9- Mixed Anatomy (1)MSQs Only

Question 1

1 of 610
What is the most useful test to clinically distinguish between an upper and lower motor neurone lesion of the facial nerve?

Answer 1

Raise eyebrow

Upper motor neurone lesions of the facial nerve- Paralysis of the lower half of face.
Lower motor neurone lesion- Paralysis of the entire ipsilateral face.

Question 2

2 of 610
Which of the following structures separates the posterior cruciate ligament from the popliteal artery?

.

Answer 2

Oblique popliteal ligament

The posterior cruciate ligament is separated from the popliteal vessels at its origin by the oblique popliteal ligament.It is attached above to the upper margin of the intercondyloid fossa and posterior surface of the femur close to the articular margins of the condyles, and below to the posterior margin of the head of the tibia. The transverse ligament is located anteriorly

Question 3

3 of 610
Which muscle is supplied by the superficial peroneal nerve?

Answer 3

Peroneus brevis

Question 4

6 of 610
Which of the structures listed below lies posterior to the carotid sheath at the level of the 6th cervical vertebra?

Answer 4

Cervical sympathetic chain

The carotid sheath is crossed anteriorly by the hypoglossal nerves and the ansa cervicalis. The vagus lies within it. The cervical sympathetic chain lies posteriorly between the sheath and the prevertebral fascia.

Question 4

4 of 610
A 25 year old man sustains a severe middle cranial fossa basal skull fracture. Once he has recovered it is noticed that he has impaired tear secretion. This is most likely to be the result of damage to which of the following?

Answer 4

Greater petrosal nerve

The greater petrosal nerve may be injured and carries fibres for lacrimation

Question 5

5 of 610
Which of the following is true in relation to the sartorius muscle?

Answer 5

Forms the Pes anserinus with Gracilis and semitendinous muscle

It is innervated by the superficial branch of the femoral nerve. It is a component of the pes anserinus.

Question 6

10 of 610

Which of the structures listed below overlies the cephalic vein?

Answer 6

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 6

7 of 610
Which of the following are not generally supplied by the right coronary artery?

Answer 6

The sino atrial node

The circumflex artery( Right)

The atrioventricular node

Most of the right ventricle

The right atrium
………………………………….
The circumflex artery is generally a branch of the left coronary artery.

Question 6

9 of 610
Which of the following statements relating to the right phrenic nerve is false?

Answer 6

It lies deep to the prevertebral layer of deep cervical fascia

Crosses posterior to the 2nd part of the subclavian artery( Right)

It runs on the anterior surface of the anterior scalene muscle

On the right side it leaves the mediastinum via the vena cava hiatus at a level of T8

The right phrenic nerve passes over the right atrium

Question 7

8 of 610
Which of the following statements relating to the root of the neck is false?

Answer 7

The lung projects into the neck beyond the first rib and is constrained by Sibson’s fascia

The subclavian artery arches over the first rib anterior to scalenus anterior(Right)

The trunks of the brachial plexus lie posterior to the subclavian artery on the first rib

The roots and trunks of the Brachial plexus lie between scalenus anterior and scalenus medius muscles

The thyrocervical trunk is a branch of the subclavian artery
……………………………………………
The subclavian artery lies posterior to scalenus anterior, the vein lies in front. Sibson’s fascia is another name for the suprapleural membrane.

Question 8

11 of 610
A young child undergoes a difficult craniotomy for fulminant mastoiditis and associated abscess. During the procedure the trigeminal nerve is severely damaged within Meckels cave. Which deficit is least likely to be present?

Answer 8

Anaesthesia over the ipsilateral anterior aspect of the scalp

Loss of the corneal reflex

Weakness of the ipsilateral masseter muscle

Anaesthesia of the anterior aspect of the lip

Anaesthesia over the entire ipsilateral side of the face(Right)
………………………………………….
The angle of the jaw is not innervated by sensory fibres of the trigeminal nerve and is spared in this type of injury.
Remember the trigeminal nerve provides motor innervation to the muscles of mastication. The close proximity of the site of injury to the motor fibres is likely to result in at least some compromise of motor muscle function.

Question 9

12 of 610

A 53 year old man with a carcinoma of the lower third of the oesophagus is undergoing an oesophagogastrectomy. As the surgeons mobilise the mid part of the oesophagus, where are they most likely to encounter the thoracic duct?

Answer 9

Posterior to the oesophagus

The thoracic duct lies posterior to the oesophagus and passes to the left at the level of the Angle of Louis. It exits the thorax at T12 together with the aorta.

Question 10

13 of 610

A 44 year old lady is recovering following a transphenoidal hypophysectomy. Unfortunately there is a post operative haemorrhage. Which of the following features is most likely to occur initially?

