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Name:
Surgical Anatomy of the Pelvis and Acetabulum
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Surgical Anatomy of the Pelvis and Acetabulum
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Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
ASHOK GAVASKAR: Good evening, guys. This is Dr. Ashok from Chennai and I'll set things rolling with a talk on surgical anatomy of the pelvis and acetabulum. The learning objectives for this lecture would be to discuss the key points in anatomy and development of the pelvis and acetabulum. We'll try to understand the important aspects of postural, ligamentis and neurovascular anatomy of pelvis ascetabular pertinent for treating these injuries.
ASHOK GAVASKAR: The bony anatomy of the pelvis, this consists of two innominate bones, which are formed from contributions from the ilium, ischium pubis and delta sacrum in the middle as a keystone. The acetabulum is in the middle of an innominate bone and the acetabulum is formed by contributions from ilium, ischium and predominantly and to a lesser extent from the pubis. There are three articulations, two posterior limited, two articulations called sacroiliac joints and a symphysis anteriorly.
ASHOK GAVASKAR: The width of these articulations are around 2 to 3 millimeters in adults.. But in kids it can be highly variable, so if you're diagnosing a disruption in kids, under 10 years of age, symphysal disruption are greater than 10 millimeters and an FI disruption of level 8 millimeters should arise on suspicion of an injury.
ASHOK GAVASKAR: The pelvic bones are such as no inherrant stability. The stability of the pelvis comes from strong ligaments, especially on the posterior side. These articulations, along with ligaments, gives the rings like structure to the pelvis and resultant stability. The main epiphysis in the pelvis is the tri-radial cartilage which fuses with the bones starting around15 to 16 years.
ASHOK GAVASKAR: However, there are a lot of other contributions that are mainly epiphyseal, and they serve as important attachments for the femoral musculature. They are clinically relevant because there is a risk of injury to them in certain skeletal patients. Worsening injuries are common because there is a tremendous amount of muscular forces acting perpendicularly across the epiphysis. Functionally, the pelvis is divided into two.
ASHOK GAVASKAR: The false pelvis and the true pelvis. The false pelvis consists of the sacral ala and the iliac wing. Which is filled with predominantly the iliacus muscle. The true pelvis is the deepest portion of the basin consisting of the pelvic viscera, the intra-urinary structures about and above the diaphragm. It is lined anteriorly by the intropelvic area and posteriorly by the {INAUDIBLE] sacrum and on sides by the medial wall of acetabulum.
ASHOK GAVASKAR: The anatomy of the acetabulum if you look at it, there are six main components: the anterior column, posterior column, anterior posterior and medial wall, and then the dome. The anterior and posterior column are two strong sheets of bone arranged in a y shape manner, which connect the acetabulum to the SI joint by means of a strong sheet of bone called the sciatic buttress, which is often preserved in an acetabular fracture and often serves as a constant fragment or keystone to base you with a acetabular fracture reduction upon.
ASHOK GAVASKAR: The acetabular cavity has a specific spatial orientation with regards to other portions of the pelvis. It is inclined at an angle of 50 degrees with regards to the horizontal plane. And it is an, it has an offset anteriorly of 15 to 25 degrees this is with regards to the sagittal plane, which we call this anti-version. If you look at the articular surface of the acetabulum, it is a low neck shape consisting of a smaller anterior on and a bigger posterior on. The dome is predominantly contributed to by the posterior on.
ASHOK GAVASKAR: There is also an actabular fossa, inferior limb which has got no articular cartilage. And if you look at the arrangement of articular cartilaginous acetabular cavity, you can see that the dome has the thickest and as you go down inferiorly, thus stellar cartilage thickness tremendously decreases. Another important structure that you need to remember is the acetabular labrum, which helps to deepen the acetabular cavity and also increases the area of contact the femoral head.
