9- Mixed Anatomy (3)MSQs Only

Question 1

200 of 610

A 78 year old man is lifting a heavy object when he feels a pain in his forearm and is unable to continue. He has a swelling over his upper forearm. An MRI scan shows a small cuff of tendon still attached to the radial tuberosity consistent with a recent tear. Which of the following muscles has been injured?

Answer 1

Biceps brachii

Biceps inserts into the radial tuberosity. Distal injuries of this muscle are rare but are reported and are clinically more important than more proximal ruptures.

Question 2

201 of 610

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 2

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 3

202 of 610

In relation to the middle cranial fossa, which of the following statements relating to the foramina is incorrect?

Answer 3

The foramen rotundum transmits the maxillary nerve

The foramen lacerum is closely related to the internal carotid artery

The foramen spinosum lies posterolateral to the foramen ovale

The foramen ovale transmits the middle meningeal artery(Right)

The foramen rotundum lies anteromedial to the foramen ovale
……………………………………
The foramen spinosum transmits the middle meningeal artery. The foramen ovale transmits the mandibular nerve. As the foramina weaken the bone, a fracture at this site is not uncommon.

Question 4

203 of 610

A 56 year old man is undergoing an anterior resection for a carcinoma of the rectum. Which of the structures below is least likely to be encountered during the mobilisation of the anterior rectum?

Answer 4

Denonvilliers’ fascia

Middle sacral artery(Right)

Bladder

Rectovesical pouch

Seminal vesicles
…………………………………………
With the exception of the middle sacral artery all of the other structures lie anterior to the rectum. They may all be palpated during digital rectal examination.

Question 5

204 of 610

Where are accessory spleens not found?

Answer 5

Gonads

Tail of pancreas

Greater omentum

Splenorenal ligament

Ureter(Right)
……………………………………….
Accessory spleens

• 10% population
• 1 cm size
• locations: hilum of the spleen, tail of the pancreas, along the splenic vessels, in the gastrosplenic ligament, the splenorenal ligament, the walls of the stomach or intestines, the greater omentum, the mesentery, the gonads

Question 6

205 of 610

A 58 year old lady presents with a mass in the upper outer quadrant of the right breast. Which of the following statements relating to the breast is untrue?

Answer 6

The internal mammary artery provides the majority of its arterial supply

Nipple retraction may occur as a result of tumour infiltration of the clavipectoral fascia (Right)

The internal mammary artery is a branch of the subclavian artery

Up to 70% of lymphatic drainage is to the ipsilateral axillary nodes

None of the above
……………………………………………
Both skin dimpling and nipple retraction are features of breast malignancy.
However, they usually occur as a result of tumour infiltration of the breast ligaments and ducts respectively. The clavipectoral fascia encases the axillary contents. The lymphatic drainage of the breast is to the axilla and also to the internal mammary chain. The breast is well vascularised and the internal mammary artery is a branch of the subclavian artery.

Question 7

206 of 610

Which of the following muscles is not innervated by the ansa cervicalis?

Answer 7

Sternohyoid

Mylohyoid(Right)

Omohyoid

Sternothyroid

None of the above
……………………………………………..
Ansa cervicalis muscles:

GHost THought SOmeone Stupid Shot Irene

GenioHyoid
ThyroidHyoid
Superior Omohyoid
Sterno Thyroid
SternoHyoid
Inferior Omohyoid

Mylohyoid is innervated by the mylohyoid branch of the inferior alveolar nerve.

Question 8

207 of 610

A 35 year old man presents to the surgical clinic with a suspected direct inguinal hernia. These will pass through Hesselbach’s triangle. Which of the following forms the medial edge of this structure?

Answer 8

Rectus abdominis muscle

Direct inguinal hernias pass through Hesselbachs triangle (although this is of minimal clinical significance!). Its medial boundary is the rectus muscle.

Question 9

208 of 610

A 28 year old man is undergoing an appendicectomy. The external oblique aponeurosis is incised and the underlying muscle split in the line of its fibres. At the medial edge of the wound is a tough fibrous structure. Entry to this structure will most likely encounter which of the following?

Answer 9

Internal oblique

Rectus abdominis(Right)

Transversus abdominis

Linea alba

Peritoneum
…………………………………………
This structure will be the rectus sheath and when entered the rectus abdominis muscle will be encountered.

Question 10

209 of 610

Which of the following most commonly arises from the brachiocephalic artery?

Answer 10

Thyroidea ima artery

Other occasional branches include the thymic and bronchial branch.

Question 11

210 of 610

A 42 year old woman is due to undergo a left nephroureterectomy for a transitional cell carcinoma involving the ureter. Which of the following structures is not related to the left ureter?

Answer 11

Round ligament of the uterus (Right)

Internal iliac artery

Ovarian artery

Peritoneum

Sigmoid mesocolon
………………………………….
The ureter is not related to the round ligament of the uterus, it is related to the broad ligament and is within 1.5cm of the supravaginal part of the cervix.

