Age features of the pelvis. Wide hips in men: what can it say

In newborns, the pelvis is funnel-shaped. The wings of the iliac bones are located more vertically, their crests are cartilaginous (weakly, S-curved). The small pelvis is underdeveloped, the entrance to it is narrow, longitudinally oval. The cape is weakly expressed and is formed by the 1st and 2nd sacral vertebrae. Each innominate bone consists of three parts: the ossification nuclei of the ilium, ischium and pubic bones, interconnected by a layer of cartilage.

The coccyx consists of 4-5 cartilaginous vertebrae. In the thickness of the I-III sacral vertebrae, there are five nuclei of ossification. During the period early childhood the ossification nuclei of the sacrum significantly increase in size, and in the preschool period they begin to merge with each other, forming separate vertebrae (segments) of the sacrum. In parallel with the growth of individual bones, the structure of the pelvis changes, and the position of the pelvis changes. In the preschool period, the first sacral vertebra is displaced in the ventral, and P-Sh in the dorsal direction. As a result, the sacrum acquires kyphosis, and the cape is formed between the V lumbar and I sacral vertebrae.

In parallel, the position of the iliac bones changes, the bodies of which experience rotation around the sagittal axis. As a result, their wings begin to diverge to the sides and the pelvis loses its funnel-shaped shape. The line of entry into the small pelvis becomes distinctly expressed. Change the size of the entrance to the pelvis. In the pubertal period, the pelvis acquires features characteristic of the pelvis of an adult. The pelvic cavity acquires a cylindrical shape in girls. The pelvic surface of the sacrum loses its fragmentary structure.

In newborns, the muscle that raises the anus to its main parts is not differentiated and is a thin (0.8-1 mm) muscle plate. During early childhood and preschool age, the muscle thickens and differentiates into two parts: m rubococygeus and m iliococygeus, passing one into the other.

The rectum in newborns is relatively long (50-60 mm), its sections are poorly differentiated. The pelvic region is short, stretched and completely occupies the cavity of the small pelvis. Ampullary, the department is usually absent. The anal section has a considerable length (30-40 mm), its narrowed diameter in the perineal part does not exceed 15 mm (V. Frolovsky). At the site of the transition of the pelvic to the anal, there is a pronounced transverse fold of the mucosa - plica transversalis interior. The location level corresponds to the bottom of the rectovesical or recto-uterine cavity and is projected onto the 1st coccygeal vertebra. The wall of the rectum is not fully formed, its muscular wall is poorly developed. The mucous membrane is not sufficiently fixed, which can lead to its prolapse. Throughout the anal part, the mucous membrane forms high longitudinal folds (columna anales), between which lie deep sinus analis. The hemorrhoidal zone is individually different, in some newborns it is well expressed, in other cases it is only outlined in the form of a narrow strip.

As the child grows, the structure of the rectum and its topography change. In the first year of a child's life, its diameter increases significantly, while the intestine shortens (up to 37-47 mm).

In children aged 1-3 years, the transitional form of the rectum is much more common, and in the preschool years, the ampullar form of the rectum is observed (L.V. Loginova-Katricheva).

• Surgical anatomy birth defects, organs of small pelvis and perineum.
• Exstrophy and diverticulum Bladder refer to anomalies in the development of the bladder.
• Exstrophy of the bladder occurs as a result of a violation of embryogenesis, due to a violation of the development of the genital tubercle and especially the anterior abdominal wall, a severe defect develops, accompanied by the absence of the anterior wall of the bladder and the corresponding part of the anterior abdominal wall. AT lower sections of the abdomen in such children, the mucous membrane is visible rear wall bladder with hypertrophic folds, its edges are soldered to the skin of the anterior abdominal wall. In the lower sections of the protrusion, the openings of the ureters are visible. With age, it scars and becomes covered with papillomotous growths. The defect is characterized by a divergence of the pubic bones, congenital inguinal hernia, cryptorchidism; in girls - splitting of the clitoris, etc.

The cause of the occurrence of diverticula is explained by the presence of "weak" places in the walls of the bladder, or by the incomplete reverse development of the urachus.

