Clinical Anatomy Problems

Question 1

A sick college freshman comes to see you with headache, fever and vomiting. Upon physical examination you note stiffness in his neck. You decide to do a spinal tap to see if he has meningitis. When doing the procedure, how do you want to position the patient and why?

Answer 1

You will put the patient in the fetal position lying on one side. This is so you can open up the posterior space between the lumbar vertebrae and stretch out the ligamentum flavum so it is easier to get the needle into the lumbar cistern.

Question 2

A 55 year old male comes to the ER complaining of onset of paralysis in his legs and incontinence. Personal history only indicates atherosclerosis and a previous heart attack. What is the most likely cause of paralysis?

Answer 2

Obstructive arterial disease can occlude segmental medullary arteries that supply blood to the spinal cord (specifically the great anterior medullary artery of Adamkeiwicz). Blockage of blood supply to nerves = paralysis.

Question 3

A 16 year old female comes to see you after taking a fall during gymnastics. She complains of back pain that she cannot resolve with Ibuprofen. You order an X-ray and note spondylolysis. What bone has she broken?

Answer 3

The pars interarticularis of the vertebrae

Question 4

You wake up after a party and see your buddy passed out with his arm hanging over a chair. He wakes up and tells you he cannot hold anything with that hand. He looks at you and says, it just needs to wake up. What do you tell him?

Answer 4

He compressed his radial nerve all night and nerve compressions are serious injuries that are sometimes not recoverable.

Question 5

After a car crash, a 25 year old male has erectile dysfunction. You suspect it is due to a nerve injury. Trace the path of the nerve from the effector organ to where signal should initiate.

Answer 5

Moving up the axon from the synaptic cleft in the effector organ, you will soon hit the post-synaptic neuron cell body in ganglia that resides near the effector organ. Moving up that you hit the axon of the presynaptic neuron that came a long way from the sacrum.

Question 6

You are performing an epidural anesthetic injection for a laboring pregnant woman. She jerks due to a contraction while you have the needle in her back but she is uninjured. Minutes later she experiences a horrible onset of headaches. Through what layer in the spinal cord did your needle go through when she jerked?

Answer 6

The arachnoid matter. Puncturing this layer allows CSF contained in the subarachnoid space to leak out and put pressure on the spinal cord, resulting in a dural headache.

Question 7

You are performing a cordotomy on a patient with lots of pressure and pain in his legs. What landmark do you use to make sure you cut the right nerve and which nerve do you want to cut?

Answer 7

You use the denticulate ligament as a landmark for the dorsal and ventral roots. You want to cut the dorsal root because it is sensory.

Question 8

A 22 year old football player comes to see you complaining of acute low back pain after competing in a dead lift competition. After telling him he has a “slipped disc”, he tells you he is premed and wants to know what actually happened. What do you say?

Answer 8

When he leans forward to perform the dead lift the flexion of the spine pushes the nucleus pulposis in his disc posteriorly and it creates pressure against the annulus fibrosus. When he lifts, the annulus fibrosus breaks, fluid from the nucleus pulposis is ejected into the vertebral canal and pressure on spinal nerves creates this acute pain.

Question 9

A high school football player gets hit in the head and instantly cannot move anymore. What are likely mechanisms of paralysis from getting hit in the head?

Answer 9

Fractured dens, torn transverse ligament or torn alar ligament.

Question 10

A patient gets into a car accident and claims they had sever whiplash and want to sue the person that hit them. What do you recommend before she goes on to sue?

Answer 10

Get an MRI to use as evidence that the anterior longitudinal ligament was torn due to whiplash.

Question 11

A 23 year old medic was injured in an IED blast and you think he may have broken his lower back. What is the most likely vertebrae to be broken in a blast?

Answer 11

T12. It is the link between the stiff thoracic vertebrae and the flexible lumbar vertebrae.

Question 12

A baby does not learn to walk until two years old. What effect might this have on the development of the child’s spine?

Answer 12

When babies are born the entire spine is kyphosis. Learning to lift their head develops cervical lordosis and walking develops lumbar lordosis. This child may have decreased lumbar lordosis.

Question 13

A 65 year old woman complains of chronic low back pain. The radiograph indicates extensive osteoarthritis and you decide to perform a rhizotomy on the patient’s low back spinal nerves to relieve her pain. Which joints will be denervated by your treatment?

Answer 13

Zygopophyseal joints. These are the joints between the SAP and IAP of the vertebrae and often become arthritic and cause low back pain.

Question 14

You diagnose a patient with HNP. What joint does this patient have a problem with?

Answer 14

Symphyseal joint. These “joints” are just your discs.

Question 15

A patient experiencing low back pain requests that you give them a caudal epidural steroid injection. You agree that it could help and do the procedure. Where do you inject the steroid and where does it go?

Answer 15

You enter through the sacral hiatus, pierce the sacrococcygeal ligament and inject steroid in the space where the cauda equina resides.

Question 16

What cervical joints are highly susceptible to development of osteophytes?

Answer 16

Uncovertebral joints on the vertebral body

Question 17

Twin brothers both diagnosed with connective tissue disorders come to see you. One is having issues with hyperflexion of his AA joint and the other with hyperextension of his AA joint. Which tendons are experiencing problems in these brothers?