Question 12

211 of 610

Which muscle is not innervated by the trigeminal nerve?

Answer 12

Medial pterygoid

Mylohyoid

Stylohyoid(Right)

Masseter

Temporalis
…………………………………………..
Stylohyoid is innervated by the facial nerve.

Question 13

212 of 610

A 45 year old man is undergoing a left hemicolectomy. As the surgeons mobilise the left colon they identify a tubular structure lying at the inferior aspect of psoas major. What is it most likely to be?

Answer 13

Left ureter

The left ureter lies posterior to the left colon. The sigmoid colon and upper rectum may be more closely related to the iliac vessels. These are not typically found above L4.

Question 14

216 of 610

Into which of these veins does the middle thyroid vein drain?

Answer 14

Internal jugular

It drains to the internal jugular vein. Which is one of the reasons why it bleeds so copiously if a ligature slips.

Question 14

213 of 610

From which of the following structures does the long head of the triceps muscle arise?

Answer 14

Infraglenoid tubercle

The long head arises from the infraglenoid tubercle. The fleshy lateral and medial heads are attached to the posterior aspect of the humerus between the insertion of the teres minor and the olecranon fossa.

Question 14

214 of 610

A 62 year old man presents with arm weakness. On examination, he has a weakness of elbow extension and loss of sensation on the dorsal aspect of the first digit. What is the site of the most likely underlying defect?

Answer 14

Radial nerve

The long head of the triceps muscle may be innervated by the axillary nerve and therefore complete loss of triceps muscles function may not be present even with proximally sited nerve lesions.

Question 15

215 of 610

Which of the following structures is not at the level of the transpyloric plane?

Answer 15

Hilum left kidney

Superior mesenteric artery

Fundus of the gallbladder

Cardioesophageal junction(Right)

Root of transverse mesocolon
………………………………………………
Cardiooesophageal junction level = T11

A knowledge of this anatomic level is commonly tested.
The oesophagus extends from C6 (the lower border of the cricoid cartilage) to T11 at the cardioesophageal junction. Note that in the neonate the oesophagus extends from C4 or C5 to T9.

Question 16

217 of 610

As it exits the axilla the radial nerve passes over the inferior border which of the muscles listed below?

Answer 16

Teres major

The radial nerve passes through the triangular interval to leave the axilla. The superior border of this is bounded by the teres major muscle to which the radial nerve is closely related.

Question 17

218 of 610

Which of the following statements about the spleen is false?

Answer 17

The hilum contains the splenic vessels.

The spleen is derived from endodermal tissue. (Right)

The white pulp has immune function.

The colon lies inferiorly.

Weighs 150g.
……………………………………………
1,3,5,7,9,11 (odd numbers up to 11)

The spleen is: 1 inch thick, 3 inches wide, 5 inches long, weighs 7oz (150-200g), lies between the 9th and 11th ribs

Most of the gut is derived endodermally except for the spleen which is from mesenchymal tissue.

Question 18

219 of 610

The recurrent laryngeal is connected to which of the following nerves?

Answer 18

Vagus

Question 19

220 of 610

Which of these statements relating to the external carotid is false?

Answer 19

It ends by bifurcating into the superficial temporal and ascending pharyngeal artery (Right)

Its first branch is the superior thyroid artery

The superior thyroid, lingual and facial arteries all arise from its anterior surface

The ascending pharyngeal artery is a medial branch

Initially it lies anteromedial to the internal carotid
……………………………………..
It terminates by dividing into the superficial temporal and maxillary branches. The external carotid has eight branches, 3 from its anterior surface ; thyroid, lingual and facial. The pharyngeal artery is a medial branch. The posterior auricular and occipital are posterior branches.

Question 20

221 of 610

A 63 year old man is due to undergo a splenectomy. Which splenic structure lies most posteriorly?

Answer 20

Lienorenal ligament

The lienorenal ligament lies most posteriorly. The antero-lateral connection is via the phrenicocolic ligament. Anteriorly the gastro splenic ligament. These structures condense around the vessels at the splenic hilum.

Question 21

222 of 610

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 21

Lesser trochanter of the femur

The psoas major inserts into the lesser trochanter.

Question 22

223 of 610

Which of the following is not a content of the anterior triangle of the neck?

Answer 22

Ansa cervicalis

Vagus nerve

Anterior jugular vein

Transverse cervical nerve (Right)

Hypoglossal nerve
……………………………………………
The transverse cervical nerve lies within the posterior triangle. The anterior jugular vein is formed in the submental region and descends in the superficial fascia near the median plane. It passes inferior to enter the suprasternal space, it is linked to the contralateral anterior jugular vein by the jugular venous arch.

Question 23

224 of 610 During embryological development, which of the following represent the correct origin of the pancreas?

