Fracture of the pelvic bones consequences. Treatment of pelvic fractures and rehabilitation rules. Marginal fractures of the pelvic bones

The pelvic bones are the main supporting complex of the human body., interconnected by powerful ligaments and well covered with a massive layer of muscles. To break the pelvis, you need to apply a lot of force, so isolated pelvic fractures are observed only in 13-38.2% (Pohlemarn T., 1998, Lazarev A.F., 1992), and in other cases they are observed in patients with combined and multiple trauma as a result of car accidents and falls from a height.

For practical purposes, we have separated everythingpelvic fracturesinto two groups, the tactics and treatment techniques of which are fundamentally different. Group 1 includes fractures of the anterior and posterior semirings of the pelvis, ruptures pubic symphysis and sacroiliac joint. These fractures account for about 80% of all injuries (according to our data - 78%). Group 2 includes fractures and fracture-dislocations of the acetabulum (22% of all pelvic injuries).

All pelvic injuryand the acetabulum, we classified according to the accepted international system AO / ASIF. This classification, now known as the AO classification, was based on the Tile (1987) and Letournel (1981) pelvic and acetabular injury classification systems, which were updated by the AO group in 1990.

This classification is universal, taking into account the direction of action of displacing moments, the localization and nature of damage to the ligamentous apparatus and the stability of the pelvic ring, which greatly facilitates the diagnosis and selection of the optimal method of treatment. In accordance with the classification, pelvic injuries are divided into 3 types (Fig. 3-2).

. Type A fractures are stable, with minimal displacement and, as a rule, without disruption of the integrity of the pelvic ring.

Type B fractures - the so-called rotationally unstable (but vertically stable), arising from the effect of lateral compression or rotational forces on the pelvis.

Type C fractures - injuries with rotational and vertical instability, s complete break pelvic ring.

According to this scheme, anatomical damage divided according to the degree of stability in relation to the entire pelvic ring (Fig. 3-3).

A - all fractures without damage to the pelvic ring. This is a detachment of the anteroposterior or anteroinferior iliac crest, fractures of the ischial tuberosities. Type A2 includes unilateral or bilateral fractures of the pubic and ischial bones, but without displacement of the fragments, therefore, with preserved, in stable condition pelvic ring. Type A3 includes transverse or marginal fractures of the sacrum and coccyx, both without and with minimal displacement. The integrity of the pelvic ring is also not violated.

C - injuries are characterized by rotational instability. At the same time, the ligamentous complex of the posterior pelvis and bottom remains intact or partially damaged on one or both sides.

Type B1 fractures are called open book injuries. external rotation. Both halves of the pelvis are unstable, deployed on one or both sides, and the pubic symphysis is torn.



Rice. 3-2. The principle of classification of fractures and ruptures of the joints of the pelvis according to Tile-AO-ASIF.


If the pubic articulation has diverged within 20-25 mm, then, as a rule, only the ligaments of the pubic symphysis are torn. With a greater divergence, the sacroiliac ligaments are necessarily damaged.




Rice. 3-3. Classification of fractures and ruptures of the joints of the pelvis according to Tile-AO-ASIF.


In type B2 injuries, there is a rupture of the sacroiliac ligaments on one side with a fracture of the pubic and ischial bones of the same half of the pelvis. In this case, the pubic symphysis can be both preserved and torn, more often in the anteroposterior direction. A sacral fracture may occur posteriorly, but there is no vertical displacement of the pelvic ring.

Bilateral fractures of the posterior and anterior half-rings of the pelvis, as a rule, with a rupture of the pubic symphysis of the "open book" type, are classified as VB.

C - anatomically severe injuries with rotational and vertical instability. They are characterized by complete rupture of the pelvic ring and floor, including the entire posterior sacroiliac ligament complex. The displacement of the pelvic ring is already occurring both horizontally and vertically. And with fractures of type C2 C3, the displacement occurs in the anteroposterior direction. In type C1 injuries with severe unilateral displacement, there may be a unilateral fracture of the ilium, a fracture-dislocation in the sacroiliac joint, or a complete vertical fracture of the sacrum.

In type C2 injuries, destruction of the pelvic ring is more significant, especially in the posterior regions. Completely, with displacement, the ilium and sacrum are broken, the posterior displacement is more than 10 mm.

Type C3 injuries are necessarily bilateral, with a more significant displacement of one half of the pelvis in the anteroposterior direction, and also in combination with a fracture of the acetabulum.

Acetabular fractures are also divided into 3 types (Fig. 3-4). Type A - fractures extend to the front or (more often) back of the articular surface. Bone fragments of the acetabulum are localized within only one column of the pelvis - anterior or posterior. In all 3 groups of this type of fractures, the articular surface of the cavity does not have significant damage.

Type B - the fracture line, or at least part of it, is located transversely. Part of the articular surface always remains connected with ilium. Transverse fractures can be T- and U-shaped. If with fractures of types B1 and B2, displacements occur only in the zone of the acetabulum, then with injuries of type B3, the pelvic column or ilium is included in the fracture zone.

Type C - fractures of both columns and the corresponding parts of the articular surfaces of the acetabulum. There are significant anatomical lesions extending to the pelvic bones. In type C1 injuries, the fracture line extends to the ilium. In type C2 injuries, the separation of bone fragments occurs along the anterior border of the entire ilium and the anterior column. If the sacroiliac joint and the sacrum are involved in the fracture zone, then these injuries belong to the most life-threatening type for the patient - SZ, since they are accompanied by significant bleeding from the presacral vascular plexuses.



Rice. 3-4. Classification of acetabular fractures according to Letournel-AO-ASIF.

Observational practice has shown that overall structure injuries of the pelvic ring, there is an absolute increase in the anatomically most severe fractures of the pelvis and acetabulum, which are classified according to the international AO system as injuries of types B and C.

Since the pelvic bones and the soft tissues surrounding them are well supplied with blood, a pelvic injury is accompanied by blood loss, reaching 2-3 liters or more. In this regard, pelvic fractures are a fairly significant shockogenic factor.

If there are fractures of the anterior half-ring of the pelvis, the outflow of blood is localized in the anterior part of the small pelvis in the paravesical tissue and through the obturator openings and adductor muscles goes to the inner surface of the thigh. With ruptures of the pubic symphysis, the hematoma is located between the divergent pubic bones and extends to the perivesical tissue, perineum, and also to the tissue surrounding spermatic cords in men in the scrotum. In this case, the scrotum can reach the size of a soccer ball, since loose fiber does not prevent the free circulation of blood. In women, the hematoma spreads along the round ligaments to the labia and perineum.

Displaced fractures of the ilium and sacrum cause damage not only to intraosseous vessels, but mainly to numerous venous plexuses surrounding the pelvic bones and muscle vessels. The outflowing blood spreads into the retroperitoneal tissue, which is quite loose and does not interfere with the free distribution and accumulation of blood, resulting in the formation of the so-called retroperitoneal hematoma. In the retroperitoneal space, the anterior and posterior sections are distinguished: the anterior is located anterior to the fascia praerenalis and its anterior wall is the posterior leaf of the peritoneum, and the posterior is posterior to the fascia refrorenalis, and back wall his are the psoas muscles (Figure 3-5).

In the anterior retroperitoneal space there are retroperitoneal organs - the kidneys, pancreas, part of the duodenum and the ascending and descending parts of the colon, and in the posterior - the iliac vessels, the aorta and the inferior vena cava.

With displaced fractures of the large pelvis, the hematoma spreads for the most part along the posterior retroperitoneal space. Hematomas of the anterior retroperitoneal space are more typical for damage to the kidneys and pancreas. Imbibition of both retroperitoneal spaces occurs with multiple fractures of the pelvic bones.

