1. Describe the lymphatic drainage of the breast into the venous system. (6 pts)
2. Review the anatomy of the profunda femoris artery (12 pts)
3. Review the anatomy of the right ventricle including structure, relationships, and innervation. (8 pts)
4. Review the course of the left vagus nerve and its branches in the thorax.  (8 pts)
5. Review the anatomy of the dorsum of the foot and include muscles, relationships, vasculature, and innervation.  (12 pts)
6. Discuss the anatomy and function of the gluteus medius and minimus muscles. (8 pts)

1.  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
• supraclavicular nodes
• cervical nodes
5. parasternal nodes
• along the internal thoracic artery
6. subcutaneous lymphatics
• distribute to wide area if deep lymphatics are blocked (e.g. cancer)
7. left/right differences
• right side into right (subclavian) lymph duct
• left side into thoracic duct and left subclavian v.
8. 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.

2.  Review the anatomy of the profunda femoris artery, including its course, key relationships (especially when the artery and/or its branches leaves one region of the thigh to enter another), and branches.  (12 pts)

1. Branch of (common) femoral a. on the posterior lateral side within 2 cm of the inquinal ligament (base of femoral triangle)
2. Inferior course on the anterior surface of iliopsoas, pectineus, adductor brevis, adductor magnus, and posterior surface of adductor longus
3. Within femoral triangle profunda femoral a/v exits posteromedial deep to super border of adductor longus and inferior to inferior border of pectineus
4. Leaves femoral triangle between pectineus and adductor longus
5. continues between adductor longus and adductor magnus to supply the adductor mm
6. medial femoral circumflex a. - leaves floor of femoral triangle between pectineus and iliopsoas
• acetabular branch - anastomosis with posterior branch of obturator and contributes to artery of ligament of head of femur
• ascending branch - anterior surface of quadratus femoris, contributes to cruciate anastomosis
• transverse branch - anterior surface of quadratus femoris toward joint capsule and cruciate anastomosis
7. lateral femoral circumflex a.
• runs laterally across anterior surface of iliopsoas
• ascending branch - deep to sartorious between rectus femoris and tensor fascia lata toward cruciate anastomosis
• transverse branch - leaves laterally deep to sartorius and then run between rectus femoris and vastus intermedius and contributes to cruciate anastomosis
• descending branch - descends posterior to rectus femoris and on anterior surface of vasti and then enters mm and contributes to genicular anastomosis
8. first perforating a. - perforates the most superior aspect of adductor magnus and/or adductor brevis and then ascends toward cruciate anastomosis
9. perforating aa. - perforates the tendonus insertions of adductor magnus and adductor brevis medial to shaft of femur
• arise from profunda femoris a. on anterior surface of adductor magnus
• supplies much of the posterior compartment including the hamstrings and the sciatic nerve
• 1st perforating contributes to cruciate anastomosis and gluteal region

3.  Review the anatomy of the right ventricle including structure, relationships, and innervation. (8 pts)

1. General comments:  The right ventricle is "C" shaped relative to the more circular left venticle.  Wall thickness is about 1/3 that of the left ventricle.  This reflects differences in the distribution of the pulmorary artery (lungs) and the aorta (entire body).  The ventrical is lined by endocardium.
2. Tricuspid valve (right atrioventricular valve)
• 3 cusps - anterior, posterior, and septal, prevent retrograde flow from ventricle to atrium
• chordae tendinae - cord like structures attaching the cusps to the papillary mm,
• papilary mm. - anterior, posterior, and septal, each papillary mm stabilizes more than one cusp
• prevent eversion of valve cusps
3. Trabeculae carnea - muscular ridges of the right ventricle
• septomarginal trabeculae - arising from the interventricular septum and extending to anterior papillary m.,  carries purkinje fibers
4. Interventricular septum and conduction - separates the right and left ventricles
• membranous portion - superior near pulmonary trunk
• AV node - AV bundle - right and left crus (Purkinje fibers) distribute to ventricles
• right crus forms moderator band within septomarginal trabeculae
5. Conus arteriosus (infundibulum) - smooth "neck of funnel" leading toward the pulmonary valve
6. Pulmonary valve - 3 cusps, lunules, nodules
• prevent retrograde flow from the pulmonary trunk into the right ventrical
7. Vascularization
• Right coronary a., marginal a, anterior and posterior interventricular aa,
• small cardiac v., anterior cardiac vv.

4.  Review the course of the left vagus nerve and its branches in the thorax.  (8 pts)

1. The left vagus nerve enters the superior aperture of the thoracic cavity running along the lateral side of the left common carotid artery.
2. Within the superior mediastinum the nerve crosses lateral to the arch of the aorta near the level of the ligamentum arteriosum.
• The left recurrent laryngeal nerve branches at this level and circles the aorta immediately posterior to the ligamentum arteriosum. It then ascends along a groove between the trachea and the esophagus (tracheoesophageal groove).
• Cardiac branches leave the vagus to contribute to the superficial and deep cardiac plexuses and to the pulmonary plexuses.
3. Inferior to the arch of the aorta, the left vagus courses inferiorly and posteriorly and passes posterior to the root of the lung.
4. Upon reaching the esophagus the vagus nerve ramifies and contributes to the esophageal plexus of nerve fibers.
5. Near the diaphragm the majority of fibers from the left vagus nerve converge to form the anterior vagal trunk. This trunk passes through the esophageal hiatus to enter the abdomen.