Answer 23

Ventral and dorsal endodermal outgrowths of the duodenum The pancreas develops from a ventral and dorsal endodermal outgrowth of the duodenum. The ventral arises close to, or in common with the hepatic diverticulum, and the larger, dorsal outgrowth arises slightly cranial to the ventral extending into the mesoduodenum and mesogastrium. When the buds eventually fuse the duct of the ventral rudiment becomes the main pancreatic duct.

Question 24

225 of 610 A 42 year old teacher is admitted with a fall. An x-ray confirms a fracture of the surgical neck of the humerus. Which nerve is at risk?

Answer 24

Axillary The Axillary nerve winds around the bone at the neck of the humerus. The axillary nerve is also at risk during shoulder dislocation.

Question 25

226 of 610 A 32 year old man is stabbed in the neck and the inferior trunk of his brachial plexus is injured. Which of the modalities listed below is least likely to be affected?

Answer 25

Initiating abduction of the shoulder(Right) Abduction of the fingers Flexion of the little finger Sensation on the palmar aspect of the little finger Gripping a screwdriver …………………………………………………………. Inferior trunk of brachial plexus. . C8 and T1 roots . Contributes to ulnar nerve and part of median nerve The inferior trunk of the brachial plexus is rarely injured. Nerve roots C8 and T1 are the main contributors to this trunk. Therefore an injury to this site will most consistently affect the ulnar nerve. The inferior trunk also contributes to the median nerve by way of the medial cord and therefore some impairment of grip is almost inevitable.

Question 26

227 of 610 Which of the following is not a direct branch of the facial nerve?

Answer 26

Greater petrosal nerve Nerve to stapedius Auriculotemporal(Right) Chorda tympani Buccal branch of facial nerve ......................................................... The auriculotemporal nerve is a direct branch of the mandibular nerve. Other branches of the mandibular nerve include: Lingual Inferior alveolar Nerve to the mylohyoid Mental

Question 27

228 of 610 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 27

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

Question 28

229 of 610 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 28

Ilioinguinal

Question 29

230 of 610 A 45 year old man presents with bilateral inguinal hernias. The surgical team decide to repair these laparoscopically through an extraperitoneal approach. Through an infraumbilical incision the surgeons displace the inferior aspect of the rectus abdominis muscle anteriorly and place a prosthetic mesh into the area to repair the hernias. Which structure will lie posterior to the mesh?

Answer 29

Peritoneum During a TEP repair of inguinal hernia the only structure to lie posterior to the mesh is peritoneum. The question is really only asking which structure lies posterior to the rectus abdominis muscle. Since this region is below the arcuate line, the transversalis fascia and peritoneum lie posterior to it. Bucks fascia lies in the penis.

Question 30

231 of 610 You are working as an anatomy demonstrator and the medical students decide to test your knowledge on the Circle of Willis. Which of the following comments is false?

Answer 30

The anterior communicating artery links the right and left sides Asymmetry of the circle of willis is a risk factor for the development of intracranial aneurysms Majority of blood passing through the vessels mix together(Right) Includes the anterior communicating artery The circle surrounds the stalk of the pituitary gland ……………………………………….. There is minimum mixing of blood passing through the vessels.

Question 31

232 of 610 A 34 year old man with a submandibular gland stone is undergoing excision of the submandibular gland. The incision is sited transversely approximately 4cm below the mandible. After incising the skin, platysma and deep fascia which of the following structures is most likely to be encountered.

Answer 31

Facial vein When approaching the submandibular gland the facial vein and submandibular lymph nodes are the most superficially encountered structures. Each sub mandibular gland has a superficial and deep part, separated by the mylohyoid muscle. The facial artery passes in a groove on the superficial aspect of the gland. It then emerges onto the surface of the face by passing between the gland and the mandible. The facial vein is encountered first in this surgical approach because the incision is made 4cm below the mandible (to avoid injury to the marginal mandibular nerve).

Question 32

233 of 610 How many unpaired branches leave the abdominal aorta to supply the abdominal viscera?

Answer 32

Three There are three unpaired branches to the abdominal viscera. These include the coeliac axis, the SMA and IMA. Branches to the adrenals, renal arteries and gonadal vessels are paired. The fourth unpaired branch of the abdominal aorta, the median sacral artery, does not directly supply the abdominal viscera.

Question 33

234 of 610 Which of the following muscles is not within the posterior compartment of the lower leg?

Answer 33

Peroneus brevis(Right) Flexor digitorum longus Soleus Popliteus Flexor hallucis longus ............................................... Peroneus brevis lies in the lateral compartment.

Question 34

235 of 610 Which of these muscles is not a component of the rotator cuff?

Answer 34

Subscapularis Teres minor Supraspinatus Infraspinatus Deltoid(Right) ...................................... Deltoid may abduct the shoulder and is not a rotator cuff muscle.