Rice. 3-5. Topography of the retroperitoneal space. A - sagittal section through the right kidney. In - the same, through left kidney. Designations: 1 - liver; 2 - fascia praerenalis; 3 - fascia refrorenalis; four - right kidney; 5 - duodenum; 6 - capsula adiposa; 7 - abdominal cavity; 8 - caecum; 9 - pancreas; ten - sigmoid colon; 11 - left kidney.

There are large, medium and small retroperitoneal hematomas. Large hematoma reaches the upper pole of the kidney, the middle one - to the lower one, the small one does not pass the level of the anterior superior iliac spines. Blood from the anterior retroperitoneal space may leak into the abdominal cavity, causing a picture acute abdomen. Unlike hemoperitoneum, due to an injury to the abdominal organs, the amount of blood is no more than 300-500 ml and it appears 2 hours or more after the injury.

Local damage to the acetabulum, as a rule, does not cause the formation of retroperitoneal and preperitoneal hematomas.

The spilled blood is concentrated in the area of ​​the hip joint and under the gluteal muscles. The volume of the hematoma is much smaller due to the limited space for its spread: on the one hand, as this is prevented by the pelvic bones and the muscles that line them, and on the other hand, by the muscles surrounding the hip joint from the outside and the strong low-stretch wide fascia of the thigh.

The frequency of extra-pelvic injuries in patients with pelvic fractures is presented in Table. 3-3 (our data).

Table 3-3. Associated injuries (in%) in patients with trauma to the bones and joints of the pelvis.

Hello dear site visitors! The hip joint connects the thigh bone to the pelvic bone. This is the largest joint in human body and therefore its fracture is fraught with great difficulties.

Often a fracture in the hip joint occurs in older people. This happens due to a decrease in activity in the body, a violation metabolic processes and the occurrence of various inflammatory processes.

In this case, damage to the upper parts of the thigh occurs. In old age, treatment takes much longer.

Before you know what to do in such a situation, it is worth understanding the main causes of a crack.

Here they are:

1. Injuries or fractures often occur in people over 55 years of age. At the same time, the risks of complications increase.
2. Women are more susceptible to such damage than men. In this case, the higher the growth, the more likely to get injured.
3. Strong physical activity.
4. Problems arise in patients with inflammatory diseases joints and bones. With age, the risk of developing arthrosis, arthritis or osteoporosis increases. These diseases soften bones. However, even a minor injury can cause negative consequences.

At a younger age, such an injury can occur, for example, after a car accident. Risk factors include impaired coordination, neurological disease, and impaired coordination.

In old age, high fragility of bones is manifested.

Trauma symptoms

In people with little pain threshold It could just be a dislocation or a sprain.
An accurate diagnosis can only be made by a doctor.

But there are some characteristic features:

1. In the prone position, the foot is unnaturally turned outward.
2. When moving the foot to its normal position, severe pain is felt.
3. The pain is felt even when tapping the heel.
4. Can't lift heel.
5. With a fracture of the neck, there is intense pain in the groin.
6. During the examination, there is a strong pulsation of the artery, which runs in the thigh area.

All these manifestations cannot be ignored. After all, the bones can grow together incorrectly and the fracture will end in disability.

Bruising or bruising may occur several days after the injury. A fracture occurs at the head of the femur.

Because of what, the spit of the femur can also suffer.

First aid

Many people wonder if it is possible to walk with such an injury. In fact, before the doctor arrives, the patient cannot be moved on his own at all. You must immediately call an ambulance.

If there is bleeding, then you need to apply a tourniquet from improvised means. In this case, you can not disturb the place of injury.
Here are some recommendations:

1. The injured limb is fixed in one position, without shifts.
2. It is important to achieve immobilization of the leg with a special splint or even a stick or branch.
3. The joints of the leg and pelvis must be secured.
4. To get rid of pain, you need to take analgesics.

Features of treatment

The duration of treatment also depends on this.
Conservative methods are often used for uncomplicated fractures in children or young adults. This provides immobilization of the joint and traction with a special device.

This allows you to keep your foot in the correct position.
Treatment in a child or in an adult necessarily implies a lack of load. Unlike a bruise, in this case, bed rest may be indicated. for a long time- up to six months.

Also appointed.
In difficult situations, you need surgical intervention. The operation can significantly reduce after injury. Endoprosthetics or bone autoplasty can reduce the risk of complications.

Folk methods

Folk remedies are used as an addition to the main treatment, as well as to protect against the occurrence of diseases that may appear after an injury.

For example, you can prepare a decoction that strengthens cartilage. To prepare it, you need to take in equal parts willow bark, burdock root, birch leaves, parsley roots and linden flowers. The dry mixture must be poured hot water and bring to a boil. The infusion should be drunk twice a day.

Rehabilitation

The recovery period depends on the state of the body and on how accurately the patient follows the recommendations of the doctor.

Crutches are used to relieve pressure on the joint.

Exist following methods rehabilitation:

1. performed with the permission of a doctor. Motor activity begins with torso flips. Then breathing exercises are applied.
2. Physiotherapy and special.
3. Chondoprotectors and calcium preparations are prescribed that support cartilage tissue.

Massage is able to improve blood circulation and lymph outflow, and also protects the limbs from the occurrence of bedsores.

In addition, it is a preventive measure against pneumonia. Massage helps to normalize muscle tone and prevent muscle atrophy.
And therapeutic exercises prevent the occurrence of complications and is the prevention of osteoporosis.

Complexes of exercises for patients are selected individually, taking into account personal characteristics.

Proper nutrition is also necessary. The diet should include foods rich in calcium. These are greens, cheese, cottage cheese and dairy products.
Even after complex fractures, joints can be fully restored, so do not despair if this happens.

It is important to follow all medical recommendations and regularly engage in recovery procedures.

A pelvic fracture is an extremely severe type of injury due to pain and a high degree of blood loss.

Very often, this injury is accompanied by pain shock. The presence of multiple fractures in this area in 50% of cases can cause lethal outcome.

What causes a fracture?

Most of all, the pelvic bones are prone to injury in the elderly (due to their fragility due to calcium leaching), as well as in professional athletes.

In addition, there are a number of factors that can cause this type of damage. These include the following:

• falling from a great height;
• transport accident, which leads to compression of the pelvic region;
• collision of a car with a pedestrian, in case of impact of the victim by the protruding parts of the car;
• industrial injuries;
• the presence of chronic osteoporosis;
• rail injuries.

How to determine damage?

Bone fractures are accompanied by numerous manifestations that allow you to quickly diagnose the type of injury. These manifestations largely depend on the type and severity of the fracture. To general external manifestations the following characteristic factors can be attributed:

• the occurrence of an extensive hematoma;
• swelling of the injury site;
• strong pain;
• deformation of the pelvic region;
• pain shock followed by sharp decline blood pressure and an increase in heart rate (occurs in 30% of victims);
• bleeding;
• Verneuil's symptom - pain that occurs with minimal compression of the pelvic region.

separate, specific signs This injury is largely due to the severity and type of fractures. Depending on the location of the injury, the following symptoms may occur:

1. In the event of an injury to the symphysis, the patient can bend the legs, but this process is accompanied by sharp pain, moreover motor functions limited.
2. Pain in the ilium is observed with damage to the upper pelvic region.
3. In case of violation of the integrity of the pelvic ring, the victim experiences severe pain in the perineal region with a tendency to increase when moving or pressing on the pelvic region.
4. Disorders of the functioning of the hip joint, which may be accompanied by severe pain, are characteristic of fractures of the so-called acetabulum.
5. In cases of coccygeal lesions, there are difficulties in the process of defecation, lack of gluteal sensitivity, urinary incontinence, sacral pain.
6. With a fracture of the sciatic or upper branches pubic bones, the patient usually experiences a severe pain shock with all the accompanying symptoms. Besides, this species damage is accompanied by the so-called frog posture.
7. With injuries in the posterior semiring of the pelvis, pain in the area of ​​injury, bruising and increased mobility half rings when they are squeezed.
8. With detachments of the pre-upper axis, fragmental displacement is observed, leading to external shortening of the lower limb.

