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CHAPTER 3 The Upper Limb and Breast
C5
Musculocutaneous
A
71
• Crosses in front of the exor retinaculum to form the
supercial palmar arch with the supercial branch of
the radial artery.
• e ulnar nerve accompanies the artery on its medial
side in the distal two-thirds of the forearm and across
the exor retinaculum.
BRACHIAL PLEXUS (Fig. 3.10)
Partly in the neck and partly in axilla, the plexus is composed as follows:
• Roots: between scalenus anterior and scalenus medius.
• Trunks: in the posterior triangle of the neck.
• Divisions: behind the clavicle.
• Cords: in the axilla.
Roots (5)
• Anterior primary rami of C5, 6, 7, 8, T1.
Trunks (3)
• Upper (C5, 6).
• Middle (C7).
• Lower (C8, T1).
Divisions (6)
• Each trunk divides into anterior and posterior divisions.
Cords (3)
• Lateral: fused anterior divisions of upper and middle
trunks.
• Medial: anterior division of lower trunk.
• Posterior: fusion of all three posterior divisions.
Nerves
From the continuation of the cords:
• Musculocutaneous nerve: from the lateral cord.
• Ulnar nerve: from the medial cord.
• Radial nerve: from the posterior cord.
• Axillary nerve: from the posterior cord.
• Median nerve: from a cross-communication between
lateral and medial cords.
Branches of the Brachial Plexus
Roots
• Nerve to rhomboids.
• Nerve to subclavius.
• Nerve to serratus anterior (long thoracic nerve of Bell,
C5, 6, 7).
Trunks
• Suprascapular: upper trunk; supplies supraspinatus and
infraspinatus.
Cords:
Lateral
• Musculocutaneous.
• Lateral pectoral.
• Lateral root of median.
Medial
• Medial pectoral nerve.
• Medial cutaneous nerve of the arm and forearm.
• Ulnar nerve.
• Medial root of median.
Posterior
• oracodorsal nerve (to latissimus dorsi).
• Subscapular nerve.
• Axillary nerve.
• Radial nerve.
C6
C7
C8
T1
Roots
Fig. 3.10 The brachial plexus.
Upper trunk
Middle trunk
Lower trunk
nterior and posterior
divisions
Lateral cord
Medial cord
Posterior cord
Ulnar nerve
Axillary nerve
nerve
Radial nerve
Median nerve
72
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SECTION I Anatomy
e brachial plexus can be pre-xed or post-xed on
rare occasions. A pre-xed plexus has a contribution from
C4; a post-xed from T2.
Nerves of the Upper Limb
• Axillary.
• Radial.
• Musculocutaneous.
• Median.
• Ulnar.
Axillary Nerve
• Root value C5, 6.
• Arises from posterior cord.
• Winds round surgical neck of humerus.
• Accompanied by circumex humeral arteries.
• Muscular branches to deltoid, teres minor.
• Cutaneous branch supplying sensation to skin over
deltoid.
Radial Nerve
• Root value C5, 6, 7, 8, T1.
• Arises from the posterior cord.
• Lies initially behind the axillary artery.
• Passes posteriorly between the long and medial head of
the triceps.
• Accompanied by profunda brachii artery.
• Lies in the spiral groove of the humerus.
• Pierces the lateral intermuscular septum at the
lower third of the humerus and enters the anterior
compartment.
• Lies between brachialis and brachioradialis.
• Gives o posterior interosseous nerve at level of lateral
epicondyle.
• Radial nerve continues as supercial branch to
brachioradialis.
• Above wrist emerges posteriorly from under brachiora-
dialis and supplies sensation by cutaneous branches to
posterior aspect of radial three-and-a-half digits.
• Main radial nerve supplies triceps, anconeus, bra-
chioradialis, extensor carpi radialis longus and part of
brachialis.
• Posterior interosseous branch supplies supinator,
abductor pollicis longus and all remaining extensor
muscle.
• Cutaneous supply is to the back of the arm, the exor
and radial aspects of the dorsum of the hand.
