9- Mixed Anatomy (2)MSQs Only Flashcards
100 of 610
A 38 year old lady is due to undergo a parathyroidectomy for hyperparathyroidism. At operation the inferior parathyroid gland is identified as being enlarged. A vessel is located adjacent to the gland laterally. This vessel is most likely to be the:
Common carotid artery
The common carotid artery is a lateral relation of the inferior parathyroid.
103 of 610
A 60 year old female attends the preoperative hernia clinic. She reports some visual difficulty. On examination she is noted to have a homonymous hemianopia. Where is the lesion most likely to be?
Optic tract
………………………………….
Lesions before optic chiasm:
Monocular vision loss = Optic nerve lesion
Bitemporal hemianopia = Optic chiasm lesion
Lesions after the optic chiasm:
Homonymous hemianopia = Optic tract lesion
Upper quadranopia = Temporal lobe lesion
Lower quadranopia = Parietal lobe lesion
Unfortunately we thought as surgeons we could forget about visual field defects!
However the college seem to like them. Remember a homonymous hemianopia is indicative of an optic tract lesion. Parietal lobe lesions tend to cause inferior quadranopias and there is a bitemporal hemianopia with optic chiasm lesion or pituitary tumours.
102 of 610
During an Ivor Lewis Oesophagectomy for carcinoma of the lower third of the oesophagus which structure is divided to allow mobilisation of the oesophagus?
Azygos vein
The azygos vein is routinely divided during an oesophagectomy to allow mobilisation. It arches anteriorly to insert into the SVC on the right hand side.
101 of 610
What is the largest branch of the brachial artery?
Profunda brachii artery
The profunda brachii artery is the largest branch and then continues in the radial groove of the humerus.
104 of 610
Which of the following structures separates the subclavian artery from the subclavian vein?
Scalenus anterior
The artery and vein are separated by scalenus anterior. This muscle runs from the transverse processes of C3,4,5 and 6 to insert onto the scalene tubercle of the first rib.
105 of 610
A 67 year old man is undergoing an angiogram for gastro intestinal bleeding. The radiologist advances the catheter into the coeliac axis. At what spinal level does this vessel typically arise from the aorta?
T12
The coeliac axis lies at T12, it takes an almost horizontal angle off the aorta. It has three major branches.
106 of 610
Which of the nerves below innervates the tensor tympani muscle?
Trigeminal
The tensor tympani muscle (in conjunction with stapedius) helps to mitigate the effects of loud sounds. The tensor tympani is innervated by the trigeminal nerve (the stapedius by the facial). In some people with hyperacousia, the tensor tympani muscle does not function normally.
107 of 610
A 34 year old male is being examined in the pre-operative assessment clinic. A murmur is identified in the 4th intercostal space just next to the left side of the sternum. From where is it most likely to have originated?
Tricuspid valve
The tricuspid valve is generally referred to being best auscultated adjacent to the sternum. The plane of projected sound from the mitral area is best heard in the region of the cadiac apex.
109 of 610
Which of the following structures lies posterior to the femoral nerve in the femoral triangle?
Iliacus
The iliacus lies posterior to the femoral nerve in the femoral triangle. The femoral sheath lies anterior to the iliacus and pectineus muscles.
108 of 610
The vertebral artery traverses all of the following except?
Transverse process of C6
Transverse process of the axis
Vertebral canal
Foramen magnum
Intervertebral foramen (Right)
………………………………………….
The vertebral artery passes through the foramina which are located in the transverse processes of the cervical vertebra, it does not traverse the intervertebral foramen.
110 of 610
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?
Superior gluteal nerve
Damage to the superior gluteal nerve will result in a Trendelenburg gait.
111 of 610
A 44 year old man is undergoing a parotidectomy and the surgeon is carefully preserving the facial nerve. Unfortunately his trainee then proceeds to divide it. Which of the following will not be affected as a result?
Taste sensation from anterior two thirds of the tongue
The chorda tympani branches inside the facial canal and will therefore be unaffected by this most unfortunate event! The corneal reflex is mediated by the opthalmic branch of the trigeminal nerve sensing the stimulus on the cornea, lid or conjunctiva; the facial nerve initiates the motor response of the reflex.
113 of 610
A 32 year old rugby player is hit hard on the shoulder during a rough tackle. Clinically, his arm is hanging loose on the side. It is pronated and medially rotated. What structure is most likely to have been compromised?
Brachial trunks C5-6
The patient has an Erb’s palsy involving brachial trunks C5-6.
