Pelvic fractures complicated by damage to the pelvic organs. Osteosynthesis: the essence of the operation, indications, rehabilitation, prices. What is osteosynthesis

13.07.2014

Ruptures of the pelvic joints are considered rotational injuries and occur under the influence of great force. This is compression of the pelvis in the anteroposterior direction or an indirect blow to one of the halves of the pelvis, for example, through a lower limb bent and abducted outward. As a rule, one of the halves of the pelvis is torn off; bilateral rotation of both halves is rare.

These injuries include ruptures of the pubic symphysis and sacroiliac joint. They are characteristic of multiple and combined injuries and, in isolated form, occur as casuistry.

The pubic symphysis and sacroiliac joint provide stability to the pelvic ring anteriorly and posteriorly in conjunction with the lig. sacrospinal and lig. sacrotuberale. The pubic bones are connected to each other by the interpubic cartilaginous disc, the superior pubic ligament and the powerful arcuate inferior pubic ligament. The sacroiliac joint is a syndesmosis. The sacrum and iliac bones are connected to each other by interosseous sacroiliac ligaments. The syndesmosis is strengthened anteriorly by the anterior sacroiliac ligaments and the more powerful posterior sacroiliac ligaments. Mobility in these joints is minimal and does not exceed 3-4 mm in women and 1-2 mm in men.

Ruptures of the pelvic joints are considered rotational injuries and occur under the influence of great force. This is compression of the pelvis in the anteroposterior direction or an indirect blow to one of the halves of the pelvis, for example, through a lower limb bent and abducted outward. As a rule, one of the halves of the pelvis is torn off; bilateral rotation of both halves is rare. In 70% of cases, ruptures of the pubic symphysis occur simultaneously with fractures lower limbs, especially the hips. The causes of these severe injuries include car accidents and falls from great heights. Isolated ruptures of the pubis are observed when the pelvis is compressed in the anteroposterior direction, for example, when the victim is pressed against a wall by a car bumper or when a car wheel hits the pelvis. In a work environment, these injuries most often occur on a construction site when a worker is crushed by a collapsed wall or concrete slab.

If the rupture of the pubis is less than 2 cm, then the posterior pelvic complex remains relatively stable, since there is no complete rupture of the ligaments, but there are ruptures of individual fibers. If the pubic rupture is more than 2 cm, the sacroiliac ligaments are also completely torn or there is a fracture of the wings (lateral mass) of the sacrum.

When a vertical force is added to the rotation of the pelvis, the pelvis is rotated like an “open book”, and the severed half of the pelvis is displaced upward.

The clinical picture for large tears of the pubic symphysis is quite bright. The pelvis is significantly expanded (in men it becomes like a woman’s), the lower limb on the side of the rupture is turned outward, sometimes to such an extent that the outer surface of the knee joint lies on the surface of the bed. Internal rotation is not possible. With passive movements of the leg, patients feel abnormal mobility of the severed half of the pelvis. Diastasis is determined by palpation between the pubic bones. The hematoma of the scrotum quickly grows, sometimes to the size of a child's ball; in women - hematoma of the labia majora, more on the side of the avulsion.

In women, due to stretching of the vulva, weakening of the external urethral sphincter may occur with constant or periodic urinary incontinence, which is incorrectly interpreted as a urethrovaginal fistula. In our experience, when diastasis of the symphysis pubis is eliminated and fixed, normal sphincter function is restored and urinary incontinence stops.

X-ray diagnostics seem to be simple, but there are a number of injuries that are quite difficult to detect, and they determine the treatment tactics. These include damage to the posterior complex - the presence and location of sacral fractures and the size of diastasis in the sacroiliac joint. These details can only be determined on transverse and longitudinal CT scans of the sacrum.

Indications for extrafocal osteosynthesis of the pubic symphysis and technique for its implementation

Treatment of injuries to the pubic symphysis with a discrepancy of less than 2 cm is conservative. If there are no fractures of other pelvic bones and vertical displacement of half of the pelvis, then on the 2-3rd day the victim is ordered a reinforced pelvic bandage according to his size. In this bandage, the patient can turn in bed, and after 2-3 weeks walk on crutches with support on both legs. If the vertical displacement is less than 1 cm, a bandage is also ordered, but the period of bed rest is extended to 4 weeks. Vertical displacement of more than 1 cm is an indication for the application of skeletal traction for a period of 6 weeks after the achieved reposition.

Tears of the pubic symphysis greater than 2 cm with instability of the severed half of the pelvis were an indication for surgical treatment. Currently, there are two methods of osteosynthesis - extrafocal with various ANFs and submersible - with wires, screws and plates.

Up to 40 ANF designs have been proposed, which can be divided into 3 groups: rod, wire, and wire-rod based on the method of attaching the devices to the iliac crests. Rod devices predominate, in which Steinman-type threaded rods are screwed into the iliac crests. When inserted into the center of the ridge, they hold well and provide stable fixation. Disadvantages include the possibility of infection, especially in the presence of a colostomy and cystostomy, and migration of rods if inserted incorrectly, which happens in obese patients.

Pin fastening in the arcs of the Ilizarov apparatus (V.M. Shigarev) or diverging pins (Sh. Besaev) is possible in thin male patients, but in obese men and women it presents relative difficulties both during insertion into the bone and during subsequent care them. They are not as widespread as rod ones, and we have no information about their use abroad.

For submersible osteosynthesis of the pubic symphysis, lavsan tapes, wires, and metal staples were historically proposed, but all of them did not provide adequate stability and are currently abandoned. The generally accepted technique is osteosynthesis with a metal reconstructive plate with 4 or more screws along the AO. It provides proper stability and the possibility of early activation of patients, although not in all cases.

Osteosynthesis of the sacroiliac joint is performed with screws with a 32 mm thread along the AO or with a bolt behind the iliac crests.

An intermediate system between external and internal fixation is the minimally invasive internal rod system V.M. Shapovalova et al. (2000), but we have no experience with its use and cannot judge its effectiveness.

In most cases, extrafocal osteosynthesis of the pubic symphysis is performed at the resuscitation stage, and it is an integral part of trauma care for seriously injured patients with polytrauma. However, this method is also used in OMST in those patients who did not undergo pelvic fixation in the intensive care unit, and in patients who were transferred from hospitals where the technique for treating complex pelvic injuries has not been mastered. Some patients require remounting of the devices in cases where there is suppuration of the rods or the stability of fixation is lost.

Indications for the use of ANF in OMST:

Tears of the pubic symphysis” in the presence of a cystostomy or colostomy. The main condition is satisfactory sealing of the urinary or fecal fistula. Modern colostomy bags and Petzer-type catheters allow this to be done quite successfully;

Failure of the ANF device applied in the intensive care unit, the cause of which is the loosening of screws placed not in the center of the iliac crest or in an oblique direction, in which the screw comes out of the bone. If the rods of the device have not had time to fester, then you can place the rods in a new place and remount the device;

Suppuration in the area of ​​the rods is usually accompanied by their loosening and loss of fixation stability. Suppuration is usually limited soft tissues and partly bone. We did not observe the development of core osteomyelitis in any case. In these cases, the device was removed, the rods were removed, and the wounds at the site where the rods were inserted were treated. After healing of the wounds, repeated extralesional osteosynthesis of the ANF was performed 1-2 weeks later.

ANFs applied to the pelvis for the above indications are intended for long-term fixation of the pelvic bones, therefore high demands are placed on their stability. Stability was achieved by introducing at least three rods into each ridge and an additional one rod into the roof of the acetabulum as the strongest and thickest place of the ilium. To do this, after connecting the rods passed through the iliac crest together, under the control of the image intensifier, a wire was inserted 1 cm above the edge of the acetabulum and parallel to the wire another 1 cm above, a channel was drilled and a Schanz screw was inserted, which was connected to the three previously inserted. In a similar way, a strong connection of 4 rods was created on the other side. This system is very durable, since the additional screw prevents the first three from bending during the approach of the halves of the pelvis. After this, the halves of the pelvis were brought together manually or using two threaded rods (Fig. 7-8).

If extrapelvic injuries allowed, the patient could be placed in bed on the 2-3rd day, and after 4-5 days he was allowed to walk with the help of crutches or a walker. The period of immobilization was 8 weeks, after which the ANF was removed and the patient wore a pelvic bandage for up to 4 months from the moment of injury. The timing of immobilization depended on the type of damage to the posterior semi-ring of the pelvis. If these were fractures of the sacrum or ilium, then the time frame could be reduced to 3 months, since during this time the fractures completely healed. The prognosis for pure ruptures of the sacroiliac joint was less favorable. Restoration of the ligaments of this joint occurs only if the rupture of the pubic symphysis is completely eliminated within 1 week and no vertical displacement remains. The more time has passed since the injury, the more difficult it is to compare the separated halves of the pelvis and the worse the result. The ligaments are not restored, but are replaced by a scar, as a result of which mobility in the sacroiliac joint is maintained, manifested by pain and instability when walking. Some patients cannot sit.

Rice. 7-8. Scheme of “reinforced ANF” applied to the pelvis for ruptures of the pubic symphysis.

Indications for submersible osteosynthesis of the pubic symphysis and technique for its implementation

In our country, preference is given to extrafocal osteosynthesis of the pubic symphysis, and the number of traumatologists who have experience in internal osteosynthesis is not as large as abroad, where the picture is exactly the opposite. There, extrafocal osteosynthesis is mainly a method of temporary immobilization for unstable ruptures of the pubis, forming part of the “damage control” system.

