muscles. The median nerve emerges from the ulnar region, located between the two heads of the pronator teres.

Between the lateral muscle group and the tendon of the biceps brachii muscle, the sulcus cubitalis anterior lateralis is determined. n goes here. cutaneus antebrachii lateralis (continued musculocutaneous nerve), and in the depth of the groove - the radial nerve and a. collateralis radialis. The division of the radial nerve into superficial and deep branches occurs at the level of the head of the radial bone. The superficial branch of the radial nerve goes down to the radial groove of the forearm. The deep branch of the radial nerve is directed to the posterior region of the forearm, piercing m. supinator

Posterior ulnar region

1. The skin of the posterior ulnar area is thick and relatively mobile.

2. In the subcutaneous tissue at the level of the elbow joint there is bursa subcutanea olecrani.

3. The proper fascia is thickened, has the appearance of an aponeurosis and is involved in the formation of the posterior fascial bed of the forearm. It is fused with the condyles of the humerus and the posterior edge of the ulna.

Medial groove between olecranon and the medial epicondyle of the humerus contains the ulnar nerve and the superior collateral ulnar artery. The ulnar nerve here lies superficially under its own fascia, which is the cause of its frequent injuries (bruises, compression, dislocations, etc.).

The ulnar arterial network is formed by the branches of the brachial artery (aa. collateralis ulnaris superior et inferior), deep brachial artery (aa. collateralis radialis et media), radial artery (a. recurrens radialis), ulnar artery (rami anterior et posterior a. recurrentis ulnaris) and posterior interosseous artery (a. interossea recurrens).

Forearm area

Boundaries of the forearm area:

1. upper – a circular line drawn 4 cm below the elbow bend line;

2. lower - a circular line 2 cm above the distal skin fold of the wrist.

Anterior forearm

1. The skin of the anterior surface is thin, mobile, and easily folded.

2. Subcutaneous tissue has a layered, loose structure.

3. The superficial fascia is thin and forms containers for superficial vessels and nerves. The external cutaneous nerve of the forearm accompanies the external veins. The branches of the internal cutaneous nerve of the forearm accompany the trunks of v. basilica antebrachii.

4. The fascia proper is represented by a dense, thin sheet. It gives spurs to the radial, ulna bones and together with the interosseous membrane forms 2 muscle beds: external and anterior.

The external bed includes the brachioradialis muscle, extensor carpi longus and extensor carpi brevis. All muscles are separated from each other by thin fascial partitions.

The anterior bed is limited in front by its own fascia, and behind by bones and the interosseous membrane. It contains the intermuscular, muscular-interosseous gaps and Pirogov's cellular space (in the lower third). The anterior bed is divided into superficial and deep sections by a deep fascial layer.

In the anterior region of the forearm, the muscles are located in four layers sequentially in the direction from the outside to the inside:

1. 1st layer – brachioradialis, pronator teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris;

2. 2nd layer – flexor digitorum superficialis;

3. 3rd layer – flexor pollicis longus and flexor digitorum profundus;

4. 4th layer - only in the lower third of the forearm - pronator quadratus.

The vessels and nerves of the forearm are represented by 4 bundles: external, internal, median and anterior interosseous. The external bundle is located between the brachioradialis muscle and the flexor carpi radialis muscle in the sulcus radialis. In this groove are the radial artery, the paired veins accompanying it, and the superficial branch of the radial nerve, which lies lateral to the artery. At the border of the middle and lower thirds of the forearm, this branch passes to the posterior surface of the region.

The medial bundle (ulnar artery with two veins and the ulnar nerve) is located between the flexor carpi ulnaris and the flexor digitorum superficialis in the sulcus ulnaris. The ulnar nerve occupies a medial position relative to the artery.

The median bundle includes n. medianus and accompanying a. mediana (from the anterior interosseous artery). In the upper third of the forearm, the median nerve passes between the heads of the pronator teres, in the middle third - in the space between the superficial and deep flexor digitorum muscles. In the lower third of the forearm n. medianus passes between the tendons of the flexor carpi radialis and flexor digitorum superficialis, covered anteriorly by the palmaris longus tendon.

