ANATOMY OF THE PELVIS

The pelvis is made up of ilium, ischia, pubis, sacrum and coccyx. Anatomically it is divided into the greater/false and lesser/true pelvis, along the line of the pelvic inlet. The perineum is the area below the pelvic floor. Pelvic inlet: ala of the sacrum, body of S1, a rim on the pelvic bones that join at the pubic symphysis. Pelvic outlet: diamond-shaped and formed of the body of S1, ala of the sacrum, ischial tuberosities, inferior pubic rami, coccyx and sacrotuberous ligaments. ORIENTATION: key to understanding where the organs of the pelvis sit, is understanding that it is steeply angled (see left). The pelvic cavity is therefore mostly tucked inside the sacrum and not between the iliac crests. GENDER DIFFERENCES 1. Pelvic inlet shape: circular in female, heart-shaped in male. 2. Subpubic angle: more obtuse in women (80 - 85) than men (50 - 60). This can be approximated by the thumb-index finger and first and second finger angles. 3. Ischial spines: less prominent medially in women (that baby has to fit in somewhere).

SACROILIAC JOINT Bones: Between the ala of the sacrum and the iliac parts of the pelvis. Articulation: Irregular, corrugated joints between L-shaped facets. They have both synovial and fibrous parts. Ligaments: The SIJ is heavily stabilized by ligaments: i. Anterior sacro-iliac ligament, which is a thickening of the joint capsule anteriorly. This is a continuum of the ilio-lumbar ligaments and form a hood over and around the L5 ventral rami thus providing a close union with the lumbar spine (consequently dysfuntion of both is common) ii.) Interosseous sacro-iliac ligament, which is the strongest. It is posterosuperior to the joint and fills the gap between the ilium and the sacrum. iii) Posterior sacro-iliac ligament, which covers the interosseous sacro-iliac ligament. The sacro-iliac joint has several tasks: 1. Transmission of the weight force of the upper body from the lumbar spine to the hips and lower extremities provides a bi-axial pathway. 2. Transmission of reaction force from the ground via the lower extremities to the lumbar spine. 3. Aiding locomotion by dampening the movements from both above and below coping with torque and momentum. 4. Supporting the pelvic viscera and their supporting tissues as well as allowing for the expansion of the pelvis girdle in labour. (The pelvis in labour is a whole other topic which wont be mentioned here).

PUBIC SYMPHYSIS Bones: the pubis has a body and two arms/rami, that articulate via the pubic symphysis. The pubic tubercles are the prominent rounded crests on the superior surface. The inferior pubic ramus joins with the ischium to form the bottom part of the obturator foramen. The superior pubic ramus meets the ilium to form the upper part of the obturator foramen. Articulation: Joint surfaces are covered by hyaline cartilage and linked by fibrocartilage. Movement occurs as a direct result of ilial movement, mainly around the transverse axis, although some shearing force occurs too. Ligaments: superior and inferior pubic ligaments. SACROCOCCYGEAL JOINT Bones: The coccyx is a little triangular bone formed of four fused rudimentary vertebrae. Articulation: The upper surface/base has an oval facet for a synovial plane joint articulation with the sacrum. Ligaments: The anterior and posterior sacrococcygeal ligaments and gluteus maximus all attach to the coccyx. The lateral parts of the coccyx give attachments to levator ani. ATTACHMENTS OF THE GLUTEI Muscle Attachment
Gluteus maximus Ilium, behind posterior gluteal line; posterior surface of sacrum and coccyx, sacrotuberous lig, aponeurosis of erector spinae. Ilium, inferior to iliac crest. Ilium, between middle and inferior gluteal lines. Iliac crest between ASIS and iliac tubercle.

Attachment
ITB, gluteal tuberosity of femur.

Innervation
Inferior gluteal n. (L5, S1, S2)

Function
Upper part: abducts & externally rotates thigh. Lower part: extends thigh, assists in adduction. Abducts thigh, medial rotator of thigh. Abducts thigh, medial rotator of thigh. Flexes and abducts thigh.