Answer 10

Bi-temporal hemianopia

The pituitary is covered by a sheath of dura and an expanding haematoma at this site may compress the optic chiasm in the same manner as an expanding pituitary tumour.

Question 11

14 of 610
Which nerve directly innervates the sinoatrial node?

Answer 11

Superior cardiac nerve

Right vagus nerve

Left vagus nerve

Inferior cardiac nerve

None of the above( Right)
………………………………………..
No single one of the above nerves is responsible for direct cardiac innervation (which those who have handled the heart surgically will appreciate).
The heart receives its nerves from the superficial and deep cardiac plexuses. The cardiac plexuses send small branches to the heart along the major vessels, continuing with the right and left coronary arteries. The vagal efferent fibres emerge from the brainstem in the roots of the vagus and accessory nerves, and run to ganglia in the cardiac plexuses and within the heart itself.

The background vagal discharge serves to limit heart rate, and loss of this background vagal tone accounts for the higher resting heart rate seen following cardiac transplant.

Question 11

15 of 610
Which of the following is not contained within the middle mediastinum?

Answer 11

Main bronchi

Arch of the azygos vein

Thoracic duct(Right)

Pericardium

Aortic root

Question 11

16 of 610
An injury to the spinal accessory nerve will have the greatest effect on which of the following movements?

Answer 11

Upward rotation of the scapula

The spinal accessory nerve innervates trapezius. The entire muscle will retract the scapula. However, its upper and lower fibres act together to upwardly rotate it.

Question 12

8 of 610

Which of the following statements relating to the root of the neck is false?

Answer 12

The lung projects into the neck beyond the first rib and is constrained by Sibson’s fascia

The subclavian artery arches over the first rib anterior to scalenus anterior( Right)

The trunks of the brachial plexus lie posterior to the subclavian artery on the first rib

The roots and trunks of the Brachial plexus lie between scalenus anterior and scalenus medius muscles

The thyrocervical trunk is a branch of the subclavian artery
………………………………………….
The subclavian artery lies posterior to scalenus anterior, the vein lies in front. Sibson’s fascia is another name for the suprapleural membrane.

Question 13

18 of 610

Which cranial nerve provides general sensation to the anterior two thirds of the tongue?

Answer 13

Trigeminal

Taste to the anterior two thirds of the tongue is supplied by the facial nerve, the trigeminal supplies general sensation, this is mediated by the mandibular branch of the trigeminal nerve (via the lingual nerve)

Question 14

17 of 610

Which of the following is not closely related to the capitate bone?

Answer 14

Lunate bone

Scaphoid bone

Ulnar nerve( Right)

Hamate bone

Trapezoid bone
……………………………………………
The ulnar nerve and artery lie adjacent to the pisiform bone. The capitate bone articulates with the lunate, scaphoid, hamate and trapezoid bones, which are therefore closely related to it.

Question 15

20 of 610

A 49 year old man undergoes a low anterior resection for cancer. He is assessed in the outpatient clinic post operatively. His wounds are well healed. However, he complains of impotence. Which of the following best explains this problem?

Answer 15

Damage to the nervi erigentes

The penis takes autonomic nerves from the nervi erigentes that lie near the seminal vesicles. These may be compromised by direct surgical trauma (such as use of diathermy in this area) and also by radiotherapy that is used in these patients pre operatively. The result is that up to 50% of patients may develop impotence following rectal cancer surgery.

Question 16

19 of 610

A 23 year old man is admitted with a suspected ureteric colic. A KUB style x-ray is obtained. In which of the following locations is the stone most likely to be visualised?

Answer 16

The tips of the transverse processes between L2 and L5

The ureter lies anterior to L2 to L5 and stones may be visualised at these points, they may also be identified over the sacro-iliac joints

Question 17

22 of 610

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 17

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 18

23 of 610

A 17 year old male has a suspected testicular torsion and the scrotum is to be explored surgically. The surgeon incises the skin and then the dartos muscle. What is the next tissue layer that will be encountered during the dissection?

Answer 18

External spermatic fascia

The layers that will be encountered are
1. Skin
2. Dartos fascia and muscle
3. External spermatic fascia
4. Cremasteric muscle and fascia
5. Internal spermatic fascia
6. Parietal layer of the tunica vaginalis

The layers of the spermatic cord and scrotum are a popular topic in the MRCS exam.
A mnemonic which may help:
Some Damned Examiner Called It The Testes (skin dartos external fascia cremaster internal fascia tunica Testes)

Question 19

21 of 610

Into which of the following structures does the superior part of the fibrous capsule of the shoulder joint insert?

