The Gluteal Region

PELVIS
 also known as
innominate bone or
coxal bone
 large, flat pelvic bone
formed by the fusion of
three primary bones
BONES OF THE LOWER LIMB
BONES OF THE PELVIC GIRDLE
2 hip bones – articulates with each other anteriorly at symphysis pubis
Sacrum – articulates with 2 hip bones posteriorly at sacroiliac joint
Coccyx

Pelvis – strong basin structure composed of pelvic girdle and its joints
2 Parts:
pelvic brim – formed by sacral promontory behind
iliopectineal lines laterally
symphysis pubis anteriorly
false pelvis – above brim
true pelvis – below the brim
FALSE PELVIS
- little clinical importance
bounded behind : lumbar vertebrae
lateral: iliac fossa and iliacus muscles
front: lower part of anterior abdominal wall
- supports abdominal contents
- helps support the gravid uterus after 3rd month of
pregnancy
- helps guide fetus into true pelvis during early stages
of labor
TRUE PELVIS
- it is the bony canal through which the child passes during birth
1. Pelvic Inlet of Pelvic Brim
posteriorly: sacral promontory
lateral: iliopectineal lines
anterior: symphysis pubis
2. Pelvic Outlet
posterior: coccyx
lateral: ischial tuberosities
anterior: pubic arch – anteriorly between ischiopubic rami, laterally sciatic
notches
- does not present a smooth outline but has 3 wide notches
- diamond shape
Sex Differences of the Pelvis
1. False pelvis is shallow in females and deep in male
2. Pelvic inlet is transversely oval a in female but heart shaped in
male because of the indentation produced by the promontory of the
sacrum in males
3. Pelvic cavity is roomier in female than in male, distance between
inlet and outlet is much shorter
4. The pelvic outlet is larger in female than in male.
5. Ischial tuberosities are everted in female and turned in in the male
6. The sacrum is shorter, wider and flatter in female than in male
7. The subpubic angle or pubic arch is more rounded and wider in
female than in male
 - sciatic notches are divided by sacrotuberous and
sacrospinous ligaments into Greater and Lesser Sciatic
Foramina
Bounderies of Pelvic Outlet
front: ischiopubic rami and symphysis pubis
behind: sacrotuberous ligaments and coccyx
3. Pelvic Cavity
- lies between the inlet and outlet
- a short, curved canal with shallow anterior wall and a
deeper
posterior wall
 Ilium ISCHIUM PUBIS

Each hip bone is specialized to receive half the weight of the upper
body when standing and all of it periodically during walking .
The three separate bones are joined by cartilage at the
acetabulum.
The hip bone articulate with the sacrum at the
sacroiliac joints and form the antrolateral walls of
the pelvis; they also articulate with one another
anteriorly at the symphysis pubis.
 Ilium
 Upper, flattened part of the hip
bone
 Forms the superior part that
extends upward from the
acetabulum and the acetabular
fossa, where the femur articulates
 Ilium
 Anteriorly, the ilium has stout
anterior superior and
anterior inferior iliac spines
that provide attachment for
ligaments & tendons of lower
limb muscles.

 Beginning at the anterior

superior iliac spine (ASIS), the
long curved and thickened
superior border of the ilium, the
iliac crest, extends posteriorly,
terminating at the posterior
superior iliac spine.

 A prominence on the external

lip of the crest, the iliac tubercle,
lies posterior to the ASIS. The
posterior inferior spine marks
the superior end of the greater
sciatic notch, which is the
large notch above and behind
the acetabulum.
Ischium
 It forms the lower
and back part of the
hip bone and is fused
with the ilium and
pubis.
• L shaped, possessing an
upper thicker part, the
body, and a lower
thinner part, the ramus
 Ischium
 The ramus of the ischium joins the inferior
ramus of the pubis to form a bar of bone,
the ischiopubic ramus.

 The posterior border of the ischium forms

the inferior margin of a deep indentation
called the greater sciatic notch.

 The large, triangular ischial spine at the

inferior margin of this notch provides
ligamentous attachment. It projects from
the posterior border of the ischium and
intervenes between the greater and
lesser sciatic notches.

 The rough bony projection at the junction

of the inferior end of the body of the
ischium and its ramus is the large ischial
tuberosity.
 Ischium
 The ramus of the ischium joins the
inferior ramus of the pubis to form a bar
of bone, the ischiopubic ramus.

 The posterior border of the ischium

forms the inferior margin of a deep
indentation called the greater sciatic
notch.

 The large, triangular ischial spine at the

inferior margin of this notch provides
ligamentous attachment. It projects from
the posterior border of the ischium and
intervenes between the greater and
lesser sciatic notches.