ASHOK GAVASKAR: It's got an anterior and a posterior on which attaches to the transverse acetabular ligament inferior. With regards to stability of the pelvis, it predominantly comes from the posterior pelvic ring because it is along the line of weight transmission, whereas the anterior ring merely acts as a strut preventing collapse of the pelvis. This is important because even in patients who have a smaller or a mild injury to the anterior ring, but even in patients who got extremis of the bladder where the entire anterior ring is missing, the disability with regards to mobility and weight bearing is often minimal
ASHOK GAVASKAR: So with regards to stability, the posterior pelvic ring is the most important. Through knowledge of these acetabular, anatomy is important if you are going to treat pelvic fractures with surgery because not every portion of the pelvis is safe and strong to put your screws or whatever kind of internal fixation that you use. To highlight these concepts a little bit further Dr Gansslen
ASHOK GAVASKAR: described as triggering idea very described three rings iliac, acetabular, opturator and the periphery of this ring is safe and strong to put your fixation or anchoring points. So if you look at the iliac wing, there are a lot of options possible along the periphery of the iliac wing. In acetabular ring, you can put separate acetabular and acetabular screws on the opturator
ASHOK GAVASKAR: in the pubic and ischium corridors. Similarly, Milton Shapro described this as fixation pathways, where you describe these corridors as tubes often curved. So if you want to put straight implants through them, sound knowledge and technique is necessary. So I'll just take you through to some of the important access fixation pathways that you might be able to use in your practice.
ASHOK GAVASKAR: In the ilium, there are two. One is the iliac crest pathway and the other is the AIIS pathway These are predominantly used for putting your external fixator pins out the tube, the AIIS pathway is bigger, stronger and is more useful to use as an external fixator construct because it gives you a tremendous amount of stability and strength to correct rotational displacements. The second is the anterior column or the pubic anterior fixation pathway,
ASHOK GAVASKAR: this is more tricky. There are two constrictions. One of them are the estimates of the pubis and one at the level of the joint. And it is often narrow and variable, and it can be sometimes very difficult to see along straight screw. Often small in females, so if you have an anterior ring fracture, anterior column fracture, sometimes you might be able to put in six five screw,
ASHOK GAVASKAR: sometimes you might struggle to even pull a 3.5 millimeter screw so you need to really carefully plan this one. On the contrary, the posterior column or the Ischial OFP this is much wider and predictable. The corridor is bigger to put in a 6.5 or a 7.3 millimeter screw consistently. You can do this for a thromantic rate. The possibility of injuring sciatic nerve is much lesser if you stay medially.
ASHOK GAVASKAR: Anteriorly, the Parasymphyseal OFP is extremely important because that serves as anchoring point for your symphysial plate and if you can push on your plate and direct your screws carefully, there are possibility of inserting long screws without injuring vital structures. But you need to remember the structures are at risk. If you go laterally, there is a possibility of risk to the obturator vessels and the external iliac vessels.
ASHOK GAVASKAR: If you screws are long, you can injure the urethra and you also have to keep the bladder in mind. The Iliosacral OF is very, very important because it is the most common pathway used for posterior break fixation. It's got a vestibular shape, narrowest at the level of the sacral forearm and then widens laterally. There are two types of fixations possible.
ASHOK GAVASKAR: One is in your sacrum, where you start posteriorly and then go towards the midline anteriorly. This is used for fixing sacroiliac joint disruptions and then you have trans-iliac, trans-sacral option where you have an absolutely horizontal pathway, which is predominantly used for fixing sacral fractures. You have to remember the structures that are at risk. A lot of structures that you can injure anywhere when you're using the ilio-sacral pathway, including the sacral nerve routes, the lumbosacral trunk, the internal iliac vessels, and sometimes even the superior medial nerve can start to feel tough, point is to posterior.
ASHOK GAVASKAR: With regards to your ilio-sacral pathway, you need to know about the dysmorphic sacrum. Dysmorphic sacrum can be common to the tune of up to 35 degree 35% as reported by Chief Routt. And a dysmorphic sacrum means nothing for the patient but as a pelvic surgeon, it is very important if you are trying to fix the posterior ring by proper screw fixation because the pathway in a dysmorphic sacrum is much different than a normal sacrum.
ASHOK GAVASKAR: The normal sacrum in both S1 and S2. You can insert illio-sacral or trans-illiac screws and the S1 pathway is always bigger than S2, whereas in the dysmorphic sacrum is different is to offer a bigger and safe corridor than it is in a dysmorphic sacrum. And at S1 it is not possible to put in a transverse iliac style screw. Sometimes you may be able to put in an illio-sacral screw and sometimes it may be very small to do that as well.
ASHOK GAVASKAR: Some of the characteristics that you can use to identify dysmorphic sacrum on a CT scan include rudimentary transverse process, Delphi S1 and then you have a down sloping, sacral post system disk between S1 and S2. And anterior foramina. And then you have to settle permanently at the level of the illiac rest, which is otherwise normally will resist in the normal sacrum.
