Subinguinal Region - Study Guide (non-Exhaustive)

Anatomical Direction and Relationships

1. Superior
2. Inferior
3. Anterior
4. Posterior
5. Lateral
6. Medial

• At what point does a penetration traveling from superficial to deep reverse and then travel from deep to superficial?

Layers of Fascia

1. epidermis
2. dermis
3. subcutaneous fascia - tela subcutanea
4. muscular fascia - deep f., investing fascia, fascia latae
5. muscle proper
   • epimysium
   • perimysium

Bony landmarks

• anterior superior iliac spine (ASIS)
• femur - thigh
• greater trochanter
• lesser trochanter
• intertrochanteric line
• patella - sesemoid bone
• medial femoral condyle
• lateral femoral condyle
• medial epicondyle
• adductor tubercle
• lateral epicondyle
• fibula
• tibia - leg
• tibial tuberosity

Saphenous opening - hiatus, fossa ovalis, specialization of deep fascia

1. great saphenous vein - medial
2. from superfical (distal on vein) to deep (proximal on vein) by way of saphenous opening
3. Fascia lata - deep fascia and thigh, investing fascia
4. superior cornu
5. iinferior cornu
6. falciform margin - lateral edge
7. great saphenous vein tributaries
   • superficial circumflex iliac vein
   • superficial epigastric vein
   • superficial (external) pudendal vein

Muscular and vascular lacunae - femoral sheath

• inguinal lig. - anterior superior iliac spine to pubic tubercle
• iliopsoas muscle fills muscular lacuna - lateral space
  • anterior - inguinal lig. - external oblique aponeurosis
  • lateral - lateral femoral cutaneous nerve
  • medial - iliopectinal arch
  • femoral nerve - within iliopsoas muscle
• femoral sheath
  • diverticulum of transversalis fascia
  • three compartments
    • lateral - femoral artery
    • intermediate - femoral vein
    • medial - lymphatics, femoral ring

Femoral triangle

• Boundaries
  • superior - inguinal ligament
  • inferior - adductor canal
  • anterior - fascia lata, saphenous opening
  • posterior - iliopsoas, pectineus, adductor longus
  • lateral - sartorius
  • medial - adductor longus
• Contents
  • NAVL
  • additional arteries and veins
  • named nerves
  • fascial specializations

Muscles

• mono-articulate and bi-articulate
• hybrid
• functioinal reversal of origin and insertion

Cross section of the thigh

• muscle groupings
• layers of fascia
• Great sapheous vein at mid-thigh is within what fascial layer? At superior thigh near inguinal ligament?
• iliotibial tract - lateral
  • tensor fascia lata, by way of the iliotibial tract, is related to the tibia. Does tensor fascia latae act at the knee?
• anterior muscles - flexor of the hip and extensors at the knee
• posterior muscles - extensors of the hip and flexors of the knee
• medial muscles - adduction of the hip and flexion/rotation of the knee

Cruciate anastomosis of the hip

• collateral circulation
• anastomosis
• arteries
  1. lateral femoral circumflex
  2. medial femoral circumflex
  3. inferior gluteal artery
  4. first perforating artery
  5. obturator artery

Subinguinal Region - Study Guide

True/False

1. Flexing the hip causes the knee to move anterior.
2. Extendingf the knee causes the foot to move anterior.
3. A midsaggital view of the lower extremity may include a mid-shaft view of both the femur and the tibia.
4. A coronal view of the lower extremity may include a mid-shaft view both the femur and the tibia.
5. A horizontal view of the lower extremity may include a mid-shaft view of both the a mid-shaft view.
6. Tela subcutanea condenses to form the investing fascia of the thigh.
7. The investing fascia is deep to the skin and superficial to the tela subcutanea.
8. Abduction of both thighs will cause the knees to move together.
9. The intertrochanteric line is posterior to the intertrochanteric crest.
10. The adductor tubercle is continuous with the lateral epicondyle.
11. The femur is the largest bone of the leg.
12. The falciform edge of the saphenous hiatus is immediately anterior to the femoral vein.
13. The inferior cornu of the saphenous hiatus is immediately anterior the the femoral vein and posterior to the great saphenous vein.
14. The external pudendal artery, but not the external pudendal vein passes through the saphenous hiatus.
15. The medial region of the saphenous hiatus is marked by a well defined edge of the fascia lata.
16. The superior cornu of the saphenous hiatus is crossed by the superficial epigastric vein.
17. The rectus femoris, but not the vastus intermedius, flexes the hip and flexes the knee.
18. The femoral nerve, at the level of the inguinal ligament, lies deep to the iliacus fascia.
19. The medial extent of the femoral sheath is opposed to the lacunar ligament.
20. The lateral extent of the femoral sheath is opposed to the iliopectineal arch.
21. The femoral sheath is a prolongation of the iliacus fascia that surrounds the femoral nerve.
22. A femoral hernia passes through the femoral canal to then enter the femoral canal.
23. The lateral border of the femoral triangle is marked by the medial border of the sartorius muscle.
24. The femoral artery, withing the femoral triangle, crosses to the posterior side of the femoral vein.
25. The lateral, medial, and posterior intermuscular septae define three compartments for the thigh.
26. The transverse branch of the later femoral circumflex artery passes deep to sartorius and anterior to rectus femoris
27. The external pudendal vein, but not the external pudendal artery, passes through the saphenous hiatus.