Often, pelvic fractures are accompanied by damage to internal organs or the formation of a retroperitoneal hematoma. This process is accompanied additional manifestations. These include the following factors:

• violations of urination and stagnation of urine are characteristic of injury to the urethra;
• hematuria, which usually occurs when the bladder ruptures;
• acute abdomen;
• constipation;
• bleeding from the perineum or urethra occur when these organs are injured.

Varieties of damage

Fractures of the pelvic bones differ in a number of their manifestations and forms. They also differ depending on the location. The classification includes the following types of injuries:

1. Unstable fractures of the pelvic ring. AT this case the pelvic bones are displaced in a horizontal or vertical direction.
2. Fracture dislocation.
3. Damage to the bottom or edge of the acetabulum, accompanied by femoral dislocation.
4. Partial pelvis. The presented injury is characterized by a violation of the integrity of individual bone fragments, but practically does not affect the area of ​​the pelvic ring.

In addition, a distinction is made between open and closed damage. Open trauma to the pelvic bones is usually observed in the case of a direct blow and is a violation of the integrity of the pelvic bones near the sacral canal. The presented injury is accompanied by pain shock and intense bleeding.

They are damage to the pelvic ring, which does not damage the internal organs or nearby tissues. Such injuries can be single or multiple.

The following subspecies are included in the classification:

• fracture with displacement of bones (this damage is especially dangerous for the patient);
• fractures without displacement.

In addition, pelvic injuries are divided into uncomplicated and complicated. The latter is accompanied by damage to internal organs.

Possible consequences

Fractures of the pelvic bones are a severe injury, which is not only extremely dangerous to health, but also poses a threat to the life of the patient. The fact is that they are fraught not only with damage to bone tissue, but also often cause a violation of the integrity of internal organs. This, in turn, leads to serious violations in the patient's body. Most often, the following manifestations are recorded in victims:

• peritonitis;
• fecal phlegmon;
• violations of the defecation process;
• stasis of urine;
• internal bleeding;
• purulent infections;
• hemorrhages in the cavity of internal organs;
• tendon ruptures, which can cause lameness.

In order to minimize the risk of developing pathological consequences, it is necessary for the patient to provide prompt and competent first aid, to provide him with the correct treatment process.

First aid

If you suspect a fracture in the pelvic area, you should immediately call an ambulance. And before the arrival of the brigade of medical workers, it is recommended to take the following measures:

1. By applying a tourniquet and a splint, stop bleeding, which is usually observed in case of an open fracture.
2. Disinfect the edges of the damage. This manipulation is necessary to avoid the penetration of infection, possible inflammation, blood poisoning.
3. Immobilization (ensuring the immobility of the injury site) is an indispensable condition for the success of subsequent treatment. Therefore, when transporting the victim, it is necessary to lay him on a flat stretcher, placing a dense roller under his feet.
4. In case of ruptures and fractures of the symphysis, it is necessary to ensure the immobility of the hips and the pelvic region by tightly tightening these parts of the body; in this case, the transport tire is not superimposed. This can be done with an ordinary sheet or clothing items.

In 30% of cases, pelvic injury is accompanied by traumatic shock, and with multiple and open fractures, this figure reaches 100%. Exactly this manifestation often causes the death of the victim even before the arrival of the ambulance. Therefore, it is extremely important to recognize traumatic shock and alleviate its symptoms.

Signs of traumatic shock:

• profuse bleeding is possible;
• tachycardia;
• heart rhythm disturbances;
• loss of consciousness;
• sharp blanching of the skin;
• drop in blood pressure up to a hypotensive crisis;
• shallow and difficult breathing;
• general lethargy and confusion.

How to provide first aid for traumatic shock?

1. Give the body of the victim the most comfortable position and provide him with maximum peace.
2. You can reduce pain with the help of analgesics or other painkillers.
3. Strong and sweet hot tea will help relieve some of the pain.
4. Immobilization is also indicated for manifestations of traumatic shock associated with traumatic injuries. For this, any improvised means are suitable.
5. Traumatic shock is often accompanied by hypothermia, which occurs regardless of weather conditions. To avoid this, you should properly wrap the victim in warm clothes.

How to diagnose an injury?

A pelvic fracture is diagnosed based on the overall clinical picture and symptoms. The presence of damage can also be determined using the method of palpation. However, in order to avoid errors in the diagnosis, to establish the type and degree of fracture, the following procedures are prescribed to the patient:

• radiography of the pelvic region, which allows you to determine the exact location of the damage and its severity;
• computed tomography, necessary to study the state of adjacent nerve endings, blood vessels, nearby tissues and internal organs.

How to treat damage?

Treatment of this type of injury largely depends on the severity of the injury and the presence of associated complications. Therapy is prescribed by a traumatologist. This is an individual process, which is based on an accurate diagnosis, the general clinical picture and the personal characteristics of the victim. Generally therapeutic process It is subdivided into two main groups: conservative and surgical.

Conservative treatment is usually used for closed or single violations of the integrity of the bone tissue and is as follows:

• the use of crutches in order to reduce the pressure of the patient's weight on the pelvic region;
• bed rest;
• immobilization;
• blood transfusion (if necessary);
• painkillers;
• taking drugs that help reduce blood clotting;
• the use of an external fixator, which gives doctors the opportunity to control the state of internal organs, nerve endings and blood vessels in the pelvic region.

Surgical treatment is an operation accompanied by the insertion of special internal fixators into the pelvic bones. This technique used for complicated fractures, in case of damage to nearby internal organs.

rehabilitation period

The recovery process after a fracture pelvic bone lasts from three to five months, depending on the severity of the injury and general condition the health of the victim. During the first month, the victim is shown bed rest. Further recovery includes the following:

• massage;
• physical therapy, which contributes to the speedy recovery of damaged muscle tissues and tendons;
• the use of calcium supplements;
• physiotherapy.

Prevention is based on the observance of simple rules by the patient:

1. Strengthen your body with regular exercise.
2. Observe the necessary safety measures when traveling by transport and when playing sports.
3. Make sure you have enough calcium in your diet. This substance is necessary for strengthening bone tissue.

A fracture in the pelvic area can cause disability and even death of the patient. Therefore, at the slightest suspicion of this type of injury, you should immediately consult a doctor and strictly follow all his recommendations.

A pelvic fracture is not just damage to the integrity of the bones, but a life-threatening condition. Inside the pelvic ring are the internal organs, blood vessels, nerves. In case of a fracture, fragments can injure soft tissues, which leads to massive blood loss, which can be up to 3 liters. Damage to nerve endings causes pain shock up to loss of consciousness. Emergency care should be provided as quickly as possible, because every minute the risk of complications and death increases.

The pelvis is not one bone, as many might think. It consists of three parts, firmly connected to each other. The structure of the pelvis is taken into account in the diagnosis, determining the type of fracture, because often only one bone is damaged.

The pelvic ring consists of three paired bones:

• pubic;
• iliac;
• ischial.

The reasons

Pelvic fractures are caused by great strength. The risk group includes athletes who are engaged in weightlifting, elderly people with impaired mineral metabolism, diseases of the thyroid gland, adrenal glands.

The immediate causes of a pelvic fracture include:

1. Pressure on the pelvic ring with a heavy object (during an accident, earthquake, house collapse, natural disasters).
2. A strong blow to the pelvic area during fights, training.
3. In athletes, a fracture of the pelvic bone can occur according to the type of crack. When lifting a barbell with a large weight, the gluteal muscles, biceps femoris work. Most of them are attached to ischium. With sudden movements, muscle fibers contract, which leads to cracks.
4. When falling from a height, often all the force of the impact falls on the pelvis. Especially in cases where there is a fall into a horizontal position.
5. Osteoporosis (decrease in bone density); hereditary or acquired disorders of mineral metabolism increase the risk of fractures.
6. In women, fused fractures of the pelvic bones can complicate the process of childbirth in the future. large fruit, polyhydramnios, a narrow pelvis lead to cracks, bone damage. This is more the exception than the rule. Timely diagnosis during pregnancy will help to avoid complications.

