The Bony Pelvis.pdf

The pelvis is the lower part of the trunk of the human body between the abdomen and the thighs.
Topographically it is made up of a bony and ligamentous framework which is lined internally and externally by soft tissue and it is closed inferior by a layer of muscle and fascia which constitute the pelvic floor.
The perineum lies below the pelvic floor.
The pelvis in its broadest sense is an anatomical region bounded behind by the sacrum and coccyx, on each side and anteriorly by the innominate bones which are the hip bones, or pelvic bones.
These bones form the skeletal base for the lower limb.

1. Dr. NDAYISABA CORNEILLE
CEO of CHG
MBChB,DCM,BCSIT,CCNA
SupportedBY

2. PELVIS
•The pelvis is the lower part of
the trunk of the human body
between the abdomen and the
thighs.
•Topographically it is made up of a bony and
ligamentous framework which is lined
internally and externally by soft tissue and it is
closed inferior by a layer of muscle and fascia
which constitute the pelvic floor.
•The perineum lies below the
pelvic floor.
Dr Ndayisaba Corneille 2

3. Boundaries of the Pelvis
•Thepelvisinitsbroadestsenseis
ananatomicalregionbounded
behindbythesacrumandcoccyx,
oneachsideandanteriorlybythe
innominateboneswhicharethe
hipbones,orpelvicbones.
•Thesebonesformtheskeletal
baseforthelowerlimb.
Dr Ndayisaba Corneille 3

4. DIVISION OF THE PELVIS
•Animaginaryplanepassing
throughthelineaterminalis
(PelvicBrim)dividesthe
entirepelvisintotwoparts:
–anupperlargerpartwhichis
referredtoasthegreater
pelvisalsoknownasthe
falsepelvisorthepelvis
majorand
–alowersmallerpartwhichis
referredtoasthelesser
pelvis,alsoknownasthe
truepelvisortheminor
pelvis
Dr Ndayisaba Corneille 4

5. •Thelineaterminalesis
formedbythe
–anteriorborderofthe
baseofthe1
st
sacrum
formedby(thesacral
Promontoryandmargin
oftheala),
–thearcuatelineofthe
iliumand
–thepectineallineofthe
pubis.
Dr Ndayisaba Corneille 5

6. THE GREATER PELVIS (FALSE, MAJOR
PELVIS)
•Thisisthepartofthe
pelvislyingabovethe
lineaterminalis.
•Posteriorliesthe5
th
Lumbervertebrate
•laterallyitisboundedby
theiliacfossawhile
•anteriorlywheretheilium
isdeficientitisbounded
bythelowerpartofthe
anteriorabdominalwall.
Dr Ndayisaba Corneille 6

7. CONTENTS OF THE GREATER PELVIS………………….
•It is generally considered part of
the abdominal cavity (because of
this, it is also called the false
pelvis).
•The greater pelvis contains
–Part of the ileum,
–Ceacum,
–Appendix and
–Sigmoid colon
Dr Ndayisaba Corneille 7

8. LESSER PELVIS
•Itispartofthepelvislying
belowandbehindthelinea
terminalis.
•Itissaidtohavesuperior
apertureorPelvicinlet,Pelvic
cavityandaninferiorapertureor
Pelvicoutlet
•Thetruepelvisinfemalesis
modifiedtoserveasthebirth
carnal.
Dr Ndayisaba Corneille 8

9. CONTENTS OF LESSER PELVIS
•The lesser pelvis contains the rectum, bladder, and some of the internal
genitalia (sex organs).
•The rectum lies in the curve of the sacrum and coccyx; the bladder is in front,
behind the pubic symphysis.
•In the female, the uterus and vagina occupy the interval between these
viscera.
Dr Ndayisaba Corneille 9

10. The superior aperture: Pelvic Inlet
•Thesuperiorapertureisformed
posteriorlybytheanteriorsurface
ofthebaseofthebodyofthe1
st
sacrum,
•oneachside(laterally)itisbounded
bythearcuatelineandthepectineal
line
•whileanteriorlyitisboundedbythe
pubiccrestandtheanterior
continuationofthepectinealline.
Dr Ndayisaba Corneille 10

