1. Review: Pelvic Wall
Superior:
Ant.:
Post.
Lat.

2. The Pelvic Floor (Inferior Pelvic Wall)

3. 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:
Rt. & Lf. Coccygeus m.
Rt. & Lf. Levator ani m.

4. 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

5. 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.

7. 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

8. 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.

9. 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)

11. Posterior Fibers of Levator Ani Muscle
Iliococcygeus
Post. Tendinous arch & ischial spine 
Anococcygeus lig. & coccyx
**More aponeurotic than muscular

12. The Pelvic Fascia

13. 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 ???

14. 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

15. Different Ligaments of Pelvic Fascia
Pubovesical lig. (F) Or
Puboprostatic lig. (M)

16. Different Ligaments of Pelvic Fascia
- Pubocervical lig. (F)
- Sacrocervical lig. (F) or sacroprostatic lig. (M)

17. 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”

19. Review Pelvic Space Pelvice Wall - 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?

20. Gender Variations in Pelvis and Pelvic Fractures

21. Mostly due to adaptation of female pelvis for child bearing
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

22. 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

23. 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)

26. Gender Variations 7. sacrum Shorter, wider & flatter in female
More concave in male
8. Obturator foramen
Oval or triangular in female
Round in male

27. Pelvic Fractures

28. Do not include the Acetabular Fractures  Lower limb 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

29. 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)

30.  Saunders, Elsevier, Netter’s Clinical Anatomy, 3rd ed.

31. 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, 3rd ed.

32. Unstable Pelvic Fractures
2. Straddle Fracture
Partially unstable
Appearance:
Double break of ant. Pelvic ring in both sides
*usually associated with inj. to urogenital viscera (Bladder & urethra)
 Saunders, Elsevier, Netter’s Clinical Anatomy, 3rd ed.

33. 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
May accompanied by one or more of the followings:
Fracture of transverse process of L5
Avulsion of ischial spine
Stretching of sacral nerves
 Saunders, Elsevier, Netter’s Clinical Anatomy, 3rd ed.
Most common complication??

34. 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

35. 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