Types of fractures

Signs of a pelvic fracture depend on the type of injury, the presence of complications. If the pelvic ring, which is the plane of entry into the small pelvis, is broken, the patient's condition deteriorates sharply, movements of the lower limbs are almost impossible, and stability is lost. The risk of blood loss with this type of fracture is high. Emergency care should be provided in as soon as possible. Damage to one bone is not so life-threatening, but it should not be treated negligently. Immobilization, transportation is carried out slowly so as not to damage the vessels, internal organs, and not worsen the situation.

There are the following types of pelvic fractures:

• isolated - fractures of the pubic, ischial or iliac bones, as a rule, are called stable. Under the action of a traumatic force, a fracture of the most protruding parts occurs: crests or wings of the ilium, tubercles of the ischium, branches of the pubis;
• unstable fractures are accompanied by violations of the pelvic ring. In most cases, internal organs are injured. Depending on the location of the damage, vertically unstable fractures are distinguished, when the displacement occurs in vertical plane. Rotational fractures are characterized by horizontal displacement of fragments;
• acetabular injury. A fracture of the hip bone occurs due to a violation of the integrity of the bottom or edges of the articular surface of the cavity.
• concomitant injury: pelvic fractures are accompanied by dislocations in the pubic or sacroiliac joint.

Local manifestations

Despite some differences in the clinical picture, there are common signs of a pelvic fracture. These symptoms indicate the presence of damage, the need for emergency care.

1. The pain syndrome is expressed as strongly as possible. When trying to touch the pelvis, the patient begins to scream, tries to move away.
2. There is a deformation of the bones, an unnatural position of the limbs.
3. Hematomas, hemorrhages under the skin are characteristic symptoms of fractures. Under the influence of a traumatic factor, the vessels burst, which leads to bruising.
4. AT severe cases bleeding occurs.
5. When the fragments are displaced, crepitus (crunching) can be heard in the damaged area.
6. Violation of blood circulation, an increase in vascular permeability leads to edema.
7. Fracture of the hip bone is accompanied by limited mobility of the lower extremities. It is impossible to lift or move the leg due to increasing pain (symptom of stuck heel).

Note! With small fractures, cracks, the patient can walk. In most cases, there is unexpressed pain, discomfort during movement. Consultation with a doctor is required, because improperly fused bones can cause constant chronic pain.

General symptoms

In addition to local changes, with pelvic fractures, there is a pronounced general symptoms. Violation of the integrity of the bones, pain syndrome, blood loss lead to the occurrence of traumatic shock. As a rule, the patient immediately after the injury is excited, does not feel pain. After a few minutes, the condition begins to worsen. There is pale skin, cold, clammy sweat. The pressure drops sharply, which is due to the presence of bleeding from the vessels and the pelvic bones themselves, which have a spongy structure.

Rapid heart rate is a defense mechanism. In order to ensure the supply of nutrients, oxygen to the brain and other organs, with an insufficient amount of blood, the heart is forced to work faster. Also important role plays an adrenaline rush as a reaction to a stressful situation.

Sometimes the condition is complicated by fainting. Loss of consciousness occurs due to severe pain, which significantly exceeds the threshold of pain sensitivity. Another mechanism is oxygen starvation brain with massive bleeding.

Damage to internal organs

The urinary system, lower intestines, uterus, tubes and ovaries in women are most susceptible to injury. Signs of a pelvic fracture are varied, depending on the degree of damage to a particular organ:

• urinary retention, the presence of blood in the urethra indicate a rupture of the urethra. It is impossible to put a catheter due to severe pain, mechanical obstacles;
• if the bladder is damaged, hematuria is observed (impurities of blood in the urine);
• blood in the rectum or vagina is a sign of damage to the corresponding organs.

Iliac fractures

If the ilium is damaged, shortening of the limb, pain in the wing or crest on the corresponding side is observed. Exists specific symptom reverse moves when it is easier for the patient to move backwards.

More often with this type of injury, the pelvic ring is not broken. The patient takes a forced position, in which the pain decreases: lying on his back, legs bent at the knee joints, separated to the side. For clarity, the posture of a person with pelvic fractures (frog posture) is shown in the photo.

Ischial fractures

Damage occurs when falling on the pelvis, more often in winter or during sports. The patient complains of acute pain, swelling, redness on the buttocks.

Fractures with violation of the integrity of the pelvic ring

Pelvic fractures with violation of the integrity of the anterior and posterior half rings are characterized by pathological mobility with slight pressure on the pelvis, asymmetry. The pain syndrome is pronounced strongly, leading to loss of consciousness. There are bruises and bruises on the skin.

How to make a diagnosis?

The main diagnostic method is x-ray in two or three projections. With the help of this study, you can find out about the number of fractures, their localization, the integrity of the pelvic ring, the presence of fragments.

If needed Additional Information about the condition of ligaments, joints, the presence of small cracks, are used modern methods: computed or magnetic resonance imaging.

Mandatory is carried out ultrasound examination organs of the abdominal cavity, small pelvis. Free fluid in the abdominal cavity, blurred, distorted contours of organs are alarming.

If you suspect internal bleeding, rupture of the spleen, bladder, diagnostic laparoscopy is necessary. surgeon using special device examines the condition of the internal organs through the incisions of the anterior abdominal wall. If damage is detected, non-viable tissues are removed, bleeding stops, tears are sutured. Thus, laparoscopy is used for both diagnostic and therapeutic purposes.

In addition, special symptoms are applied, which consist in the application of an axial load that causes pain. However, such symptoms are checked carefully so as not to aggravate the fracture and cause injury to the organs.

If a pelvic fracture is suspected, call emergency care. The sooner the patient is taken to the hospital, the greater the chance of a successful recovery.

If external bleeding occurs, you need to stop it, only a doctor in a hospital can handle the internal one. For this, improvised materials are used: a belt, a scarf, clothes twisted into a tourniquet. The main task is to save the life of a person, not allowing him to die from bleeding before the arrival of an ambulance.

Remember! You cannot move the patient on your own. This can lead to damage to organs by bone fragments, increased bleeding.

After the arrival of the doctor, it is necessary to carry out anesthesia, give the correct posture to the patient, and take him to the hospital as soon as possible.

Pelvic fractures are accompanied by severe pain with any movement. The frog posture is optimal for transportation. The patient is laid on his back, his legs are bent at the knee joints, placing a roller under them. In most cases, the legs are spread apart, but if the pain intensifies, they must be kept together. For convenience, you can tie the knee joints.

Treatment

In the hospital, first of all, you need to stabilize the person’s condition: stop the bleeding, administer pain relief.

The issue of anesthesia (pain relief) is decided individually. Intraosseous or intrapelvic administration of novocaine, lidocaine is used. In severe cases, general anesthesia and urgent surgery are indicated, the purpose of which is to stabilize the fracture, eliminate organ damage, if this occurs, and stop bleeding.

It is necessary to replenish the volume of blood loss with the help of intravenous administration of plasma, saline, blood substitutes. It is worth remembering that the volume of blood loss can be from 3 to 5 liters, and it increases with the instability of the pelvic ring.

After stabilization of all vital functions with an uncomplicated fracture, the surgeon proceeds to the direct treatment of pelvic fractures. The choice of tactics for managing a patient with fractures depends on the severity of the condition, the presence of complications.

1. Immobilization of simple fractures without displacement is carried out on a shield or in a special hammock. The state of the immune system, the presence of concomitant diseases, age affect how long the fracture heals. On average, this period is 3 months, but it can be more.
2. Displaced fractures - direct reading to skeletal traction. Needles are passed through the bone, which are fixed on the outside on a special frame. This procedure allows you to pull the bone fragments apart. As a rule, surgical intervention follows.
3. The operation consists of fixing all parts of the pelvis with pins, metal plates, screws, and rods in an external fixation device. After osteosynthesis, immobilization is indicated for 3-4 months.

