Pelvic fractures present very severe injuries. According to various authors, they make up from 0.3 to 6% in relation to all fractures.

Classification of pelvic fractures

The various types of pelvic bone fractures can be combined into two main groups: 

1) fractures that do not violate the integrity of the pelvic ring,

2) fractures that violate the integrity of the pelvic ring.

The first group is divided into the following subgroups: 

1) transverse fracture of the sacrum;

2) tailbone fracture;

3) acetabular fracture;

4) transverse fracture of the ilium wing;

5) a fracture of one of the branches of the pubic or ischium;

6) fracture of the iliac crest;

7) fracture of the awns;

8) fracture of the tubercle of the ischium.

Fractures of the second group are divided into five subgroups: 

1) a vertical fracture of the anterior half ring:

a) a fracture of both branches of the pubic bone,

b) the pubic and ischial bones (single and bilateral);

2) vertical fracture of the posterior semicircle:

a) fracture of the iliac wing,

b) oblique and vertical fracture of the sacrum;

3) a double vertical fracture of the posterior and anterior half rings of the Malgen type ;

4) multiple fractures of the pelvic ring;

5) fracture -dislocation and dislocation of the pelvic bones.

When examining the pelvic area, you should use both hands to feel the right and left sides of the pelvis. In this case, you can feel the crests, anterior iliac spine, symphysis, ischium and pubic bones, ischial tubercles, sacroiliac joints, sacrum, tailbone. Such palpation allows you to determine the most painful places, the displacement of fragments, the asymmetry in the location of the bone protrusions, sometimes crepitus.
The main mass of the pelvic ring is covered with a large thickness of muscles and fatty tissue and is not accessible to palpation, therefore, examination and palpation should be supplemented by the identification of symptoms of transverse compression and rotation of the pelvis. Performing counter compression by applying pressure on the wings of the ilium and large trochanters and turning the pelvic ring by applying pressure on the crests of the ilium, the areas of greatest pain and the presence of fractures in deeply located pelvic bones are determined. The data obtained complement the comparative measurements and the study of limb function.

Violation of the function of the lower extremities is expressed the more, the more severe damage to the pelvis. In case of fractures that violate the integrity of the pelvic ring, the active function is always impaired: the patient cannot lift his leg and hardly bends its IB joints, dragging the heel along the bed. Examination of the patient can be supplemented by internal (rectal) examination, in which you can feel the bottom of the acetabulum, sacrum, coccyx and the area of ​​the pubic joint. Internal research should be resorted mainly to suspected central hip dislocation.

With acetabular fractures, symptoms typical of all intraarticular fractures are revealed: a sharp restriction of movement, pain, forced limb position. In cases where the fracture is complicated by a dislocation of the hip, symptoms typical of one or another type of dislocation are revealed.
With severe damage to the pelvis, the picture of shock comes to the forefront, which should be fought first of all (blood transfusion, warming, morphine, rest, etc.).

For all injuries of the pelvic ring, the clinical examination of the patient should be supplemented with radiography. An x-ray is taken in the anteroposterior direction, you need to shoot the entire pelvis. In addition, a profile picture is advisable in cases of suspected fracture of the sacrum or tailbone.

The anatomical and functional outcomes of treatment are of particular importance for pelvic fractures, since persistent violations of the normal anatomical structure of the pelvis and the relationship of its individual parts lead to severe, in most cases irreparable disability. In women, pelvic deformity can interfere with the normal course of “pregnancy and childbirth.

The indications for the use of various treatment methods for pelvic fractures should be based on the classification given. If fractures without a violation of the integrity of the pelvic ring, with the exception of certain types, have a favorable prognosis, then injuries of the second group that violate the continuity of the pelvic ring in connection with a difficult prognosis certainly require special treatment methods.
Of the first group, marginal fractures are most favorable. In these cases, seldom any significant displacements of the detached bone-periosteal fragment are observed, which, when so quickly grows together (3-4 weeks), without causing functional disorders. Only at large displacements, operational fixation of the fragment with (muscles attached to it at the place of separation is shown .

