Hip and Pelvis


Chapter 6

Hip and Pelvis



David B. Weiss, Seth R. Yarboro, James A. Browne



Regional Anatomy and Surgical Intervals



Regional Anatomy


Osteology


Pelvis (Figs. 6-1 and 6-2)









Nerves


Extension of Nerves from the Lumbosacral Plexus (Fig. 6-14)



Branches of the sacral plexus


Sciatic nerve (L4 and L5 and S1, S2, and S3)


Exits the greater sciatic notch (GSN) and travels inferiorly, passing along the posterior aspect of the ischial tuberosity before passing into the posterior compartment of the thigh


The typical course is anterior to the piriformis and posterior to the superior/inferior gemellus, obturator internus, and quadratus femoris, but significant variation either through or around the piriformis can exist


Has tibial and peroneal divisions that are indistinguishable around the hip but later divide


The peroneal portion is more superficial and thus more prone to injury from posterior wall fracture and/or posterior hip dislocation or from retraction


Superior gluteal nerve (innervates the gluteus medius, gluteus minimus, and tensor fasciae latae muscles)


Exits the GSN and turns sharply superior to innervate the gluteus medius/minimus and tensor fasciae latae


A risk of injury exists with extensive superior and medial dissection above the GSN


Inferior gluteal nerve (innervates the gluteus maximus)


Exits the GSN inferior to the sciatic nerve and enters the gluteus maximus


Is at risk with extensive medial dissection around the posterior column near the GSN


Branches of the lumbar plexus


Lateral femoral cutaneous nerve


Exits the pelvis just medial to the ASIS (with wide variation up to 3 cm to either side)


Wide variation also exists with regard to the position of this nerve in relation to the sartorius muscle; it typically runs along the superficial lateral border, but it may run deeper or along the medial tensor fasciae latae (TFL)


Provides pure sensory innervation to anterolateral thigh


At risk with dissection or retraction during Smith-Petersen and direct anterior hip approaches and with ilioinguinal pelvic approaches


Obturator nerve


Innervates the adductors and travels inferior and lateral along the true pelvis below the pelvic brim and along the quadrilateral plate


Enters medial compartment of thigh as it penetrates superior aspect of obturator membrane in obturator foramen


Is at risk with exposure and retractor or hardware placement during ilioinguinal or Stoppa approaches


Femoral nerve (largest branch L2, L3, and L4)


Exits the pelvis over the anterior wall of the hip and lateral to the femoral artery and vein


Is at risk with anterior retractor placement during anterior and posterior approaches to the hip and during middle window dissection and retraction for ilioinguinal approaches


Anterior division—sensation to the anterior and medial thigh via the medial and intermediate cutaneous nerves of the thigh


Posterior division—quadriceps muscles and saphenous nerve




Vascularity (Fig. 6-15)


Internal Iliac Artery







Cross-Sectional Anatomy (Figs. 6-16 to 6-19)


Hazards (Figs. 6-20 and 6-21)


Femoral Triangle










Nerves


Sciatic Nerve












Surgical Approaches to the Pelvis



Posterior Approach to the Sacroiliac Joint


Indications







Incision (Fig. 6-27)







Anterior Approach to the Pubic Symphysis (Video 6-1)image


Indication












Ilioinguinal Approach to the Pelvis (Video 6-2)image


Background








Jun 7, 2016 | Posted by in ORTHOPEDIC | Comments Off on Hip and Pelvis
Premium Wordpress Themes by UFO Themes