3-Lower limp MSQs Only (1)

Question 1

4 of 467

A 45 year old motor cyclist sustains a tibial fracture and is noted to have anaesthesia of the web space between his first and second toes. Which of the nerves listed below is most likely to be compromised?

Answer 1

Deep peroneal nerve

The deep peroneal nerve lies in the anterior muscular compartment of the lower leg and can be compromised by compartment syndrome affecting this area. It provides cutaneous sensation to the first web space.
The superficial peroneal nerve provides more lateral cutaneous innervation.

Question 2

10 of 467
A 72 year old man develops a foot drop after a revision total hip replacement. Which nerve is likely to have been affected?

Answer 2

Sciatic

Whilst many of these nerves can be injured in hip surgery, for a foot drop to develop in this context (i.e. revision THR), the sciatic nerve is the most likely.

Question 3

11 of 467
A 20 year old lady presents with pain on the medial aspect of her thigh. Investigations show a large ovarian cyst. Compression of which of the nerves listed below is the most likely underlying cause?

Answer 3

Obturator

The cutaneous branch of the obturator nerve is frequently absent. However, the obturator nerve is a recognised contributor to innervation of the medial thigh and large pelvic tumours may compress this nerve with resultant pain radiating distally.

Question 4

17 of 467
A 34 year old man is injured by farm machinery and sustains a laceration at the superolateral aspect of the popliteal fossa. The medial aspect of biceps femoris is lacerated. Which of the following underlying structures is at greatest risk of injury?

Answer 4

Common peroneal nerve

The common peroneal nerve lies under the medial aspect of biceps femoris and is therefore at greatest risk of injury. The tibial nerve may also be damaged in such an injury (but is not listed here).
The sural nerve branches off more inferiorly.

Question 5

18 of 467

During a block dissection of the groin, the sartorius muscle is identified. What is the nerve supply to this muscle?

Answer 5

Anterior division of the femoral nerve

Sartorius is supplied by the anterior (superficial) branch of the femoral nerve.
Most of the branches of the superficial femoral nerve are cutaneous. However, it does also supply sartorius.

Question 6

24 of 467

A 56 year old man undergoes a low anterior resection with legs in the Lloyd-Davies position. Post operatively he complains of foot drop. Which nerve has been injured?

Answer 6

Common peroneal nerve

Positioning legs in Lloyd- Davies stirrups can carry the risk of peroneal nerve neuropraxia if not done carefully.

Question 7

31 of 467

Which of the following forms the medial wall of the femoral canal?

Answer 7

Lacunar ligament

The femoral canal and the femoral triangle are distinct anatomical structures. Do not confuse them, especially in the time pressured exam situation.

Question 8

33 of 467

A 67 year old man is undergoing a transurethral resection of a bladder tumour using diathermy. Suddenly during the procedure the patient’s thigh begins to twitch. Stimulation of which of the following nerves is the most likely cause?

Answer 8

Obturator

The obturator nerve is most closely related to the bladder

Question 9

46 of 467

A 34 year old man is shot in the postero- inferior aspect of his thigh. Which of the following lies at the most lateral aspect of the popliteal fossa?

Answer 9

Common peroneal nerve

The contents of the popliteal fossa are (from medial to lateral):
Popliteal artery
Popliteal vein
Tibial nerve
Common peroneal nerve

The sural nerve is a branch of the tibial nerve and usually arises at the inferior aspect of the popliteal fossa. However, its anatomy is variable.

Question 10

50 of 467

What is the origin of the superior gluteal artery?

Answer 10

Internal iliac artery

The inferior gluteal artery arises from the anterior trunk of the internal iliac artery
The superior gluteal artery arises from the posterior trunk of the internal iliac artery

Question 11

52 of 467

Which of the nerves listed below is responsible for the innervation of gluteus maximus?

Answer 11

Inferior gluteal nerve

Question 12

63 of 467

A 76 year old man complains of symptoms of claudication. The decision is made to measure his ankle brachial pressure index. The signal from the dorsalis pedis artery is auscultated with a hand held doppler device. This vessel is the continuation of which of the following?

Answer 12

Anterior tibial artery

The dorsalis pedis is a continuation of the anterior tibial artery.

Question 12

64 of 467

A 67 year old man is due to undergo a revisional total hip replacement using a posterior approach. After dividing gluteus maximus in the line of its fibres there is brisk arterial bleeding. Which of the following vessels is likely to be responsible?