INJURY OF THE BRACHIAL PLEXUS
(t) Complete avulsion of all roots of the plexus :leads to :
paralysis of all muscles of upper limb except trapezius
Supplied by supraclavicular and intercostobrachial respectively
(b) anaesthesia of all skin of u-L except skin of tip of shoulder &floor of axilla.
(2) Injury of the upper trunk (C5,6) :Erb’s paralysis : leads ta:
(a) paralysis of abductors &lat-rotators of arm+Flexors &supinators of forearm
(b) anaesthesia of skin of lat-aspect of forearm & lower/2 of arm.
(c) Deformity: porter’s or policeman tip position-
(3) Injury of the lower trunk (C8,TI) : Klumpke’s paralysis : leads to:
(a) paralysis of flexors of wrist & fingers +all intrinsic muscles of the hand.
b andesthesia of the skin along the ulnar border of forearm &hand.
(e) Deformity : claw hand deformity
112 of 610
A 73 year old man undergoes an excision biopsy of a lymph node that is closely applied to sternocleidomastoid. This muscle is mobilized and a nerve that is present is damaged. Which muscle below is most likely to be affected?
Trapezius
The accessory nerve has a number of lymph nodes applied to it near the sternocleidomastoid muscle. It is particularly at risk if SCM is mobilized. If injured, the trapezius muscle and SCM will be paralysed.
114 of 610
You are assisting in an open right adrenalectomy for a large adrenal adenoma. The consultant is distracted and you helpfully pull the adrenal into the wound to improve the view. Unfortunately this is followed by brisk bleeding. The vessel responsible for this is most likely to be:
Inferior vena cava
It drains directly via a very short vessel. If the sutures are not carefully tied then it may be avulsed off the IVC. An injury best managed using a Satinsky clamp and a 6/0 prolene suture.
117 of 610
Which of the following does not pass through the superior orbital fissure?
Opthalmic artery
…………………………
Mnemonic for the nerves passing through the supraorbital fissure:
Live Frankly To See Absolutely No Insult
Lacrimal
Frontal
Trochlear
Superior Division of Oculomotor
Abducens
Nasociliary
Inferior Division of Oculomotor nerve
The opthalmic artery arises from the internal carotid immediately after it has pierced the dura and arachnoid. It runs through the optic canal below the optic nerve and within its dural and arachnoid sheaths. It terminates as the supratrochlear and dorsal nasal arteries.
115 of 610
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?
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.
116 of 610
At which level is the hilum of the left kidney located?
L1
Remember L1 (‘left one’) is the level of the hilum of the left kidney
118 of 610
Which of the muscles listed below is attached to the anterior aspect of the fibrous capsule that encases the elbow joint?
Brachialis
The brachialis inserts some of its fibres into the fibrous joint of the elbow capsule and when it contracts, it helps to flex the joint.
119 of 610
Parasympathetic fibres innervating the parotid gland originate from which of the following?
Otic ganglion
Secretion of saliva by the parotid gland is controlled by nerve fibres originating in the inferior salivatory nucleus; these leave the brain via the tympanic nerve (branch of glossopharyngeal nerve (CN IX), travel through the tympanic plexus (located in the middle ear), and then form the lesser petrosal nerve until reaching the otic ganglion. After synapsing in the Otic ganglion, the postganglionic (postsynaptic) fibres travel as part of the auriculotemporal nerve (a branch of the mandibular nerve (V3) to reach the parotid gland.
Inferior salivary nucleus - tympanic n of IX - tympanic
plexus in middle ear - lesser petrosal n ->- otic
ganglion ->- auriculotemporal ot V - parotid gland
121 of 610
At which of the following levels does the inferior thyroid artery enter the thyroid gland?
C6
It enters the gland at C6.
120 of 610
An occlusion of the anterior cerebral artery may compromise the blood supply to the following structures except:
Medial inferior surface of the frontal lobe
Corpus callosum
Medial surface of the frontal lobe
Olfactory bulb
Brocas area ( Right)
…………………………………
Brocas area is usually supplied by branches from the middle cerebral artery.
122 of 610
Which of the cranial nerves listed below is least likely to carry parasympathetic fibres?
II
Cranial nerves carrying parasympathetic fibres
X IX VII III (1973)
The optic nerve carries no parasympathetic fibres.