B. D. Ivanova, A.V. Kolsanov, S.S. Chaplygin, P.P. Yunusov, A.A. Dubinin, I.A. Bardovsky, S. N. Larionova

The skeleton is the backbone of the whole organism. Separate parts of the skeleton serve to protect such the most important organs, like the brain, heart, lungs, etc. In addition, skeletal system in conjunction with muscular system forms the organs of human movement, while the bones are levers actuated through the muscles attached to them. Nervous system gives impulses to muscle contraction.

The skeleton of a child is laid down in the early uterine period and consists mainly of cartilage tissue. Even in the uterine period, cartilage tissue begins to be replaced bone tissue. The process of ossification proceeds gradually, and not all bones of the skeleton ossify at the same time. The ossification process is completed by the age of 20-25.

Changes occur in the chemical composition of bone tissue throughout a person's life up to a very old age. At younger ages, there are very few calcium and phosphorus salts in the bone tissue. Due to the fact that there are few calcium salts in the bones of children, and organic elements predominate, and the processes of ossification are far from complete, the skeleton of children has great elasticity and can easily be subjected to curvature.

The spine in an adult has three curvatures. One of them - the cervical - has a bulge forward, the second - the thoracic - is bulging back, the third - the lumbar curvature is directed forward. In a newborn, the spinal column has almost no bends. The first cervical curvature is formed in a child already when he begins to hold his head on his own. The second in order is the lumbar curvature, which also faces forward with a bulge when the child begins to stand and walk. The thoracic curvature, which is convexly backward, is the last to form, and by the age of 3-4 years, the child's spine acquires curves characteristic of an adult, but they are not yet stable. Due to the great elasticity of the spine, these curves are smoothed out in children in the supine position. Only gradually, with age, the curvature of the spine becomes stronger, and by the age of 7, the constancy of the cervical and thoracic curvature is established, and by the onset of puberty, the lumbar curvature.

Only gradually, as the child grows, does the process of ossification of the spine occur. Until the age of 14, the spaces between the vertebral bodies are still filled with cartilage. At the age of 14-15, new ossification points appear between the vertebrae in the form of thin plates on the upper and lower surfaces of the vertebrae. Only by the age of 20 do these plates fuse with the vertebral body. The line of their fusion remains pronounced until the age of 21. The tops of the transverse and spinous processes of the vertebrae up to 16-20 years also remain covered with cartilage when ossification points appear on them. Fusion of cartilaginous plates with arches is completed after 20 years.

These features of the development of the spine of a child and adolescent cause its slight compliance and possible curvature in case of incorrect body positions and prolonged stress, especially unilateral. In particular, curvature of the spine occurs when sitting incorrectly on a chair or at a desk, especially in cases where the school desk is improperly arranged and does not correspond to the height of children; when sleeping for a long time with a bent torso on one side, etc. Curvature of the spine can be in the form of a bend in the neck (especially in infants if they are not carried properly on their hands) and chest parts side of the spine (scoliosis). Scoliosis of the thoracic spine most often occurs at school age as a consequence of improper seating. Antero-posterior curvature of the thoracic spine (kyphosis) is also observed as a result of prolonged improper seating. Curvature of the spine can also be in the form of excessive curvature in the lumbar region (lordosis). This is why school hygiene is so great importance a properly arranged desk and imposes strict requirements for the seating of children and adolescents.

Fusion of segments of the sternum also occurs relatively late. So the lower segments of the sternum grow together at the age of 15-16, and the upper segments only by the age of 21-25, and only the handle of the sternum remains independent. In case of prolonged incorrect landing in cases where a child or teenager rests his chest on the edge of the desk cover, a change may occur. chest and there may be disturbances in its development. This, in turn, adversely affects the normal development and activity of the lungs, heart and large blood vessels located in the chest.

The development of the pelvic bones in children, especially girls, is also of hygienic interest. The adult pelvis consists of two nameless bones and a sacrum wedged between them. The latter represents five pelvic vertebrae fused together. The pelvis in children is different in that each innominate bone consists of three independent parts adjacent to each other: the ilium, ischium and pubis. Only from about the age of 7 do these bones begin to fuse with each other, and the process of their fusion basically ends by the age of 20-21, when the nameless bone becomes one. This circumstance must be taken into account, especially in relation to girls, since their genitals are enclosed in the pelvis. With sharp jumps from a great height onto a hard surface, an imperceptible displacement of the pelvic bones that have not yet fused and, subsequently, their incorrect fusion can occur.