The anterior interosseous neurovascular bundle is represented by the anterior interosseous artery with 2 veins and the nerve of the same name. The artery gives off numerous branches to the muscles of the forearm and participates in the formation of the arterial network of the wrist.

Between the 3rd and 4th layers of muscles in the anterior part of the forearm there is a deep cellular space of the Pirogov forearm. It extends upward along the interosseous membrane to the origin of the deep flexor digitorum, and continues downward into the carpal tunnel. Purulent leaks from the middle fascial bed of the palm through the canalis carpi, from the radial and ulnar synovial sacs of the hand in complicated tendovaginitis can spread into Pirogov's space.

Features of the topographic-anatomical relationships of the middle and lower thirds of the forearm:

1. in the upper and middle thirds of the forearm, the neurovascular bundles are covered by muscles, in the lower third they lie superficially under their own fascia;

2. in the lower third of the radial groove of the forearm only the radial artery passes; in the upper and middle thirds of the forearm outward from it there is a superficial branch of the radial nerve;

3. in the ulnar groove the artery passes, accompanied by the corresponding nerve, only in the middle and lower thirds. With incised transverse wounds in the lower third of the forearm, as a rule, combined damage to the superficial veins and nerves in the subcutaneous tissue, tendons and main neurovascular bundles passing in the grooves is observed. Surgical treatment of such wounds often requires performing a vascular suture, suturing nerves and tendons, which causes certain difficulties.

Posterior forearm

1. The skin on the back of the forearm is thicker than on the front.

2. The dorsal tributaries vv pass through the subcutaneous tissue. cephalica et basilica. The branches of the lateral, medial and posterior cutaneous nerves of the forearm participate in the innervation of the skin.

3. The superficial fascia is poorly expressed.

4. The fascia proper is dense and is connected by numerous processes to the bones of the forearm. The muscles of the posterior forearm are located in two layers.

Superficial layer (from outside to inside): extensor carpi radialis longus; extensor carpi radialis brevis; extensor digitorum communis; extensor of the fifth finger; extensor carpi ulnaris.

Deep layer (from outside to inside): arch support; abductor pollicis longus; abductor pollicis brevis; extensor pollicis longus; extensor index finger.

Between the two layers of muscles there is a cellular space, limited on the sides by fascial partitions. In the space there is a neurovascular bundle of the posterior region of the forearm - a. interossea posterior with two veins and the deep branch of the radial nerve. Along the way a. interossea posterior, which at the distal end of the forearm pierces the interosseous septum and anastomoses with the anterior interosseous artery; the cellular space of the posterior surface of the forearm communicates with Pirogov’s space.

Wrist area

Region boundaries:

1. upper - a horizontal line drawn through the bases of the styloid processes;

2. lower - a horizontal line drawn through the pisiform bone.

Vertical lines drawn through the styloid processes divide the wrist into anterior and posterior regions. Bone base the wrists are made up of 8 bones arranged in 2 rows.

Anterior wrist area

1. The skin is thin, mobile, gathers in folds, and is devoid of hair.

2. Subcutaneous tissue is poorly developed. It contains the origins of v. cephalica, v. basilica, v. mediana an-tebrachii, terminal branches of the medial and lateral cutaneous nerves of the forearm, palmar branches of the median and ulnar nerves.

3. The superficial fascia is thin, loosely connected to its own fascia.

4. The proper fascia in this area thickens and is called the palmar carpal ligament. In front, the tendon of the palmaris longus muscle fuses with it. Down own link the wrist passes into the flexor retinaculum - retinaculum flexorum.

At the lateral edge of the pisiform bone is the ulnar carpal tunnel. It is a continuation of the ulnar groove of the forearm and is located between lig. carpi palmare and reti-naculum flexorum. The canalis carpi ulnaris contains the ulnar artery with veins and the ulnar nerve. The deep branch of the ulnar nerve is separated immediately as it exits the canal. Distally, the deep branch of the ulnar artery arises. Heading to the radial side, these vessels and nerves at the medial edge of the palmar aponeurosis pass into the median palmar bed. Through the ulnar canal of the wrist, it is possible for a purulent process to spread from the middle bed of the palm into the cellular space of Pirogov.

