Clinical Anatomy 20:433–439 (2007)

ORIGINAL COMMUNICATION

Corona Mortis: An Anatomical Study

with Clinical Implications in Approaches
to the Pelvis and Acetabulum
S. DARMANIS,* A. LEWIS, A. MANSOOR, AND M. BIRCHER
Pelvic and Acetabulum Unit, Orthopaedic and Trauma Department,
St. George’s Hospital, London, United Kingdom

The ‘‘corona mortis’’ is an anatomical variant, an anastomosis between the ob-

turator and the external iliac or inferior epigastric arteries or veins. It is
located behind the superior pubic ramus at a variable distance from the sym-
physis pubis (range 40–96 mm). The name ‘‘corona mortis’’ or crown of death
testifies to the importance of this feature, as significant hemorrhage may occur
if accidentally cut and it is difficult to achieve subsequent hemostasis. It con-
stitutes a hazard for orthopedic surgeons especially in the anterior approach to
the acetabulum. We carried out forty cadaver dissections (80 hemi-pelvises)
through the ilioinguinal approach. A vascular anastomosis was found in 83%
of specimens. Of these, 60% had a large diameter (>3 mm) channel along the
posterior aspect of the superior pubic ramus. In clinical practice, however, 492
anterior approaches (to the best of our knowledge the largest series
described) have been carried out over the last 15 years by the senior author
(MB) and only five of these problematic vessels were discovered, and in only
two cases was there troublesome bleeding. This study confirms a paradox: in
anatomical dissections a large vessel was identified behind the superior pubic
ramus, whereas in clinical practice this vessel does not seem to be as great a
threat as initially perceived. Orthopedic surgeons planning an anterior ap-
proach to the acetabulum, such as the ilioinguinal or the intrapelvic approach
(modified Stoppa), have to be cautious when dissecting near the superior
pubic ramus. Despite the high prevalence of these large retropubic vessels in
the dissecting room, surgeons should exercise caution but not alter their surgi-
cal approach for fear of excessive hemorrhage. Clin. Anat. 20:433–439, 2007.
C 2006
V Wiley-Liss, Inc.

Key words: corona mortis; complication; ilioinguinal approach; retropubic space

INTRODUCTION (Hong et al., 2004), persistent pelvic bleeding (Marsman

The purpose of our study is to find out the incidence,
location, and dimensions of aberrant, retropubic, anasto-
mosing arteries or veins, the corona mortis, that connect
the external iliac and obturator vessels and determine
whether they interfere with the clinical approaches to the
pelvis and acetabulum. These approaches are used by or-
thopedic surgeons to reduce and fix fractures of the pelvic
girdle (particularly at the symphysis pubis and the superior
pubic ramus) and of the acetabulum (particularly the ante-
rior column). The corona mortis has been said to cause
massive uncontrolled bleeding (Sarikcioglu et al., 2003),
significant bleeding (Teague et al., 1996), profuse bleeding
et al., 1984), or life-threatening hemorrhage (Berberoglu
et al., 2001). To avoid this catastrophic complication, the
surgeon can choose an alternative approach to the pelvis or
acetabulum, which may produce an inferior surgical out-
*Correspondence to: Spyros Darmanis, Orthopaedic Surgeon, 18
Efkalipton Street, Athens 15126, Greece.
E-mail: darmanis@otenet.gr
Received 23 June 2005; Revised 17 November 2005; Accepted
13 June 2006
Published online 30 August 2006 in Wiley InterScience (www.
interscience.wiley.com). DOI 10.1002/ca.20390

