Lecture 13

Question 1

What is on each side of the pelvis?

Answer 1

Two os coxa - basically two pelvises.

Question 2

What is each os coxa formed from?

Answer 2

1. Ilium.
2. Ischium - posteriorly.
3. Pubis - inferiorly and pubis.

They meet at the acetabulum.

Question 3

What is on the posterior side of the os coxa?

Answer 3

1. Greater sciatic notch.
2. Ischial spine.
3. Lesser sciatic notch.
4. ischial tuberosity.

Question 4

What are the key landmarks of the pelvis?

Answer 4

1. Pubic symphysis - in the midline.
2. Pubic tubercle.
3. Pubic crest.
4. Arcuate line.
5. AIIS.
6. Sacroiliac joint - where the sacrum and the ilium join.
7. Lumbrosacral joint - where the lumbar bones join to the sacrum.
8. Iliac fossa.
9. ASIS.

Question 5

What are the key features of the sacrum?

Answer 5

There are 5 vertebrae which are fused. There is an ala - lateral. There are 4 anterior sacral foramen (passage for nerves). There is a coccyx on the end. There is the sacral canal, at the bottom there is a sacral hiatus (covered by a membrane - caudal nerve blocks). There is also posterior sacral foramen.

Question 6

What is the difference between the True and False Pelvis?

Answer 6

The false pelvis is the part above the pelvic inlet (abdominal cavity). Everything below the pelvic inlet is the true pelvis (pelvic cavity).

Question 7

What makes up the pelvic inlet?

Answer 7

1. Sacral promontory.
2. Alae of sacrum.
3. Arcuate line.
4. Pectineal line.
5. Pubic tubercle.
6. Pubic crest.
7. Pubic symphysis.

Question 8

What is pelvic tilt?

Answer 8

The pelvis is tilted forward 60 degrees anteriorly and the ASIS is line with the pubic symphysis. The sacrum is also titled 40 degrees.

Question 9

What are the pelvic boundaries?

Answer 9

Anterior, posterior and lateral walls are all bony. The floor is muscular (pelvic diaphragm).

Question 10

Describe male and female variation of pelvis?

Answer 10

In the female the sub-pubic angle is more than 90 degrees whereas in men it is smaller than 90 degrees. In females the inlet is large and circular whereas in men it is heart shaped. The iliac crest are wider in females. The outlet in females is less obstructed - due to childbirth. The sacrum is tilted back in females whereas in males it is tilted forward.

Question 11

What are the two key ligaments in the pelvis?

Answer 11

1. Sacrotuberous ligament.
2. Sacrospinous ligament.
   These ligaments form the greater sciatic foramen and lesser sciatic foramen.

Question 12

What are the other ligaments in the pelvis?

Answer 12

1. Anterior sacroiliac ligament - synovial joint. Allows a little bit of flexion and movement.
2. Posterior sacroiliac ligament - fibrous joint. Strongest one out of the joints.

Question 13

What are the muscles of the pelvic wall?

Answer 13

1. Piriformis muscle - lateral hip rotators that pass from the body of the sacrum out to the greater trochanter of the hip.
2. Obturator internus muscle - internal in the pelvis and covers majority of the obturator foramen. Lateral rotator.

Question 14

What are the vessel passageways of the pelvis?

Answer 14

1. Superior gluteal nerve (and vessels) - goes above the piriformis muscle in the greater sciatic foramen.
2. Sciatic nerve, inferior gluteal nerve, posterior femoral cutaneous and quadrates femoris nerves - go below the piriformis muscle in the greater sciatic foramen.
3. Pudendal nerve and internal pudendal vessels and obturator internus nerve leave the greater sciatic foramen and curve around the the SS ligament and re-enter below the pelvic floor into the perineum.
4. The obturator vessels go through the obturator canal.

Question 15

What does the internal iliac artery divide into?

Answer 15

Anterior and Posterior.

Question 16

What are the branches of the anterior division of the internal iliac artery?

