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The pubic symphysis is a unique joint consisting of a fibrocartilaginous disc sandwiched between the articular surfaces of the pubic bones. During pregnancy, circulating hormones such as relaxin induce resorption of the symphyseal margins and structural changes in the fibrocartilaginous disc, increasing symphyseal width and mobility.
This systematic review of the English, German and French ligro focuses on the normal anatomy of the adult human pubic symphysis. Several aspects of the anatomy of the pubic symphysis remain unknown or unclear: These deficiencies hinder our understanding of the testuut form and function of the joint, which is latxrjet relevant when attempting to understand the mechanisms underlying pregnancy-related pubic symphyseal pain, a neglected and relatively common cause of pubic pain.
A better understanding of the normal anatomy of the human pubic symphysis should improve our understanding of such problems and contribute tesrut better treatments for patients suffering from symphyseal pain and dysfunction. The pubic symphysis forms the strong midline union between the pubic bones of the pelvis. The symphyseal nature of this joint was recognized as long ago as by Vesalius who challenged the prevailing Hippocratic belief that the pubic bones became widely separated in labour Eastman, Hunter provided one of the first detailed descriptions of the joint, emphasizing the strength of its ligaments and its mobility in the last trimester of pregnancy Fig.
Sections of the pubic symphysis as depicted by William Hunter A Coronal section from a nulliparous female. B Axial section from a woman with puerperal fever.
The interpubic cleft is visible in the centre of the joint. The joint comprises the medial surfaces of the pubic bones and an intervening fibrocartilaginous disc, which may contain a cleft. Functionally, it resists tension, shearing and compression and yet is able to widen during pregnancy. During pregnancy, symphyseal pain typically causes difficulty with weight-bearing activities such as walking and climbing stairs, and turning over in bed Jain et al.
The reported incidence and point prevalence of pregnancy-related pelvic girdle pain, which includes symphyseal pain, varies widely. Given the scale and significance of this problem, and the lack of effective management strategies Jain et al. This should enable us to better understand morphological changes that may occur in this joint during pregnancy and the postpartum period.
This systematic review of the anatomy of the adult human pubic symphysis focuses on its libri parts, blood supply, innervation, biomechanics, and pregnancy-related changes. Early development of the joint is not considered in detail, and only animal studies relevant to human anatomy have been included.
The initial search strategy is summarized in Fig. Primary articles refer to those in which the anatomy of the pubic symphysis was the focus of the article, whereas secondary articles contained relevant data, but the anatomy of latarket joint was a more peripheral concern.
Selected historical texts tesut also included, particularly if they provided anatomical information based on the author’s original observations. Additional searches were conducted to retrieve relevant papers on biomechanics search terms: The most recent gross anatomical study of the pubic symphysis was published more than 20 years ago Gamble et al.
Only the three oldest studies Aeby, ; Zulauf, ; Loeschcke, provide quantitative data from relatively large numbers of specimens, including young and pregnant cadavers but, even in these studies, precise reference points for measurements were layarjet documented. Posteriorly, the surfaces are parallel but usually diverge anteriorly, superiorly and inferiorly Aeby, ; Fick, Coronal T1-weighted magnetic resonance image of the pubic symphysis in a supine year-old woman anterior view.
Note that the joint is asymmetric.
The articular surfaces are covered in hyaline cartilage, which varies between 1 and 3 mm in thickness Aeby, ; Luschka, ; Fick, ; Frazer, ; Sutro, ; Frick et al. Loeschcke noted that the thickness of the hyaline cartilage decreased with advancing age.
The subchondral bony surfaces are irregular in young adults Luschka, ; Fick, but, radiographically, become smooth and straighter at around 30 years of testur Todd, before degenerative changes joint narrowing, subchondral sclerosis and irregularity set in from around the sixth decade Todd, Putschar described 8—12 subchondral transverse bony ridges in young individuals and noted that these gradually disappeared by around 25 years of age. In a radiographic study of cadavers, Sutro noted that the subchondral bone appeared increasingly porotic after the age of 50 tsstut.
Bony fusion of the pubic symphysis is described in some adult primates such as the red leaf monkey Presbytis rubicunda Tague, but has latrjet been documented in healthy adult humans. Four ligaments reinforce the pubic symphysis, but only the superior and inferior pubic ligaments are listed in Terminologia Anatomica Federative Committee on Anatomical Terminology, The superior pubic ligament bridges the superior margins of the joint and is attached to the pubic crest as far laterally as the pubic tubercles Fick, ; Gamble et al.
Dissection images of the pubic symphysis from an elderly cadaver of unknown parity. A Anterior view of the pubic symphysis showing blending of the tendons of rectus abdominis RA and pyramidalis P with the anterior pubic ligament. Note the decussation of the gracilis G tendons. C The left medial pubic surface after bisection of the fibrocartilaginous interpubic disc.
The inferior pubic ligament, also referred to as the subpubic Gray, ; Frazer, or arcuate Frick et al. Quantitative data on the ligament are sparse. A small gap exists between its sharp inferior edge and the anterior margin of the perineal membrane; this transmits the deep dorsal vein of the penis or clitoris Fick, ; Standring, The anterior pubic ligament connects the pubic bones anteriorly and merges with their periosteum laterally Knox, ; Luschka, ; Fick, Fig.