11. Pelvic Outlet
•The pelvic outlet also known
as the inferior aperture is
bounded
–posterior by the tip of
coccyx,
–lateral by the ischial
tuberosity and
–anteriorly by the pubic arch
which is formed by the
ventral rami of the pubic and
the ischial bone as they unite
anteriorly.
Dr Ndayisaba Corneille 11

12. Dr Ndayisaba Corneille 12

13. OBSTETRICAL OUTLET:
•This outlet has greater practical significance,
because it includes the narrow pelvic strait
through which the fetus must pass.
•It is otherwise known as bony outlet.
•Shape: it is diamond shaped.
•It is bounded by the lower border of the
symphysis pubis anteriorly, the ischial
spines laterally, and the tip of the sacrum
posteriorly
Dr Ndayisaba Corneille 13

14. THE PELVIC CAVITY
•The pelvic cavity is the
continuation of the abdominal
cavity into the Pelvis through the
Pelvic brim or Pelvic inlet. It
extends from the pelvic brim
above to the Pelvic outlet below.
•The Abdominal cavity continues
inferiorly into the Pelvic cavity as
such they are sometimes referred
to as Abdominopelvic cavity
Dr Ndayisaba Corneille 14

15. Pelvic cavity……………………
•its shape is almost rounded. It
consist of
–Anterior border: Symphysis pubis
–Posterior border: Sacral hollow
–Lateral border: Soft tissues
•It has two openings: a Superior and
Inferior Aperture or Outlet
•This cavity is a short, curved canal,
deeper on its posterior than on its
anterior wall.
Dr Ndayisaba Corneille 15

16. Dr Ndayisaba Corneille 16

17. THE BONY PELVIS
•Thebonypelvisistheirregular
bonygriddlebetweenthefemoral
headsandthefifthlumbar
vertebra.
•Itismassivebecauseitsprimary
functionistowithstand
compressionandotherforcesdue
tobodyweight,abdominal
powerfulmusculatureandlower
limbmusculature.
•Itisofgreatimportancein
obstetric,forensicand
anthropologicalapplications.
Dr Ndayisaba Corneille 17

18. The bony pelvis………………..
•Thebonypelvisisformed
by:
–thehipbone(pelvicbone)in
frontandatthesides,and
–thesacrumandcoccyx
behind.
Dr Ndayisaba Corneille 18

19. Pelvic Bone
•The two hip bones are
joined at the pubic
symphysis
•Hip bones articulate
with the sacrum at the
sacroiliac joints and the
femur at the hip joint
•It is composed of Ilium,
ischium and pubis and
they fused at the
acetabulum.
Dr Ndayisaba Corneille 19

20. THE PUBIS:
•Itformstheanteriorpartofthepelvic
bone.
•Itsbodyforms1/5
th
oftheacetabulum.
•Itssymphysealsurfaceuniteswiththe
oppositesidetoformthepubic
symphysis.
•Thesuperiorandinferiorpubicrami
participateintheformationofthe
obturatorforamen.
•Itsinferiorramusfuseswiththeischial
ramustoformtheischiopubicramus.
Dr Ndayisaba Corneille 20

21. HIP BONES: PUBIS
•Body of pubis
•Superior ramus of
pubis
•Inferior ramus of pubis
•Pubis crest
•Pubic tubercle
•Pecten pubis
(pectineal line of
pubis)
•Subpubic angle
Dr Ndayisaba Corneille 21

22. The Ischium
•ItisV-shapeandformstheposteriorinferior
partofthepelvicbone.
•Itpresentsaroughenedprojection.Theischial
tuberositythatprotrudesposteroinferiorly
fromthebodyoftheischium.
•Itisthesiteforattachmentofthe
sacrotuberousligament;originoftheinferior
gemellusmuscle,quadratusfemorismuscle
andthehamstringmuscles.
•Itsposteriormarginismarkedbyaprominent
ischialspinethatseparatesthelessersciatic
notchbelowfromthegreatersciaticnotch
above.
Dr Ndayisaba Corneille 22

23. HIP BONE: ISCHIUM
•Body of ischium
•Superior Ischial
Ramus
•Inferior ischial
ramus
•Ischial spine
•Ischial tuberosity
Dr Ndayisaba Corneille 23

24. The Ilium
•ItIsthemostsuperiorin
position.
•Itpresentstheiliaccrestwhich
runsbetweentheantero-and
postero-superioriliacspines,
beloweachofthesearethe
correspondinginferiorspines.
•Itsinneraspectbearsthelarge
auricularsurfacewhich
articulateswiththesacrum.
Dr Ndayisaba Corneille 24

