Lecture 1 a

What is the pelvic girdle comprised of?

What is the pelvic girdle comprised of?

sacrum, ilium, ishium, pubis

The 3 bones of the ox coxa meet and fuse at what boney landmark?

actabulum, where the femur sits

Review bone markings of os coxa and sacrum

what is your butt bone that you sit on?

ischium

What is the ischiopubic ramus?

the space that is between the ischial ramus and inferior pubic ramus

What is the name of the boney structure between the greater and lesser sciatic notch?

ischial spine

What is the auricular surface?

where the os coxa articulates with the sacrum

What travels through the sacral canal?

nerves from the vertebral canal

What is sacral cornu?

the space surrounding the sacral hiatus

What is the sacroiliac joint?

synovial joint located between the sacrum and ilium, provides stability, support, and plays a role in absorbing impact from walking

What is the pubic symphysis?

cartilaginous joint, consisting of a fibrocartilaginous disc and ligaments uniting the two pubic bones

What is the subpubic angle?

the angle formed by the union of the right and left pubic bones, formed at the bottom

What is Sacrioiliac joint pain and where does it present?

Presents in the low back and buttocks and radiates into the lower limb, can be acute or chronic and can be caused due to too much movement or too little

What are risk factors and treatment for SI Joint pain?

repetivie joint use, uneven leg length, previous spine injury

Treatment: physical therapy, chiropractic, stretching

Where are iliolumbar ligaments found?

between ilium and lumbar vertebrae

Where are anterior sacroiliac ligaments found?

anterior portion of the sacrum to the ilium

Where are sacrotuberous ligaments found?

From the sacrum to the ischial tuberosity

Where are the sacrospinous ligaments found?

from the spine of the ischium to the sacrum

Where is the obturator membrane found?

within the obturator foramen

Where is the inguinal ligament found?

From the ASIS to the pubic tubercle

What are the two ligaments that help with the pubic symphisis?

superior and inferior pubic ligament

Where does the posterior sacroiliac ligaments run?

from the posterior part of the sacrum to the ilium

True or False: \n \n The obturator membrane covers the entire obturator foramen.

False! \n \n There is the obturator canal where the obturator nerve and vessels run through.

What separates the greater and lesser sciatic foramens?

The sacrospinous ligament

What hormone causes the pelvis to relax which leads to increased joint diameters?

relaxin, increases movement of SI joint and pubic symphysis

How much do pevlic diameters increase when the hormone relaxin is released?

10-15%, this then leads to increased risk of joint dislocation in all parts of the body

What is the greater pelvis?

the false pelvis, superior to the pelvic inlet, iliac blades and surrounds the inferior abdominal viscera

What is the lesser pelvis?

the true pelvis, inferior to the pelvic inlet, boney structures surround the pelvic cavity and house the pelvic viscera

How does the pelvis sit normally?

ASIS and pubis are in line with eachother and the pelvic girdle is tilted anterioly

How does the abdominal and pelvic cavities meet then?

at the oblique angle, this puts our weight on bones instead of muscles

In anterior-posterior compression what is typically fractured?

typically fracture of the pubic rami, due to crush accidents

How can fracture of the pelvis occur?

direct trauma to pelvic bones or transmitted by lower limb, can cause injury to soft tissue and neurovascular structures in the pelvis

What are the superior and inferior borders of the pelvic cavity?

superior: pelvic inlet

inferior: pelvic outlet

what are the contents of the pelvic cavity?

Contents: inferior portion of ureters, urinary bladder, rectum, pelvic genital organs, blood vessels, lymphatics, and nerves \n \n **May also see part of the small and large intestine

What is the pelvic inlet comprised of?

promontory and ala of sacrum, arcuate line, pectineal line and pubic crest

What is the pelvic outlet comprised of?

pubic arch, ischial tuberosities, scarotubrous ligament, tip of the coccyx

anteroposterior dimension

childbirth: 11 cm or greater

transverse diameter

between arcuate lines, childbirth: 13.5 cm or greater

oblique diameter

sacroiliac joint to opposite pubic ramus

where is the mid-pelvic level

between the ischial spines, narrowest part of canal, childbirth 10 cm or greater

The true conjugate dimension is the same as what other dimension?

anteroposterior dimension

the one that has the shortest AP diameter for fetal head and the middle of sacral promontory to center of margin of pubic symphysis?

obstetric conjugate

_____ conjugate - estimate of true and obstetric diameters via pelvic exam  \n ~1.5 cm longer than obstetric conjugate

diagonal conjugate

anteroposterior pelvic outlet

minimum 11.5 cm

Comparisons of pelvic morphology what are features of estrogen driven pelvis

short flared, wide, shallow, oval and rounded, comparitvely larger

What are features of an testosterone driven pelvis?

tall, narrow, heart shaped, comparitvely smaller

2 walls of the pelvic cavity: \n Lateral wall = _____ m. \n Posterior wall = ____ m.