From the group of isolated pelvic fractures having a completely favorable anatomical and functional prognosis, acetabular fractures should be distinguished. These intraarticular injuries, although they do not violate the continuity of the pelvic ring, always threatened by the development of contractures, tugopodvnzhnosti even ankylosis of the hip joint, and therefore in need of early functional treatment.
at the turn of the bottom or roof vertluzh of the hollow without displacement of the femoral head shows early functional treatment by applying adhesive traction to the limb and performing therapeutic exercises from the first days of treatment.If the fracture of the bottom of the acetabulum is accompanied by a central dislocation or subluxation of the femoral head, the treatment should be directed to the direction of the latter, which is achieved removing the head from the pelvis and holding it in the correct position until the bottom of the acetabulum shadan is restored (2.5-3 months).

The most effective method of positioning and holding the femoral head is the method of constant traction using two skeletal rods, one of which is placed on a large trochanter, the second on the condyles of the thigh. Early functional therapy combined with a constant traction system provides a good anatomical and functional outcome. Therapeutic gymnastics for the injured hip joint is carried out for a long time in the supine position of the patient, since the limb load after the central dislocation of the thigh is allowed no earlier than 5 months from the day of the injury.

Fractures of the roof and the posterior edge of the acetabulum are often accompanied by a posterior dislocation of the thigh. In cases where the broken-off fragment is not prejudiced and is not an obstacle to the single-stage reposition head, a reduction should be made urgently, followed by (before fusion), use long extension for the final adhesive to prevent secondary displacement and ran- nyuyu gymnastics. In cases of infringement of the broken off fragment in the joint and failure when trying to simultaneously adjust the hip of the patient, you need to operate.

Fractures, fractures , disrupting the continuity of the pelvic ring, are the most severe multiple injuries, accompanied by a significant displacement of individual fragments, violating the shape and size of the pelvis.

The fragment separated from the pelvic ring under the influence of muscle traction is displaced in the cranial direction, which causes asymmetry of the right and left pelvic half and the relative shortening of the lower limb on the side of the displacement. Such a shift (in the absence of proper treatment will inevitably lead to severe irreversible disability; with rational treatment, the prognosis for both restoration of shape and function is quite favorable.

A powerful layer of muscles enveloping the pelvic ring, a small surface of the fracture planes and a plurality of fractures do not allow us to expect positive results from simultaneous reduction The only effective treatment for double vertical pelvic ring injuries is the skeletal method It provides restoration of the anatomical relationship, holding fragments in the position of achieved board, until the development of bone callus and restoration of normal function.The
extension is not limited to skeletal traction, but represents a system of traction, each of which has a specific purpose. on the side of the pelvic fragment displaced in the cranial direction This main traction eliminates longitudinal displacement with a load of an average of 8 kg.

To keep the body and main body of the pelvis in the correct position, glue traction is applied to the second leg. Traction control, which helps to reduce the displaced fragment, is created by raising the foot end of the bed (body weight) and applying a soft fixing loop through the inguinal region of the healthy side. In cases when a dislocation in the symphysis joins the fractures, after eliminating the displacement of the fragments along the length of the pelvis, the patient should be hung in a wide hammock loop.

Skeletal traction is stopped after l.5 months, replacing it with glue rods for another month. Crutches are allowed after 3 months, without crutches – 4 months after the injury. In cases of isolated discrepancy of the pelvis in the symphysis, which is a typical birth injury, the patient should immediately suspend the pelvis of the patient in a hammock for 6-8 weeks depending on the degree of displacement.

Recently, for chronic injuries, surgical treatment has been used, consisting in osteoplastic replacement of the defect formed in the pubic articulation and restoration of bone continuity of the pelvic ring.

Pelvic fractures, especially combined damage to the anterior half ring, can be complicated by damage to the bladder or urethra.

Bladder rupture occurs with pelvic fractures 5 times less often than rupture of the urethra.
With an intraperitoneal rupture of the bladder, dullness over the pubis is absent percussion , sharp pain in the symphysis region and above the pubis is noted, in addition, tension and pain in the lower abdomen. Symptom Brush, on-Blumberg pronounced. During catheterization, an insignificant amount of urine is released, often liquid blood and blood clots.
Urinary tract ruptures are less common in women than in men. There are partial or incomplete ruptures (ruptures of the mucous membrane of the urethra) and complete.