25. HIP BONE: ILIUM
•Ala of ilium
•Body of ilium
•Iliac crest
•Iliac fossa
•Anterior superior iliac spine
(ASIS)
•Anterior inferior iliac spine
(AIIS)
•Posterior superior iliac spine
(PSIS)
•Posterior inferior iliac spine
(PIIS
Dr Ndayisaba Corneille 25

26. THE SACRUM
•Itisformedbyfivefusedsacral
vertebraewhose transverse
processesandfusedcostalprocesses
formsthealarplateorthelateral
mass.
•Anteriorly,istheanteriorsacral
foraminawhichtransmitstheventral
primaryramiofthesacralspinal
nerve
Dr Ndayisaba Corneille 26

27. Posterior View
•Posteriorly the spinal processes fuse to form
the median sacral crest
•Presentalsoisaposteriorsacral
foraminawhichtransmitsthedorsalprimary
rami,
•Caudallyisthesacralhiatuswhichisformed
duetotheunfusedlaminarofthe5
th
sacral
vertebrae.Itisthesightforcaudalanesthesia.
•Itislocatedatthesurfacebyanimportant
landmarkformedbythesacralcornuaformed
bythepedicleofthe5
th
sacralvertebrae.
•Second sacral vertebrate
marks the end of dura and
arachnoid mater as well as
the subarachnoid space
SacralCanal
Dr Ndayisaba Corneille 27

28. Abnormalities of Sacral Bone
•Sacralizationis a common irregularity of
the spine, where the transverse process of
the fifthlumbar vertebrafuse with the
sacrum
•The fifthlumbar vertebramay fuse fully
or partially on either side of the sacrum, or
on both sides.
•Lumbarisationis where the 1
st
sacral
vertebra fuses with the 5
th
Lumbar Vertebra
•Sacralizationand lumbarization are
congenital anomalies that occurs in the
embryo.
•Unilateral or Bilateral lumbarisation
•Unilateral or Bilateral sacralisation
Dr Ndayisaba Corneille 28

29. THE COCCYX
•Coccyx is a vestigial
tail. It consists of
four fused vertebra
forming a small
triangular bone.
•its base articulates
with the lower end
of the sacrum.
Dr Ndayisaba Corneille 29

30. FUNCTIONS OF BONY PELVIS
•1) To protect pelvic viscera
•2) To support the weight of the body -transfer
the weight of the upper body from the axial to
the lower appendicular skeleton
•3) Provides attachment for muscles
•4) In females, it provide bony support for the
birth canal
Dr Ndayisaba Corneille 30

31. Pelvic joints
•There are four
pelvic joints
•Two sacroiliac
joints
•One sacro-
coccygeal joint
•One Pubic
symphysis
Dr Ndayisaba Corneille 31

32. Pubic Symphysis
•It is a secondary cartilaginousjoint
•Articular surface is covered with
hyaline articular cartilage
•Disc of fibro-cartilage lies between the
articular surface
•A cavity may develop in the discbut it
is not linedwith synovialmembrane
•There is normally very little movement
at the pubic symphysis, except during
the latter months of pregnancy
Dr Ndayisaba Corneille 32

33. Sacroiliac Joint
•Modified synovial plane joint
•Articular surfaces are rough
•It bound by the Anterior and
Posterior sacroiliac
ligaments which is one of the
strongest ligaments in the
body
•This articulation is almost
immobile, except during
pregnancy
Dr Ndayisaba Corneille 33

34. Sacroiliac Joint Accessory Ligaments
•Sacrotuberous
ligaments
•Sacrospinous
ligaments
•Iliolumbar
ligaments
•The sacrotuberousand
sacrospinous ligaments
converts the greater and
lesser sciatic notches
to Foraminae
GS
F
LSF
Dr Ndayisaba Corneille 34

35. Sacro coccygeal joint
•The sacrococcygeal joint: this
joint is formed where the base
of the coccyx articulate with the
tip of the sacrum
•During labourthe coccyx moves backwards at
the sacrococcygeal joint to give more space for
the delivery of the baby this is called nodding.
•Fracture of a fused sacrococcygeal joint or at the
fused coccygeal joints or arthritis in these joints
causes a painful condition known as
coccygodynia.
Dr Ndayisaba Corneille 35

