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Pelvic girdle


Core Procedures

  • Femoral hernia repair

  • Saphenofemoral exposure for endarterectomy, embolectomy, bypass, and endovascular repair of aneurysms

  • Exposure/puncture of femoral artery/vein

  • Open reduction internal fixation for fractured acetabulum/femur

  • Above-knee amputation

  • Gluteal approach for hip replacement

Pelvis and gluteal region

Surgical surface anatomy

The summit of the iliac crest is level with the fourth lumbar vertebral body in adults and with the fifth vertebral body in children aged up to 10 years. The sciatic nerve is more or less at the midpoint between the ischial tuberosity and the greater trochanter of the femur ( Fig. 79.1 ). The proximal border of the greater trochanter lies approximately a hand's breadth below the iliac tubercle, level with the centre of the head of the femur. The femoral artery is at a mid-inguinal position between the anterior superior iliac spine and pubic tubercle ; the femoral nerve and femoral vein lie lateral and medial to this vessel, respectively (see Fig. 79.3 ). The lateral femoral cutaneous nerve most commonly travels a finger's breadth medial to the anterior superior iliac spine.

Fig. 79.1, The posterior thigh and gluteal region. Gluteus maximus and medius have been cut and retracted. The hamstring muscles are also retracted to show the underlying anatomy, such as the sciatic nerve.

Clinical anatomy

The pelvic girdle consists of the paired hip bones, which articulate anteriorly at the pubic symphysis and posteriorly at the sacro-iliac joint. The gluteal region is demarcated by the gluteal fold inferiorly, a line joining the greater trochanter to the anterior superior iliac spine laterally, the iliac crest superiorly and the midline medially. It contains a large skeletal muscle mass that covers several vulnerable neurovascular structures and incorporates junctional zones between the lower limb, pelvis and perineum at the sciatic foramina. Surgery to this region can injure the sciatic nerve and the gluteal nerves and vessels (see Fig. 79.1 ; ); a posterior (gluteal) approach is commonly used to operate on the hip joint.

Sciatic foramina

Knowledge of the sciatic foramina is key to understanding the gluteal region and, in particular, its neurovascular supply. These foramina lie deep to gluteus maximus, which some have viewed as the ‘pelvic deltoid’. The greater sciatic foramen is bounded anterosuperiorly by the greater sciatic notch, posteriorly by the sacrotuberous ligament and inferiorly by the sacrospinous ligament and ischial spine. It is partly filled by the emerging piriformis (see Fig. 79.1 ), above which the superior gluteal vessels and nerve leave the pelvis. The inferior gluteal vessels and nerve, internal pudendal vessels and pudendal nerve, sciatic and posterior femoral cutaneous nerves, and the nerves to obturator internus and quadratus femoris all leave the pelvis below it. The undivided sciatic nerve can emerge above or through piriformis. The major divisions of this nerve can lie on either side of the muscle, or (the most common variant) one division passes between the heads of the divided muscle and the other either above or below it.

The lesser sciatic foramen is bounded anteriorly by the body of the ischium, superiorly by its spine and sacrospinous ligament, and posteriorly by the sacrotuberous ligament. It transmits the tendon and the nerve to obturator internus, the internal pudendal vessels and the pudendal nerve.

Perforators and skin flaps

The gluteal region has an average of 21 perforators, which arise from three main source arteries: the superior and inferior gluteal and the internal pudendal. The flaps based on these perforators can be used as free flaps for breast reconstruction and as local flaps for covering defects in the sacral and perineal regions.

Tips and Anatomical Hazards

  • Any surgery to the hip region in children can injure the growth plate, resulting in abnormal proximal femoral development. If there are fractures involving the epiphysis, expeditious restoration of normal bony alignment is essential in order to minimize the risk of subsequent abnormal growth.

  • The blood supply to the head of the femur is derived from an arterial ring around the neck, just outside the attachment of the fibrous capsule, comprising the medial and lateral circumflex femoral arteries with minor contributions from the superior and inferior gluteal vessels. From this ring, ascending branches pierce the capsule to ascend the neck beneath the reflected synovial membrane ( Fig. 79.2 ). These vessels become the retinacular arteries and form a subsynovial intracapsular anastomosis. Here they are at risk from a displaced fracture of the neck of the femur. If the fracture is intracapsular, not only is the intraosseous blood supply disrupted but also the retinacular vessels are vulnerable. If the fracture is extracapsular, the retinacular vessels will remain intact and avascular necrosis of the head of the femur is much less likely.

    Fig. 79.2, Anterior and posterior views of the proximal femur and its blood supply.

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