With a rupture of the urethra, sharp pains are noted in the middle of the perineum, dullness over the pubis. The bladder is domed under the abdominal wall. Convulsive contraction of the internal sphincter leads to urinary retention in the overflowing bladder. From the external opening of the urethra, drops are released. In the perineum and scrotum, hematomas are formed, reaching large sizes. When (catheterization of the urethra (before operation) does not pass the catheter into the bladder.

For a more accurate diagnosis is advisable to apply urethrogram by Rusanov , which is introduced into the urethra 10-20 ml of 40% solution sergozina penicillin and instantly produce a radiograph. Stepping beyond the limits of the boundaries of the urethra of the contrast medium indicate a rupture of the
canal.In case of damage to the urinary tract, one of the first, very important measures is surgery, apply mine after withdrawal (of a patient from a state of shock. This is primarily necessary to eliminate the possibility of urinary infiltration during extraperitoneal ruptures of the bladder or urethra and peritonitis during intraperitoneal ruptures of the bladder.

In all cases of intraperitoneal rupture of the bladder, laparotomy, suturing bladder wounds, sutures on the integument, and the insertion of a permanent catheter through the urethra and bladder.
With extraperitoneal ruptures of the bladder under local anesthesia, a suprapubic section of the bladder is produced, the wound is sutured if possible. A drainage tube is inserted into the suprapubic opening of the bladder to divert urine.

With ruptures of the urethra and the grave condition of the patient, surgical intervention should be limited to the imposition of suprapubic fistula. Restoring patency of the urethra is postponed for 11 / 2-2 months.
If the divergence of the edges of the torn urethra is small, the urethra is sutured above the catheter through the perineal wound, which is sutured. The catheter is left for 18-24 days.
A drainage tube is inserted into the cystotomy opening to divert urine. A purse string suture is placed around the bladder wall to seal the drainage.
Vaginal ruptures are accompanied by bleeding from the genital gap; they are most easily identified by inspection using a vaginal speculum.
Rupture of the rectum is rare. With a rupture of the rectum, sharp pain in the anus is noted. The nature and degree of rupture is easier to determine with a rectal mirror.
Disability after a pelvic fracture, accompanied by a rupture of the pelvic organs, is restored extremely slowly. The duration of treatment in the hospital is long, sometimes up to 4 months. A significant part of patients (about 65%) is transferred to temporary or permanent disability.

The prevalence of anorectal malformations

Anorectal deficiencies are observed in relation to 1:10 000 normal births. In 97% of children with these deficiencies, concomitant anomalies of other organs and systems are observed.

Rectal embryogenesis

The rectum, covered with a mucous membrane, develops with the endoderm of the primary intestinal tube, and its perineal part comes from the ectodermal funnel. They are separated by a cesspool, which perforates at 6-8 weeks of embryo development. Delayed perforation gives the bulk of congenital malformations of the rectum. The ectodermal funnel is combined not with the lower end – the apex, but with the front wall of the rectum. The end section of the embryo has a pronounced tail process, the thickness of which is deeper, more caudal than the anus, of the final intestine. This department was called the postanal gut. As the fetus develops, the caudal appendage atrophies, and the postanal intestine also decreases. The rectal cesspool of the vertical cloacal membrane drops in the frontal plane from top to bottom and is divided into two sections – the anterior urogenital ( sinus urogenitalis ) and the posterior rectal ( sinus anorectalis ). The membrane of the cesspool consists of two ectodermal plates – urogenital and rectal, with mesoblast tissue embedded between them . From the distal part of the membrane, the middle part of the perineum develops after the cloacal membrane lowers and separates the rectum from the urogenital region. In the mesoblast of the membranes of the cloaca, the sexual rudiments, consisting of male embryos from the Wolf channels, and in female embryos from the Mueller channels, pass. From these genital embryos, the internal and external male and female genital organs develop. In parallel with the development of the pelvic organs, the perineum is also formed. It is formed from two folds, rising on both sides of the cloaca.

Classification of anorectal malformations

Classifying anorectal malformations is quite difficult, and therefore there are numerous classifications of these shortcomings. In our practical work, we adhere to the classification of anorectal malformations after A. Penn. According to her, anorectal malformations in boys and girls are distinguished separately.