Musculocutaneous Nerve
• Root value C5, 6, 7.
• Continuation of lateral cord of brachial plexus.
• Pierces coracobrachialis and runs between biceps and
brachialis.
• Supplies biceps, brachialis and coracobrachialis.
• Innervates the skin of the lateral forearm.
Median Nerve
• Root value C6, 7, 8, T1.
• Arises from the joining of branches of the medial and
the lateral cord of the plexus.
• Lies initially anterior to the third part of the axillary
ar tery.
• Continues along the lateral aspect of the brachial artery.
• Crosses supercial (occasionally deep) to the brachial
artery at midhumeral level to lie on the medial side of
the brachial artery.
• Enters the forearm between the heads of pronator teres.
• At this level it gives o the anterior interosseous branch.
• e median nerve then lies on the deep aspect of exor
digitorum supercialis.
• Supercial at the wrist lying to the ulnar side of exor
carpi radialis in the midline.
• Gives o palmar cutaneous branch at the wrist, which
passes supercial to the exor retinaculum and supplies
the palmar skin over the thenar eminence.
• It then passes deep to the exor retinaculum, giving
a branch to the thenar muscles beyond the distal skin
crease.
• Supplies in its course all muscles of the exor aspect of
the forearm (except exor carpi ulnaris and the ulnar
half of exor digitorum profundus), the muscles of the
thenar eminence and the radial two lumbricals.
• Supplies sensation to the radial three-and-a-half digits
and skin of the radial side of the palm.
Ulnar Nerve
• Root value C7, 8, T1.
• Formed by the medial cord of the plexus.
• Lies medial to the axillary and brachial artery to
midhumerus.
• Pierces the medial intermuscular septum, descending
on the anterior surface of the triceps.
• Passes behind the medial epicondyle (where it is palpable).
• Descends between exor carpi ulnaris and exor digitorum profundus and then lies supercial on the radial
side of the tendon of exor carpi ulnaris.
• Accompanies ulnar artery in distal two-thirds of forearm, which lies to its radial side.
• Gives o a dorsal cutaneous branch 5 cm above the
wrist, which is sensory to the dorsal aspect of the ulnar
one-and-a-half ngers.
• Crosses the exor retinaculum supercially.
CHAPTER 3 The Upper Limb and Breast
73
• Supplies:
• exor carpi ulnaris
• medial half of exor digitorum profundus
• hypothenar muscles
• interossei
• medial two lumbricals
• adductor pollicis.
ANATOMY OF NERVE LESIONS
Brachial Plexus
Erb’s (Erb–Duchenne) Paralysis
• Forced downward traction on arm during birth.
• Fall on side of head and shoulder, forcing the two
apart.
• Root C5, C6 aected.
• Paralysis of deltoid, supraspinatus, infraspinatus, brachialis, biceps.
• Arm hangs limply by side (abductors paralysed) with
forearm pronated (brachialis and biceps ex and
supinate) and palm facing backwards (waiter’s tip
position).
Klumpke’s paralysis
• Upward traction on arm may damage T1 (e.g. breech
delivery).
• Intrinsic muscles of hand paralysed.
• Claw hand:
• unopposed action of long exors and long extensors
• extensors extend metacarpophalangeal joints
• exors ex the interphalangeal joints
• use of the intrinsic muscles is lost; therefore, they
cannot extend the interphalangeal joints, and hence
clawing occurs owing to unopposed action of the
long exors.
• Associated area of numbness along inner and upper
arm and forearm centred on elbow joint level.
• May be associated with Horner’s syndrome due to traction on sympathetic chain.
• Wasting of small muscles of hand; ‘channels’ between
metacarpals, wasting of rst dorsal interosseus.
• Similar lesions may occur with Pancoast’s tumour or a
cervical rib.
Axillary Nerve
• Damaged in fracture of surgical neck of humerus or
anterior dislocation of the shoulder joint.
• Deltoid paralysed, therefore abduction lost.
• Small patch of anaesthesia over the insertion of deltoid
(‘badge area’).