Answer 12

Inferior gluteal artery

The inferior gluteal artery runs on the deep surface of the gluteus maximus muscle. It is a branch of the internal iliac artery. It is commonly divided during the posterior approach to the hip joint.

Question 13

71 of 467

Which of these nerves passes through the greater and lesser sciatic foramina?

Answer 13

Pudendal nerve

Structures passing through the lesser and greater sciatic foramina (medial to lateral): PIN
Pudendal nerve
Internal pudendal artery
Nerve to obturator internus

It passes between the piriformis and coccygeus muscles and exits the pelvis through the the greater sciatic foramen. It crosses the spine of the ischium and reenters the pelvis through the lesser sciatic foramen. It passes through the pudendal canal.

The pudendal nerve gives off the inferior rectal nerves. It terminates into 2 branches: perineal nerve, and the dorsal nerve of the penis or the dorsal nerve of the clitoris.

Question 14

80 of 467

A 65 year old man with long standing atrial fibrillation develops an embolus to the lower leg. The decision is made to perform an embolectomy, utilising a trans popliteal approach. After incising the deep fascia, which of the following structures will the surgeons encounter first on exploring the central region of the popliteal fossa?

Answer 14

Tibial nerve

The tibial nerve lies superior to the vessels in the inferior aspect of the popliteal fossa. In the upper part of the fossa the tibial nerve lies lateral to the vessels, it then passes superficial to them to lie medially. The popliteal artery is the deepest structure in the popliteal fossa.

Question 15

83 of 467

A 43 year old lady presents with varicose veins and undergoes a saphenofemoral disconnection, long saphenous vein stripping to the ankle and isolated hook phlebectomies. Post operatively she notices an area of numbness superior to her ankle. What is the most likely cause for this?

Answer 15

Saphenous nerve injury

The sural nerve is related to the short saphenous vein. The saphenous nerve is related to the long saphenous vein below the knee and for this reason full length stripping of the vein is no longer advocated.

Question 16

90 of 467

A 34 year old man undergoes excision of a sarcoma from the right buttock. During the procedure the sciatic nerve is sacrificed. Which of the following will not occur as a result of this process?

Answer 16

Loss of extension at the knee joint

Extension of the knee joint is caused by the obturator and femoral nerves. Sensation to the posterior aspect of the thigh is via the posterior cutaneous nerve of the thigh and this is a direct branch from the plexus itself.

Question 17

117 of 467

A 24 year old lady is stabbed in the buttock. Following the injury the wound is sutured in the
emergency department. Eight weeks later she attends the clinic, as she walks into the clinic room she has a waddling gait and difficulty with thigh abduction. On examination she has buttock muscle wasting. Which nerve has been injured?

Answer 17

Superior gluteal nerve

Damage to the superior gluteal nerve will result in a Trendelenburg gait.

Question 18

121 of 467

A 72 year old man has a fall. He is found to have a fractured neck of femur and goes on to have a left hip hemiarthroplasty. Two months post operatively he is found to have an odd gait. When standing on his left leg his pelvis dips on the right side. There is no foot drop. What is the cause?

Answer 18

Superior gluteal nerve damage

This patient has a trendelenburg gait caused by damage to the superior gluteal nerve causing weakness of the abductor muscles. Classically a patient is asked to stand on one leg and the pelvis dips on the opposite side. The absence of a foot drop excludes the possibility of polio or L5 radiculopathy.

Question 19

122 of 467

Which of the following structures lies posterior to the femoral nerve in the femoral triangle?

Answer 19

Iliacus

The iliacus lies posterior to the femoral nerve in the femoral triangle. The femoral sheath lies anterior to the iliacus and pectineus muscles.

Question 20

128 of 467

Which of the following ligaments contains the artery supplying the head of femur in children?

Answer 20

Ligamentum teres

Question 21

133 of 467

A 42 year old woman complains of a burning pain of her anterolateral thigh which worsens on walking. There is a positive tinel sign over the inguinal ligament. Which nerve is affected?

Answer 21

Lateral cutaneous nerve of the thigh

The lateral cutaneous nerve supplies sensation to the anterior and lateral aspect of the thigh. Entrapment is commonly due to intra and extra pelvic causes. Treatment involves local anaesthetic injections.

Question 22

147 of 467

Which muscle does not insert on the medial surface of the greater trochanter?

Answer 22

Quadratus femoris

Mnemonic for muscle attachment on greater trochanter is POGO:
Piriformis
Obturator internus
Gemelli
Obturator externus

The quadratus femoris fibres pass laterally to be inserted into the quadrate tubercle on the
intertrochanteric crest of the femur. The other muscles all insert on the trochanteric fossa lying medial to the greater trochanter.