The wearing of high-heeled shoes by adolescent girls also contributes to the change in the shape of the pelvis. human foot has the form of a vault, the bases of which are the back stop calcaneus, and in front - the heads of the first and second metatarsal bones. The arch has the ability of elastic stretching, "springs", due to which impacts on the soil are softened. Narrow shoes, tightening the foot, make it difficult for the arch to work as a spring and lead to the formation flat foot(the vault is smoothed). High heels change the shape of the arch and the distribution of the load on the foot, shift the center of gravity forward, as a result of which you have to tilt your torso back so as not to fall forward when walking. Constant wearing shoes with high heels leads to a change in the shape of the pelvis. With incompletely fused pelvic bones, this deviation of the body and a shift in the center of gravity can lead to a change in the shape of the pelvis, and, moreover, in the direction of reducing the outlet of the pelvic cavity due to the approach of the pubic bones to the sacrum. It is quite obvious that for a girl, when she becomes a woman, this curvature of the pelvis can become fatal and adversely affect the birth function.

The cranial bones of the newborn are also in the stage of ossification and have not yet fused with each other, with the exception of upper jaw and intermaxillary bone. The cranial bones are connected to each other by a soft connective tissue membrane. Between them there are places that are not yet covered with bone tissue, peculiar membranous spaces - large and small fontanelles, covered connective tissue. A small fontanel overgrows by 2-3 months, and a large one by 1 year is already covered with bone tissue. The cranial sutures finally fuse only by 3-4 years, sometimes later. In children in early age the brain part of the skull is more developed than the front.

The bones of the skull grow most intensively during the first year. In subsequent years, the growth of the skull occurs unevenly: periods of strong growth are replaced by periods of relative calm. Thus, a relatively strong growth of the skull occurs from birth to 4 years, from 6 to 8 years and from 11 to 13 years. From 7 to 9 years there is a strong growth of the base of the skull. In the period from 6 to 8 years, it is already noticeable strong development facial part of the skull. But the most intensive development of the facial part of the skull begins from 13 to 14 years of age and then proceeds during puberty, when the final ratio between the brain and front part skulls.

The ossification of the tubular bones that make up the skeleton of the limbs begins in the fetal period and proceeds extremely slowly. Inside the middle part of the tubular bone (diaphysis), a cavity is formed, which is filled with bone marrow. The ends of long tubular bones (epiphyses) have their own separate ossification points. Complete fusion of the diaphysis and epiphyses is completed at the age of 15 to 25 years.

The development of the process of ossification of the hand is of great importance in hygienic terms, since through the hand the child learns to write and perform various labor movements. The newborn has no carpal bones at all yet and they are only just emerging. The process of their development proceeds gradually, and they become clearly visible, but not yet fully developed, only in children of 7 years old. Only by the age of 10-13 the process of ossification of the wrist is completed. The process of ossification of the phalanges of the fingers ends by 9-11 years.

These features of ossification of the hand have importance for correct setting teaching children writing and labor processes. It is quite obvious that for a child's not completely ossified hand, it is necessary to give a pen that is accessible to him in size and shape for writing. In this regard, it becomes clear that a quick (fluent) letter to children lower grades fails, while for adolescents, in whom the process of ossification of the hand ends, as a result of a gradual and systematic exercise, fluent writing becomes available.

From the foregoing, it is clear that not only in children younger ages, but even in adolescents in high school, the processes of ossification are not yet fully completed, and in many parts of the skeleton they continue until the period of adulthood. The described features of bone development in children and adolescents put forward a number of hygienic requirements, which have already been partially indicated above. Due to the fact that the process of ossification of the skeleton of a child of preschool and school age has not yet been completed, the incorrect organization of educational work and forcing the child to exercises of the motor apparatus beyond his age can bring him great harm and cause mutilation of the child's skeleton. Especially dangerous in this regard are excessive and one-sided physical stresses.

Moderate and accessible to children physical exercise, on the contrary, are one of the means of strengthening bone tissue. Extremely important for a growing organism physical exercises associated with respiratory movements and entailing the expansion and collapse of the chest, as they contribute to its growth and strengthening of bone tissue.