Complications

Despite all efforts, 20% of patients develop backfire pelvic fracture. Multiple injuries, improper fusion of fragments, massive blood loss affect further health. The most common complications include:

• syndrome chronic pain occurs when the bones are not aligned correctly, nerve endings are damaged;
• lameness, change in gait;
• muscle atrophy, stiffness of the hip joint occur as a result of prolonged immobilization. To avoid complications, it is recommended to gradually load the lower limbs, exercise after the permission of the doctor;
• to severe complications include violations of the internal organs: urinary incontinence, sexual dysfunction, decreased sensitivity in the lower extremities.

Unfortunately the treatment long-term effects pelvic fracture is a complex process. With the help of painkillers, vitamins, therapeutic exercises, it is only possible to reduce the symptoms. It is impossible to restore all functions completely.

Recovery

How long a pelvic fracture will heal depends not only on the type of damage, but also on the implementation of all the doctor's recommendations, the diligence of the patient himself in the course of their implementation. Rehabilitation for fractures is carried out only under the supervision of a specialist.

Standing up on your own, making sudden movements, charging is prohibited! Bones at the time of such "amateur" may not yet grow together, which will lead to complications.

1. Therapeutic exercise is the main method of preventing atrophy (weakness) of muscles, stiffness in the joints. Recovery begins immediately after stabilization of the condition or operation. The early recovery period should begin with breathing exercises, contraction of individual muscle groups and holding them in this position for several minutes. When the bones begin to grow together and the doctor allows a light warm-up, physical activity must be increased. First, the exercises are performed in a supine position, closer to recovery - standing. Rehabilitation after a pelvic fracture is aimed at restoring muscle strength, the full range of active movements.
2. Swimming or just walking in the water is shown.
3. Massage improves blood circulation in the damaged area, removes lymph stagnation, venous blood. Light massage movements lead to an increase in muscle tone.
4. With food, building material enters the body to restore bone tissue. It is necessary to eat foods rich in calcium: green vegetables, cabbage, parsley, cottage cheese, cheese, nuts, sea fish, legumes.
5. If one meal is not enough, the doctor prescribes special calcium preparations.
6. Chondroprotectors, collagen are necessary to prevent bone destruction, to restore cartilage tissue.
7. Rehabilitation for fractures includes physiotherapy. Their large selection, which is determined by the attending physician.
8. For a long time, patients are recommended to wear a bandage, corsets, use crutches, walkers in order to reduce the load on the pelvis.

It is impossible to predict how long the recovery will take. It all depends on the effort internal reserves organism, the severity of the injury. As a rule, fusion of pelvic fractures takes from 5-6 months to a year.

Pelvic fractures

Pelvic fractures are among the most severe injuries of the musculoskeletal system: with isolated fractures of the pelvic bones, 30% of patients are admitted in a state of traumatic shock, mortality is 6%; with multiple fractures of the pelvis, shock is observed in almost all victims, and mortality reaches 20%.

AT last years marked increase in the incidence of pelvic injuries. The most common cause is motor vehicle injuries.

Fracture mechanism pelvic bones in most patients with direct: blows or compression of the pelvis. In young people, especially those actively involved in sports, avulsion fractures of the apophyses are observed as a result of excessive tension of the attached muscles.

Depending on the location of the fracture, the degree of violation of the integrity of the pelvic ring, several groups of injuries to the pelvic bones are distinguished: 1) marginal fractures of the pelvic bones; 2) fractures of the pelvic ring without breaking its continuity; 3) fractures of the pelvic ring with a violation of its continuity (in the anterior section, in the posterior section, in the anterior and posterior sections); 4) fractures of the acetabulum.

In addition, pelvic injuries can be combined with damage to the pelvic organs,

Clinic and principles of diagnostics. Signs of gas bone damage can be divided into 2 groups: general and local. Common signs of pelvic fractures include symptoms of traumatic shock, "acute abdomen", signs of damage to the urinary tract and other organs of the pelvis. TO. local features A pelvic fracture includes symptoms of a fracture of a particular bone (pain, hematoma or swelling, bone crepitus with mutual displacement of bone fragments) and functional disorders of the musculoskeletal system.

Common signs of pelvic fractures. Shock in pelvic fractures is observed in approximately 30% of patients with isolated fractures and in 100% of patients with multiple and concomitant injuries.

The cause of shock is massive bleeding from damaged soft tissues and bones with simultaneous damage or compression of the nerve elements. The soft tissues of the pelvic region and the pelvic bones have a high pain sensitivity. Therefore, the pain component in the genesis of traumatic shock in pelvic fractures is one of the leading ones. Good blood supply to the pelvic area and anatomical features the structures of the vascular system in the pelvic region cause significant blood loss, which, with isolated fractures of the pelvic bones, reaches 1 liter, and with multiple fractures, much more. Bleeding from pelvic fractures sometimes lasts 2-3 days. Clinical manifestations of shock depend on the rate of blood loss: with isolated fractures, the rate of blood loss is small, with multiple fractures, bleeding becomes profuse. Another cause of large blood loss in pelvic fractures is a violation of the blood coagulation system. In the first 2-3 days, hypofibrinogenemia is noted, fibrinolytic activity of the blood increases. These features of hemorrhage in pelvic fractures should be taken into account when conducting therapeutic measures.

Clinic of "acute abdomen" with fractures of the pelvic bones, it can be caused by a hematoma in the anterior abdominal wall with fractures of the pubic bones or retroperitoneal hematoma with fractures of the posterior pelvis, as well as damage to internal organs.

Differential diagnosis of the cause of "acute abdomen" depends on the severity of the victim. If the patient's condition is satisfactory, dynamic monitoring of the clinical manifestations of "acute abdomen" is carried out. Usually, if the cause is a hematoma of the anterior abdominal wall or retroperitoneal, the clinic does not increase. Progression of symptoms of peritoneal irritation is a sign of damage to internal organs. Intrapelvic anesthesia according to Selivanov-Shkolnikov or anesthesia of the fracture site in case of damage to the anterior half ring lead to a significant subsidence of the signs of "acute abdomen" with well-being in the abdominal cavity, which is a good differential diagnostic technique.

In a serious condition of the patient, when the clinical picture of trouble in the abdominal cavity can be blurred, expectant management is unacceptable. It is necessary to apply objective diagnostic methods. Some of the most reliable methods are laparocentesis, laparoscopy, lavage of the abdominal cavity with a groping catheter, and in doubtful cases, diagnostic laparotomy.

Symptoms of urinary tract injury. At the time of admission of patients with severe pelvic trauma, if it is impossible to urinate independently, regardless of the presence or absence of signs of damage, in order general research it is necessary to find out the condition of the urinary tract.

Damage to the urethra is characterized by a triad of symptoms: bleeding from the urethra, urinary retention and hematoma in the perineum. The severity of these signs may vary depending on the location of the damage (anterior or posterior urethra), the nature of the damage (penetrating or non-penetrating). In doubtful cases, it is advisable to conduct urethrography.

With extraperitoneal bladder injury patients report pain over the pubic joint. Urination disorders can be different: the impossibility of independent urination, urination in small portions or a weak stream, sometimes patients experience frequent fruitless urges or they end with the release of a small amount of blood-stained urine or blood. Generally hematuria is a sign of damage urinary organs. It is generally accepted that initial hematuria is typical for damage to the urethra, terminal - for damage to the bladder, total - for damage to the kidneys. late signs extraperitoneal damage to the bladder is the development of urinary infiltration of the pelvic tissue: the appearance of swelling over the pubis and pupart ligaments; intoxication clinic.