- Obturator Internus \n - Piriformis

Obturator internus \n \n • Origin: _____ \n • Insertion: _____ \n • Innervation: _____ \n • Action: _____

• Origin: internal surface of ilium, ischium, pubis, and obturator membrane \n \n • Insertion: greater trochanter of femur \n \n • Innervation: nerve to obturator internus (L5, S1, S2) \n \n • Action: lateral rotation of the thigh; holds head of femur in acetabulum

Piriformis \n \n • Origin: _____ \n • Insertion: _____ \n • Innervation: _____ \n • Action: _____

• Origin: pelvic surface of S2-S4, superior margin of greater sciatic notch, and sacrotuberous ligament \n \n • Insertion: greater trochanter of femur \n \n • Innervation: anterior rami of S1 and S2 \n \n • Action: lateral rotation and abduction of thigh; holds head of femur in acetabulum

The greater sciatic foramen is above and below the ___ muscle.

Piriformis m.

What exits the pelvic cavity via the (superior; above the piriformis) Greater sciatic foramen?

Superior gluteal nerve and vessels

Sciatic nerve, inferior gluteal, posterior femoral cutaneous and quadratus femoris nerves and vessels pass through and exit the _____.

- (inferior) Greater Sciatic Foramen

What runs through the Lesser sciatic foramen?

- Pudendal nerve  \n - Internal pudendal vessels \n - Nerve to obturator internus \n - obturator internus muscle

The obturator nerve and vessels exit the pelvic cavity via the ____.

obturator canal

The floor of the pelvic cavity is also known as ___.

pelvic diaphragm

Coccygeus \n • Origin: ____ \n • Insertion: ____ \n • Innervation: ____

• Origin: ischial spine \n \n • Insertion: Inferior end of sacrum and coccyx \n \n • Innervation: branches of S4 and S5

What are the three muscles that the levator ani is composed of?

illiococcygeus, pubococcygeus, puborectalis

What are the origin, insertion, and innervation of the levator ani?

•Origin: body of pubis; tendinous arch of obturator fascia; ischial spine \n •Insertion: perineal body; coccyx, anococcygeal ligament; walls of prostate or vagina, rectum, and anal canal \n •Innervation: nerves to levator ani and coccygeus (S3, S4)

What are the two openings of the floor of the pelvic cavity?

1. Anal Aperture (anal canal and anus) \n 2) Urogenital Hiatus (urethra, prostate, and vagina)

What is the purpose of the puborectalis?

most medial muscle of levator ani group, forms a U-shaped sling around anorectal angle, acts as a sphincter and maintains fecal continence

What is the pelvic diaphragm?

layer of paired skeletal muscles that has an opening in the midline forming a sling

What are all the tings that the pelvic diaphragm does? •Supports pelvic viscera

•Separates ____ from the ____ \n •Together ____ the pelvic floor (forced expiration, coughing, vomiting, urinating, and defecating) \n •Allows for the passage of the portions of the ____ , ____ , and ____ systems \n •Acts as a ____ \n • True or False: Motor AND sensory innervation - both GSE and GSA

- Separates pelvis from the perineum \n - raises \n - urinary, genital, and GI systems \n - sphincter \n - True

What is the purpose of the pelvic floor?

to support the head during childbirth, can often result in damage to the pelvic floor musculature and ligaments

What are the most commonly torn muscles during childbirth?

pubococcygeus and puborectalis

What are issues that females face with pelvic floor disfunction?

decreases support for pelvic organs, urinary and fecal incontinence, prolapse of pelvic organs

What is pelvic organ prolapse?

descending or drooping of the pelvic organs into or outside the vaginal canal or anus (caused by anything that increases pressure in the abdominopelvic cavity)

Types of prolapse refer to the organs involved:  \n • Cystocele - _____ \n • Urethrocele - _____ \n • Uterine - _____ \n • Vaginal vault - _____ \n • Enterocele - _____ \n • Rectocele - _____ \n \n Treated with:

• Cystocele - bladder into the vagina (most common) \n • Urethrocele - urethra \n • Uterine - uterus \n • Vaginal vault - vagina \n • Enterocele - small intestines \n • Rectocele - rectum \n \n \n - exercises to strengthen the pelvic floor, pessaries (devices inserted into body to strengthen pelvic floor), or surgical intervention

there is a difference in the pubococcygeus muscle in males and females what are the perspective muscles called?

males-puboprostaticus

females-pubovaginalis

Variation of the Pelvic Diaphragm: \n \n Urethra runs through the ____ in males. \n \n Urethra is _____ to the vagina in females.

- prostate \n - anterior

Variation of the Pelvic Diaphragm: \n \n Name changes in venous structures \n Male = ____ \n Female = ____

- deep dorsal vein of the penis \n - deep dorsal vein of the clitoris

where is the perineum located?

inferior to the pelvic diaphragm

What are the borders of the perineum?