Answer 19

The anatomical neck of the humerus

The shoulder joint is a shallow joint, hence its great mobility. However, this comes at the expense of stability. The fibrous capsule attaches to the anatomical neck superiorly and the surgical neck inferiorly

Question 20

25 of 610

A 28 year old man is shot in the right chest and develops a right haemothorax necessitating a thoracotomy. The surgeons decide to place a vascular clamp across the hilum of the right lung. Which of the following structures will lie most anteriorly at this point?

Answer 20

Phrenic nerve

The phrenic nerve lies anteriorly at the root of the right lung.

Question 21

26 of 610

What is the most inferior anterior aortic branch?

Answer 21

Inferior mesenteric artery

The IMA leaves the front of the aorta usually about 3 to 4cm superior to its bifurcation. The median sacral is not an anterior branch.

Question 21

28 of 610
Which of these muscles is supplied by the musculocutaneous nerve?

Answer 21

Brachialis

Mnemonic
Muscles innervated by the musculocutaneous nerve BBC:
Biceps brachii
Brachialis
Coracobrachialis

Question 21

27 of 610

Which cranial nerve supplies the motor fibres of styloglossus?

Answer 21

Hypoglossal

The hypoglossal nerve supplies motor innervation to all extrinsic and intrinsic muscles of the tongue. The only possible exception to this is palatoglossus, which is innervated by the vagus.

Question 22

30 of 610

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 22

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 23

29 of 610

A 36 year old male is admitted for elective surgery for a lymph node biopsy in the supraclavicular region. Post operatively the patient has difficulty shrugging his left shoulder. What is the most likely reason?

Answer 23

Accessory nerve lesion

The accessory nerve lies in the posterior triangle and may be injured in this region. Apart from problems with shrugging the shoulder, he may also have difficulty lifting his arm above his head.

Question 24

31 of 610

A 56 year old lady undergoes a Hartmann’s style resection of the sigmoid colon, with ligation of the vessels close to the colon. Which of the following vessels will be responsible to supplying the rectal stump directly?

Answer 24

Superior rectal artery

This question is addressing the blood supply to the rectum. Which is supplied by the superior rectal artery. High ligation of the IMA may compromise this structure. However, the question states that during the Hartmans procedure the vessels were ligated close to the bowel. Implying that the superior rectal was preserved.

Question 25

32 of 610

A 42 year old lady undergoes a difficult cholecystectomy and significant bleeding is occurring. The surgeons place a vascular clamp transversely across the anterior border of the epiploic foramen. Which of the following structures will be occluded in this manoeuvre?

Answer 25

Portal vein

The portal vein, hepatic artery and CBD are occluded

Question 26

24 of 610

Which of the muscles listed below would be affected if the radial nerve were injured in a humeral shaft fracture?

Answer 26

Supinator

Question 26

33 of 610

Which of the following nerves is responsible for the motor innervation of the sternocleidomastoid muscle?

Answer 26

Accessory nerve

The motor supply to the sternocleidomastoid is from the accessory nerve. The ansa cervicalis supplies sensory information from the muscle.

Question 26

35 of 610

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

Answer 26

Saphenous nerve

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

Question 27

36 of 610

An ENT surgeon is performing a radical neck dissection. She wishes to fully expose the external carotid artery. To do so she inserts a self retaining retractor close to its origin. Which of the following structures lies posterolaterally to the external carotid at this point?

Answer 27

Internal carotid artery

The internal carotid artery lies posterolaterally to the external carotid artery at it’s origin from the common carotid. The superior thyroid, lingual and facial arteries all arise from its anterior surface.

Question 28

38 of 610

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 28

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 28

37 of 610

Considering the pituitary gland, which of the following is false?

Answer 28

The anterior pituitary secretes thyroid stimulating hormone

The anterior pituitary develops from Rathkes pouch

Patients with craniopharyngioma may develop bi temporal hemianopia

The pituitary is in direct contact with the optic chiasm(Right)

The posterior pituitary secretes oxytocin via a positive feedback loop
………………………………………….
Although the optic chiasm is closely related to the pituitary, and craniopharyngiomas may compress this structure leading to bitemporal hemianopia, it is separated from the chiasm itself by a dural fold.

Question 28

39 of 610

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 28

Flexor digitorum longus

Plantaris(Right)

Tibialis posterior

Flexor hallucis longus

None of the above
……………………………………
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 29

40 of 610
Which of the following overlies the outer muscular layer of the intrathoracic oesophagus?

Answer 29

Loose connective tissue

The oesophagus has no serosal covering and hence holds sutures poorly. The Auerbach’s and Meissner’s nerve plexuses lie in between the longitudinal and circular muscle layers and submucosally. The sub mucosal location of the Meissner’s nerve plexus facilitates its sensory role.