Anorectal malformations in boys:

Anal- skin fistula.
Anal stenosis
Anal membrane. In these defects, a colostomy is not indicated. Rectourethral fistula: • Bulbar. • Prostatic. Rectovesical fistula. Anorectal agenesis without fistula. Atresia direct kishki.Pri data vices shown overlay kolostomy.Anorektalnye defects in girls: Anal -kozhny (crotch) svisch.Pri this vice colostomy not shown. Vestibular fistula, vaginal fistula, anorectal agenesis without fistula, atresia of the rectum, persistent cesspool – with these malformations, a colostomy is indicated .

Anal- skin (perineal) fistula

An anal- skin fistula is a low variant of the anomaly. The rectum is usually localized within the sphincter mechanism. Only its low part is shifted forward. Sometimes the fistula does not open on the perineum, but continues in the form of an epithelial passage along the midline, opening anywhere in the suture of the perineum, scrotum, or even at the base of the penis. The diagnosis is made on the basis of a routine examination of the perineum, without any additional examination methods.

Anal stenosis

Anal stenosis is a congenital narrowing of the anus and is often combined with a slight displacement of the latter anteriorly. At the same time, meconium stands out in the form of a narrow strip.

Anal membrane

In this rare form, deficiencies in the site of the anus are a thin membrane through which meconium is visible . Treatment is a resection of this membrane, or, if necessary, anoplasty .

Rectourethral fistula

A rectourethral fistula can open in the urethra in its lower (bulbar) time- tini or in the upper (prostatic) section. Directly above the fistula of the rectum and urethra combined by a common wall, is of great importance during operations. The rectum is usually dilated and surrounded by levator fibers behind and on the sides . Between it and the skin of the perineum are the striated muscles that form the muscle complex. When these fibers contract, the skin surrounding the anal fossa rises. On the level of the skin along the midline on each side of it are so-called paras-gitapni muscle volokna.Pri low urethral fistula usually well-developed muscles, buttocks, and the medial sulcus anal fossa. With a rectourethral fistula, meconium is often released from the urethra – a clear indication of the presence of this variant of the defect.

Rectovesical fistula

With this form of flaws, the rectum opens into the neck of the bladder. The prognosis in such cases is usually unsatisfactory, since the levator , the muscular complex and the external sphincter are underdeveloped. Buttocks are often deformed and have signs of dysgenesis . Almost the entire pelvis is also underdeveloped. The crotch is usually sagging, with obvious muscle underdevelopment. Disadvantages include 10% of all anal atresias.

Anorectal agenesis without fistula

In most patients with this rare form of malformation, the buttocks and muscles are well developed. The rectum ends about 2 cm from the skin of the perineum. The prognosis for bowel function is good. Between the rectum and the urethra, even in the absence of a fistula, there is a common thin wall (which is important to consider with surgical treatment).

Rectal atresia

This form of deficiency occurs in 1% of all anorectal abnormalities. At the same time, boys have an extremely rare variant of defects, the rectum may end blindly (atresia) or narrow stenosis. The upper section of the rectum is widened, while the lower section is a narrow anal canal 1-2 cm deep. Atresized sections of the rectum the intestines can be separated by a thin membrane, and sometimes a layer of fibrous tissue. Usually, in such cases, all the anatomical structures are available that are necessary to ensure the normal function of the locking mechanism and the prognosis, accordingly, is excellent. Since the anal canal such children well razovyu- TII , and the sensitivity of the anorectal area completely preserved. Muscle structures are usually almost completely normal. Clinic of atresia of the rectum and anorectal agenesis General condition of the newborn on the first day remains satisfactory. From the second day symptoms of intestinal obstruction begin. Bloating builds up. The child becomes restless, crying. Vomiting appears first eaten food, and then meconium . Symptoms of intestinal obstruction progressively increase, and on 4-6 days from birth, if surgical care is not provided, the child dies. Diagnosis of rectal atresia and anorectal anagenesis. When diagnosing, it is important to decide the level of rectal placement.

The following methods are used:

• survey and sensing of the anus.
• Reception of Wangensteen – Kakovich ( invertogram ) – examination of a child in front of the X-ray machine in a suspended position upside down by legs. The distance between the gas bubble in the rectum and perineum skin give the level of occurrence of colorectal
• puncture method of diagnosis with MB. Sitkovskiy – punktuyut crotch needle until IU The horse with the blind end of the rectum.