Upper and lower limb exercises enhance growth processes long bones, and, conversely, the lack of movement, pressure on the bone tissue (by swaddling, clothes squeezing the body, etc.), incorrect body position entail a slowdown in the growth of bone tissue. On the development of bones, their chemical composition and strength have a certain influence on the nutritional conditions and external environment surrounding the child and adolescent.

For normal development bone tissue in children requires the presence of benign air, an abundance of light (especially constant access to direct sun rays), free movements of all members of the body and rational nutrition of the body.

/ Fedorov I.I. // Forensic-medical examination. - M., 1963 - No. 4. - S. 18-25.

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

Received 4/III 1963

Age features of the pelvic bones

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Age features pelvic bones / Fedorov I.I. // Forensic-medical examination. - M., 1963. - No. 4. - S. 18-25.

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

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

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

Ilium by the time of birth, it is clearly differentiated radiographically into the body and wing. Its upper edge is arcuately curved and has smooth contours; The lower posterior spine and the greater ischial notch are well defined. The lower edge is angled down, its sides are straight and smooth (Fig. 1).

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

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

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

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

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

The synostosis of the crest with the ilium begins at the anterior margin of the wing and gradually spreads to its middle and posterior thirds.

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

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

Table 1

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

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

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

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

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

table 2

Timing of synostosis of the iliac crest

Rice. 3. X-ray of the symphysis area of ​​a 19-year-old boy.
1 - ischium apophysis; 2 - apophysis of the lower branch of the pubic bone.

Table 3

The term of synostosis of the apophysis of the ischium

Rice. Fig. 4. X-ray of the anatomical preparation of the pubic bones of the symphysis area of ​​a 13-year-old boy.
1 - the serration ("saw") of the pubic bones is clearly visible.

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

Pubic bone by the time of birth, on the radiographs of all examined, it is represented by one upper branch, located obliquely (see Fig. 1).

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

Table 4

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

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

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

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

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

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

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

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

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

Table 5

With the end of the synostosis of the bones that form the acetabulum, the "bones of the acetabulum" are not detected.

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

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

findings

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

Pelvic fractures in children make up about 4% of all bone fractures and occur mainly between the ages of 6 and 12 years. The cause is severe injuries, most often associated with road accidents and falls from great heights. Avulsion fractures are also observed as a result of muscle tension, for example, avulsion of the external anterior superior iliac spine during the tension of the sartorius muscle during a game of football or gymnastic exercises.

To understand fracture pathogenesis pelvic bones in children should take into account a number of features of the child's pelvis. These include: weakness ligamentous apparatus in the pubic and sacroiliac joints; the presence of cartilaginous layers separating all three pelvic bones (pubic, ischial and iliac) from each other and cartilaginous layers along the crest and all four axes of the ilium. The pelvic ring, due to the flexibility of children's bones, is more elastic, however, it has a different thickness. Pelvic fractures can result from the direct impact of an injury at the site of force application (direct fracture) or at a distance from the site of direct impact (indirect fracture). In this regard, isolated, double and multiple bone fractures are observed along the pelvic ring. The plane of the fracture mainly runs in the vertical direction: there is often a divergence of the bones in places where the cartilaginous layers are located, which is a feature of pelvic fractures in childhood.

There are the following fractures of the pelvic bones:

1) isolated fractures of individual bones without violating the integrity of the pelvic ring, due to the direct impact of trauma; these include fractures of the iliac wing, ischium, or pubis;
2) fractures with violation of the integrity of the pelvic ring, which are divided into:
a) fractures anterior section pelvic ring with damage to the ischium and pubic bones on one or both sides, rupture of the pubic joint, or a combination of these injuries,
b) fractures of the posterior pelvic ring, which include fractures of the sacrum, ilium and ruptures of the sacroiliac joint,
c) double vertical fractures of the Malgen type;
3) fractures of the acetabulum;
4) fracture-dislocations, in which bone fractures are combined with dislocation of the pubic or sacroiliac joint.

Pelvic fractures can be closed or open, are often accompanied by damage to other bones, rupture of the kidney, bladder, urethra, diaphragm and intestines.

In all cases, the child must be carefully examined so as not to miss the accompanying damage.