Question 30

41 of 610

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 30

Tibialis posterior

Flexor hallucis longus

Flexor digitorum brevis

Soleus

Peroneus tertius(right)
……………………………………..
Peroneus tertius is innervated by the deep peroneal nerve.

Question 31

42 of 610

A 23 year old man is due to undergo a mitral valve repair for mitral regurgitation. Which of the following is a feature of the mitral valve?

Answer 31

Its closure is marked by the first heart sound

The mitral valve is best auscultated over the cardiac apex, where its closure marks the first heart sound. It has only two cusps. These are attached to chordae tendinae which themselves are linked to the wall of the ventricle by the papillary muscles.

Question 32

49 of 610
During a carotid endarterectomy the internal carotid artery is cross clamped. Assuming that no shunt is inserted, which of the following vessels will not have diminished or absent flow as a result?

Answer 32

Anterior cerebral artery

Ophthalmic artery

Middle cerebral artery

Maxillary artery(Right)

None of the above
…………………………………………
Mnemonic for branches of the cerebral portion of the internal carotid artery
‘Only Press Carotid Arteries Momentarily’

Only = Opthalmic
Press = Posterior communicating
Carotid = Choroidal
Arteries = Anterior cerebral
Momentarily = Middle cerebral

The maxillary artery is a branch of the external carotid artery.

Question 33

44 of 610

Which of the following structures is not directly related to the right adrenal gland?

Answer 33

Diaphragm posteriorly

Kidney inferiorly

Right renal vein(right)

Inferior vena cava

Hepato-renal pouch
…………………………………………….
The right renal vein is very short and lies more inferioly

Question 34

45 of 610

An 18 year old man is stabbed in the neck and has to undergo repair of a laceration to the internal carotid artery. Post operatively he is noted to have a Horners syndrome. Which of the following will not be present?

Answer 34

Apparent enopthalmos

Loss of sweating on the entire ipsilateral side of the face(right)

Constricted pupil

Mild ptosis

Normal sympathetic activity in the torso
………………………………..
The anhidrosis will be mild as this is a distal lesion and at worst,only a very limited area of the ipsilateral face will be anhidrotic.

Question 35

47 of 610

A 22 year old man undergoes a superficial parotidectomy for a pleomorphic adenoma. The operation does not proceed well and a diathermy malfunction results in division of the buccal branch of the facial nerve. Which of the following muscles will not demonstrate impaired function as a result?

Answer 35

Mentalis

Question 35

46 of 610

At which of the following vertebral body levels does the common carotid artery typically bifurcate into the external and internal carotid arteries?

Answer 35

C4

It terminates at the upper border of the thyroid cartilage, Which is usually located at C4.

Question 36

50 of 610

Which of the following is not a branch of the subclavian artery?

Answer 36

Superior thyroid artery( Right)

Vertebral artery

Thyrocervical trunk

Internal thoracic artery

Dorsal scapular artery
……………………………….
Mnemonic for the branches of the subclavian artery: VIT C & D

V ertebral artery
I nternal thoracic
T hyrocervical trunk

C ostalcervical trunk
D orsal scapular

Superior thyroid artery is a branch of the external carotid artery.

Question 37

48 of 610

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 37

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 38

51 of 610

A 38 year old man presents to the clinic with shoulder weakness. On examination he has an inability to initiate shoulder abduction. Which of the nerves listed below is least likely to be functioning normally?

Answer 38

Suprascapular nerve(right)

Medial pectoral nerve

Axillary nerve

Median nerve

Radial nerve

Question 38

43 of 610

The oesophagus is constricted at the following levels apart from:

Answer 38

Cricoid cartilage

Arch of the aorta

Lower oesophageal sphincter(Right)

Left main stem bronchus

Diaphragmatic hiatus
…………………………………………………….
Constrictions of the oesophagus : ABCD
A- Arch of the Aorta
B- Left main Bronchus
C- Cricoid Cartilage
D- Diaphragmatic Hiatus

The oesophagus is not constricted at the level of the lower oesophageal sphincter.

Question 38

52 of 610

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

Answer 38

Ulnar nerve

Median nerve

Cephalic vein(Right)

Long head of triceps

Median cubital vein
……………………………………
The cephalic vein lies superficially and on the contralateral side of the arm to the brachial artery. The relation of the ulnar nerves and others are demonstrated in the image below:

Question 39

53 of 610

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 39

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. The vessels and its branches are illustrated below:

Question 40

56 of 610
A 22 year old man presents with appendicitis. At operation the appendix is retrocaecal and difficult to access. Division of which of the following anatomical structures should be undertaken?