After stabilization of the victim’s condition, on the 5-7th day they switch to immersion osteosynthesis. We have performed more than 120 operations of internal osteosynthesis of the pubic symphysis and can give reasoned recommendations for its use.

Quite a lot of devices have been proposed for submersible osteosynthesis of ruptures of the pubic symphysis; most of them are currently of historical significance and have not been used in practice even by their authors. Some of these devices are purely speculative (for example, “lacing” of the pubic symphysis according to A.V. Kirilenko), others are not reliable enough. The latter includes the use of wire and textile sutures, which are passed and tightened either around the vertical branches of the pubic bones, or around screws inserted into the vertical branches of the pubic bones. We observed several such patients transferred from hospitals in other cities. All of their wires broke and their Dacron ribbons were torn. This is understandable, since the pelvis experiences significant rotational loads and such fixation is initially doomed to failure.

Main credit for development modern techniques fixation of the pubic symphysis belongs to the AO group, which proposed using a reconstruction plate and spongy 3.5 and 4.5 mm screws for this purpose. This technique is currently generally accepted. The advantages of internal stable osteosynthesis of discrepancies of the symphysis pubis along the AO compared to extrafocal fixation are as follows.

The absence of bulky external structures that mentally and physically depress patients. They cannot wear regular clothes, avoid socializing and long time feel seriously ill. The majority of patients with ANF do not have the opportunity to have sex, which creates serious inferiority complexes in some of them. Internal osteosynthesis eliminates these problems. As soon as the patient begins to walk independently, he quickly adapts to normal life and can be in society without causing the compassionate glances of others. Patients with non-physical work return to their previous activities quite early.

There is no danger of suppuration and loosening of the rods. The first is especially important in obese patients, and the second in women with thin iliac bones. Due to the pressure of the rods inserted into the cancellous bone, bone tissue resorption quickly occurs on the edge of the drilled canal, the canal enlarges and the fixation of the rods to the bone weakens.

Possibility of more accurate comparison of pubic bones with removal of cartilage, interposition of ligaments and other soft tissues. This ensures the restoration of the ligaments that support the penis and serves as a prevention of impotence, which is of great importance for young men.

There are injuries to the pubic symphysis that can only be repaired through open surgery. These include ruptures of the pubic symphysis with a simultaneous fracture of the pubic and ischial bones with anterior rotation of the resulting segment, as well as chronic untreated ruptures of the pubic symphysis, which require arthrodesis of the pubic and sacroiliac joint.

Internal osteosynthesis of the pubic symphysis is contraindicated in the presence of urinary and fecal fistulas, purulent wounds of the perineum, general purulent complications combined injuries.

Injuries to the bladder (extraperitoneal) may not be diagnosed immediately after injury and are discovered during osteosynthesis of the pubic symphysis. We encountered this situation on 2 occasions. In one case, after a Pfannenstiel incision, an accumulation of about 20 ml of hysterical fluid was discovered in one of the corners of the wound behind the pubic bone. After osteosynthesis of the symphysis pubis, urine began to leak from the wound through the drainage. At the same time, the patient urinated naturally on his own. The drainage had to be maintained for 14 days. The amount of urine released through it gradually decreased from 400 ml per day to 20-50 ml, after which the drainage was removed, a permanent catheter was placed in the bladder for 3 days and the urinary fistula closed on its own. There was no suppuration in the area of ​​the plate.

In another case, we performed osteosynthesis of the symphysis pubis 2.5 months after injury in a patient with a ruptured bladder. His cystostomy closed 1 month after injury, and he urinated naturally for 1.5 months. Imagine our surprise when, after cutting the skin and tissue above the pubis, in the wound we saw the end of the Foley catheter inserted before the operation. The anterior wall of the bladder was practically absent. Obviously, it was sutured with tension, and subsequently the sutures were cut, which was facilitated by a 16 cm rupture of the symphysis pubis. We mobilized the walls of the bladder and sutured it with double-row sutures, after which we performed osteosynthesis of the symphysis pubis with a modified reconstructive plate. The pelvic cavity has almost halved. A permanent catheter was placed for 3 weeks. Primary healing occurred with complete restoration of urination function and the anatomical structure of the pelvic ring.

Technique of internal osteosynthesis of the pubic symphysis with reconstructive plates

In the process of preparing for surgery, it is necessary to order a reinforced pelvic bandage according to the circumference of the victim’s pelvis. For tears larger than 10 cm, it is necessary to subtract 5 cm from the resulting size, since after the operation the patient’s pelvic circumference will decrease. Before the operation, be sure to catheterize the bladder with a Foley catheter and make sure that urine is released into the urinal. This procedure is to prevent damage to the bladder during surgery.

Great importance has the size of a diastasis between the pubic bones. The larger it is, the larger the surgical incision is required and the more dangerous this incision is, since it involves spermatic cords, external iliac artery and vein, femoral nerve. To eliminate this diastasis, we used a tightening device we developed, which was attached to the operating table.

The reduction device consisted of two halves, which were installed on the operating table runners at the level of the femoral trochanters (Fig. 7-9). By rotating special steering wheels, lateral pressure was created on both halves of the pelvis, causing them to come closer.

The use of a reduction device made it possible in many cases to completely bring both halves of the pelvis together and perform osteosynthesis from a 6 cm long incision, which was quite safe. A transverse suprapubic Pfannenstiel-type incision was used as an operative approach. First, the skin, tissue and aponeurosis were dissected.

Rice. 7-9. Device for repositioning tears of the pubic symphysis.

Upon opening the aponeurosis, an extensive hematoma was identified, located behind the pubic bones in the prevesical tissue. Using a sharp spoon or chisel, articular cartilage was removed from the vertical branches of the pubic bones. After this, the halves of the pelvis were additionally compressed with a reduction device until the diastasis was completely eliminated. If there was an upward or posterior displacement of the severed half of the pelvis, it was compared using a single-pronged hook inserted into the obturator foramen in the area of ​​the angle between the horizontal and vertical rami of the pubic bone. Having made sure that the reposition was successful, we moved on to installing the reconstruction plate.

A modified reconstructive plate with 4 screws with a bridge in the middle was installed along the upper edge of the pubic bones. This plate corresponded to the AO reconstructive plate with 5 screws, but did not have a “weak” point, corresponding to the middle hole of the plate, which bears the main load and where it sometimes breaks. We used a plate for 6.5 and 4 mm cancellous screws. The plate is first placed on the intact half of the pelvis. Using an awl, mark a hole corresponding to the center of the vertical branch of the pubic bone, drill a hole with a drill strictly in the center of the vertical branch of the pubic bone and pass it with a tap. Measure the depth of the hole. If the entire vertical branch has been passed, then its depth will be at least 40 mm.

The plate is attached to the intact horizontal ramus of the pubic bone, first with a long cancellous screw with a solid thread, then with a short one. After this, the severed half of the pelvis is reduced again and the second half of the plate is fixed with two screws in the same order. If repositioning of the pelvis is carried out with considerable effort, which happens more than 3 weeks after the injury and in cases where there is a rupture of the sacroiliac joint, a second plate is additionally installed with 4 screws along the anterior surface of the horizontal branches of the pubic bones (Fig. 7- 10).

Before suturing the wound, check whether the color of the urine released through the catheter has changed. A drainage is placed behind the pubic bones from a separate puncture incision. The aponeurosis is sutured with frequent sutures made of non-absorbable suture material (lavsan, silk) to avoid the formation of postoperative hernias. Sutures are placed on the tissue and skin. The drainage is connected to an “accordion” (corrugated tank). A pelvic bandage is put on, and if for some reason it is not there, then the patient’s legs are tied in the area of ​​the knee joints.

The urinary catheter is left until the next morning. Leg bending and pelvic lifting also begin the next day. If the lower extremities are intact, the patient can be placed on his feet in a brace 3 weeks after the operation, with support on the leg that corresponds to the fixed half of the pelvis, and after 6 weeks, support on the other leg can be allowed. A control x-ray is taken after 1.5 and 3 months. The bandage must be worn for 3 months; you can sleep without a bandage on your side after 1.5 months.

Rice. 7-10. Osteosynthesis of the symphysis pubis with two plates.

For fractures of the lateral mass of the sacrum and if osteosynthesis of the sacroiliac joint is performed, this period is reduced by 2 weeks.

Postoperative complications were observed in 6 (4.7%) operated patients with ruptures of the pubic symphysis. In 5 patients, pubic fixation failed due to incorrect insertion of the main screws not in the center of the bone. In 2 patients, failure of osteosynthesis occurred due to underestimation of their mental status, since the second plate was not placed in front. They grossly violated the regime and began to get up on the 3rd day after the operation. In 1 patient described above, a urinary fistula opened due to a bladder rupture that was not diagnosed before surgery, which closed spontaneously after 3 weeks.

The need for osteosynthesis of the sacroiliac joint arises when there are clean tears with a diastasis of more than 6 mm according to CT data. We performed it in a closed manner along the AO in most cases in the 2nd stage after osteosynthesis of the pubic symphysis. The patient was turned to healthy side. Stepping anteriorly 4-5 cm from the posterior iliac spine, an incision 2 cm long was made.

A finger was used to bluntly separate the gluteal muscles down to the ilium. A 4.5 mm hole was drilled through the protective tube using a spongy drill. The direction of the drill is perpendicular to the longitudinal axis of the sacrum and anteriorly by 20°. The drilled hole was passed through with a 6.5 mm tap, after which a 6.5 mm screw with a washer 45–60 mm long and a limited thread of 32 mm was inserted. By tightening the screw, diastasis in the sacroiliac joint was eliminated. Fixation of the sacroiliac joint was required in 24 (19.0%) patients, including 6 on both sides.