Question 35

236 of 610 Which of the nerves listed below is responsible for the innervation of gluteus medius?

Answer 35

Superior gluteal nerve

Question 36

237 of 610 A 73 year old lady presents with a femoral hernia. Which of the following structures forms the lateral wall of the femoral canal?

Answer 36

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

Question 37

238 of 610 A 56 year old man is undergoing a radical nephrectomy via a posterior approach. Which of the following structures is most likely to be encountered during the operative approach?

Answer 37

12th rib The 11th and 12th ribs lie posterior to the kidneys and may be encountered during a posterior approach. A pneumothorax is a recognised complication of this type of surgery.

Question 38

239 of 610 Which of the following structures are not closely related to the adductor longus muscle?

Answer 38

Long saphenous vein Tendon of iliacus(Right) The profunda branch of the femoral artery Pectineus muscle Femoral nerve ……………………………………. 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 38

240 of 610 A 53 year old male presents with a carcinoma of the transverse colon. Which of the following structures should be ligated close to their origin to maximise clearance of the tumour?

Answer 38

Middle colic artery The middle colic artery supplies the transverse colon and requires high ligation during cancer resections. It is a branch of the superior mesenteric artery.

Question 38

241 of 610 Which of the following is not a carpal bone?

Answer 38

Trapezium Triquetrum Trapezoid Trapezius(Right) Lunate ..................................................... Mnemonic for the Carpal Bones Sally Likes To Play The Tiny Chrome Harmonica She Looks Too Pretty Try To Catch Her Scared Lovers Try Positions That They Can't Handle Trapezius is a muscle of the back.

Question 38

242 of 610 An 18 year old man is undergoing an orchidectomy via a scrotal approach. The surgeons mobilise the spermatic cord. From which of the following is the outermost layer of this structure derived?

Answer 38

External oblique aponeurosis The outermost covering of the spermatic cord is derived from the external oblique aponeurosis. This layer is added as the cord passes through the superficial inguinal ring.

Question 39

243 of 610 A 23 year old man has a cannula inserted into his cephalic vein. Through which structure does the cephalic vein pass?

Answer 39

Clavipectoral fascia The cephalic vein is a favored vessel for arteriovenous fistula formation and should be preserved in patients with end stage renal failure The cephalic vein penetrates the clavipectoral fascia (but not the pectoralis major) prior to terminating in the axillary vein.

Question 40

244 of 610 A 60 year old female is undergoing a Whipples procedure for adenocarcinoma of the pancreas. As the surgeons begin to mobilise the pancreatic head they identify a large vessel passing inferiorly over the anterior aspect of the uncinate process. What is it likely to be?

Answer 40

Superior mesenteric artery The superior mesenteric artery arises from the aorta and passes anterior to the lower part of the pancreas. Invasion of this structure is a relative contra indication to resectional surgery.

Question 41

245 of 610 A man sustains a laceration between the base of the little finger and wrist. Several weeks after the injury there is loss of thumb adduction power. Which nerve is most likely to have been injured?

Answer 41

Deep ulnar nerve

Question 42

246 of 610 A 63 year old man undergoes a radical cystectomy for carcinoma of the bladder. During the procedure there is considerable venous bleeding. What is the primary site of venous drainage of the urinary bladder?

Answer 42

Vesicoprostatic venous plexus The urinary bladder has a rich venous plexus surrounding it, this drains subsequently into the internal iliac vein. The vesicoprostatic plexus may be a site of considerable venous bleeding during cystectomy.

Question 43

247 of 610 A 35 year old man is admitted to hospital with vomiting, nausea and severe headaches. An MRI scan reveals a tumour of the cerebellopontine angle. Which one of the following pairs of cranial nerves is most likely to be compressed by this tumour?

Answer 43

Facial and vestibulocochlear The cerebellopontine angle is located between the superior and inferior limbs of the angular cerebellopontine fissure formed by the petrosal cerebellar surface folding around the pons and middle cerebellar peduncle. The cerebellopontine fissure opens medially and has superior and inferior limbs that meet at a lateral apex. The fourth through the eleventh cranial nerves are located near or within the angular space between the two limbs commonly referred to as the cerebellopontine angle. The commonest lesion to affect this site is an acoustic neuroma. Therefore the vestibulocochlear nerve is commonly compromised. Larger lesions may also affect the facial nerve which lies closest to this site.

Question 44

249 of 610 A 72 year old man is undergoing a repair of an abdominal aortic aneurysm. The aorta is cross clamped both proximally and distally. The proximal clamp is applied immediately inferior to the renal arteries. Both common iliac arteries are clamped distally. A longitudinal aortotomy is performed. After evacuating the contents of the aneurysm sac a significant amount of ongoing bleeding is encountered. This is most likely to originate from:

Answer 44

Lumbar arteries The lumbar arteries are posteriorly sited and are a common cause of back bleeding during aortic surgery. The other vessels cited all exit the aorta in the regions that have been cross clamped.