V
C 2006 Wiley-Liss, Inc.
434 Darmanis et al.
Fig. 1. Corona mortis and its relationship with other
anatomical structures as well as the plate and screws
inserted in the symphysis pubis.
come. This study was carried out to identify whether the co-
rona mortis actually (in clinical practice) is a threat in the
anterior approach to the pelvis and acetabulum, or if more
ink than blood has been spilt over this anatomical variant.
METHODS AND MATERIALS
Forty cadavers (80 hemipelvises) were used in our
study. There were 27 male and 13 female cadavers with a
Fig. 2. An aberrant obturator artery originating from external iliac may endanger
surgical procedures to the superior pubic ramus and should be identified and ligated.
mean age of 58 years (range 24–82 years). The cadavers
were donated for anatomical examination in accordance
with the UK Anatomy Act (1984). The study was performed
in the Anatomy Department at the St George’s Medical
School. The cadavers were perfused through the femoral
artery with a mixture of alcohol, glycerol, phenol, and
water. They were dissected using bilateral ilioinguinal
approaches. The aponeurosis of the external oblique muscle
was incised from the pubic tubercle, through the superficial
inguinal ring, extending laterally along the fibers of the
external oblique aponeurosis to a point just above the ante-
rior superior iliac spine. The lower flap was then reflected
and the inguinal ligament defined. The ‘‘medial window’’
was developed by releasing the rectus abdominis muscle
from the pubic bone. Great care was taken at the superior
pubic ramus to preserve as many vessels as possible and
certainly all with a diameter >1–2 mm (Fig. 1). All vessels
connecting the obturator vessels with the external iliac or
inferior epigastric systems as well as aberrant vessels
(Fig. 2) were identified and their courses and branches
recorded. The diameter of all vessels as well as their dis-
tance from the symphysis pubis was measured with cal-
lipers (Fig. 3).
In the clinical cases, the ilioinguinal approach was car-
ried out as described in the previous paragraph. Following
the release of the rectus abdominis muscle the retropubic
space was packed with swabs. Incision through the inguinal
ligament exposed the structures passing deep to it, includ-
ing the femoral artery, vein, and lymphatics medially (la-
cuna vasorum). Laterally, the lateral cutaneous nerve of
the thigh and the femoral nerve usually lay within the iliop-
soas muscle (lacuna musculorum). The iliopsoas fascia (or
iliopectineal fascia) separates the two lacunae (compart-

Fig. 3. Distance and location of a retropubic vessel related to the symphysis
pubis (intrapelvic view).
ments). To allow exposure of the quadrilateral surface, a
surgical term for the body of the ischium (Letournel, 1961),
and gain access to the true pelvis it is essential to divide
the iliopsoas fascia completely. To expose this, the medial
surface of the iliopsoas fascia is freed by carefully elevating
the external iliac vessels and their satellite lymphatics from
the fascial septum using blunt-tipped scissors or a hemo-
stat. The iliopsoas muscle is then retracted laterally and the
iliopsoas fascia is incised up to iliopectineal eminence using
scissors. A finger can then be inserted beneath the iliac
vessels from lateral to medial. This permits the application
of a rubber sling around the external iliac vessels and the
adjacent lymphatics. Before the surgeon inserts the sling
beneath the vessels, the postero-superior area of the supe-
rior pubic ramus (intra-pelvic side of the femoral ring)
should be carefully palpated for any large pulsating vessels.
Placing the sling and gently retracting the iliac vessels will
allow the surgeon to look carefully at the area below the
iliac vessels for any abnormal retropubic vessels (corona
mortis) (Fig. 5).
In the clinical cases where a modified Stoppa approach
was used (Cole and Bolhofner, 1994) the surgical procedure
was as follows. A transverse incision was made 2 cm above
the symphysis pubis extending approximately between the
superficial inguinal ring on each side. The rectus abdominis
muscle was split vertically from inferior to superior with
care to remain extra-peritoneal in the superior portion. With
careful protection of the bladder, sharp dissection was used
to elevate the rectus muscle to expose the pubic symphy-
sis, body of the pubic bone, and superior pubic ramus, pro-
tecting the neurovascular structures (external iliac vein and
artery and the femoral nerve) by gentle retraction. The sur-
geon has to stand at the opposite side of the table to visual-
Corona Mortis 435
ize and palpate a possible corona mortis. The iliopsoas (ilio-
pectineal) fascia superiorly and the obturator fascia in-
feriorly can be divided to expose the medial wall of the
acetabulum and the pelvic brim.
RESULTS
Anatomical
In the cadaveric study, bilateral ilioinguinal approaches
were carried out in 80 hemipelvises. A vascular communica-
tion (>1–2 mm in diameter) was found in 66 hemipelvises
(83%) (Fig. 4). In 2 specimens (2.5%) a large diameter
vessel was present (4 or more millimeters) (Fig. 2). In one
case the large diameter vessel was a corona mortis artery
running almost vertically behind the superior pubic ramus
connecting the external iliac artery with the obturator ar-
tery at 5.2 cm lateral to the symphysis pubis. In the other
case the large vessel was an aberrant obturator artery,
which originated from the external iliac artery behind the
superior pubic ramus entering the obturator foramen verti-
cally (Fig. 2).
Arterial Corona Mortis
Of the 80 cadaveric hemipelvises, 29 (36%) had an arte-
rial connection. Multiple arterial anastomoses were found in
only one specimen. The average distance of the connecting
artery from the symphysis pubis was 71 mm (42–88 mm).
In all the hemipelvises, the artery passed vertically to the
upper surface of the superior pubic ramus forming a ‘‘vasc-
436 Darmanis et al.