Here is an observation.

Patient V., 40 years old, was in the Research Institute of Emergency Medicine named after. N.V. Sklifosovsky from 12/25/04 to 02/08/05. Diagnosis: rupture of the pubic symphysis and left sacroiliac joint; fracture of the lateral mass of the sacrum on the left. According to the patient, he was injured at a construction site - he was crushed under a concrete slab. Upon admission to the Institute, the patient was examined by a traumatologist, a neurosurgeon, and a surgeon; a dynamic ultrasound of the abdominal organs and retroperitoneal space was performed; no damage to the abdominal organs was detected. The pelvic bone fracture was fixed with skeletal traction. Upon admission to the intensive care unit, infusion, transfusion and antibacterial therapy was administered. After stabilization of his condition, he was transferred to OMST on December 26, 2004.

On January 12, 2005, the symphysis pubis was fixed with a reconstructive AO plate and the left sacroiliac joint was fixed with a screw. During osteosynthesis of the sacroiliac joint, blood began to flow abundantly from under the fragment of the lateral mass of the sacrum. It was not possible to achieve hemostasis by applying a clamp or ligating a bleeding vessel. The bleeding was stopped by packing, and the patient underwent intraoperative angiographic examination of the pelvic vessels, the superior gluteal artery damaged during the injury was identified, and its embolization was performed (Fig. 7-11). Against the background of antibacterial (ceftriaxone 1 g 2 times No. 10, amikacin 1 g No. 5), infusion (Gordox according to the scheme), transfusion, antithrombotic (Fraxiparine) therapy, postoperative wounds healed by primary intention. An ultrasound Dopplerogram of the deep veins of the lower extremities did not reveal any disruption of the outflow through the deep and subcutaneous channels.

The patient in a pelvic band walks with additional support on crutches. He was discharged in satisfactory condition under the supervision of a traumatologist at the regional trauma center. It is recommended to walk with measured support on the left leg in a pelvic bandage for up to 4 months after surgery, take Detralex 1 tablet 2 times a day for 3 months.

Fig.7-11. Osteosynthesis of the pubic and sacroiliac joints. The operation revealed a traumatic injury to the inferior gluteal artery, which was embolized.

V.A. Sokolov
Multiple and combined injuries

Tags: Hip injuries, Polytrauma
Start of activity (date): 07/13/2014 12:28:00
Created by (ID): 1
Key words: pelvic trauma

tori and obturator externus muscle. This exposes the lower edge of the obturator foramen. Taken outside sciatic nerve. The sacrotuberous bone is dissected near

ligament and advance the knife upward to the ischial spine, protecting the internal pudendal vessels, which go around the ischial spine in this area.

For surgical intervention only on the ischial tuberosity, the incision can be made along the gluteal fold. After such a cut, an almost invisible scar is obtained (Fig. 140).

The pubo-ischial, combined intermuscular, combined pubo-isciatic (Fig. 141), pubo-iliac (Fig. 142) approaches are also used. For surgical interventions on the ischium, it is advisable to use the approach according to S.T. Zatsepin (Fig. 143, 144).

Access to the ilium. The position of the patient is on the stomach. An incision 15-20 cm long is made from the middle of the ridge

141. Combined pubic-isciatic approach.

142. Puboiliac approach: the fascia is incised, the gluteal* muscles and the tensor fascia lata muscle are cut off from the iliac crest.

143. Incision line for access to the ischium according to S. T. Zatsepin.

144. Access to the ischium according to S. T. Zatsepin: the gluteus bolf muscle is cut off and raised upward; The sciatic nerve is clearly visible in the foreground.

ilium to the posterior superior iliac spine. After dissecting the skin and subcutaneous fat, they penetrate between the muscles attached to the iliac crest, use a wide rasp to separate them from the wings of the bone from the inside and outside and move them to the sides (Fig. 145, a).

145. Access to the posterior semi-ring of the pelvis.

a - access to the posterosuperior spine of the iliac wing; b - top access to

sacrum; c - goblet-shaped; d - X-shaped.

Access to the sacroiliac joint. An L-shaped incision is made along the wing of the ilium and at the level of the sacroiliac joint. The fibers of the gluteus maximus muscle are cut off from the iliac crest and displaced downward and outward. This opens wide access to the sacroiliac joint (Fig. 145, b). Arc-shaped incisions in the area of ​​the iliosacral joints can be convex inward and outward.

Goblet approach to the sacrum. A longitudinal incision is made along the midline of the sacrum, which is curved upward at the bottom, towards the ischial tuberosities (Fig. 145, c).

An X-shaped incision is known - from the superoposterior spines along the midline of the sacrum down to the ischial tuberosities (Fig. 145, d), allowing to expose the sacrum and its articulations.

Access to the coccyx. The position of the patient is on the stomach with a cushion under the symphysis.

An incision up to 10 cm long is made between the buttocks exactly above the tailbone. You can use a horseshoe-shaped incision, the concave part of which is turned towards the anus. After dissection of the skin and subcutaneous fatty tissue, the area of ​​the sacrococcygeal joint is skeletonized. After this, good access to the vertebral bodies of the coccyx opens.

SURGICAL INTERVENTIONS ON THE PELVIC BONES

O P E R A T I O N A F O R E D N E M P O L U C O L C E T A Z A

Osteosynthesis of the pubic bones can be carried out using wire, Mylar tape, metal clamps of various designs, bone grafts, or a combined method. However, the wire fastening method is unreliable, since the cerclage suture in some cases cuts through the cancellous bone. Metal osteosynthesis allows for good comparison of fragments, strong fixation and eliminates external immobilization in the postoperative period, creating conditions for early functional treatment.

For reposition and fixation in case of damage to the anterior and posterior semi-rings of the pelvis, devices are used that use parts of the Ilizarov apparatus and others. Often, stabilization of the anterior semi-ring of the pelvis is supplemented by open reposition in the area of ​​the sacroiliac joint and fixation with threaded rods, which are carried out in the frontal plane from one wing of the ilium to the other. This method of fixation allows patients to get up early and begin active functional treatment.

Synthesis of the pubic symphysis with lavsan tape. Provision

b o l o g o - on the back. About pain - general. An incision above the pubic symphysis exposes the upper and lower

branches of the pubic bones. Two pairs of holes are drilled in both pubic bones, through which a double lavsan tape is passed like a lacing and brought together until both pubic bones touch. The ends of the tape are sewn together

are located on the front surface of the newly formed joint (Fig. 146).

fractures accompanied by compression of the main neurovascular trunks, improperly healed fractures. P o l o-

146. Restoration of the symphysis pubis with Mylar tape.

147. Connection of the pubic bones with a staple.

148. Osteosynthesis of the symphysis pubis with a plate and screws.

wife of a sick person - on the back. About pain - general.

A metal rod (screw) is inserted from the medial end of the superior branch along the central longitudinal line. In this case, one should remember the presence of an internal bone bridge, which complicates the advancement of the fixator.

The advantage of this method of fixation is that the free end of the rod lies on the anterior surface of the pubic area.

symphysis and can be easily removed through a small incision. Synthesis of the pubic symphysis with staples. INDICATIONS - unilateral and bilateral lateral fractures of the superior ramus of the pubis

equal to the distance between the pubic tubercles. The branches of the fixator are installed at the top of the palpable tubercles and driven into the thickness of the horizontal and vertical branches of the pubic bones. To protect tissue from damage and to ensure uniform immersion of the structure into the bone, blows with a hammer are applied not to the bracket, but to a wide chisel, which is placed on the horizontal part of the fixator. The matched fragments are fastened with a staple, the ends of which are driven in from the side of the prevesical space, and their lower sections are bent on the anterior surface.

Take a plate of the appropriate size (the gap between the internal holes of the plate is equal to the distance between

pubic tubercles). The plate is modeled according to the curvature of the horizontal branches of the pubic bones, placed on their anterior surface after reposition and fixed with screws, long

so that it receives support on the lower branch of the pubic bone. The clamp hooks are tightened with a bolt (Fig. 150). Metal structures are removed 3-4 months after surgery.

Fixation of the pubic symphysis with coupling bolts. A bolt of the appropriate size is selected (its length is equal to the distance between the nearest contours of the obturator foramina) and inserted into the channels drilled in the vertical branches in the transverse direction between the indicated points. Place on the ends of the bolts

remove the support washers and screw the nuts until the articulated surfaces of the pubic bones are completely brought together.

149. Osteosynthesis of the pubic bones: the plate is placed in front of the horizontal branches of the pubic bones.

150. Osteosynthesis of the symphysis pubis with latching hooks.

Channels for inserting the brace bolt-screed are drilled in the pubic bones below the pubic tubercles on the side of the pubic area.

Zyrny space.

Bone grafting with a butterfly autograft for a rupture of the pubic symphysis. Indications: chronic ruptures of the pubic symphysis with impaired gait and bladder function. The position of the patient is on the back. ABOUT PAIN -

n and e - general.

151. Osteosynthesis of pubic bones with a butterfly graft.

First, a “butterfly” autograft is cut out from the platform of the upper third of the tibia. A transverse incision exposes the lower branches of the pubic bones. Delete cartilage tissue from the articulating surfaces and apply notches on them. On the front surface of the vertical branches of the pubic bones, transverse ledges are knocked out with a chisel - grooves, the shape corresponding to the previously prepared graft. The depth of the ledges is half the thickness of the bone. Using a tightening device (clamp), diastasis between the pubic bones is eliminated. The graft is placed in the prepared bed and strengthened transosseously. Layer sutures are applied and

aseptic dressing. The patient is placed on the bed, the pelvis is suspended in a hammock.

