1. Review the boundaries (6 in number) and contents (vasculature, nerves, lymphatics) of the femoral triangle.  State the relationship of structures entering and leaving this region. (12 pts)

1. superior boundary: Inguinal ligament spanning the anterior superior iliac spine and pubic tubercle (including a figure would help)
• contents of  the muscular and vascular lacunae enter the femoral triangle (discuss relations)
• Vascular lacuna.
• The vascular lacuna is located posterior to the inguinal ligament, medial to the iliopectineal arch, lateral to the lacunar ligament, and anterior to the pectineal fascia.
• The contents include, from the lateral to medial, the femoral artery, the femoral vein, and the femoral canal.
• These contents are contained within compartments of the femoral sheath.  These compartments are separated by septa that run between the inguinal ligament and the pectineal fascia.
• Femoral hernias occur in this region.
• abdominal viscera may enter the femoral canal through the femoral ring.
• Muscular lacuna
• posterior to inguinal ligament and lateral to iliopectineal arch
• femoral nerve enters femoral triangle deep to iliacus fascia
• lateral femoral cutaneous nerve enters femoral triangle lateral to femoral nerve and near anterior superior iliac spine
2. lateral boundary: sartious
• lateral femoral circumflex a/v exits laterally deep to sartious and between rectus femoris and vasti
3. medial boundary: adductor longus
• profunda femoral a/v exits posteromedial deep to super border of adductor longus and continues between adductor longus and adductor magnus
4. inferior boundary: adductor canal at the apex
• Adductor canal.
• At the apex of the femoral triangle is the beginning of the adductor canal.
• The femoral artery and vein, and the saphenous nerve enter the adductor canal.
• artery anterior to vein - note: this relation betrays relation of popliteal vessels
• The adductor canal is bounded anteromedially by the sartorius muscle. Anterolaterally, it is bounded by the vastus medialis.  Posteriorly it is bounded by adductor longus and adductor magnus.
• nerve to vastus intermedius enters adductor canal
5. posterior boundary: iliopsoas, pectineus, and possibly parts of adductor brevis and adductor longus
• the medial femoral circumflex a/v exits between iliopsoas and pectineus
• the deep femoral artery exits between iliopsoas and adductor longus
6. anterior boundary: fascia lata and saphenous hiatus (show relations fig)
• the contents of the cribriform fascia exit the femoral triangle at this location
• superficial/external pudendal a/v
• superficial epigastric a/v
• superficial circumflex iliac a/v
• the great saphenous vein
• anterior femoral cutaneous nn pierce fascia lata anterior.
7. further discussion
• The saphenous hiatus
• is a specialization of the fascia lata located in the anteromedial thigh just inferior to the inguinal ligament and superficial to the femoral sheath.  The lateral margin overlies the femoral artery.  The medial aspect overlies the femoral canal.  Superiorly is the inguinal ligament.  Approximately 2cm inferior to the inguinal ligament is the inferior cornu over which the great saphenous vein forms an arch as it leaves superficial fascia and enters the femoral vein.  Notable tributaries of the great saphenous vein within the saphenous hiatus are the external pudendal vein coursing medially, the superficial epigastric vein coursing superiorly, and the superficial circumflex iliac vein coursing laterally and superiorly.  Accompanying these veins are branches of the femoral artery.  These vessels are piercing through the surrounding cribriform fascia.  The distinct lateral margin of the saphenous hiatus is the falciform edge.  There are superior and inferior borders referred to as the superior and inferior cornu.  Medially, the hiatus is indistinct and blends with the pectineus fascia.  The femoral ring is located immediately deep to the medial aspect of the saphenous hiatus.  A femoral hernia, if present, can be palpated at this location.  Additionally, a femoral pulse can be located and, thus, easy surgical access to a major artery or vein is possible.
• Femoral canal
• Lymph funnel shaped lymph channel located in the most medial compartment of the femoral sheath.
• Femoral ring is at the superior opening of this canal.
• Formed by an 1.5cm extension of transversalis fascia from the abdominal cavity into the thigh.
• Exposed to superficial fascia by the saphenous hiatus.
• Site of femoral hernia
• more common in females because of wider pelvic bones and larger femoral ring.