Radial Nerve
• Damaged in fractures of midsha of humerus, or compression of nerve against humerus when a drunk falls
asleep with the arm over the back of a hard chair, trapping the nerve between the chair and the humerus
(‘Saturday night palsy’). Also pressure from crutch, but
axillary weightbearing crutches are rare nowadays.
• Posterior interosseous may be damaged in fractures
or dislocations of the radial head or in the surgical
approach to the radial head.
• Results in wrist drop if main nerve is damaged.
• Damage to posterior interosseous branch allows extension of the wrist (due to extensor carpi radialis longus,
which is supplied by the main radial nerve before the
posterior interosseous branch is given o).
• Small area of anaesthesia on the skin on dorsum of rst
web space.
Median Nerve
• Damaged in lacerations at the wrist and supracondylar
fractures of the humerus.
• Damage at the elbow results in:
• loss of forearm pronation
• weakness of wrist exion with ulnar deviation (ex-
ion depends on exor carpi ulnaris and the medial
half of exor digitorum profundus)
• loss of sensation on the lateral palm and radial three-
and-a-half digits.
• Damage at wrist results in:
• paralysis of the thenar muscles (except adductor
pollicis)
• paralysis of radial two lumbricals
• loss of sensation over radial three-and-a-half digits.
• Damage of the nerve at both sites causes loss of accurate opposition, and the loss of cutaneous innervation
makes this a serious injury with loss of tactile response.
Ulnar Nerve
• Damage at medial epicondyle, e.g. fracture of the medial
epicondyle or dislocations of the elbow; lacerations at
wrist.
• Damage at the wrist results in:
• clawing of the hand similar to Klumpke’s paraly-
sis, except less clawing in second and third digits
because of median nerve supply to lumbricals, which
is intact
• sensory loss over medial one-and-a-half ngers.
• Damage at the elbow results in:
• similar lesion to wrist except less clawing in fourth
and h ngers, as exor digitorum profundus to
those ngers is paralysed
74
Distal pulp
the pulp space
Branch to base of
Synovial sheath for
Synovial
for flexor
Synovial sheath for
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SECTION I Anatomy
• exor carpi ulnaris is paralysed, therefore a tendency
to radial deviation at the wrist.
• Damage to ulnar nerve leaves a remarkably ecient
hand. Conrmation of the diagnosis is by testing for
lack of sensation of the medial one-and-a-half digits,
and loss of abduction and adduction of the ngers with
the hand at on a table (excludes trick movements of
long exors and extensors).
SPACES OF THE HAND
Pulp Spaces of Fingers (Fig. 3.11)
• Pulp space is fat packed between brous septa from skin
to periosteum.
• Blood vessels have to pass through this space, except the
proximal branch to the base of the distal phalanx.
• Pulp space infection increases the pressure in the space.
is may result in arterial thrombosis and necrosis of
the distal phalanx with the exception of its base, which
is spared because of the proximal branch.
Bursae of the Hand and Synovial Tendon
Sheaths (Fig. 3.12)
• Flexor tendons traverse a bro-osseous tunnel for each
digit.
• e brous sheaths end at insertion of exor digitorum
profundus.
• e brous sheaths are lined by synovial membrane.
• Second, third and fourth ngers have synovial sheaths
that close proximally at the metacarpal head.
• Synovial sheaths of thumb and little nger extend proximally into the palm.
• Synovial sheath of long exor of the thumb extends
through the palm deep to the exor retinaculum to
2.5 cm proximal to wrist (radial bursa).
• Synovial sheath of h nger forms the ulnar bursa,
which encloses all nger tendons in the palm and
extends proximally deep to the exor retinaculum for
2.5 cm above the wrist.
• e radial and ulnar bursae may communicate.
• Infection of the synovial sheath to the second, third and
fourth digits is conned to the nger. However, infection of the rst and h sheaths may spread into the
palm or from one bursa to another.
Palmar Spaces
Midpalmar Space
• Behind the exor tendons and ulnar bursa.
• In front of the third, fourth and h metacarpals.