Then through the same needle is introduced iodo-LIPOL followed radiography distal colon kishki.Pervichnaya diagnosis of anorectal diseases in boys and the choice of method lecheniyaNovorozhdenny with anorectal anomaly: Acad disadvantages clinically clear (80-90%): crotch fistula, the fistula along the crotch seam, anal stenosis, anal membrane – minimum rear sagittal anorektoplastika newborn without colostomy “slack crotch”. meconium in the urine, the air in the bladder – colostomy – 4-8 weeks to exclude ities Leica Geosystems defects, ensure the normal development of the child, and then – holding the back sagittal anorektoplastika

Carrying invertogramy :

• If diastasis less than 1 cm – the minimum posterior sagittal anorektoplastika newborn without colostomy .
• If diastasis is more than 1 cm – colostomy – after 4-8 weeks, exclude concomitant defects, verify the normal development of the child, then perform posterior sagittal anorectoplasty.

In more than 80% of cases, examination of the perineum allows you to clearly determine the type of defect and decide on whether colostomy overlay . All those defects that are traditionally considered “low” require perineal anoplasty (minimal posterior sagittal anoplasty ) without protective colostomy .

These include: a perineal fistula with a subepithelial passage (with or without a) along the midline suture of the perineum, anal stenosis and an anal membrane. The presence of a sagging perineum or discharge with urine meconium is an indication for colostomy , which in such cases promotes intestinal decompression and ensures successful future suture healing after the main operation. After applying the colostomy, the child is discharged home. If the child develops well and does not have concomitant abnormalities (heart or gastrointestinal tract) requiring treatment, then re-hospitalization for posterior sagittal anorectoplasty is performed at the age of 1-2 months. Surgery in such young children requires more experience, while in older patients, surgery for anorectal malformations is no longer so complicated. That is why patients with such abnormalities are usually operated on at a later date (at the age of, as a rule, about 1 year).

The main intervention at the age of 1 month has important advantages. So, the child lives with a colostomy for a short period of time, the difference in the diameters of the proximal and distal intestines is not so pronounced in the closure of the colostomy , it is easier to carry out vascularization and significantly less psychological trauma to the child during various painful manipulations in the anorectal zone. But intervention in young children is possible only if the surgeon has the appropriate experience. In cases where urine diversion is indicated, it is necessary to conduct a urological examination before applying the colostomy . A colostomy and urine diversion should be performed simultaneously. Sometimes , according to clinical data, the surgeon cannot decide on the application of a colostomy . In such cases (less than 20% of all anorectal malformations in boys), an X-ray examination is indicated – invertography (a picture in the upside down position with a label in place of the missing anus).

A simple method is to study in lateral position when the child is placed face down and the pelvis is to be lifted . Examination should be carried out 16-24 hours after birth. By this time, due to insufficient filling of the intestinal loops and low intraluminal pressure, the air does not reach the distal intestines and therefore the results of the study cannot be reliable. In addition, meconium may come out of the urethra during the waiting period , which facilitates identification of the type of anomaly and eliminates the need for x-ray examination . If the height of the atresia, according to x-ray, more than 1 cm, then a colostomy is indicated . If the distance is less than 1 cm, then the defect can be regarded as low and then perineal surgery without protective colostomy is indicated .

Anal- skin (perineal) fistula

From a surgical and prognostic point of view, this frequent variant of the deficiency is the equivalent of a skin fistula in boys. With this form, rectal abnormalities are located inside the sphincter mechanism, with the exception of its lower part, which is anteriorly displaced. The rectum and vagina are well separated from each other.

Vestibular fistula

With this serious wadi, the prognosis in terms of bowel function is usually good if surgical treatment is correctly and competently performed. With this wadi, the gut opens directly behind the hymen on the eve of the vagina. Immediately above the fistula of the rectum and vagina are separated only by a thin common wall. In such patients, muscles and sacrum are usually well developed and innervation is not disturbed. However, in some cases, with this form of defect, the sacrum is underdeveloped. It is possible to accurately identify this form of defects on the basis of clinical data with the usual, but very diligent examination of the perineum and genitals of the newborn girl. Many pediatric surgeons successfully correct this flaw without a protective colostomy.

