REIDER PART 2 01
Pelvis, Hip, and Thigh John M. Martell
The pelvis is a complex bony structurc that is formed by the joining of seven individual components. On each side of the pclvis, the ilium, the ischium, and the pubis fuse together to become a pelvic, or innominate, bonę. The right and left pelvic bones join each other ante-riorly at the pubie symphysis and join the sacrum poste-riorly at the sacroiliac joints to form a closed ring. As with the skuli and the ribs, the pelvic ring protects vital inter-nal structures. The primary orthopaedic function of the pelvis, however, is to serve as a stable central base for human locomotion. The pelvis provides a foundation for the spine and upper body and the point of origin or insertion for many muscles of the thorax, the hip, and the thigh.
The hip consists of the femoral head, the most prox-imal aspect of the femur, and the acetabulum, a socket located in the center of the lateral surfacc of the pelvis. Portions of the ilium, the ischium, and the pubis coalesce during skeletal development to form the acetabulum. The great depth of the acetabulum combines with the strong iliofemoral ligaments to make the hip a very stable joint. Despite this great stability, the ball-and-socket design of the hip joint allows considerable motion in three planes. The hips provide stable support for the pelvis and upper body while still allowing the lower extrcmitics to assume a tremendous variety of positions in space. Distal to the hip, the femoral shaft undergirds the muscles of the thigh, serving as the site of origin and insertion for many of the muscles required for normal ambulation.
■ INSPECTION
Surface Anatomy
Anterior AsPEcr
The bony landmarks of the pelvis are easily identified in the average patient (Fig. 5-1). In the presence of obesity, the pendulous abdominal fat, or panniculus, tends to obscure these landmarks. When such padents are examined in the supine position, the panniculus tends to shift supe-riorly and to expose morę of the normal anatomy.
Pelvis. The most prominent feature of the pelvis is the arching superior margin of the ilium, known as the iliac crest. The iliac crest is visible in many patients and pal-pable in most. In obese patients, it lies immediately beneath the abdominal fold at the waist. As its name implies, the anterior superior iliac spine (ASIS) is the anterior terminus of the iliac crest. The ASIS serves as the site of origin for the inguinal ligament, a fibrous band that traverses the anterior pelvis and inserts just lateral to the pubie symphysis on a smali prominence of the pubis known as the pubie tubercle. The inguinal ligament serves as the insertion for some of the abdominal muscles, and its fascia envelops the round ligament in women and the spermatic cord in men. The ASIS also serves as the origin for the sartorius muscle, which is visible in lean or muscular individuals. The sartorius courses obliquely across the anterior thigh to insert on the proxi-mal medial tibia as the outer layer of the pes anserinus.
The ASIS may be used to reference the location of the lateral femoral cutaneous nerve, which is not normally visiblc. The lateral femoral cutaneous nerve exits the pelvis and enters the anterolateral thigh about 2 cm medial to the ASIS. This is the site at which the nerve may be compressed by tight clothing, leading to the uncom-fortable condition known as meralgia paresthetica.
Further mcdially, the femoral nerve, artery, and vein pass deep to the inguinal ligament as they enter the anterior thigh. These structures are not directly visible, although the pulsations of the artery may be seen in a lean patient. In others, the femoral artery should be pal-pable just medial to the midpoint of the inguinal ligament. The femoral nerve is just lateral to the artery, and the femoral vein is just medial to it. After passing beneath the inguinal ligament, the neurovascular structures pass through the femoral triangle. The boundaries of the femoral triangle, which may be visible, include the inguinal ligament superiorly, the sartorius muscle later-ally, and the adductor longus muscle mcdially.
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