36. Movement in the Pelvic Joint
•In the non-pregnant state there is very little movement
in these joints, but during pregnancy endocrine activity
causes the ligaments to soften, which allows for slight
movement.
•This may provide more room for the fetal head as it
passes through the pelvis.
•The symphysis pubis may separate slightly in later
pregnancy. If it widens appreciably, the degree of
movement permitted may give rise to pain on walking.
•The sacro-coccygeal joint permits coccyx to be
deflected backward during the birth of the head
Dr Ndayisaba Corneille 36

37. MEASUREMENT OF THE FEMALE PELVIS
•Thesevaluesareofgreatimportance
inobstetricsforpredictingthe
likelihoodofavaginaldelivery.
•Accuratemeasurementsofthemothers
pelvicinletandoutletisdeterminedin
othertoknowifthesizeandposition
ofthefetalheadcouldcause
complicationsduringdelivery.
•Thesemeasurementsinclude:
Dr Ndayisaba Corneille 37

38. MEASUREMENT OF THE PELVIC INLET:
•ConjugateDiameter:
–Trueconjugate
–DiagonalConjugate
–ObstetricConjugate
•TransverseDiameter
•AnatomicalTransverseDiameter
•ObstetricTransverseDiameter
•ObliqueDiameter
•RightObliqueDiameter
•LeftObliqueDiameter
•Sacrocotyloiddiameter
Dr Ndayisaba Corneille 38

39. True conjugate
•This is the anterior
posterior diameter
from the sacral
promontory to the
superior margin of
the pubic
symphysis. It is
about 11 to 11.5cm
in females, but in
males it is 10cm.
Dr Ndayisaba Corneille 39

40. Diagonal Conjugate
•This is measured from the sacral promontory
to the inferior margin of the pubic
symphysis. It is about 12cm.
Vaginal Examination to Determine Diagonal Conjugate
Dr Ndayisaba Corneille 40

41. Obstetric Conjugate
•Obstetric Conjugate: This is the least A.P
diameter from the sacral promontory to a
point a few millimeters below the superior
margin of the pubic symphysis. It is about
10.5cm.
•It is shortest AP diameter through which
the head must pass.
•It cannot be measured clinically
•For clinical purposes, obstetric conjugate
is estimated indirectly by subtracting 1.5
to 2 cm from diagonal conjugate
•If the Obstetric conjugate is less than 10 cm,
it is called contracted pelvic inlet.
Dr Ndayisaba Corneille 41

42. Transverse Diameters: Anatomical and Obstetric T D
•Anatomical Transverse
Diameter is the widest
distance across the
pelvic brim. It is about
13 to 13.5cm in females
and in males it is about
12.5cm.
•The largest diameter of
pelvic inlet = Transverse
diameter
Dr Ndayisaba Corneille 42

43. Obstetric transverse diameter
•It bisects the
true
conjugate and
is slightly
shorter than
the
anatomical
transverse
diameter.
Dr Ndayisaba Corneille 43

44. Oblique Diameters: Right and Left O. D.
•The right oblique diameter passes from the right sacroiliac joint to the left iliopectineal
eminence and the left oblique extends from the left sacroiliac joint to the right
iliopectineal eminence. Each measures about 12cm.
Dr Ndayisaba Corneille 44

45. The Sacrocotyloiddiameter
•The sacrocotyloid
diameter is
measured from
the sacral
promotoryto the
iliopectineal
eminence, on the
same side, and is
approximately9c
ms
Dr Ndayisaba Corneille 45

46. Diameters of the Pelvic
cavity
•The cavity extends from the brim
above to the outlet below. It is
almost circular in shape.
•The anterior wall is formed by the
pubic bones and symphysis pubis
and its depth is4cm.
•The posterior wall is formed by the
curve of the sacrum which
is12cmin length.
•The diameters, similar in direction to
the brim, are all considered to
Dr Ndayisaba Corneille 46