Closed fractures of the pelvic bones without breaking the integrity of the pelvic ring and damage internal organs refer to milder pelvic injuries that occur at the site of application of force (for example, fractures of the ischial and pubic bones when falling on the buttocks). Fractures of the anterior superior iliac spine can also be avulsion and, as a result of contraction of the sartorius muscle, can be displaced for a considerable distance.

clinical picture. General state with this type of fracture remains satisfactory. Pain is noted at the fracture site during palpation and percussion, movement causes pain, a positive “symptom of stuck heel”. With avulsion fractures of the anterior superior iliac spine, hip abduction is painful, while with fractures of the ischial and pubic bones, adduction is painful. In the area of ​​the fracture, traumatic swelling and sometimes a hematoma are determined. The diagnosis is specified after X-ray examination.

Treatment is carried out in a hospital.

Closed fractures of the pelvic bones with violation of the integrity of the pelvic ring without damage to internal organs refer to severe injuries caused by street traffic injury or a fall from a height. They may be single or multiple. With single fractures, the integrity of the anterior half ring in the region of the pubic or ischial bones is most often violated. With multiple fractures, a fracture of the anterior ring on both sides can occur with the formation of bone fragments resembling a butterfly or leaf in shape.

The simultaneous fracture of the anterior and posterior semirings, first described by Malgenem, refers to severe injuries of the pelvic bones, when a typical displacement of fragments occurs - the medial fragment of the pubic bone is displaced downward, the lateral fragment upward and outward.

clinical picture. The general condition is usually severe, the effects of shock are more or less pronounced. On examination, asymmetry of the anterior-superior iliac spines is noted. In the area of ​​the pubic articulation, crepitation of fragments is sometimes determined. On palpation, the area of ​​bone damage is sharply painful. The patient cannot raise the outstretched leg - a positive symptom of "stuck heel". The localization of the fracture is also indicated by the presence of swelling, hematoma and abrasions. For some forms of fracture of the pelvic bones, the forced position of the patient is characteristic. With a rupture of the pubic joint, a position is noted on the back with bent at the knee joints and adducted limbs. With a fracture of the anterior pelvic ring, a position with bent at the knee joints and abducted legs (“frog position” according to Volkovich) is characteristic. The diagnosis is clarified by X-ray examination of the pelvic bones and the area of ​​the hip joints.

Closed fractures of the pelvic bones with a violation of the integrity of the pelvic ring usually occur with symptoms of traumatic shock.

Treatment. Usually, patients with such an injury end up in a hospital, bypassing the clinic, but if a child with a pelvic injury is taken to a trauma center or surgical room, then a number of measures should be taken before sending the child to the hospital: measure blood pressure, determine hemoglobin and hematocrit, take an x-ray of the pelvic bones and begin anti-shock measures. To reduce pain, the child is placed according to Volkovich in the “frog position” (the legs are bent at the hip and knee joints and divorced, under knee joints put a roller). Administer heart medications. Cold is applied locally (ice pack). In the conditions of the dressing room, intrapelvic anesthesia according to Shkolnikov-Selivanov can be performed. Anesthesia according to this method is a highly effective anti-shock and anesthetic measure.

Technique of intrapelvic anesthesia according to Shkolnikov-Selivanov. The position of the patient is on the back. A thin needle produces anesthesia of the skin 1-2 cm medially from the anterior superior iliac spine. Next, a long needle, placed on a syringe with a 0.25% solution of novocaine, is advanced to a depth of 10-12 cm so that its tip slides along the inner wall of the ilium. When advancing the needle, a novocaine solution is injected. A child with a pelvic fracture is injected with 60 to 150 ml of a 0.25% solution of novocaine, depending on age. With concomitant fractures of the long tubular bones of the extremities, anesthesia of the damaged area with a 2% solution of novocaine at the rate of 1 ml per 1 year of the patient's life and immobilization in transport bus. In case of fractures of the pelvic bones without damage to the internal organs, drugs can be used at an age dosage.

Transportation is careful, on a rigid stretcher.

