EMRCS Flashcards
Which of the following nerves supplies the skin on the palmar aspect of the thumb?
Ulnar Median Radial Musculocutaneous None of the above
Answer: B
The median nerve supplies cutaneous sensation to this region.
The superior aspect of the vagina drains to which of the following lymph node groups?
Superficial inguinal nodes Para-aortic nodes Internal iliac nodes Meso rectal nodes Obturator nodes
Ans: C
The lymph vessels from the superior aspect of the vagina join the internal and external iliac nodes, those from the inferior aspect of the vagina drain to the superficial inguinal nodes.
Which of the following structures is not transmitted by the jugular foramen?
Hypoglossal nerve Accessory nerve Internal jugular vein Inferior petrosal sinus Vagus nerve
Ans: A
Contents of the jugular foramen:
Anterior: inferior petrosal sinus
Intermediate: glossopharyngeal, vagus, and accessory nerves
Posterior: sigmoid sinus (becoming the internal jugular vein) and some meningeal branches from the occipital and ascending pharyngeal arteries
The jugular foramen may be divided into three compartments:
Anterior compartment transmits the inferior petrosal sinus
Middle compartment transmits cranial nerves IX, X and XI
Posterior compartment transmits the sigmoid sinus
A 19 year old female is admitted with suspected meningitis. The House Officer is due to perform a lumbar puncture. What is the most likely structure first encountered when the needle is inserted?
Ligamentum flavum Denticulate ligament Dural sheath Pia Mater Supraspinous ligament
Ans: E
Lumbar punctures are performed to obtain cerebrospinal fluid. In adults, the procedure is best performed at the level of L3/L4 or L4/5 interspace. These regions are below the termination of the spinal cord at L1.
During the procedure the needle passes through:
The supraspinous ligament which connects the tips of spinous processes and the interspinous ligaments between adjacent borders of spinous processes
Then the needle passes through the ligamentum flavum, which may cause a give as it is penetrated
A second give represents penetration of the needle through the dura mater into the subarachnoid space. Clear CSF should be obtained at this point
A 45 year old motor cyclist sustains a tibial fracture and is noted to have anaesthesia of the web space between his first and second toes. Which of the nerves listed below is most likely to be compromised?
Superficial peroneal nerve Deep peroneal nerve Sural nerve Long saphenous nerve Tibial nerve
Ans: B
The deep peroneal nerve lies in the anterior muscular compartment of the lower leg and can be compromised by compartment syndrome affecting this area. It provides cutaneous sensation to the first web space. The superficial peroneal nerve provides more lateral cutaneous innervation.
A 63 year old lady is undergoing an axillary sentinel lymph node biopsy as part of her breast cancer treatment. Which of the structures listed below is most likely to be encountered?
Subclavian artery Intercostobrachial nerve Upper cord of the brachial plexus Lower cord of the brachial plexus Axillary nerve
Answer: B
This can be a challenging question. A particularly careless surgeon could encounter all of these. However, during a routine level 1 axillary exploration which is where the majority of sentinel nodes will be located, the nerves most commonly encountered are the intercostobrachial nerves.
A patient undergoes a femoral hernia repair and at operation the surgeon decides to enter the abdominal cavity to resect small bowel. She makes a transverse incision two thirds of the way between umbilicus and the symphysis pubis. Which of the structures listed below is least likely to be divided?
Rectus abdominis External oblique aponeurosis Peritoneum Fascia transversalis Posterior lamina of the rectus sheath
Answer: E
An incision at this level lies below the arcuate line and the posterior wall of the rectus sheath is deficient at this level.
What is the lymphatic drainage of the ovaries?
Internal iliac nodes Common iliac nodes Para-aortic nodes Para uterine nodes Inguinal nodes
Ans: C
The lymphatic drainage of the ovary follows the gonadal vessels and drainage is therefore to the para-aortic nodes.
A 35 year old farm labourer injures the posterior aspect of his hand with a mechanical scythe. He severs some of his extensor tendons in this injury. How many tunnels lie in the extensor retinaculum that transmit the tendons of the extensor muscles?
One Three Four Five Six
Answer: E
There are six tunnels, each lined by its own synovial sheath.
A 23 year old man undergoes an orchidectomy. The right testicular vein is ligated; into which structure does it drain?
Right renal vein Inferior vena cava Common iliac vein Internal iliac vein External iliac vein
Ans: B
The testicular venous drainage begins in the septa and these veins together with those of the tunica vasculosa converge on the posterior border of the testis as the pampiniform plexus. The pampiniform plexus drains to the testicular vein. The left testicular vein drains into the left renal vein. The right testicular vein drains into the inferior vena cava.
Which of the muscles listed below is not innervated by the median nerve?
Flexor pollicis brevis Lateral two lumbricals Pronator teres Opponens pollicis Adductor pollicis
Ans: E
Adductor pollicis is innervated by the ulnar nerve.
Medial two lumbricals innervated by the ulnar nerve.
A 44 year old lady is undergoing an abdominal hysterectomy and the ureter is identified during the ligation of the uterine artery. At which site does it insert into the bladder?
Posterior Apex Anterior Base Superior aspect of the lateral side
Ans: D
The ureters enter the bladder at the upper lateral aspect of the base of the bladder. They are about 5cm apart from each other in the empty bladder. Internally this aspect is contained within the bladder trigone.
A 23 year old man is involved in a fight outside a nightclub and sustains a laceration to his right arm. On examination, he has lost extension of the fingers in his right hand. Which of the nerves listed below is most likely to have been divided?
Median Musculocutaneous Radial Ulnar Axillary
Ans: C
The radial nerve supplies the extensor muscle group.
What is the correct embryological origin of the stapes?
First pharyngeal arch Second pharyngeal arch Third pharyngeal arch Fourth pharyngeal arch Fifth pharyngeal arch
Ans: B
Embryological origin stapes = 2nd pharyngeal arch
The incus is most likely to arise from the first arch.
A 72 year old man develops a foot drop after a revision total hip replacement. Which nerve is likely to have been affected?
Sciatic Femoral Obturator Superior gluteal Inferior gluteal
Ans: A
Whilst many of these nerves can be injured in hip surgery, for a foot drop to develop in this context (i.e. revision THR), the sciatic nerve is the most likely.
An injured axillary artery is ligated between the thyrocervical trunk of the subclavian and subscapular artery. Subsequent collateral circulation is likely to result in reversal of blood flow in which of the vessels listed below?
Circumflex scapular artery Transverse cervical artery Posterior intercostal arteries Suprascapular artery Profunda brachii artery
Ans: A
It’s an easy question really, we just made the wording difficult (on purpose). It is asking about the branches of the axillary artery and knowledge of the fact that there is an extensive collateral network around the shoulder joint. As a result, the occlusion of the proximal aspect of the circumflex humeral inflow (from the axillary artery) ceases and there is then retrograde flow through it from collaterals.
The circumflex scapular artery is a branch of the subscapular artery and normally supplies the muscle on the dorsal aspect of the scapula. In this instance, flow is reversed in the circumflex scapular and subscapular arteries forming a collateral circulation around the scapula.
A 20 year old lady presents with pain on the medial aspect of her thigh. Investigations show a large ovarian cyst. Compression of which of the nerves listed below is the most likely underlying cause?
Sciatic Genitofemoral Obturator Ilioinguinal Femoral cutaneous
Ans: C
The cutaneous branch of the obturator nerve is frequently absent. However, the obturator nerve is a recognised contributor to innervation of the medial thigh and large pelvic tumours may compress this nerve with resultant pain radiating distally.
A 73 year old man presents with a tumour at the central aspect of the posterior third of the tongue. To which of the following lymph node groups is it most likely to metastasise?
Submental Submandibular Ipsilateral deep cervical nodes Contralateral deep cervical nodes Bilateral deep cervical nodes
Ans: E
Posterior third tumours of the tongue commonly metastasise to the bilateral deep cervical lymph nodes
Tumours of the posterior third of the tongue will typically metastasise early and bilateral nodal involvement is well recognised, this is most often true of centrally located tumours and those adjacent to the midline as the lymph vessels may cross the median plane at this location.
A 6 month old child is brought to the surgical clinic because of non descended testes. What is the main structure that determines the descent path of the testicle?
Processus vaginalis Cremaster Mesorchium Inguinal canal Gubernaculum
Ans: E
The gubernaculum is a ridge of mesenchymal tissue that connects the testis to the inferior aspect of the scrotum. Early in embryonic development the gubernaculum is long and the testis are located on the posterior abdominal wall. During foetal growth the body grows relative to the gubernaculum, with resultant descent of the testis.
A 21 year old man undergoes surgical removal of an impacted 3rd molar. Post operatively, he is noted to have anaesthesia on the anterolateral aspect of the tongue. What is the most likely explanation?
Injury to the hypoglossal nerve Injury to the inferior alveolar nerve Injury to the lingual nerve Injury to the mandibular branch of the facial nerve Injury to the glossopharyngeal nerve
Ans: C
The lingual nerve is closely related to the third molar and up to 10% of patients undergoing surgical extraction of these teeth may subsequently develop a lingual neuropraxia. The result is anaesthesia of the ipsilateral anterior aspect of the tongue. The inferior alveolar nerve innervates the teeth themselves.
What is the most important structure involved in supporting the uterus?
Round ligament Broad ligament Uterosacral ligaments Cardinal ligaments Central perineal tendon
Ans: E
The central perineal tendon provides the main structural support to the uterus. Damage to this structure is commonly associated with the development of pelvic organ prolapse, even when other structures are intact.
A 43 year old typist presents with pain at the dorsal aspect of the upper part of her forearm. She also complains of weakness when extending her fingers. On examination triceps and supinator are both functioning normally. There is weakness of most of the extensor muscles. However, there is no sensory deficit. Which of the following nerves has been affected?
Anterior interosseous Median Posterior interosseous Palmar cutaneous Ulnar
Ans: C
The radial nerve may become entrapped in the arcade of Frohse which is a superficial part of the supinator muscle which overlies the posterior interosseous nerve. This nerve is entirely muscular and articular in its distribution. It passes postero-inferiorly and gives branches to extensor carpi radialis brevis and supinator. It enters supinator and curves around the lateral and posterior surfaces of the radius. On emerging from the supinator the posterior interosseous nerve lies between the superficial extensor muscles and the lowermost fibres of supinator. It then gives branches to the extensors.
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
Ans: C
Oxyphil cells are typically found in parathyroid glands
A 34 year old man is injured by farm machinery and sustains a laceration at the superolateral aspect of the popliteal fossa. The medial aspect of biceps femoris is lacerated. Which of the following underlying structures is at greatest risk of injury?
Gracilis Sural nerve Nerve to semimembranosus Popliteal artery Common peroneal nerve
Ans: E
The common peroneal nerve lies under the medial aspect of biceps femoris and is therefore at greatest risk of injury. The tibial nerve may also be damaged in such an injury (but is not listed here). The sural nerve branches off more inferiorly.
What is the lymphatic drainage of the male spongy urethra?
External iliac nodes Internal iliac nodes Para aortic nodes Deep inguinal nodes Meso rectal nodes
Ans: D
The lymphatic drainage of the spongy urethra and the glans penis is to the deep inguinal nodes. The prostatic and membranous urethra drains to the internal iliac nodes.
A 34 year old lady suffers from hyperparathyroidism. The right inferior parathyroid is identified as having an adenoma and is scheduled for resection. From which of the following embryological structures is it derived?
Second pharyngeal pouch Third pharyngeal pouch Fourth pharyngeal pouch First pharyngeal pouch None of the above
Ans: B
The inferior parathyroid is a derivative of the third pharyngeal pouch. The superior parathyroid originates from the fourth pharyngeal pouch.
A 23 year old man falls and slips at a nightclub. A shard of glass penetrates the skin at the level of the medial epicondyle, which of the following sequelae is least likely to occur?
Atrophy of the first dorsal interosseous muscle Difficulty in abduction of the the 2nd, 3rd, 4th and 5th fingers Claw like appearance of the hand Loss of sensation on the anterior aspect of the 5th finger Partial denervation of flexor digitorum profundus
Ans: C
Injury to the ulnar nerve in the mid to distal forearm will typically produce a claw hand. This consists of flexion of the 4th and 5th interphalangeal joints and extension of the metacarpophalangeal joints. The effects are potentiated when flexor digitorum profundus is not affected, and the clawing is more pronounced.More proximally sited ulnar nerve lesions produce a milder clinical picture owing to the simultaneous paralysis of flexor digitorum profundus (ulnar half).
This is the ‘ulnar paradox’, due to the more proximal level of transection the hand will typically not have a claw like appearance that may be seen following a more distal injury. The first dorsal interosseous muscle will be affected as it is supplied by the ulnar nerve.
A 56 year old man is undergoing a superficial parotidectomy for a pleomorphic adenoma. During the dissection of the parotid, which of the following structures will be encountered lying most superficially?
Facial nerve External carotid artery Occipital artery Maxillary artery Retromandibular vein
Ans: A
Most superficial structure on the parotid gland = facial nerve
The facial nerve is the most superficial structure in the parotid gland. Slightly deeper to this lies the retromandibular vein, with the arterial layer lying most deeply.
A 43 year old man is stabbed outside a nightclub. He suffers a transection of his median nerve just as it leaves the brachial plexus. Which of the following features is least likely to ensue?
Ulnar deviation of the wrist Complete loss of wrist flexion Loss of pronation Loss of flexion at the thumb joint Inability to oppose the thumb
Ans: B
Loss of the median nerve will result in loss of function of the flexor muscles. However, flexor carpi ulnaris will still function and produce ulnar deviation and some residual wrist flexion. High median nerve lesions result in complete loss of flexion at the thumb joint.
A 78 year old man is due to undergo an endarterectomy of the internal carotid artery. Which of the following nervous structures are most at risk during the dissection?
Recurrent laryngeal nerve Sympathetic chain Hypoglossal nerve Phrenic nerve Lingual nerve
Ans: C
Nerves at risk during a carotid endarterectomy:
Hypoglossal nerve
Greater auricular nerve
Superior laryngeal nerve
Which of the structures listed below articulates with the head of the radius superiorly?
Capitulum Trochlea Lateral epicondyle Ulna Medial epicondyle
Ans: A
The head of the radius articulates with the capitulum of the humerus.
Which of the following fascial structures encases the apex of the lungs?
Waldeyers fascia Sibsons fascia Pretracheal fascia Clavipectoral fascia None of the above
Ans: B
Sibson’s fascia overlies the apices of both lungs
The suprapleural fascia (Sibson’s fascia) runs from C7 to the first rib and overlies the apex of both lungs.It lies between the parietal pleura and the thoracic cage.
As regards the internal jugular vein, which of the following statements is untrue?
It lies within the carotid sheath It is the continuation of the sigmoid sinus The terminal part of the thoracic duct crosses anterior to it to insert into the right subclavian vein The hypoglossal nerve is closely related to it as it passes near the atlas The vagus nerve is closely related to it within the carotid sheath
Ans: C
Each jugular vein begins in the jugular foramen, where they are the continuation of the sigmoid sinus. They terminate at the medial end of the clavicle where they unite with the subclavian vein.