Question 23

145 of 467

A 68 year old man with critical limb ischaemia is undergoing a femoro-distal bypass graft. During mobilisation of the proximal part of the posterior tibial artery which of the following is at greatest risk of injury?

Answer 23

Tibial nerve

The tibial nerve is closely related to the posterior tibial artery. The tibial nerve crosses the vessel posteriorly approximately 2.5cm distal to its origin. At its origin the nerve lies medial and then lateral after it crosses the vessel as described.

Question 24

153 of 467

Which of the following structures lies deepest in the popliteal fossa?

Answer 24

Popliteal artery

From superficial to deep:
The common peroneal nerve exits the popliteal fossa along the medial border of the biceps tendon. Then the tibial nerve lies lateral to the popliteal vessels to pass posteriorly and then medially to them. The popliteal vein lies superficial to the popliteal artery, which is the deepest structure in the fossa.

Question 25

156 of 467

An intravenous drug user develops a false aneurysm and requires emergency surgery. The procedure is difficult and the femoral nerve is inadvertently transected. Which of the following muscles is least likely to be affected as a result?

Answer 25

ٍAdductor magnus

Mnemonic for femoral nerve supply
(don’t) M I S V Q Scan for PE
M edial cutaneous nerve of the thigh
I ntermediate cutaneous nerve of the thigh
S aphenous nerve
V astus
Q uadriceps femoris
S artorius
PE ectineus

Adductor magnus is innervated by the obturator and sciatic nerve. The pectineus muscle is sometimes supplied by the obturator nerve but this is variable. Since the question states least likely, the correct answer is adductor magnus.

Question 26

159 of 467

Which of the following structures does not pass posteriorly to the medial malleolus?

Answer 26

Tibialis anterior tendon

Mnemonic for structures posterior to the medial malleolus:
Tom Dick And Nervous Harry
T ibialis posterior tendon
flexor Digitorum longus
A rtery
N erve
H allucis longus

Question 27

164 of 467

A 44 year old man has a malignant melanoma and is undergoing a block dissection of the groin. The femoral triangle is being explored for intra operative bleeding. Which of the following forms the medial border of the femoral triangle?

Answer 27

Adductor longus

Adductor longus forms the medial boundary of the femoral triangle

Question 28

165 of 467

The foramen marking the termination of the adductor canal is located in which of the following?

Answer 28

Adductor magnus

The foramen marking the distal limit of the adductor canal is contained within adductor magnus. The vessel passes through this region to enter the popliteal fossa.

Question 29

169 of 467

A 24 year old motor cyclist is involved in a road traffic accident. He suffers a tibial fracture which is treated with an intra medullary nail. Post operatively he develops a compartment syndrome. Surgical decompression of the anterior compartment will relieve pressure on all of the following muscles except?

Answer 29

Peroneus brevis (Right)
Cegetla
Peroneus tertius
Extensor digitorum longus
Tibialis anterior
None of the above

The anterior compartment contains:TEPEA
Tibialis anterior
Extensor digitorum longus
Peroneus tertius
Extensor hallucis longus
Anterior tibial artery
All the muscles are innervated by the deep peroneal nerve.

Question 30

178 of 467

A sprinter attends A&E with severe leg pain. He had forgotten to warm up and ran a 100m sprint race. Towards the end of the race he experienced pain in the posterior aspect of his thigh. The pain worsens, localising to the lateral aspect of the knee. The sprinter is unable to flex the knee. What structure has been injured?

Answer 30

Biceps femoris tendon

The biceps femoris is commonly injured in sports that require explosive bending of the knee as seen in sprinting, especially if the athlete has not warmed up first. Avulsion most commonly occurs where the long head attaches to the ischial tuberosity. Injuries to biceps femoris are more common than to the other hamstrings.

Question 31

174 of 467

A 42 year old lady is reviewed in the outpatient clinic following a routine surgical procedure. She complains of diminished sensation at the dorso-lateral aspect of her foot. Which of the following nerves is most likely to be affected?

Answer 31

Sural

The sural nerve supplies the lateral aspect of the foot. It runs alongside the short saphenous vein and may be injured in short saphenous vein surgery.

Question 32

185 of 467

The sciatic nerve lies deep to the following structures except:

Answer 32

Gluteus maximus
The femoral cutaneous nerve
Long head of biceps femoris
Gluteus medius ( Right)
Branch of the inferior gluteal artery

The gluteus medius does not extend around to the sciatic nerve.