ASHOK GAVASKAR: And you also have the anterior indentation of the sacral, which is quite typical in a dysmorphic sacrum. So these are some of the characteristics that you can use to identify and differentiate sacral dysmorphia from a normal sacral. So leading from the Arseus anatomy like you need to be aware of their pelvic neuromuscular anatomy as well. The pelvis is supplied by contributions from the lumbar plexus, sacral plexus, and also from the lumbosacral trunk.
ASHOK GAVASKAR: The pelvis also has a rich arterial supply coming from the iliac system, predominantly the internal iliac plantas. The venous anatomy of the pelvis is also important because this is the one that commonly bleeds in an exam relating pelvic fractures. And some of these structures often represent structures that twist either at the injury or during surgical means.
ASHOK GAVASKAR: And you need to know where it bleeds from so that you can treat this patient successfully. If you look at the incidence of pelvic fractures, 15 to 30 percentage of them have hemodynamic instability, and 8% of patients are lumbar-sacral plexus injuries. And if you look at the mortality rate, it goes up to almost 60% if you have a bleeding pelvic fracture. So you need to know where the bleeding comes from
ASHOK GAVASKAR: if you need to stop it. Most often the bleed comes from the venous system and bony and the fractured bony self faces. The principal venous plexus is an important source of bleed because it is intimately in communication with the anterior sacrum. And this is one of the reasons why strategy of using an external fixator with pelvic packing to provide pelvic tamponade as most as a treatment of choice in treating bleeding fractures in the Western world.
ASHOK GAVASKAR: And this has reduced mortality to the tune of 20% as compared to previous. Arterial bleeding can happen in pelvic fractures, around 15% is most commonly comes from mid-sized pelvic vessels, often from the superior gluteal, and sometimes obturator artery. So this is one of the reasons why therapeutic embolization is not the first choice of treatment in many of the Western countries.
ASHOK GAVASKAR: Some of the other structures that I will touch upon include the lumbosacral trunk, which is contributed by the L4 and L5. It is clinically relevant with regards to anterior approach to the sacroiliac joint because the lumbosacral trunk crosses from medially to laterally from superior to distal direction. So whenever you approach the sacroiliac joint, you need to be aware of this fact so that you tailored to the lumbosacral trunk and avoid ensuring that. You need to keep your section completely sub-periostial, identify the trunk and stay lateral to it.
ASHOK GAVASKAR: The corridor of safety is much bigger than distal. Sciatic nerve is the biggest, the largest nerve that comes from the sacral plexus with contributions from S1, S2, S3 and also from the lumbosacral trunk. It exits the pelvis to the response forearm and and stays anterior for the piriformis muscle. But this is not often the case and variations are possible and you need to be aware of this fact whenever you do a kocher-langenbeck approach and whenever you do a kocher-langenbeck approach, you need to make sure that you keep the hip extended and the knee flexed to keep the sciatic nerve
ASHOK GAVASKAR: relax, as you can see here. And the nerve becomes much tenser when you reverse these positions. Now there are three of importance that gets injured often. Probably the most common articular injury in the pelvic fracture is a superior gluteal arteral injury. This is common when you have posterial column fractures when the nerve can be torn or sometimes it gets entangled and then it starts bleeding, then you start reducing your fracture.
ASHOK GAVASKAR: So you need to be aware of this fact because like when the muscle gets torn, sometimes you can get back crack in to pelvis and the bleeding can become uncontrollable from outside. Another possibility is like there is a possibility of the superior gluteal artery getting injured through during the extremely ephemeral approach. This was a paper published from North America where they reported that the approach is quite safe and they did not encounter a lot of injuries when they did.
ASHOK GAVASKAR: They encountered only one thrombosis and no direct to injury, about 41 cases, so pretty much safe there. Another possibility is like when you put those idiosacral screws Cody Collinge reported around 18% incidence of superior gluteal artery injury on based on a cadaver study. And he also said that most of those are most of those injuries, we don't know because there is good tamponade, because the technique is percutaneous and most of the times the screws themselves provide reasonably good tamponade.
ASHOK GAVASKAR: Lastly, a word about Corona Mortis. Corona Mortis is a communication between the obturator and the external iliac or the inferior gastric system. The communication is often venous and small, but sometimes large. Arterial connections are also possible, and they can lead to significant bleeding. If you are not aware of it when you do your anterior approach. So when you go laterally from the pubis, you need to be aware of its presence.
ASHOK GAVASKAR: It's often situated around 3 to 7 centimeters, not to the tubercle. So you need to be aware of this fact, when you extend your approach laterally. So to conclude, sound knowledge of the OCI's and the neuromuscular anatomy is important to treat this pelvic injuries safer and in a sound manner. Thank you.