Walking is allowed after 2"/2-3 months (Fig. 151) using a pelvic bandage. As a rule, the engrafted bone trans-

the plant is resorbed in its middle part and the symphysis gap is restored.

go - on the back. About pain - general.

An autograft measuring 9X3 cm is cut out from the wing of the ilium. A longitudinal suprapubic incision up to 13-15 cm long is made. The exposed pubic bones are freed from soft tissue. On the shifting half of the pelvis, a chisel is used to make a slit across almost the entire width of the pubic joint, but the cortical layer in the proximal and distal parts is preserved. The gap in the lower rami of the pubic bones extends to the obturator foramen. The autograft should be 5-6 cm longer than the diastasis. The ends of the graft should be slightly pointed. One end of the transplant is inserted into the gap on the displaced half of the pelvis and driven in with a hammer. The other end is inserted through a defect in the cortical layer of the distal part and, after it is immersed in the second pubic bone, the maximum

152. Combined method of fixation of the symphysis.

significant compression of the pelvis in the frontal plane until disappearance

or extreme reduction of diastasis.

In the bed, the patient is placed in a hammock, the ends of which are thrown over blocks with a load located on the sides of the blood

tee. Walking is allowed after 2-2"/2 months.

Plastic osteosynthesis of a symphysis tear can be performed with a graft in combination with fixation with a bracket, wire,

lavsan tape (Fig. 152).

OPERATIONS ON THE POSTERIOR SEMI-RING OF THE PELVIS

If the sacroiliac joints are damaged, repositioning arthrodesis is indicated to restore the continuity of the pelvic ring, which should be performed after restoration of the symmetry.

Osteosynthesis of the sacroiliac joint with a staple. Indications - isolated injuries or combined ruptures of the sacroiliac joints, dislocation of the half pelvis, vertical fractures of the sacrum. The position of the patient is on the stomach. About pain - general.

Using an L-shaped incision (Fig. 153), the skin, subcutaneous fatty tissue, and superficial fascia are dissected and the posterior superior iliac spines are skeletonized. On the healthy side, the incision is not deepened; on the damaged side, access is expanded by detaching the fibers of the longus dorsi muscle from the iliac crest. After this, the joint space of the damaged sacroiliac joint or sacrum becomes accessible for inspection.

sacral fracture rate.

A staple is selected, the length of which is equal to the distance between the tips of the superoposterior iliac spines. Under the leaf of the lumbodorsal aponeurosis, along the line connecting both spines, a tunnel is made with a straight perforator, through which a fixation bracket or fixing bolt is passed (Fig. 154).

153. Cut line for osteosynthesis of the posterior pelvic semiring.

154. Osteosynthesis of the posterior pelvic semiring with a staple.

155. Extra-articular arthrodesis of the sacroiliac joint.

156. Arthrodesis of the lower sacrum in the iliac joint.

For osteosynthesis of the posterior part of the pelvic ring, using a coupling bolt at the base of the superoposterior spines, a perforator is used to drill a bone canal along the line connecting both bone protrusions. A bolt of the appropriate size is inserted into the channel. Support washers are placed on its ends and the nuts are screwed until the iliac bones are in complete contact with the sacrum or fragment -

mi sacrum. The patient is on bed rest for 8-10 weeks.

1. The skin, subcutaneous and fatty tissue are dissected and thus the I and II spinous processes of the sacrum and the posterior superior iliac spine are exposed. They cut with a chisel

spinous process Si. Then it releases a small linear horizontal section of the sacrum lying towards the ilium. At this level, a tunnel is made under the muscles, directed towards the edge of the ilium, where a small groove is made. A bone autograft is prepared and introduced through the tunnel to the resected spinous process. The graft is rotated so that its spongy surface lies on the refreshed surface of the sacrum. The graft is tightly fixed (Fig. 155).

2. The iliac crest is exposed. A fragment is excised with a chisel triangular shape. Then the corresponding part of the sacrum and ilium is refreshed and the fragment is inserted perpendicular to the sacroiliac joint (Fig. 156). Bed rest is prescribed for 2-3 months until complete consolidation.

HIP JOINT ANATOMY

The hip joint connects the acetabulum of the pelvic bone to the head femur. The acetabulum is deepened by a thick cartilaginous ring (labrum acetabulare). It passes over the notch of the acetabulum in the form of a transverse ligament (lig. transversum acetabuli). Between the fossa of the acetabulum and the fossa of the head of the femur passes the ligament of the head of the femur. The surface of the acetabulum is lined with cartilage and is called the “lunar surface” (fades lunata). The strong capsule of the hip joint is strengthened by the iliofemoral, ischiofemoral, and pubofemoral ligaments, the fibers of which, intertwining, form a circular zone (zona orbicularis) at the level of the femoral neck. The cartilaginous surface of the head of the femur actually forms a hemisphere, along the periphery of which the feeding vessels penetrate

The iliopsoas muscle is attached to the lesser trochanter. The front of the joint is covered by the pectineus muscle, the adductor longus femoris muscle, the obturator externus muscle, the rectus head of the quadriceps femoris muscle, and the sartorius muscle. Along the outer surface of the hip joint lies the tensor fascia lata. The vastus lateralis muscle is attached to the greater trochanter. The piriformis muscle, the obturator internus muscle, the superior and inferior gemellus muscles, and the quadratus femoris muscle pass along the posterior surface of the hip joint. This layer of muscle is covered by the gluteus maximus, medius and minimus muscles.

It should also be taken into account that the femoral vessels, femoral nerve and sciatic nerve pass through the hip joint. The femoral nerve passes next to the iliopsoas muscle through the lacuna musculorum and is separated from the femoral artery by a deep layer of fascia lata. Femoral vein lies somewhat medial and posterior to the femoral artery, projecting onto the anterior surface of the femoral head. Sciatic nerve leaving for. infrapiriformis, lies on the internal obturator and gemellus muscles.

ACCESS TO THE HIP JOINT

More than 100 approaches to the hip joint have been proposed. They are divided into five main groups: front, internal, rear, lateral, combined.

FRONT ACCESS

The patient's position is on the back, the table is tilted to

a few degrees in the healthy direction.

Guter access. The skin incision starts from the anterior superior iliac spine, goes down and slightly inwards along the outer edge of the sartorius muscle. The length of the incision is 12-15 cm. After dissecting the skin and subcutaneous fatty tissue in the upper corner of the wound, small branches of the lateral cutaneous nerve and the superficial circumflex iliac artery, which are not important for limb function. They penetrate deep between the sartorius muscle and the tensor fascia lata. Both muscles are pulled apart, exposing the rectus femoris muscle, which is retracted medially. In this case, the anterior surface of the hip joint capsule is exposed in depth. It should be remembered that the medial circumflex femoral artery is located horizontally under

fibers of the rectus femoris muscle (Fig. 157).

Access by Judet. This approach to the anterior surface of the joint differs from the previous one only in that the incision goes along the anterior edge of the sartorius muscle and deep into the joint.

157. Access according to Güter.

158. External pertrochanteric access

To hip joint (a, b).

extends to the inner edge of the rectus head of the quadriceps femoris muscle, penetrating between the rectus femoris muscle and the iliopsoas muscle. This route is more dangerous, since the incision passes close to the great vessels.

LATERAL ACCESS

The position of the patient is on the back, with the table tilted to the healthy side, or on the healthy side.

External pertrochanteric access. A skin incision up to 20 cm long begins from the iliac crest and runs through the middle of the greater trochanter (Fig. 158). The fascia is dissected along the incision. Then they find the space between the anterior edge of the gluteus medius muscle and the muscle that strains the fascia lata of the thigh, and penetrate deep between them (Fig. 159). Greater skewer

The femur along with the muscles attached to it is cut off with a sharp wide chisel and pulled back with a sharp hook in the proximal direction. In the anterior corner of the wound, the tensor fascia lata and the rectus femoris and iliopsoas muscles located underneath are retracted. In this case, the anterior surface of the joint capsule is widely exposed.

159. External access to the hip joint: the skin and subcutaneous fat are incised.

Access via Ollier. The skin incision with this approach has an arcuate shape and goes around the greater trochanter (Fig. 160, a). After dissecting the skin, subcutaneous fat and fascia, the flap is peeled off and turned upward; thus exposing the fascia of the gluteus maximus muscle and the tensor fascia lata muscle. The fascia is cut and turned upward (Fig. 160.6). The tip of the greater trochanter is cut off with a chisel and moved upward. This opens access to the femoral neck and hip joint capsule.

Access via Vreden. The skin incision starts from the anterior superior iliac spine, goes down, and goes around the greater trochanter in front. Then the incision is smoothly bent posteriorly at a distance of 6-7 cm distal to the greater trochanter (Fig. 161, a). The fascia is cut. They penetrate deep between the tensor fascia lata, the gluteus medius and minimus muscles on one side and the sartorius on the other. In the distal part of the incision, the fascia lata of the thigh and the fascia of the gluteus maximus muscle are incised. The flap is retracted back and up. An osteotomy of the greater trochanter is performed, which, together with the attached muscles, is retracted upward and posteriorly. The capsule of the hip joint and part of the surface of the ilium are exposed (Fig. 161.6).

160. Access to the hip joint according to Ollier.

A - cut line; b - the greater trochanter is cut off.

161. Access to the hip joint according to Vreden.

A - cut line; b - the sartorius muscle is retracted inwards, the gluteus minimus and medius muscles are retracted outwards, the joint capsule is opened.