The cranial preganglionic parasympathetic nerves arise from specific nuclei in the CNS. These synapse at one of four parasympathetic ganglia; otic, pterygopalatine, ciliary and submandibular. From these ganglia the parasympathetic nerves complete their journey to their target tissues via CN V (trigeminal) branches (ophthalmic nerve CNV branch 1, Maxillary nerve CN V branch2, mandibular nerve CN V branch 3)
123 of 610
An elderly man develops a squamous cell carcinoma affecting the lobule of his ear. To which lymph node is the lesion most likely to metastasize?
Superficial cervical nodes
The lobule drains to the superficial cervical nodes.
124 of 610
A 10 year old child has a grommet inserted for a glue ear. What type of epithelium is present on the external aspect of the tympanic membrane?
Stratified squamous
The external aspect of the tympanic membrane is lined by stratified squamous epithelium. This is significant clinically in the development of middle ear infections when this type of epithelium may migrate inside the middle ear.
125 of 610
A 5 year old boy presents with recurrent headaches. As part of his assessment he undergoes an MRI scan of his brain. This demonstrates enlargement of the lateral and third ventricles. Where is the most likely site of obstruction?
Aqueduct of Sylvius
The CSF flows from the 3rd to the 4th ventricle via the Aqueduct of Sylvius.
126 of 610
A 28 year old rugby player injures his right humerus and on examination is noted to have a minor sensory deficit overlying the point of deltoid insertion into the humerus. Which of the nerves listed below is most likely to have been affected?
Axillary
This patch of skin is supplied by the axillary nerve
127 of 610
The following statements relating to the musculocutaneous nerve are true except?
It arises from the lateral cord of the brachial plexus
It provides cutaneous innervation to the lateral side of the forearm
If damaged, then extension of the elbow joint will be impaired( Right)
It supplies the biceps muscle
It runs beneath biceps
……………………………………………
It supplies biceps, brachialis and coracobrachialis. If damaged then elbow flexion will be impaired.
129 of 610
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?
Loss of extension at the knee joint(Right)
Foot drop
Inability to extend extensor hallucis longus
Diminished sensation of the posterior aspect of the thigh
Loss of sensation to the posterior aspect of the lower leg
………………………………………..
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.
134 of 610
A 40 year old lady trips and falls through a glass door and sustains a severe laceration to her left arm. Amongst her injuries it is noticed that she has lost the ability to adduct the fingers of her left hand. Injury to which of the following nerves is most likely to account for her examination findings?
Ulnar
The interossei are supplied by the ulnar nerve.
133 of 610
A 53 year old man is undergoing a radical gastrectomy for carcinoma of the stomach. Which of these structures will need to be divided to gain access to the coeliac axis?
Lesser omentum
The lesser omentum will need to be divided. During a radical gastrectomy this forms one of the nodal stations that will need to be taken.
131 of 610
A cervical rib is due to which of the following?
Elongation of the transverse processes of the 7th cervical vertebra
Cervical ribs occur as a result of the elongation of the transverse process of the 7th cervical vertebra. It is usually a fibrous band that attaches to the first thoracic rib.
130 of 610
A 23 year old lady with troublesome axillary hyperhidrosis is undergoing a thorascopic sympathectomy to treat the condition. Which of the following structures will need to be divided to access the sympathetic trunk?
Parietal pleura
The sympathetic chain lies posterior to the parietal pleura. During a thorascopic sympathectomy this structure will need to be divided. The intercostal vessels lie posteriorly. They may be damaged with troublesome bleeding but otherwise are best left alone as deliberate division will not improve surgical access.
132 of 610
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?
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.
135 of 610
A 33 year old man is stabbed in the right chest and undergoes a thoracotomy. The right lung is mobilised and the pleural reflection at the lung hilum is opened. Which of the structures listed below does not lie within this region?
Pulmonary artery
Azygos vein(Right)
Pulmonary vein
Bronchus
None of the above
………………………………………….
The pleural reflections encase the hilum of the lung and continue inferiorly as the pulmonary ligament. It encases the pulmonary vessels and bronchus. The azygos vein is not contained within it.
137 of 610
Which of the nerves listed below is responsible for the innervation of gluteus maximus?
Inferior gluteal nerve
136 of 610
The pudendal canal is a fascial canal located on the lateral wall of the ischioanal fossa. In this location, it lies on the inferior border of which of the following muscles?
Obturator internus
The coccygeus, pubococcygeus and iliococcygeus form part of the pelvic diaphragm and are not related to it. The piriformis exits the pelvis via the greater sciatic foramen and is not associated with the canal in the ischiorectal fossa.
138 of 610
What is the origin of the superior gluteal artery?
