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Review: Pelvic Wall Superior: Ant.: Post. Lat. The Pelvic Floor (Inferior Pelvic Wall) Formed by Pelvic Diaphragm A bowl- shaped group of muscles that lie within lesser (true) pelvis Divides the true pelvis into: - Main pelvic cavity (above) - Perineum (below) Main muscle components of PD: 1. Rt. & Lf. Coccygeus m. 2. Rt. & Lf. Levator ani m. Coccygeus Muscle (Ischiococcygeus) Small muscle, extends: Ischial spine Lat. Lower sacrum & coccyx Lies on the deep surface of ?? & attaches to it. Innervation: branches of S4 & S5 Actions: Supports pelvic viscera Slightly flexes coccyx S4 S5 Levator Ani Muscle A wide muscular sheet that originates from: - Pubic bone (ant.) - Tendinous arch of obt. fascia - Ischial spine (post.) Insertion: - the m. in opposite side at midline - Coccyx Innervation: - n. to levator ani (S4) - Inferior rectal branch of pudendal n Actions: support , ano-rectal angle, & sphinectoric fxns. Levator Ani Muscle A gap is present anteriorly between the 2 levator ani m. to allow Passage of urethra & vagina (F). Urogenital Hiatus Levator ani divides into 3 parts: Ant. Fibers Intermediate fibers Post. fibers Anterior Fibers of Levator Ani Muscle Short muscular slips From pubic bone blend with fascia around strc. In the midline Subdivided into: - Pubovaginalis (sphincter vaginae) or puboprostaticus (levator prostatae) - puboperinealis: inserted around perineal body (mass of fibrous tissue) - puboanalis: around the anus ©Wolters Kluwer/LWW, Moore Clinically Oriented Anatomy, 7th ed. Intermediate Fibers of Levator Ani Muscle Composed of 2 main parts: 1. Puborectalis Thick narrow part forms a sling around ano-rectal jxn. 80o ano-rectal angle Maintains fecal continence 2. Pubococcygeus Thinner wider part Pubic body and ant. Part of tendinous arch Ano-coccygeal body (Ligament) Posterior Fibers of Levator Ani Muscle Iliococcygeus Post. Tendinous arch & ischial spine Anococcygeus lig. & coccyx **More aponeurotic than muscular The Pelvic Fascia Pelvic Fascia Parietal Fascia: Membranous layer of variable thickness that lines the muscles of pelvic wall. - Named according to muscle it covers - Obturator fascia tendinous arch of Levator ani muscle - Piriformis fascia - Coccygeal fascia - sup. Fascia of pelvic diaphragm (LA) Continues with inf. Fascia of LA through ??? Pelvic Fascia Visceral Fascia: The fascia that covers & supports pelvic viscera Forms adventitial layer of pelvic organs In certain locations: Thickenes & extends from the organ to pelvic wall as a ligament to suspend the organ Ligaments are named according to their attachments Different Ligaments of Pelvic Fascia Pubovesical lig. (F) Or Puboprostatic lig. (M) Different Ligaments of Pelvic Fascia - Pubocervical lig. (F) - Sacrocervical lig. (F) or sacroprostatic lig. (M) Different Ligaments of Pelvic Fascia Cardinal (L, principal) (Transverse cervical) lig. Uterine cervix Obt. Fascia on the lat. Wall Contains ?? Passing inside it clinically: close relationship with ureter during hysterectomy “Water under the Bridge” Review Pelvic Space - Greater (False) Pelvis: part of ?? - Lesser (True) pelvis: divided by PD into ?? & ?? * True & False Pelves are separated by Pelvic Brim (Boundaries?) Pelvice Wall - Pelvic girdle: 4 bones ? & 4 joints? - Pelvic Muscles: 4 Muscles? - Pelvic Fascia: Parietal where & Names? Visceral Ligaments 4? Gender Variations in Pelvis and Pelvic Fractures Gender Variations Mostly due to adaptation of female pelvis for child bearing 1. General Structure Thicker bones with more prominent bony markings in male Due to stronger muscles Gender Variations 2. False Pelvis Shallow in female & deep in male Due to ?? 3. True pelvis Wider, shorter & cylindrical shape in Female Narrow, deeper, & tapering funnel shaped in male Gender Variations 4. Pelvic Inlet (P. brim) Oval to round shape in female 5. Pelvic outlet Larger in female Due to everted ?? 6. Pubic arch & subpubic angle Narrow in male (70o) Wide in female ( 80o) Gender Variations 7. sacrum Shorter, wider & flatter in female More concave in male 8. Obturator foramen Oval or triangular in female Round in male Pelvic Fractures Pelvic Fractures Do not include the Acetabular Fractures Lower limb fractures Divided into 2 types: 1. Stable Fracture Involve one point break only 2. Unstable Fractures two or point breaks displacement Tile Classification System: Based on the integrity of SI joint A , B , & C fracture types Stable Pelvic Fractures 1. Fractures of coccyx Rare Common symptom coccydynia (localized pain & inflam. In the coccyx) Usual history: falling down on buttock 2. Transverse Sacral Fracture Uncommon, No Rx, care on sitting (use of inflatable ring may help) 3. Fracture of Iliac wing (Duverney Fracture): Commonly after a direct blow Minimal displacement because of attachment of ?? on inside surface & gluteal muscles on the outside 4. Ipsilateral fracture of pubic & ischial rami: Only symptomatic Rx Short-term bed rest & limited activity Use of walking aids (walker or crutches) Saunders, Elsevier, Netter’s Clinical Anatomy, 3rd ed. Unstable Pelvic Fractures Divided into: Partially unstable (Rotational), & Completely unstable (R & V) 1. Open Book Fracture Partially unstable From heavy impact to the groin Disrupted symphysis pubis (Pubic Symphysis Diastasis) Appearance: Wide ant. separation of pelvic ring With teared ant. Sacroiliac lig. Slight opening of the joint *the post. Lig. Remains intact Saunders, Elsevier, Netter’s Clinical Anatomy, 3 rd ed. Unstable Pelvic Fractures 2. Straddle Fracture Partially unstable Appearance: Double break of ant. Pelvic ring in both sides Saunders, Elsevier, Netter’s Clinical Anatomy, 3 rd ed. *usually associated with inj. to urogenital viscera (Bladder & urethra) Unstable Pelvic Fractures 3. Vertical Shear Fracture completely unstable (R & V) Appearance: Upward dislocation of sacroiliac joint & ipsilateral fracture of pubic rami Upward (sup.) shift of hemipelvis Saunders, Elsevier, Netter’s Clinical Anatomy, 3 rd ed. May accompanied by one or more of the followings: 1. Fracture of transverse process of L5 2. Avulsion of ischial spine 3. Stretching of sacral nerves Most common complication?? Hemorrhage in Pelvic Fractures The mortality rate in PF 5-15% (high) ½ due to hemorrhagic shock Source of bleeding: - Fractured bone - Pelvic veins - Pelvic arteries: Most serious & leading cause of death in PF most common artery involved is ?? (largest branch of IA artery) emergency care otherwise death within 24 hrs Branches of internal iliac artery Visceral: Sup. Vesical - Umbilical Inf. Vesical or ?? Uterine – also gives a vaginal branch Middle rectal Lower limb: Sup. Gluteal a inf,. Gluteal a Obturator Perineum: Int. pudendal a Somatic Iliolumbar Lat. Sacral 10 branches: 3 post. Division & 7 from ant. division