A skin incision 12-14 cm long is made from the posterosuperior iliac spine towards the greater trochanter and ends on the thigh 4-5 cm below the trochanter. The cut shape is oval. The fibers of the gluteus maximus muscle are cut and bluntly pulled apart. Then, penetrating between the gluteus medius and piriformis muscles, they exit directly onto the posterior surface of the hip joint capsule.

and thence approximately along the anterior margin of the gluteus maximus muscle to the iliac crest. The deep fascia is cut along the skin incision, then the wound is widened. They find the space between the gluteus maximus and gluteus medius muscles and penetrate deeper. The gluteus medius muscle is retracted anteriorly. The sciatic nerve must be protected from trauma (Fig. 162, a). Next, through the fat layer they penetrate to the short rotators of the hip: the piriformis, superior and inferior gemellus, obturator internus and quadratus femoris muscles, which are attached to the posterior edge of the greater trochanter. The tendons of these muscles are dissected using a Kocher probe at a distance of 1 cm from the site

the hip is in the position of maximum abduction. A skin incision up to 10 cm long is made in the middle of the inner surface of the thigh along the projection of the long adductor and gracilis muscles, starting from the place of attachment of these muscles to the pubic part. The muscles are exposed and retracted to the side, while the joint capsule opens (Fig. 163).

COMBINED ACCESSES

Smith-Petersen access. The position of the patient is on his back, the table is tilted to the healthy side.

The incision begins at the border between the anterior and middle thirds of the iliac crest, passes through the upper anterior iliac spine and along the anterior surface of the thigh between the tensor fascia lata and the rectus femoris muscle (Fig. 164). In this case, the branches of the superficial artery surrounding the ilium and the terminal branches of the superior gluteal artery are damaged. From the outer surface of the iliac

162. Posterior approach to the hip joint.

a - the gluteus medius muscle and the tensor fascia lata muscle are retracted medially, the sciatic nerve is visible in the lower corner of the wound; b - the tendons of the short rotators of the femur are cut off at the point of attachment to the greater trochanter.

163. Incision line for internal access to the hip joint.

Epidemiology
Fractures of the pelvic bones in children are a severe and fairly common injury - from 3-7% to 29.4%, while in the last decade there has been a clear trend towards an increase in the frequency of this type of injury.
When studying the immediate and long-term consequences, it was proven that even “relatively mild” fractures threaten to impair posture and gait, and in girls lead to deformation of the pelvic ring and subsequently to disruption of labor. Therefore, the problem of rehabilitation of victims is extremely relevant.
Apophysiolysis occurs in older children and adolescents involved in sports under heavy physical exertion: track and field athletes, gymnasts, students of choreographic schools. Similar fractures occur when performing the splits, a sharp start while running, at the moment of take-off during high jumps and when hitting the ball. This mechanism of injury is observed with anterosuperior and anteroposterior apophysiolysis of the ilium.

Etiology
Fractures of the pelvic bones occur, as a rule, with strong compression in the sagittal or frontal direction, which is observed in car accidents (collisions with pedestrians), collapses of buildings and land, as well as falls from a great height.
Avulsive (avulsion, marginal, isolated) fractures of the pelvic bones occur in most cases in adolescents involved in sports, which is explained by the anatomical structure of the pelvis, namely the presence of growth zones to which the thigh muscles are attached. During physical exertion, avulsive fractures of the apophyses of the ilium and ischium occur.
Avulsion fractures of the pelvic bones occur most easily. Fractures of the apophyses of the pelvic bones, as a rule, are not combined with damage to the pelvic organs.

Classification
Fractures of the pelvic bones are divided into closed and open; they can be combined with damage to the pelvic organs (combined injuries) or accompanied by injury to large vessels and nerves - complicated fractures. Often, pelvic fractures are part of multiple injuries, including traumatic brain injury, injury to the spine or chest organs.
A separate group consists of gunshot wounds, which are the most severe due to extensive damage to surrounding organs and tissues.

The following types of pelvic bone fractures are distinguished:

1. Regional (isolated) fractures of the pelvic bones that are not involved in the formation of the pelvic ring: fractures of the crest and wing of the ilium;

• avulsion or avulsion fractures;
• fractures of the apophyses of the anterosuperior and posteroinferior iliac spines;
• apophysiolysis of the ischium;
• sacral fractures;
• coccyx fractures (Fig. 17-4).

Rice. 17-4. Regional fractures of the pelvic sections not involved in the formation of the pelvic ring: 1 - isolated fractures of the iliac wing; 2 — fractures of the anterosuperior iliac spine; 3 — fractures of the anterioinferior iliac spine; 4 - fractures of the ischial tuberosity; 5 — isolated fractures of the sacrum below the sacroiliac joint; 6 - damage to the coccyx.

1. Fractures of the bones of the pelvic ring without breaking its continuity:

• unilateral or bilateral fractures of the pubic or ischial bones;
• fractures of the pubic bone on one side, the ischial bone on the other (Fig. 17-5).

Rice. 17-5. Fractures of the bones of the pelvic ring without breaking its continuity: 1 - fracture of the pubic bone; 2 - fracture of the ischium; 3 - diagonal fracture of the anterior semi-ring.

1. Fractures of the pelvic ring with disruption of its continuity (Fig. 17-6):

• unilateral or bilateral fracture of the pubic and ischial bones;
• symphysis rupture;
• longitudinal or diagonal fracture of the ilium;
• rupture of the sacroiliac joint;
• vertical fracture of the sacrum (the fracture line runs along the sacral foramina of the sacrum (Vualemier fracture) (Fig. 17-7);
• Duvernay's transverse fracture.

1. Fractures of the acetabulum:

• fractures of the edge of the cavity;
• fractures of the bottom of the cavity, including those accompanied by central dislocation of the hip - protrusio acetabuli;
• fracture of the acetabulum in combination with damage to the bone structures of other parts of the pelvis.

Rice. 17-6. Fractures of the bones of the pelvic ring with a violation of its continuity: 1 - fracture anterior section pelvic ring; 2 - fracture of the posterior pelvic ring; 3 - Malgenya fracture.

Rice. 17-7. Double vertical fracture of the sacrum (Vualemier fracture).
A double vertical fracture of the pelvic bones (Malgenya fracture, Fig. 17-8), in which the integrity of the pelvic ring is disrupted in the anterior and posterior sections, is rare. Various variants of Malgaigne or Voilmier-type fractures may occur, for example, a unilateral fracture in the anterior section and a fracture in the posterior section on the same or opposite side (diagonal vertical fractures Author! Check the correct spelling of this name. RTS S, Fig. 17-9) . In some cases, dislocation of the lateral pelvis may occur.

Rice. 17-8. Double vertical fracture of the pelvic bones (Malgenya fracture).

Rice. 17-9. Diagonal vertical fracture of the pelvic bones. Y Author! Please check that this surname is correct.

Fractures of the pelvic bones that do not lead to disruption of the integrity of the pelvic ring are classified as stable fractures, while those that violate the integrity are classified as unstable.
Open fractures of the pelvic bones are rare. Open ruptures of the sacroiliac joint are sometimes accompanied by detachment of the skin and subcutaneous fat of the lumbar and gluteal regions.

Clinical picture and diagnosis
Clinical examination

For the diagnosis of pelvic fractures in children, anamnesis is of great importance, identifying the circumstances and mechanism of injury, the type, general condition and posture of the patient.
The child often takes a forced position - on his back, with the lower limbs extended, barely apart and rotated outward, or the so-called “frog pose” (Volkovich’s symptom), when the legs are bent at the hips and knee joints and divorced.
Knowing the mechanism of injury and the place of application of the traumatic force, it is easier to begin further clarification of the diagnosis. Pain that occurs at the site of a suspected fracture with gentle compression of the pelvis (Verneuil's symptom) or spreading by the wings of the iliac bones (Larrey's symptom) serves as an important diagnostic sign.
In addition, Drachuk's symptom ("ballooned sacrum") can be detected - the appearance of pain when careful rhythmic pressure is applied to the sacrum with the fingertips of the hand placed under it. You should also check the Mouse symptom - pain when compressed in the vertical direction from the iliac crest to the ischial tuberosity.
An equally important symptom in most cases of pelvic fractures is dysfunction of the lower extremities, namely: pain in flexion, abduction and rotational movements of the hip.
A fracture of the anterior semi-ring is characterized by the symptom of a “stuck heel” - the patient cannot lift the outstretched leg due to emerging and intensifying pain from pressure on the broken bone of the contracting iliopsoas muscle, but it is relatively easy to pull the leg towards the body, bending it at the hip and knee joints .
A rectal examination is of great importance, which can help detect a fracture of the coccyx, sacrum, acetabulum, pubic or ischial bones, and sometimes determine the nature of the displacement of fragments. This study may reveal concomitant injuries to the rectum or vagina.
At clinical examination In the victim, it is necessary first of all to find out the mechanism of injury, since this fact is very important in apophysiolysis of the pelvic bones. All children with apophyseolysis of the pelvic bones, whether it is damage to the anterosuperior iliac spine or ischial tuberosity, complain of pain and limited function of the hip joint. However, visible changes—the presence of hemorrhages and hematomas—are not detected in these children. And only knowledge of the mechanism of injury allows you to make a correct diagnosis. When jumping high or taking a sharp start while running, a separation of the anterosuperior iliac spine may occur. Apophysiolysis of the anterioinferior spine occurs as a result of a sharp blow to the ball and forced flexion in the hip joint. Apophysiolysis of the ischial tuberosity occurs when performing splits in ballet, during athletics exercises, and among hockey goalkeepers.