The vein lies within the carotid sheath throughout its course. Below the skull the internal carotid artery and last four cranial nerves are anteromedial to the vein. Thereafter it is in contact medially with the internal (then common) carotid artery. The vagus lies posteromedially.
A 28 year old man requires a urethral catheter to be inserted prior to undergoing a splenectomy. Where is the first site of resistance to be encountered on inserting the catheter?
Bulbar urethra Membranous urethra Internal sphincter Prostatic urethra Bladder neck
Ans: B
The membranous urethra is the least distensible portion of the urethra. This is due to the fact that it is surrounded by the external sphincter.
At the level of the wrist joint, which of the statements below best describes the relationship of the ulnar artery to the ulnar nerve?
It lies on its radial side It lies deep to it It lies superficial to it It lies on its ulnar side None of the above
Ans: A
In the middle of the forearm, the artery is overlapped by the flexor carpi ulnaris and on the flexor retinaculum it is covered by a superficial layer from that structure. In its distal two-thirds, flexor digitorum superficialis lies on its radial side, and the ulnar nerve is situated on its ulnar side.
A 24 year old man falls and sustains a fracture through his scaphoid bone. From which of the following areas does the scaphoid derive the majority of its blood supply?
From its proximal medial border From its proximal lateral border From its proximal posterior surface From the proximal end From the distal end
Ans: E
The blood supply to the scaphoid enters from a small non articular surface near its distal end. Transverse fractures through the scaphoid therefore carry a risk of non union.
A 21 year old man has an inguinal hernia and is undergoing a surgical repair. As the surgeons approach the inguinal canal they expose the superficial inguinal ring. Which of the following forms the lateral edge of this structure?
Inferior epigastric artery Conjoint tendon Rectus abdominis muscle External oblique aponeurosis Transversalis fascia
Ans: D
The external oblique aponeurosis forms the anterior wall of the inguinal canal and also the lateral edge of the superficial inguinal ring. The rectus abdominis lies posteromedially and the transversalis posterior to this.
A patient sustains damage to the median nerve during a carpal tunnel release. Which of the following muscles will be affected?
Abductor digiti minimi Abductor pollicis brevis Adductor pollicis Palmaris brevis Flexor digiti minimi brevis
Ans: B
Of the muscles listed, only the abductor pollicis brevis is innervated by the median. In questions like this one, ensure you don’t become confused between adductor and abductor.
Which of the following cranial venous sinuses is unpaired?
Transverse sinus Superior sagittal sinus Cavernous sinus Sigmoid sinus Inferior petrosal sinus
Ans: B
The superior sagittal sinus is unpaired
Which of the following laryngeal tumours will not typically metastasise to the cervical lymph nodes?
Glottic Supraglottic Subglottic Transglottic Aryepiglottic fold
Ans: A
The vocal cords have no lymphatic drainage and therefore this region serves as a lymphatic watershed. The supraglottic part drains to the upper deep cervical nodes through vessels piercing the thyrohyoid membrane. The sub glottic part drains to the pre laryngeal, pre tracheal and inferior deep cervical nodes. The aryepiglottic and vestibular folds have a rich lymphatic drainage and will metastasise early.
Which of the following forms the medial wall of the femoral canal?
Pectineal ligament Adductor longus Sartorius Lacunar ligament Inguinal ligament
Ans: D
Borders of the femoral canal Laterally Femoral vein Medially Lacunar ligament Anteriorly Inguinal ligament Posteriorly Pectineal ligament
Which of the structures listed below accompanies the aorta as it traverses the aortic hiatus?
Oesophagus Thoracic duct Vagal trunks Right phrenic nerve Left phrenic nerve
Ans: B
The aorta is accompanied by the thoracic duct as it traverses the aortic hiatus. The vagal trunks accompany the oesophagus which passes through the muscular part of the diaphragm on the right. The right phrenic nerve accompanies the IVC as it passes through the caval opening. The left phrenic nerve passes through the muscular part of the diaphragm anterior to the central tendon on the left.
A 67 year old man is undergoing a transurethral resection of a bladder tumour using diathermy. Suddenly during the procedure the patient’s thigh begins to twitch. Stimulation of which of the following nerves is the most likely cause?
Femoral Pudendal Sciatic Obturator Gluteal
Ans: D
The obturator nerve is most closely related to the bladder
A 5 year old boy is playing with some small ball bearings. Unfortunately, he inhales one. To which of the following lung regions is the ball most likely to settle?
Right lower lobe Left main bronchus Right upper lobe Left lower lobe None of the above
Ans: A
As the most dependent part of the right lung a small object is most likely to lodge here. Most objects will preferentially enter the right lung owing to the angle the right main bronchus takes from the trachea.
A patient presents with superior vena caval obstruction. How many collateral circulations exist as alternative pathways of venous return?
None One Two Three Four
Ans: E
There are 4 collateral venous systems:
Azygos venous system
Internal mammary venous pathway
Long thoracic venous system with connections to the femoral and vertebral veins (2 pathways)
Despite this, venous hypertension still occurs.
An 18 year old man is cutting some plants when a small piece of vegetable matter enters his eye. His eye becomes watery. Which of the following is responsible for relaying parasympathetic neuronal signals to the lacrimal apparatus?
Pterygopalatine ganglion Otic ganglion Submandibular ganglion Ciliary ganglion None of the above
Ans: A
The parasympathetic fibres to the lacrimal apparatus transit via the pterygopalatine ganglion.
Which of the nerves listed below is directly responsible for the innervation of the lateral aspect of flexor digitorum profundus?
Ulnar nerve Anterior interosseous nerve Radial nerve Median nerve Posterior interosseous nerve
Ans: B
The anterior interosseous nerve is a branch of the median nerve and is responsible for innervation of the lateral aspect of the flexor digitorum profundus.
A 45 year old lady is undergoing a Whipples procedure for carcinoma of the pancreatic head. The bile duct is transected. Which of the following vessels is mainly responsible for the blood supply to the bile duct remnant?
Cystic artery Hepatic artery Portal vein Left gastric artery None of the above
Ans: B
The bile duct has an axial blood supply which is derived from the hepatic artery and from retroduodenal branches of the gastroduodenal artery. Unlike the liver there is no contribution by the portal vein to the blood supply of the bile duct. Damage to the hepatic artery during a difficult cholecystectomy is a recognised cause of bile duct strictures. In this scenario the distal vessels have been removed as the patient is undergoing a resection.
What vessel is the origin of the middle rectal artery?
Aorta Inferior mesenteric artery Superior mesenteric artery Internal iliac artery Internal pudendal artery
Ans: D
The rectum is supplied by 3 main vessels
Superior rectal artery from inferior mesenteric artery
Middle rectal artery from the internal iliac artery
Inferior rectal artery from the internal pudendal artery
Which of the structures listed below are most closely related to the axillary nerve within the quadrangular space?
Posterior circumflex humeral vessels Axillary artery Anterior circumflex humeral vessels Radial artery Acromiothoracic artery
Ans: A
The posterior circumflex humeral vessels which are branches of the axillary artery are related to the axillary nerve within the quadrangular space.
A 43 year old lady is undergoing a total thyroidectomy for an extremely large goitre. The surgeons decide that access may be improved by division of the infra hyoid strap muscles. At which of the following sites should they be divided?
In their upper half In their lower half In the middle At their origin from the hyoid At the point of their insertion
Ans: A
Should the strap muscles require division during surgery they should be divided in their upper half. This is because their nerve supply from the ansa cervicalis enters in their lower half.
A 7 year old boy presents with right iliac fossa pain and there is a clinical suspicion that appendicitis is present. From which of the following embryological structures is the appendix derived?
Vitello-intestinal duct Uranchus Foregut Hindgut Midgut
Ans: E
The appendix is derived from the midgut
A 22 year old women has recently undergone a surgical excision of the submandibular gland. She presents to the follow up clinic with a complaint of tongue weakness on the ipsilateral side to her surgery. Which nerve has been damaged?
Hypoglossal nerve Lingual nerve Inferior alveolar nerve Facial nerve Lesser petrosal nerve
Ans: A
Three cranial nerves may be injured during submandibular gland excision.
Marginal mandibular branch of the facial nerve
Lingual nerve
Hypoglossal nerve
Hypoglossal nerve damage may result in paralysis of the ipsilateral aspect of the tongue. The nerve itself lies deep to the capsule surrounding the gland and should not be injured during an intracapsular dissection. The lingual nerve is probably at greater risk of injury. However, the effects of lingual nerve injury are sensory rather than motor.
You decide to take an arterial blood gas from the femoral artery. Where should the needle be inserted to gain the sample?
1-2 cm inferiorly to the mid point of the inguinal ligament 1-2cm inferiorly to the mid inguinal point 2cm inferomedially to the pubic tubercle 2cm superomedially to the pubic tubercle 3cm inferolaterally to the deep inguinal ring
Ans: B
The mid inguinal point is midway between the anterior superior iliac spine and the symphysis pubis
The mid inguinal point in the surface marking for the femoral artery.
A 67 year old man undergoes a carotid endarterectomy and seems to recover well following surgery. When he is reviewed on the ward post operatively he complains that his voice is hoarse. What is the most likely cause?
Damage to the accessory nerve Damage to the cervical plexus Damage to the glossopharyngeal nerve Damage to the hypoglossal nerve Damage to the vagus
Ans: E
Many of these nerves are at risk of injury during carotid surgery. However, only damage to the vagus would account for a hoarse voice.
A 25 year old man has an inguinal hernia, which of the following structures must be divided (at open surgery) to gain access to the inguinal canal?
Transversalis fascia External oblique aponeurosis Conjoint tendon Rectus abdominis Inferior epigastric artery
Ans: B
This question is asking what structure forms the anterior wall of the inguinal canal. The anterior wall is formed by the external oblique aponeurosis. Once this is divided the canal is entered, the cord can be mobilised and a hernia repair performed. The transversalis fascia and conjoint tendons form the posterior wall and would not routinely be divided to gain access to the inguinal canal itself.
Which muscle initiates abduction of the shoulder?
Infraspinatus Latissimus dorsi Supraspinatus Deltoid Teres major
Ans: C
The intermediate portion of the deltoid muscle is the chief abductor of the humerus. However, it can only do this after the movement has been initiated by supraspinatus. Damage to the tendon of supraspinatus is a common form of rotator cuff disease.
Which of the following nerves is most commonly damaged during a superficial parotidectomy?
Greater auricular Facial Greater occipital Accessory Opthalmic branch of the trigeminal
Ans: A
The greater auricular nerve and in particular its lobular branch is commonly injured in parotid surgery and consent usually makes particular reference to this. In a superficial parotidectomy, the facial nerve should not be injured and this is less common than a greater auricular nerve injury.
A 34 year old man is shot in the postero- inferior aspect of his thigh. Which of the following lies at the most lateral aspect of the popliteal fossa?
Popliteal artery Popliteal vein Common peroneal nerve Tibial nerve Small saphenous vein
Ans: C
The contents of the popliteal fossa are (from medial to lateral): Popliteal artery Popliteal vein Tibial nerve Common peroneal nerve
The sural nerve is a branch of the tibial nerve and usually arises at the inferior aspect of the popliteal fossa. However, its anatomy is variable.
A 67 year old man has an abdominal aortic aneurysm which displaces the left renal vein. Which branch of the aorta is most likely to affected at this level?
Inferior mesenteric artery Superior mesenteric artery Coeliac axis Testicular artery None of the above
Ans: B
The left renal vein lies behind of the SMA as it branches off the aorta. Whilst juxtarenal AAA may sometimes require the division of the left renal vein, direct involvement of the SMA may require a hybrid surgical bypass and subsequent endovascular occlusion.
An 21 year old man undergoes an uncomplicated tonsillectomy for recurrent attacks of tonsillitis. Post operatively he complains of otalgia. Which nerve is responsible?
Trigeminal Hypoglossal Glossopharyngeal Facial Vagus
Ans: C
The glossopharyngeal nerve supplies this area and the ear and otalgia may be the result of referred pain.
A 12 year old boy undergoes surgery for recurrent mastoid infections. Post operatively he complains of an altered taste sensation. Which of the following nerves has been injured?
Glossopharyngeal Greater petrosal Olfactory Trigeminal Chorda tympani
Ans: E
The chorda tympani branch of the facial nerve passes forwards through itrs canaliculus into the middle ear, and crosses the medial aspect of the tympanic membrane. It then passes antero-inferiorly in the infratemporal fossa. It distributes taste fibres to the anterior two thirds of the tongue.
What is the origin of the superior gluteal artery?
Internal iliac artery External iliac artery Femoral artery Common iliac artery Circumflex femoral artery
Ans: A
The inferior gluteal artery arises from the anterior trunk of the internal iliac artery
The superior gluteal artery arises from the posterior trunk of the internal iliac artery
The first root of the brachial plexus commonly arises at which of the following levels?
C6 C5 C3 C2 C8
Ans: B
It begins at C5 and has 5 roots. It ends with a total of 15 nerves of these 5 are the main nerves to the upper limb (axillary, radial, ulnar, musculocutaneous and median)
What is the anatomical level of the transpyloric plane?
T11 T12 L1 L4 T10
Ans: C
Which of the nerves listed below is responsible for the innervation of gluteus maximus?
Inferior gluteal nerve Superior gluteal nerve Posterior femoral cutaneous nerve Sciatic nerve Perineal nerve
Ans: A
Superior gluteal nerve
Arises from dorsal surface of the sacral plexus (L4, 5, S1)
Passes into gluteal region together with superior gluteal vessels
Supplies gluteus medius and minimus
Inferior gluteal nerve
Arises from dorsal surface of sacral plexus (L5, S1 and S2)
Runs medial to the posterior femoral cutaneous nerve
Enters gluteal region at inferior border of piriformis
Supplies gluteus maximus
When the brachial plexus is injured in the axilla as a result of a crutch palsy, which of the nerves listed is most commonly affected?
Thoracodorsal nerve Suprascapular nerve Radial nerve Ulnar nerve Long thoracic nerve
Ans: C
The radial nerve is most commonly injured and results in a wrist drop. The ulnar nerve arises from the medial cord and is rarely affected as a result of this injury mechanism.
A 35 year old man falls and sustains a fracture to the medial third of his clavicle. Which vessel is at greatest risk of injury?
Subclavian vein Subclavian artery External carotid artery Internal carotid artery Vertebral artery
Ans: A
The subclavian vein lies behind subclavius and the medial part of the clavicle. It rests on the first rib, below and in front of the third part of the subclavian artery, and then on scalenus anterior which separates it from the second part of the artery (posteriorly).
The pudendal canal is a fascial canal located on the lateral wall of the ischioanal fossa. In this location, it lies on the inferior border of which of the following muscles?