In the anterior region of the wrist, the median nerve and 9 finger flexor tendons pass through the canalis carpi (4 - superficial, 4 - deep flexor digitorum and the tendon of the flexor pollicis longus). The canal is formed by the palmar surface of the carpal bones, located in the form of a groove and the retinaculum flexorum, stretched between the outer carpal bones. The digital flexor tendons pass through the canalis carpi into the synovial sheaths (bags).

The radial synovial sac contains the tendon of the flexor pollicis longus; at the top it enters Pirogov's space, ending blindly. Downwards, the radial synovial sac ends blindly at the level of the base of the nail phalanx of the 1st finger.

The ulnar synovial sac, surrounding the flexor tendons of the fingers, continues distally along the tendons of the fifth finger and ends blindly at the base of the nail phalanx of the little finger. In the median bed of the palm, this bag ends at the level of the middle of the metacarpal bones. At the top, the ulnar synovial sac also enters Pirogov's space, where it ends blindly.

In some cases, the radial and ulnar synovial sacs of the digital flexor tendons at the level of the carpal tunnel communicate with each other. Therefore, with tendovaginitis, a transition of the suppurative process from one sac to another is possible (crossed or V-shaped phlegmon of the palm). A purulent process from the elbow sac can break into the deep cellular space of Pirogov.

Inflammation of the digital flexor tendons or thickening of the flexor retinaculum can lead to compression of the median nerve and the vessels that supply it—carpal tunnel syndrome. This can occur with professional overstrain of the fingers and hand (gymnasts, gardeners, builders, etc.), arthrosis of the wrist, tumors of the carpal tunnel, etc.

The radial canal of the wrist is formed by the splitting of lig. carpi palmare and contains the flexor carpi radialis tendon surrounded by a synovial sheath.

Posterior wrist

Under lig. carpi dorsale, thanks to the septa connecting the ligament to the bones of the wrist, 6 osteofibrous canals are formed. The canals contain extensor tendons, surrounded by synovial sheaths. The sequence of tendon placement from the lateral to the medial side of the wrist is as follows:

1. m. abductor pollicis longus et extensor pollicis brevis;

2. m. extensor carpi radialis longus et brevis;

3. m. extensor pollicis longus;

4. m. extensor digitorum et m. extensor indicis;

5. m. extensor digiti minimi;

6. m. extensor carpi ulnaris.

The radial artery, passing to the back of the hand under the tendons of the radial extensor carpi and the abductor muscle of the 1st finger through the “anatomical snuffbox”, gives off in the medial direction the dorsal branch of the wrist, which is involved in the formation of the rete carpi dorsale.

Brush area

Region boundaries:

1. at the top – a transverse line drawn at the level of the pisiform bone;

2. below – palmar-digital fold.

There is a distinction between the palm of the hand and the back of the hand.

On the palm, the eminence of the thumb (thenar) and the eminence of the little finger (hypothenar) are determined. Between these elevations there is a triangular depression with the apex facing proximally (corresponding to the shape and location of the palmar aponeurosis).

1. The skin of the palm is dense and has low mobility, as it is connected by fibrous septa to the palmar aponeurosis. The skin is rich in sweat glands and lacks hair and sebaceous glands.

2. Subcutaneous tissue is enclosed in cells limited fibrous cords, heading from the skin to the palmar aponeurosis, which contributes to the spread of purulent processes deeper. When there are skin defects, the edges of the wound on the palm of the hand gape, and it can be difficult to close them with sutures.

3. The proper fascia of the eminences of the thumb and little finger has the appearance of thin plates through which the muscles are visible. In the middle part of the palm it is represented by a triangular-shaped dense tendon plate - the palmar aponeurosis. The apex of the palmar aponeurosis faces the wrist and is fused with the lig. carpi palmare, tendon of the palmaris longus muscle and with the retinaculum flexorum.