Instrumental methods
In case of pelvic bone fractures, it is necessary to exclude damage to the urinary tract. Radiography in all cases complements the data of the clinical study. Intravenous urography plays a very important role in the diagnosis of urinary tract damage.
Topical diagnosis of bone fractures and ruptures of pelvic joints, which is based on x-ray examination, presents significant difficulties, which is confirmed by high frequency discrepancies between clinical and pathological diagnoses. Most often, injuries to the structures that form the posterior part of the pelvic ring remain unrecognized intravitally (fractures of the lateral masses of the sacrum, damage to the sacroiliac joint).
The insufficient effectiveness of diagnosing pelvic fractures is primarily due to insufficient information from clinicians about the characteristics of biomechanical damage to the pelvic ring. A number of these features determine the multiplicity and frequency of bone fractures and ruptures of pelvic joints. Often injuries occur at a considerable distance from the site of application of the traumatic force.
The limited information content of X-ray examination can be significantly increased by performing radiographs in a standard posterior projection, supplemented by computed tomography (CT) of the pelvic bones, which has now become more accessible.
Multislice CT, which allows you to obtain both a three-dimensional image of the pelvis (3D reconstruction) and sections of the pelvic bones on required levels, significantly reduces the likelihood of diagnostic error.
With extensive injuries to the pelvis and especially the posterior section, massive hemorrhages often occur, which is associated with the peculiarities of the anatomical structure of the vascular system and blood supply to the pelvic bones.
Venous drainage from the bones occurs through the dense venous network of the spongy substance and the central veins accompanying the arteries that supply these bones.
The venous trunks of the periosteum are directly connected to the sinuses of the spongy substance. The largest venous trunks of the periosteum of the pelvic bones are located on the gluteal surface of the ilium and enter the system of the gluteal veins. Pelvic bone and periosteal veins widely anastomose with the veins of adjacent muscles and even with the veins of internal organs. In addition, the arteries feeding the bone branch, and their two terminal branches flow into the “lakes” of blood, from where large veins originate (Shkolnikov L.G., 1968). This is why unfavorable conditions develop to stop bleeding from non-collapsing vessels of the bone substance. Therefore, bleeding from pelvic fractures can be prolonged and profuse. Bleeding that has already stopped can resume with the slightest movements of the patient, when shifting and insufficiently careful examination.
Literature data indicate that the diagnosis of hematomas in closed fractures pelvic bones is carried out mainly on the basis clinical picture. The frequency of detection of massive interstitial hemorrhages during a sectional study of the dead, as well as the severe anemia of the victims, indicate the importance of blood loss in these fractures.
E.S. Karpenko (1953) believes that in almost 72% of those who died in the first day after injury, retroperitoneal “hematomas” are detected, reaching the level of the kidneys. There is a direct relationship between the risk of death and the volume of the “hematoma” and the severity of shock (Wagner E.A. et al., 1982).
Until now, the question of the sources of bleeding in pelvic fractures remains unresolved. Thus, damage to the hypogastric artery is indicated by G.A. Gomzakov (1955). Most authors recognize that the source of blood loss is fragments of the pelvic bones.
Research by A.A. Martysheva (1975) showed that the volume of blood loss reaches 1500-2000 ml3 and even 3000 ml3, which is typical for fractures of the sacrum and ilium on the opposite side, as well as Malgenya type fractures. It is also necessary to take into account not only the volume of blood loss, but also the volumetric velocity, which can reach 800-1000 ml/h.
In recent years, computed angiography has been successfully used to diagnose damage to large vessels. This high-tech research method helps determine the optimal treatment tactics, which reduces the likelihood of death.

Treatment
Treatment of pelvic bone fractures without violating the integrity of the pelvic ring and especially with its violation, complicated by bleeding into the retroperitoneal and intrapelvic tissue and with damage to internal organs, is very difficult.
Among the traditional conservative and surgical methods of treating pelvic fractures, until now there have been no highly effective and low-traumatic treatment methods that would promote early activation of patients and provide satisfactory and good treatment results. Over the past 20 years, occlusive methods of ligation and intravascular embolization of the internal iliac arteries have been successfully used to stop massive pelvic bleeding. After stopping the bleeding and bringing the victim out of shock, traumatologists must solve the problems of reliable fixation and reposition of pelvic bone fractures. For this purpose, external fixation rod devices and structures for immersion osteosynthesis are used.
Treatment outcomes for children with multiple pelvic fractures depend on the location and nature of the damage, the effectiveness of repositioning the fragments forming the pelvic ring, and the stability of fixation. According to R.A. Kashishian et al. (1994), unfavorable treatment results are usually observed in patients with disorders of the posterior semi-ring of the pelvis treated with traditional conservative methods. Post-traumatic pelvic deformities in such children do not tend to self-correct during growth.

Marginal (isolated) fractures of the pelvic bones
Treatment of isolated fractures of the pelvic bones without violating the integrity of the pelvic ring in the past was mainly conservative, but it has now been established that conservative treatment methods do not always allow a clear comparison of fragments, much less accelerate the activation of patients.

Conservative treatment. In case of avulsions of the apophysis of the ischial tuberosity or ilium, the victim was placed on a backboard in the “frog” position (according to Volkovich) on his back - his legs were bent at the hip joints and slightly separated by 15-20°. Rollers are placed in the popliteal fossae. From the 3-4th day a course of therapeutic exercises was prescribed. Bed rest continued for 3 weeks. Loading of the limb began from the 4th week.

Surgery apophysiolysis of the anterosuperior spine of the iliac wing is performed under general anesthesia. In all cases, there is a displacement of the bone fragment in the distal direction by two diameters of the base of the torn fragment.
Surgical technique: the victim is placed on the operating table on his back. The hip joint is flexed up to 45° using a roller, which is placed in the popliteal area of ​​the affected limb. A layer-by-layer tissue dissection is made from an arcuate skin incision 5 cm long, bordering the outer side of the anterosuperior spine. It should be noted that in all cases there was no hematoma in the fracture area. The torn apophysis of the anterosuperior iliac spine in children is an osteochondral fragment ranging in size from 2.2 cm to 3-4 cm, associated with a tendon-muscular pedicle.
Using a tetrahedral awl, the apophysis is compared with the “maternal” bed and fixed to the ilium with a Kirschner wire. In the area of ​​the upper pole of the apophysis, 2-3 nylon sutures are applied to achieve more durable fixation. Then the wound is sutured tightly in layers. The period of fixation of the fragment with a Kirschner wire is 3 weeks.
3 weeks after the operation, after X-ray control and confirmation of consolidation of the fracture, the Kirschner wire is removed and the child is allowed to walk. Within 1 month, limb function is restored.
Fractures and dislocations of the coccyx treated conservatively, using bed rest for 3 weeks. Surgical treatment for this pathology is performed only in the presence of coccydynia, since if technical rules are not followed, the operation can lead to serious complications - dysfunction of the rectal sphincter. Removal of the coccyx fragment is performed with mandatory and thorough restoration of the posterior part of the pelvic floor.

Fractures of the pelvic ring bones with disruption of its continuity
A feature of surgical tactics in the treatment of victims with severe pelvic trauma is the expediency of high surgical activity using low-traumatic methods or traumatological aid.
According to the Research Institute of Emergency Medicine named after. I.I. Dzhanelidze (1997), taking into account the severity of the patient’s condition and the variety of options for severe pelvic trauma, there are indications for surgical intervention or trauma treatment:

• with ruptures of the pubic joint, fractures of the anterior semi-ring of the pelvis with a violation of its continuity;
• with ruptures of the sacroiliac joint, fractures of the posterior pelvis with a violation of its continuity;
• in case of damage to the pelvic bones with vertical displacement of its parts;
• for fractures of the acetabulum with hip dislocation, including central hip dislocation;
• with open injuries to the pelvis with wounds or extensive skin detachment in the lumbar region, as well as in the sacrum and perineum;
• when combined different types pelvic injuries.

The St. Petersburg Research Institute of Emergency Medicine successfully uses a method for predicting the severity of injury and accompanying traumatic shock, developed by Yu.N. Tsibin and I.V. Galtseva (1997). This method is sufficiently covered in the literature and has been implemented in many clinics. According to it, victims with severe trauma are divided into two groups:
First group includes victims who have a positive prognosis for life (regardless of the duration of shock). It includes two subgroups: subgroup A and subgroup B (Table 1).
Table 1. Treatment tactics for victims with severe pelvic injuries

Subgroup A— it includes victims with a prognosis of shock duration of up to 12 hours. Surgical interventions on the musculoskeletal system in this group can be performed with virtually no restrictions. For injuries of the pelvic ring, low-traumatic methods of transosseous osteosynthesis are indicated without restrictions. Reposition and fixation of both the anterior and posterior sections of the pelvis, reduction of hip dislocation, damper skeletal traction using an external fixation device and other traumatological aids are acceptable.
Subgroup B— it includes victims with a positive prognosis for life with a shock duration of more than 12 hours. In this subgroup, surgical interventions for pelvic injuries that provide bone fixation are acceptable. Repositions are also indicated for injuries with slight displacement of the bones, which do not cause additional trauma and are performed with external fixation devices. Such operations include transosseous fixation for rupture of the pubic symphysis or fracture of the pubic and ischial bones. If the anterior and posterior sections of the bony ring of the pelvis are damaged with displacement, skeletal traction is applied, and the anterior section of the pelvis is fixed with a device. If simultaneous reduction of the central dislocation of the hip is unsuccessful, double skeletal traction is applied (for the tibial tuberosity - along the axis of the limb, and with the help of a fixation unit, lateral traction is created for the area of ​​the greater trochanter).