Coccygeus Obturator internus Pubococcygeus Iliococcygeus Piriformis
Ans: B
The coccygeus, pubococcygeus and iliococcygeus form part of the pelvic diaphragm and are not related to it. The piriformis exits the pelvis via the greater sciatic foramen and is not associated with the canal in the ischiorectal fossa.
Where are the greatest proportion of musculi pectinati found?
Right ventricle Left ventricle Right atrium Pulmonary valve Aortic valve
Ans: C
The musculi pectinati are found in the atria, hence the reason that the atrial walls in the right atrium are irregular anteriorly.
The musculi pectinati of the atria are internal muscular ridges on the anterolateral surface of the chambers and they are only present in the area derived from the embryological true atrium.
What is the lymphatic drainage of the upper ureter?
Common iliac nodes Para aortic nodes External iliac nodes Internal iliac nodes Meso colic nodes
Ans: B
The upper ureter drains to the para-aortic nodes, the lower ureter drains to the common iliac nodes.
Which of the nerves listed below provides sensory innervation to the skin overlying the lateral aspect of the nose?
Infratrochlear nerve Zygomatic nerve Nasopalatine nerve Lateral nasal branches of the ethmoidal nerve Frontal nerve
Ans: D
The lateral aspect of the external nose is innervated by lateral nasal branches of the anterior ethmoidal nerve. The ethmoidal nerve is a branch of the nasociliary nerve which is one of the divisions of the trigeminal.
Which of the following statements relating to the right phrenic nerve is false?
It lies deep 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 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
Ans: B
Path
The phrenic nerve passes with the internal jugular vein across scalenus anterior. It passes deep to prevertebral fascia of deep cervical fascia.
Left: crosses anterior to the 1st part of the subclavian artery.
Right: Anterior to scalenus anterior and crosses anterior to the 2nd part of the subclavian artery.
On both sides, the phrenic nerve runs posterior to the subclavian vein and posterior to the internal thoracic artery as it enters the thorax.
Right phrenic nerve
In the superior mediastinum: anterior to right vagus and laterally to superior vena cava
Middle mediastinum: right of pericardium
It passes over the right atrium to exit the diaphragm at T8
Left phrenic nerve
Passes lateral to the left subclavian artery, aortic arch and left ventricle
Passes anterior to the root of the lung
Pierces the diaphragm alone
Which of the following structures separates the subclavian artery and vein?
Digastric muscle Prevertebral fascia Anterior scalene muscle Middle scalene muscle Omohyoid
Ans: C
The anterior scalene muscle is an important anatomical landmark and separates the subclavian vein (anterior) from the subclavian artery (posterior).
A 33 year old man is stabbed in the right chest and undergoes a thoracotomy. The right lung is mobilised and the pleural reflection at the lung hilum is opened. Which of the structures listed below does not lie within this region?
Pulmonary artery Azygos vein Pulmonary vein Bronchus None of the above
Ans: B
The pleural reflections encase the hilum of the lung and continue inferiorly as the pulmonary ligament. It encases the pulmonary vessels and bronchus. The azygos vein is not contained within it.
A 56 year old man requires long term parenteral nutrition and the decision is made to insert a PICC line for long term venous access. This is inserted into the basilic vein at the region of the elbow. As the catheter is advanced, into which venous structure is the tip of the catheter most likely to pass from the basilic vein?
Subclavian vein Axillary vein Posterior circumflex humeral vein Cephalic vein Superior vena cava
Ans: B
The basilic vein drains into the axillary vein and although PICC lines may end up in a variety of fascinating locations the axillary vein is usually the commonest site following from the basilic. The posterior circumflex humeral vein is encountered prior to the axillary vein. However, a PICC line is unlikely to enter this structure because of its angle of entry into the basilic vein.
An individual is noted to have a left sided superior vena cava. By which pathway is blood from this system most likely to enter the heart?
Via the coronary sinus Via the azygos venous system and into the superior vena cava Via anomalies in the pumonary vascular bed Via the left atrium and persistent foramen ovale Directly into the roof of the right atrium
Ans: A
Persistent left superior vena cava is the most common anomaly of the thoracic venous system. It is prevalent in 0.3% of the population and is a benign entity of failed involution during embryogenesis.
An 8 year old boy falls onto an outstretched hand and sustains a supracondylar fracture. In addition to a weak radial pulse the child is noted to have loss of pronation of the affected hand. Which nerve is compromised?
Median Radial Ulnar Musculocutaneous Axillary
Ans: A
This is a common injury in children. In this case the angulation and displacement have resulted in median nerve injury.
A 40 year old lady trips and falls through a glass door and sustains a severe laceration to her left arm. Amongst her injuries it is noticed that she has lost the ability to adduct the fingers of her left hand. Injury to which of the following nerves is most likely to account for her examination findings?
Ulnar Median Radial Musculocutaneous Axillary
Ans: A
The interossei are supplied by the ulnar nerve.
A 53 year old man is undergoing a radical gastrectomy for carcinoma of the stomach. Which of the following structures will need to be divided to gain access to the coeliac axis?
Lesser omentum Greater omentum Falciform ligament Median arcuate ligament Gastrosplenic ligament
Ans: A
The lesser omentum will need to be divided. During a radical gastrectomy this forms one of the nodal stations that will need to be taken.
A 76 year old man complains of symptoms of claudication. The decision is made to measure his ankle brachial pressure index. The signal from the dorsalis pedis artery is auscultated with a hand held doppler device. This vessel is the continuation of which of the following?
Posterior tibial artery Anterior tibial artery Peroneal artery Popliteal artery None of the above
Ams: B
The dorsalis pedis is a continuation of the anterior tibial artery.
A 67 year old man is due to undergo a revisional total hip replacement using a posterior approach. After dividing gluteus maximus in the line of its fibres there is brisk arterial bleeding. Which of the following vessels is likely to be responsible?
Profunda femoris artery External iliac artery Internal iliac artery Obturator artery Inferior gluteal artery
Ans: E)
The inferior gluteal artery runs on the deep surface of the gluteus maximus muscle. It is a branch of the internal iliac artery. It is commonly divided during the posterior approach to the hip joint.
A 17 year old lady presents with right iliac fossa pain and diagnosed as having acute appendicitis. You take her to theatre to perform a laparoscopic appendicectomy. During the procedure the scrub nurse distracts you and you inadvertently avulse the appendicular artery. The ensuing haemorrhage is likely to be supplied directly from which vessel?
Inferior mesenteric artery Superior mesenteric artery Ileo-colic artery Internal iliac artery None of the above
Ans: C
The appendicular artery is a branch of the ileocolic artery.
Which of the vessels listed below is the most inferiorly sited single aortic branch?
Common iliac artery Inferior mesenteric artery Superior mesenteric artery Gonadal artery Median sacral artery
Ans: E
The median sacral artery leaves the aorta a little above its bifurcation. It descends in the midline anterior to L4 and L5.
A 63 year old man who smokes heavily presents with dyspepsia. He is tested and found to be positive for helicobacter pylori infection. One evening he has an episode of haematemesis and collapses. What is the most likely vessel to be responsible?
Portal vein Short gastric arteries Superior mesenteric artery Gastroduodenal artery None of the above
Ans: D
He is most likely to have a posteriorly sited duodenal ulcer. These can invade the gastroduodenal artery and present with major bleeding. Although gastric ulcers may invade vessels they do not tend to produce major bleeding of this nature.
Which of the structures listed below are not located within the mediastinum?
Thymus Heart Great vessels Arch of azygos vein Vertebral bodies
Ans: E
The vertebral bodies lie outside of the mediastinum, as do the lungs.
A 22 year old man is stabbed in the chest at the level of the junction between the sternum and manubrium. Which structure is at greatest risk?
Left atrium Oesophagus Thyroid gland Inferior vena cava Aortic arch
Ans: E
At the level of the Angle of Louis (Manubriosternal angle), is the surface marking for the aortic arch. The oesophagus is posteriorly located and at less risk.
Which of these nerves passes through the greater and lesser sciatic foramina?
Pudendal nerve Sciatic nerve Superior gluteal nerve Inferior gluteal nerve Posterior cutaneous nerve of the thigh
Ans: A
Structures passing through the lesser and greater sciatic foramina (medial to lateral): PIN
Pudendal nerve
Internal pudendal artery
Nerve to obturator internus
Which of the following is not found within the deep perineal pouch in an adult male?
Pudendal nerve Dorsal nerve of the penis Sphinter urethrae Urethral artery Obturator nerve
Ans: E
Contents of the deep perineal pouch
Urethral sphincter
Transversus perinei
Dorsal nerve of penis, muscular branches of the perineal nerve
Deep and dorsal arteries of penis, stem of origin of artery to the bulb of penis, urethral artery.
A cervical rib is due to which of the following?
Hyperplasia of the annulus fibrosus Proliferation of the nucleus pulposus Fusion of the transverse processes of the 6th and 7th cervical vertebrae An accessory cervical vertebra Elongation of the transverse processes of the 7th cervical vertebra
Ans: E
Cervical ribs occur as a result of the elongation of the transverse process of the 7th cervical vertebra. It is usually a fibrous band that attaches to the first thoracic rib.
Which of the structures listed below is not a content of the carotid sheath?
Internal jugular vein Internal carotid artery Vagus nerve Recurrent laryngeal nerve Common carotid artery
Ans: D
Contents of carotid sheath: Common carotid artery Internal carotid artery Internal jugular vein Vagus nerve
A 28 year old rugby player injures his right humerus and on examination is noted to have a minor sensory deficit overlying the point of deltoid insertion into the humerus. Which of the nerves listed below is most likely to have been affected?
Radial Axillary Musculocutaneous Median Subscapular
Ans: B
This patch of skin is supplied by the axillary nerve
A 22 year old man is undergoing a wedge excision of his great toenail. As the surgeon passes a needle into the area to administer local anaesthetic, the patient notices a sharp pain. By which pathway will this sensation be conveyed to the central nervous system?
Anterior corticospinal tract Posterior spinocerebellar tract Cuneate fasciculus Vestibulospinal tract Spinothalamic tract
Ans: E
Spinothalamic tract- Pain and temperature
Vestibulospinal tract- Motor neuronal signals relating to posture
Cuneate fasciculus- Fine touch, pressure and proprioception
Posterior spinocerebellar tract- Proprioceptive signals to cerebellum
Anterior corticospinal tract- Conveys motor signals from precentral gyrus to motor cells within the cord
A 73 year old lady is admitted with brisk rectal bleeding. Despite attempts at resuscitation the bleeding proceeds to cause haemodynamic compromise. An upper GI endoscopy is normal. A mesenteric angiogram is performed and a contrast blush is seen in the region of the sigmoid colon. The radiologist decides to embolise the vessel supplying this area. At what spinal level does it leave the aorta?
L2 L1 L4 L3 T10
Ans: D
The inferior mesenteric artery leaves the aorta at L3. It supplies the left colon and sigmoid. Its proximal continuation to communicate with the middle colic artery is via the marginal artery.
Inspection of the left ventricle reveals all except which of the following?
Papillary muscles Trabeculae carnae Chordae tendinae Conus arteriosus Openings of the venae cordis minimae
Ans: D
The conus arteriosus (infundibulum) is the smooth walled outflow tract of the right ventricle leading to the pulmonary trunk.
A 23 year old lady with troublesome axillary hyperhidrosis is undergoing a thorascopic sympathectomy to treat the condition. Which of the following structures will need to be divided to access the sympathetic trunk?
Intercostal vein Intercostal artery Parietal pleura Visceral pleura None of the above
Ans: C
The sympathetic chain lies posterior to the parietal pleura. During a thorascopic sympathetomy this structure will need to be divided. The intercostal vessels lie posteriorly. They may be damaged with troublesome bleeding but otherwise are best left alone as deliberate division will not improve surgical access.
In which space is a lumbar puncture performed?
Subdural space Epidural space Subarachnoid space Extradural space Intraventricular space
Ans: C
Samples of CSF are normally obtained by inserting a needle between the third and fourth lumbar vertebrae. The tip of the needle lies in the sub arachnoid space, the spinal cord terminates at L1 and is not at risk of injury. Clinical evidence of raised intracranial pressure is a contraindication to lumbar puncture.
A 21 year old man is stabbed in the antecubital fossa. A decision is made to surgically explore the wound. At operation the surgeon dissects down onto the brachial artery. A nerve is identified medially, which nerve is it likely to be?
Radial Recurrent branch of median Anterior interosseous Ulnar Median
Ans: E
A 65 year old man with long standing atrial fibrillation develops an embolus to the lower leg. The decision is made to perform an embolectomy, utilising a trans popliteal approach. After incising the deep fascia, which of the following structures will the surgeons encounter first on exploring the central region of the popliteal fossa?
Popliteal vein Common peroneal nerve Popliteal artery Tibial nerve None of the above
Ans: D
The tibial nerve lies superior to the vessels in the inferior aspect of the popliteal fossa. In the upper part of the fossa the tibial nerve lies lateral to the vessels, it then passes superficial to them to lie medially. The popliteal artery is the deepest structure in the popliteal fossa.
A 53 year old man is undergoing a distal pancreatectomy for trauma. Which of the following vessels is responsible for the arterial supply to the tail of the pancreas?
Splenic artery Pancreaticoduodenal artery Gastric artery Hepatic artery Superior mesenteric artery
Ans: A
Pancreatic head is supplied by the pancreaticoduodenal artery
Pancreatic tail is supplied by branches of the splenic artery
A 43 year old lady presents with varicose veins and undergoes a saphenofemoral disconnection, long saphenous vein stripping to the ankle and isolated hook phlebectomies. Post operatively she notices an area of numbness superior to her ankle. What is the most likely cause for this?
Sural nerve injury Femoral nerve injury Saphenous nerve injury Common peroneal nerve injury Superficial peroneal nerve injury
Ans: C
The sural nerve is related to the short saphenous vein. The saphenous nerve is related to the long saphenous vein below the knee and for this reason full length stripping of the vein is no longer advocated.
Which of the following muscles does not attach to the radius?
Pronator quadratus Biceps Brachioradialis Supinator Brachialis
Ans: E
The brachialis muscle inserts into the ulna. The other muscles are all inserted onto the radius.
A 25 year old man is stabbed in the upper arm. The brachial artery is lacerated at the level of the proximal humerus, and is being repaired. A nerve lying immediately lateral to the brachial artery is also lacerated. Which of the following is the nerve most likely to be?
Ulnar nerve Median nerve Radial nerve Intercostobrachial nerve Axillary nerve
Ans: B
The brachial artery begins at the lower border of teres major and terminates in the cubital fossa by branching into the radial and ulnar arteries. In the upper arm the median nerve lies closest to it in the lateral position. In the cubital fossa it lies medial to it.
What is the course of the median nerve relative to the brachial artery in the upper arm?
Medial to anterior to lateral Lateral to posterior to medial Medial to posterior to lateral Medial to anterior to medial Lateral to anterior to medial
Ans: E
Relations of median nerve to the brachial artery:
Lateral -> Anterior -> Medial
Which of the following is not a content of the cavernous sinus?