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
139 of 610
A 67 year old man has an abdominal aortic aneurysm which displaces the left renal vein. Which branch of the aorta is most likely to be affected
Superior mesenteric artery
The left renal vein lies behind of the SMA as it branches off the aorta. Whilst juxtarenal AAA may sometimes require the division of the left renal vein, direct involvement of the SMA may require a hybrid surgical bypass and subsequent endovascular occlusion.
141 of 610
A patient presents with superior vena caval obstruction. How many collateral circulations exist as alternative pathways of venous return?
Four
There are 4 collateral venous systems:
· Azygos venous system
· Internal mammary venous pathway
. Long thoracic venous system with connections to the femoral and vertebral
veins (2 pathways)
Despite this, venous hypertension still occurs.
140 of 610
An 18 year old man is cutting some plants when a small piece of vegetable matter enters his eye. His eye becomes watery. Which of the following is responsible for relaying parasympathetic neuronal signals to the lacrimal apparatus?
Pterygopalatine ganglion
The parasympathetic fibres to the lacrimal apparatus transit via the pterygopalatine ganglion.
141 of 610
A patient presents with superior vena caval obstruction. How many collateral circulations exist as alternative pathways of venous return?
Four
There are 4 collateral venous systems:
· Azygos venous system
· Internal mammary venous pathway
. Long thoracic venous system with connections to the femoral and vertebral veins (2 pathways)
Despite this, venous hypertension still occurs.
142 of 610
A 5 year old boy is playing with some small ball bearings. Unfortunately, he inhales one. To which of the following lung regions is the ball most likely to settle?
Right lower lobe
As the most dependent part of the right lung a small object is most likely to lodge here. Most objects will preferentially enter the right lung owing to the angle the right main bronchus takes from the trachea.
143 of 610
Which of the following laryngeal tumours will not typically metastasise to the cervical lymph nodes?
Glottic(Right)
Supraglottic
Subglottic
Transglottic
Aryepiglottic fold
………………………………………………
The vocal cords have no lymphatic drainage and therefore this region serves as a lymphatic watershed. The supraglottic part drains to the upper deep cervical nodes through vessels piercing the thyrohyoid membrane. The sub glottic part drains to the pre laryngeal, pre tracheal and inferior deep cervical nodes. The aryepiglottic and vestibular folds have a rich lymphatic drainage and will metastasise early.
144 of 610
A 24 year old man falls and sustains a fracture through his scaphoid bone. From which of the following areas does the scaphoid derive the majority of its blood supply?
From the distal end
The blood supply to the scaphoid enters from a small non articular surface near its distal end. Transverse fractures through the scaphoid therefore carry a risk of non union.
145 of 610
A 35 year old man falls and sustains a fracture to the medial third of his clavicle. Which vessel is at greatest risk of injury?
Subclavian vein
The subclavian vein lies behind subclavius and the medial part of the clavicle. It rests on the first rib, below and in front of the third part of the subclavian artery, and then on scalenus anterior which separates it from the second part of the artery (posteriorly).
146 of 610
What is the anatomical level of the transpyloric plane?
L1
147 of 610
An 21 year old man undergoes an uncomplicated tonsillectomy for recurrent attacks of tonsillitis. Post operatively he complains of otalgia. Which nerve is responsible?
Glossopharyngeal
The glossopharyngeal nerve supplies this area and the ear and otalgia may be the result of referred pain.
148 of 610
Which of the following nerves is most commonly damaged during a superficial parotidectomy?
Greater auricular
If you are confused by this, make sure you are clear on what the question is asking- its about nerve injury. Its very rare for the facial nerve to be injured during parotid surgery.
The greater auricular nerve and in particular its lobular branch is commonly injured in parotid surgery and consent usually makes particular reference to this. In a superficial parotidectomy, the facial nerve should not be injured and this is less common than a greater auricular nerve injury.
149 of 610
Which muscle initiates abduction of the shoulder?
Supraspinatus
The intermediate portion of the deltoid muscle is the chief abductor of the humerus. However, it can only do this after the movement has been initiated by supraspinatus. Damage to the tendon of supraspinatus is a common form of rotator cuff disease.
150 of 610
Where are the reticulo-endothelial cells concentrated within the spleen?
Within the white pulp
The reticuloendothelial cells are concerned with the immune functions of the spleen and these are therefore concentrated in the white pulp.
152 of 610
During a block dissection of the groin, the sartorius muscle is identified. What is the nerve supply to this muscle?