Second group consists of victims with severe pelvic trauma, who upon admission to the anti-shock unit had a negative prognosis for life. These patients, as a rule, experience significant disorders of vital functions - hemodynamics and breathing. A complex of resuscitation and anti-shock measures for these victims is carried out without removing immobilizing bandages and transport splints. For hemostatic purposes and to ensure temporary immobility of bone fragments, the pelvic area is fixed with a hammock. One of the important anti-shock measures is the intrapelvic blockade according to Shkolnikov-Selivanov, which is very effective and simple to perform. If, as a result of antishock therapy, it is possible to achieve sustainable stabilization of hemodynamics and an improvement in the prognosis, then, if necessary, skeletal traction is applied. In some cases (before transfer to the intensive care unit), fixation osteosynthesis of the pelvis is indicated.
When choosing a trauma treatment for the treatment of patients with severe pelvic trauma, preference should be given to the transosseous osteosynthesis technique. Methods for transosseous osteosynthesis of the pelvis have been developed, which involve the introduction of rods or a combination of rods and wires into various parts of the pelvis. They are successfully used in the long-term period of injury, but cannot always be used in patients with shock. Most often they are quite traumatic, or a necessary condition To introduce the structure is to change the patient’s body position. Turning on the side or stomach during the operation is not indifferent to the condition of the victim in acute period injuries.

To determine the most optimal “fields” for the insertion of wires, CT studies of the pelvic bones were carried out. As a result of the study, taking into account topographic and anatomical features, the following areas of the pelvic bones were noted.

• Anterosuperior spine and iliac crest.
• The posterior section of the ilium is 2-3 cm from the sacroiliac joint.
• Acetabular zone of the ilium.
• Horizontal ramus of the pubis.

These areas of the pelvic bones are distinguished by their comparative massiveness and the absence of important anatomical formations and, finally, they are in the projections of the reference lines of the pelvis. Depending on the problem being solved, for various pelvic injuries, these areas are used to insert wires.
Specifier units and some parts from the Ilizarov apparatus (threaded and telescopic rods, plates, adapter blocks, etc.) are used as an external fixation structure. An original small-sized surgical drill with a variable speed of rotation of an electric motor is also used to insert the needles. It greatly facilitates the passage of the needles, prevents tissue burns due to the low rotation speed, and most importantly, it allows the wires to be passed through any plane of the pelvis in the required area with maximum safety in relation to anatomical formations.
Knitting needles with a diameter of 2 mm and a length of 20 cm are used. They are made from standard knitting needles with and without stops. Knitting needles with stops are made in such a way that there is a distance of 3 cm from the pointed part to the stop.
The technique of performing the operation is quite simple, does not require changing the patient’s position on the table, and the intervention takes little time. Each technique has its own characteristics depending on the nature of the damage and the task being performed. They are given in descriptions of transosseous osteosynthesis for the most common pelvic injuries.
Fixation in case of damage to the anterior semi-ring(rupture of the symphysis, fracture of the pubic and ischial bones) is carried out as follows. The anterosuperior iliac spine is determined by palpation, through it in the oblique-sagital plane 4-5 bundle-shaped intersecting spokes are passed to a depth of 5-6 cm. One of the spokes with a stop is inserted from a point located 6-7 cm outside the anterosuperior spine with exit to the insertion area beam. Its tail part is bitten off, and the front part sinks under the skin with emphasis. It is more convenient to carry out this knitting needle first. In the same way, the needles are passed through the other ilium. In each bundle, the spokes are rigidly fastened together with one repositioning-fixation unit. Using 1-2 telescopic or threaded rods, the fixation nodes are brought closer or apart in the frontal plane, reducing the anterior pelvis.
This technique can also be effective in combination with injuries to the anterior pelvic ring and the anterior interosseous ligaments of the sacroiliac joint (pelvic “open book” injuries).
In case of damage from complete rupture of the posterior pelvic ring The following option for external fixation of the pelvis is used.
Bundles of short intersecting needles are inserted into the anterosuperior spines in the same way as when fixing the anterior pelvis, with the only difference that the tail part of the wire with the stop is not cut off. From the injection site of this needle, a second bundle of 5-6 intersecting needles is inserted with stops in a certain area of ​​the pelvis (iliac crest, posterior ilium and acetabular zone). These knitting needles are inserted with a drill through only one cortical plate, then they are punched to the thrust area with a light hammer. In the same way, two units are installed on the other half of the pelvis, and all four spoke clamps are mounted between each other using telescopic and threaded rods using adapter blocks. A closed structure of sufficient rigidity is formed around the pelvis, allowing for reposition and fixation of damaged parts of the pelvis both simultaneously and over time. Reposition is carried out taking into account radiographic data. The main guideline in this case should be the comparative width of the ilium. If on the damaged side the width of the iliac wing is greater than on the opposite side, i.e., the damaged half of the pelvis is located closer to the frontal plane, then compression should be performed between the anterior fixation nodes. If the wing of the ilium is shorter, i.e., closer to the sagittal plane, then distraction is performed on the anterior rods.
If the pelvis is damaged with a significant vertical displacement of the bones, the above-described technique is preceded by preliminary reduction on an orthopedic table.
In recent years, in addition to the described methods of transosseous osteosynthesis, submersible osteosynthesis of the pelvic bones with bone plates has been introduced into clinical practice. Surgical interventions are performed using low-traumatic intermuscular approaches and are distinguished by the ability to perform precise reposition of bone fragments. Accuracy of reposition is especially important in childhood, when residual deformities can negatively affect the development of the pelvis and other parts of the musculoskeletal system.
Acetabular fractures
For hip dislocation with acetabular fractures (including central hip dislocation), another version of the external fixation device can be used.
After manual reduction of the dislocation, two fixed nodes are installed, as when fixing the anterior pelvis, and one node with a bundle of 3-4 short diverging wires placed in the upper third of the anterior outer surface of the femoral diaphysis. The fixed unit, located in the thigh area, is mounted to the external fixation device using a telescopic rod with a damper. The damper is a spring with a diameter of 10 mm and a length of 15-29 cm, in the lumen of which the threaded part of the telescopic rod is installed. The assembled system allows for constant skeletal “self-traction”.
In case of central fracture-dislocation, to implement lateral traction, another unit with a bundle of pins is installed in the area of ​​the greater trochanter with a damper rod along the axis of the femoral neck (FNC). The assembled systems help to significantly activate the victims, allowing them to walk with the help of crutches.
If there is damage to the pelvis with wounds or skin detachment in the lumbar region, sacrum or perineum, then each of the above fixation options can also be used for hanging in a bed from Balkan frames. The suspended position of the body by the pelvic area facilitates the treatment of wounds, patient care, and helps prevent bedsores and other complications of injury.
If in the early period of injury, due to the severity of the victim’s condition or other reasons, reposition and fixation of the damaged bones was not performed, then it is performed in subsequent periods. In old cases, open reduction is performed. Access to the fracture area depends on the nature and location of the injury. In addition to transosseous osteosynthesis, various internal fixators can be used.

Approximate periods of incapacity for work
In the postoperative period, patients need careful care. You should regularly conduct therapeutic exercises to improve blood circulation and prevent complications of injury.
The timing of consolidation, the time required for fixation with a device or submersible structure, and restoration of working capacity are largely determined by the nature of the injury and the individual characteristics of victims with severe pelvic trauma.

All materials on the site were prepared by specialists in the field of surgery, anatomy and related disciplines.
All recommendations are indicative in nature and are not applicable without consulting a doctor.

Osteosynthesis is a surgical operation to connect and fix bone fragments formed during fractures. The goal of osteosynthesis is to create optimal conditions for anatomically correct fusion of bone tissue. Radical surgery is indicated when conservative treatment is considered ineffective. The conclusion about the inappropriateness of a therapeutic course is made on the basis of a diagnostic study, or after the unsuccessful use of traditional methods for healing fractures.

To connect fragments of the osteoarticular apparatus, frame structures or separate fixing elements are used. The choice of the type of fixator depends on the nature, scale and location of the injury.

Scope of osteosynthesis

Currently, well-developed and time-tested osteosynthesis techniques are successfully used in surgical orthopedics for injuries of the following departments:

• Shoulder girdle; shoulder joint shoulder; forearm;
• Elbow joint;
• Pelvic bones;
• Hip joint;
• Shin and ankle joint;
• Hip;
• Brush;
• Foot.

Osteosynthesis of bones and joints involves restoring the natural integrity of the skeletal system (comparing fragments), fixing fragments, and creating conditions for the fastest possible rehabilitation.

Indications for osteosynthesis

Absolute indications for osteosynthesis are fresh fractures, which, according to accumulated statistical data, and due to the structural features musculoskeletal system, cannot grow together without surgery. These are, first of all, fractures of the femoral neck, patella, radius, elbow joint, clavicle, complicated by significant displacement of fragments, formation of hematomas and rupture of the vascular ligament.

Relative indications for osteosynthesis there are strict requirements for rehabilitation periods. Urgent surgeries are prescribed for professional athletes, military personnel, sought-after specialists, and also for patients suffering from pain caused by improperly healed fractures (pain syndrome causes pinched nerve endings).

Types of osteosynthesis

All types of surgery to restore the anatomy of the joint by comparing and fixing bone fragments are carried out using two methods - submersible or external osteosynthesis

External osteosynthesis. The compression-distraction technique does not involve exposing the fracture site. As fixators, the needles of the guide apparatus are used (Dr. Ilizarov’s technique), passed through the injured bone structures (the direction of the fixation structure must be perpendicular to the bone axis).