Oculomotor nerve Internal carotid artery Opthalmic nerve Abducens nerve Optic nerve
Ans: E
Mnemonic for contents of cavernous sinus:
O TOM CAT
Occulomotor nerve (III) Trochlear nerve (IV) Ophthalmic nerve (V1) Maxillary nerve (V2) Carotid artery Abducent nerve (VI) T
OTOM=lateral wall components
CA= components within sinus
Relations
Medial Lateral
Pituitary fossa
Sphenoid sinus Temporal lobe
Contents
Lateral wall components (from top to bottom:)
Oculomotor nerve
Trochlear nerve
Ophthalmic nerve
Maxillary nerve
Contents of the sinus (from medial to lateral:)
Internal carotid artery (and sympathetic plexus)
Abducens nerve
Surgical occlusion of which of these structures, will result in the greatest reduction in hepatic blood flow?
Portal vein Common hepatic artery Right hepatic artery Coeliac axis Left hepatic artery
Ans: A
The portal vein transports 70% of the blood supply to the liver, while the hepatic artery provides 30%. The portal vein contains the products of digestion. The arterial and venous blood is dispersed by sinusoids to the central veins of the liver lobules; these drain into the hepatic veins and then into the IVC. The caudate lobe drains directly into the IVC rather than into other hepatic veins.
A 43 year old man is due to undergo an excision of the sub mandibular gland. Which of the following incisions is the most appropriate for this procedure?
A transversely orientated incision 3cm below the mandible A transversely orientated incision immediately inferior to the mandible A vertical incision 3 cm anterior to the angle of the mandible and extending inferiorly A transversely orientated incision 2cm above the mandible A transversely orientated incision 12cm below the mandible
Ans: A
To access the sub mandibular gland a transverse incision 3cm below the mandible should be made. Incisions located higher than this may damage the marginal mandibular branch of the facial nerve.
A 5 year old boy presents with recurrent headaches. As part of his assessment he undergoes an MRI scan of his brain. This demonstrates enlargement of the lateral and third ventricles. Where is the most likely site of obstruction?
Foramen of Luschka Foramen of Magendie Foramen of Munro Aqueduct of Sylvius None of the above
Ans: D
The CSF fills the space between the arachnoid mater and pia mater (covering surface of the brain). The total volume of CSF in the brain is approximately 150ml. Approximately 500 ml is produced by the ependymal cells in the choroid plexus (70%), or blood vessels (30%). It is reabsorbed via the arachnoid granulations which project into the venous sinuses.
Circulation
- Lateral ventricles (via foramen of Munro)
- 3rd ventricle
- Cerebral aqueduct (aqueduct of Sylvius)
- 4th ventricle (via foramina of Magendie and Luschka)
- Subarachnoid space
- Reabsorbed into the venous system via arachnoid granulations into superior sagittal sinus
Composition Glucose: 50-80mg/dl Protein: 15-40 mg/dl Red blood cells: Nil White blood cells: 0-3 cells/ mm3
A 23 year old man presents with appendicitis. A decision is made to perform an appendicectomy. The operation commences with a 5cm incision centered on McBurneys point. Which of the following structures will be encountered first during the dissection?
External oblique aponeurosis Internal oblique muscle Transversalis fascia Rectus sheath Peritoneum
Ans: A
The external oblique will be encountered first in this location. The rectus sheath lies more medially.
The external oblique muscle is the most superficial of the abdominal wall muscles. It originates from the 5th to 12th ribs and passes inferomedially to insert into the linea alba, pubic tubercle and anterior half of the iliac crest. It is innervated by the thoracoabdominal nerves (T7-T11) and sub costal nerves.
A 23 year old man is undergoing an inguinal hernia repair. The surgeons mobilise the spermatic cord and place it in a hernia ring. A small slender nerve is identified superior to the cord. Which nerve is it most likely to be?
Iliohypogastric nerve Pudendal nerve Femoral branch of the genitofemoral nerve Ilioinguinal nerve Obturator nerve
Ans: D
The ilioinguinal nerve passes through the inguinal canal and is the nerve most commonly identified during hernia surgery. The genitofemoral nerve splits into two branches, the genital branch passes through the inguinal canal within the cord structures. The femoral branch of the genitofemoral nerve enters the thigh posterior to the inguinal ligament, lateral to the femoral artery. The iliohypogastric nerve pierces the external oblique aponeurosis above the superficial inguinal ring.
A 34 year old man undergoes excision of a sarcoma from the right buttock. During the procedure the sciatic nerve is sacrificed. Which of the following will not occur as a result of this process?
Loss of extension at the knee joint Foot drop Inability to extend extensor hallucis longus Unchanged sensation to the posterior aspect of the thigh Loss of sensation to the posterior aspect of the lower leg
Ans: A
Extension of the knee joint is caused by the obturator and femoral nerves. Sensation to the posterior aspect of the thigh is via the posterior cutaneous nerve of the thigh and this is a direct branch from the plexus itself.
Where does the spinal cord terminate in neonates?
L1 L2 L3 L4 L5
Ans: C
At the 3rd month the foetus’s spinal cord occupies the entire length of the vertebral canal. The vertebral column then grows longer exceeding the growth rate of the spinal cord. This results with the cord being at L3 at birth and L1-2 by adulthood.
A 45 year old man is undergoing a low anterior resection for a carcinoma of the rectum. Which of the following fascial structures will need to be divided to mobilise the mesorectum from the sacrum and coccyx?
Denonvilliers fascia Colles fascia Sibsons fascia Waldeyers fascia None of the above
Ans: D
Fascial layers surrounding the rectum:
Anteriorly lies the fascia of Denonvilliers
Posteriorly lies Waldeyers fascia
Waldeyers fascia separates the mesorectum from the sacrum and will need to be divided.
A 10 year old child has a grommet inserted for a glue ear. What type of epithelium is present on the external aspect of the tympanic membrane?
Stratified squamous Ciliated columnar Non ciliated columnar Non stratified squamous None of the above
Ans: A
The external aspect of the tympanic membrane is lined by stratified squamous epithelium. This is significant clinically in the development of middle ear infections when this type of epithelium may migrate inside the middle ear.
A 73 year old lady is admitted with acute mesenteric ischaemia. A CT angiogram is performed and a stenotic lesion is noted at the origin of the superior mesenteric artery. At which of the following levels does this branch from the aorta?
L1 L2 L3 L4 L5
Ans: A
The SMA leaves the aorta at L1. It passes under the neck of the pancreas prior to giving its first branch the inferior pancreatico-duodenal artery.
The following statements relating to the musculocutaneous nerve are true except?
It arises from the lateral cord of the brachial plexus It provides cutaneous innervation to the lateral side of the forearm If damaged, then extension of the elbow joint will be impaired It supplies the biceps muscle It runs beneath biceps
Ans: C
supplies biceps, brachialis and coracobrachialis. If damaged then elbow flexion will be impaired.
Which of the following structures does not pass through the foramen ovale?
Lesser petrosal nerve Accessory meningeal artery Maxillary nerve Emissary veins Otic ganglion
Ans: C
Mnemonic: OVALE
O tic ganglion V3 (Mandibular nerve:3rd branch of trigeminal) A ccessory meningeal artery L esser petrosal nerve E missary veins
Which of the cranial nerves listed below is least likely to carry parasympathetic fibres?
III VII IX X II
Ans: E
Cranial nerves carrying parasympathetic fibres
X IX VII III (1973)
A 72 year old man is undergoing an open abdominal aortic aneurysm repair. The aneurysm is located in a juxtarenal location and surgical access to the neck of aneurysm is difficult. Which of the following structures may be divided to improve access?
Cisterna chyli Transverse colon Left renal vein Superior mesenteric artery Coeliac axis
Ans: C
The left renal vein will be stretched over the neck of the anuerysm in this location and is not infrequently divided. This adds to the nephrotoxic insult of juxtarenal aortic surgery as a supra renal clamp is also often applied. Deliberate division of the Cisterna Chyli will not improve access and will result in a chyle leak. Division of the transverse colon will not help at all and would result in a high risk of graft infection. Division of the SMA is pointless for a juxtarenal procedure.
At which of the following levels does the inferior thyroid artery enter the thyroid gland?
C6 C2 C4 C3 C5
Ans: A
It enters the gland at C6.
An occlusion of the anterior cerebral artery may compromise the blood supply to the following structures except:
Medial inferior surface of the frontal lobe Corpus callosum Medial surface of the frontal lobe Olfactory bulb Brocas area
Ans: E
Brocas area is usually supplied by branches from the middle cerebral artery.
What is the longest part of the male urethra?
Membranous urethra Spongy urethra Prostatic urethra Urethra within the internal urethra orifice Urethra within the urethral crest
Ans: B
The spongy urethra is around 15cm long and is the longest part of the male urethra.
Parasympathetic fibres innervating the parotid gland originate from which of the following?
Submandibular ganglion Otic ganglion Ciliary ganglion Pterygopalatine ganglion None of the above
Ans: B
Secretion of saliva by the parotid gland is controlled by nerve fibres originating in the inferior salivatory nucleus; these leave the brain via the tympanic nerve (branch of glossopharyngeal nerve (CN IX), travel through the tympanic plexus (located in the middle ear), and then form the lesser petrosal nerve until reaching the otic ganglion. After synapsing in the Otic ganglion, the postganglionic (postsynaptic) fibres travel as part of the auriculotemporal nerve (a branch of the mandibular nerve (V3) to reach the parotid gland.
Following an oesophagogastrectomy the surgeons will anastomose the oesophageal remnant to the stomach, which of the following is not part of the layers that comprise the oesophageal wall?
Serosa Adventitia Muscularis propria Submucosa Mucosa
Ans: A
The oesophageal wall lacks the serosa layer
The wall lacks a serosa which can make the wall hold sutures less securely.
Which of the following structures suspends the spinal cord in the dural sheath?
Filum terminale Conus medullaris Ligamentum flavum Denticulate ligaments Anterior longitudinal ligament
Ans: D
The spinal cord is approximately 45cm in men and 43cm in women. The denticulate ligament is a continuation of the pia mater (innermost covering of the spinal cord) which has intermittent lateral projections attaching the spinal cord to the dura mater.
Where is the ‘safe triangle’ for chest drain insertion located?
4th intercostal space, mid axillary line 5th intercostal space, mid axillary line 4th intercostal space, mid scapular line 5th intercostal space, mid scapular line 4th intercostal space, mid clavicular line
Ans: B
‘Safe Triangle’ for chest drain insertion:
5th intercostal space, mid axillary line
A 32 year old rugby player is hit hard on the shoulder during a rough tackle. Clinically, his arm is hanging loose on the side. It is pronated and medially rotated. What structure is most likely to have been compromised?
Brachial trunks C5-6 Brachial trunks C6-7 Brachial trunks C8 - T1 Anterior interosseous nerve Posterior interosseous nerve
Ans: A
The patient has an Erb’s palsy involving brachial trunks C5-6.
Your consultant decides to perform an open inguinal hernia repair under local anaesthesia. Which of the following dermatomal levels will require blockade?
T10 T12 T11 S1 S2
Ans: B
See the figure
A 73 year old man undergoes an excision biopsy of a lymph node that is closely applied to sternocleidomastoid. This muscle is mobilized and a nerve that is present is damaged. Which muscle below is most likely to be affected?
Trapezius Rhomboid major Deltoid Supraspinatus Rhomboid minor
Ans: A
The accessory nerve has a number of lymph nodes applied to it near the sternocleidomastoid muscle. It is particularly at risk if SCM is mobilized. If injured, the trapezius muscle and SCM will be paralysed.
A 35 year tennis player attends reporting tingling down his arm. He says that his ‘funny bone’ was hit very hard by a tennis ball. There is weakness of abduction and adduction of his extended fingers. Which nerve has been affected?
Ulnar Anterior interosseous Posterior interosseous Median Musculocutaneous
Ans: A
The ulnar nerve arises from the medial cord of the brachial plexus (C8, T1 and contribution from C7). The nerve descends between the axillary artery and vein, posterior to the cutaneous nerve of the forearm and then lies anterior to triceps on the medial side of the brachial artery. In the distal half of the arm it passes through the medial intermuscular septum, and continues between this structure and the medial head of triceps to enter the forearm between the medial epicondyle of the humerus and the olecranon. It may be injured at this site in this scenario.
A 44 year old man is undergoing a parotidectomy and the surgeon is carefully preserving the facial nerve. Unfortunately his trainee then proceeds to divide it. Which of the following will not be affected as a result?
Taste sensation from anterior two thirds of the tongue Closing the ipsilateral eyelid Raising the ipsilateral side of the lip Ipsilateral corneal reflex None of the above
Ans: A
The chorda tympani branches inside the facial canal and will therefore be unaffected by this most unfortunate event! The corneal reflex is mediated by the opthalmic branch of the trigeminal nerve sensing the stimulus on the cornea, lid or conjunctiva; the facial nerve initiates the motor response of the reflex.
Which cranial nerve supplies general sensation to the posterior third of the tongue?
Facial Trigeminal Vagus Hypoglossal Glossopharyngeal
Ans: E
The glossopharyngeal nerve supplies general sensation to the posterior third of the tongue and contributes to the gag reflex.
A 45 year old lady develops severe back pain and on examination is found to have clinical evidence of an L5/ S1 radiculopathy. Her symptoms deteriorate and eventually a laminectomy is performed. During a posterior surgical approach the surgeons encounter a tough ligamentous structure lying anterior to the spinous processes. This structure is most likely to be the
Transverse spinal ligament Supraspinal ligament Anterior longitudinal ligament Ligamentum flavum Posterior longitudinal ligament
Ans: D
Which of the following does not pass through the superior orbital fissure?
Lacrimal nerve Abducens nerve Opthalmic artery Trochlear nerve Superior opthalmic vein
Ans: C
Mnemonic for the nerves passing through the supraorbital fissure:
Live Frankly To See Absolutely No Insult
Lacrimal Frontal Trochlear Superior Division of Oculomotor Abducens Nasociliary Inferior Division of Oculomotor nerve
An 18 year old man undergoes a tonsillectomy for attacks of recurrent acute tonsillitis. Whilst in recovery he develops a post operative haemorrhage. Which of the following vessels is the most likely culprit?
Facial vein External palatine vein External carotid artery Internal jugular vein None of the above
Ans: B
The external palatine vein lies immediately lateral to the tonsil and if damaged may be a cause of reactionary haemorrhage following tonsillectomy.
Which of the nerves listed below is responsible for providing innervation to the lower molar teeth?
Greater palatine nerve Nasopalatine nerve Inferior alveolar nerve Zygomatic nerve Mandibular nerve
Ans: C
The branches of the lower molar and premolar teeth are supplied by branches of the inferior alveolar nerve. Those of the canine and incisors by the incisive branch of the same nerve. The gingiva and supporting structures are innervated by the lingual nerve.
A patient is found to have an ischaemic left colon. Which artery arising from the aorta at around the level of L3 is most likely to account for this situation?
Superior mesenteric artery Inferior mesenteric artery Superior rectal artery Ileocolic artery Middle colic artery
Ans: B
At which level does the aorta traverse the diaphragm?