2.  Review the anatomy of the knee joint and include bones, articulations, ligaments, cavities and bursa, vasculature, muscles, and fascial specializations that contribute to the stability of the knee joint.  State when and why the knee joint is maximally stabilized. (15 pts)

1. Bones and Articulations (x pts)
• Synovial hinge joint between the femoral and tibial condyles.
• Tibial plateau is cupped by the medial and lateral menisci.
• Femoral condyles
• Patella articulates anteriorly as a sesamoid bone in the quadriceps tendon.
2. ligaments (x pts)
• Medial collateral ligament (attached to medial meniscus).
• medial femoral epicondyle to the medial tibial condyle.
• resists abduction of tibia.
• Lateral collateral ligament (interval between lateral meniscus and ligament transmits popliteus m.
• From lateral femoral epicondyle to the head of the fibula
• resists adduction of tibia.
• Anterior cruciate ligament
• from lateral posterior femoral condyle to anterior aspect of tibial intercondyler eminence.
• resists forward displacement of the tibia.
• Posterior cruciate ligament.
• from posterior medial femoral condyle to posterior aspect of tibial intercondyler eminence.
• resists posterior displacement of tibia.
• Oblique popliteal and arcuate ligaments strengthen the posterior joint capsule.
• coronary, transverse genicular, and meniscofemoral ligaments secure the menisci.
3. Cavities and bursae (x pts)
• Synovial joint cavity
• attaches to edges of menisci - articular surface is intrasynovial
• Alar folds anterior to  anterior crucial ligament - posterior limit of midsaggital synovial cavity
• reflections of the synovial membrane along the intercondylar fossa - cruciate ligaments are extrasynovial.
• continuous with suprapatellar bursa (quadriceps bursa)
• prepatellar bursa
• infrapatellar bursa
4. Capsular joint cavity (x pts)
• ligaments making up the capsule (above)
• intercondylar area is extrasynovial
• popliteus tendon within cavity
5. Muscles, Movements and limitations of movement (x pts)
• Primarily flexion and extension (hinge joint).
• Some rotation (30-40 degrees) is possible when the knee is flexed.
• Flexion is primarily by the hamstrings, short head of biceps, gracilis, and sartorius.
• innervated by tibial portion sciatic, peroneal portion sciatic, obturator, and femoral nerves respectively.
• minor flexion by popliteus, gastrocnemius, and plantaris.
• flexion is limited by quadriceps, cruciate ligaments, and by opposing soft tissues (calf and thigh).
• Extension is primarily by the quadriceps and tensor fascia lata.
• innervation by femoral nerve and superior gluteal nerve.
• extension is limited by hamstrings, cruciate ligaments, collateral ligaments, posterior joint capsule.
• Medial rotation of tibia is primarily by popliteus, semitendonosus, gracilis, and sartorius.
• innervation by tibial nerve, tibial portion sciatic, obturator, and femoral nerves respectively.
• limitation of movement by collateral ligaments
• Lateral rotation of tibia is primarily by biceps femoris.
• innervation by tibial and peroneal portions of sciatic nerve.
• limitation of movements by collateral ligaments.
• Abduction and adduction is limited by the medial and lateral collateral ligaments.
6. Fascial Specializatons (x pts)
• patellar retinaculum
• iliotibial tract
• investing fascia
7. vascular supply (x pts)
• Genicular anastomosis
• Superior and inferior, medial and lateral genicular arteries, and middle genicular from the popliteal artery.
• descending genicular artery from femoral artery and descending branch from lateral femoral circumflex artery
• Fibular circumflex artery, and anterior and posterior tibial recurrent arteries from the anterior and posterior tibial artery
• Accompanying veins
8. Innervation (Hilton's Law) (x pts)
• small branches of the femoral, obturator, and sciatic, and tibial nerves pierce the joint capsule.
9. "Screw Home" (x pts)
• Consider when the knee is extended with the foot planted on the ground. In this case, the tibia is fixed by virtue of the planted foot. Thus, rotation of the knee occurs as movement of the femur. The femur rotates medially as the knee "locks" in extension. The lateral femoral condyle is smaller than the medial femoral condyle. As the knee is extended the smaller condyle moves through its arc before the medial condyle. Thus, movement stops at the lateral condyle while the femoral medial condyle continues to move further posteriorly. This movement results in a medial rotation of the femur.
• This medial rotation torques the joint capsule and it's ligamentus specializations (medial and later collateral ligs).  The "twisting" of the capsular ligaments causes the region to tighten. This firmly approximates the femoral condyles to the tibial plateau and "locks" the knee. The femur "screws" medially onto the tibial plateau due to the larger medial condyle and the twisting of the capsular ligaments.  On extension, the knee goes through a "screw home" rotation that results in "close packing."
• The final medial rotation of the femur is driven by the line of gravity moving anterior to the axis of the knee joint.  Thus, locking the knee is driven by gravity.  Unlocking the knee requires muscular involvement.  The popliteus, having lateral superior to medial inferior attachments, posterior to the axis of the knee, can  to lateral rotate the femur (reverse origin and insertion) and, thus, unlock the knee joint.