Immersion osteosynthesis– an operation in which a fixing element is inserted directly into the fracture area. The design of the fixator is selected taking into account the clinical picture of the injury. In surgery, three methods of performing submersible osteosynthesis are used: extraosseous, transosseous, intraosseous.

External transosseous osteosynthesis technique

Osteosynthesis using a guide apparatus allows you to fix bone fragments while maintaining the natural mobility of the articular ligament in the injured area. This approach creates favorable conditions for the regeneration of osteochondral tissue. Transosseous osteosynthesis is indicated for fractures of the tibia, open fractures of the tibia, and humerus.

The guide apparatus (type of design by Ilizarov, Gudushauri, Akulich, Tkachenko), consisting of fixing rods, two rings and crossed spokes, is assembled in advance, having studied the nature of the location of the fragments using an x-ray.

From a technical point of view, the correct installation of a device that uses different types knitting needles is a difficult task for a traumatologist, since the operation requires mathematical precision of movements, understanding of the engineering design of the device, and the ability to make operational decisions during the operation.

The effectiveness of competently performed transosseous osteosynthesis is extremely high (recovery period takes 2-3 weeks), it does not require special preoperative preparation patient. There are practically no contraindications for performing surgery using an external fixation device. The transosseous osteosynthesis technique is used in each case if its use is appropriate.

Technique of bone (submersible) osteosynthesis

Bony osteosynthesis, when fixators are installed with outside bones, used for uncomplicated displaced fractures (comminuted, flap-shaped, transverse, periarticular forms). Metal plates connected to the bone tissue with screws are used as fixing elements. Additional fixators that the surgeon can use to strengthen the joining of fragments are the following parts:

Structural elements are made of metals and alloys (titanium, stainless steel, composites).

Technique of intraosseous (immersion osteosynthesis)

In practice, two techniques are used for intraosseous (intramedullary) osteosynthesis - these are closed and open type operations. Closed surgery is performed in two stages - first, bone fragments are compared using a guide apparatus, then a hollow metal rod is inserted into the medullary canal. The fixation element, advanced with the help of a guide device into the bone through a small incision, is installed under X-ray control. At the end of the operation, the guidewire is removed and sutures are applied.

At open method the fracture area is exposed, and the fragments are compared using a surgical instrument, without the use of special equipment. This technique is simpler and more reliable, but at the same time, like any abdominal surgery, is accompanied by blood loss, violation of the integrity of soft tissues, and the risk of developing infectious complications.

Locked intramedullary fusion (BIOS) is used for diaphyseal fractures (fractures of long bones in the middle part). The name of the technique is due to the fact that the metal fixation rod is blocked in the medullary canal by screw elements.

For femoral neck fractures, osteosynthesis has been proven to be highly effective at a young age, when bone well supplied with blood. The technique is not used in the treatment of elderly patients who, even with relatively good health indicators, experience dystrophic changes in the joint-bone apparatus. Fragile bones cannot withstand weight metal structures resulting in additional injuries.

After intraosseous surgery on the hip, a plaster cast is not applied.

For intraosseous osteosynthesis of the bones of the forearm, ankle and lower leg, an immobilization splint is used.

The femur is the most vulnerable to a fracture of the diaphysis (at a young age, the injury most often occurs in professional athletes and fans of extreme car driving). To fasten fragments of the femur, elements of various designs are used (depending on the nature of the injury and its scale) - three-bladed nails, screws with a spring mechanism, U-shaped structures.

Contraindications to the use of BIOS are:

• Arthrosis of 3-4 degrees with pronounced degenerative changes;
• Arthritis in the acute stage;
• Purulent infections;
• Diseases of the hematopoietic organs;
• Impossibility of installing a fixator (the width of the medullary canal is less than 3 mm);
• Childhood.

Osteosynthesis of the femoral neck without splinter displacements is carried out using a closed method. To increase the stabilization of the skeletal system, a fixing element is inserted into the hip joint and subsequently secured in the wall of the acetabulum.

The stability of intramedullary osteosynthesis depends on the nature of the fracture and the type of fixation chosen by the surgeon. The most effective fixation is provided for fractures with straight and oblique lines. The use of an excessively thin rod can lead to deformation and breakage of the structure, which is a direct need for secondary osteosynthesis.

Technical complications after operations (in other words, doctor errors) are not often encountered in surgical practice. This is due to the widespread introduction of high-precision monitoring equipment and innovative technologies Detailed osteosynthesis techniques and extensive experience accumulated in orthopedic surgery make it possible to foresee all possible negative aspects that may arise during the operation or during the rehabilitation period.

Technique for transosseous (submersible) osteosynthesis

Fixing elements (bolts or screw elements) are inserted into the bone in the fracture area in a transverse or oblique-transverse direction. This osteosynthesis technique used for helical fractures (that is, when the fracture line of the bones resembles a spiral). For strong fixation of fragments, screws of such a size are used that the connecting element protrudes slightly beyond the diameter of the bone. The head of the screw or screw tightly presses the bone fragments against each other, providing a moderate compression effect.

For oblique fractures with a steep fracture line, the technique of creating a bone suture is used, the essence of which is to “bind” the fragments with a fixing tape (round wire or flexible stainless steel plate tape)

In the area of ​​the injured areas, holes are drilled through which wire rods are pulled, used to fix the bone fragments at the points of contact. The clamps are firmly pulled together and secured. After signs of healing of the fracture appear, the wire is removed to prevent atrophy of the bone tissues compressed by the metal (as a rule, a second operation is performed 3 months after the osteosynthesis operation).

The technique of using a bone suture is indicated for fractures of the humeral condyle, patella and olecranon.

It is very important to carry out primary osteosynthesis as soon as possible for fractures in the elbow and knee area. Conservative treatment is extremely rarely effective, and, moreover, leads to limited flexion-extension mobility of the joint.

The surgeon chooses a technique for fixing fragments based on X-ray data. For a simple fracture (with one fragment and without displacement), the Weber osteosynthesis technique is used - the bone is fixed with two titanium wires and wire. If several fragments have formed and they have been displaced, then metal (titanium or steel) plates with screws are used.

Application of osteosynthesis in maxillofacial surgery

Osteosynthesis has been successfully used in maxillofacial surgery. The purpose of the operation is to eliminate congenital or acquired abnormalities of the skull. To eliminate deformities of the lower jaw formed as a result of trauma or abnormal development masticatory apparatus, the compression-distraction method is used. Compression is created using orthodontic structures fixed in oral cavity. The clamps create uniform pressure on the bone fragments, ensuring a tight marginal connection. In surgical dentistry, a combination of various structures is often used to restore the anatomical shape of the jaw.

Complications after osteosynthesis

Unpleasant consequences after minimally invasive forms of surgery are extremely rare. When conducting open operations The following complications may develop:

1. Soft tissue infection;
2. Osteomyelitis;
3. Internal hemorrhage;
4. Arthritis;
5. Embolism.

After the operation, antibiotics and anticoagulants are prescribed for preventive purposes, painkillers are prescribed according to indications (on the third day, drugs are prescribed taking into account patient complaints).

Rehabilitation after osteosynthesis

The rehabilitation time after osteosynthesis depends on several factors:

• Complexity of injury;
• Locations of injury
• Type of osteosynthesis technique used;
• Age;
• Health conditions.

The recovery program is developed individually for each patient, and includes several areas: physical therapy, UHF, electrophoresis, medicinal baths, mud therapy (balneology).

After elbow surgery patients experience severe pain for two to three days, but despite this unpleasant fact, it is necessary to develop the arm. In the first days, the exercises are carried out by a doctor, performing rotational movements, flexion-extension, and extension of the limb. In the future, the patient performs all points of the physical education program independently.

For developing the knee, hip joint special simulators are used, with the help of which the load on the joint apparatus is gradually increased, muscles and ligaments are strengthened. Therapeutic massage is mandatory.

P after immersion osteosynthesis of the femur, elbow, patella, tibia The recovery period takes from 3 to 6 months, after using the transosseous external technique - 1-2 months.

Conversation with a doctor

If osteosynthesis surgery is planned, the patient should receive as much information as possible about the upcoming treatment and rehabilitation course. This knowledge will help you properly prepare for your stay in the clinic and for the rehabilitation program.

First of all, you should find out what type of fracture you have, what type of osteosynthesis the doctor plans to use, and what the risks of complications are. The patient should know about further treatment methods and rehabilitation periods. Absolutely all people are concerned about the following questions: “When can I start working?”, “How fully can I care for myself after surgery?”, and “How severe will the pain be after surgery?”

The specialist is obliged to detail, consistently, and accessible form illuminate everything important points The patient has the right to find out how the fixations used in osteosynthesis differ from each other and why the surgeon chose this particular type of design. Questions should be thematic and clearly formulated.

Remember that the work of a surgeon is extremely complex, responsible, constantly connected with stressful situations. Try to follow all the instructions of your doctor, and do not neglect any recommendations. This is the main basis for rapid recovery after a complex injury.

Cost of the operation

The cost of osteosynthesis surgery depends on the severity of the injury and, accordingly, on the complexity of the medical technologies used. Other factors influencing the price of medical care are: the cost of the fixation structure and medicines, level of service before (and after) surgery. For example, osteosynthesis of the clavicle or elbow joint in different medical institutions can cost from 35 to 80 thousand rubles, surgery on the tibia - from 90 to 200 thousand rubles.

Remember that the metal structures must be removed after healing of the fracture - for this, repeated surgery is performed, for which you will have to pay, although an order of magnitude less (from 6 to 35 thousand rubles).

Free operations are carried out according to a quota. This is a very real possibility for patients who may wait 6 months to a year. The traumatologist issues a referral for additional examination and medical examination (at the place of residence).