Answer 40

Lateral peritoneal attachments of the caecum

The commonest appendiceal location is retrocaecal. Those struggling to find it at operation should trace the tenia to the caecal pole where the appendix is located. If it cannot be mobilised easily then division of the lateral caecal peritoneal attachments (as for a right hemicolectomy) will allow caecal mobilisation and facilitate the procedure.

Question 41

58 of 610

A 28 year old man lacerates the posterolateral aspect of his wrist with a knife in an attempted suicide. On arrival in the emergency department the wound is inspected and found to be located over the lateral aspect of the extensor retinaculum (which is intact). Which of the following structures is at greatest risk of injury?

Answer 41

Superficial branch of the radial nerve

The superficial branch of the radial nerve passes superior to the extensor retinaculum in the position of this laceration and is at greatest risk of injury. The dorsal branch of the ulnar nerve and artery also pass superior to the extensor retinaculum but are located medially.

Question 42

55 of 610

A 73 year old man is due to undergo a radical prostatectomy for carcinoma of the prostate gland. To which of the following lymph nodes will the tumour drain primarily?

Answer 42

Internal iliac

The prostate lymphatic drainage is primarily to the internal iliac nodes and also the sacral nodes. Although internal iliac is the first sit

Question 43

57 of 610

A 43 year old man is reviewed in the clinic following a cardiac operation. A chest x-ray is performed and a circular radio-opaque structure is noted medial aspect of the 4th intercostal space on the left. Which of the following procedures is the patient most likely to have undergone?

Answer 43

Mitral valve replacement with metallic valve

Question 44

59 of 610

Through which of the following foramina does the genital branch of the genitofemoral nerve exit the abdominal cavity?

Answer 44

Deep inguinal ring

The genitofemoral nerve divides into two branches as it approaches the inguinal ligament. The genital branch passes anterior to the external iliac artery through the deep inguinal ring into the inguinal canal. It communicates with the ilioinguinal nerve in the inguinal canal (though this is seldom of clinical significance).

Question 45

60 of 610

A man with lung cancer and bone metastasis in the thoracic spinal vertebral bodies, sustains a pathological fracture at the level of T4. The fracture is unstable and the spinal cord is severely compressed at this level. Which of the findings below will not be present 6 weeks after injury?

Answer 45

Extensor plantar reflexes

Spasticity of the lower limbs

Diminished patellar tendon reflex( Right)

Urinary incontinence

Sensory ataxia
……………………………………………..
A thoracic cord lesion causes spastic paraperesis, hyperrflexia and extensor plantar responses (UMN lesion), incontinence, sensory loss below the lesion and ‘sensory’ ataxia.These features typically manifest several weeks later, once spinal shock (in which areflexia predominates) has resolved.

Question 46

62 of 610

Which of the following does not pass through the superior orbital fissure?

Answer 46

Oculomotor nerve

Abducens nerve

Ophthalmic artery ( Right)

Ophthalmic division of the trigeminal nerve

Ophthalmic veins
…………………………………………
The ophthalmic artery, a branch of the internal carotid enters the orbit with the optic nerve in the canal.

Question 46

61 of 610

During the course of a radical gastrectomy the surgeons detach the omentum and ligate the right gastro-epiploic artery. From which vessel does it originate?

Answer 46

Gastroduodenal artery

The gastroduodenal artery arises at the superior part of the duodenum and descends behind it to terminate at its lower border. It terminates by dividing into the right gastro-epiploic artery and the superior pancreaticoduodenal artery. The right gastro-opiploic artery passes to the left and passes between the layers of the greater omentum to anastomose with the left gastro-epiploic artery.

Question 46

65 of 610

A 32 year old motorcyclist is involved in a road traffic accident. His humerus is fractured and severely displaced. At the time of surgical repair the surgeon notes that the radial nerve has been injured. Which of the following muscles is least likely to be affected by an injury at this site?

Answer 46

Extensor carpi radialis brevis

Brachioradialis

Abductor pollicis longus

Extensor pollicis brevis

None of the above (Right)
……………………………………………………
Muscles supplied by the radial nerve

BEST
Brachioradialis
Extensors
Supinator
Triceps

The radial nerve supplies the extensor muscles, abductor pollicis longus and extensor pollicis brevis (the latter two being innervated by the posterior interosseous branch of the radial nerve).

Question 46

64 of 610

Which structure is least likely to be found at the level of the sternal angle?

Answer 46

Left brachiocephalic vein

The left brachiocephalic vein lies posterior to the manubrium, at the level of its upper border. The sternal angle refers to the transition between manubrium and sternum and therefore will not include the left brachiocephalic

Question 47

63 of 610

A 43 year old man suffers a pelvic fracture which is complicated by an injury to the junction of the membranous urethra to the bulbar urethra. In which of the following directions is the extravasated urine most likely to pass?