Question 33

Question 186 of 467

Which of the following forms the floor of the anatomical snuffbox?

Answer 33

Scaphoid bone

The scaphoid bone forms the floor of the anatomical snuffbox. The cutaneous branch of the radial
nerve is much more superficially and proximally located.

Question 34

188 of 467

A 72 year old lady is suspected of having a femoral hernia. At which of the following sites is it most likely to be identifiable clinically?

Answer 34

Below and lateral to the pubic tubercle

Femoral hernias exit the femoral canal below and lateral to the pubic tubercle. Femoral hernia occur mainly in women due to their difference in pelvic anatomy. They are at high risk of strangulation and therefore should be repaired.

Question 35

197 of 467

Which of the following represents the root values of the sciatic nerve?

Answer 35

L4 to S3

The sciatic nerve most commonly arises from L4 to S3.

Question 36

198 of 467

An 83 year old lady presents with a femoral hernia and undergoes a femoral hernia repair. Which of the following forms the posterior wall of the femoral canal?

Answer 36

Pectineal ligament

Question 37

201 of 467

Which of the following structures does not pass behind the lateral malleolus?

Answer 37

Tibialis anterior tendon

Tibialis anterior tendon passes anterior to the medial malleolus.

Question 38

203 of 467

A 78 year old man presents with symptoms consistent with intermittent claudication. To assess the severity of his disease you decide to measure his ankle brachial pressure index. To do this you will identify the dorsalis pedis artery. Which of the following statements relating to this vessel is false?

Answer 38

It originates from the peroneal artery ( Right)
It is crossed by the tendon of extensor hallucis brevis
Two veins are usually closely related to it
It passes under the inferior extensor retinaculum
The tendon of extensor digitorum longus lies lateral to it

The dorsalis pedis artery is a direct continuation of the anterior tebial artery.

Question 39

208 of 467

A 23 year old man is stabbed in the groin, several structures are injured and the adductor longus muscle has been lacerated. Which of the following nerves is responsible for the innervation of adductor longus?

Answer 39

Obturator nerve

The adductors are innervated by the obturator nerve

Question 40

210 of 467

Which of the following muscles does not recieve any innervation from the sciatic nerve?

Answer 40

Quadriceps femoris

The sciatic nerve is traditionally viewed as being a nerve of the posterior compartment. It is known to contribute to the innervation of adductor magnus (although the main innervation to this muscle is from the obturator nerve). The quadriceps femoris is nearly always innervated by the femoral nerve.

Question 41

211 of 467

Which of the structures listed below overlies the cephalic vein?

Answer 41

Extensor retinaculum
Bicipital aponeurosis
Biceps muscle
Antebrachial fascia
None of the above ( Right)

The cephalic vein is superficially located in the upper limb and overlies most the fascial planes. It pierces the coracoid membrane (continuation of the clavipectoral fascia) to terminate in the axillary vein. It lies anterolaterally to biceps.

Question 42

222 of 467

The following are true of the femoral nerve, except:

Answer 42

It is derived from L2, L3 and L4 nerve roots
It supplies sartorius
It supplies quadriceps femoris
It gives cutaneous innervations via the saphenous nerve
It supplies adductor longus ( Right)

Adductor longus is supplied by the obturator nerve.

Question 42

226 of 467

Which of the following is true in relation to the sartorius muscle?

Answer 42

Forms the Pes anserinus with Gracilis and semitendinous muscle

it is inervated by superfecial branch of the femoral nerve. it is component of the pes ansernius

Question 43

231 of 467

Which muscle is supplied by the superficial peroneal nerve?

Answer 43

Peroneus brevis

Question 44

233 of 467

Which of the following structures separates the posterior cruciate ligament from the popliteal artery?

Answer 44

Oblique popliteal ligament

The posterior cruciate ligament is separated from the popliteal vessels at its origin by the oblique popliteal ligament. The transverse ligament is located anteriorly.

Question 45

234 of 467

How many compartments are there in the lower leg?

Answer 45

4

The posterior compartment of the lower leg has both superficial and deep posterior layers, together with the anterior and lateral compartments this allows for four compartments. Decompression of the deep posterior compartment during fasciotomy may be overlooked with significant sequelae.

Question 46

241 of 467

Which nerve supplies the 1st web space of the foot?

Answer 46

Deep peroneal nerve

The first web space is innervated by the deep peroneal nerve.