Question 45

248 of 610 Which of the following statements relating to sartorius is untrue?

Answer 45

It is supplied by the femoral nerve It forms the lateral boundary of the femoral triangle The middle third forms the roof of the adductor canal It is a flexor of the hip and knee It inserts into the medial femoral condyle(Right) ................................................ It inserts into the medial aspect of the upper part of the tibia.

Question 46

250 of 610 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 46

L3 Femoral nerve stretch test, also known as Mackiewicz sign[1] is a test for disc protrusion and femoral nerve injury. The patient lies prone, the knee is passively flexed to the thigh and the hip is passively extended (reverse Lasegues). The test is positive if the patient experiences anterior thigh pain. This test is usually positive for L2-L3 and L3-L4 (high lumbar) protrusions, slightly positive or negative in L4-L5, and negative in cases of lumbosacral protrusion

Question 47

252 of 610 A motor cyclist is involved in a road traffic accident causing severe right shoulder injuries. He is found to have an adducted, medially rotated shoulder. The elbow is fully extended and the forearm pronated. Which is the most likely diagnosis?

Answer 47

C5, C6 root lesion Erbs Palsy C5, C6 lesion The features include: . Waiter's tip position · Loss of shoulder abduction (deltoid and supraspinatus paralysis) · Loss of external rotation of the shoulder (paralysis of infraspinatus) . Loss of elbow flexion (paralysis of biceps, brachialis and brachioradialis) · Loss of forearm supination (paralysis of Biceps) The motorcyclist has had an Erb's palsy (C5, C6 root lesion). This is commonly known to be associated with birth injury when a baby has a shoulder dystocia.

Question 48

251 of 610 A patient is due to undergo a right hemicolectomy for a carcinoma of the caecum. Which of the following vessels will require high ligation to provide optimal oncological control?

Answer 48

Ileo-colic artery The ileo - colic artery supplies the caecum and would require high ligation during a right hemicolectomy. The middle colic artery should generally be preserved when resecting a caecal lesion. This question is essentially asking you to name the vessel supplying the caecum. The SMA does not directly supply the caecum, it is the ileocolic artery which does this.

Question 49

253 of 610 Which of these openings transmits the afferent part of the facial nerve into the temporal bone?

Answer 49

Internal acoustic meatus It enters the temporal bone through the internal acoustic meatus and exits through the stylomastoid foramen.

Question 49

254 of 610 In a patient with a carcinoma of the distal sigmoid colon, what is the most likely source of its blood supply?

Answer 49

Inferior mesenteric artery During a high anterior resection of such tumours, the inferior mesenteric artery is ligated. Note that the branches (mainly middle rectal branch) of the internal iliac artery are important in maintaining vascularity of the rectal stump and hence the integrity of the anastomoses.

Question 49

255 of 610 Which nerve is at risk during submandibular gland excision?

Answer 49

Marginal mandibular nerve The marginal mandibular nerve lies deep to platysma. It supplies the depressor anguli oris and the depressor labii inferioris. If injured it may lead to facial asymmetry and dribbling.

Question 49

256 of 610 Which of the following is not a content of the posterior triangle of the neck?

Answer 49

Spinal accessory nerve Phrenic nerve External jugular vein Occipital lymph nodes Internal jugular vein(Right) .................................................. The IJV does not lie in the posterior triangle. However, the terminal branches of the external jugular vein do.

Question 50

257 of 610 Which of the muscles below does not cause lateral rotation of the hip?

Answer 50

Obturator internus Quadratus femoris Gemellus inferior Piriformis Pectineus(Right) .................................................. 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 51

259 of 610 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 51

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 52

258 of 610 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 52

Interosseous membrane Deep peroneal nerve Tibialis posterior(Right) Extensor hallucis longus Dorsalis pedis artery …………………………………….. 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 53

260 of 610 A 56 year old machinist has his arm entrapped in a steel grinder and is brought to the emergency department. On examination, he is unable to extend his metacarpophalangeal joints and abduct his shoulder. He has weakness of his elbow and wrist. What has been injured?

Answer 53

Posterior cord of brachial plexus The posterior cord gives rise to: · Radial nerve ((innervates the triceps, brachioradialis, wrist extensors, and finger extensors) · Axillary nerve (innervates deltoid and teres minor) · Upper subscapular nerve (innervates subscapularis) . Lower subscapular nerve (innervates teres major and subscapularis) · Thoracodorsal nerve (innervates latissimus dorsi) This is a description of a posterior cord lesion. Remember that the posterior cord gives rise to the axillary and radial nerve.

Question 54

261 of 610 A builder falls off a ladder whilst laying roof tiles. He sustains a burst fracture of L2. The MRI scan shows complete nerve transection at this level, as a result of the injury. Which clinical sign will not be present initially?