Answer 47

Anteriorly into the connective tissues surrounding the scrotum

The superficial perineal pouch is a compartment bounded superficially by the superficial perineal fascia, deep by the perineal membrane (inferior fascia of the urogenital diaphragm), and laterally by the ischiopubic ramus. It contains the crura of the penis or clitoris, muscles, viscera, blood vessels, nerves, the proximal part of the spongy urethra in males, and the greater vestibular glands in females. When urethral rupture occurs as in this case the urine will tend to pass anteriorly because the fascial condensations will prevent lateral and posterior passage of the urine.

Question 48

66 of 610

Which of the following pairings of foramina and their contents is not correct?

Answer 48

Superior orbital fissure and the oculomotor nerve

Foramina rotundum and the maxillary nerve

Jugular foramen and the hypoglossal nerve(Right)

Foramina spinosum and the middle meningeal artery

Carotid canal and the internal carotid artery
……………………………………………………..
The hypoglossal nerve passes through the hypoglossal canal.

Question 49

67 of 610

Which of the following structures passes through the quadrangular space near the humeral head?

Answer 49

Axillary nerve

The quadrangular space is bordered by the humerus laterally, subscapularis and teres minor superiorly, teres major inferiorly and the long head of triceps medially. It lies lateral to the triangular space. It transmits the axillary nerve and posterior circumflex humeral artery.

Question 49

68 of 610

What is the lymphatic drainage of the female urethra?

Answer 49

Internal iliac nodes

The entire female urethra drains to the internal iliac nodes.

Question 50

69 of 610

A man has an incision sited that runs 8cm from the deltopectoral groove to the midline of the chest. Which of the following is not at risk of injury?

Answer 50

Shoulder joint capsule

This region will typically lie medial to the joint capsule. The diagram below illustrates the plane that this would transect and as it can be appreciated the other structures are all at risk of injury.

Question 51

70 of 610

A 66 year old man is undergoing a left nephro-ureterectomy. The surgeons remove the ureter, which of the following is responsible for the blood supply to the proximal ureter?

Answer 51

Branches of the renal artery

The proximal ureter is supplied by branches from the renal artery. For the other feeding vessels - see below.

Question 52

73 of 610

Which of the following upper limb muscles is not innervated by the radial nerve?

Answer 52

Extensor carpi ulnaris

Abductor digiti minimi(right)

Anconeus

Supinator

Brachioradialis
…………………………………………….
Mnemonic for radial nerve muscles: BEST

B rachioradialis
E xtensors
S upinator
T riceps

Abductor digiti minimi is innervated by the ulnar nerve.

Question 52

71 of 610

A 45 year man presents with hand weakness. He is given a piece of paper to hold between his thumb and index finger. When the paper is pulled, the patient has difficulty maintaining a grip. Grip pressure is maintained by flexing the thumb at the interphalangeal joint. What is the most likely nerve lesion?

Answer 52

Deep branch of ulnar nerve

This is a description of Froment’s sign, which tests for ulnar nerve palsy. It mainly tests for the function of adductor pollicis. This is supplied by the deep branch of the ulnar nerve. Remember the anterior interosseous branch (of the median nerve), which innervates the flexor pollicis longus (hence causing flexion of the thumb IP joint), branches off more proximally to the wrist.

Question 53

72 of 610

An 18 year old lady with troublesome hyperhidrosis of the hands and arms is due to undergo a sympathectomy to treat the condition. Which of the following should the surgeons divide to most effectively treat her condition?

Answer 53

Sympathetic ganglia at T2 and T3

To treat hyperhidrosis the sympathetic ganglia at T2 and T3 should be divided.
Dividing the other structures listed would either carry a risk of Horners syndrome or be ineffective.

Question 54

74 of 610

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

Answer 54

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 55

75 of 610

Which of the following nerves conveys sensory information from the laryngeal mucosa?

Answer 55

Laryngeal branches of the vagus

The laryngeal branches of the vagus supply sensory information from the larynx.

Question 56

78 of 610

A 59 year old man is undergoing an extended right hemicolectomy for a carcinoma of the splenic flexure of the colon. The surgeons divide the middle colic vein close to its origin. Into which of the following structures does this vessel primarily drain?

Answer 56

Superior mesenteric vein

The middle colonic vein drains into the SMV, if avulsed during mobilisation then dramatic haemorrhage can occur and be difficult to control.