Superior: inferior fascia of pelvic diaphragm

Inferior: skin of perineal region

Perimeter: pelvic outlet

What is the perineal region?

inferiorly, diamond shaped region between the proximal thighs, mons pubis or scrotum and gluteal folds

How is the perineal region divided?

line passing through the ischial tuberosities

What are the anterior and posterior triangles called?

anterior: urogential triangle

posterior: anal triangle

True or False: \n \n Perineal region is a flat space.

False! \n \n Perineal region is NOT flat, rather a "bent" space.

What is the center of the junction between the urogenital triangle \n and anal triangle?

Perineal body  \n (aka central tendon)

Anal Triangle: \n \n - Superficial:  \n • _____  \n • _____  \n • _____  \n \n - Deep:  \n • _____  \n • _____  \n • _____

- Superficial:  \n •Gluteus maximus \n •External anal sphincter \n •Anus  \n \n - Deep:  \n •Anal canal  \n •Ischio-anal fossa \n •Pudendal canal and neurovascular bundle

What is the ischio-anal fossae?

wedge-shaped space located on each side of the anal canal

What are the borders of the ischio-anal fossae??

superior: junction of medial and lateral walls

medial: levator ani muscles and external anal sphincter

lateral: ischium, lower part of obturator internus

base: superficial and formed by skin

posterior: sacrotuberous ligaments and gluteus maximus

anterior: bodies of pubic bones

The left and right anterior recesses of the ischio-anal fossae are separated by the _____ of the pelvic diaphragm \n \n The left and right ischio-anal fossae freely communicate posterior to the anal canal and its sphincters (deep postanal space) \n •Provides a pathway for ______

- urogenital hiatus \n \n - infection to spread from right to left sides, and from the anal triangle to the urogenital triangle

Clinical Correlation: Ischioanal Abscess \n \n What is it? \n \n What 2 diseases increase the risk? \n \n Commonly misdiagnosed as ____.

- Swollen area of body tissue filled with puss. \n \n - Crohn's disease and Diabetes Mellitus both can increase the risk of an ischioanal abscess. \n \n - hemorrhoids

Contents of the Ischioanal Fossae: \n \n • _____ - supports anal canal \n \n • _____ nerve and _____ vessels (embedded in a fascial canal) \n \n • _____ artery, vein, and nerve - cross the fossa to reach anal canal and sphincters

- Dense fat \n \n - Pudendal nerve and internal pudendal vessels \n \n - Inferior rectal

What spinal levels does the pudendal nerve come from?

Sacral plexus S2-S4

What types of fibers does the pudendal nerve have?

GSA and GSE fibers

the pudenal nerve branches to what in order to go to anal triangle?

Inferior rectal nerve

Major branch(es) of pudendal n. going to Urogenital Triangle:

- Perineal n. \n - Dorsal nerve to clitoris/penis

The perineal nerve splits into: \n \n and

Superficial and Deep Perineal nn. \n \n Superficial then becomes : Posterior labial/scrotal branches

Pudendal nerve arises from - \n \n Exits the pelvic cavity via the _____ \n \n Crosses posterior to the / \n \n Re-enters the pelvic cavity via the _____ \n \n Enters the perineum via the anal triangle \n \n Gives off_____ n. prior to entering the pudendal canal

- S2-S4 \n - greater sciatic foramen \n - ischial spine/sacrospinous ligament \n - lesser sciatic foramen \n - inferior rectal n.

What is the pudendal canal?

the passageway within the obturator fascia, along the inferior border of the medial aspect of the obturator internus

What are the contents of the pudendal canal?

internal pudendal a. v., pudendal nerve, nerve to obturator internus

The blood supply of the anal triangle comes from?

internal pudendal artery

What does the internal pudendal artery split into?

inferior rectal artery and perineal artery

What are anal columns?

longitudinal ridges on interior surface of anal canal

What are anal valves?

the inferior ends of the anal columns

What is the anocutaneous line?

the white line where we can see a change in epithelium

Internal anal sphincter \n •Surrounds the upper / of anal canal \n •(Voluntary or Involuntary?) sphincter \n + ______ fibers -> tonal contraction \n + ______ fibers -> inhibit contraction

- 2/3  \n - Involuntary \n + Sympathetic \n + Parasympathetic

External anal sphincter \n •Surrounds the inferior ____ of anal canal \n •Attached to ____ anteriorly and to the ____ posteriorly via the ____ ligament \n • (Voluntary or Involuntary?) sphincter \n + Innervated by ____ nerve

- 2/3 - perineal body \n - coccyx \n - anococcygeal \n - Voluntary \n - inferior rectal

What line is superior to the anocutaneous line?

pectinate line

What type of innervation occurs superior and inferior to the pectinate line?

superior: visceral motor

inferior: somatic motor