Answer 54

Flaccid paralysis of the legs Extensor plantar response(Right) Sensory loss in the legs Incontinence Areflexia …………………………………………… In lower motor neuron lesions everything is reduced The main purpose of this question is to differentiate the features of an UMN lesion and a LMN lesion. The features of a LMN lesion include: · Flaccid paralysis of muscles supplied · Atrophy of muscles supplied. . Loss of reflexes of muscles supplied. . Muscles fasciculation For lesions below L1 LMN signs will occur. Hence in an L3 lesion, there will be loss of the patella reflex but there will be no extensor plantar reflex.

Question 55

263 of 610 A 73 year old man presents with a tumour at the tip of his tongue. To which of the following regions will the tumour initially metastasise?

Answer 55

Sub mental nodes

Question 56

262 of 610 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 56

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 57

264 of 610 A 18 year old man presents with an indirect inguinal hernia and undergoes surgery. The deep inguinal ring is exposed and held with a retractor at its medial aspect. Which structure is most likely to lie under the retractor?

Answer 57

Inferior epigastric artery Boundaries of the deep inguinal ring: · Superolaterally - transversalis fascia · Inferomedially - inferior epigastric artery The deep inguinal ring is closely related to the inferior epigastric artery. The inferior epigastric artery forms part of the structure referred to as Hesselbach's triangle.

Question 58

265 of 610 Which of the following is not a branch of the posterior cord of the brachial plexus?

Answer 58

Thoracodorsal nerve Axillary nerve Radial nerve Lower subscapular nerve Musculocutaneous nerve(Right) ...................................................................... Mnemonic branches off the posterior cord S ubscapular (upper and lower) T horacodorsal A xillary R adial The musculocutaneous nerve is a branch off the lateral cord.

Question 59

266 of 610 A 73 year old man has a large abdominal aortic aneurysm. During a laparotomy for planned surgical repair the surgeons find the aneurysm is far more proximally located and lies near the origin of the SMA. During the dissection a vessel lying transversely across the aorta is injured. What is this vessel most likely to be?

Answer 59

Left renal vein The left renal vein runs across the surface of the aorta and may require deliberate ligation during juxtarenal aneurysm repair.

Question 59

267 of 610 An 80 year old lady with a caecal carcinoma is undergoing a right hemicolectomy performed through a transverse incision. The procedure is difficult and the incision is extended medially by dividing the rectus sheath. Brisk arterial haemorrhage ensues. From which of the following does the damaged vessel originate?

Answer 59

External iliac artery The vessel damaged is the epigastric artery. This originates from the external iliac artery (see below).

Question 59

268 of 610 Which statement is false about the foramina of the skull?

Answer 59

The hypoglossal canal transmits the hypoglossal nerve The foramen spinosum is at the base of the medial pterygoid plate.(Right) The jugular foramen transmits the accessory nerve The foramen lacerum is located in the sphenoid bone The stylomastoid foramen transmits the facial nerve

Question 60

269 of 610 Which of the following does not exit the pelvis through the greater sciatic foramen?

Answer 60

Superior gluteal artery Internal pudendal vessels Sciatic nerve Obturator nerve(Right) Inferior gluteal nerve ................................................ The obturator nerve exits through the obturator foramen.

Question 60

270 of 610 A 48 year old lady is undergoing a left sided adrenalectomy for an adrenal adenoma. The superior adrenal artery is injured and starts to bleed, from which of the following does this vessel arise?

Answer 60

Inferior phrenic artery The superior adrenal artery is a branch of the inferior phrenic artery.

Question 61

271 of 610 In the distal third of the upper arm, where is the musculocutaneous nerve located?

Answer 61

Between the biceps brachii and brachialis muscles The musculocutaneous nerve lies between the biceps and brachialis muscles.

Question 61

272 of 610 Which of the following statements relating to the knee joint is false?

Answer 61

It is the largest synovial joint in the body When the knee is fully extended all ligaments of the knee joint are taut Rupture of the anterior cruciate ligament may result in haemarthrosis The posterior aspect of the patella is extrasynovial(Right) The joint is innervated by the femoral, sciatic and obturator nerves ……………………………………………… 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 62

273 of 610 Which of the following regions of the male urethra is entirely surrounded by Bucks fascia?

Answer 62

Spongiose part Bucks fascia is a layer of deep fascia that covers the penis it is continuous with the external spermatic fascia and the penile suspensory ligament. The membranous part of the urethra may partially pass through Bucks fascia as it passes into the penis. However, the spongiose part of the urethra is contained wholly within Bucks fascia.

Question 63

274 of 610 A 72 year old man with carcinoma of the lung is undergoing a left pneumonectomy. The left main bronchus is divided. Which of the following thoracic vertebrae lies posterior to this structure?

