The frequency of injuries and damage to the pelvis. During the Great Patriotic War, gunshot wounds of the pelvis were found in 3.8-4% of the wounded. Foreign medical statistics unites in one group injuries of the pelvis, kidneys and urinary tract. Nevertheless, in the first and second world war, injuries of these organs were noted in no more than 5% of the wounded. According to the materials of the American war in Vietnam, the average damage mentioned was 4.5% (O. Salvatiera , T. Oschner , F. Busch , 1969). Thus, the percentage of injuries of the pelvis, kidneys and urinary tract during the last wars remains stable. Closed pelvic injuries were rare in past wars. However, it can be assumed that with the use of nuclear weapons, the number of closed pelvic injuries will increase significantly. Closed pelvic injuries with and without damage to the continuity of the pelvic ring and pelvic organs In the group of closed pelvic injuries, soft tissue injuries are distinguished, as well as closed pelvic bone fractures with or without damage to the pelvic organs. Pelvic bruises are sometimes accompanied by the formation of subcutaneous hematomas or skin detachment. Perineal bruises can be complicated by urethral ruptures. Among the closed injuries of the pelvic bones, there are: 1) isolated fractures of the pelvic bones without violating the integrity of the pelvic ring; 2) pelvic fractures with a violation of the integrity of the pelvic ring; 3) double vertical fractures of the pelvic bones; 4) pelvic fractures with damage to the pelvic organs. 1. Fractures of the pelvic bones without violating the continuity of the pelvic ring are mild.
These include: fractures of the iliac wing, fractures of the sacrum below the sacroiliac joints, tailbone fractures, the remains of the ilium, isolated fractures of one of the branches of the pubic or ischium, fractures of the edge or bottom of the acetabulum, fracture of the sciatic tubercle, etc. Such fractures usually occur with the direct mechanism of injury, when the force of the traumatic agent is directed directly to the surface of one of the bones of the pelvis. Symptoms: pain in the fracture area (in the pubic area – with a fracture of the pubic bone, in the perineum – with a fracture of the sciatic bone, etc.), aggravated by leg movements. Pelvic compression in the lateral and anteroposterior directions, palpation of the pubis, sciatic tubercle, iliac spine, etc., gives pain in the fracture area. Sometimes in the fracture zone, swelling can be detected. In case of fractures of the sacrum and tailbone, a digital examination of the rectum is necessary. X-ray of the pelvic bones confirms the diagnosis of a fracture. 2. Fractures with a violation of the continuity of the pelvic ring are classified as severe injuries. They are often accompanied by traumatic shock and damage to the pelvic organs, internal bleeding into the retroperitoneal tissue. There are single and bilateral fractures of the pubic and sciatic bones, vertical iliac fractures near the sacroiliac joint, a double vertical pelvic fracture in which the pelvic ring breaks in the anterior and posterior parts ( Malgaigne fracture ), pelvic dislocation fracture – rupture of the pubic symphysis and vertical fracture of the posterior half ring, rupture of the sacroiliac joint and fracture of the anterior semiring. With fractures of the anterior pelvic ring (fractures of both branches of the pubic bones, horizontal branches of the pubic bone and ascending branches of the ischium), severe pain in the inguinal region and perineum is noted. The function of the lower extremities is impaired.
When the pelvis is squeezed laterally ( Vernewil symptom ) due to simultaneous pressure on the wings of the ilium, or dilution of the latter ( Larrey symptom ), the pain intensifies. The legs are bent at the knee and hip joints and slightly divorced. The patient cannot lift a leg straightened in the knee joint (symptom of a “sticking heel”). This symptom is explained by the fact that the ileo-rib muscle of the lower back, and the ileo -lumbar muscle during contraction lead to the displacement of fragments, causing sharp pain. With bilateral injuries, the mentioned symptoms are expressed on both sides and more distinctly. When double vertical fractures and perelomovyvihah pelvis marked asymmetry of the pelvis, an apparent shortening of the limb on the side of damage due to displacement under the action of thrust iliopsoas muscles, iliopsoas-costal lumborum, square thigh muscles and oblique muscles of the abdomen damaged half pelvis with limb in the cranial direction. The limb is somewhat reduced and rotated outwards; the anterior superior spine on the lesion side is higher than on the healthy one. This is determined both by a comparative examination of the patient in a supine position, and by comparatively measuring the distance from the base of the xiphoid process of the sternum to the right and left front upper spine. With a rupture of the pubic symphysis, the legs are bent at the knee joints, the hips are shown. When you try to dissolve their pain intensifies, it is especially severe when combining a rupture of the pubic symphysis with a fracture of the bones of the anterior half ring.
The symptom of a “sticking heel” is noted, as with an isolated fracture of the anterior half ring. With pelvic fractures, with a developed vasculature, there may be hemorrhages in the perineum or in the inguinal region. Imbibition of subcutaneous tissue and skin with blood is detected in the first hours or a day after an injury. Similar bruising, only more common, also occurs with fractures of the posterior pelvic half ring. Abundant hemorrhages during fractures of the pelvic bones are due to the fact that the damaged intrathoracic vessels do not subside and the fracture site constantly bleeds. Significant bleeding occurs with fractures of the posterior pelvic ring, where the pelvic bones are more massive. The spilled blood, accumulating in the fiber, leads to the formation of extensive retroperitoneal hematomas, often simulating a picture of an “acute abdomen” – the abdomen is swollen, tense and painful, and stool and urination are delayed. With percussion – dullness of the sound in the lower abdomen, the symptom of Shchetkin-Blumberg ( Blumberg ) is positive. The hemoglobin and hematocrit values at the beginning of the formation of such retroperitoneal hematomas may not be changed, but in a later period anemia that is persistent and permanent in nature increases. With unilateral and bilateral complete fractures of the pelvic ring, a symptom of Volkovich may be noted: the hips are slightly open , the lower extremities are rotated outward and slightly bent at the knee and hip joints (frog pose). The clinical picture of a rare vertical iliac fracture with splitting of only the upper edge of the acetabulum ( Duverney type fracture ) is characterized by a partial preservation of active movements and a significant amount of passive movements in the hip joint, which does not happen with fractures with disruption of the pelvic ring. The nature of the displacements of the fragments and the morphology of the fracture are specified radiographically. 3. Pelvic fractures complicated by damage to the pelvic organs average 15% of all pelvic fractures. Displaced fragments of the ascending branches of the sciatic bones and descending branches of the pubic bones most often damage the urethra and bladder, less often the prostate gland. With fractures of the left iliac bone and the left half of the sacrum, the rectal ampoule can be damaged. Damage to large vessels during pelvic fractures is accompanied by large (1.5-2 l) blood loss. Clinic.
The condition of the victims is usually severe. Symptoms of acute blood loss and traumatic shock prevail. When ruptured or squeezed by fragments of the anterior half of the urethra or neck of the bladder, there is a delay in urination. Ruptures of the urethra can be full or partial. In both cases, there is a delay in urination, the bladder is full, the patient is worried about the frequent inconclusive urge to urinate. An enlarged bladder is palpated above the pubic symphysis. With extraperitoneal ruptures of the bladder, urine infiltrates the pelvic tissue, then urinary leakage can spread to the perineum, hips and buttocks, causing purulent-septic complications over time. With intraperitoneal ruptures of the bladder, urine enters the abdominal cavity, which leads to the development of peritonitis. A digital examination of the rectum facilitates the diagnosis of pelvic fractures and related injuries.