Question 56

76 of 610

A 72 year old man presents with haemoptysis and undergoes a bronchoscopy. The carina is noted to be widened. At which level does the trachea bifurcate?

Answer 56

T5

The trachea bifurcates at the level of the fifth thoracic vertebra. Or the sixth in tall subjects.

Question 57

77 of 610

A 23 year old man is stabbed in the chest approximately 10cm below the right nipple. In the emergency department a abdominal ultrasound scan shows a large amount of intraperitoneal blood. Which of the following statements relating to the likely site of injury is untrue?

Answer 57

The quadrate lobe is contained within the functional right lobe.

The right lobe of the liver is the most likely site of injury. Therefore the answer is B as the quadrate lobe is functionally part of the left lobe of the liver. The liver is largely covered in peritoneum. Posteriorly there is an area devoid of peritoneum (the bare area of the liver). The right lobe of the liver has the largest bare area (and is larger than the left lobe).

Question 58

83 of 610

A 22 year old man is undergoing an endotracheal intubation. Which of the following vertebral levels is consistent with the origin of the trachea?

Answer 58

C6

The trachea commences at C6. It terminates at the level of T5 (or T6 in tall subjects in deep inspiration).

Question 58

80 of 610

Which of the following is not a content of the porta hepatis?

Answer 58

Portal vein

Hepatic artery

Cystic duct( Right)

Lymph nodes

None of the above
……………………………………
The cystic duct lies outside the porta hepatis and is an important landmark in laparoscopic cholecystectomy. The structures in the porta hepatis are:
· Portal vein
· Hepatic artery
. Common hepatic duct

These structures divide immediately after or within the porta hepatis to supply the functional left and right lobes of the liver.
The porta hepatis is also surrounded by lymph nodes, that may enlarge to produce obstructive jaundice and parasympathetic nervous fibres that travel along vessels to enter the liver.

Question 58

81 of 610

Which of the following pairings are incorrect?

Answer 58

Aortic bifurcation and L4

Transpyloric plane and L1

Termination of dural sac and L4 ( Right)

Oesophageal passage through diaphragm and T10

Transition between pharynx and oesophagus at C6
…………………………………..
Vena cava T8 (eight letters)
Oesophagus T10 (ten letters)
Aortic hiatus T12 (twelve letters)

It terminates at S2, which is why it is safe to undertake an LP at L4/5 levels. The spinal cord itself terminates at L1.

Question 59

79 of 610

Which of the following structures is not closely related to the carotid sheath?

Answer 59

Sternothyroid muscle

Sternohyoid muscle

Hypoglossal nerve

Superior belly of omohyoid muscle

Anterior belly of digastric muscle( Right)
………………………………………………………..
At its lower end the carotid sheath is related to sternohyoid and sternothyroid. Opposite the cricoid cartilage the sheath is crossed by the superior belly of omohyoid. Above this level the sheath is covered by the sternocleidomastoid muscle. Above the level of the hyoid the vessels pass deep to the posterior belly of digastric and stylohyoid. Opposite the hyoid bone the sheath is crossed obliquely by the hypoglossal nerve.

Question 60

82 of 610

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

Answer 60

Semimembranosus

Quadriceps femoris ( Right)

Biceps femoris

Semitendinosus

Adductor magnus
………………………………………………..
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 61

84 of 610

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 61

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 tibial artery.

Question 62

85 of 610

A 22 year old man is involved in a fight and sustains a stab wound in his upper forearm. On examination there is a small, but deep laceration. There is an obvious loss of pincer movement involving the thumb and index finger with minimal loss of sensation. The most likely nerve injury is to the:

Answer 62

Anterior interosseous nerve

The anterior interosseous nerve is a motor branch of the median nerve just below the elbow. When damaged it classically causes:
. Pain in the forearm
. Loss of pincer movement of the thumb and index finger (innervates the long flexor muscles of flexor pollicis longus & flexor digitorum profundus of the index and middle finger)
. Minimal loss of sensation due to lack of a

Question 63

86 of 610

A 45 year old man sustains a significant head injury and a craniotomy is performed. The sigmoid sinus is bleeding profusely, into which of the following structures does it drain?

Answer 63

Internal jugular vein

The sigmoid sinus is joined by the inferior petrosal sinus to drain into the internal jugular vein.

Question 63

87 of 610

The sciatic nerve lies deep to the following structures except:

Answer 63

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 64

89 of 610

A 29 year old woman has had a Pfannenstiel incision. She has pain over the inguinal ligament which radiates to the lower abdomen. There is tenderness when the inguinal canal is compressed. Which of the following is most likely to have been affected?

Answer 64

Ilioinguinal nerve

Question 65

90 of 610

A 24 year old man falls and lands astride a manhole cover. He suffers from an injury to the anterior bulbar urethra. Where will the extravasated urine tend to collect?