47. MEASUREMENT OF THE PELVIC OUTLET
•The pelvic outlet is slightly smaller than
the pelvic brim, but it would be unusual
for a fetal head to be able to pass through
the brim and not be able to pass through
the outlet.
•Antero-posterior diameter (13cm): it
Extend from lower border of symphysis
pubis to the tip of coccyx.
•Oblique diameter (12): it extend from Rt.
orLt. Sacro spinous ligament to the
contralateral Obturator foramen
•Transverse diameter (11cm): between the
ischial spines.
Dr Ndayisaba Corneille 47

48. Dr Ndayisaba Corneille 48

49. ORIENTATION OF THE PELVIC
•Intheanatomicalposition,the
pelvisshouldbeplacedinsucha
waytheanteriorsuperioriliacspine
liesonthesameverticalplanewith
thetopofthepubicsymphysis.
•Thoughinthelivingthefemale
anteriorsuperioriliacspineistilted
abitforwardasaresultofthisthe
lumbarcurvaturebecomesmore
curvedandthebuttockbecomes
moreprominent.
Dr Ndayisaba Corneille 49

50. VARIATION OF THE PELVIS
•The general shape of the pelvis is grouped into four base on
Caldwell-MoloyClassification of Pelvic Types
1.TheGynaecoid:
2.TheAndroid:
3.Platypelloid:
4.Anthropoids:
Dr Ndayisaba Corneille 50

51. • Gynaecoidpelvis(50%)
• Anthropoid pelvis (25%)
• Android pelvis (20%)
• Platypelloidpelvis (5%)
Dr Ndayisaba Corneille 51

52. Gynaecoidpelvis: (50%)
•It is commonly known as the
female pelvis because that
type occurs most frequently
in women.
•Most suitable for childbirth.
•Wider brim.
•Ischial spines are blunt
•Sub pubic angle is greater
than 90 degrees
•Sub-pubic arch is wide enough to
accommodate the examiners four knuckles or
clenched fist
Dr Ndayisaba Corneille 52

53. Android pelvis: (20%)
•It is commonly known as
male pelvis because it
occurs more frequently in
men.
•Heart shaped brim
•Anterior posterior
diameter is shorter
•Transverse diameter is
wider
•Childbirth is difficult
Dr Ndayisaba Corneille 53

54. SEX DIFFERENTIATION
•This is of great important inforensic anthropology in order to
determine the sex of the pelvis in medicolegal situations.
•When presented with a pelvis for identification emphasis should be
laid on:
1.Pubicarch:tonoteitsprominenceasaresultofattachmentofcrusofthe
penisorclitoris.
2.Thesizeoftheacetabulum:whichislargerinmalethaninfemale.
3.Thedistancebetweentheacetabulum,iliumandthepubicsymphysis:
whichislongerinfemalesthaninmales.
4.Thesizeofthefacetbaseofthesacruminrelationtothealaofthesacrum
(smallerinfemaleandlargerinmale).
5.Subpubicangleitistheangleofthepubicarchwhichislargerinfemale
thaninmale.
Dr Ndayisaba Corneille 54

55. Dr Ndayisaba Corneille 55

56. MUSCLES OF THE LATERAL PELVIC
WALL
Obturator Internus Muscle and Piriformis
Dr Ndayisaba Corneille 56

57. Obturator Internus Muscle
•Origin:Ittakesitsoriginfromthedeepsurfaceof
obturatormembraneanditsassociatedbonysurface,
itsfibersconvergeandpassthroughthelessersciatic
foramen.
•Insertion:Insertedintothegreatertrochanterof
thefemurjustabovethetrochantericfossa.
•NerveSupply:NervetoObturatorinternus(L5,
L11,L12).
•Action:Becauseofitsposteriormedialinsertionit
helpsinabductionoftheflexedhipandinlateral
rotation.
OIM
Dr Ndayisaba Corneille 57

58. Piriformi
s
PIRIFORMIS
Itisatriangularshapedmusclewhichservesas
animportantlandmarkintheglutealregion.Its
positionshouldbecomparedwiththatofPminor.
Origin:Fromtheanteriorsurfaceof2
nd
–4
th
sacralvertebrae,lateraltotheanteriorsacral
foramina,
INSERTION:Itpassestobeinsertedintothe
greatertrochanterofthefemurjustabovethe
insertionoftheObturatorinternusmuscle.
NerveSupply:BranchesfromventralramiofL5,
S1–S3.
Action:lateral rotator and abduction of the femur
Dr Ndayisaba Corneille 58