3.  A 35-yr old male arrives in the clinic with a nail that penetrates the sole of the foot and pierces the spring ligament.  Discuss the fascia, muscles, tendons, nerves (including cutaneous innervation), bones, and vasculature involved with such an injury.  (10 pts)

1. Skin and plantar aponeurosis
2. Medial plantar a. and v.
• The lateral plantar a.v. is posterio-lateral to site of penetration and is spared
• Deep plantar arch is distal to site of penetration and is spared
3. Medial border of flexor digitorum brevis and lateral border of abductor hallucis
4. Tendons of flexor digitorum longus and flexor hallucis longus
• near or immediately distal to crossing of tendons
• lateral border of tibialis posterior tendon might be damaged
5. Medial border of quadratus plantae
6. Spring ligament
7. Head of talus within floor of talocalcaneonavicular joint

4.  Discuss the anatomy of the right atrium.  Include mention of the conducting system and anatomical landmarks.  (8 pts)

1. Quandrangular
2. Tricuspid valve (AV Ostium)
3. Crista terminalis - muscle
• Separates the smooth posterior wall (sinus venarum) from the muscular anterior wall (pectinate mm)
• Marks the surface projection of the sulcus terminalis
• Superior extent marks location of sinuartrial node near entry of SVA
4. Pectinate muscle
5. Opening of IVC
• Valve of IVC
• Ostia of coronary sinus is to the left of IVC
6. Opening of SVC
• landmark for location of sinuatrial (SA) node
7. Interatrial septum
• Fossa ovalis - remnant of fetal foramen ovale
• Coronary Sinus - landmark for location of Atrioventricular (AV) node
8. The sinoatrial node is a crescent shaped heart region about 8mm long and located at the superior aspect of the sulcus terminalis within the wall of the right atrium.  It is referred to as the pacemaker of the heart owing to its electrical characteristics and crucial role in timing of the cardiac cycle.  The SA node connects to the AV node by internodal tracts.
9. vascular supply
• anterior cardiac vv
• small cardiac vv
• marginal branch of right coronary
• sinuatrial artery - nodal branch to SA node

5.  Describe the lymphatic drainage of the breast. (6 pts)

1. Laterally, lymph drainage from the breast is into groups of axillary nodes.  Most of this drainage is into the pectoral nodes located along pectoral branches of the thoracoacromial vessels. Pectoral nodes drain into the apical nodes located near the apex of the axilla.  On the left, the axillary nodes give rise to the subclavian lymphatic trunk. This vessel commonly drains into the thoracic duct and then the angle of internal jugular.  The right subclavian duct often drains directly into the venous system.  Apical nodes also have drainages into cervical and supraclavicular nodes.  Metastatic disease in these nodes is especially difficult to remove.
2. The medial aspect of the breast is drained by intercostal vessels into parasternal nodes.  Parasternal and paratrachial drainages combine to form the bronchomediastinal lymph trunks.  Drainage continues into the right lymphatic duct on the right and the thoracic duct on the left.
3. The breast is also drained by subcutaneous vessels.  These vessels have a wide distribution ranging from the cervical region to the inguinal region and crossing the midline.  If the deeper lymph channels are blocked, as may be the case with cancer, subcutaneous drainage may greatly increase and widely disperse cancerous cells.
4. axillary notes receive 75% of lymphatic drainage

pectoral nodes - lateral border of pectoralis major
apical nodes - beneath the clavicle
parasternal nodes
along the internal thoracic artery
subcutaneous lymphatics
distribute to wide area if deep lymphatics are blocked (e.g. cancer)
left/right differences
right side into right (subclavian) lymph duct
left side into thoracic duct and left subclavian v.
5. Summary

Laterally, lymph drainage from the breast is into groups of axillary nodes.  Most of this drainage is into the pectoral nodes located along pectoral branches of the thoracoacromial vessels. Pectoral nodes drain into the apical nodes located near the apex of the axilla.  On the left, the axillary nodes give rise to the subclavian lymphatic trunk. This vessel commonly drains into the thoracic duct and then the angle of internal jugular.  The right subclavian duct often drains directly into the venous system.  Apical nodes also have drainages into cervical and supraclavicular nodes.  Metastatic disease in these nodes is especially difficult to remove.
The medial aspect of the breast is drained by intercostal vessels into parasternal nodes.  Parasternal and paratrachial drainages combine to form the bronchomediastinal lymph trunks.  Drainage continues into the right lymphatic duct on the right and the thoracic duct on the left.
The breast is also drained by subcutaneous vessels.  These vessels have a wide distribution ranging from the cervical region to the inguinal region and crossing the midline.  If the deeper lymph channels are blocked, as may be the case with cancer, subcutaneous drainage may greatly increase and widely disperse cancerous cells.

6.  Briefly describe the inferior limits of the parietal and visceral pleura. (3 pts)

1. Inferior limits of visceral pleura
• Midclavicular - T6
• Midaxillary - T8
• Midscapular - T10
2. Inferior limits of parietal pleura
• Midclavicular - T8
• Midaxillary - T10
• Midscapular - T12