Definition and Short Answer

1. Femoral ring and canal
2. What is the significance of knowing about fascial layers?
3. What is the relationship between investing fascia, epimysium, and perimysium?
4. Blood flow in veins is from superficial to deep. Thus, veins are said to "travel" from superficial to deep. What about the anatomy of veins when stated in proximal to distal terminology?
5. The adductor canal provides a communication between what two named regions?
6. The dorsal surface of the foot faces the ventral surface of the trunk. How can this be?
7. A projectile enters the ventrum of the trunk, passes through the abdominopelvic cavity, and exits from the dorsum of the trunk. At what point did the direction of the penetration change from superficial/deep to deep/superficial? Was the projectile always passing from anterior to posterior?
8. In light of the previous question, discuss the ambiguity of "behind," "in front of," "below," "on top of," "over," "roof," and "floor."
9. Why might a radiologist become annoyed if a colleague is imprecise in using (or failing to use) the terms thigh, leg, foot, and lower extremity?
10. During flexion of the hip the thigh moves anterior whereas during flexion of the knee the leg moves posterior. Thus, it appears that flexion denotes movement that is in the opposite direction at these joints. Is there an organising principle that makes sense of this?
11. Whenever a muscle crosses a joint it acts at that joint. The sartorius muscle crosses two joints; the hip joint and the knee joint. Discuss the primary, secondary, and tertiary actions of sartorius at the hip joint and the primary action of sartorius at the knee joint. Sartorius is known as the "tailor's muscle." Why?
12. Bony tubercles are shaped during life by the mechanical stresses applied to the bone. What might be inferred about the life of an individual with a large lesser trochanter compared to the life of an individual with a small lesser trochanter? A small tibial tuberosity versus a large tibial tuberosity?
13. Flexion has been defined as the approximation of two ventral surfaces. Does flexion of the hip and flexion of the knee agree with this "embryological" definition of flexion? Explain?
14. Discuss the lateral and medial relations of the iliopectineal arch. Be prepared to account for the ant/post and sup/inf relations.
15. How might a chronic femoral hernia promote the formation of varicose veins?
16. Discuss the immediate relations of the femoral ring. Account for 6 directions - ant/post, med/lat, and sup/inf. Your discussion of relations should start with the most salient relations and then elaborate a bit further. Relate sup/inf to named spaces (cavities and canals in this case).
17. Discuss the relations (6 directions) of the apex of the femoral triangle. Similar to the femoral ring, the most salient relations for sup/inf are argueably a space and a canal.
18. The femoral ring provides a communication between the ___________ cavity and the _________ canal. The adductor canal provides a communication between the ________ triangle and the __________ fossa.
19. What artery(s) leave the femoral triangle passing between the iliopsoas and the pectineus? Between pectineus and adductor longus? Between rectus femoris and vastus intermedius (after passing deep to sartorius)? Through the adductor canal? What artery enters the femoral triangle through the vascular lacuna?

Essay

1. Discuss the boundaries, contents, and relationships of femoral sheath
   • superior -
   • inferior -
   • anterior -
   • posterior -
   • lateral -
   • medial -
2. The femoral ring is two dimensional. There are lateral, medial, anterior, and posterior boundaries. What about superior and inferior? Why, based on your knowledge of the boundaries for the femoral ring, is a femoral hernia prone to strangulation? What are the boundaries?
3. Provide a general discussion of the femoral triangle. What boundaries of the femoral triangle are crossed by each content of the femoral triangle?
4. What are the relationships as the femoral, deep femoral, medial femoral circumflex, and lateral femoral circumflex arteries leave the femoral triangle?
5. Discuss the adductor canal and hiatus. What structures pass through each?
6. Relationships of the anterior superior iliac spine.
7. Medial compartment of the femoral sheath.
8. Structures crossing each of the six boundaries of the femoral triangle.
9. Relationships of adductor brevis.
10. Cruciate anastomosis

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