With intraperitoneal rupture of the bladder victims note pain in the lower abdomen, which then becomes diffuse. Urination disorders can be in the form of frequent fruitless urges, sometimes a small amount of bloody urine or blood is excreted. Sometimes independent urination is preserved, but the urine stream is sluggish.

If a bladder injury is suspected or if the patient is in a serious condition, when the victim is unable to urinate on his own, catheterization must be performed. If the bladder is damaged, there may be no urine, it may stand out in a weak stream, you can get a small amount of urine stained with blood. The nature of the damage to the bladder is specified by performing retrograde cystography: after catheterization of the bladder, up to 200 ml of a 10% solution of sergosin with antibiotics (5,000,000 IU of penicillin) is injected, x-rays are taken in two projections, then contrast agent remove and repeat radiographs. Repeated images allow you to quite clearly determine the localization of streaks that could be blocked by the contours of the bladder.

Principles of treatment of common manifestations of pelvic fractures.

Treatment of traumatic shock. The most important anti-shock measures for pelvic injuries are general and local anesthesia, adequate replacement of blood loss, and proper immobilization of the fracture.

General anesthesia achieved with the use of medical anesthesia. Local anesthesia is carried out using anesthesia of the fracture site, intrapelvic anesthesia according to Selivanov-Shkolnikov or intraosseous anesthesia. In case of marginal fractures of the pelvis, fractures of the pelvic ring without discontinuity or with discontinuity in the anterior section, it is advisable to use local anesthesia introduction concentrated solution anesthetic (50-60 ml 1-1, 5% solution of novocaine) into the fracture area. Anesthesia can be repeated at renewal pain syndrome In case of pelvic fractures with discontinuity of the pelvic ring in the posterior region, as well as in the anterior and posterior regions, it is advisable to perform anesthesia according to Selivanov-Shkolnikov or intraosseous anesthesia. However, it must be remembered that novocaine has a hypotensive effect, and therefore the introduction of a large amount of it in shock until the volume of circulating blood is replenished is not indifferent.

The technique of intrapelvic anesthesia: 1 cm medially from the anterior-superior spine with a thin needle, anesthesia of the skin is performed, then a long needle (12-I cm) penetrates into the internal iliac fossa. In this case, the needle is turned with a cut to the wing of the ilium and its advancement in depth is carried out next to the bone with the simultaneous introduction of a solution of novocaine. With a unilateral fracture, 200-300 ml of 0.25% novocaine solution are injected; With a bilateral fracture, 150-200 ml of an anesthetic solution are injected from each side.

Intraosseous anesthesia is performed by injecting an anesthetic solution through a needle inserted into the iliac wing crest. To slow down the resorption of the anesthetic solution, V. A. Polyakov proposed intraosseous administration of a mixture of 10 ml of a 5% solution of novocaine and 90 ml of gelatinol. The solution is injected 50 ml into both wings. There comes a persistent analgesic effect up to 24 hours. In addition, filling the vascular bed with gelatinol helps stop bleeding.

Bleeding in isolated pelvic fractures is characterized by a slower rate and less blood loss, patients rarely go to severe shock, therefore, blood transfusion should be carried out in fractional portions during the first 2-3 days after injury.

At severe degrees shock, significant blood loss is noted, and therefore close to adequate blood replacement should be carried out at a high volumetric transfusion rate in the first hours after injury. With continued profuse bleeding from damaged tissues, surgical methods for stopping bleeding are indicated - ligation of both internal iliac arteries.

In connection with severe hypocoagulation, hypofibrinogenemia and increased fibrinolytic activity of the blood in the first hours after the injury, it is necessary to take measures to increase blood coagulation, which is achieved by using epsilon aminocaproic acid, fibrinogen, and direct blood transfusion.

Immobilization for pelvic fractures with discontinuity of the pelvic ring and displacement of bone fragments is achieved by using a system of permanent skeletal traction. Application only bed rest with orthopedic laying of limbs on standard splints or with the help of rollers in the popliteal areas without fracture reposition is unacceptable.

Treatment of urinary tract injuries. With non-penetrating ruptures of the urethra, conservative therapy is used: prescribe antibacterial drugs for disinfection of the urinary tract, plentiful drink, cold on the perineum. With urinary retention, patients undergo bladder catheterization in compliance with the strictest rules asepsis (danger of introducing infection) or an indwelling catheter is inserted. Healing of damage to the urethra occurs within 1.5-2 weeks. The development of scar tissue during healing of the urethra can lead to the formation of a stricture, which is clinically manifested by difficulty urinating. The narrowing of the urethra is eliminated by bougienage, which begins 2 to 4 weeks after the injury. Sometimes you have to resort to repeated courses of bougienage. With penetrating ruptures of the urethra, therapeutic measures should solve the following tasks: restoring the anatomical integrity of the urethra, diverting urine and eliminating urinary infiltration of paraurethral tissues. These tasks can be solved simultaneously and in stages. The volume of surgical intervention depends on several factors: the severity of the patient's condition, the presence of conditions and the possibility of a primary urethral suture. Primary urethral suture can be performed only with persistent removal of the patient from shock, full compensation of blood loss and sufficient experience of the surgeon in carrying out such surgical interventions. Surgery performed under general anesthesia, it is advisable to start with a suprapubic section of the bladder. Epicystostomy allows not only to divert urine into postoperative period, but also - retrograde conduction catheter into the urethra. The place of rupture of the urethra is exposed by a perineal incision. The paraurethral hematoma is emptied, the urethra is sutured over the catheter, the paraurethral tissue is drained. A permanent catheter is left in the urethra for 2-3 weeks. Prevention and treatment of urethritis is carried out by daily administration of a concentrated solution of antibiotics into the urethra. If the ends of the urethra cannot be sewn together, the catheter is left for 6-8 weeks, that is, for the entire period of scar formation and restoration of the urethral defect. If there are no conditions for the primary urethral suture (the patient's serious condition, the absence of an experienced surgeon), surgical intervention on the urinary tract is carried out in 2 stages. At stage I, surgery is performed to prevent life-threatening complications (urinary leakage) - epicystostomy and drainage of urohematoma. Restoration of the integrity of the urethra is carried out after the fusion of the fracture of the pelvic bones.

Treatment of bladder injuries. With non-penetrating ruptures (rupture of the mucous membrane), conservative therapy is carried out. Patients are prescribed drugs for disinfection of the urinary tract. With urinary retention, leave a permanent catheter or conduct periodic catheterization. With penetrating ruptures of the bladder, surgical treatment is performed, the task of which is to suture the bladder, divert urine and drain paravesical tissue in the presence of urinary streaks.

With an intraperitoneal rupture of the bladder, it is sutured with two-story sutures. Diversion of urine is carried out by inserting an indwelling catheter for several days. In case of insufficient tightness of the seam, it is advisable to strengthen it with a free gland. In the presence of urinary peritonitis, drainage of the abdominal cavity is performed.

With an extraperitoneal rupture of the bladder, a suprapubic section of the bladder is performed. The bladder wound is sutured if access to it does not require wide exposure of the bladder. Drainage of perivesical tissue is carried out by various approaches: through the obturator openings, through the perineum, above the pupart ligament, in front of the coccyx. The method of drainage is determined by the prevalence of urinary infiltration and the intensity of development purulent infection. Urine is drained through the suprapubic fistula into an indwelling catheter. The permanent catheter is removed when spontaneous urination is restored.

Marginal fractures of the pelvic bones

Marginal fractures of the pelvic bones include fractures of the coccyx, fractures of the sacrum distal to the sacroiliac joint, fractures of the iliac wing and apophyses (anterior superior and anterior inferior pelvic spine, ischial tuberosity).

Tailbone fracture

It comes from a direct blow or a fall on the buttocks. Fracture-dislocations in the sacrococcygeal joint are more often observed.

Clinic. Disturbed by pain in the coccyx, aggravated by palpation, walking, defecation. Sometimes swelling or hematoma is locally determined. The pain is aggravated by rectal examination. Radiological confirmation of damage is not always possible, so the diagnosis should be based on clinical signs.