T10 T9 T8 T11 T12
A: E
Memory aid:
T8 (8 letters) = vena cava
T10 (10 letters) = oesophagus
T12 (12 letters) = aortic hiatus
What is the arterial blood supply to the lacrimal apparatus?
Nasociliary artery Supra orbital artery Internal carotid artery Ophthalmic artery Supra trochlear artery
A: D
The ophthalmic artery supplies the gland
A 24 year old lady is stabbed in the buttock. Following the injury the wound is sutured in the emergency department. Eight weeks later she attends the clinic, as she walks into the clinic room she has a waddling gait and difficulty with thigh abduction. On examination she has buttock muscle wasting. Which nerve has been injured?
Superior gluteal nerve Obturator nerve Sciatic nerve Femoral nerve Inferior gluteal nerve
Ans: A
Damage to the superior gluteal nerve will result in a Trendelenburg gait.
At which level is the hilum of the left kidney located?
L1 L2 T12 T11 L3
A: A
Remember L1 (‘left one’) is the level of the hilum of the left kidney
During a radical neck dissection, division of which of the following fascial layers will expose the ansa cervicalis?
Pretracheal fascia Carotid sheath Prevertebral fascia Investing layer of fascia Sibsons fascia
Ans: A
The ansa cervicalis lies anterior to the carotid sheath. It may be exposed by division of the pretracheal fascia at the posterolateral aspect of the thyroid gland. The pre vertebral fascia lies more posteriorly and division of the investing layer of fascia will not expose this nerve.
A 73 year old lady presents with symptoms of faecal incontinence. On examination she has weak anal sphincter muscles. What are the main nerve root values of the nerves supplying the external anal sphincter?
S2,3 L5, S1 S4,5 S5 S2,3,4
Ans: E
S2, 3, 4 Keeps the poo off the floor
The external anal sphincter is innervated by the inferior rectal branch of the pudendal nerve, this has root values of S2, 3 and the perineal branch of S4.
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
Ans: C
The ulnar nerve and artery are at most immediate risk in this injury.
A 72 year old man has a fall. He is found to have a fractured neck of femur and goes on to have a left hip hemiarthroplasty. Two months post operatively he is found to have an odd gait. When standing on his left leg his pelvis dips on the right side. There is no foot drop. What is the cause?
Sciatic nerve damage L5 radiculopathy Inferior gluteal nerve damage Previous poliomyelitis Superior gluteal nerve damage
Ans: E
This patient has a trendelenburg gait caused by damage to the superior gluteal nerve causing weakness of the abductor muscles. Classically a patient is asked to stand on one leg and the pelvis dips on the opposite side. The absence of a foot drop excludes the possibility of polio or L5 radiculopathy.
Which of the following structures lies posterior to the femoral nerve in the femoral triangle?
Adductor longus Pectineus Psoas major Iliacus None of the above
Ans: D
The iliacus lies posterior to the femoral nerve in the femoral triangle. The femoral sheath lies anterior to the iliacus and pectineus muscles.
Mnemonic for femoral nerve supply
(don’t) M I S V Q Scan for PE
M edial cutaneous nerve of the thigh
I ntermediate cutaneous nerve of the thigh
S aphenous nerve
V astus
Q uadriceps femoris
S artorius
PE ectineus
You are assisting in an open right adrenalectomy for a large adrenal adenoma. The consultant is distracted and you helpfully pull the adrenal into the wound to improve the view. Unfortunately this is followed by brisk bleeding. The vessel responsible for this is most likely to be:
Portal vein Phrenic vein Right renal vein Superior mesenteric vein Inferior vena cava
Ans: E
A 28 year old lady requires an episiotomy for a ventouse vaginal delivery. Which of the nerves listed below will usually be anaesthetised to allow the episiotomy?
Femoral Ilioinguinal Pudendal Genitofemoral Sacral plexus
Ans: C
The pudendal nerve innervates the posterior vulval area and is routinely blocked in procedures such as episiotomy.
A motorcyclist is involved in a road traffic accident. He suffers a complex humeral shaft fracture which is plated. Post operatively he complains of an inability to extend his fingers. Which of the following structures is most likely to have been injured?
Ulnar nerve Radial nerve Median nerve Axillary nerve None of the above
Ans: B
Mnemonic for radial nerve muscles: BEST
B rachioradialis
E xtensors
S upinator
T riceps
An enthusiastic surgical registrar undertakes his first solo splenectomy. The operation is far more difficult than anticipated and the registrar leaves a tube drain to the splenic bed at the end of the procedure. Over the following 24 hours approximately 500ml of clear fluid has entered the drain. Biochemical testing of the fluid is most likely to reveal:
Elevated creatinine Elevated triglycerides Elevated glucagon Elevated amylase None of the above
Ans: D
During splenectomy the tail of the pancreas may be damaged. The pancreatic duct will then drain into the splenic bed, amylase is the most likely biochemical finding. Glucagon is not secreted into the pancreatic duct.
A 48 year old lady is undergoing an axillary node clearance for breast cancer. Which of the structures listed below are most likely to be encountered during the axillary dissection?
Cords of the brachial plexus Thoracodorsal trunk Internal mammary artery Thoracoacromial artery None of the above
Ans: B
Beware of damaging the thoracodorsal trunk if a latissimus dorsi flap reconstruction is planned.
The thoracodorsal trunk runs through the nodes in the axilla. If injured it may compromise the function and blood supply to latissimus dorsi, which is significant if it is to be used as a flap for a reconstructive procedure.
A 56 year old lady is referred to the colorectal clinic with symptoms of pruritus ani. On examination a polypoidal mass is identified inferior to the dentate line. A biopsy confirms squamous cell carcinoma. To which of the following lymph node groups will the lesion potentially metastasise?
Internal iliac External iliac Mesorectal Inguinal None of the above
Ans: D
Lesions distal to the dentate line drain to the inguinal nodes. Occasionally this will result in the need for a block dissection of the groin.
Mesorectal lymph nodes (superior to dentate line) Inguinal nodes (inferior to dentate line)
Which of the following ligaments contains the artery supplying the head of femur in children?
Transverse ligament Ligamentum teres Iliofemoral ligament Ischiofemoral ligament Pubofemoral ligament
Ans: B
A 72 year old man develops a hydrocele which is being surgically managed. As part of the procedure the surgeons divide the tunica vaginalis. From which of the following is this structure derived?
Peritoneum External oblique aponeurosis Internal oblique aponeurosis Transversalis fascia Rectus sheath
A: A
The tunica vaginalis is derived from peritoneum, it secretes the fluid that fills the hydrocele cavity.
A 43 year old lady is donating her left kidney to her sister and the surgeons are harvesting the left kidney. Which of the following structures will lie most anteriorly at the hilum of the left kidney?
Left renal artery Left renal vein Left ureter Left ovarian vein Left ovarian artery
Ans: B
The renal veins lie most anteriorly, then artery and ureter lies posteriorly.
What is the sensory nerve supply to the angle of the jaw?
Maxillary branch of the trigeminal nerve Mandibular branch of the trigeminal nerve C3-C4 Greater auricular nerve (C2-C3) Buccal branch of the facial nerve
Ans: D
The trigeminal nerve is the major sensory nerve to the face except over the angle of the jaw. The angle of the jaw is innervated by the greater auricular nerve.
A 63 year old man is undergoing a coronary artery bypass procedure. During the median sternotomy which structure would routinely require division?
Parietal pleura Interclavicular ligament Internal mammary artery Brachiocephalic vein Left vagus nerve
Ans: B
The interclavicular ligament lies at the upper end of a median sternotomy and is routinely divided to provide access.
A 42 year old woman complains of a burning pain of her anterior thigh which worsens on walking. There is a positive tinel sign over the inguinal ligament. Which nerve is affected?
Ilioinguinal nerve Genitofemoral nerve Lateral cutaneous nerve of the thigh Femoral nerve Saphenous nerve
Ans: C
The lateral cutaneous nerve supplies sensation to the anterior and lateral aspect of the thigh. Entrapment is commonly due to intra and extra pelvic causes. Treatment involves local anaesthetic injections.
Which of the following structures separates the subclavian artery from the subclavian vein?
Scalenus anterior Scalenus medius Sternocleidomastoid Pectoralis major Pectoralis minor
Ans: A
The artery and vein are separated by scalenus anterior. This muscle runs from the transverse processes of C3,4,5 and 6 to insert onto the scalene tubercle of the first rib.
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
Ans: E
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.
A 43 year old lady is due to undergo an axillary node clearance as part of treatment for carcinoma of the breast. Which of the following fascial layers will be divided during the surgical approach to the axilla?
Sibsons fascia Pre tracheal fascia Waldayers fascia Clavipectoral fascia None of the above
Ans: D
The clavipectoral fascia is situated under the clavicular portion of pectoralis major.
What are the boundaries of the ‘safe triangle’ for chest drain insertion?
Bounded by trapezius, latissimus dorsi, and laterally by the vertebral border of the scapula Bounded by latissimus dorsi, pectoralis major, line superior to the nipple and apex at the axilla Bounded by latissimus dorsi, serratus anterior, line superior to the nipple and apex at the axilla Bounded by trapezius, deltoid, rhomboid major and teres minor Bounded by trapezius, deltoid and latissimus dorsi
Ans: B
Where is a gomphoses type of fibrous joint typically found?
Teeth Skull Manubriosternum Ribs Femur
Ans: A
The vertebral artery traverses all of the following except?
Transverse process of C6 Transverse process of the axis Vertebral canal Foramen magnum Intervertebral foramen
Ans: E
The vertebral artery passes through the foramina which are located in the transverse processes of the cervical vertebra, it does not traverse the intervertebral foramen.
A 60 year old female attends the preoperative hernia clinic. She reports some visual difficulty. On examination she is noted to have a homonymous hemianopia. Where is the lesion most likely to be?
Frontal lobe Pituitary gland Parietal lobe Optic chiasm Optic tract
Ans: E
Lesions before optic chiasm:
Monocular vision loss = Optic nerve lesion
Bitemporal hemianopia = Optic chiasm lesion
Lesions after the optic chiasm:
Homonymous hemianopia = Optic tract lesion
Upper quadranopia = Temporal lobe lesion
Lower quadranopia = Parietal lobe lesion
A 34 year old male is being examined in the pre-operative assessment clinic. A murmur is identified in the 4th intercostal space just next to the left side of the sternum. From where is it most likely to have originated?
Mitral valve Aortic valve Pulmonary valve Right ventricular aneurysm Tricuspid valve
Ans: E
The tricuspid valve is generally referred to being best auscultated adjacent to the sternum. The plane of projected sound from the mitral area is best heard in the region of the cadiac apex.
Pulmonary valve
Left second intercostal space, at the upper sternal border
Aortic valve
Right second intercostal space, at the upper sternal border
Mitral valve
Left fifth intercostal space, just medial to mid clavicular line
Tricuspid valve
Left fourth intercostal space, at the lower left sternal border
Which of the following statements relating to quadratus lumborum is false?
Causes flexion of the thoracic spine Causes the rib cage to be pulled down Innervated by anterior primary rami of T12 and L1-3 Attached to the iliac crest Inserts into the 12th rib
Ans: A
Quadratus lumborum
Origin: Medial aspect of iliac crest and iliolumbar ligament
Insertion: 12th rib
Action: Pulls the rib cage inferiorly. Lateral flexion.
Nerve supply: Anterior primary rami of T12 and L1-3
The rectus abdominis causes flexion of the thoracic spine and therefore the statement suggesting that quaratus lumborum does so is incorrect.
A 23 year old climber falls and fractures his humerus. The surgeons decide upon a posterior approach to the middle third of the bone. Which of the following nerves is at greatest risk in this approach?
Ulnar Antebrachial Musculocutaneous Radial Intercostobrachial
Ans: D
The radial nerve wraps around the humerus and may be injured during a posterior approach. An IM nail may be preferred as it avoids the complex dissection needed for direct bone exposure.
A 67 year old man is undergoing an angiogram for gastro intestinal bleeding. The radiologist advances the catheter into the coeliac axis. At what spinal level does this vessel typically arise from the aorta?
T10 L3 L4 T12 None of the above
Ans: D
Which muscle does not insert on the medial surface of the greater trochanter?
Gemelli Obturator internus Piriformis Quadratus femoris Obturator externus
Ans: D
Mnemonic for muscle attachment on greater trochanter is POGO: Piriformis Obturator internus Gemelli Obturator externus
What is the largest branch of the brachial artery?
Radial artery Ulnar artery Profunda brachii artery Humeral nutrient artery Ulnar collateral artery
Ans: C
The profunda brachii artery is the largest branch and then continues in the radial groove of the humerus.
During a radical gastrectomy for carcinoma of the stomach the surgeons remove the omentum. What is the main source of its blood supply?
Ileocolic artery Superior mesenteric artery Gastroepiploic artery Middle colic artery Inferior mesenteric artery
Ans: C
A 38 year old lady is due to undergo a parathyroidectomy for hyperparathyroidism. At operation the inferior parathyroid gland is identified as being enlarged. A vessel is located adjacent to the gland laterally. This vessel is most likely to be the:
External carotid artery Common carotid artery Internal carotid artery External jugular vein None of the above
Ans: B
The common carotid artery is a lateral relation of the inferior parathyroid.
Relations
Laterally Common carotid
Medially Recurrent laryngeal nerve, trachea
Anterior Thyroid
Posterior Pretracheal fascia
A 45 year old man has a long femoral line inserted to provide CVP measurements. The catheter passes from the common iliac vein into the inferior vena cava. At which of the following vertebral levels will this occur?
L5 L4 S1 L3 L2
Ans: A
The common iliac veins fuse with the IVC at L5.
At which of the following levels does the inferior vena cava exit the abdominal cavity?
T6 T7 T10 T8 T12
Ans: D
Which of the following structures lies deepest in the popliteal fossa?
Popliteal artery Popliteal vein Tibial nerve Common peroneal nerve Popliteal lymph nodes
Ans: A
The common peroneal nerve exits the popliteal fossa along the medial border of the biceps tendon. Then the tibial nerve lies lateral to the popliteal vessels to pass posteriorly and then medially to them. The popliteal vein lies superficial to the popliteal artery, which is the deepest structure in the fossa.
How to remember the nerve roots of reflexes?
To remember nerve roots and their reflexes:
1-2 Ankle (S1-S2)
3-4 Knee (L3-L4)
5-6 Biceps (C5-C6)
7-8 Triceps (C7-C8)
A 23 year old man complains of severe groin pain several weeks after a difficult inguinal hernia repair. Which nerve is most likely to have been involved?
Genitofemoral Ilioinguinal Femoral Iliohypogastric Pudendal
Ans: B
The ilioinguinal nerve may have been entrapped in the mesh causing a neuroma.
Which of the positions listed below best describes the location of the coeliac autonomic plexus?