Segment:0 .
ASHOK GAVASKAR: Good evening, guys. This is Dr. Ashok from Chennai and I'll set things rolling with a talk on surgical anatomy of the pelvis and acetabulum. The learning objectives for this lecture would be to discuss the key points in anatomy and development of the pelvis and acetabulum. We'll try to understand the important aspects of postural, ligamentis and neurovascular anatomy of pelvis ascetabular pertinent for treating these injuries.
ASHOK GAVASKAR: The bony anatomy of the pelvis, this consists of two innominate bones, which are formed from contributions from the ilium, ischium pubis and delta sacrum in the middle as a keystone. The acetabulum is in the middle of an innominate bone and the acetabulum is formed by contributions from ilium, ischium and predominantly and to a lesser extent from the pubis. There are three articulations, two posterior limited, two articulations called sacroiliac joints and a symphysis anteriorly.
ASHOK GAVASKAR: The width of these articulations are around 2 to 3 millimeters in adults.. But in kids it can be highly variable, so if you're diagnosing a disruption in kids, under 10 years of age, symphysal disruption are greater than 10 millimeters and an FI disruption of level 8 millimeters should arise on suspicion of an injury.
ASHOK GAVASKAR: The pelvic bones are such as no inherrant stability. The stability of the pelvis comes from strong ligaments, especially on the posterior side. These articulations, along with ligaments, gives the rings like structure to the pelvis and resultant stability. The main epiphysis in the pelvis is the tri-radial cartilage which fuses with the bones starting around15 to 16 years.
ASHOK GAVASKAR: However, there are a lot of other contributions that are mainly epiphyseal, and they serve as important attachments for the femoral musculature. They are clinically relevant because there is a risk of injury to them in certain skeletal patients. Worsening injuries are common because there is a tremendous amount of muscular forces acting perpendicularly across the epiphysis. Functionally, the pelvis is divided into two.
ASHOK GAVASKAR: The false pelvis and the true pelvis. The false pelvis consists of the sacral ala and the iliac wing. Which is filled with predominantly the iliacus muscle. The true pelvis is the deepest portion of the basin consisting of the pelvic viscera, the intra-urinary structures about and above the diaphragm. It is lined anteriorly by the intropelvic area and posteriorly by the {INAUDIBLE] sacrum and on sides by the medial wall of acetabulum.
ASHOK GAVASKAR: The anatomy of the acetabulum if you look at it, there are six main components: the anterior column, posterior column, anterior posterior and medial wall, and then the dome. The anterior and posterior column are two strong sheets of bone arranged in a y shape manner, which connect the acetabulum to the SI joint by means of a strong sheet of bone called the sciatic buttress, which is often preserved in an acetabular fracture and often serves as a constant fragment or keystone to base you with a acetabular fracture reduction upon.
ASHOK GAVASKAR: The acetabular cavity has a specific spatial orientation with regards to other portions of the pelvis. It is inclined at an angle of 50 degrees with regards to the horizontal plane. And it is an, it has an offset anteriorly of 15 to 25 degrees this is with regards to the sagittal plane, which we call this anti-version. If you look at the articular surface of the acetabulum, it is a low neck shape consisting of a smaller anterior on and a bigger posterior on. The dome is predominantly contributed to by the posterior on.
ASHOK GAVASKAR: There is also an actabular fossa, inferior limb which has got no articular cartilage. And if you look at the arrangement of articular cartilaginous acetabular cavity, you can see that the dome has the thickest and as you go down inferiorly, thus stellar cartilage thickness tremendously decreases. Another important structure that you need to remember is the acetabular labrum, which helps to deepen the acetabular cavity and also increases the area of contact the femoral head.
ASHOK GAVASKAR: It's got an anterior and a posterior on which attaches to the transverse acetabular ligament inferior. With regards to stability of the pelvis, it predominantly comes from the posterior pelvic ring because it is along the line of weight transmission, whereas the anterior ring merely acts as a strut preventing collapse of the pelvis. This is important because even in patients who have a smaller or a mild injury to the anterior ring, but even in patients who got extremis of the bladder where the entire anterior ring is missing, the disability with regards to mobility and weight bearing is often minimal
ASHOK GAVASKAR: So with regards to stability, the posterior pelvic ring is the most important. Through knowledge of these acetabular, anatomy is important if you are going to treat pelvic fractures with surgery because not every portion of the pelvis is safe and strong to put your screws or whatever kind of internal fixation that you use. To highlight these concepts a little bit further Dr Gansslen
ASHOK GAVASKAR: described as triggering idea very described three rings iliac, acetabular, opturator and the periphery of this ring is safe and strong to put your fixation or anchoring points. So if you look at the iliac wing, there are a lot of options possible along the periphery of the iliac wing. In acetabular ring, you can put separate acetabular and acetabular screws on the opturator
ASHOK GAVASKAR: in the pubic and ischium corridors. Similarly, Milton Shapro described this as fixation pathways, where you describe these corridors as tubes often curved. So if you want to put straight implants through them, sound knowledge and technique is necessary. So I'll just take you through to some of the important access fixation pathways that you might be able to use in your practice.