Answer 17

The anterior longitudinal ligament in the spine prevents hyperextension and the posterior longitudinal ligament prevents hyperflexion.

Question 18

People often say, use your legs not your back when lifting heavy things. Exactly what muscles of the back are they telling you that your should not use?

Answer 18

Erector spinae (Iliocostalis, longissimus, semispinalis) because they put pressure on the ligaments in your back when flexed

Question 19

Regardless of the level, what structure do you want to be inferior to when performing a spinal tap?

Answer 19

Conus medullaris in the lumbar cistern. This is the terminal end of the spinal cord.

Question 20

A soldier is hit by an IED and nerves severed by shrapnel. What is the highest nerve level that could be severed where he could still self feed?

Answer 20

C6-C8. C4-C5 results in quadriplegia.

Question 21

You see a patient who was bucked from a bull in a rodeo. His arm hangs to the side and the lateral part of his forearm has lost sensation. What muscles have been affected in this injury?

Answer 21

This is likely an upper brachial plexus injury (Erb-Duchenne Palsy). This happens as a result of trauma pulling or stretching the C5 and C6 portions of the plexus away from the spinal cord. This results in loss of function in the deltoid, biceps and brachialis muscles.

Question 22

Your friend calls you while backpacking with a pack full of canned food. He tells you he started having muscle spasms in his arm after ten hours of hiking. What is likely being damaged by his heavy backpack?

Answer 22

This is due to chronic injury to superior portions of the brachial plexus that result in Backpacker’s Palsy. The weight of the backpack results in damage to the musculocutaneous and radial nerves.

Question 23

A patient comes in the day after receiving a vaccination complaining of muscle weakness in her arm. It started as severe shoulder pain the night before. What do you think her condition is?

Answer 23

Acute brachial plexus neuritis.

Question 24

You see a patient who spent the day painting the ceiling in his house. He complains of tingling down his arm and weak grip. You note that his arm is erythematous. Why did painting his ceiling cause these problems?

Answer 24

The cords of the brachial plexus were likely compressed between the coracoid process and pectoralis minor tendon.

Question 25

After grandma slipped on a sheet of ice, she reached up to grab a hand rail to break her fall. Though her fall was broken, she complained that her hand was clumsy for days thereafter.

Answer 25

When she fell she likely avulsed the lower nerves (C8,T1) of the brachial plexus, this causes Klumpke Paralysis: damage to areas supplied by the ulnar nerve. Another finding could be claw hand.

Question 26

A 50 year old woman comes to see you with red, tender streaks in her left arm after gardening the day before. She knows she is cancer free because she has had regular check ups with her oncologist. What could be causing these symptoms?

Answer 26

This sounds like lymphangitis. She could have gotten an infection in her arm from a scrape while gardening that moved to her lymph node and caused it to become inflamed.

Question 27

After doing a biopsy of a woman’s axillary lymph node, she experiences swelling in that arm over the next few days? What is happening to her arm?

Answer 27

This is a result of taking out the lymph node and lymph fluid building up in the arm: lymphedema.

Question 28

A skateboarder comes to the ER after falling off a handrail he was grinding. You look at an X-ray and he has broken the surgical neck of the humerus. What nerve are you worried about with this break? How could you tell if his break was more distal that the surgical neck of the humerus without X-ray?

Answer 28

Axillary nerve. If the break was more distal you’d worry about the radial nerve and would see wrist drop.

Question 29

What nerve or blood supply may be compromised if you cannot screw a screw into a piece of wood?

Answer 29

Screwing a screw is a motion of supination which is controlled by the biceps brachii. This muscle is innervated by the musculocutaneous nerve and receives blood supply from the muscular branches of the brachial artery.

Question 30

A norteno is stabbed in the armpit during a gang fight. The bleeding is controlled and he thinks he will be fine to not go to the hospital. Once the wound is healed, he still experiences weakness when picking up a glass of water to drink and when screwing a screw in with a screwdriver. How did the stabbing produce these symptoms and what is still allowing him to weakly perform these actions?

Answer 30

The knife likely penetrated the musculocutaneous nerve which innervates the coracobrachialis, long and short heads of the biceps, and brachialis. These are all involved in flexion of the forearm and supination, which the patient is having trouble with. He is still able to do these things weakly because the brachioradialis has limited function in these movements and is innervated by the radial nerve (C6-C7).

Question 31

If you are a concert pianist, which nerve do you really not want severed in a car accident? If it had to be severed in the upper arm where would you hope it happened?

Answer 31

The radial nerve. It supplies innervation to triceps, brachioradialis, and extensor/supinator muscles of the forearm and hand. You would hope it was severed below the radial groove so you could preserve all of the triceps except the medial head.

Question 32

You are preparing to do an IV on a patient and are aiming for a prominent vein in their elbow. What veins come together to make this vein?

Answer 32

The cephalic and basilic veins converge to form the median vein.

Question 33

You are rotating in the ER and see a patient who was in a motorcycle accident. He was thrown against a curb, causing the acromion to go one way and his neck to go the other. What

Answer 33

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