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.
153 of 610
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?
Common peroneal nerve
Positioning legs in Lloyd- Davies stirrups can carry the risk of peroneal nerve neuropraxia if not done carefully.
151 of 610
A 28 year old man requires a urethral catheter to be inserted prior to undergoing a splenectomy. Where is the first site of resistance to be encountered on inserting the catheter?
Membranous urethra
The membranous urethra is the least distensible portion of the urethra. This is due to the fact that it is surrounded by the external sphincter.
154 of 610
A 23 year old man falls and slips at a nightclub. A shard of glass penetrates the skin at the level of the medial epicondyle, which of the following sequelae is least likely to occur?
Atrophy of the first dorsal interosseous muscle
Difficulty in abduction of the the 2nd, 3rd, 4th and 5th fingers
Claw like appearance of the hand(Right)
Loss of sensation on the anterior aspect of the 5th finger
Partial denervation of flexor digitorum profundus
……………………………………………………
Injury to the ulnar nerve in the mid to distal forearm will typically produce a claw hand. This consists of flexion of the 4th and 5th interphalangeal joints and extension of the metacarpophalangeal joints. The effects are potentiated when flexor digitorum profundus is not affected, and the clawing is more pronounced.More proximally sited ulnar nerve lesions produce a milder clinical picture owing to the simultaneous paralysis of flexor digitorum profundus (ulnar half).
This is the ‘ulnar paradox’, due to the more proximal level of transection the hand will typically not have a claw like appearance that may be seen following a more distal injury. The first dorsal interosseous muscle will be affected as it is supplied by the ulnar nerve.
155 of 610
What is the most important structure involved in supporting the uterus?
Central perineal tendon
The central perineal tendon provides the main structural support to the uterus. Damage to this structure is commonly associated with the development of pelvic organ prolapse, even when other structures are intact.
157 of 610
An injured axillary artery is ligated between the thyrocervical trunk of the subclavian and subscapular artery. Subsequent collateral circulation is likely to result in reversal of blood flow in which of the vessels listed below?
Circumflex scapular artery
It’s an easy question really, we just made the wording difficult (on purpose). It is asking about the branches of the axillary artery and knowledge of the fact that there is an extensive collateral network around the shoulder joint. As a result, the occlusion of the proximal aspect of the circumflex humeral inflow (from the axillary artery) ceases and there is then retrograde flow through it from collaterals.
It is all about anastomosis around shoulder jt, distal components of anastomosis dorsal scapular from subclavian anastomosis with circumflex scapular of subscapular if 3rd part axillary art.
The circumflex scapular artery is a branch of the subscapular artery and normally supplies the muscle on the dorsal aspect of the scapula. In this instance, flow is reversed in the circumflex scapular and subscapular arteries forming a collateral circulation around the scapula.
156 of 610
A 53 year old man presents with unilateral hyperacousia. Which of the following nerves is least likely to be functioning normally?
Vestibulocochlear
Glossopharyngeal
Facial(Right)
Trochlear
Vagus
…………………………………………………..
Damage to the nerve in the bony canal may result in impaired innervation to stapedius and therefore sounds are no longer dampened. Another cause of hyperacusis is increased activity in the tensor tympani muscle, this is innervated by the trigeminal nerve.
158 of 610
A 44 year old lady is undergoing an abdominal hysterectomy and the ureter is identified during the ligation of the uterine artery. At which site does it insert into the bladder?
Base
The ureters enter the bladder at the upper lateral aspect of the base of the bladder.
They are about 5cm apart from each other in the empty bladder. Internally this aspect is contained within the bladder trigone.
160 of 610
A 63 year old lady is undergoing an axillary sentinel lymph node biopsy as part of her breast cancer treatment. Which of the structures listed below is most likely to be encountered?
Subclavian artery
Intercostobrachial nerve(Right)
Upper cord of the brachial plexus
Lower cord of the brachial plexus
Axillary nerve
…………………………………………………
This can be a challenging question. A particularly careless surgeon could encounter all of these. However, during a routine level 1 axillary exploration which is where the majority of sentinel nodes will be located, the nerves most commonly encountered are the intercostobrachial nerves.
159 of 610
The superior aspect of the vagina drains to which of the following lymph node groups?
Internal iliac nodes
Superior Vagina - int & ext iliac L.N
Inferior Vagina - Superfacial ing L.N
161 of 610
During a Patey mastectomy, the pectoralis minor muscle is divided to gain access to the level IlI axillary nodes. What is the nerve supply to this structure?