5.  Review the anatomy of the dorsum of the foot and include muscles, relationships, vasculature, and innervation.  (12 pts)

1. superficial fascia - contains superficial vv and nn
• great saphenous v., short saphenous v., and dorsal venus arch
• dorsal lateral cutaneous n. of the foot (continuous with sural n.) - supplies dorsal lateral foot
• superficial peroneal n. - supplies cutaneous sensation to dorsum of foot
• deep peroneal n. - enters superfical region at web between first and second toes
2. deep fascia - specialized thickenings
• inferior extensor retinaculum
• prevents "bowstringing" of peroneus tertius, extensor digitorum longus, extensor hallucis longus, tibialis anterior
• inferior peroneal retinaculum
• supports peroneus longus and brevis tendons
3. extensor hood (expansion)
• central cord (base middle phalanges) and lateral cords (base of distal phalanges)
• site of attachment for plantar and dorsal interossei, lumbricals, long and short extensor tendons
4. intrinsic muscles - extend the mp and ip joints
• extensor hallucis brevis and extensor digitorum brevis
• origin from anterolateral calcaneus and deep surface of inferior extensor retinaculum
• tendons approach long tendons from the lateral side
• dorsal interosseous mm
• bipennate taking two heads of origin from adjacent metatarsals
• adduction, flex mp, extend ip
5. extrinsic muscles
• peroneus tertius - eversion
• extensor hallucis longus, extensor digitorum longus - extension at ankle, mp, and ip joints
• tibialis anterior - ankle extension and inversion
• peroneus longus and brevis - eversion
6. dorsalis pedis a. - enters dorsum between tibialis anterior and extensor hallucis longus, deep to inferior extensor retinaculum
• lateral tarsal a. - deep to intrinsic musculature
• medial tarsal a. - deep to tendons of extensor hallucis longus and tibialis anterior
• arcuate a. - branches near base of first metatarsal, courses lateral deep to intrinsic and extrinsic tendons
• helps supply dorsal metatarsal aa and dorsal digital aa
• dorsal metatarsal aa. - run along dorsal (posterior) surface of dorsal interosseous mm.
• enters plantar side by passing between heads of first dorsal interosseous to become deep plantar arch
7. deep peroneal n. - runs along lateral side of dorsalis pedis
1. lateral branches to intrinsic mm
2. cutaneous branch to web between 1st and 2nd toes

6.  Discuss the anatomy and function of the gluteus medius and minimus muscles, and include a review of the vascular supply, relationships, and innervation.  In addition, explain the ramifications of a loss of these muscles with respect to walking.  (8 pts)

1. Origins and Insertions - fan shaped
• gluteus medius - ala of ilium between anterior and posterior gluteal lines, superior greater trochanter
• gluteus minimus - ala of ilium between anterior and inferior gluteal lines, superior greater trochanter anterior to gluteus medius
2. Actions
• primary - abduction of the femur (abduction of pelvic girdle for reversal of origin/insertion during walking)
• secondary - anterior fibers provide medial rotation
3. Neurovascular relations - neural supply by superior gluteal nerve
• superior gluteal n.a. leaves pelvis to enter gluteal region through the greater sciatic foramen
• enters gluteal region superior to piriformis
• courses laterally between gluteus medius (anterior to) and minimus (posterior to) to reach tensor fascia lata
• posterior branch of superior gluteal a. enters gluteus maximus without superior gluteal n.
4. Abductors of  the hip - provide stabilization of the pelvic girdle
• gluteus minimus - ileum to superior greater trochater (deepest of gluteal mm)
• gluteus medius - ileum to superior greater trochanter - posterior to gluteus minimus, deep to gluteus maximus
• tensor fascia lata - anterior superior iliac spine to iliotibial tract (lateral side of superior fibular and surrounding area)
5. Disruption of gate.   Paralysis of gluteus medius and minimus causes dropping of the pelvic girdle opposite to the side of injury.   Normally, during walking, gluteus minimus and gluteus medius pull downward on the pelvic girdle opposite to the limb in swing phase.  This action stabilizes the pelvic girdle.  The gluteus minimus and medius mm are viewed as arising from the femur (greater trochanter) and inserting upon the ilium. This demonstrates a reversal of origin and insertion.  When gluteus medius and minimus are paralyzed the pelvis drops to the side of swing phase.  In order to restore the line of gravity, the patient leans to the side of the injury.  The resulting gate is known as Trendelenberg's gate (gluteal waddle).