ASHOK GAVASKAR: In the ilium, there are two. One is the iliac crest pathway and the other is the AIIS pathway These are predominantly used for putting your external fixator pins out the tube, the AIIS pathway is bigger, stronger and is more useful to use as an external fixator construct because it gives you a tremendous amount of stability and strength to correct rotational displacements. The second is the anterior column or the pubic anterior fixation pathway,
ASHOK GAVASKAR: this is more tricky. There are two constrictions. One of them are the estimates of the pubis and one at the level of the joint. And it is often narrow and variable, and it can be sometimes very difficult to see along straight screw. Often small in females, so if you have an anterior ring fracture, anterior column fracture, sometimes you might be able to put in six five screw,
ASHOK GAVASKAR: sometimes you might struggle to even pull a 3.5 millimeter screw so you need to really carefully plan this one. On the contrary, the posterior column or the Ischial OFP this is much wider and predictable. The corridor is bigger to put in a 6.5 or a 7.3 millimeter screw consistently. You can do this for a thromantic rate. The possibility of injuring sciatic nerve is much lesser if you stay medially.
ASHOK GAVASKAR: Anteriorly, the Parasymphyseal OFP is extremely important because that serves as anchoring point for your symphysial plate and if you can push on your plate and direct your screws carefully, there are possibility of inserting long screws without injuring vital structures. But you need to remember the structures are at risk. If you go laterally, there is a possibility of risk to the obturator vessels and the external iliac vessels.
ASHOK GAVASKAR: If you screws are long, you can injure the urethra and you also have to keep the bladder in mind. The Iliosacral OF is very, very important because it is the most common pathway used for posterior break fixation. It's got a vestibular shape, narrowest at the level of the sacral forearm and then widens laterally. There are two types of fixations possible.
ASHOK GAVASKAR: One is in your sacrum, where you start posteriorly and then go towards the midline anteriorly. This is used for fixing sacroiliac joint disruptions and then you have trans-iliac, trans-sacral option where you have an absolutely horizontal pathway, which is predominantly used for fixing sacral fractures. You have to remember the structures that are at risk. A lot of structures that you can injure anywhere when you're using the ilio-sacral pathway, including the sacral nerve routes, the lumbosacral trunk, the internal iliac vessels, and sometimes even the superior medial nerve can start to feel tough, point is to posterior.
ASHOK GAVASKAR: With regards to your ilio-sacral pathway, you need to know about the dysmorphic sacrum. Dysmorphic sacrum can be common to the tune of up to 35 degree 35% as reported by Chief Routt. And a dysmorphic sacrum means nothing for the patient but as a pelvic surgeon, it is very important if you are trying to fix the posterior ring by proper screw fixation because the pathway in a dysmorphic sacrum is much different than a normal sacrum.
ASHOK GAVASKAR: The normal sacrum in both S1 and S2. You can insert illio-sacral or trans-illiac screws and the S1 pathway is always bigger than S2, whereas in the dysmorphic sacrum is different is to offer a bigger and safe corridor than it is in a dysmorphic sacrum. And at S1 it is not possible to put in a transverse iliac style screw. Sometimes you may be able to put in an illio-sacral screw and sometimes it may be very small to do that as well.
ASHOK GAVASKAR: Some of the characteristics that you can use to identify dysmorphic sacrum on a CT scan include rudimentary transverse process, Delphi S1 and then you have a down sloping, sacral post system disk between S1 and S2. And anterior foramina. And then you have to settle permanently at the level of the illiac rest, which is otherwise normally will resist in the normal sacrum.
ASHOK GAVASKAR: And you also have the anterior indentation of the sacral, which is quite typical in a dysmorphic sacrum. So these are some of the characteristics that you can use to identify and differentiate sacral dysmorphia from a normal sacral. So leading from the Arseus anatomy like you need to be aware of their pelvic neuromuscular anatomy as well. The pelvis is supplied by contributions from the lumbar plexus, sacral plexus, and also from the lumbosacral trunk.