Gluteus medius Gluteus minimus

Lateral surface greater trochanter Anterior surface of greater trochanter. ITB

Sup gluteal n. (L4, L5, S1) Sup gluteal nerve (L4, L5, S1) Sup gluteal n. (L4, L5, S1)

Tensor fasciae latae

PELVIC LIGAMENTS The sacrotuberous and sacrospinous ligaments do not reinforce joints, but are important in defining the foramina of the pelvis. Sacrotuberous ligament: superficial to the sacrospinous lig, it attaches from the PSIS, down along the sacrum and coccyx, then onto the medial aspect of the ischial tuberosity. Sacrospinous ligament: a little triangular ligament attaching from the sacrum and coccyx to the ischial spine. FORAMEN Formed by sacrotuberous and sacrospinous ligaments: Greater sciatic foramen: this is a major thoroughfare between pelvis and lower limb, divided by piriformis. Above piriformis: superior gluteal nerves and vessels. Below piriformis: inferior gluteal nerves and vessels, sciantic n., pudendal n., internal pudendal vessels, posterior femoral cutaneous nerves, nerves to obt internus and quad femoris muscles. Lesser sciatic foramen: passageway between perineum and gluteal region. Pudendal nerve and internal pudendal vessels pass through here, first emerging through the GSF, then looping atound the sacrospinous ligament to get into the perineum via the LSF.

PELVIC WALL: obturator internus and piriformis contribute to the lateral walls of the pelvis. They both come out of the pelvis to attach to the femur. Obturator internus is covered with a thick layer of fascia and gives rise to some of the fibres of levator ani. Muscle
Obturator internus

Attachment
Obturator membrane and surrounding bone

Attachment
Medial surface of greater trochanter

Innervation
N. to obt internus (L5, S1) L5, S1, S2.

Function
External rotation of the extended hip joint. Abduction of flexed hip. As above.

Piriformis

Anterior surface of sacrum

Medial surface of greater trochanter

PELVIC FLOOR The pelvic floor separates the pelvic cavity from the perineum. Some texts consider the diaphragm and floor to be distinct, where the pelvic diaphragm is made up of the levator ani, and the floor also includes perineal fascia. The pelvic floor supports the pelvic viscera (bladder, intestines, uterus) and maintains continence via the urinary and anal sphincters. Levator ani is considered to have three parts: ischiococcygeus (sometimes called coccygeus), iliococcygeus and pubococcygeus. Pubococcygeus forms the main part of levator ani and has other, named sections according to the pelvic visera it relates to. Iliococcygeus joins its opposite partner by a fibrous insertion to form a raphe, which is continuous with the anococcygeal ligament. The boundaries between each are not clear and they can perform similar functions. Levator ani must be able to relax to allow urine and faeces to be passed out. It is active in respiratory inspiration and can contract to increase intra-abdominal pressure. Muscle
Ischiococcygeus (aka coccygeus)

Attachment
Internal surface of the true pelvis, where obturator fascia condenses Inner surface of the ischial spine.

Attachment
Lateral margins coccyx and S5

Innervation
S3, S4 (directly)

Function
Assists in contributing to urinary and faecal continence. Supports pelvic viscera. Assists in contributing to urinary and faecal continence. Supports pelvic viscera.

Iliococcygeus

Pubococcygeus

Posterior body of the pubis

Tip of sacrum and coccyx; other fibres form a raphe in the midline continuous with the anococcygeal ligament. Coccyx. Some fibres form puborectalis a muscular sling that wraps around the anorectal junction. Others form part of the urethral sphincter and anal canal.

S3, S4 (directly)

S2, S3 (pudendal n.)

Lateral compressor of the visceral canals that cross the pelvic floor. Puborectalis reinforces the external anal sphincter and helps to create anorectal angle.

PELVIC ORGANS (not really covered today) The pelvis is a snug home for all the urogenitary apparatus. It is soft and squidgy, so if anything is removed, another organ will expand and move into its space.

Pouch of Douglas/recto-uterine pouch: extension of the peritoneal cavity between rectum and posterior wall of the uterus in the female. This is the lowest point in the female abdominopelvic cavity and is therefore a site for accumulation of infection and fluids. LIGAMENTS OF THE UTERUS