Answer 63

T6 The left main bronchus lies at T6. Topographical anatomy of the thorax is important as it helps surgeons to predict the likely structures to be injured in trauma scenarios (so popular with examiners)

Question 64

275 of 610 A 22 year old man sustains a blow to the side of his head with a baseball bat during a fight. He is initially conscious. However, he subsequently loses consciousness and then dies. Post mortem examination shows an extradural haematoma. The most likely culprit vessel is a branch of which of the following?

Answer 64

Maxillary artery The middle meningeal artery is the most likely source of the extradural haematoma in this setting. It is a branch of the maxillary artery. The middle cerebral artery does not give rise to the middle meningeal artery. Note that the question is asking for the vessel which gives rise to the middle meningeal artery ("the likely culprit vessel is a branch of which of the following")

Question 65

277 of 610 The common peroneal nerve, or its branches, supply the following muscles except:

Answer 65

Peroneus longus Tibialis anterior Extensor hallucis longus Flexor digitorum brevis( Right) Extensor digitorum longus ...................................................... Flexor digitorum is supplied by the tibial nerve.

Question 65

276 of 610 A 28 year old man is stabbed outside a nightclub in the upper arm. The median nerve is transected. Which of the following muscles will demonstrate impaired function as a result?

Answer 65

Abductor pollicis brevis Palmaris brevis - Ulnar nerve Palmar interossei- Ulnar nerve Adductor pollicis - Ulnar nerve Abductor pollicis longus - Posterior interosseous nerve Abductor pollicis brevis - Median nerve The median nerve innervates all the short muscles of the thumb except the adductor and the deep head of the short flexor. Palmaris and the interossei are innervated by the ulnar nerve.

Question 66

278 of 610 A 53 year old man with a chronically infected right kidney is due to undergo a nephrectomy. Which of the following structures would be encountered first during a posterior approach to the hilum of the right kidney?

Answer 66

Ureter The ureter is the most posterior structure at the hilum of the right kidney and would therefore be encountered first during a posterior approach.

Question 67

279 of 610 A 44 year old lady who works as an interior decorator has undergone a mastectomy and axillary node clearance to treat breast cancer. Post operatively, she comments that her arm easily becomes fatigued when she is painting walls. What is the most likely explanation?

Answer 67

Injury to the thoracodorsal nerve The most likely explanation for this is that the thoracodorsal nerve has been injured. This will result in atrophy of latissimus dorsi and this will become evident with repetitive arm movements where the arm is elevated and moving up and down (such as in painting). Injury to the pectoral nerves may produce a similar picture but this pattern of injury is very rare and the pectoral nerves are seldom injured in breast surgery.

Question 68

280 of 610 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 68

Great saphenous vein Deep circumflex iliac artery(Right) Superficial circumflex iliac artery Femoral vein Femoral branch of the genitofemoral nerve ……………………………………………. 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 68

281 of 610 The integrity of which muscle is assessed by the Trendelenburg test?

Answer 68

Gluteus medius

Question 69

282 of 610 A man is undergoing excision of a sub mandibular gland. As the gland is mobilised, a vessel is injured lying between the gland and the mandible. Which of the following is this vessel most likely to be?

Answer 69

Facial artery The high salivary viscosity of submandibular gland secretions favors stone formation. Most stones are radio-opaque. The marginal mandibular nerve is the most superficial structure. The facial artery lies between the gland and mandible and is often ligated during excision of the gland. The lingual artery may be encountered but this is usually later in the operative process as Whartons duct is mobilised.

Question 70

283 of 610 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 70

Femoral nerve This is a classical description of a femoral nerve injury.

Question 71

284 of 610 A 62 year old man is undergoing a left hemicolectomy for carcinoma of the descending colon. The registrar commences mobilisation of the left colon by pulling downwards and medially. Blood soon appears in the left paracolic gutter. The most likely source of bleeding is the:

Answer 71

Spleen The spleen is commonly torn by traction injuries in colonic surgery. The other structures are associated with bleeding during colonic surgery but would not manifest themselves as blood in the paracolic gutter prior to incision of the paracolonic peritoneal edge.

Question 72

285 of 610 Which of the following structures attaches periosteum to bone?

Answer 72

Sharpeys fibres Periosteum is attached to bone by strong collagenous fibers called Sharpey's fibres, which extend to the outer circumferential and interstitial lamellae. It also provides an attachment for muscles and tendons.

Question 72

286 of 610 A 23 year old man falls and injures his hand. There are concerns that he may have a scaphoid fracture as there is tenderness in his anatomical snuffbox on clinical examination. Which of the following forms the medial border of this structure?

Answer 72

Extensor pollicis longus It's boundaries are extensor pollicis longus medially and laterally by the tendons of abductor pollicis longus and extensor pollicis brevis.

Question 73

287 of 610 A 56 year old man is having a long venous line inserted via the femoral vein into the right atrium for CVP measurements. The catheter is advanced through the IVC. At which of the following levels does this vessel enter the thorax?