Pelvic fractures with damage to internal organs. Pelvic fractures are often complicated by damage to the urethra or bladder. Most often they are observed with fractures located closer to the symphysis of the pubic bones and with fractures of the Malgenya type. Often there is urinary retention and hematuria in fractures of the pelvic bones without violating the integrity of the bladder and urethra. It can be reflex and is caused by spasm of the sphincter of the bladder or hematoma of the perineum. The latter is caused by minor damage to the bladder mucosa, associated with a medial fracture of the pelvic bones. In all cases, emergency hospitalization is indicated.

Bladder rupture usually occurs as a result of hydrostatic pressure on the wall, which is damaged at the apex at the point of transition of the parietal peritoneum to the bottom of the bladder. Less commonly, the bladder wall is damaged by the sharp edge of a bone fragment. Bladder rupture can be extraperitoneal or intraperitoneal.

With an extraperitoneal rupture of the bladder, urine flows into the perivesical tissue, forming urinary streaks in the pelvic cavity, in the retroperitoneal space. The patient's condition is grave. Diagnosis of extraperitoneal bladder rupture is sometimes difficult due to the absence of symptoms of peritoneal irritation. Pain in the lower abdomen, dysuric phenomena are noted. The bladder is empty, not determined either by palpation or by percussion. However, there is a continuous urge to urinate without passing urine or passing very little bloody urine. In more late dates there is a test-like painful swelling in the inguinal regions.

Intraperitoneal rupture of the bladder is characterized by the outpouring of urine into the abdominal cavity, which causes clinical picture peritonitis. The muscles of the anterior abdominal wall are tense, Shchetkin-Blumberg's symptom is positive, the abdomen is painful. Tongue dry, lined. Repeated vomiting. Along with these symptoms, dysuric phenomena are noted, similar to extraperitoneal damage to the bladder.

Damage urethra are observed mainly in boys with fractures of the pelvic half-ring and fractures of the Malgen type. Blood is released from the external opening of the urethra (usually in drops); sometimes the external opening of the urethra is covered with a bloody crust. There is a complete urinary retention with an overflowing bladder, which is sometimes palpated in the form of a spherical formation above the pubis and is determined by percussion. Growing edema and hematoma are noted in the perineum.

It is necessary to examine the patient and transport him carefully, since compression of the pelvic bones from the sides can cause displacement of bone fragments and turn an incomplete rupture of the urethra into a complete one.

Catheterization is contraindicated! It is dangerous with additional damage in places of tears and ruptures, traumatic, painful and uninformative. The best diagnostic method is urethrocystography, which, when the urethra or bladder is ruptured, gives a clear x-ray picture of the level of damage based on leakage of the contrast agent into the paraurethral or paravesical tissue.

One of the severe concomitant injuries in a pelvic fracture is a traumatic rupture of the diaphragm (usually on the left) with displacement of part of the organs abdominal cavity into the chest. The diagnosis is made on the basis of clinical and radiological findings. Pleural puncture is contraindicated, as there is a threat of injury to the intestinal wall, stomach or parenchymal organ. In this regard, in case of fractures of the pelvic bones, fluoroscopy of the chest organs with the study of the contours of the diaphragm is mandatory. After the anti-shock measures indicated emergency hospitalization.

Guide children's polyclinic surgery.-L.:Medicine. -1986

Predisposing factors for this fracture may include:

• Falls from a great height;
• Road accidents;
• With excessive physical activity(for example: if the baby, not knowing, and not knowing how, tries to “sit down” on the twine, or unsuccessfully jumped in length);
• Rickets;
• Osteomyelitis;
• Cancer neoplasms of the skeletal system;
• Metastasis malignant tumors into the skeletal system
• Imperfect osteogenesis.

Symptoms

Clinical signs and manifestations depend on the location of the fracture. Thus, we can distinguish:

The marginal fracture of the pelvic bones is a fairly mild variant of these fractures. It is not combined with other injuries and fractures. You can recognize this by the following manifestations:

• First, there is a slight pain at the fracture site;
• After a couple of hours, a hematoma appears;
• The pain intensifies, it becomes impossible to make movements;
• Flexion and extension of the leg is difficult and is accompanied by severe pain;
• Hip abduction is difficult;
• Shortening of the limb.

A fracture of the pelvic ring without displacement is determined by a sharp pain. The child has an unnatural posture: the baby lies with half-bent and spread legs. If the pubic bone is damaged, then there is an inability to raise the straight leg on its own (stuck heel syndrome).