ASHOK GAVASKAR: The pelvis also has a rich arterial supply coming from the iliac system, predominantly the internal iliac plantas. The venous anatomy of the pelvis is also important because this is the one that commonly bleeds in an exam relating pelvic fractures. And some of these structures often represent structures that twist either at the injury or during surgical means.
ASHOK GAVASKAR: And you need to know where it bleeds from so that you can treat this patient successfully. If you look at the incidence of pelvic fractures, 15 to 30 percentage of them have hemodynamic instability, and 8% of patients are lumbar-sacral plexus injuries. And if you look at the mortality rate, it goes up to almost 60% if you have a bleeding pelvic fracture. So you need to know where the bleeding comes from
ASHOK GAVASKAR: if you need to stop it. Most often the bleed comes from the venous system and bony and the fractured bony self faces. The principal venous plexus is an important source of bleed because it is intimately in communication with the anterior sacrum. And this is one of the reasons why strategy of using an external fixator with pelvic packing to provide pelvic tamponade as most as a treatment of choice in treating bleeding fractures in the Western world.
ASHOK GAVASKAR: And this has reduced mortality to the tune of 20% as compared to previous. Arterial bleeding can happen in pelvic fractures, around 15% is most commonly comes from mid-sized pelvic vessels, often from the superior gluteal, and sometimes obturator artery. So this is one of the reasons why therapeutic embolization is not the first choice of treatment in many of the Western countries.
ASHOK GAVASKAR: Some of the other structures that I will touch upon include the lumbosacral trunk, which is contributed by the L4 and L5. It is clinically relevant with regards to anterior approach to the sacroiliac joint because the lumbosacral trunk crosses from medially to laterally from superior to distal direction. So whenever you approach the sacroiliac joint, you need to be aware of this fact so that you tailored to the lumbosacral trunk and avoid ensuring that. You need to keep your section completely sub-periostial, identify the trunk and stay lateral to it.
ASHOK GAVASKAR: The corridor of safety is much bigger than distal. Sciatic nerve is the biggest, the largest nerve that comes from the sacral plexus with contributions from S1, S2, S3 and also from the lumbosacral trunk. It exits the pelvis to the response forearm and and stays anterior for the piriformis muscle. But this is not often the case and variations are possible and you need to be aware of this fact whenever you do a kocher-langenbeck approach and whenever you do a kocher-langenbeck approach, you need to make sure that you keep the hip extended and the knee flexed to keep the sciatic nerve
ASHOK GAVASKAR: relax, as you can see here. And the nerve becomes much tenser when you reverse these positions. Now there are three of importance that gets injured often. Probably the most common articular injury in the pelvic fracture is a superior gluteal arteral injury. This is common when you have posterial column fractures when the nerve can be torn or sometimes it gets entangled and then it starts bleeding, then you start reducing your fracture.
ASHOK GAVASKAR: So you need to be aware of this fact because like when the muscle gets torn, sometimes you can get back crack in to pelvis and the bleeding can become uncontrollable from outside. Another possibility is like there is a possibility of the superior gluteal artery getting injured through during the extremely ephemeral approach. This was a paper published from North America where they reported that the approach is quite safe and they did not encounter a lot of injuries when they did.
ASHOK GAVASKAR: They encountered only one thrombosis and no direct to injury, about 41 cases, so pretty much safe there. Another possibility is like when you put those idiosacral screws Cody Collinge reported around 18% incidence of superior gluteal artery injury on based on a cadaver study. And he also said that most of those are most of those injuries, we don't know because there is good tamponade, because the technique is percutaneous and most of the times the screws themselves provide reasonably good tamponade.
ASHOK GAVASKAR: Lastly, a word about Corona Mortis. Corona Mortis is a communication between the obturator and the external iliac or the inferior gastric system. The communication is often venous and small, but sometimes large. Arterial connections are also possible, and they can lead to significant bleeding. If you are not aware of it when you do your anterior approach. So when you go laterally from the pubis, you need to be aware of its presence.
ASHOK GAVASKAR: It's often situated around 3 to 7 centimeters, not to the tubercle. So you need to be aware of this fact, when you extend your approach laterally. So to conclude, sound knowledge of the OCI's and the neuromuscular anatomy is important to treat this pelvic injuries safer and in a sound manner. Thank you.
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