Answer 65

Connective tissue of the scrotum

This portion of the urethra is contained between the perineal membrane and the membranous layer of the superficial fascia. As these are densely adherent to the ischiopubic rami, extravasated urine cannot pass posteriorly because the 2 layers are continuous around the superficial transverse perineal muscles.

Question 65

88 of 610

The right and left pulmonary arteries are derived from which of the following embryological aortic arches?

Answer 65

Sixth

Pulmonary vessels develop from the sixth arch

1st - maxillary art
1st + 2nd - external ctd
3rd - proximal ICT + Common ctd
4th right - Rt subclavian till the origin of internal mammary
4th left - arch of the aorta from the It common ctd til the ductus arteriosus
5th - degenerates
6th rt (proximal portion) - right pulmonary
6th It - It pulmonary and ductus arteriosus

Question 66

91 of 610

A 43 year old man is diagnosed as having a malignancy of the right adrenal gland. The decision is made to resect this via an open anterior approach. Which of the following will be most useful during the surgery?

Answer 66

Mobilisation of the colonic hepatic flexure

Mobilisation of the hepatic flexure and right colon are standard steps in open adrenal surgery from an anterior approach. Mobilisation of the liver is seldom required.

Question 66

92 of 610

A 72 year old man is undergoing a left pneumonectomy for carcinoma of the bronchus. As the surgeons approach the root of the lung, which structure will lie most anteriorly (in the anatomical plane)?

Answer 66

Phrenic nerve

The phrenic nerve is the most anteriorly located structure in the lung root. The vagus nerve lies most posteriorly.

Question 66

93 of 610

Which of the following is the first vessel to branch from the external carotid artery?

Answer 66

Superior thyroid artery

Mnemonic
(Order in which they branch off)Some (sup thyroid)Attendings (Ascending Pharyngeal)Like (Lingual)Freaking (Facial)Out (Occipital)Potential (Post auricular)Medical (Maxillary)Students (Sup temporal)

The first branch of the external carotid artery is the superior thyroid artery. The inferior thyroid artery is derived from the thyrocervical trunk. The other branches are illustrated below.

Question 66

94 of 610

Two teenagers are playing with an airgun when one accidentally shoots his friend in the abdomen. He is brought to the emergency department. On examination there is a bullet entry point immediately to the right of the rectus sheath at the level of the 1st lumbar vertebra. Which of the following structures is most likely to be injured by the bullet?

Answer 66

Fundus of the gallbladder

The fundus of the gallbladder lies at this level and is the most superficially located structure.

Question 67

95 of 610

A 32 year old man is undergoing a splenectomy. Division of which of the following will be necessary during the procedure?

Answer 67

Short gastric vessels

During a splenectomy the short gastric vessels which lie within the gastrosplenic ligament will need to be divided. The splenic flexure of the colon may need to be mobilised. However, it will almost never need to be divided, as this is watershed area that would necessitate a formal colonic resection in the event of division.

Question 68

96 of 610

A motorcyclist is injured in a road traffic accident and is not wearing a helmet. He suffers a severe closed head injury and develops raised intracranial pressure. The first cranial nerve to be affected by this process is likely to be:

Answer 68

Abducens

The abducens nerve (CN VI) has a long intra cranial course and is thus susceptible to raised intra cranial pressure. It also passes over the petrous temporal bone and 6th nerve palsies are also seen in mastoiditis.

Question 68

97 of 610

A 63 year old man is undergoing a coronary artery bypass procedure. During the median sternotomy which structure would routinely require division?

Answer 68

Interclavicular ligament

The interclavicular ligament lies at the upper end of a median sternotomy and is routinely divided to provide access. The pleural reflections are often encountered and should not be intentionally divided, if they are, then a chest drain will need to be inserted on the affected side as collections may then accumulate in the pleural cavity. Other structures encountered include the pectoralis major muscles, again if the incision is truly midline then these should not require formal division. The close relationship of the brachiocephalic vein should be borne in mind and it should be avoided, iatrogenic injury to this structure will result in considerable haemorrhage.

Question 69

98 of 610

Which of the positions listed below best describes the location of the coeliac autonomic plexus?

Answer 69

Anterior to the aorta

Question 69

99 of 610
Which of the following nerves is responsible for innervation of the triceps muscle?

Answer 69

Radial

To remember nerve roots and their reflexes:

1-2 Ankle (S1-S2)
3-4 Knee (L3-L4)
5-6 Biceps (C5-C6)
7-8 Triceps (C7-C8)

The radial nerve innervates all three heads of triceps, with a separate branch to each head.