Medial pectoral nerve
Pectoralis minor is supplied by the medial pectoral nerve
162 of 610
Which of the following statements relating to sternocleidomastoid is untrue?
The external jugular vein lies posteromedially.(Right)
It is supplied by the accessory nerve.
It has two heads of origin
It inserts into the lateral aspect of the mastoid process.
It marks the anterior border of the posterior triangle.
………………………………………………
The external jugular vein lies lateral (i.e. superficial) to the sternocleidomastoid.
The following statements regarding the rectus abdominis muscle are true except:
It runs from the symphysis pubis to the xiphoid process
Its nerve supply is from the ventral rami of the lower 6 thoracic nerves
It has collateral supply from both superior and inferior epigastric vessels
It lies in a muscular aponeurosis throughout its length(Right)
It has a number of tendinous intersections that penetrate through the anterior layer of the muscle
……………………………………………..
Rectus abdominis
· Arises from the pubis.
. Inserts into 5th, 6th, 7th costal cartilages.
. The muscle lies in the rectal sheath, which also contains the superior and inferior epigastric artery and vein.
· Action: flexion of thoracic and lumbar spine.
· Nerve supply: anterior primary rami of T7-12.
The aponeurosis is deficient below the arcuate line.
165 of 610
Which of the following options in relation to the liver is true?
Ligamentum venosum is an anterior relation of the liver
The portal triad comprises the hepatic artery, hepatic vein and tributary of the bile duct
The liver is completely covered by peritoneum
There are no nerves within the porta hepatis
The caudate lobe is superior to the porta hepatis(Right)
……………………………………………..
‘VC goes with VC’
The ligamentun Venosum and Caudate is on same side as Vena Cava [posterior].
Ligamentum venosum is posterior to the liver. The portal triad contains the portal vein rather than the hepatic vein. There is the ‘bare area of the liver’ created by a void due to the coronary ligament layers being widely separated. There are sympathetic and parasympathetic nerves in the porta hepatis.
164 of 610
Which of the following structures does not pass anterior to the lateral malleolus?
Anterior tibial artery
Extensor digitorum longus
Lateral branch of the superficial peroneal nerve
Peroneus brevis(Right)
Peroneus tertius
……………………………………….
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
166 of 610
How many valves lie between the superior vena cava and the right atrium?
None(Right)
One
Two
Three
Four
…………………………………
There are no valves which is why it is relatively easy to insert a CVP line from the internal jugular vein into the right atrium.
168 of 610
Which of the following muscles is penetrated by the parotid duct?
Buccinator
The duct crosses the masseter muscle and buccal fat pad and then penetrates the buccinator muscle to enter the oral cavity opposite the second upper molar tooth.
167 of 610
The following are true of the ulnar nerve except:
It innervates the palmar interossei
Derived from the medial cord of the brachial plexus
Supplies the muscles of the thenar eminence(Right)
Supplies the medial half of flexor digitorum profundus
Passes superficial to the flexor retinaculum
……………………………………………………….
The muscles of the thenar eminence are supplied by the median nerve and atrophy of these is a feature of carpal tunnel syndrome.
169 of 610
A 6 year old sustains a supracondylar fracture of the distal humerus. There are concerns that the radial nerve may have been injured. What is the relationship of the radial nerve to the humerus at this point?
Anterolateral
The radial nerve lies anterolateral to the humerus in the supracondylar area.
171 of 610
Which of the following fingers is not a point of attachment for the palmar interossei?
Middle finger(Right)
Little finger
Ring finger
Index finger
None of the above
……………………………………………..
The middle finger has no attachment of the palmar interosseous.
170 of 610
A 33 year old man sustains an injury to his forearm and wrist. When examined in clinic he is unable to adduct his thumb. What is the most likely underlying nerve lesion?
Deep branch of the ulnar nerve
Damage to the deep branch of the ulnar nerve may result in an inability to adduct the thumb. This is tested clinically by trying to withdraw a piece of paper from a patients hand grasped between thumb and index
172 of 610
A 73 year old lady is admitted with right iliac fossa pain. A plain abdominal x-ray is taken and the caecal diameter measured. Which of the following caecal diameters is pathological?
10cm
8 cm is still within normal limits. However, caecal diameters of 9 and 10 are pathological and should prompt further investigation.
173 of 610
A 73 year old lady with long standing atrial fibrillation develops a cold and pulseless white arm. A brachial embolus is suspected and a brachial embolectomy is performed. Which of the following structures is at greatest risk of injury during this procedure?
