The iliac crest is the curved superior border of the ilium, extending from the anterior superior iliac spine (ASIS) anteriorly to the posterior superior iliac spine (PSIS) posteriorly. The outer lip provides attachment for the tensor fasciae latae, the gluteus medius, and the external oblique; the inner lip for the iliacus and internal oblique; the intermediate zone for the transversus abdominis. The iliac tubercle (approximately 5 cm behind the ASIS) is the widest lateral point.
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| Ossification | Ossifies from a secondary apophysis that appears at about 13-15 years, spreading from anterior to posterior (Risser sign), and fuses with the ilium at about 20-25 years. |
The iliac crest is the most common donor site for autologous bone graft in orthopaedic and oral/maxillofacial surgery. Anterior iliac crest graft is harvested 2 cm posterior to the ASIS; posterior crest graft (richer in cancellous bone) is harvested posterior to the PSIS. Donor site morbidity includes chronic pain (20%), haematoma, nerve injury, and hernia. The lateral femoral cutaneous nerve (2 cm medial to ASIS), the cluneal nerves posteriorly, and the ilioinguinal nerve along the inner crest are at risk during harvest.
Place your hands on the person's waist, fingers pointing forward, and press down firmly through the soft tissue until you meet a long curved bony ridge. Trace it from the ASIS at the front, through the iliac tubercle, to the PSIS at the back. The highest points of the two crests line up with the L4 spinous process or the L4-L5 gap.
Anterior iliac crest bone graft harvest produces donor site pain in up to 20% of patients at one year, with risk of lateral femoral cutaneous nerve injury from harvesting too close to the ASIS, haematoma, and rarely hernia through the thinned outer cortex, managed by meticulous closure in layers and avoiding dissection within 2 cm of the ASIS.
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