59. THE MUSCLES OF THE PELVIC FLOOR
•The pelvic floor is composed of
–the pelvic diaphragm,
•The pelvic floor separates the pelvic
cavity from the perineum.
•The muscles that forms the pelvic floor is
–the levatorani and
–the coccygeus muscle
Dr Ndayisaba Corneille 59

60. Dr Ndayisaba Corneille 60

61. LEVATOR ANI
•The levatorani
muscle is made
up of two parts,
–the lateral
portion and
–medial portion.
Dr Ndayisaba Corneille 61

62. the lateral portion of Levatorani
•The lateral portion arises from the
posterior and lateral aspect of the
pelvic bone and from the arcus tendinus
which is a condensation of the fascia
that covers the obturator internus
muscle (the white line).
•The part of the lateral portion which
arises from Pubic bone passes
backward forming a sling around the
anorectal junction this part of the
levatorani is referred to as the
puborectalis.
•It functions as a pinch valve and keeps
the anorectal junction at 90
O
angle,
thereby maintaining the continence of
feces within the rectum. Part of the
puborectalis insert into the external anal
sphincter to reinforce it.
Dr Ndayisaba Corneille 62

63. the lateral portion of Levatorani………
•The parts of the lateral portion
arising from the pubis and part of
the arcus tendinuspasses
downward and backward as the
pubococcygeus to meet at the
midline behind the perineal body
to form the anococcygeal rephae.
•This raphaeextends from the tip
of the coccyx to the anorectal
junction
•The part that arises from the ischial
spines and the posterior aspect of
thetendinous arch is referred to as
the iliococcygeus muscle it is
attached to the posterior aspect of
thetendinous arch
Dr Ndayisaba Corneille 63

64. Dr Ndayisaba Corneille 64

65. The medial portion of the levatorani
•The medial portion arises from
the pubic bone close to the
median plane.
•The medial portion of the
levatorani is also called the
Prerectalfibers of puborectalis.
•It forms a sling around the
prostate in males
(puboprostateaor around the
vagina-pubovaginaeor vaginal
sphincter)
•Some part of it inserts into the
perineal body while some of it
blends with the longitudinal
muscle of the anal canal as the
puboanalis.
Dr Ndayisaba Corneille 65

66. •NerveSupply:Abranchfromthepudendal
nerveknownastheinferiorrectalbranchand
branchesfromtheventralramiofthe4
th
sacral
Nerve.
•Action:Ithelpstosupportthepelvicviscera
whilethepuborectalisfunctionduring
defecationprocess.
Dr Ndayisaba Corneille 66

67. THE COCCYGEUS MUSCLE
•Itisatriangularshaped
muscle.Itarisesfromthe
ischialspinetobeinserted
intothecoccyxandthe
adjacentpartofthesacrum.
•It over lies the
sacrospinousligament
•Nerve Supply:Ventral
branchesofS4andS5
•Action:Ithelpstopull
forwardthecoccyxduring
defecation.
Dr Ndayisaba Corneille 67

68. Dr Ndayisaba Corneille 68

69. Functions
•The roles of the pelvic floor muscles are:
•pelvic floor support as well as aid in the sphincteric action
on rectum and vagina. Aids defecation, micturition and
parturition by increasing intra-abdominal pressure.
•Support of abdominopelvic viscera (bladder, intestines,
uterus etc.) through their tonic contraction.
•Resistance to increases in intra-pelvic/abdominal pressure
during activities such as coughing or lifting heavy objects.
•Urinary and faecalcontinence. The muscle fibreshave a
sphincter action on the rectum and urethra. They relax to
allow urination and defecation
Dr Ndayisaba Corneille 69

70. Dr Ndayisaba Corneille 70

71. Episiotomy
•To avoid this pressure damage on pelvic
and perineal floor, during childbirth
episiotomy is normally employed to
avoid tearing the muscles.
•Age, number of normal vaginal
deliveries, weight, chronic cough, family
history of pelvic floor dysfunction are
notable risk factors.
•Damaged pelvic floor can be repaired
surgically and the muscles can be
strengthened through pelvic floor
exercises called kegelexercises.
Dr Ndayisaba Corneille 71

72. END
Dr Ndayisaba Corneille
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DR NDAYISABA CORNEILLE
MBChB,DCM,BCSIT,CCNA
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