4. The palmar aponeurosis consists of superficial longitudinal bundles going to the bases of the fingers and deep transverse fibers. The spaces between the bundles of the aponeurosis are called commissural openings. They are located opposite the II, III, IV interdigital spaces, are triangular in shape, filled with adipose tissue and correspond to the palmar pads on the skin. Through these holes subcutaneous tissue communicates with the palmar subgaleal space.

Sex differences in bony pelvis are already evident in a newborn child, the formed pelvis of which contains an abundant amount of cartilage between the centers of ossification and in their circumference. The pelvis of a newborn girl is lower and wider than the pelvis of a newborn boy, which is expressed relatively large size diameter of the pelvic inlet. The pubic arch of a newborn girl is also somewhat wider than that of a boy.

In general, a study of pelvises in newborn children showed completely different relationships in the size and shape of the pelvis in different genders. In addition to the degree of ossification, the newborn pelvis differs in many ways from the adult pelvis. The sacrum with its relatively narrow wings has an almost straight surface from top to bottom, and the place of its articulation with the last lumbar vertebra, located high above the entrance to the pelvis, protrudes only slightly in the form of a cape (promontorium). The anterior surface of the sacrum in both horizontal and vertical directions is devoid of concavity. The tailbone is curved slightly forward. The curvature of the spinal column in the lumbar and thoracic regions, in accordance with the absence of curvature of the sacrum, is insignificant. The iliac bones, located almost vertically, rise steeply upward and have only a slightly concave inner surface.

The shape of the child's pelvis, along with embryonic moments and growth energy, is influenced primarily by the pressure produced from the spinal column when sitting, standing and walking, the counterpressure from the lower extremities associated with the pelvic ring in the hip joints, as well as the pressure exerted from the iliac muscles. bones on the pubic symphysis.

Physiological kyphosis of the thoracic spine results in compensatory curvature of the lumbar part ( lumbar lordosis) and in addition determines the rotation of the sacrum around it horizontal axis, and the cape, under pressure from the body, moves down and forward. The apex of the sacrum, held in its lower parts by strong cords of the spinosacral and tuberosacral ligaments, cannot move back, which is why the entire sacrum must sometimes bend around its horizontal axis and thereby becomes concave in front. The sacral vertebrae are most strongly compressed in the back and are lower here than in the front.

If there is no burden from the spinal column, for example, when lying on the back for a long time, then the pelvis acquires features characteristic of the pelvis of a newborn. Under the influence of such factors, physiological curvatures of the spinal column and sacrum can be smoothed out, as well as increased tension of the pelvis in the transverse direction (recumbent pelvis). If, further, there is no back pressure from the thighs when existing pressure from the side of the spinal column, then the opportunity for the pelvis to expand in the transverse direction becomes disproportionately large. In the absence of a strong connection between the pelvic bones at the symphysis (split pelvis), the pelvic ring should gape widely in front.

Since the posterior ends of the iliac bones are connected to the sacrum by strong ligaments and, with a strong displacement of the promontory forward, must follow the movements of the sacrum, due to this the femurs acquire a tendency to diverge from one another and, as it were, tear the pelvic ring at the symphysis. As the symphysis resists the possibility of this rupture, it is also pulled back. Thus, the stretching of the pelvis in the transverse direction increases, while the anteroposterior size of the pelvic ring decreases accordingly. As a result, the pelvic entrance takes on a typical transverse oval shape with a promontory protruding from behind.

So, characteristic changes in the pelvis of a newborn consist of rotation and flexion of the sacrum, an increase in the transverse and a decrease straight sizes pelvis

If the pressure exerted by the torso is very significant, and the pelvis is too pliable due to the elasticity and softness of its walls, then with excessive transverse tension a narrowed pelvis is formed, the so-called flat pelvis. Similar to the emergence of such a pelvis, one can generally easily imagine the emergence of all sorts of narrow pelvises, and also trace the entire process of transformation of the pelvis of the fetus and child into a sexually mature pelvis.

If you are just planning a child, then modern medicine at the most early stages allows for PGD - preimplantation genetic diagnosis. This diagnosis will make it possible to identify many deviations at the gene level in the very initial period of embryo development.