Median nerve
The median nerve lies close to the brachial artery in the antecubital fossa. This is the usual site of surgical access to the brachial artery for an embolectomy procedure. The median nerve may be damaged during clumsy application of vascular clamps to the artery.
174 of 610
A 43 year old lady is undergoing an axillary node clearance for breast cancer. The nodal disease is bulky. During clearance of the level 3 nodes there is suddenly brisk haemorrhage. The most likely vessel responsible is:
Thoracoacromial artery
The thoracoacromial artery pierces the pectoralis major and gives off branches within this space. The level 3 axillary nodes lie between pectoralis major and minor.Although the thoracodorsal trunk may be injured during an axillary dissection it does not lie within the level 3 nodes.
There are three levels of axillary lymph nodes (the nodes in the underarm or “axilla” area):
- Level I is the bottom level, below the lower edge of the pectoralis minor muscle.
- Level Il is lying underneath the pectoralis minor muscle.
- Level Ill is above the pectoralis minor muscle.
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A 63 year old man is undergoing a right pneumonectomy for carcinoma of the bronchus. As the surgeons approach the root of the lung, which structure will lie most posteriorly (in the anatomical plane)?
Vagus nerve
The vagus nerve is the most posteriorly located structure at the lung root. The phrenic nerve lies most anteriorly.
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The transversalis fascia contributes to which of the following?
Deep inguinal ring
The internal spermatic fascia (derived from transversalis fascia) invests:
Ductus deferens
Testicular vessels
The principal outpouching of the transversalis fascia is the internal spermatic fascia. The mouth of the outpouching is the deep inguinal ring.
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The motor nucleus of cranial nerve V supplies all except which of the following muscles?
Masseter
Posterior belly of digastric(Right)
Temporalis
Tensor tympani
Tensor veli palatini
………………………………………….
The posterior belly of digastric is supplied by the branchial motor component of the facial nerve. All of the other muscles are supplied by axons from the motor nucleus of cranial nerve V.
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Which of the following nerves is the primary source of innervation to the anterior scrotal skin?
Ilioinguinal nerve
The pudendal nerve may innervate the posterior skin of the scrotum. The anterior innervation of the scrotum is primarily provided by the ilioinguinal nerve. The genital branch of the genitofemoral nerve provides a smaller contribution.
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Which of the following statements relating to the gallbladder is untrue?
The fundus is usually intra peritoneal
Arterial supply is from the cystic artery
The cystic artery is usually located in Calots triangle
Calots triangle may rarely contain an aberrant hepatic artery
Cholecystokinin causes relaxation of the gallbladder(Right)
…………………………………………….
CCK causes gallbladder contraction.
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A 32 year old lady is admitted with weakness, visual disturbance and peri orbital pain. On examination, she is noted to have mydriasis and diminished direct response to light shone into the affected eye. The consensual response is preserved when light is shone into the unaffected eye. Which of the cranial nerves listed below is responsible for the diminished direct response?
Optic
This describes a relative afferent pupillary defect (RAPD). RAPD is a defect in the direct response to light. It is due to damage in optic nerve or severe retinal disease. If an optic nerve lesion is present the affected pupil will not constrict to light when light is shone in the that pupil during the swinging flashlight test. However, it will constrict if light is shone in the other eye (consensual response).
The most likely cause for this is an optic neuritis (not really surgical!). Other causes include ischemic optic disease or retinal disease, severe glaucoma causing trauma to optic nerve and direct optic nerve damage (trauma, radiation, tumor).
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An 22 year old soldier is shot in the abdomen and amongst his various injuries is a major disruption to the abdominal aorta. There is torrential haemorrhage and the surgeons decide to control the aorta by placement of a vascular clamp immediately inferior to the diaphragm. Which of the following vessels may be injured in this maneouvre?
Inferior phrenic arteries
As the first branches of the abdominal aorta the inferior phrenic arteries are at greatest risk. The superior phrenic arteries lie in the thorax. The potential space at the level of the diaphragmatic hiatus is a potentially useful site for aortic occlusion. However, leaving the clamp applied for more than about 10-15 minutes usually leads to poor outcomes.
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Which of the following is a recognised tributary of the retromandibular vein?
Maxillary vein
The retromandibular vein is formed from the union of the maxillary and superficial temporal vein
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A 44 year old lady has undergone a mastectomy and axillary node clearance. Post operatively, she notices a patch of anaesthesia of her axillary skin when she applies an underarm deodorant. Which nerve has most likely been affected?