Answer 73

T8 The IVC passes through the diaphragm at T8.

Question 74

288 of 610 Which of the following relationship descriptions regarding the scalene muscles is incorrect?

Answer 74

The brachial plexus passes anterior to the middle scalene muscle The phrenic nerve lies anterior to the anterior scalene muscle The subclavian artery passes posterior to the middle scalene(Right) The subclavian vein lies anterior to the anterior scalene muscle at the level of the first rib The anterior scalene inserts into the first rib .................................................................... The subclavian artery passes anterior to the middle scalene.

Question 75

289 of 610 A 16 year old boy is hit by a car and sustains a blow to the right side of his head. He is initially conscious but on arrival in the emergency department is comatose. On examination his right pupil is fixed and dilated. The neurosurgeons plan immediate surgery. What type of initial approach should be made?

Answer 75

Right parieto-temporal craniotomy A unilateral dilated pupil is a classic sign of transtentorial herniation. The medial aspect of the temporal lobe (uncus) herniates across the tentorium and causes pressure on the ipsilateral oculomotor nerve, interrupting parasympathetic input to the eye and resulting in a dilated pupil. In addition the brainstem is compressed. As the ipsilateral oculomotor nerve is being compressed, craniotomy (rather than Burr Holes) should be made on the ipsilateral side.

Question 75

290 of 610 From which embryological structure is the ureter derived?

Answer 75

Mesonephric duct The ureter develops from an outpouching that arises from the mesonephric duct. The mesonephric duct is associated with the metanephric duct that develops within the metenephrogenic blastema. This forms the site of the ureteric bud which branches off the mesonephric duct.

Question 76

291 of 610 The following muscles are supplied by the recurrent laryngeal nerve except:

Answer 76

Transverse arytenoid Posterior crico-arytenoid Cricothyroid(Right) Oblique arytenoid Thyroarytenoid ……………………………………… Innervates: all intrinsic larynx muscles (excluding cricothyroid) The external branch of the superior laryngeal nerve innervates the cricothyroid muscle.

Question 77

292 of 610 A 23 year old man falls over whilst intoxicated and a shard of glass transects his median nerve at the proximal border of the flexor retinaculum. His tendons escape injury. Which of the following features is least likely to be present?

Answer 77

Weakness of thumb abduction Loss of sensation on the dorsal aspect of the thenar eminence(Right) Loss of power of opponens pollicis Parasthesia of the palmar aspect of the second digit Loss of power of abductor pollicis brevis ………………………………….. The median nerve may be injured proximal to the flexor retinaculum. This will result in loss of abductor pollicis brevis, flexor pollicis brevis, opponens pollicis and the first and second lumbricals. When the patient is asked to close the hand slowly there is a lag of the index and middle fingers reflecting the impaired lumbrical muscle function. The sensory changes are minor and do not extend to the dorsal aspect of the thenar eminence. Abductor pollicis longus will contribute to thumb abduction (and is innervated by the posterior interosseous nerve) and therefore abduction will be weaker than prior to the injury.

Question 77

293 of 610 What is the level of the hyoid bone?

Answer 77

C3

Question 78

294 of 610 A 28 year teacher reports difficulty with writing. There is no sensory loss. She is known to have an aberrant Gantzer muscle. Which of the following nerves has been affected?

Answer 78

Anterior interosseous Anterior interosseous lesions occur due to fracture, or rarely due to compression. The Gantzer muscle is an aberrant accessory of the flexor pollicis longus and is a risk factor for anterior interosseous nerve compression. Remember loss of pincer grip and normal sensation indicates an interosseous nerve lesion.

Question 79

296 of 610 An 18 year old male presents to casualty with a depressed skull fracture. This is managed surgically. Over the next few days he complains of double vision on walking down stairs and reading. On testing ocular convergence, the left eye faces downwards and medially, but the right side does not do so. Which of the nerves listed below is most likely to be responsible?

Answer 79

Trochlear The trochlear nerve has a relatively long intracranial course and this makes it vulnerable to injury in head trauma. Head trauma is the commonest cause of an acute fourth nerve palsy. A 4th nerve palsy is the commonest cause of a vertical diplopia. The diplopia is at its worst when the eye looks medially which it usually does as part of the accommodation reflex when walking down stairs.

Question 79

295 of 610 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 79

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

Question 79

297 of 610 Which of the following structures accompanies the posterior interventricular artery within the posterior interventricular groove?

Answer 79

Middle cardiac vein

Question 79

298 of 610 Which of the following structures is not closely related to the piriformis muscle?

Answer 79

Superior gluteal nerve Sciatic nerve Inferior gluteal artery Inferior gluteal nerve Medial femoral circumflex artery(Right) …………………………………………… 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 80

299 of 610 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 80

S1 and S2