 The rough bony projection at the

junction of the inferior end of the body
of the ischium and its ramus is the large
ischial tuberosity.
PUBIs
 . It forms the anterior
part of the hip bone
and is fused with the
ilium and ischium.
 Divided into a
flattened medially
placed body and
superior and inferior
rami that project
laterally from the body.
 PUBIs
 Medially, the symphysial surface of
the body of the pubis articulates
with the corresponding surface of
the body of the contralateral pubis
by means of the pubic
symphysis.
 The anterosuperior borer of the
united bodies and symphysis forms
the pubic crest.
 Small projections at the lateral
ends of this crest, the pubic
tubercle.
 This tubercle provides attachment
for the subcutaneous inguinal ring
and the inguinal ligament
 The posterior margin of the
superior ramus of the pubis has a
sharp raised edge, the pecten
pubis.
 obturator foramen
 Large opening created by the ischium and
pubis bones through which nerves and
blood vessels pass
 Lies inferior to the acetabulum and is
covered almost entirely by the obturator
membrane

 acetabulum
 on the outer surface of the hip bone is a
deep depression, called the acetabulum,
which articulates with the almost spherical
head of the femur to form the hip joint

 acetabular notch
 inferior margin of the acetabulum is
deficient and is marked by the acetabular
notch

 acetabular fossa
 the articular surface of the acetabulum is
limited to a horseshoe-shaped area and is
covered with hyaline cartilage. The floor of
the acetabulum is nonarticular and is
called the acetabular fossa.
 Nice to know…

In children, triradiate cartilage closure occurs at approximately

twelve years of age in girls and fourteen years in boys.
Dimeglio, A. (2001). “Growth in Pediatric Orthopaedics”. J Pediatr Orthop. 21 (4): 549-
555.
 Clinical Correlation
 Injuries to the hips make up
less than 3% of lower limb
injuries.
 In general, most injuries result
from acute trauma during
contact sports such as hockey
and football and from overuse
during endurance sports such
as marathon races.
 Fractures of the hip bone are
referred to as pelvic
fractures. Unfortunately, the
term hip fracture is most
commonly applied to fractures
of the femoral head, neck, or
trochanters.
JOINTS OF THE PELVIC GIRDLE
A. SACRO-ILIAC JOINTS
- strong, weight-bearing compound joints
consisting of :
a. anterior synovial joint (between the
ear- shaped auricular surfaces of the sacrum
and ilium, covered with articular cartilage)
b. posterior syndesmosis (between the
tuberosities of these bones)
 limited mobility is allowed
- transmitting the weight of most of the
body to the hip bones
o Weight is transferred from the axial
skeleton to the ilia via the sacroiliac
ligaments → femurs during standing → the
ischial tuberosities during sitting
o As long as tight apposition is maintained
between the articular surfaces - sacro-iliac
joints remain stable
Ligaments of SI JOints
1. Anterior sacro-iliac ligaments
- thin , anterior part of the fibrous
capsule of the synovial part of the joint
2. Interosseous sacro- iliac ligaments
- are the primary structures involved in
transferring the weight of the upper body
from the axial skeleton to the two ilia of
the appendicular skeleton
3. Posterior sacro-iliac ligaments
- posterior external continuation of the
same mass of fibrous tissue
4. Sacrotuberous ligaments
- massive
- posterior sacro-iliac ligaments joined
by fibers extending from the posterior
margin of the ilium and the base of the
coccyx
- passes from the posterior ilium and
lateral sacrum and coccyx to the ischial
tuberosity transforming the sciatic notch of
the hip bone into a large sciatic foramen
5. Sacrospinous ligament
- passes from lateral sacrum and coccyx
to the ischial spine
- further subdivides this foramen into
greater and lesser sciatic foramina
B. Pubic symphysis
- consists of a fibrocartilaginous inter-
pubic disc and surrounding ligaments
uniting the bodies of the pubic bones in the
median plane
- interpubic disc is generally wider
in women
Ligaments
1. Superior pubic ligament
- connects the superior aspects of the
pubic bodies and interpubic disc, extending
as far laterally as the pubic tubercles
2. Inferior (arcuate) pubic ligament
- is a thick arch of fibers that
connects the inferior aspects of the joint
components, rounding off the sub- pubic
angle as it forms the apex of the pubic arch
Foramina of the Gluteal Region
GREATER SCIATIC FORAMEN
- formed by the greater sciatic notch of
the hip bone and the sacrotuberous and
sacrospinous ligaments
- it provides an exit from the pelvis into
the gluteal region
Structures that exit the foramen:
 piriformis
 Sciatic nerve
 Posterior cutaneous nerve of thigh
 Superior and inferior gluteal nerves
 Nerves to obturator internus and quadratus femoris
 Pudendal nerve
 Superior and inferior gluteal arteries and veins
 Internal pudendal artery and vein