Anterolateral to the aorta Posterolateral to the aorta Anterolateral to the sympathetic chain Anteromedial to the sympathetic chain Posterior to L1
Ans: A
An intravenous drug user develops a false aneurysm and requires emergency surgery. The procedure is difficult and the femoral nerve is inadvertently transected. Which of the following muscles is least likely to be affected as a result?
Sartorius Vastus medialis Pectineus Quadriceps femoris Adductor magnus
Ans: E
Mnemonic for femoral nerve supply
(don’t) M I S V Q Scan for PE
M edial cutaneous nerve of the thigh
I ntermediate cutaneous nerve of the thigh
S aphenous nerve
V astus
Q uadriceps femoris
S artorius
PE ectineus
What is the nerve root value of the external urethral sphincter?
S4 S1, S2, S3 S2, S3, S4 L3, L4, L5 L5, S1, S2
Ans: C
The external urethral sphincter is innervated by branches of the pudendal nerve, therefore the root values are S2, S3, S4.
A 45 year old man is stabbed in the abdomen and the inferior vena cava is injured. How many functional valves does this vessel usually have?
0 1 3 2 4
Ans: A
Mnemonic for the Inferior vena cava tributaries: I Like To Rise So High:
Iliacs Lumbar Testicular Renal Suprarenal Hepatic vein
Which of the following structures does not pass posteriorly to the medial malleolus?
Posterior tibial artery Tibial nerve Tibialis anterior tendon Tendon of flexor digitorum longus Tendon of flexor hallucis longus
Ans: C
Mnemonic for structures posterior to the medial malleolus:
Tom Dick And Nervous Harry
T ibialis posterior tendon flexor Digitorum longus A rtery N erve H allucis longus
Which of the following statements relating to the root of the neck is false?
The lung projects into the neck beyond the first rib and is constrained by Sibson's fascia The subclavian artery arches over the first rib anterior to scalenus anterior The trunks of the brachial plexus lie posterior to the subclavian artery on the first rib The roots and trunks of the Brachial plexus lie between scalenus anterior and scalenus medius muscles The thyrocervical trunk is a branch of the subclavian artery
Ans: B
The subclavian artery lies posterior to scalenus anterior, the vein lies in front. Sibson’s fascia is another name for the suprapleural membrane.
A patient presents to the clinic following a surgical procedure. She complains that she is unable to shrug her shoulder. What is the most likely underlying nerve injury?
Accessory nerve Cervical plexus Ansa cervicalis Long thoracic nerve Axillary nerve
Ans: A
The accessory nerve may be injured in operations in the posterior triangle. Injury will affect trapezius.
A 53 year old man is to undergo a thyroidectomy. Which nerve is at greatest risk?
Hypoglossal Recurrent laryngeal Ansa cervicalis Accessory Marginal mandibular
Ans: B
Recurrent laryngeal nerve injury may complicate thyroid surgery in up to 1- 2% of cases.
The cords of the brachial plexus are most closely related to which of the following vessels?
Subclavian artery Axillary artery Axillary vein Subclavian vein Brachial artery
Ans: B
The trunks are related to the subclavian artery superiorly. The cords of the plexus surround the axillary artery, they are named according to their positions relative to this structure.
Which of the following are not generally supplied by the right coronary artery?
The sino atrial node The circumflex artery The atrioventricular node Most of the right ventricle The right atrium
Ans: B
The circumflex artery is generally a branch of the left coronary artery.
Right coronary artery
The RCA supplies:
Right atrium
Diaphragmatic part of the right ventricle
Usually the posterior third of the interventricular septum
The sino atrial node (60% cases)
The atrio ventricular node (80% cases)
Left coronary artery
The LCA supplies:
Left atrium
Most of left ventricle
Part of the right ventricle
Anterior two thirds of the inter ventricular septum
The sino atrial node (remaining 40% cases)
Innervation of the heart
Autonomic nerve fibres from the superficial and deep cardiac plexus. These lie anterior to the bifurcation of the trachea, posterior to the ascending aorta and superior to the bifurcation of the pulmonary trunk. The parasympathetic supply to the heart is from presynaptic fibres of the vagus nerves.
A 44 year old man has a malignant melanoma and is undergoing a block dissection of the groin. The femoral triangle is being explored for intra operative bleeding. Which of the following forms the medial border of the femoral triangle?
Femoral artery Biceps femoris Adductor longus Sartorius Adductor magnus
Ans: C
Femoral triangle anatomy
Boundaries
Superiorly Inguinal ligament
Laterally Sartorius
Medially Adductor longus
Floor Iliopsoas, adductor longus and pectineus
Roof
Fascia lata and Superficial fascia
Superficial inguinal lymph nodes (palpable below the inguinal ligament)
Long saphenous vein
The foramen marking the termination of the adductor canal is located in which of the following?
Adductor longus Adductor magnus Adductor brevis Sartorius Semimembranosus
Ans: B
The foramen marking the distal limit of the adductor canal is contained within adductor magnus. The vessel passes through this region to enter the popliteal fossa.
Which of the following is the first vessel to branch from the external carotid artery?
Superior thyroid artery Inferior thyroid artery Lingual artery Facial artery Occipital artery
Ans: A
Mnemonic
(Order in which they branch off)Some (sup thyroid)Attendings (Ascending Pharyngeal)Like (Lingual)Freaking (Facial)Out (Occipital)Potential (Post auricular)Medical (Maxillary)Students (Sup temporal)
The first branch of the external carotid artery is the superior thyroid artery. The inferior thyroid artery is derived from the thyrocervical trunk. The other branches are illustrated below.
A motorcyclist is injured in a road traffic accident and is not wearing a helmet. He suffers a severe closed head injury and develops raised intracranial pressure. The first cranial nerve to be affected by this process is likely to be:
Oculomotor Hypoglossal Motor branch of the trigeminal Abducens Sensory branch of the trigeminal
Ans: D
The abducens nerve (CN VI) has a long intra cranial course and is thus susceptible to raised intra cranial pressure. It also passes over the petrous temporal bone and 6th nerve palsies are also seen in mastoiditis.
Which structure separates the cephalic vein and the brachial artery in the antecubital fossa?
Brachioradialis muscle Biceps muscle Origin of flexor digitorum profundus muscle Pronator quadratus muscle Origin of flexor digitorum superficialis muscle
Ans: B
A 23 year old rugby player sustains a Smiths Fracture. On examination, opposition of the thumb is markedly weakened. Which of the following nerves is least likely to be working normally?
Ulnar Median Radial Musculocutaneous Palmar cutaneous
Ans: B
This high velocity injury can often produce significant angulation and displacement. Both of these may impair the function of the median nerve with loss of function of the muscles of the thenar eminence.
A 24 year old motor cyclist is involved in a road traffic accident. He suffers a tibial fracture which is treated with an intra medullary nail. Post operatively he develops a compartment syndrome. Surgical decompression of the anterior compartment will relieve pressure on all of the following muscles except?
Peroneus brevis Peroneus tertius Extensor digitorum longus Tibialis anterior None of the above
Ans: A
A 43 year old lady underwent an attempted placement of a central line into the internal jugular vein. Unfortunately, the doctor damaged the carotid artery and this necessitated surgical exploration. As the surgeons incise the carotid sheath a nerve is identified lying between the internal jugular vein and the carotid artery. Which of the following is this nerve most likely to be?
Glossopharyngeal nerve Hypoglossal nerve Superior laryngeal nerve Recurrent laryngeal nerve Vagus
Ans: E
The vagus lies in the carotid sheath. The hypoglossal nerve crosses the sheath, but does not lie within it.
A patient has a chest drain insertion. There is fresh blood at the chest drain insertion area. Which vessel has been damaged?
Pericardiophrenic artery Intercostal vein Right ventricle Vagus artery Intercostal artery
Ans: E
The intercostal vein is more superior than the artery and is thus slightly less susceptible to injury.
Two teenagers are playing with an airgun when one accidentally shoots his friend in the abdomen. He is brought to the emergency department. On examination there is a bullet entry point immediately to the right of the rectus sheath at the level of the 1st lumbar vertebra. Which of the following structures is most likely to be injured by the bullet?
Head of pancreas Right ureter Right adrenal gland Fundus of the gallbladder Gastric antrum
A: D
The fundus of the gallbladder lies at this level and is the most superficially located structure.
Which of the following muscles inserts onto the lesser tuberostiy of the the humerus?
Subscapularis Deltoid Supraspinatus Teres minor Infraspinatus
Ans: A
With the exception of subscapularis which inserts into the lesser tuberosity, the muscles of the rotator cuff insert into the greater tuberosity.
Which of the following nerves is not contained within the posterior triangle of the neck?
Accessory nerve Phrenic nerve Greater auricular nerve Ansa cervicalis Lesser occiptal nerve
Ans: D
Ansa cervicalis is a content of the anterior triangle of the neck.
A 42 year old lady is reviewed in the outpatient clinic following a routine surgical procedure. She complains of diminished sensation at the dorso-lateral aspect of her foot. Which of the following nerves is most likely to be affected?
Sural Superficial peroneal Deep peroneal Medial plantar Lateral plantar
Ans: A
The sural nerve supplies the lateral aspect of the foot. It runs alongside the short saphenous vein and may be injured in short saphenous vein surgery.
Which of the following anatomical planes separates the prostate from the rectum?
Sibsons fascia Denonvilliers fascia Levator ani muscle Waldeyers fascia None of the above
Ans: B
The Denonvilliers fascia separates the rectum from the prostate. Waldeyers fascia separates the rectum from the sacrum
A 56 year old lady is undergoing an adrenalectomy for Conns syndrome. During the operation the surgeon damages the middle adrenal artery and haemorrhage ensues. From which of the following structures does this vessel originate?
Aorta Renal artery Splenic artery Coeliac axis Superior mesenteric artery
Ans: A
The middle adrenal artery is usually a branch of the aorta, the lower adrenal artery typically arises from the renal vessels.
A 73 year old lady suffers a fracture at the surgical neck of the humerus. The decision is made to operate. There are difficulties in reducing the fracture and a vessel lying posterior to the surgical neck is injured. Which of the following is this vessel most likely to be?
Axillary artery Brachial artery Thoracoacromial artery Transverse scapular artery Posterior circumflex humeral artery
Ans: E
Which of the structures listed below lies posterior to the carotid sheath at the level of the 6th cervical vertebra?
Hypoglossal nerve Vagus nerve Cervical sympathetic chain Ansa cervicalis Glossopharyngeal nerve
Ans: C The carotid sheath is crossed anteriorly by the hypoglossal nerves and the ansa cervicalis. The vagus lies within it. The cervical sympathetic chain lies posteriorly between the sheath and the prevertebral fascia.
A sprinter attends A&E with severe leg pain. He had forgotten to warm up and ran a 100m sprint race. Towards the end of the race he experienced pain in the posterior aspect of his thigh. The pain worsens, localising to the lateral aspect of the knee. The sprinter is unable to flex the knee. What structure has been injured?
Anterior cruciate ligament Posterior cruciate ligament Semimembranosus tendon Semitendinosus tendon Biceps femoris tendon
E)
The biceps femoris is commonly injured in sports that require explosive bending of the knee as seen in sprinting, especially if the athlete has not warmed up first. Avulsion most commonly occurs where the long head attaches to the ischial tuberosity. Injuries to biceps femoris are more common than to the other hamstrings.
A 64 year old man has a suspected lymphoma and lymph node biopsy from the posterolateral aspect of the right neck is planned. Which of the nerves listed is at greatest risk?
Accessory Long thoracic External laryngeal Facial Vagus
Ans: A
The accessory nerve has a superficial course and is easily injured. It lies under platysma and may be divided during the early part of the procedure.
A 24 year old man falls and lands astride a manhole cover. He suffers from an injury to the anterior bulbar urethra. Where will the extravasated urine tend to collect?
Lesser pelvis Connective tissue of the scrotum Deep perineal space Ischiorectal fossa Posterior abdominal wall
Ans: B
This portion of the urethra is contained between the perineal membrane and the membranous layer of the superficial fascia. As these are densely adherent to the ischiopubic rami, extravasated urine cannot pass posteriorly because the 2 layers are continuous around the superficial transverse perineal muscles.
A 73 year old man presents with symptoms of mesenteric ischaemia. As part of his diagnostic work up a diagnostic angiogram is performed .The radiologist is attempting to cannulate the coeliac axis from the aorta. At which of the following vertebral levels does this is usually originate?
T10 L2 L3 T8 T12
Ans: E
Coeliac trunk branches:
Left Hand Side (LHS)
Left gastric
Hepatic
Splenic
A 45 year old man presents with a lipoma located posterior to the posterior border of the sternocleidomastoid muscle, approximately 4cm superior to the middle third of the clavicle. During surgical excision of the lesion troublesome bleeding is encountered. Which of the following is the most likely source?
Internal jugular vein External jugular vein Common carotid artery Vertebral artery Second part of the subclavian artery
Ans: B
The external jugular vein runs obliquely in the superficial fascia of the posterior triangle. It drains into the subclavian vein. During surgical exploration of this area the external jugular vein may be injured and troublesome bleeding may result. The internal jugular vein and carotid arteries are located in the anterior triangle. The third, and not the second, part of the subclavian artery is also a content of the posterior triangle
The sciatic nerve lies deep to the following structures except:
Gluteus maximus The femoral cutaneous nerve Long head of biceps femoris Gluteus medius Branch of the inferior gluteal artery
Ans: D
Which of the following upper limb muscles is not innervated by the radial nerve?
Extensor carpi ulnaris Abductor digiti minimi Anconeus Supinator Brachioradialis
Ans: B
Mnemonic for radial nerve muscles: BEST
B rachioradialis
E xtensors
S upinator
T riceps
During a liver resection a surgeon performs a pringles manoeuvre to control bleeding. Which of the following structures will lie posterior to the epiploic foramen at this level?
Hepatic artery Cystic duct Greater omentum Superior mesenteric artery Inferior vena cava
Ans: E
Bleeding from liver trauma or a difficult cholecystectomy can be controlled with a vascular clamp applied at the epiploic foramen.
The epiploic foramen has the following boundaries:
Anteriorly (in the free edge of the lesser omentum): Bile duct to the right, portal vein behind and hepatic artery to the left.
PosteriorlyInferior vena cava
Inferiorly1st part of the duodenum
SuperiorlyCaudate process of the liver
A 72 year old lady is suspected of having a femoral hernia. At which of the following sites is it most likely to be identifiable clinically?
Mid inguinal point Above and medial to the pubic tubercle Below and lateral to the pubic tubercle Mid point of the inguinal ligament 3 cm superomedially to the superficial inguinal ring
Ans: C
Which muscle is responsible for causing flexion of the distal interphalangeal joint of the ring finger?
Flexor digitorum superficialis Lumbricals Palmar interossei Flexor digitorum profundus Flexor digiti minimi brevis
A: D
Flexor digitorum superficialis and flexor digitorum profundus are responsible for causing flexion. The superficialis tendons insert on the bases of the middle phalanges; the profundus tendons insert on the bases of the distal phalanges. Both tendons flex the wrist, MCP and PIP joints; however, only the profundus tendons flex the DIP joints.