Fig. 4. Typical corona mortis and its relationship with the obturator, external
iliac systems, and with the symphysis pubis.

ular arch’’ around the superior pubic ramus. A few varia-
tions were observed where the arterial connection origi-
nated more posteriorly and passed anteroinferiorly on the
lateral wall of the pelvis and connected with the obturator
artery as it entered the obturator foramen.
Venous Corona Mortis
Venous anastomoses were more common than arterial.
A venous connection was found in 48 specimens (60%
hemipelvises). The average distance of the connecting vein
from the symphysis pubis was 65 mm (39–82 mm). The
anastomosing vein passed over the superior pubic ramus in
close proximity to the femoral ring and the lacunar liga-
ment. It passed medial to the iliopectineal eminence and
the iliopsoas muscle. It then descended vertically next to
the artery, if present, and finally connected to the obturator
vein.
Aberrant Obturator Vessels
In one hemipelvis an aberrant obturator artery originat-
ing from the external iliac artery was identified. In three
hemipelvises there was an aberrant obturator vein originat-
ing from the external iliac vein. In the four hemipelvises,
these aberrant obturator vessels all entered the obturator fo-
ramen at the same point as the classical corona mortis. Their
origin was always more posterior at an acute angle crossing
the superior pubic ramus (Fig. 3). In one case the aberrant
obturator artery passed lateral to the femoral ring and the
pectineal ligament and then descended into the pelvis. The
mean distance of the aberrant obturator vessels crossing
the superior edge of the superior pubic ramus was 12 mm
(range of 9–14 mm) posterior to the average distance of
corona mortis from the symphysis pubis.
Both a connecting artery and a connecting vein were
found in 22 specimens. Furthermore, 27 sides had more

TABLE 1. Vascular Distribution in Our Dissection

Vessels Sides (hemipelvises)
Crossing the sup. pubic ramus (any vessel) 66/80 (83%)
Any vessel diameter >4 mm 2/80 (2.5%)
Arterial anastomosis 29/80 (36%)
Multiple arterial an. 1/80
Venous anastomosis 48/80 (60%)
Multiple venous an. 5/80
More than one vessel (vein, artery, or both) 27/80
Both vein and artery 22/80
Bilateral vascular abnormalities 34/40
Bilateral symmetry in vascular distribution 2/40
Aberrant obturator artery from external iliac artery 1/80 (1.25%)
Aberrant obturator vein from external iliac vein 3/80 (3.75%)

