anatomy 18.04 part 2

Question 1

A 73 year old man develops a lesion affecting the lobule of his ear. Into which of the following lymph node groups will the lesion drain?

Deep cervical

Superficial cervical

Retroauricular nodes

Occipital nodes

Internal jugular nodes

Answer 1

The lobule of the ear drains to the superficial cervical nodes.

The lateral surface of the upper half drains to the superficial parotid lymph nodes
The cranial surface of the superior half drains to the mastoid nodes and deep cervical lymph nodes
The lower half and lobule drain into the superficial cervical lymph nodes.

Question 2

Which of the following options in relation to the liver is true?

Ligamentum venosum is an anterior relation of the liver

The portal triad comprises the hepatic artery, hepatic vein and tributary of the bile duct

The liver is completely covered by peritoneum

There are no nerves within the porta hepatis

The caudate lobe is superior to the porta hepatis

Answer 2

‘VC goes with VC’

The ligamentun Venosum and Caudate is on same side as Vena Cava [posterior].
Ligamentum venosum is posterior to the liver. The portal triad contains the portal vein rather than the hepatic vein. There is the ‘bare area of the liver’ created by a void due to the coronary ligament layers being widely separated. There are sympathetic and parasympathetic nerves in the porta hepatis.

Question 3

A surgical resection specimen is analysed histologically. The pathologist comments that at the periphery of the resected specimen, oxyphil cells are identified. In which of the structures listed below are these cells typically found?

Thymus

Thyroid gland

Parathyroid gland

Lymph node

Adrenal gland

Answer 3

Oxyphil cells are typically found in parathyroid glands

Question 4

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

It lies superficial to the prevertebral layer of deep cervical fascia

Crosses posterior to the 2nd part of the subclavian artery

It runs on the anterior surface of the anterior scalene muscle

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

The right phrenic nerve passes over the right atrium

Answer 4

The question asks which statement is false. The phrenic nerve descends on scalenus anterior posterolateral to the IJV and passing anterior to the cervical pleura and the second part of the subclavian artery, behind the subclavian vein. The question branch stated that the nerve passed posterior to the artery (which is false) and this is therefore the correct answer.

Question 5

How many compartments are there in the lower leg?

2

1

3

5

4

Answer 5

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

Question 6

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

Soleus posteriorly

Tibial nerve laterally

Deep peroneal nerve laterally

Flexor hallucis longus postero-inferiorly

Popliteus

Answer 6

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

Question 7

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

L4 to S3

L1 to L4

L3 to S1

S1 to S4

L5 to S1

Answer 7

The sciatic nerve most commonly arises from L4 to S3.

Question 8

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

Three groups of ligaments provide mechanical stability

The sural nerve lies medial to the Achilles tendon at its point of insertion

Eversion of the foot occurs at the sub talar joint

The flexor hallucis longus tendon is the most posterior structure at the medial malleolus

The saphenous nerve crosses the ankle joint.

Answer 8

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

Question 9

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

Main bronchi

Arch of the azygos vein

Thoracic duct

Pericardium

Aortic root

Answer 9

The thoracic duct lies within the posterior and superior mediastinum.

Question 10

A 23 year old lady with sialolithiasis of the submandibular gland is undergoing excision of the gland. Which of the following nerves is at risk as the duct is mobilised?

Lingual nerve

Buccal nerve

Facial nerve

Glossopharyngeal

Vagus

Answer 10

The lingual nerve wraps around Whartons duct. The lingual nerve provides sensory supply to the anterior 2/3 of the tongue.

Question 11

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

Vagus nerve

Submandibular gland

Phrenic nerve

Internal jugular vein

Hypoglossal nerve

Answer 11

The phrenic nerve is a content of the posterior triangle. The anterior triangle contains the carotid sheath and its contents.

Question 12

A 53 year old man is undergoing a left hemicolectomy for carcinoma of the descending colon. From which embryological structure is this region of the gastrointestinal tract derived?

Vitellino-intestinal duct

Hind gut

Mid gut

Fore gut

Woolffian duct

Answer 12

The left colon is embryologically part of the hind gut. Which accounts for its separate blood supply via the IMA.

Question 13

A 56 year old man is left impotent following an abdomino-perineal excision of the colon and rectum. What is the most likely explanation?

Psychosexual issues related to an end colostomy

Damage to the sacral venous plexus during total mesorectal excision

Damage to the left ureter during sigmoid mobilisation

Damage to the hypogastric plexus during mobilisation of the inferior mesenteric artery

Damage to the internal iliac artery during total mesorectal excision

Answer 13

Autonomic nerve injury is the most common cause.

Question 14

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

Superior mesenteric vein

Portal vein

Inferior mesenteric vein

Inferior vena cava

Ileocolic vein

Answer 14

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

Question 15

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?

Middle cerebral artery

Internal carotid artery

Anterior cerebral artery

Maxillary artery

Mandibular artery

Answer 15

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 16

A 56 year old lady is due to undergo a left hemicolectomy for carcinoma of the splenic flexure. The surgeons decide to perform a high ligation of the inferior mesenteric vein. Into which of the following does this structure usually drain?

Portal vein

Inferior vena cava

Left renal vein

Left iliac vein

Splenic vein

Answer 16

Beware of ureteric injury in colonic surgery.
The inferior mesenteric vein drains into the splenic vein, this point of union lies close to the duodenum and this surgical maneouvre is a recognised cause of ileus.

Question 17

A 22 year old falls over and lands on a shard of glass. It penetrates the palmar aspect of his hand, immediately lateral to the pisiform bone. Which of the following structures is most likely to be injured?

Palmar cutaneous branch of the median nerve

Lateral tendons of flexor digitorum superficialis

Ulnar artery

Flexor carpi radialis tendons

Lateral tendons of flexor digitorum profundus

Answer 17

The ulnar nerve and artery are at most immediate risk in this injury. This is illustrated in the image below:

Question 18

Which of the following structures attaches periosteum to bone?

Sharpey’s fibres

Peripheral lamellae

Elastic fibres

Fibrolamellar bundles

Purkinje fibres

Answer 18

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 19

Which of the following muscles lies medial to the long thoracic nerve?

Serratus anterior

Latissimus dorsi

Coracobrachialis

Pectoralis minor

None of the above

Answer 19

Serratus anterior

Question 20

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:

Marginal artery

Left testicular artery

Spleen

Left renal vein

None of the above

Answer 20

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 21

A 73 year old man undergoes a sub total oesophagectomy with anastomosis of the stomach to the cervical oesophagus. Which vessel will be primarily responsible for the arterial supply to the oesophageal portion of the anastomosis?

Superior thyroid artery

Internal carotid artery

Direct branches from the thoracic aorta

Inferior thyroid artery

Subclavian artery

Answer 21

The cervical oesophagus is supplied by the inferior thyroid artery. The thoracic oesophagus (removed in this case) is supplied by direct branches from the thoracic aorta.

Question 22

Which structure separates the cephalic vein and the brachial artery in the antecubital fossa?

Brachioradialis muscle

Bicipital aponeurosis

Origin of flexor digitorum profundus muscle

Pronator quadratus muscle

Origin of flexor digitorum superficialis muscle

Answer 22