• First and second metacarpals are cut o by adductor
pollicis, which arises from the sha of third metacarpal.
Thenar Space
• Supercial to second and third metacarpals and adductor pollicis.
• Separated from midpalmar space by brous partition.
• Infection in spaces is usually from a direct penetrating
injury or neglected tendon sheath infection.
• Infection rare in spaces, due to antibiotics.
flexor tendons to
middle finger
Digital
artery
distal phalanx (does not
pass through pulp space)
space
Fibrous
septa
Branches to shaft of distal
phalanx passing through
sheath
tendons
Fig. 3.11 Distal pulp space of a finger showing the
blood supply to the distal phalanx. (From Easterbrook
P Basic Medical Sciences for MRCP Part 1, 2nd
edn. Churchill Livingstone, Edinburgh, 1999, with
permission.)
Fig. 3.12 The synovial sheaths of the wrist and hand,
anterior view.
Fibrous flexor
sheath
flexor pollicis
longus
Flexor
retinaculum
CHAPTER 3 The Upper Limb and Breast
Thenar muscles
Trapezoid
Capitate
Hypothenar muscles
Ulnar artery
75
Palmar infections may result in marked dorsal oedema.
is is caused by the thick palmar skin being rmly bound
down to the underlying palmar aponeurosis. In contrast,
the skin of the dorsum of the hand is loose and uid can
readily collect deep into it.
Palmar Aponeurosis
• Part of the deep fascia of the hand.
• Blends with the brous exor sheath of the ngers.
• Attached to sides of proximal and middle phalanges.
• Dupuytren’s contracture results in thickening and contraction of the palmar fascia with exion of the metacarpophalangeal joints and proximal interphalangeal
joints. e distal interphalangeal joint is not involved.
SPECIALIZED AREAS OF THE ARM
Axilla
e axilla is a pyramidal space through which structures
from the head, neck and thorax pass into the arm, and
structures from the arm pass into the thorax. Being pyramidal it has a base, four walls and an apex.
• Base: skin and fascia of the armpit.
• Medial wall: rib cage covered by serratus anterior.
• Lateral wall: bicipital groove of the humerus.
• Anterior wall: pectoralis major and pectoralis minor.
• Posterior wall: latissimus dorsi, teres major and, more
superiorly, supscapularis.
• Apex is bounded anteriorly by the clavicle, rst rib
medially, and the acromion and superior border of the
scapula posteriorly.
• Contents:
• brachial plexus
• axillary artery
• axillary vein
• lymph nodes
• fat.
Antecubital Fossa
• Bounded by pronator teres medially and brachioradialis
laterally.
• Its oor is formed by brachialis and supinator.
• e roof is formed by skin, supercial fascia and deep
fascia augmented by the bicipital aponeurosis.
• Contents include the brachial artery and medial to it,
the median nerve.
Carpal Tunnel (Fig. 3.13)
• e exor retinaculum forms the roof of a tunnel, the
oor and walls of which are formed by the concavity of
the carpal bones.
• Within this tunnel are the tendons of exor digitorum
supercialis, exor digitorum profundus, exor pollicis
longus and exor carpi radialis (the latter tendon is in
its own separate osseofascial compartment).
• e most important structure to pass through the tunnel is the median nerve. Any lesion diminishing the size
of the tunnel may result in compression of the median
nerve (carpal tunnel syndrome).
• e supercial palmar branch of the nerve is given o
proximal to the exor retinaculum, and therefore there
is no sensory impairment on the lateral side of the palm
if the nerve is compressed in the carpal tunnel.
Anatomical Snuffbox
• Medial border formed by tendon of extensor pollicis
longus.
• Lateral border formed by the tendons of abductor pollicis longus and extensor pollicis brevis.
• Contents include the base of the metacarpal of the
thumb, the trapezium, the scaphoid, the radial styloid
and the dorsal branch of the radial artery.
• Important clinically as tenderness can be felt in the anatomical snuox with fractures of the scaphoid.