Fig. 5. A small bundle containing a corona mortis was identified behind the
superior pubic ramus in an ilioinguinal approach.
than one anastomotic vessel (more than an artery or more
than a vein or more than an artery and a vein) and also
include the previously mentioned 22 specimens. There was
a multiple arterial connection (two arteries) in one hemipel-
vis and five sides out of 80 had multiple venous anastomo-
ses: four sides with two venous branches and one side with
three. Thirty-four cadavers out of 40 had bilateral vascular
variations, but only 2 specimens demonstrated bilateral
symmetry in the vascular connections: one case had a
bilateral corona mortis artery and the other a bilateral aber-
rant obturator vein. Our results are depicted in Table 1.
Overall, the average diameter of the anastomotic vessels
was 2.6 mm (general range 1.6–3.5 mm), although two
vessels were 4.2 mm (corona mortis artery) and 4.7 mm
(aberrant obturator artery). There were no statistically sig-
nificant differences between the sex and the build of the
individual subjects and the variations of the vessels. The
mean distance from the lacunar ligament to the vascular
arch corona mortis at the superior pubic ramus was 14 mm
(range 11–16 mm). The mean distance from the corona
mortis to the symphysis was 68 mm (range 40–96 mm)
(Fig. 3).
Clinical Setting
The senior author (MB) from 1989 to 2005 carried out
492 anterior approaches (ilioinguinal and modified Stoppa)
to the pelvis and acetabulum. All patients (352 male and
140 female; average age 34 years, range 7–80 years) had
fractures of the pelvis and acetabulum. The major causes
were road traffic accidents and fall from heights. Other
causes were sports activities. The patients had fractures of
the pelvic girdle or displaced fractures of the acetabulum.
Specifically, the acetabulum fractures were anterior wall
Corona Mortis 437
and anterior column, transverse, transverse with anterior
wall, ‘‘T’’ shaped fracture, and both column fractures
according to the Letournel and Judet classification
(Letournel and Judet, 1993). The modified Stoppa approach
was carried out in 24 patients with an acetabular fracture,
where the anterior column fracture was of the low variety
(i.e., the fracture did not extend to the iliac blade and it
was below the anterior inferior iliac spine). All patients were
operated upon around 14 days following their injury (range
5–26 days). Seventeen patients underwent secondary pro-
cedures following complications of their major surgery.
Such complications included infection, loss of reduction,
intra-articular placement of screws. In all these cases there
was raised awareness at operation of the possibility of
abnormal anastomotic vessels around the superior pubic
ramus (Fig. 5). A retrospective analysis of these patients
revealed a corona mortis, which was identified and ligated
in only five individuals. In one instance, the vessel was
accidentally cut and the patient was transfused with 12
units of blood. In the remaining cases, although operative
dissection could not be as detailed as in the anatomy room,
no abnormal vessels that would necessitate any procedure
other than coagulation with the diathermy were found.
Postoperatively, no patients experienced any substantial
blood loss that would make the surgeon consider excessive
hemorrhage from a large vessel such as the corona mortis.
Even if the vessel had missed the surgeon’s attention, it
would almost certainly have been accidentally injured by
the periosteal elevator when the superior pubic ramus was
being exposed. Thus, despite the presence of a corona
mortis in a high percentage of cadavers, it is much less fre-
quently seen at surgery, but in experienced hands its pres-
ence at operation does not always result in a significant
clinical problem.
438 Darmanis et al.
DISCUSSION
Abnormal anastomotic vessels between the external iliac
and the obturator systems have been referred to as the co-
rona mortis and, although this connection is usually
regarded as arterial, it can be arterial or venous, or both
(Letournel, 1993; Letournel and Judet, 1993; Teague et al.,
1996; Tornetta et al., 1996; Berberoglu et al., 2001; Kara-
kurt et al., 2002; Lau and Lee, 2003; Sarikcioglu et al.,
2003; Hong et al., 2004; Okcu et al., 2004).
Arterial Corona Mortis
In the literature, arterial anastomosing channels were
mentioned less frequently than venous connections and the
prevalence of arterial corona mortis ranged from 10 to
43%. Karakurt et al. (2002) carried out angiographic stud-
ies, which revealed an arterial incidence of 29% but they
did not mention the number of arteries present. Tornetta
et al. (1996) dissected 50 cadaver halves through an ilioin-
guinal approach and mentioned vertically orientated vessels
behind the superior pubic ramus in 84% of the halves.
There was an arterial connection in only 34% of them.
Teague et al. (1996) using the ilioinguinal approach in
40 cadavers (78 sides) found that 73% of hemipelvises had
a single large diameter communicating vessel, which were
arterial in 43% of his specimens. More recently, Okcu et al.
(2004) found that arterial anastomoses were only 19% of
their anastomosing vessels. Hong et al. (2004) found an
anastomotic vessel in 72% (50 hemipelvises), of which only
34% were found to be arterial. These results are consistent
with our observations (Table 1).
Venous Corona Mortis
The venous corona mortis is usually found in higher fre-
quency than the arterial corona mortis. A review of the lit-
erature demonstrated an incidence between 52 and 96%.
This venous connection does not necessarily imply the exis-
tence of an aberrant artery or vice versa. According to
Tornetta et al. (1996), 70% of their specimens had a ve-
nous connection. Teague et al. (1996) found an incidence
of 59% venous channels connecting between the obturator
and either the inferior epigastric or the external iliac vein. A