Question 47

258 of 467

A 78 year old lady falls over in her nursing home and sustains a displaced intracapsular fracture of the femoral neck. A decision is made to perform a hemi arthroplasty through a lateral approach. Which of these vessels will be divided to facilitate access?

Answer 47

Transverse branch of the lateral circumflex artery

During the Hardinge style lateral approach the transverse branch of the lateral circumflex artery is divided to gain access.

Question 48

266 of 467

A 72 year old lady with osteoporosis falls and sustains an intracapsular femoral neck fracture. The fracture is completely displaced. Which of the following vessels is the main contributor to the arterial supply of the femoral head?

Answer 48

Circumflex femoral arteries

The vessels which form the anastomoses around the femoral head are derived from the medial and lateral circumflex femoral arteries. These are usually derived from the profunda femoris artery.

Question 49

277 of 467

The following statements relating to the ankle joint are true except?

Answer 49

• Three groups of ligaments provide mechanical stability
• The sural nerve lies medial to the Achilles tendon at its point of insertion ( Right)
• Eversion of the foot occurs at the sub talar joint
• The flexor hallucis longus tendon is the most posterior structure at the medial malleolus
• The saphenous nerve crosses the ankle joint.

The sural nerve lies behind the distal fibula. Inversion and eversion are sub talar movements. The structures passing behind the medial malleolus from anterior to posterior include: tibialis posterior, flexor digitorum longus, posterior tibia vein, posterior tibial artery, nerve, flexor hallucis longus.

Question 50

279 of 467

A 19 year old man is playing rugby when he suddenly notices a severe pain at the posterolateral aspect of his right thigh. Which of the following muscle groups is most likely to have been injured?

Answer 50

Long head of biceps femoris

The biceps femoris is the laterally located hamstring muscle. The semitendinosus and semimembranosus are located medially. Rupture of gastrocnemius and soleus may occur but is less common.

Question 51

286 of 467

A 22 year old man is involved in a fight and is stabbed in the posterior aspect of his right leg. The knife passes into the popliteal fossa. He sustains an injury to his tibial nerve. Which muscle is least likely to be compromised as a result?

Answer 51

Peroneus tertius

Peroneus tertius is innervated by the deep peroneal nerve.

Question 52

Question 291 of 467

At which of the following anatomical locations does the common peroneal nerve bifurcate into the superficial and deep peroneal nerves?

Answer 52

At the lateral of the neck of the fibula

The common peroneal nerve bifurcates at the neck of the fibula (where it is most likely to be injured).

Question 53

292 of 467

A 48 year old motor cyclist sustains a complex lower limb fracture in a motor accident. For a time the popliteal artery is occluded and eventually repaired. Subsequently he develops a compartment syndrome and the anterior and superficial posterior compartments of the lower leg are decompressed. Unfortunately, the operating surgeon neglects to decompress the deep posterior compartment. Which of the following muscles is least likely to be affected as a result?

Answer 53

Plantaris

Muscles of the deep posterior compartment:
- Tibialis posterior
- Flexor hallucis longus
- Flexor digitorum longus
- Popliteus

The plantaris muscle lies within the superficial posterior compartment of the lower leg.

Question 54

293 of 467

A 23 year old lady is undergoing a trendelenberg procedure for varicose veins. During the dissection of the saphenofemoral junction, which of the structures listed below is most liable to injury?

Answer 54

Deep external pudendal artery

The deep external pudendal artery runs under the long saphenous vein close to its origin and may be injured. It is at greatest risk of injury during the flush ligation of the saphenofemoral junction. Provided an injury is identified and vessel ligated, injury is seldom associated with any serious adverse sequelae.

Question 55

296 of 467

A 52 year female post hysterectomy attends clinic. She reports pain and reduced sensation over the medial aspect of her thigh. Clinically thigh adduction is weak. What is the most likely nerve injury?

Answer 55

Obturator nerve

The obturator nerve supplies sensation to the medial aspect of the thigh and causes adduction and internal rotation of the thigh.
Injury occurs during pelvic or abdominal surgery.
L3 cord compression is unlikely.

Question 56

302 of 467

Which of the following is a content of the adductor canal?

Answer 56

Saphenous nerve

It contains the saphenous nerve and the superficial branch of the femoral artery.

Question 57

305 of 467
A 56 year old lady with metastatic breast cancer develops an oestolytic deposit in the proximal femur. One morning whilst getting out of bed she notices severe groin pain. X-rays show that the lesser trochanter has been avulsed. Which muscle is the most likely culprit?

