Which of the following bones participate in the formation of the acetabulum 1 ilium 2 ischium 3 pubis?

Composition of the Hip Bone

The hip bone is comprised of the three parts; the ilium, pubis and ischium. Prior to puberty, the triradiate cartilage separates these parts – and fusion only begins at the age of 15-17.

Together, the ilium, pubis and ischium form a cup-shaped socket known as the acetabulum (literal meaning in Latin is ‘vinegar cup‘). The head of the femur articulates with the acetabulum to form the hip joint.

We shall now look at the individual parts of the hip bone, and their respective bony landmarks.

Fig 2 – The hip bone of a 5 year old, with triradiate cartilage still present.

The Ilium

The ilium is the widest and largest of the three parts of the hip bone, and is located superiorly. The body of the ilium forms the superior part of the acetabulum (acetabular roof). Immediately above the acetabulum, the ilium expands to form the wing (or ala).

The wing of the ilium has two surfaces:

• Inner surface – has a concave shape, which produces the iliac fossa (site of origin of the iliacus muscle).
• External surface (gluteal surface) – has a convex shape and provides attachments to the gluteal muscles.

The superior margin of the wing is thickened, forming the iliac crest. It extends from the anterior superior iliac spine (ASIS) to the posterior superior iliac spine (PSIS).

On the posterior aspect of the ilium there is an indentation known as the greater sciatic notch.

Fig 3 – The bony landmarks of the ilium.

Clinical Relevance: Anterior Superior Iliac Spine

The anterior superior iliac spine (ASIS) is an important anatomical landmark:

• Mid-inguinal point – halfway between the ASIS and the centre of the pubic symphysis. The femoral artery can be palpated here.
• Mid-point of the inguinal ligament – halfway between the ASIS and the pubic tubercle.

In clinical practice, a patient’s “true” leg length is measured from the ASIS to the medial malleolus at the ankle joint. This is distinct from “apparent” leg length, which is measured from the umbilicus to the medial malleolus.

True leg length discrepancy is a feature of various hip disorders, as well as being a potential complication of hip joint replacement (arthroplasty).

The Pubis

The pubis is the most anterior portion of the hip bone. It consists of a body, superior ramus and inferior ramus (ramus = branch).

• Pubic body – located medially, it articulates with the opposite pubic body at the pubic symphysis. Its superior aspect is marked by a rounded thickening (the pubic crest), which extends laterally as the pubic tubercle.
• Superior pubic ramus – extends laterally from the body to form part of the acetabulum.
• Inferior pubic ramus – projects towards the ischium.

Together, the superior and inferior rami enclose part of the obturator foramen – through which the obturator nerve, artery and vein pass through to reach the lower limb.

Fig 4 – Bony landmarks of the pubis.

Fig 5 – The orientation of the hip bones within the pelvis.

Clinical Relevance – Pubic Rami Fractures

Pubic rami fractures can sometimes be observed on x-rays in elderly patients who are investigated after simple low energy falls from standing height. In this context and provided they are the only injury a patient has sustained, these fractures are usually treated without surgery.

Healing can be expected within 6-8 weeks and patients are encouraged to fully weight bear straightaway.

The Ischium

The ischium forms the posteroinferior part of the hip bone. Much like the pubis, it is composed of a body, an inferior ramus and superior ramus.

The inferior ischial ramus combines with the inferior pubic ramus forming the ischiopubic ramus, which encloses part of the obturator foramen. The posterorinferior aspect of the ischium forms the ischial tuberosities and when sitting, it is these tuberosities on which our body weight falls.

Near the junction of the superior ramus and body is a posteromedial projection of bone; the ischial spine.

Two important ligaments attach to the ischium:

• Sacrospinous ligament – runs from the ischial spine to the sacrum, thus creating the greater sciatic foramen through which lower limb neurovasculature (including the sciatic nerve) transcends.

• Sacrotuberous ligament – runs from the sacrum to the ischial tuberosity, forming the lesser sciatic foramen.

Read more about the greater and lesser sciatic foramen here.

Fig 6 – Bony landmarks of the ischium.

Clinical Relevance: Pelvic Fractures

There are two broad groups of pelvic fractures:

• Low energy injuries:
  • For example, a simple fall from standing height in an osteoporotic patient resulting in pubic rami fracture.
  • These are usually ‘stable’ injuries, not requiring surgery.
• High energy injuries with direct or transmitted trauma:
  • For example, after a high speed road traffic accident. These result in more extensive fractures which may include the acetabulum and sacroiliac joint.
  • These can be ‘unstable’ injuries and may require urgent surgery.
  • Higher energy injuries can be associated with soft tissue and vascular injury. In particular, the bladder and urethra are at high risk of damage. Vascular injury can result in life threatening haemorrhage.

In the context of a high energy major trauma patient, the pelvis can be a major source of bleeding due to fracture. As a result, major trauma patients are assumed to have a pelvic fracture until proven otherwise and a ‘pelvic binder’ is used to stabilise the pelvis and minimise further bleeding. Circumferential pressure is applied by the binder at the level of the greater trochanters – an important anatomical landmark.

By James Heilman, MD [CC-BY-SA-3.0], via Wikimedia Commons

Fig 7 – X-Ray demonstrating an acetabular fracture (arrow).