A 34 year old lady undergoes a thyroidectomy for Graves disease. Post operatively she develops a tense haematoma in the neck. In which of the following fascial planes will it be contained?
Gerotas fascia Waldeyers fascia Pretracheal fascia Sibsons fascia Clavipectoral fascia
C)
The pretracheal fascia encloses the thyroid and is unyielding. Therefore tense haematomas can develop.
A 32 year old lady complains of carpal tunnel syndrome. The carpal tunnel is explored surgically. Which of the following structures will lie in closest proximity to the hamate bone within the carpal tunnel?
The tendon of abductor pollicis longus The tendons of flexor digitorum profundus The tendons of flexor carpi radialis longus Median nerve Radial artery
B)
The carpal tunnel contains nine flexor tendons:
Flexor digitorum profundus
Flexor digitorum superficialis
Flexor pollicis longus
The tendon of flexor digitorum profundus lies deepest in the tunnel and will thus lie nearest to the hamate bone.
A 45 year old man sustains a significant head injury and a craniotomy is performed. The sigmoid sinus is bleeding profusely, into which of the following structures does it drain?
Internal jugular vein Straight sinus Petrosal sinus Inferior sagittal sinus External jugular vein
A)
The sigmoid sinus is joined by the inferior petrosal sinus to drain into the internal jugular vein.
Which nerve supplies the interossei of the fourth finger?
Radial Median Superficial ulnar Deep ulnar Posterior interosseous
D)
Mnemonic:
PAD and DAB
Palmer interossei ADduct
Dorsal interossei ABduct
In which of the following cranial bones does the foramen spinosum lie?
Sphenoid bone Frontal bone Temporal bone Occipital bone Parietal bone
A)
The foramen spinosum (which transmits the middle meningeal artery and vein) lies in the sphenoid bone.
Which of the following is not considered a major branch of the descending thoracic aorta?
Bronchial artery Mediastinal artery Inferior thyroid artery Posterior intercostal artery Oesophageal artery
C)
The inferior thyroid artery is usually derived from the thyrocervical trunk, a branch of the subclavian artery.
An 18 year old lady with troublesome hyperhidrosis of the hands and arms is due to undergo a sympathectomy to treat the condition. Which of the following should the surgeons divide to most effectively treat her condition?
Sympathetic ganglia at T1, T2 and T3 Sympathetic ganglia at T2 and T3 Sympathetic ganglia at T1 and T2 Stellate ganglion Superior cervical ganglion
B)
To treat hyperhidrosis the sympathetic ganglia at T2 and T3 should be divided. Dividing the other structures listed would either carry a risk of Horners syndrome or be ineffective.
A 44 year old lady is recovering following a transphenoidal hypophysectomy. Unfortunately there is a post operative haemorrhage. Which of the following features is most likely to occur initially?
Cavernous sinus thrombosis Abducens nerve palsy Bi-temporal hemianopia Inferior homonymous hemianopia Central retinal vein occlusion
C)
The pituitary is covered by a sheath of dura and an expanding haematoma at this site may compress the optic chiasm in the same manner as an expanding pituitary tumour.
During a right hemicolectomy the caecum is mobilised. As the bowel is retracted medially a vessel is injured, posterior to the colon. Which of the following is the most likely vessel?
Right colic artery Inferior vena cava Aorta External iliac artery Gonadal vessels
E)
The key in this question is that its during the caecal mobilization. The gonadal vessels and ureter are important posterior relations that are at risk during a right hemicolectomy. During latter stages of the procedure, the ileocolic artery and vein are traced along the anterior aspect of the duodenum. At this point it is possible to injure these, the superior mesenteric vein or the middle colic vein, injury to any of these can result in torrential bleeding that is very difficult to control.
A 53 year old man with a carcinoma of the lower third of the oesophagus is undergoing an oesophagogastrectomy. As the surgeons mobilise the lower part of the oesophagus, where are they most likely to encounter the thoracic duct?
Anterior to the oesophagus On the left side of the oesophagus On the right side of the oesophagus Immediately anterior to the azygos vein Posterior to the oesophagus
E)
The thoracic duct lies posterior to the oesophagus and passes to the left at the level of the Angle of Louis. It enters the thorax at T12 together with the aorta.
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
Ans: A
The sciatic nerve most commonly arises from L4 to S3.
An 83 year old lady presents with a femoral hernia and undergoes a femoral hernia repair. Which of the following forms the posterior wall of the femoral canal?
Pectineal ligament Lacunar ligament Inguinal ligament Adductor longus Sartorius
A)
Borders of the femoral canal Laterally Femoral vein Medially Lacunar ligament Anteriorly Inguinal ligament Posteriorly Pectineal ligament
A 45 year man presents with hand weakness. He is given a piece of paper to hold between his thumb and index finger. When the paper is pulled, the patient has difficulty maintaining a grip. Grip pressure is maintained by flexing the thumb at the interphalangeal joint. What is the most likely nerve lesion?
Posterior interosseous nerve Deep branch of ulnar nerve Anterior interosseous nerve Superficial branch of the ulnar nerve Radial nerve
B)
This is a description of Froment’s sign, which tests for ulnar nerve palsy. It mainly tests for the function of adductor pollicis. This is supplied by the deep branch of the ulnar nerve. Remember the anterior interosseous branch (of the median nerve), which innervates the flexor pollicis longus (hence causing flexion of the thumb IP joint), branches off more proximally to the wrist.
Which of the following cranial foramina pairings are incorrect?
Carotid canal and internal carotid artery. Foramen ovale and mandibular nerve. Optic canal and ophthalmic artery. Optic canal and ophthalmic nerve. Foramen rotundum and maxillary nerve.
D)
The optic canal transmits the optic nerve. The ophthalmic nerve traverses the superior orbital fissure.
A 22 year old man is involved in a fight and sustains a stab wound in his upper forearm. On examination there is a small, but deep laceration. There is an obvious loss of pincer movement involving the thumb and index finger with minimal loss of sensation. The most likely nerve injury is to the:
Ulnar nerve Radial nerve Anterior interosseous nerve Axillary nerve Median nerve
C)
The anterior interosseous nerve is a motor branch of the median nerve just below the elbow. When damaged it classically causes:
Pain in the forearm
Loss of pincer movement of the thumb and index finger (innervates the long flexor muscles of flexor pollicis longus & flexor digitorum profundus of the index and middle finger)
Minimal loss of sensation due to lack of a cutaneous branch
A 66 year old man is undergoing a left nephro-ureterectomy. The surgeons remove the ureter, which of the following is responsible for the blood supply to the proximal ureter?
Branches of the renal artery External iliac artery Internal iliac artery Direct branches from the aorta Common iliac artery
A)
The proximal ureter is supplied by branches from the renal artery. For the other feeding vessels - see below.
Which of the following structures does not pass behind the lateral malleolus?
Peroneus brevis tendon Sural nerve Short saphenous vein Peroneus longus tendon Tibialis anterior tendon
E) Tibialis anterior tendon passes anterior to the medial malleolus
Structures posterior to the lateral malleolus and superficial to superior peroneal retinaculum
Sural nerve
Short saphenous vein
Structures posterior to the lateral malleolus and deep to superior peroneal retinaculum
Peroneus longus tendon
Peroneus brevis tendon
The calcaneofibular ligament is attached at the lateral malleolus
A 63 year old man is admitted with severe headache, nausea and recent epileptic fit. Fundoscopy shows papilloedema. He is also noted to have diplopia. Which of the cranial nerves listed is responsible?
Abducens Optic Oculomotor Facial Trigeminal
A)
The long intracranial course of this nerve makes it susceptible to damage early in the course of raised ICP.
A 78 year old man presents with symptoms consistent with intermittent claudication. To assess the severity of his disease you decide to measure his ankle brachial pressure index. To do this you will identify the dorsalis pedis artery. Which of the following statements relating to this vessel is false?
It originates from the peroneal artery It is crossed by the tendon of extensor hallucis brevis Two veins are usually closely related to it It passes under the inferior extensor retinaculum The tendon of extensor digitorum longus lies lateral to it
A)
The dorsalis pedis artery is a direct continuation of the anterior tibial artery.
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
C)
The phrenic nerve is a content of the posterior triangle. The anterior triangle contains the carotid sheath and its contents.
A 32 year old attends neurology clinic complaining of tingling in his hand. He has radial deviation of his wrist and there is mild clawing of his fingers, with the 4th and 5th digits being relatively spared. What is the most likely lesion?
Ulnar nerve damage at the wrist Ulnar nerve damage at the elbow Radial nerve damage at the elbow Median nerve damage at the wrist Median nerve damage at the elbow
B)
The ulnar paradox- the higher the lesion, the less the clawing of the fingers seen clinically.
At the elbow the ulnar nerve lesion affects the flexor carpi ulnaris and flexor digitorum profundus.
A 22 year old man is undergoing an endotracheal intubation. Which of the following vertebral levels is consistent with the origin of the trachea?
C2 T1 C6 C4 C3
C)
The trachea commences at C6. It terminates at the level of T5 (or T6 in tall subjects in deep inspiration).
A young child undergoes a difficult craniotomy for fulminant mastoiditis and associated abscess. During the procedure the trigeminal nerve is severely damaged within Meckels cave. Which deficit is least likely to be present?
Anaesthesia over the ipsilateral anterior aspect of the scalp Loss of the corneal reflex Weakness of the ipsilateral masseter muscle Anaesthesia of the anterior aspect of the lip Anaesthesia over the entire ipsilateral side of the face
E)
The angle of the jaw is not innervated by sensory fibres of the trigeminal nerve and is spared in this type of injury.
Remember the trigeminal nerve provides motor innervation to the muscles of mastication. The close proximity of the site of injury to the motor fibres is likely to result in at least some compromise of motor muscle function.
Which of the following is not a branch of the external carotid artery?
Facial artery Lingual artery Superior thyroid artery Mandibular artery Maxillary artery
D)
External carotid artery branches mnemonic:
‘Some Angry Lady Figured Out PMS’
Superior thyroid (superior laryngeal artery branch) Ascending pharyngeal Lingual Facial (tonsillar and labial artery) Occipital Posterior auricular Maxillary (inferior alveolar artery, middle meningeal artery) Superficial temporal
A 23 year old man is stabbed in the groin, several structures are injured and the adductor longus muscle has been lacerated. Which of the following nerves is responsible for the innervation of adductor longus?
Femoral nerve Obturator nerve Sciatic nerve Common peroneal nerve Ilioinguinal nerve
B) The adductors are innervated by the obturator nerve
Which of the following statements relating to the basilar artery and its branches is false?
The superior cerebellar artery may be decompressed to treat trigeminal neuralgia Occlusion of the posterior cerebral artery causes contralateral loss of the visual field The oculomotor nerve lies between the superior cerebellar and posterior cerebral arteries The posterior inferior cerebellar artery is the largest of the cerebellar arteries arising from the basilar artery The labyrinthine branch is accompanied by the facial nerve
D)
The posterior inferior cerebellar artery is the largest of the cerebellar arteries arising from the vertebral artery. The labyrinthine artery is long and slender and may arise from the lower part of the basilar artery. It accompanies the facial and vestibulocochlear nerves into the internal auditory meatus. The posterior cerebral artery is often larger than the superior cerebellar artery and it is separated from the vessel, near it’s origin, by the oculomotor nerve. Arterial decompression is a well established therapy for trigeminal neuralgia.
Which of the following muscles does not recieve any innervation from the sciatic nerve?
Semimembranosus Quadriceps femoris Biceps femoris Semitendinosus Adductor magnus
B)
The sciatic nerve is traditionally viewed as being a nerve of the posterior compartment. It is known to contribute to the innervation of adductor magnus (although the main innervation to this muscle is from the obturator nerve). The quadriceps femoris is nearly always innervated by the femoral nerve.
A 23 year old man is involved in a fight and is stabbed in his upper arm. The ulnar nerve is transected. Which of the following muscles will not demonstrate compromised function as a result?
Flexor carpi ulnaris Medial half of flexor digitorum profundus Palmaris brevis Hypothenar muscles Pronator teres
E) M edial lumbricals A dductor pollicis F lexor digitorum profundus/Flexor digiti minimi I nterossei A bductor digiti minimi and opponens
Innervates all intrinsic muscles of the hand (EXCEPT 2: thenar muscles & first two lumbricals - supplied by median nerve)
Which of the following pairings are incorrect?
Aortic bifurcation and L4 Transpyloric plane and L1 Termination of dural sac and L4 Oesophageal passage through diaphragm and T10 Transition between pharynx and oesophagus at C6
C) Vena cava T8 (eight letters)
Oesophagus T10 (ten letters)
Aortic hiatus T12 (twelve letters)
It terminates at S2, which is why it is safe to undertake an LP at L4/5 levels. The spinal cord itself terminates at L1.
A 22 year old man is involved in a fight. He sustains a laceration to the posterior aspect of his wrist. In the emergency department the wound is explored and the laceration is found to be transversely orientated and overlies the region of the extensor retinaculum, which is intact. Which of the following structures is least likely to be injured in this scenario?
Dorsal cutaneous branch of the ulnar nerve Tendon of extensor indicis Basilic vein Superficial branch of the radial nerve Cephalic vein
B)
The extensor retinaculum attaches to the radius proximal to the styloid, thereafter it runs obliquely and distally to wind around the ulnar styloid (but does not attach to it). The extensor tendons lie deep to the extensor retinaculum and would therefore be less susceptible to injury than the superficial structures.
Structures superficial to the retinaculum
Basilic vein
Dorsal cutaneous branch of the ulnar nerve
Cephalic vein
Superficial branch of the radial nerve
Which of the following is not a content of the porta hepatis?
Portal vein Hepatic artery Cystic duct Lymph nodes None of the above
C)
The cystic duct lies outside the porta hepatis and is an important landmark in laparoscopic cholecystectomy. The structures in the porta hepatis are:
Portal vein
Hepatic artery
Common hepatic duct
A 21 year old develops tonsillitis. He is in considerable pain. Which of the following nerves is responsible for the sensory innervation of the tonsillar fossa?
Facial nerve Trigeminal nerve Glossopharyngeal nerve Hypoglossal nerve Vagus
C) The glossopharyngeal nerve is the main sensory nerve for the tonsillar fossa. A lesser contribution is made by the lesser palatine nerve. Because of this otalgia may occur following tonsillectomy.
A man has an incision sited that runs 8cm from the deltopectoral groove to the midline. Which of the following is not at risk of injury?
Cephalic vein Shoulder joint capsule Axillary artery Pectoralis major Trunk of the brachial plexus
B)
This region will typically lie medial to the joint capsule. The diagram below illustrates the plane that this would transect and as it can be appreciated the other structures are all at risk of injury.
A surgeon is due to perform a laparotomy for perforated duodenal ulcer. An upper midline incision is to be performed. Which of the following structures is the incision most likely to divide?