Answer 57

Psoas major

The psoas major inserts into the lesser trochanter and contracts when raising the trunk from the
supine position. When oestolytic lesions are present in the femur the lesser trochanter may be
avulsed.

Question 58

Question 309 of 467

Which of the nerves listed below is at greatest risk of injury with a laceration to the upper lateral margin of the popliteal fossa?

Answer 58

Common peroneal nerve

The sural nerve exits at the lower infero-lateral aspect of the fossa and is more at risk in short saphenous vein surgery. The tibial nerve lies more medially and is even less likely to be injured in this location.

Question 59

317 of 467

An elderly man falls and lands on his hip. On examination, his hip is tender to palpation and x-rays are taken. There are concerns that he may have an intertrochanteric fracture. What is the normal angle between the femoral neck and the femoral shaft?

Answer 59

130°

The normal angle in males between the femoral head and shaft is 130°. Changes to this angle may occur as a result of disease or pathology and should be investigated. Females have an angle that is around 110-120°

Question 60

318 of 467

A 22 year old man suffers a compound fracture of the tibia. During attempted surgical repair the deep peroneal nerve is divided. Which of the following muscles will not be affected as a result?

Answer 60

Peroneus longus

Peroneus longus is innervated by superfecial peroneal nerve (L4, L5, S1)

Question 61

319 of 467

An 18 year old athlete attends orthopaedic clinic reporting pain and swelling over the medial aspect of the knee joint. The pain occurs when climbing the stairs, but is not present when walking on flat ground. Clinically there is pain over the medial, proximal tibia and the McMurray test is negative.
What is the most likely cause of this patient’s symptoms?

Answer 61

Pes Anserinus Bursitis

Pes anserinus: GOOSE’S FOOT
Combination of sartorius, gracilis and semitendinous tendons inserting into the anteromedial proximal tibia.

Pes Anserinus Bursitis is common in sportsmen due to overuse injuries. The main sign is of pain in the medial proximal tibia. As the McMurray test is negative, medial meniscal injury is excluded.

Question 62

324 of 467

Which of the following nerves innervates the long head of the biceps femoris muscle?

Answer 62

Tibial division of sciatic nerve

The short head of biceps femoris, which may occasionally be absent, is innervated by the common peroneal component of the sciatic nerve. The long head is innervated by the tibial division of the sciatic nerve.

Question 63

328 of 467

Which of the following bones is related to the cuboid’s distal articular surface?

Answer 63

5th metatarsal

The cuboid is located at the lateral aspect of the foot between the calcaneus posteriorly and the 4th and 5th metatarsals distally.

Question 64

336 of 467

A 25 year old man is stabbed in the groin and the area, which lies within the femoral triangle is explored. Which structure forms the lateral wall of the femoral triangle?

Answer 64

Sartorius

The sartorius forms the lateral wall of the femoral triangle

Question 65

Question 339 of 467

A 25 year old man undergoes an excision of a pelvic chondrosarcoma, during the operation the obturator nerve is sacrificed. Which of the following muscles is least likely to be affected as a result?

Answer 65

Sartorius

Sartorius is supplied by the femoral nerve. In approximately 20% of the population, pectineus is supplied by the accessory obturator nerve. Adductor magnus has a composite supply from the obturator and sciatic nerves.

Question 66

Question 348 of 467

A 72 year old man with non reconstructible arterial disease is undergoing an above knee amputation. The posterior compartment muscles are divided. Which of the following muscles does not lie in the posterior compartment of the thigh?

Answer 66

Quadriceps femoris

The quadriceps femoris lies in the anterior compartment.

Question 66

346 of 467

A 40 year old lady presents with varicose veins, these are found to originate from the short saphenous vein. As the vein is mobilised which structure is at greatest risk of injury?

Answer 66

Sural nerve

The sural nerve is closely related and damage to this structure is a major cause of litigation. The
other structures may all be injured but the risks are lower.

Question 66

350 of 467

Which of the following structures is not closely related to the posterior tibial artery?

Answer 66

Deep peroneal nerve laterally

The deep peroneal nerve lies in the anterior compartment. The tibial nerve lies medially. At its termination it lies deep to the flexor retinaculum. The tibial nerve lies medial to the popliteal vessels but lateral to the posterior tibial artery.

Question 67

358 of 467

A 30 year old man presents with back pain and the surgeon tests the ankle reflex. Which of the following nerve roots are tested in this manoeuvre?

