What are the attachments of the capsule of the hip joint?
- acetabular labrum
- transverse ligament
- intertrochanteric line where neck of femur joins greater trochanter
anterior surface of neck of femus is wholly intracapsular
p195 fig 3.9
What is the supracristal plane, where is it located and what does it signify clinically?
- between highest points the left and right iliac crests
- passes through the spine of L4 vertebra
- it is a landmark for counting vertebral spines for lumbar puncture
Key sex differences between male and femal pelvises
females have
- broader pelvis with drawn out ilial ala
- wide subpubic angle
- less indendtation of the pelvic inlet by sacral promontory more “oval” outline
- greater sciatic notch at almost right angle (less than male)
- obturator foramen is triangular (male oval)
- distance from pubic tubercle to acetabular margin greater than diameter of acetabulum in female (equal or less in male)
- sacral body narrower than ala
- sacral auricular surface occupies 2 vertebra (2.5 in males)
Piriformis
- location
- nerve supply
- surface marking
- middle 3 pieces of sacrum through greater sciatic foramen into greater trochanter
- anterior rami S1 & S2
- surface marking: lower border is from midpoint of line between PSIS and tip of coccyx to tip of greater trochanter
What are some of the key relations of piriformis?
- posterior to sacral plexus
- upper border next to gluteus medius
- lower border next to superior gemellus
- superior gluteal artery and nerve above, inferior gluteal artery and nerve below
- sciatic nerve and perineal branch of posteiror femoral cutaneous below
What passes through the greater sciatic foramen?
- piriformis
- inferior and superior gluteal vessels and nerves
- sciatic nerve
- pudendal nerve, internal pudendal artery and vein
- posterior femoral cutaneous nerve
- nerve to obturator internis
- nerve to quadratus femoris
What passes through the lesser sciatic foramen?
What are its boundaries?
- the tendon of the Obturator internus
- internal pudendal vessels
- pudendal nerve
- nerve to the obturator internus
Anterior: the tuberosity of the ischium
Superior: the spine of the ischium and sacrospinous ligament
Posterior: the sacrotuberous ligament
Where are the superficial inguinal nodes?
What do they drain?
- 20 notes in T shaped pattern in subcut fat of fermoal triangle
VERTICAL GROUP: drains lymphatics from deep fascia to skin of lower limb
LATERAL GROUP: buttock, flank, and back below level of waist
MEDIAL GROUP: below umbilicus and medial to line drawn up from ASIS including perineum, anal canal, urethra and external genitalia
What is a Richter hernia? What type of hernia does this usually occur with?
A Richter hernia describes a strangulated hernia with entrapment of portion of the circumference of the bowel within a hernial sac with a small opening from the peritoneal cavity. This classically occurs with femoral (not inguinal) hernias
What is the triangle of hesselbach? Why is it relevant?
Bounded by the inferior epigastric vessels laterally, the lateral edge of rectus medially and the inguinal ligament below
It is often the site of weakness of transversalis fascia through which a direct inguinal hernia enters the inguinal canal
What are the nerves of the lumbar plexus?
Which roots form them?
What are their relations to the psoas major?
I (twice) Get Laid On Fridays
2 from 1, 2 from 2, 2 from 3
- iliohypogastric L1
- ilioinguinal L1
- genitofemoral (anteriorly) L1-L2
- lateral cutaneous nerve of thigh L2-L3
- obturator (medial) L2, L3, L4
- femoral L2, L3, L4
All except genitofemoral and obturator nerve exit lateral
Lumbosacral plexus also exits medial
Describe the makeup, location and critical structures surrounding the lumbosacral trunk/sacral plexus.
Lumbosacral trunk: L4/L5
Sacral plexus: lumbosacral trunk + 4 sacral nerves
rests on pirriformis, covered anteirorly by strong fascia, anteriot o that are lateral sacral arteris and veins
Superiorly, common iliacs lie over lumbosacral trunk
What do the anterior/posterior branches of the obturator nerve supply?
ANTERIOR BRANCH
- adductor longus
- adductor brevis
- gracilis
- hip joint
- cutaneous medial thigh
POSTERIOR BRANCH
- adductor magnus
- obturator externus
- knee
these branches are separated by the obturator externus and adductor brevis
What structures are supplied by the genitofemoral nerve?
best remembered as the FEMOROGENITAL (p. 529)
- L1 femoral: skin below inguinal ligament
- L2 genital: spermatic cord/round ligament, sensory to tunica vaginalis and spermatic fasciae, small area of anterior labial skin, motor to cremaster
What is the supply of the lateral femoral cutaneous nerve?
p 530
- iliac fascia
- peritoneum of iliac fossa
- lateral side of thigh to knee
What is the anatomical course of the femoral nerve?
p 530
- crosses iliac fossa in cutter between psoas and iliacus
- beneath inguinal ligament lateral to femoral sheath
- divided by lateral femoral circumflex artery into superficial and deep
What is Heyde’s syndrome?
PR bleeding in the setting of angiodysplasia in association with aortic stenosis
What do the superficial and deep branches of the femoral nerve supply?
What are their distal branches?
SUPERFICIAL
- pectineus
- sartorius
- intermediate femoral cutaneous nerve (skin and fascia lata over thigh)
- medial femoral cutaneous nerve (medial thigh and front of knee)
DEEP
- rectus femoris
- vastus lateralis
- vastus intermedius
- vastus medialis
- saphenous nerve
What are the nervei erigentes and what do they do?
pelvic splanchnic nerves
- detrusor
- smooth muscle of internal sphincter of bladder
- smooth muscle of internal sphincter of anal canal
- parasympathetics to hindgut
- sensory to derivatives of the cloaca (prostate, bladder, rectal ampulla, cervix, vagina)
Which muscles make up the urogenital diaphragm? Where is it located?
p 518
mass of muscles above urogenital diaphragm
- sphincter urethrae (external urethral sphincter)
- deep transverse perineal muscles
located in deep perineal pouch
What makes up the edges of the trigone of the bladder?
What structures stabilise it in the male/female
- internal urethral orifice centrally
- two urethral orifices above and laterally
MALE: fixed to prostate
- pelvic fascia at front of vagina
What is the blood supply of the bladder? What is its drainage?
- superior and inferior vesical arteries
- small contributions from obturator, inferior gluteal, uterine and vaginal arteries
Vesicoprostatic plexus in groove between bladder/prostate. Similar in females in communications with veins at the base of the broad ligament
What is the autonomic nerve supply to the pelvic viscera?
Which is responsible for distension, which are responsible for pain?
MOTOR
- parasympathetic pelvic splanchnic nerves: motor
- L1/L2 sympathetics via superior hypogastric and pelvic plexi : inhibit detrusor and supply superficial trigonal muscle and internal sphincter (in males)
SENSORY
distension: parasympathetic
pain: parasympathetic and sympathetic
Name from top to bottom the structures passed by the ureter in the pelvis?
- OVER internal iliac artery
- BEHIND ovary
- OVER obturator nerve
- OVER obliterated umbilical (superior vesical) artery
- OVER obturator artery and vein
only two structures cross in front
- uterine artery in females
- ductus deferens crosses IN FRONT to run medial
- enters base of bladder at the upper lateral angle