Vaginal fistula

This anomaly is very rare. Since the rectum is connected with the lower or upper part of the vagina with this liquid form of deficiencies, a diagnosis of this form can be made when meconium is released through the hymen in a newborn girl . A defect in the back of the hymen is another sure sign, which confirms the diagnosis. Anorectal agenesis without fistula in girls is much more common than in boys, and in terms of therapeutic tactics and prognosis it absolutely corresponds to the same variant of anomaly in boys.

Persistent cesspool in girls

A complex defect in which the rectum, vagina and urinary tract merge into a single channel. The diagnosis can be confidently made on the basis of clinical data. It can be suspected in cases where the newborn girl with atresia of the anus has very small genitalia. With careful dilution of the labia, a single hole can be seen on the perineum. The length of the common channel varies from 1 to 7 cm and is of great importance in terms of the technique of surgical intervention and relative to the prognosis. If the length of the common channel exceeds 3.5 cm, then this is usually the most difficult variant of the anomaly, in which various methods of plastic surgery of the vagina have to be applied. Sometimes the rectum opens high in the vagina. Quite often, the vagina is excessively stretched and filled with mucous secretion ( hydrocolpos ). An overstretched vagina squeezes the urinary bubble triangle, which often leads to the development of megaloureter . On the other hand, the presence of a large-sized vagina facilitates its plasticity. With cloacal defects, membranes or doubling of the vagina and uterus are quite common, expressed to varying degrees. In a similar situation, the rectum usually opens between two vaginas. With low cloacal defects of the buttocks, they are usually well developed, the perineum looks normal, the muscles are formed correctly and the innervation is not broken. Accordingly , the prognosis is often good.

This group includes unusual options for anorectal deficiencies, each of which is a rather difficult task for the surgeon, and the treatment methods, like the prognosis, are extremely diverse. It is clear that with mixed anomalies there cannot be a single “recipe”. Each case requires individual podhoda.Pervichnaya diagnosis of anorectal malformations in girls and choice of lecheniya

Novorozhdenny with anorectal anomaly inspection of the perineum: Fistula is (92%): 

• Cloaca (urgent assessment of the urinary system) – colostomy (at indications: vaginostomiya , urinary diversion) – conducting posterior sagittal anorectovaginourethroplasty .
• Vaginal or vestibular fistula – colostomy – posterior sagittal anorectoplasty .
• Skin (perineal) fistula – minimal posterior sagittal anorectoplasty in a newborn without a colostomy . No fistula (10%): 

Carrying out an invertogram :

• If the diastasis is less than 1 cm – the minimum posterior sagittal anorectoplasty in a newborn without a colostomy .
• If diastasis is more than 1 cm – colostomy – after 4-8 weeks, exclude concomitant malformations, verify the normal development of the child, then conduct posterior sagittal anorectoplasty . 

In girls, a review of the genitals provides more information about the nature of the defect than in boys. If when examining the genitals, only one hole is determined, then this indicates the presence of cloaca. In this case, it is urgent to conduct a urological examination to exclude concomitant defects. After this, a colostomy and / or vagiostasis is applied , as well as a cystostomy or some other variant of urine diversion. The main stage of surgical treatment of cloaca is called posterior sagittal anorectovaginos-urethroplasty and is usually performed after 6 months of age . Girls with anorectal problems of tumor formation in the lower abdomen are pathognomonic for hydrocolpos . In this case, it is necessary to drain the vagina by tubular vaginostomy , which allows the urethra to defecate freely in the bladder. Identification during examination of the perineum of a vaginal or vestibular fistula is an indication for colostomy . However, since these fistulas are often quite good enough to empty the intestines, there is no urgency in applying a colostomy in this situation. In such cases, the child can be discharged home, and if it grows and develops normally, then a colostomy is applied two weeks before the main operation. 

If girls have a skin fistula, the tactics and prognosis are the same as for boys with this form of vice. Girls with an atresia of the anus, in which meconium does not leave within 16 hours after birth (from the genitals), should be examined radiologically ( invertogram ). Treatment is carried out according to the same principles as for boys with these types of anomalies. Urological examination of each child with an atresia of the anus should include ultrasound of the kidneys and the entire abdomen to exclude hydronephrosis or other deficiencies accompanied by impaired urine outflow. If abnormalities are detected during ultrasound, then a further in-depth urological examination is necessary.