Treatment with fractures of the coccyx, it consists in anesthesia and rest for several days. Pain is relieved by local anesthesia, laying the patient in a circle. If the pain syndrome recurs, the anesthesia is repeated. Indications for surgical treatment fracture-dislocations of the coccyx occur when improperly fused fractures of the coccyx with displacement into the cavity of the small pelvis with obstruction of the administration of physiological functions or severe pain syndrome. Surgical intervention is to remove a fragment of the coccyx. Ability to work with fractures of the coccyx is restored after 2-4 weeks.

Fractures of the apophyses of the pelvic bones

They often come from indirect violence - excessive muscle tension, and this damage is typical for young people involved in sports. These fractures may be based on degenerative-dystrophic processes in the apophyses. Less often, a fracture occurs from the direct application of a traumatic force, and the damage is not limited to the awn only, but also captures part of the main bone. Most often, damage to the anterior-superior iliac spine occurs, and fractures of the ischial tuberosity are less common.

Clinic of these injuries is quite characteristic: patients complain of pain in the apophysis area, swelling or hematoma is also determined here. Functional disorders touch the muscles starting from the corresponding apophysis. So, with a fracture of the anterior-upper spine, it is difficult to move the patient forward and raise the straightened limb. Sometimes there is a symptom of "reverse" - the pain when moving the patient forward is more pronounced than when moving backward. With a fracture of the apophysis of the ischium, the function of the leg flexors is disrupted, and when they are strained, the pain intensifies.

Treatment. The fracture site is anaesthetized. The limb is laid in such a way as to maximally relax the muscles attached to the apophysis. So, with a fracture of the anterior-upper spine, the limb is bent at the hip joint and retracted; with a fracture of the ischial tuberosity, extension in the hip joint and flexion of the lower leg are achieved. The correct position is ensured by laying on the rails or by using a permanent adhesive stretching system. Bed rest continues for 2-3 weeks, working capacity is restored after 3-4 weeks. Persons who are actively involved in sports need to limit training loads for six months. Indications for surgical treatment are extremely rare with significant displacement of fragments and severe pain or dysfunction.

Fractures of the iliac wing

They occur more often and arise from direct trauma or compression of the victim with localization of pressure in a limited area.

Clinic. Patients note pain at the fracture site, swelling is noticeable, and a few hours after the injury - a hematoma, which causes the smoothness of the contours of the pelvis on the side of the fracture. The pain increases with movement, especially with tension of the oblique muscles of the abdomen and gluteal muscles,

Treatment with fractures of the iliac wing, it consists in anesthesia, which is achieved by introducing an anesthetic into the fracture site, and providing bed rest for 3-4 weeks. Muscle relaxation is achieved by orthopedic laying on standard splints or by using a permanent adhesive traction system. Ability to work is restored after 5-6 weeks.

Fractures of the pelvic ring with a violation of its continuity in the anterior section

This group of fractures includes unilateral or bilateral fractures of the pubic and ischial bones. The biomechanical feature of these fractures is that they are accompanied by a violation of the mechanical strength of the pelvic ring and, under load, the half of the pelvis can be displaced at the level of the fracture due to mobility in the sacroiliac joints. Therefore, the load on the limbs can be resolved only after a sufficiently strong union of the fracture - after 6-8 weeks. The mechanism of injury: compression of the pelvis, a fall from a height or from a direct blow.

Clinic. The general condition of patients with unilateral fractures of the pelvic ring suffers little, the effects of traumatic shock are rare. The pain in the area of ​​the fracture is aggravated by an attempt to move the limb. Swelling in the area of ​​the anterior half-ring of the pelvis, expressed in the first hours after the injury, after 2-3 days is replaced by bruising in the surrounding tissues. With bilateral fractures of the anterior half-ring of the pelvis, the general condition of the patient is unsatisfactory. Typically forced position of the patient with bent and divorced limbs. The diagnosis is clarified by X-ray examination.

Treatment should consist in anesthetizing the fracture and ensuring immobilization. The effect of anesthesia is achieved by intrapelvic anesthesia according to Selivanov-Shkolnikov on one or both sides. Immobilization is carried out using a permanent adhesive stretching system on one or both sides. The need for skeletal traction usually does not arise, since significant mixing in length due to muscle retraction is not observed due to the integrity of the posterior pelvis. The duration of bed rest is 6-7 weeks, followed by the resolution of a dosed load, full load is possible from the 8th week. Ability to work is restored after 10-12 weeks.

Pelvic ring fractures with discontinuity in the posterior region

These injuries are extremely rare in the form of a vertical fracture of the sacrum or ilium and are accompanied by severe pain and significant blood loss, causing disturbances in the general condition of the patient. The mechanism of injury often consists in compression of the pelvis in the anterior-posterior direction.

Clinic. The general condition of the patient is significantly impaired, most patients are diagnosed with shock. Disturbed by pain in the posterior pelvis, the support function is impaired, the patient's position is passive. Possible manifestations of the clinic "acute abdomen" due to retroperitoneal hematoma. The diagnosis is confirmed by radiography.

Treatment. Pain relief is achieved by intrapelvic anesthesia. In case of fractures without displacement, a system of permanent adhesive traction is applied on the side of the injury. If there is a shift in width, the latter is eliminated by using a hammock. Given that the posterior pelvis carries a significant static load, patients are allowed to walk with crutches no earlier than after 10 weeks, and full load is allowed after 12-14 weeks. Ability to work is restored after 14-16 weeks.

Fracture-dislocation of the pelvis

Fractures of the pelvic ring with a violation of its continuity in the anterior and posterior sections - fracture-dislocation of the pelvis

These injuries are among the most severe pelvic fractures: in all patients they are accompanied by shock caused by pain and severe blood loss, often combined with damage to the internal organs of the abdomen or urinary tract, as well as damage to the limbs. Injuries often occur as a result of compression of the pelvis, less often when falling from a height. Several variants of damage to the anterior and posterior pelvis with discontinuity are possible: vertical fracture of the anterior and posterior pelvis, fracture of the pubis and ischium and vertical fracture of the sacrum, vertical fractures in the anterior and posterior sections of the pelvis opposite sides- diagonal fractures, ruptures of the pubic and sacroiliac joints - isolated or combined. There are practically no “pure” isolated ruptures of the pelvic joints, since mixing in one of them can occur only if the ligamentous apparatus in the other is partially or completely disrupted. The exception is the "rupture" of the symphysis that occurs during childbirth.

Clinic. Signs of a serious general condition of the patient come to the fore. The position of the victim is passive - the limbs are bent and the hip joints are somewhat abducted and rotated outward on the side of the injury. The movements of the limb on the side of the injury are sharply limited and painful. When the half of the pelvis is displaced, asymmetry is noticeable, swelling and hematoma quickly appear at the fracture sites. For diagnostic purposes, compression of the pelvis recommended by some authors in the sagittal or frontal planes is not advisable, since this can lead to secondary displacement of the fragments and an increase in the shock reaction. The diagnosis is confirmed by radiography.

Treatment

With vertical fractures of the pelvis without displacement treatment is carried out by the method of constant skeletal traction with small loads for 8 weeks in the average physiological position of the limbs. A dosed load on the limb from the side of the injury is allowed after 10 weeks, a full load - after 3-4 months. Ability to work is restored after 5-6 months in the absence of concomitant pathology.