Flexor
retinaculum
Flexor carpi
radialis
Trapezium
Flexor pollicis
longus
Fig. 3.13 Transverse section through carpal tunnel at level of distal carpal bones, showing the relations of
structures to the flexor retinaculum.
Ulnar nerve
Median nerve
Flexor tendons
(superficialis plus
profundus)
Hamate
76
Palmaris
Abductor pollicis
indicis
digitorum
Median nerve
Flexor digitorum
Flexor digitorum
Extensor pollicis
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SECTION I Anatomy
Flexor carpi
Flexor pollicis
longus
Radial
artery
longus
brevis
Extensor carpi
radialis longus
Extensor carpi
radialis brevis
radialis
Extensor pollicis
longus
longus
Extensor
superficialis
profundus
Ulnar artery
Flexor carpi
ulnaris
Ulnar nerve
Ulnar styloid
process
Extensor carpi
ulnaris
Extensor digiti
minimi
Extensor
Fig. 3.14 Relations around the wrist. Transverse section through distal right radius and ulna styloid, made with
hand and forearm in full supination and viewed from distal aspect.
• Dorsal branch of the radial artery lies close to the
cephalic vein and therefore this is an appropriate site for
creating arteriovenous stulae for dialysis.
• apical: immediately behind the clavicle at the apex
of the axilla above pectoralis minor, and arranged
along the axillary vein (all other axillary nodes drain
through this group).
Structures Around the Wrist Joint
ese are shown in Fig. 3.14.
• From these nodes the subclavian lymph trunk emerges.
• Surgical anatomy of the axillary lymph nodes is important in relation to breast surgery. From this point of view
LYMPHATICS OF THE UPPER LIMB
• Supercial and deep lymphatics. Supercial lymphatics
accompany the veins and the deep lymphatics accompany the arteries.
• Few supercial lymph nodes in the upper limbs: chiey
the epitrochlear nodes.
• Eerents from epitrochlear nodes pierce the deep fascia
and end in the axillary nodes.
Axillary Lymph Nodes
they are classied into three levels:
• level 1 nodes: present below and lateral to the inferolateral border of pectoralis minor
• level 2 nodes: behind pectoralis minor
• level 3 nodes: above the upper border of pectoralis
mi nor.
Distribution of Dermatomes and Cutaneous
Nerves in the Upper Limb
ese are shown in Fig. 3.15 (dermatomes) and Fig. 3.16
(cutaneous nerves).
• Drain the following:
• the breast
• the pectoral region
• the upper abdominal wall down to the umbilicus
• the skin of the back down to the iliac crest
• the upper limb.
• Arranged in ve groups, although these are not distinct:
• lying deep to pectoralis major along the lower border
of pectoralis minor
• posterior: along the subscapular vessels
• lateral: along the axillary vein
• central: in the axillary fat
THE BREAST
• e female breast is made up of:
• fat
• brous tissue
• glandular tissue.
• Fat predominates in the non-lactating breast.
• Contains 15–20 lobules of glandular tissue.
• Lobules separated by brous septa running from the
subcutaneous tissues to the fascia of the chest wall (the
ligaments of Astley Cooper).
CHAPTER 3 The Upper Limb and Breast
Anterior
Posterior
cutaneous
Posterior cutaneous
nerve of arm
77
C3
C4
T3
C5
C6
T2
T1
C7
C8
Fig. 3.15 Dermatomes of the upper limb.
C5
C6
Supraclavicular nerve
• Each gland drains into a lactiferous duct, which converges towards the nipple, and each becomes dilated to
form a lactiferous sinus beneath the areola.
• e areola is lubricated by the glands of Montgomery—
large modied sebaceous glands.
Blood Supply
• e axillary artery via lateral thoracic and acromiothoracic branches.
• e internal mammary (thoracic) artery via its perforating branches.
• From the intercostal arteries via the lateral perforating
branches.
• Venous drainage is to the corresponding veins.
Lymphatic Drainage
• Along tributaries of the axillary vessels to the axillary
lymph nodes.
• Along tributaries of the internal mammary vessels to
the internal mammary chain.
