Lower Limb and Thorax Written Examination Part III- August 31, 2001

The College of Medicine of The Pennsylvania State University

Note: This is an outline of items to discuss -- NOT the "Answer"
[ The Structural Basis of Medical Practice ]

Table of Contents
  1. Review the lymphatic drainage of the lung. (5 pts)
  2. Review the anatomy of the posterior thigh. (10 pts)
  3. Review the anatomy of the piriformis m. and the superior gluteal n.. (10 pts)
  4. Review the anatomy of the posterior nediastinum. (10 pts)
  5. Review the fascial barriers separating the pericardial cavity from the pleural cavity. (5 pts)
  6. Review the anatomy and function of the knee joint. (12 pts)

1. Review the lymphatic drainage of the lung. (5 pts)

  1. Pulmonary nodes of each lung drain toward bronchopulmonary nodes
  2. Bronchopulmonary nodes drain into tracheobronchial nodes
  3. Join drainage from parasternal nodes to form bronchomediastinal lymph trunks
  4. Bronchomediastinal trunks drain into the subclavian vv.
  5. Possible right and left lung differences
  6. Right into right lymphatic duct - bracheocephalic v.
  7. Left into thoracic duct - bracheocephalic v.
Clinical note - Large paratracheal nodes may compress lung (middle lobe syndrome)
Clinical note - Adhesions of visceral and parietal pleura introduces alternative drainage patterns.

2. Discuss the anatomy of the posterior compartment of the thigh, including function, boundaries, relationships, innervations, and vascularization, along with a definition of the hamstring muscles. (10 pts)

  1. Function
  2. Boundaries
  3. Relationships (see boundaries)
  4. Innervations
  5. Vascularization
  6. Definition of the hamstrings

3. Discuss the anatomical relationships of the piriformis muscle. Furthermore, describe the course of the superior gluteal nerve in the gluteal region, and the functional deficits and compensations(s) resulting from injury. (10 pts)

  1. General Comments: The upper medial quadrant injection put the superior gluteal nerve at risk. Disruption of gate is largely due to dropping of the pelvic girdle opposite to the injury. When the lower limb opposite to the injury is raised (swing phase) the pelvis sags to that side. Normally, gluteus minimus and gluteus medius pull downward on the pelvic girdle opposite to the limb in swing phase. This keeps raises the opposite side upward during swing phase. This demonstrates a reversal of origin and insertion. In this case, opposite of embyologic origin and insertion, the gluteus minimus and medius mm are viewed as arising from the femur (greater trochanter) and inserting upon the ilium. In order to restore the line of gravity, the patient leans to the side of injury. The resulting gate is known as Trendelenberg's gate (gluteal waddle).
  2. Relations of piriformis - superficial is gluteus maximus
  3. Relations and innervations of superior gluteal n.
  4. Abductors (and medial rotators) of the hip - provide fixation of the pelvic girdle
  5. Why inject in upper lateral quadrant?

4. Define the posterior mediastinum and discuss its contents. (10 pts)

  1. Boundaries
  2. Relations

5. Discuss the fascial barrier separating the pericardial cavity from the pleural cavity. What structures would be vulnerable to damage in this area? (5 pts)

An infection of the pericardial cavity could erode fascial layers gaining access to the pleural cavity. Beginning within the pericardial cavity proceeding laterally, these layers are:
  1. serous parietal pericardium
  2. fibrous pericardium
  3. endothoracic fascia - the phrenic nerve and the pericardiacophrenic vessels are vulnerable within this fascia
  4. fibrous layer of mediastinal parietal pleura
  5. serous layer of parietal mediastinal pleura

6. Discuss the anatomy of the knee joint. Include bones, cartilage, ligaments, muscles, bursa, vascular supply, innervation, stabilization, center of gravity, and locking/unlocking of the knee joint. (12 pts)

  1. Bones and Articulations (x pts)
  2. ligaments (x pts)
  3. Cavities and bursae (x pts)
  4. Capsular joint cavity (x pts)
  5. Muscles, Movements and limitations of movement (x pts)
  6. Fascial Specializatons (x pts)
  7. vascular supply (x pts)
  8. Innervation (Hilton's Law) (x pts)
  9. "Screw Home" (x pts)

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The College of Medicine of the The Pennsylvania State University
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