9- Mixed Anatomy (3)MSQs Only Flashcards
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?
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.
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?
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.
202 of 610
In relation to the middle cranial fossa, which of the following statements relating to the foramina is incorrect?
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.
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?
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.
204 of 610
Where are accessory spleens not found?
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
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?
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.
206 of 610
Which of the following muscles is not innervated by the ansa cervicalis?
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.
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?
Rectus abdominis muscle
Direct inguinal hernias pass through Hesselbachs triangle (although this is of minimal clinical significance!). Its medial boundary is the rectus muscle.
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?
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.
209 of 610
Which of the following most commonly arises from the brachiocephalic artery?
Thyroidea ima artery
Other occasional branches include the thymic and bronchial branch.
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?
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.
211 of 610
Which muscle is not innervated by the trigeminal nerve?
Medial pterygoid
Mylohyoid
Stylohyoid(Right)
Masseter
Temporalis
…………………………………………..
Stylohyoid is innervated by the facial nerve.
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?
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.
216 of 610
Into which of these veins does the middle thyroid vein drain?
Internal jugular
It drains to the internal jugular vein. Which is one of the reasons why it bleeds so copiously if a ligature slips.
213 of 610
From which of the following structures does the long head of the triceps muscle arise?
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.
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?
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.
215 of 610
Which of the following structures is not at the level of the transpyloric plane?
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.
217 of 610
As it exits the axilla the radial nerve passes over the inferior border which of the muscles listed below?
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.
218 of 610
Which of the following statements about the spleen is false?
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.
219 of 610
The recurrent laryngeal is connected to which of the following nerves?
Vagus
220 of 610
Which of these statements relating to the external carotid is false?
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.
221 of 610
A 63 year old man is due to undergo a splenectomy. Which splenic structure lies most posteriorly?
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.
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?
Lesser trochanter of the femur
The psoas major inserts into the lesser trochanter.
223 of 610
Which of the following is not a content of the anterior triangle of the neck?
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.
224 of 610
During embryological development, which of the following represent the correct origin of the pancreas?
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.
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?
Axillary
The Axillary nerve winds around the bone at the neck of the humerus. The axillary nerve is also at risk during shoulder dislocation.
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?
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.
227 of 610
Which of the following is not a direct branch of the facial nerve?
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
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?
Extension of the knee joint
The femoral nerve supplies the quadriceps muscle which is responsible for extension at the knee joint.
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?
Ilioinguinal
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?
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.
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?
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.
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.
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).
233 of 610
How many unpaired branches leave the abdominal aorta to supply the abdominal viscera?
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.
234 of 610
Which of the following muscles is not within the posterior compartment of the lower leg?
Peroneus brevis(Right)
Flexor digitorum longus
Soleus
Popliteus
Flexor hallucis longus
………………………………………..
Peroneus brevis lies in the lateral compartment.
235 of 610
Which of these muscles is not a component of the rotator cuff?
Subscapularis
Teres minor
Supraspinatus
Infraspinatus
Deltoid(Right)
………………………………..
Deltoid may abduct the shoulder and is not a rotator cuff muscle.
236 of 610
Which of the nerves listed below is responsible for the innervation of gluteus medius?
Superior gluteal nerve
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?
Femoral vein
The canal exists to allow for the physiological expansion of the femoral vein, which lies lateral to it.
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?
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.
239 of 610
Which of the following structures are not closely related to the adductor longus muscle?
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.
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?
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.
241 of 610
Which of the following is not a carpal bone?
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.
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?
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.
243 of 610
A 23 year old man has a cannula inserted into his cephalic vein. Through which structure does the cephalic vein pass?
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.
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?
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.
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?
Deep ulnar nerve
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?
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.
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?
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.
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:
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.
248 of 610
Which of the following statements relating to sartorius is untrue?
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.
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?
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
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?
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.
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?
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.
253 of 610
Which of these openings transmits the afferent part of the facial nerve into the temporal bone?
Internal acoustic meatus
It enters the temporal bone through the internal acoustic meatus and exits through the stylomastoid foramen.
254 of 610
In a patient with a carcinoma of the distal sigmoid colon, what is the most likely source of its blood supply?
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.
255 of 610
Which nerve is at risk during submandibular gland excision?
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.
256 of 610
Which of the following is not a content of the posterior triangle of the neck?
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.
257 of 610
Which of the muscles below does not cause lateral rotation of the hip?
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.
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?
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.
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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?
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.
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?
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.
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?
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.
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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?
Sub mental nodes
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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?
Sartorius
At the lower border of the femoral triangle the femoral artery passes under the sartorius muscle. This can be retracted to improve access.
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?
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.
265 of 610
Which of the following is not a branch of the posterior cord of the brachial plexus?
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.
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?
Left renal vein
The left renal vein runs across the surface of the aorta and may require deliberate ligation during juxtarenal aneurysm repair.
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?
External iliac artery
The vessel damaged is the epigastric artery. This originates from the external iliac artery (see below).
268 of 610
Which statement is false about the foramina of the skull?
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
269 of 610
Which of the following does not exit the pelvis through the greater sciatic foramen?
Superior gluteal artery
Internal pudendal vessels
Sciatic nerve
Obturator nerve(Right)
Inferior gluteal nerve
…………………………………………
The obturator nerve exits through the obturator foramen.
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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?
Inferior phrenic artery
The superior adrenal artery is a branch of the inferior phrenic artery.
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In the distal third of the upper arm, where is the musculocutaneous nerve located?
Between the biceps brachii and brachialis muscles
The musculocutaneous nerve lies between the biceps and brachialis muscles.
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Which of the following statements relating to the knee joint is false?
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.
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Which of the following regions of the male urethra is entirely surrounded by Bucks fascia?
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.
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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?
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)
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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?
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”)
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The common peroneal nerve, or its branches, supply the following muscles except:
Peroneus longus
Tibialis anterior
Extensor hallucis longus
Flexor digitorum brevis( Right)
Extensor digitorum longus
………………………………………………
Flexor digitorum is supplied by the tibial nerve.
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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?
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.
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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?
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.
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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?
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.
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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?
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.
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The integrity of which muscle is assessed by the Trendelenburg test?
Gluteus medius
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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?
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.
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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?
Femoral nerve
This is a classical description of a femoral nerve injury.
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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:
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.
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Which of the following structures attaches periosteum to bone?
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.
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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?
Extensor pollicis longus
It’s boundaries are extensor pollicis longus medially and laterally by the tendons of abductor pollicis longus and extensor pollicis brevis.
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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?
T8
The IVC passes through the diaphragm at T8.
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Which of the following relationship descriptions regarding the scalene muscles is incorrect?
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.
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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?
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.
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From which embryological structure is the ureter derived?
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.
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The following muscles are supplied by the recurrent laryngeal nerve except:
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.
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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?
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.
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What is the level of the hyoid bone?
C3
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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?
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.
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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?
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.
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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?
Extensor hallucis longus tendon
The extensor hallucis longus tendon lies medial to the dorsalis pedis artery.
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Which of the following structures accompanies the posterior interventricular artery within the posterior interventricular groove?
Middle cardiac vein
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Which of the following structures is not closely related to the piriformis muscle?
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.
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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?
S1 and S2