• Although there is free communication between the lymphatic vessels lying between the lobules of the breast,
nerve of arm
Medial
nerve of
forearm
Ulnar nerve
A
Upper lateral cutaneous
nerve of arm
Intercostobrachial nerve
Lower lateral cutaneous
nerve of arm
Lateral cutaneous
nerve of forearm
Median nerve
nerve of forearm
Radial nerve
B
Posterior
cutaneous
Medial
cutaneous
Medial
cutaneous
nerve of forearm
Ulnar nerve
Fig. 3.16 The territories of supply of the cutaneous nerves of the upper limb. (A) Anterior view. (B) Posterior view.
78
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SECTION I Anatomy
there is a tendency for the lateral part of the breast to
drain towards the axilla and the medial part to drain to
the internal mammary chain.
Anatomical Classification
• Axillary nodes are arranged into ve groups:
• anterior—lying along the inferolateral border of pectoralis major related to the lateral thoracic artery
• posterior—lying along the subscapular vessels
• lateral—lying along the axillary vein
• central—lying in the axillary fat
• apical—lying immediately behind the clavicle at the
apex of the axilla superior to pectoralis minor.
Surgical Classification
• Level 1 nodes—lying inferior to the inferolateral border
of pectoralis minor, usually comprising the lateral, anterior and posterior nodes.
• Level 2 nodes—consisting of those nodes posterior to
pectoralis minor, comprising the central nodes and
some of the apical nodes.
• Level 3 nodes—consisting of those nodes beyond the
superior border of pectoralis minor, comprising the apical nodes and the infraclavicular nodes.
Male Breast
• Rudimentary.
• Small, primitive ducts may be present, supported by
brous tissue and fat.
• Carcinoma may occur.
Clinical Points
• When spread of a carcinoma of the breast has inltrated
normal pathways of lymphatic drainage, it may spread
by other routes to:
• lymphatics of the opposite breast
• contralateral axillary lymph nodes
• inguinal lymph nodes
• cervical lymph nodes.
• Incisions in the breast are made radially, to avoid cutting
across the line of the ducts.
• A blocked duct may become dilated during lactation to
form a galactocele.
• Glands of Montgomery become enlarged in pregnancy
to form Montgomery’s tubercles.
• Dimpling of the skin over a carcinoma of the breast is
the result of malignant inltration and contraction of
Cooper’s ligaments.
• e nipple may fail to evert and it is important to know
if this has been present since birth or is a recent event,
as the latter may indicate carcinoma or duct ectasia.
• Supernumerary nipples may be present along the ‘milk
line’ (line of mammary gland of primitive mammals).
OSCE SCENARIOS
OSCE Scenario 3.1
A patient attempts suicide by slashing the exor aspect of
his wrists in a radial to ulnar direction.
1. Which tendons are likely to be divided and how would
you test their integrity?
2. Which nerves are likely to be aected?
3. How would you test the integrity of these nerves?
OSCE Scenario 3.2
A patient with chronic renal failure is being assessed for
construction of a radiocephalic arteriovenous stula on the
le wrist.
1. Where would you palpate the radial and ulnar pulses to
assess their integrity?
2. e ulnar pulse is not readily palpable. What test would
you use to assess the integrity of the circulation to the
hand and how would you perform it?
OSCE Scenario 3.3
A 30-year-old male is taken to the Accident and Emergency
department, having fallen from a horse and landed on the
point of his right shoulder. On examination, any attempt to
move the shoulder is painful.
1. Describe the anatomy of the upper end of the humerus.
2. X-ray shows a fracture of the surgical neck of the
humerus. Which nerve is likely to have been damaged?
3. Describe the distribution of the nerve and how you
would test for damage to the nerve.
OSCE Scenario 3.4
A 30-year-old motorcyclist is brought to the Accident
and Emergency department aer a road trac accident.
Following application of the ATLS protocol, secondary survey revealed signicant so tissue injury to the right shoulder and axillary areas. He was unable to abduct his arm and
you suspect he has shoulder dislocation with tear to the rotator cu muscles and possible injury to the brachial plexus.