Intercostobrachial
The intercostobrachial nerves traverse the axilla and innervate the overlying skin. These can be injured or divided during axillary surgery and the result is anaesthesia of the overlying skin.
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During a tricuspid valve repair the right atrium is opened, following establishment of cardiopulmonary bypass. Which of the following structures do not lie within the right atrium?
Crista terminalis
Tricuspid valve
Fossa ovalis
Trabeculae carnae(Right)
Musculi pectinati
………………………………………………..
Structures within the right atrium:
· Musculi pectinati
· Crista terminalis
. Opening of the coronary sinus
. Fossa ovalis
The trabeculae carnae are located in the right ventricle.
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A 63 year old man is undergoing an upper GI endoscopy for dysphagia. At 33 cm (from the incisors) a malignant looking stricture is encountered. The endoscopist attempts a balloon dilatation.Unfortunately the tumour splits through the oesophageal wall. Into which region will the oesophageal contents now drain?
Posterior mediastinum
At this position the oesophagus is still likely to be intrathoracic and located in the posterior mediastinum.
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A 78 year old man develops a carcinoma of the scrotum. To which of the following lymph node groups may the tumour initially metastasise?
Inguinal
The scrotum is drained by the inguinal nodes.
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The space between the vocal cords is referred to as which of the following?
Rima glottidis
The rima glottidis is the narrowest part of the laryngeal cavity.
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At what level does the sciatic nerve usually bifurcate into the tibial and common peroneal nerves?
At the superior aspect of the popliteal fossa
The sciatic nerve passes vertically downwards over the posterior surface of the obturator internus and 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.
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During a gangland gunfight a man is shot in the chest. The bullet passes through the posterior mediastinum (from left to right). Which of the following structures is least likely to be injured
Arch of the azygos vein
The arch of the azygos vein lies in the middle mediastinum.
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A 24 year female is admitted to A&E with tingling of her hand after a fall. She is found to have a fracture of the medial epicondyle. What is the most likely nerve lesion?
Ulnar nerve
The radial nerve is located near the lateral epicondyle.
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A 25 year old man is being catheterised, prior to a surgical procedure. As the catheter enters the prostatic urethra which of the following changes will occur?
Resistance will decrease
The prostatic urethra is much wider than the membranous urethra and therefore resistance will decrease. The prostatic urethra is inclined superiorly.
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Which of the following structures are at risk of direct injury following a fracture dislocation of the femoral condyles?
Popliteal artery
The heads of gastrocnemius will contract to pull the fracture segment posteriorly.
The popliteal artery lies against the bone and mav be damaded or comnressed.
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The inferior aspect of the vagina drains to which of the following lymph node groups?
Superficial inguinal nodes
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When performing minor surgery in the scalp, which of the following regions is considered a danger area as regards spread of infection into the CNS?
Loose areolar tissue
This area is most dangerous as infections can spread easily. The emissary veins that drain this area may allow sepsis to spread to the cranial cavity.
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Which of the following is not contained within the deep posterior compartment of the lower leg?
Tibialis posterior muscle
Posterior tibial artery
Tibial nerve
Sural nerve(Right)
Flexor hallucis longus
………………………………….
The deep posterior compartment lies anterior to soleus. The sural nerve is superficially sited and therefore not contained within it.
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The thebesian veins contribute to the venous drainage of the heart. Into which of the following structures do they primarily drain?
Atrium
The thebesian veins are numerous small veins running over the surface of the heart they drain into the heart itself. Usually this is to the atrium directly.
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Which of the following muscles lies medial to the long thoracic nerve?
Serratus anterior
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What is embryological origin of the pulmonary artery?
Sixth pharyngeal arch
The proximal part of the sixth right pharyngeal arch gives origin to the right pulmonary artery. The distal part gives origin to the left pulmonary artery and the ductus arteriosus.
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A 53 year old lady presents with pain and discomfort in her hand. She works as a typist and notices that the pain is worst when she is working. She also suffers symptoms at night. Her little finger is less affected by the pain. Which of the nerves listed below is most likely to be affected?
Median
Motor supply: LOAF
L ateral 2 lumbricals
O pponens pollicis
A bductor pollicisbrevis
F lexor pollicis brevis
The most likely diagnosis here is carpal tunnel syndrome, the median nerve is compressed in the wrist and symptoms usually affect the fingers and wrist either at night or when the hand is being used (e.g. as a typist).