A displaced pelvic ring fracture is characterized by a rather serious condition patient. The first signs are:

• severe pain in the pelvic area;
• abdominal pain; forced position of the body (in case of a fracture of the pubic joint, the legs are bent and tucked in; if the anterior sections are damaged, then the small patient takes a forced frog position);
• deformation of the pelvic bones;
• shock state;
• heavy bleeding;
• damage to the nerves of the sacral region;
• the state of the patient is excited, after which the phase of inhibition begins;
• tachycardia;
• pressure drop;
• anuria;
• cyanosis of the skin;

Acetabular fracture most often occurs with other fractures and injuries. It is characterized by pain in the joint, the leg is pulled up and turned outward. The child is not able to keep the leg on the weight. Movement is difficult. The leg is shortened.

Diagnosis of a pelvic fracture in a child

To diagnose a fracture of the pelvic bones, use:

• X-ray examination of the pelvis and joints. However, sometimes the pictures may not be informative. This is typical for the confluence of a fault and a growth line. In these cases, the patient is referred for CT and MRI;
• CT scan;
• Magnetic resonance imaging;
• Consultation with a proctologist to exclude damage (rupture) of the rectum;
• If a fracture of the pelvic ring is suspected, the child is examined as carefully and accurately as possible. Palpation is only superficial, not deep. X-rays I do it on a gurney, since it is impossible to move the victim;
• Consultation at the surgeon, urologist is possible;
• Ultrasound diagnostics of the abdominal organs is carried out to detect damage to internal organs, to determine the presence of bleeding.

Complications

Complications and consequences of this type of fracture are varied. For example:

• Incorrect fusion of bones;
• Big blood loss
• Anemia;
• Damage to the pelvic and abdominal organs;
• infectious processes;
• Purulent-inflammatory process;
• Peritonitis;
• Violation of innervation;
• vascular damage;
• Paresis (with rupture of nerves);
• Fatal outcome;
• Disability;
• Lameness.

Treatment

What can you do

Timely and competently provided first aid for a fracture is the key to successful treatment and recovery. And therefore to provide first aid worth it only if you have the skills. Otherwise, you can just do more damage.

Call an ambulance; Anesthesia is performed (orally), sedatives are given; It is necessary to put a roller made from improvised means under the knees. In this case, the legs should be bent.

In no case should you set the fracture yourself, pull the victim by the legs, invite him to stand up. You cannot transport the patient yourself. You have to wait for the doctors to arrive.

What does a doctor do

Makes a preliminary diagnosis and checks it with the help of complete examination damaged area. Once the diagnosis is established and confirmed, immediate treatment begins. Produced first local anesthesia fracture sites. The following methods are used next:

• If the integrity of the pelvic ring is broken without violating the integrity of the bones, the position of the patient in the Volkovich position is shown for a period of 5 weeks;
• In case of a fracture of the ilium with simultaneous damage to the acetabulum, a Beler splint is used. If there has been a significant displacement of the bones, then the position of the body in a hammock for a period of a month is shown;
• Skeletal traction using a pose in a hammock with weights; Next is assigned rehabilitation treatment, which includes maintaining the normal functioning of the body, normal breathing is restored. rehabilitation period, which includes warm-ups, exercise therapy, electrophoresis, massage.

Prevention

Preventive measures are aimed at identifying and eliminating the causes of possible injury. Such measures include:

• Do not leave the child alone on the street, on the playground;
• Explain the rules of the road;
• Keep an eye on the baby during active games;
• Strengthen the bones of the child with vitamins, micro and macro elements;
• Identify diseases that affect bone strength.

You will also find out what can be dangerous untimely treatment ailment fracture of the pelvic bones in children, and why it is so important to avoid the consequences. All about how to prevent pelvic fractures in children and prevent complications.

BUT caring parents found on the service pages full information about the symptoms of the disease fracture of the pelvic bones in children. How do the signs of the disease in children at 1.2 and 3 years old differ from the manifestations of the disease in children at 4, 5, 6 and 7 years old? What is the best way to treat pelvic fracture in children?

Take care of the health of your loved ones and be in good shape!