1. What muscles make up the rotator cu?
2. What muscles are involved in abduction of the shoulder
joint?
3. e patient is noted to have his arm hanging adducted
by his side, medially rotated while the elbow is extended
CHAPTER 3 The Upper Limb and Breast
79
and pronated. Which part of the brachial plexus is
aected and what is this injury called?
4. Where does the long thoracic nerve originate from?
What muscle does it supply? How can you test for
potential injury to it aer axillary dissection?
hard lump in the upper outer quadrant, and you noticed
skin puckering with arm elevation. Axillary examination
demonstrated palpable enlarged lymph nodes.
1. What is the blood supply to the breast?
2. What is the lymph drainage to the breast?
3. How do you classify axillary lymph nodes anatomically
OSCE Scenario 3.5
and surgically?
A 63-year-old female attends breast clinic aer feeling a le
breast lump. On examination, she had a 3×3 cm palpable
Answers in Appendix pages 436–438
Please check your eBook at https://studentconsult.inkling.com/ for more self-assessment questions. See inside cover for
registration details.
4
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The Lower Limb
THE PELVIC GIRDLE
e pelvis is made up of:
• innominate (hip) bones
• the sacrum
• the coccyx.
ese bones are bound to one another by strong ligaments.
The Hip Bone (Os Innominatum) (Fig. 4.1)
is consists of three fused bones:
• ilium
• pubis
• ischium.
Ilium
• Anterosuperiorly is a broad, thin blade for muscle
attachment and visceral protection.
• Posteroinferiorly is a thick, weight-transmitting bar
with an articular surface at each end (laterally for the
head of the femur; medially for the sacrum).
• Iliac crest runs superiorly between the anterior and posterior superior iliac spines; below each of these lies the
corresponding inferior iliac spine.
• Posterior border of ilium curves inferiorly between the
sacroiliac joint and the ischial spine, forming the greater
sciatic notch.
• e glutei and tensor fasciae latae muscles attach to the
outer aspect of the blade of the ilium, producing welldened ridges.
• e three-layered abdominal wall muscles attach to the
anterior two-thirds of the crest.
• Latissimus dorsi and erector spinae attach posteriorly to
the crest.
• e inguinal ligament attaches laterally to the anterior
superior iliac spine.
Pubis
• Shaped like a rotated L.
• Comprises a body and superior and inferior pubic ramus.
• Superior ramus connects the acetabulum and symphyseal articular surfaces of the pubis.
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• e inferior ramus extends downwards from the
tubercle to its point of fusion with the ischium.
• e inguinal ligament attaches to the pubic tubercle.
• e adductors, perineal muscles and perineal membrane attach to the inferior ramus.
Ischium
• J-shaped bone with a massive body posteriorly bearing
the ischial component of the acetabulum.
• Inferiorly is the ischial tuberosity, which bears the
weight of the sitting trunk.
• Anteriorly is the ramus uniting with the pubis.
• e posterior border of the body bears the ischial spine,
separating the greater sciatic notch superiorly from the
lesser sciatic notch inferiorly.
• e hamstrings and short hip rotators (except piriformis) attach to the outer aspect of the tuberosity and the
lower body.
• e ischium and pubis together form the circumference
of the obturator foramen.
• All three bones fuse together at the acetabulum and
form a socket for the femoral head. e acetabulum
consists of about one-h pubis and two-hs each of
ilium and ischium.
Sacrum (Fig. 4.2)
• Made up of ve fused vertebrae and roughly triangular
in shape.
• Anterior border of upper part forms the sacral
promontory.
• e anterior aspect comprises:
• a central mass
• a row of four anterior sacral foramina on each side
(transmitting the upper four sacral anterior primary
rami)
• the lateral masses of the sacrum.
• e superior aspect of the lateral mass on each side
forms the ala.
• Posteriorly lies the sacral canal (the continuation of the
vertebral canal), surrounded by short pedicles, strong
laminae and small spinous processes.
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