LESSER SCIATIC FORAMEN

- formed by the lesser sciatic notch of the hip
bone and sacrotuberous and sacrospinous
ligaments
- provides an entrance into the perineum
from the gluteal region
Structures that pass through the
foramen:
- Tendon of obturator internus muscle
- Nerve to obturator internus
- Pudendal nerve
- Internal pudendal artery and vein
Muscles of the Gluteal Region
1. Gluteal Maximus – largest muscle in the body
- responsible for prominence of buttocks
2. Tensor Fascia Latae – runs downward and
backward to its insertion in the iliotibial tract
- assists the gluteus maximus muscle in
maintaining the knee in extended position
3. Piriformis – emerges through the greater sciatic
foramen to enter gluteal region
- it separates the superior gluteal vessels and
nerves from inferior gluteal vessels and
nerves
 4. Obturator internus
– fan-shaped muscle that lies within the
pelvis at its origin
- emerges through the lesser sciatic
foramen
Gluteus
medius
Gluteus
minimus
 piriformis

sg
oi
qf ig
 Gluteal Bursae
 Trochanteric bursa
◦ separates superior fibers of the gluteus maximus from the
greater trochanter.
◦ is commonly the largest of the bursae formed in relation to
bony prominences and is present at birth.

• Ischial bursa
 separates the inferior part of the gluteus maximus from the
ischial tuberosity;
 it is often absent

 Gluteofemoral bursa
◦ separates the iliotibial tractfrom the superior part of the
proximal attachment of the vastus lateralis.
Clinical Notes
 Trochanteric bursitis
- inflammation of the trochanteric bursa
- result from repetitive actions such as
climbing stairs while carrying heavy objects, or
running on a steeply elevated treadmill
- movements involve the gluteus maximus
and move the superior tendinous fibers
repeatedly back and forth over the bursae of
the greater trochanter
- causes deep diffuse pain in the lateral thigh
region
 -type of friction bursitis is characterized
by:
- point tenderness over the great
trochanter the pain radiates along the
iliotibial tract that extends from the iliac
tubercle to the tibia
- pain usually localized posterior to the
greater trochanter
- elicited by manually resisting abduction and
lateral rotation of the thigh while the person is
lying on the unaffected side
Ischial bursitis
-resulting from repeated stress
e.g., as from cycling, rowing, or other activities involving repetitive
hip extension while seated
- a friction bursitis resulting from excessive friction between
the ischial bursae and the ischial tuberosities
- Localized pain occurs over the bursa, and the pain increase
with movement of the gluteus maximus
-pressure points may lead to pressure sores in debilitated
people the ischial tuberosities bear the body’s weight during sitting
Fascia
 Superficial Fascia
◦ is thick, especially in women, and is impregnated
with large quantities of fat.
◦ It contributes to the prominence of the buttock.

• Deep Fascia/ Fascia Lata

- enclose the gluteus maximus muscle
◦ Above the gluteus maximus, it continues as a
single layer that covers the outer surface of the
gluteus medius and is attached to the iliac crest
Clinical Notes
Intramuscular Injection
- gluteus maximus is ideal because of
its thickness
- should be given on the upper outer
quadrant to avoid the sciatic nerve
Surface Anatomy of Gluteal Region
 line joining the highest points of the iliac
crests crosses the L4–L5 intervertebral (IV)
disc
 a useful landmark when a lumbar spinal
puncture is performed indicating the middle
of the lumbar cistern
 Intergluteal cleft
-beginning inferior to the apex of the
sacrum, is the deep groove between the
buttocks
- extends as far superiorly as the S3 or S4
segment.
 The coccyx is palpable in the superior part
of the intergluteal cleft
 Posterior superior iliac spines (PSIS)
- located at the posterior extremities of
the iliac crests
- may be difficult to palpate
- position can always be located at the
bottom of the permanent skin dimples
approximately 3.75 cm from midline
 line joining these dimples, more visible in
women than in men, passes through the
S2 spinous process
- indicates:
level of the lowest limit of the
dural sac
middle of the sacro-iliac joints
bifurcation of the common iliac
arteries
 inferior edge of Gluteus Max is located
just superior to the gluteal fold
 imaginary line drawn from the coccyx to
the ischial tuberosity indicates the inferior
edge of the gluteus maximus
 line drawn from the PSIS to a point
slightly superior to the greater trochanter
indicates the supe- rior edge of this
muscle.
 Gluteal sulcus
- the skin crease inferior to the gluteal fold
- delineates the buttocks from the posterior
aspect of the thigh
• Feel the ischial tuberosity as you bend to sit
• Nélaton line - line drawn from the ASIS to the
ischial tuberosity
- passing over the lateral aspect of the hip
region normally passes over or near the top of
the greater trochanter
Quiz:

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