Answer 16

Vesicular:
1. Umbilical - gives rise to superior vesical.
2. Superior vesical (2/3).
3. Inferior vesical - also known as uterine in females.
Visceral:
1. Uterine in females.
2. Vaginal/Prostatic.
3. Middle rectal.
Parietal:
1. Obturator - through obturator canal to medial thigh.
2. Internal pudendal - out greater sciatic foramen, loops around SS ligament and goes in lesser sciatic foramen to perineum.
3. Inferior gluteal - out greater sciatic foramen, and inferior to priformis muscle.

Question 17

Describe the male variation for the branches of the anterior division of the internal iliac artery?

Answer 17

The inferior vesicle and middle rectal supply: prostate, seminal vesicles and ductus deferens. (Testicular arteries from abdominal aorta at L2.)

Question 18

Describe the female variation for the branches of the anterior division of the internal iliac artery?

Answer 18

Uterine artery gives off vaginal artery - supply female genitalia.

Question 19

What are the branches of the posterior division of the internal iliac artery?

Answer 19

1. Iliolumbar - passing back up towards posterior abdominal wall and supplies associated muscles.
2. Lateral sacral - through sacral foramina and supplies contents of the sacral canal.
3. Superior gluteal - out of greater sciatic foramen, superior to piriformis.

Question 20

Describe the venous drainage?

Answer 20

Heaps of venous plexuses all draining to internal iliac veins. The exception is the deep dorsal vein of the penis/clitoris. The rest of perineum drains back with the internal pudendal vein. DDVoP/C passes through anterior deficiency in perineal membrane and then into vesicle/prostatic plexuses.

Question 21

Describe the sacral plexus?

Answer 21

L4-S4 - anterior rami. It is joined by L4/5 lumbrosacral trunk. Mostly going on to innervate structures external to pelvis.

Question 22

Describe the superior gluteal nerve?

Answer 22

This nerve comes from L4,5 and S1. It supplies the gluteus medius and minimus.

Question 23

Describe the inferior gluteal nerve?

Answer 23

This nerve comes from L4, S1,2. It supplies gluteus maximus.

Question 24

Where do the gluteal nerves pass?

Answer 24

Superiorly and inferiorly to piriformis muscle respectively.

Question 25

Describe the sciatic nerve?

Answer 25

Comes from L4-S3. The tibial nerve always leaves below piriformis whereas the common peroneal may leave below, above or through the piriformis muscle.

Question 26

Describe the nerves to Levator Ani and Coccygeus?

Answer 26

These come from S3-4. It innervates the muscular floor, it is at risk during childbirth or extreme pressure to the muscular floor. That is why after childbirth some women are prone to prolapse, because this nerve is damaged.

Question 27

Describe the pudendal nerve?

Answer 27

This comes from S2-4. It supplies everything int he perineum: elevator and, external and internal anal sphincters, sphincter urethrae, bulbospongiosus, ischiocavernosus, and transverse perineals.

Question 28

What are the branches of the pudendal nerve?

Answer 28

1. Inferior rectal nerve. 2. Perineal. 3. Dorsal nerve to clitoris/penis. 4. Scrotal/labial. Sex specific.

Question 29

Describe the ANS to pelvic viscera?

Answer 29

There are 2 plexuses: 1. Superior hypogastric. 2. Inferior hypogastric.

Question 30

What does the superior hypogastric plexus supply?

Answer 30

The anterior body of L5 and sacral promontory.

Question 31

What does the inferior hypogastric plexus supply?

Answer 31

Pelvic floor.

Question 32

Describe the sympathetic supply of the pelvic viscera?

Answer 32

Comes from L1/2 fibres, they descend into the pelvis via the superior hypogastric plexus and directly from sacral splanchnic nerves. The plexus splits to form two big hypogastric nerves. It causes the contraction of the internal urethral and anal sphincters - continence. It is also involved in ejaculation and moving secretions along epididymis.

Question 33

Describe the parasympathetic supply of the pelvic viscera?

Answer 33

Comes from S2-4 fibre, they ascend via hypogastric nerves to superior hypogastric plexus and into abdomen, direct into inferior hypogastric plexus. It causes vasodilation e.g. for erection (male and female). It stimulates the contraction of the bladder.

Question 34

What is a saddle fracture?

Answer 34

They involve the pelvic bones, when something has dislocated or fractured the pelvis.