more recent study by Okcu et al. (2004) found a retropubic
vascular communication between the obturator and exter-
nal iliac systems in 61%. A similar incidence of 62% was
found by Hong et al. (2004). These results were consistent
with our observations. The highest percentage ever re-
ported was that by Berberoglu et al. (2001) who quoted a
prevalence of 96% venous anastomoses, which they
believed may endanger laparoscopic procedures.
When Letournel described the ilioinguinal approach, he
found a corona mortis in 10–15% (Letournel, 1961; Letour-
nel and Judet, 1993), although clinically he encountered a
large vessel only in one case out of more than 150 ilioingui-
nal approaches. He did not specify, however, if it was a
connecting artery or vein.
Aberrant Obturator Vessels and Corona
Mortis
In the obturator vascular system, there is no consistency
in the literature regarding the prevalence of an aberrant ob-
turator artery or vein. Berberoglu et al. (2001) quoted a
prevalence of 14% of aberrant obturator arteries, but did
not mention aberrant obturator veins. Lau and Lee (2003)
found a prevalence of 22% for an aberrant obturator artery
and 27% for an aberrant obturator vein. Hong et al. (2004)
studied these vessels in detail and found 22% anomalous
obturator veins and 24% anomalous obturator arteries.
An explanation for the discrepancy in these figures is the
confusion in the literature over the term corona mortis and
what it should include. We preferred to keep the original
description that is found in the 34th Edition of Gray’s Anat-
omy (Davies and Coupland, 1967) and in the description by
Letournel and Judet (1993). Our concept is that the corona
mortis is an anastomosis between the obturator and the
external iliac or inferior epigastric artery or vein. In our
study, any aberrant obturator artery was identified but it
was not recorded as a corona mortis. An aberrant obturator
artery is present in around 20–30% of hemipelvises (much
lower than corona mortis), and is a larger vessel than the
corona mortis, originates from the external iliac or inferior
epigastric artery, and pierces the obturator membrane
close to the obturator vein. These subjects have no obtura-
tor artery, only this enlarged aberrant artery. In contrast,
subjects with a corona mortis also have an obturator artery
and vein (Davies and Coupland, 1967; Marsman et al.,
1984; Skandalakis et al., 2000; Berberoglu et al. 2001;
Hong et al., 2004). In addition, in our four hemipelvises
with aberrant obturator vessels, we observed that there
was an anatomical difference as they crossed the superior
pubic ramus more obliquely and at a more posterior posi-
tion compared to the anastomotic vessels that we called co-
rona mortis.
In conclusion, in all the clinical studies and reports it can
be seen that these retropubic anastomotic vessels are of
utmost importance to surgeons dealing with pelvic and ace-
tabular trauma. In our clinical case where there was a cata-
strophic hemorrhage as well as in the other four cases,
hemorrhage was controlled with tamponade initially and
then identification and ligation of the bleeding corona mor-
tis. The corona mortis is also very important in gynecologi-
cal operations and hernia repair, especially obturator hernia
(Skandalakis et al., 2000) and for more novel procedures
such as endoscopic extraperitoneal inguinal hernioplasty
(Berberoglu et al., 2001; Lau and Lee, 2003).
An important question is why in clinical practice the inci-
dence of excessive hemorrhage from an abnormal vessel
around the superior pubic ramus is lower than one would
expect from the anatomical dissections. The answer to this
question is still unsolved.
One theory is that a traumatic laceration of corona mor-
tis occurs during the initial injury by direct or indirect vio-
lence (blunt trauma). Displaced fractures may lacerate
these vascular channels at the time of injury. This may
cause them to go into spasm thus making them difficult to
identify at operation (Baumgartner et al., 1990; Letournel
and Judet, 1993; Teague et al., 1996; Meyers et al., 2000;
Okcu et al., 2004).
A second theory is that the discrepancy in the clinical
cases may be related to the demographic and ethnic fea-
tures among the different study populations (Lau and Lee,
2003).
A third theory is that the high incidence of corona mortis
in cadavers (compared to intraoperative findings) is a result
of occlusion of the external iliac or the obturator vessels by
arterial atherosclerosis or deep vein thrombosis particularly

in the older population. This could lead to the development
of collateral circulation and subsequent formation of aber-
rant obturator vessels or of a large corona mortis (Skanda-
lakis et al., 2000; Lau and Lee, 2003). Nevertheless, this
theory seems to ignore the obvious likely finding that the
occluded vessels and their branches would still be present,
albeit as fibrous bands. Our experience would therefore
support the first theory.
In summary, a vascular connection between the obturator
and the external iliac or inferior epigastric systems is located
over the superior pubic ramus in a high percentage of cadav-
eric dissections. Its diameter as well as its course varies, and
accidental transection can result in a potentially life-threat-
ening hemorrhage. Nevertheless, in clinical practice the in-
cidence of an excessive hemorrhage from these variant ves-
sels is extremely low. Surgeons who carry out an anterior
approach to the acetabulum have to be cautious about
encountering a leash of vessels at around 6 cm (range 40–
96 mm) lateral to the symphysis pubis. This possible danger
does not seem to be a significant clinical risk and should not
compromise the surgical decision to operate through the
ilioinguinal approach for fear of excessive hemorrhage.
ACKNOWLEDGMENT
The authors acknowledge Mr. Martin Raglan for his as-
sistance in the anatomical dissections.
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