With vertical fractures of the pelvis with displacement reposition of the fracture is carried out using constant skeletal traction for the limb on the side of the displacement of the half of the pelvis (the pin is inserted behind the epicondyles of the femur), on the opposite limb, skeletal or cuff traction is performed to prevent pelvic distortion when significant loads are applied on the main skeletal traction. Since the displacement of the half of the pelvis in length may be accompanied by a displacement in width, it is important to follow the sequence in eliminating the individual components of the displacement. Offset but length can be with a divergence of the halves of the pelvis and with overlap. When the half of the pelvis is displaced with a divergence of the fragments along the width, the displacement along the length is first eliminated by stretching along the axis of the limbs, and then the halves of the pelvis are brought together with the help of a hammock. In case of displacement with overlapping of fragments but in width, it is first necessary to eliminate the displacement of the pelvis in width. This is achieved by using lateral traction with a loop at the base of the lower limb or by using skeletal traction on the greater trochanter or pelvic wing. After eliminating the offset in width, increase the weights along the axis and eliminate the offset in length. To eliminate the displacement along the length, loads of the order of b-10 kg are used. After eliminating the displacement along the length, the weights gradually decrease and the value of the holding weight is equal to half the sum of the initial and maximum weights. The duration of traction is 8-10 weeks. A dosed load on the limb on the side of the displacement of half of the pelvis is allowed after 10-12 weeks, a full one - after 3.5-5 months, depending on the degree of the former displacement, the reduction achieved, the severity of reparative changes, and the weight of the victim. The recovery period varies considerably. Often patients go on disability.

With ruptures of the pubic joint carry out constant axial traction for both lower limbs for 6-8 weeks. The elimination of mixing in width is achieved by the simultaneous use of a hammock or skeletal traction by the wings of the ilium. After the termination of immobilization, the pelvis is fixed with a soft-elastic bandage, which must be used for six months. A dosed load on the limbs is carried out after 8 weeks, a full load is allowed after 10 weeks. Ability to work is restored after 3 months.

With dislocations of half of the pelvis (rupture of the pubic and sacroiliac joints) reposition along the length is carried out using constant skeletal traction for the epicondyle of the thigh on the side of dislocation and adhesive countertraction for the opposite limb. After eliminating the offset in length, the offset in width is repositioned using a hammock. The duration of traction and further management of the patient, as in case of fracture-dislocation of the pelvis. Patients should be advised to wear a pelvic brace for 1 year after injury.

Fractures of the acetabulum

Acetabular fractures are intra-articular injuries. They can be in the form of isolated fractures of the body of the ilium penetrating through the acetabulum, transacetabular fractures of the pelvis with angular displacement, fractures of the acetabular floor with displacement of the femoral head into the pelvic cavity (central hip dislocation), fractures of the upper-posterior edge without displacement of the femoral head and fractures of the upper posterior edge with displacement of the head (dislocation) of the femur. Mechanism of injury: fall on the area of ​​large trochanters, compression of the pelvis in the frontal plane, or frontal impact in a car accident.

Clinic. Complaints of pain in the hip joint. With fractures without displacement, active movements in the joint are possible, leading to increased pain, and partial support of the limb is rarely preserved. With displaced fractures, active movements of the limb are sharply limited, often it is in a vicious position: flexion and external rotation in case of transacetabular fracture of the pelvis, flexion and internal rotation in case of central hip dislocation, flexion, adduction and internal rotation in case of posterior hip dislocation. In fractures with displacement of the femoral head, the contours of the hip joint are violated: with posterior hip dislocations, the greater trochanter is displaced anteriorly, with a central dislocation, it sinks deep. The nature of the damage is clarified by radiography in 2 projections, since the displacement can also be in the anterior-posterior direction.

Treatment.

With isolated fractures of the iliac body penetrating into the acetabulum , the joint is unloaded using a system of permanent skeletal or adhesive traction in the average physiological position of the limb for 4 weeks. Movements in the joint begin when the acute pain syndrome subsides (after 5-7 days). A subsidized load is allowed after 4-5 weeks, a full load - after 8-10 weeks. Ability to work is restored after 10-12 weeks.

With transacetabular fractures of the pelvis there comes an angular displacement of fragments towards the pelvic cavity - the diagonal size entering the cavity of the small pelvis decreases. Reposition of fragments can be achieved by the method of constant skeletal traction for the limb of the damaged side. The needle is carried out behind the epicondyle of the thigh, the initial load is 4 kg, the comparison of fragments usually occurs with loads of 6-7 kg. The duration of traction is 8 weeks, after 2-3 weeks from the moment of injury, therapeutic exercises for the hip joint begin. Subsidized load on the limb of the injured side is possible 10-12 weeks after the injury, full load - after 4-6 months. Ability to work - after 5-7 months.

In case of fractures of the bottom of the acetabulum without displacement of the head impose a system of permanent skeletal traction for 4 weeks, therapeutic exercises begin on the 3rd-4th day, a dosed load is possible 8 weeks after the injury, full - after 12-14 weeks. Ability to work is restored after 4-5 months.

In case of fractures of the bottom of the acetabulum with displacement of the head into the pelvic cavity (central hip dislocation) reposition is achieved by using a system of constant skeletal traction: the pin is passed behind the supracondylar region of the thigh with an initial load on a skeletal traction of 4 kg. The limb is placed in the position of adduction and flexion in the hip and knee joints. To eliminate the displacement of the head, traction is carried out along the axis of the neck using a loop to the proximal end of the thigh (with a shallow penetration of the head) or skeletal traction for the region of the greater trochanter with an initial load of 4 kg. The build-up of loads is carried out initially only along the axis of the femoral neck until the dislocation of the head is eliminated. After reduction is achieved, the weights are gradually transferred to skeletal traction along the axis of the limb, leaving the initial load along the axis of the neck. After achieving reposition, the limb is gradually (within a week) retracted to an angle of 90-95°. Duration of traction -8-10 weeks. Movements in the joint are allowed after 1-2 weeks upon reaching reposition. Dosed load on the limb is possible after 2.5-3 months, full - after 4-6 months. Ability to work is restored after 5-7 months. In case of fractures of the posterior-upper edge of the acetabulum without displacement of the head (without displacement of the fragment), a system of permanent adhesive traction is applied for 4 weeks. Movements in the joint begin from the 2nd week. A dosed load is allowed after 6 weeks, a full load - after 8-10 weeks. Ability to work is restored after 3 months.

In case of fractures of the posterior superior edge of the acetabulum with displacement of the femoral head (upper and posterior hip dislocations) under general anesthesia, the dislocation is eliminated. If the reduction is stable (upon cessation of traction along the length and passive movements in the joint, the recurrence of dislocation does not occur), the joint is unloaded using constant adhesive traction for 4 weeks in the position of moderate flexion, abduction and external (with upper-posterior dislocations) or internal ( with anterior dislocations) rotation. The position of rotation contributes to the approach of the bone fragment torn off together with the capsule to its bed. Usually, stable reposition is observed when a small fragment of the edge of the acetabulum is fractured, which is not under load and such a fracture is tear-off. Therefore, after the cessation of traction, the patient is allowed a dosed load, and a full load is possible after 6-8 times. Approximately in the same period, working capacity is restored.

If hip dislocation is accompanied by a fracture of a large fragment of the roof of the acetabulum, which is located in the load zone of the head, the position of the head is unstable - the dislocation recurs after the cessation of traction along the length and adduction of the hip. Medical tactics in such cases, it depends on whether the reposition of the bone fragment occurs when the femoral head is repositioned or the fragment is not matched. If, when eliminating the dislocation, the comparison of the bone fragment is also achieved, then the stabilization of the position is achieved by using a system of constant skeletal traction for the femoral epicondyles with the use of holding weights (6-7 kg). The duration of skeletal traction is 6-8 weeks. Then, for 2-4 weeks, adhesive traction with therapeutic exercises in the hip joint is carried out. A dosed load is possible after 10-12 weeks, a full load after 4-6 months. the rotational nature of its displacement, it is necessary to quickly match the fragment and fix it with screws,

In the postoperative period, it is advisable to unload the joint using constant adhesive traction for 6-8 weeks with early therapeutic exercises. Dosed load is allowed after 10-12 weeks, full - after 4-6 months. Ability to work is restored after 5-7 months.

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