Answer 67

S1 and S2

Question 68

Question 359 of 467

Which of the following structures is not closely related to the piriformis muscle?

Answer 68

Medial femoral circumflex artery

Nerve supply of lateral hip rotators

Piriformis: ventral rami S1, S2
Obturator internus: nerve to obturator internus
Superior gemellus: nerve to obturator internus
Inferior gemellus: nerve to quadratus femoris
Quadrator femoris: nerve to quadrator femoris

The piriformis muscle is an important anatomical landmark in the gluteal region. The following
structures are closely related:
- Sciatic nerve
- Inferior gluteal artery and nerve
- Superior gluteal artery and nerve

The medial femoral circumflex artery runs deep to quadratus femoris.

Question 69

362 of 467

A 77 year old man with symptoms of intermittent claudication is due to have his ankle brachial pressure indices measured. The dorsalis pedis artery is impalpable. Which of the following tendinous structures lies medial to it, that may facilitate its identification?

Answer 69

Extensor hallucis longus tendon

The extensor hallucis longus tendon lies medial to the dorsalis pedis artery.

Question 69

371 of 467

A 22 year man is shot in the groin. On examination, he has weak hip flexion, weak knee extension, and impaired quadriceps tendon reflex, as well as sensory deficit in the anteromedial aspect of the thigh. Which structure has been affected?

Answer 69

Femoral nerve

This is a classical description of a femoral nerve injury.

Question 70

374 of 467

A 52 year old female renal patient needs a femoral catheter to allow for haemodialysis. Which of the structures listed below is least likely to be encountered during its insertion?

Answer 70

Deep circumflex iliac artery

Femoral access catheters are typically inserted in the region of the femoral triangle. Therefore the physician may encounter the femoral, vein, nerve, branches of the femoral artery and tributaries of the femoral vein. The deep circumflex iliac artery arises above the inguinal ligament and is therefore less likely to be encountered than the superficial circumflex iliac artery which arises below the inguinal ligament.

Question 70

Question 373 of 467

The integrity of which muscle is assessed by the Trendelenburg test?

Answer 70

Gluteus medius

Question 70

376 of 467

The common peroneal nerve, or its branches, supply the following muscles except:

Answer 70

Peroneus longus
Tibialis anterior
Extensor hallucis longus
Flexor digitorum brevis (right)
Extensor digitorum longus

Flexor digitorum is supplied by the tibial nerve.

Question 71

380 of 467

Which of the following statements relating to the knee joint is false?

Answer 71

The posterior aspect of the patella is extrasynovial

The posterior aspect is intrasynovial and the knee itself comprises the largest synovial joint in the body. It may swell considerably following trauma such as ACL injury. Which may be extremely painful owing to rich innervation from femoral, sciatic and ( a smaller) contribution from the obturator nerve. During full extension all ligaments are taut and the knee is locked.

Question 71

Question 382 of 467

Which of the following does not exit the pelvis through the greater sciatic foramen?

Answer 71

Obturator nerve

The obturator nerve exits through the obturator foramen.

Question 72

Question 388 of 467

A 78 year old man is undergoing a femoro-popliteal bypass graft. The operation is not progressing well and the surgeon is complaining of poor access. Retraction of which of the following structures will improve access to the femoral artery in the groin?

Answer 72

Sartorius

At the lower border of the femoral triangle the femoral artery passes under the sartorius muscle. This can be retracted to improve access.

Question 73

390 of 467

A 66 year old man with peripheral vascular disease is undergoing a below knee amputation. In which of the lower leg compartments does peroneus brevis lie?

Answer 73

Lateral compartment

The interosseous membrane separates the anterior and posterior compartments. The deep and superficial compartments are separated by the deep transverse fascia. The peroneus brevis is part of the lateral compartment.

Question 74

391 of 467

A 70 year old man is due to undergo an arterial bypass procedure for claudication and foot
ulceration. The anterior tibial artery will form the site of the distal arterial anastomosis. Which of the following structures is not closely related to it distally?

Answer 74

Tibialis posterior

As an artery of the anterior compartment, the anterior tibial artery is closely related to tibialis anterior.
The tibialis posterior is related to it at its origin.

Question 75

392 of 467

Which of the muscles below does not cause lateral rotation of the hip?

Answer 75

Pectineus

Mnemonic lateral hip rotators: P-GO-GO-Q (top to bottom)
Piriformis
Gemellus superior
Obturator internus
Gemellus inferior
Obturator externus
Quadratus femoris

Pectineus adducts and medially rotates the femur.