It is composed of several layers of collagen fibres that vary in their orientation: A E12 axial slice through a human female pubic symphysis W. B Illustration of the key anatomical features in Fig. In a microdissection study of 17 elderly cadavers, Robinson et al. In nine specimens, adductor latajet had both tendinous and muscular attachments and in the remaining eight specimens only muscle fibres were attached. Adductor brevis muscle fibres were also found to blend with the anterior aspect of the pubic symphysis in seven specimens but gracilis was attached in only one.
Two authors alluded to small perforating vessels within the ligament Fick, ; Loeschcke, Relatively little is known about the posterior pubic ligament that spans the posterior aspect of the pubic symphysis and purportedly consists of only a few thin fibres Aeby, ; Gray, Fig. The ligament is thicker in multiparous women Sutro, ; Putschar, The pubic bones are united in the midline by a fibrocartilaginous interpubic disc Fig. Last described this connection as a libor mass of transversely running fibres, whereas Gray and Fick referred to fibrous elastic tissue, and Frick mentioned oblique fibres.
Luschka noted that hyaline cartilage occasionally projects into the fibrous tissue in the centre of the joint. The disc has a narrow waist and is broader superiorly and inferiorly Weber, ; Luschka, It is wider and shorter in females Gamble et al. A posterior bulge-like projection of the mid region of the disc, most prominent in multiparous females, is known as the retropubic eminence Knox, ; Fick, The presence and extent of this projection are directly related to the existence and size of the interpubic cleft located within the disc Loeschcke, ; Putschar, see below.
Both Luschka and Fick considered that the interpubic disc has outer layers of obliquely running fibres that are thicker anteriorly, similar to the anulus fibrosus. Schmidt examined sectioned interpubic discs using polarized light microscopy and found that, in axial sections, collagen fibres form an arch posterior to the cleft before merging laterally with the adjacent periosteum. Anterior to the cleft, fibres cross at right angles between their periosteal attachments to the opposite pubic bones.
In sagittal latqrjet, fibre orientation was more complex; fibres pass forwards on each side of the cleft from its posterior aspect latarhet then cross anterior to it before running in a cranial or caudal direction Fig.
In coronal sections most fibres are vertically orientated. Sagittal section through the interpubic disc showing the arrangement of collagen fibres within laatrjet disc adapted from Schmidt, A narrow, slit-like, oval-shaped cavity has frequently latarjeh described within the fibrocartilaginous interpubic disc.
This is typically located within the superior and posterior part of the disc, occupying between one-third and one-half of the height of the disc Knox, ; Zulauf, ; Fick, ; Putschar, ; Frick et al. Only rarely is the cleft situated centrally or anteriorly within the disc Zulauf, ; Sutro, Reported variants include a single septum Frick et al.
Both the lining and content of the interpubic cleft are controversial. Aeby considered testkt the cleft was usually empty although adipose tissue or, occasionally, loose bodies from degenerating fibrocartilage have been reported within the cavity Zulauf, ; Loeschcke, There is also debate about the origin of the cleft. Zulauf stated that the cleft was present in 13 of 18 fetuses and newborns with a similar prevalence in both sexes. In contrast, others have suggested that the cleft develops in llbro second year of life Putschar,at about 7—10 years of age Aeby, ; Frazer,or at any age Gray, Several studies have investigated the width of the normal pubic symphysis in an attempt tesyut better understand the changes that occur in pregnancy Table 2.
In a study of adult cadavers, Loeschcke calculated mean joint widths to be 5 mm in men, 7. Mean widths determined by imaging studies have yielded results ranging from 2.
Unfortunately, most of tdstut studies are not directly comparable as the pubic symphysis was measured at different sites in different planes with different degrees of accuracy and with no indication of inter-rater or intrarater reliability.
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Furthermore, age, sex, parity and anthropometric indices kibro often not recorded. In the single CT study, Alicioglu et al. Few authors have investigated the blood supply of the pubic symphysis and even fewer its innervation. Lesser and more variable contributions are derived from branches of the external and internal pudendal arteries and the medial circumflex femoral artery Fick, ; Gamble et al.
Small lwtarjet vessels have been noted within the interpubic disc Loeschcke, and these may become more prominent with advancing age Putschar, The innervation of the joint is variously described as coming from the pudendal and genitofemoral nerves Gamble et al.
However, no further information is provided regarding the pattern of innervation or which branches supply specific parts of the joint.
During everyday activities, the pubic symphysis is subjected to a variety of forces. These include traction on the inferior part of the joint and compression of the superior region when standing, compression when sitting, and shearing and compression during single-leg stance Meissner et al.
The healthy joint is highly resistant to separation although, on rare occasions, it may rupture during childbirth Boland, Given the location of this joint it is not surprising that few biomechanical studies have been undertaken.
Moreover, the lack of consistency in methodology makes it difficult to compare different studies.
Compendio de anatomia descriptiva Spanish Edition, L. Testut, A. Latarjet. (Hardcover )
In laatrjet study of 15 healthy young adults six men, six nulliparous women and three multiparous womensteel pins were inserted into the superior pubic ramus on either side of the symphysis and horizontal, vertical, and sagittal movement in specific postures was measured Walheim et al.
Given the morphology of the joint, the magnitude of movement was small, with anteroposterior sagittal movements being similar in both sexes at around 0. When standing on alternate legs, tesyut mean vertical descent of the pin on the contralateral side was 1 mm in men, 1.
Maximum symphyseal movement was observed in this direction. In a subsequent experimental study in 10 fresh cadavers, Meissner et al. Similar values for vertical shift at the pubic symphysis were obtained from radiographic studies when mobility was again greatest in multiparous women Garras latwrjet al.