Question 76

398 of 467

A 40-year-old man presents with pain in his lower back and ‘sciatica’ for the past three days. He describes bending down to pick up a washing machine when he felt ‘something go’. He now has severe pain radiating from his back down the right leg. On examination he describes paraesthesia over the anterior aspect of the right knee and the medial aspect of his calf. Power is intact and the right knee reflex is diminished. The femoral stretch test is positive on the right side. Which nerve or nerve root is most likely to be affected?

Answer 76

L3

Question 76

405 of 467

Which of the following structures are not closely related to the adductor longus muscle?

Answer 76

Tendon of iliacus

Femoral triangle:
Adductor longus medially
Inguinal ligament superiorly
Sartorius muscle laterally

Adductor longus forms the medial border of the femoral triangle. It is closely related to the long saphenous vein which overlies it and the profunda branch of the femoral artery. The femoral nerve is related to it inferiorly. However, the tendon of iliacus inserts proximally and is not in contact with adductor longus.

Question 76

400 of 467

Which of the following statements relating to sartorius is untrue?

Answer 76

It inserts into the medial femoral condyle

It inserts into the medial aspect of the upper part of the tibia.

Question 77

408 of 467

A 73 year old lady presents with a femoral hernia. Which of the following structures forms the lateral wall of the femoral canal?

Answer 77

Femoral vein

The canal exists to allow for the physiological expansion of the femoral vein, which lies lateral to it.

Question 78

409 of 467

Which of the nerves listed below is responsible for the innervation of gluteus medius?

Answer 78

Superior gluteal nerve

Question 79

410 of 467

Which of the following muscles is not within the posterior compartment of the lower leg?

Answer 79

Peroneus brevis

Peroneus brevis lies in the lateral compartment

Question 80

415 of 467

A 20 year old man undergoes an open appendicectomy performed via a lanz incision. This surgeon places the incision on a level of the anterior superior iliac spine in an attempt to improve cosmesis. During the procedure the appendix is found to be retrocaecal and the incision is extended laterally. Which of the following nerves is at greatest risk of injury?

Answer 80

Ilioinguinal

Question 81

416 of 467

The femoral nerve is transected by a rather careless surgeon during a botched femoro-popliteal bypass operation. Which of the following actions will be impaired?

Answer 81

Extension of the knee joint

The femoral nerve supplies the quadriceps muscle which is responsible for extension at the knee
joint.

Question 82

420 of 467

A 23 year old man presents with delayed diagnosis of appendicitis. The appendix is retrocaecal and has perforated causing a psoas abscess. Into which structure does the psoas major muscle insert?

Answer 82

Lesser trochanter of the femur

Question 82

438 of 467

During an operation for varicose veins the surgeons are mobilising the long saphenous vein. Near its point of entry to the femoral vein an artery is injured and bleeding is encountered. From where is the bleeding most likely to originate?

Answer 82

Deep external pudendal artery

The deep external pudendal artery is a branch of the SFA and it runs medially under the long saphenous vein near its point of union with the femoral vein. The superficial external pudendal artery lies superior to the SFJ. Neither vessel is functionally important and if injured they are best ligated.

Question 82

441 of 467

Which of the following is not contained within the deep posterior compartment of the lower leg?

Answer 82

Sural nerve

The deep posterior compartment lies anterior to soleus. The sural nerve is superficially sited and therefore not contained within it.

Question 83

444 of 467

Which of the following structures are at risk of direct injury following a fracture dislocation of the femoral condyles?

Answer 83

Popliteal artery

The heads of gastrocnemius will contract to pull the fracture segment posteriorly. The popliteal artery lies against the bone and may be damaged or compressed.

Question 84

464 of 467

Which of the following structures does not pass anterior to the lateral malleolus?

Answer 84

Peroneus brevis

Peroneus brevis passes posterior to the lateral malleolus. Peroneus tertius is closely related to extensor digitorum and like that muscle, its tendon passes anterior to the lateral malleolus

Question 84

448 of 467

At what level does the sciatic nerve usually bifurcate into the tibial and common peroneal nerves?

Answer 84

At the superior aspect of the popliteal fossa

The sciatic nerve passes vertically downwards over the posterior surface of the obturator internusand quadratus femoris to the hamstring compartment of the thigh, here it is crossed posteriorly by the long head of biceps femoris. In the buttock it lies under the cover of gluteus maximus. It separates into its tibial and common peroneal components at the upper aspect of the popliteal fossa.