Rectus abdominis muscle External oblique muscle Linea alba Internal oblique muscle None of the above
C)
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
A) The middle colonic vein drains into the SMV, if avulsed during mobilisation then dramatic haemorrhage can occur and be difficult to control.
What is the lymphatic drainage of the female urethra?
Superficial inguinal nodes Deep inguinal nodes Internal iliac nodes External iliac nodes Para-aortic nodes
C)
A 23 year old man is stabbed in the chest approximately 10cm below the right nipple. In the emergency department a abdominal ultrasound scan shows a large amount of intraperitoneal blood. Which of the following statements relating to the likely site of injury is untrue?
Part of its posterior surface is devoid of peritoneum. The quadrate lobe is contained within the functional right lobe. Its nerve supply is from the coeliac plexus. The hepatic flexure of the colon lies posterio-inferiorly. The right kidney is closely related posteriorly.
B) The right lobe of the liver is the most likely site of injury. Therefore the answer is B as the quadrate lobe is functionally part of the left lobe of the liver. The liver is largely covered in peritoneum. Posteriorly there is an area devoid of peritoneum (the bare area of the liver). The right lobe of the liver has the largest bare area (and is larger than the left lobe).
A 22 year old man is involved in a fight and sustains a skull fracture with an injury to the middle meningeal artery. A craniotomy is performed, and with considerable difficulty the haemorrhage from the middle meningeal artery is controlled by ligating it close to its origin. What is the most likely sensory impairment that the patient may notice post operatively?
Parasthesia of the ipsilateral external ear Loss of taste sensation from the anterior two thirds of the tongue Parasthesia overlying the angle of the jaw Loss of sensation from the ipsilateral side of the tongue Loss of taste from the posterior two thirds of the tongue
A) The auriculotemporal nerve is closely related to the middle meningeal artery and may be damaged in this scenario. The nerve supplied sensation to the external ear and outermost part of the tympanic membrane. The angle of the jaw is innervated by C2,3 roots and would not be affected. The tongue is supplied by the glossopharyngeal nerve.
A 72 year old man presents with haemoptysis and undergoes a bronchoscopy. The carina is noted to be widened. At which level does the trachea bifurcate?
T3 T5 T7 T2 T8
B)
The trachea bifurcates at the level of the fifth thoracic vertebra. Or the sixth in tall subjects.
A 23 year old man is injured during a game of rugby. He suffers a fracture of the distal third of his clavicle, it is a compound fracture and there is evidence of arterial haemorrhage. Which of the following vessels is most likely to be encountered first during subsequent surgical exploration?
Posterior circumflex humeral artery Axillary artery Thoracoacromial artery Sub scapular artery Lateral thoracic artery
C) The thoracoacromial artery arises from the second part of the axillary artery. It is a short, wide trunk, which pierces the clavipectoral fascia, and ends, deep to pectoralis major by dividing into four branches.
The following are true of the femoral nerve, except:
It is derived from L2, L3 and L4 nerve roots It supplies sartorius It supplies quadriceps femoris It gives cutaneous innervations via the saphenous nerve It supplies adductor longus
E) Adductor longus is supplied by the obturator nerve.
Where is the vomiting centre located?
Medulla oblongata Substantia nigra Antrum of stomach Pons Midbrain
A)
Which of the following nerves conveys sensory information from the laryngeal mucosa?
Glossopharyngeal Laryngeal branches of the vagus Ansa cervicalis Laryngeal branches of the trigeminal None of the above
B) The laryngeal branches of the vagus supply sensory information from the larynx.
Which of the following nerves passes through the greater sciatic foramen and innervates the perineum?
Pudendal Sciatic Superior gluteal Inferior gluteal Posterior cutaneous nerve of the thigh
A) 3 divisions of the pudendal nerve: Rectal nerve Perineal nerve Dorsal nerve of penis/ clitoris All these pass through the greater sciatic foramen.
The pudendal nerve innervates the perineum. It passes between piriformis and coccygeus medial to the sciatic nerve.
Which of the following is true in relation to the sartorius muscle?
Innervated by the deep branch of the femoral nerve Inserts at the fibula It is the shortest muscle in the body Forms the Pes anserinus with Gracilis and semitendinous muscle Causes extension of the knee
D)
It is innervated by the superficial branch of the femoral nerve. It is a component of the pes anserinus.
A 25 year old man sustains a severe middle cranial fossa basal skull fracture. Once he has recovered it is noticed that he has impaired tear secretion. This is most likely to be the result of damage to which of the following?
Stellate ganglion Ciliary ganglion Otic ganglion Trigeminal nerve Greater petrosal nerve
E) The greater petrosal nerve may be injured and carries fibres for lacrimation
Which of the following structures passes through the quadrangular space near the humeral head?
Axillary artery Radial nerve Axillary nerve Median nerve Transverse scapular artery
C)
The quadrangular space is bordered by the humerus laterally, subscapularis superiorly, teres major inferiorly and the long head of triceps medially. It lies lateral to the triangular space. It transmits the axillary nerve and posterior circumflex humeral artery.
Which of the following pairings of foramina and their contents is not correct?
Superior orbital fissure and the oculomotor nerve Foramina rotundum and the maxillary nerve Jugular foramen and the hypoglossal nerve Foramina spinosum and the middle meningeal artery Carotid canal and the internal carotid artery
C) The hypoglossal nerve passes through the hypoglossal canal.
A 55 year old man with carcinoma of the larynx is undergoing a difficult laryngectomy. The surgeons divide the thyrocervical trunk, from which of the following vessels does this structure most commonly originate?
Subclavian artery Common carotid artery Vertebral artery External carotid artery Internal carotid artery
A) The thyrocervical trunk is a branch of the subclavian artery. It arises from the first part between the subclavian artery and the inner border of scalenus anterior. It branches off the subclavian distal to the vertebral artery.
What is the first branch of the axillary artery?
Subscapular artery Lateral thoracic artery Thoraco acromial artery Superior thoracic artery Anterior circumflex humeral artery
D)
The superior thoracic artery is the first branch of the axillary artery arises from the first part
Two branches arise from the second part, thoraco acromial and lateral thoracic
Three branches from the third part, subscapular artery, anterior and posterior circumflex humeral arteries
The following structures are closely related to the brachiocephalic artery except:
Trachea posteriorly Right brachiocephalic vein Inferior thyroid vein Right recurrent laryngeal nerve None of the above
D)
There is no brachiocephalic artery on the left, however the left brachiocephalic vein lies anteriorly to the roots of all the 3 great arteries (including the brachiocephalic artery). The right recurrent laryngeal nerve has no relation to the brachiocephalic artery.
Which of the following structures separates the ulnar artery from the median nerve?
Brachioradialis Pronator teres Tendon of biceps brachii Flexor carpi ulnaris Brachialis
B)
It lies deep to pronator teres and this separates it from the median nerve.
Which muscle is supplied by the superficial peroneal nerve?
Peroneus tertius Sartorius Adductor magnus Peroneus brevis Gracilis
D)
A man develops an infection in his external ear. The infection is extremely painful. Which of the following nerves conveys sensation from this region?
Occipital branch of the trigeminal nerve Vestibulocochlear nerve Facial nerve Auriculotemporal nerve Maxillary branch of the trigeminal nerve
D) Tensor tympania and stapedius are the only two muscles of the middle ear. Contraction of tensor tympani will tend to dampen the vibrations produced by loud sounds, it is innervated by a branch of the trigeminal nerve. The stapedius dampens movements of the ossicles in response to loud sounds and is innervated by a branch of the facial nerve.
The auriculotemporal nerve, which is derived from the mandibular branch of the trigeminal nerve supplies this area.
Which muscle is responsible for causing flexion of the interphalangeal joint of the thumb?
Flexor pollicis longus Flexor pollicis brevis Flexor digitorum superficialis Flexor digitorum profundus Adductor pollicis
A) There are 8 muscles:
- Two flexors (flexor pollicis brevis and flexor pollicis longus)
- Two extensors (extensor pollicis brevis and longus)
- Two abductors (abductor pollicis brevis and longus)
- One adductor (adductor pollicis)
- One muscle that opposes the thumb by rotating the CMC joint (opponens pollicis).
Flexor and extensor longus insert on the distal phalanx moving both the MCP and IP joints.
Which of the following structures separates the posterior cruciate ligament from the popliteal artery?
Oblique popliteal ligament Transverse ligament Popliteus tendon Biceps femoris Semitendinosus
A)
The posterior cruciate ligament is separated from the popliteal vessels at its origin by the oblique popliteal ligament. The transverse ligament is located anteriorly.
How many compartments are there in the lower leg?
2 1 3 5 4
E)
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.
Which structure is least likely to be found at the level of the sternal angle?
Left brachiocephalic vein Intervertebral discs T4-T5 Start of aortic arch 2nd pair of costal cartilages Bifurcation of the trachea into left and right bronchi
A)
The left brachiocephalic vein lies posterior to the manubrium, at the level of its upper border. The sternal angle refers to the transition between manubrium and sternum and therefore will not include the left brachiocephalic vein.
What is the most useful test to clinically distinguish between an upper and lower motor neurone lesion of the facial nerve?
Blow cheeks out Loss of chin reflex Close eye Raise eyebrow Open mouth against resistance
D)
Upper motor neurone lesions of the facial nerve- Paralysis of the lower half of face.
Lower motor neurone lesion- Paralysis of the entire ipsilateral face.
An 18 year old man is stabbed in the axilla during a fight. His axillary artery is lacerated and repaired. However, the surgeon neglects to repair an associated injury to the upper trunk of the brachial plexus. Which of the following muscles is least likely to demonstrate impaired function as a result?
Palmar interossei Infraspinatus Brachialis Supinator brevis None of the above
A)
The palmar interossei are supplied by the ulnar nerve. Which lies inferiorly and is therefore less likely to be injured.
A 23 year old man is involved in a fight, during the dispute he sustains a laceration to the posterior aspect of his right arm, approximately 2cm proximal to the olecranon process. On assessment in the emergency department he is unable to extend his elbow joint. Which of the following tendons is most likely to have been cut?
Triceps Pronator teres Brachioradialis Brachialis Biceps
A) The triceps muscle extends the elbow joint. The other muscles listed all produce flexion of the elbow joint.
You excitedly embark on your first laparoscopic cholecystectomy and during the operation the anatomy of Calots triangle is more hostile than anticipated. Whilst trying to apply a haemostatic clip you avulse the cystic artery. This is followed by brisk haemorrhage. From which source is this most likely to originate ?
Right hepatic artery Portal vein Gastroduodenal artery Liver bed Common hepatic artery
A) The cystic artery is a branch of the right hepatic artery.
A 43 year old man suffers a pelvic fracture which is complicated by an injury to the junction of the membranous urethra to the bulbar urethra. In which of the following directions is the extravasated urine most likely to pass?
Posteriorly into extra peritoneal tissues Laterally into the buttocks Into the abdomen Anteriorly into the connective tissues surrounding the scrotum None of the above
D) The superficial perineal pouch is a compartment bounded superficially by the superficial perineal fascia, deep by the perineal membrane (inferior fascia of the urogenital diaphragm), and laterally by the ischiopubic ramus. It contains the crura of the penis or clitoris, muscles, viscera, blood vessels, nerves, the proximal part of the spongy urethra in males, and the greater vestibular glands in females.
When urethral rupture occurs as in this case the urine will tend to pass anteriorly because the fascial condensations will prevent lateral and posterior passage of the urine.
Which of the following does not pass through the superior orbital fissure?
Oculomotor nerve Abducens nerve Ophthalmic artery Ophthalmic division of the trigeminal nerve Ophthalmic veins
C)
The ophthalmic artery, a branch of the internal carotid enters the orbit with the optic nerve in the canal.
Which nerve supplies the 1st web space of the foot?
Popliteal nerve Superficial peroneal nerve Deep peroneal nerve Tibial nerve Saphenous nerve
C) The first web space is innervated by the deep peroneal nerve.
During the course of a radical gastrectomy the surgeons detach the omentum and ligate the right gastro-epiploic artery. From which vessel does it originate?
Superior mesenteric artery Inferior mesenteric artery Coeliac axis Common hepatic artery Gastroduodenal artery
E)
Which of the following is not an intrinsic muscle of the hand?
Opponens pollicis Palmaris longus Flexor pollicis brevis Flexor digiti minimi brevis Opponens digiti minimi
B) Palmaris longus originates in the forearm.
Through which of the following foramina does the genital branch of the genitofemoral nerve exit the abdominal cavity?
Superficial inguinal ring Sciatic notch Obturator foramen Femoral canal Deep inguinal ring
E) The genitofemoral nerve divides into two branches as it approaches the inguinal ligament. The genital branch passes anterior to the external iliac artery through the deep inguinal ring into the inguinal canal. It communicates with the ilioinguinal nerve in the inguinal canal (though this is seldom of clinical significance).
A 63 year old lady is diagnosed as having an endometrial carcinoma arising from the uterine body. To which nodal region will the tumour initially metastasise?
Para aortic nodes Iliac lymph nodes Inguinal nodes Pre sacral nodes Mesorectal lymph nodes
B) Tumours of the uterine body will tend to spread to the iliac nodes initially.
Lymphatic drainage of the ovaries, uterus and cervix
The ovaries drain to the para-aortic lymphatics via the gonadal vessels.
The uterine fundus has a lymphatic drainage that runs with the ovarian vessels and may thus drain to the para-aortic nodes. Some drainage may also pass along the round ligament to the inguinal nodes.
The body of the uterus drains through lymphatics contained within the broad ligament to the iliac lymph nodes.
The cervix drains into three potential nodal stations; laterally through the broad ligament to the external iliac nodes, along the lymphatics of the uterosacral fold to the presacral nodes and posterolaterally along lymphatics lying alongside the uterine vessels to the internal iliac nodes.
Which of the following structures is not located in the superficial perineal space in females?
Posterior labial arteries Pudendal nerve Superficial transverse perineal muscle Greater vestibular glands None of the above
B)
The pudendal nerve is located in the deep perineal space and then branches to innervate more superficial structures.
Urogenital triangle
The urogenital triangle is formed by the:
Ischiopubic inferior rami
Ischial tuberosities
A fascial sheet is attached to the sides, forming the inferior fascia of the urogenital diaphragm.
It transmits the urethra in males and both the urethra and vagina in females. The membranous urethra lies deep to this structure and is surrounded by the external urethral sphincter.
Superficial to the urogenital diaphragm lies the superficial perineal pouch. In males this contains: Bulb of penis Crura of the penis Superficial transverse perineal muscle Posterior scrotal arteries Posterior scrotal nerves
In females the internal pudendal artery branches to become the posterior labial arteries in the superficial perineal pouch.
Which of the following is not a branch of the hepatic artery?
Pancreatic artery Cystic artery Right gastric artery Right hepatic artery Gastroduodenal artery
A)
The pancreatic artery is a branch of the splenic artery.
Which of the following structures does not pass close to the piriformis muscle in the greater sciatic foramen?
Sciatic nerve Posterior cutaneous nerve of the thigh Inferior gluteal artery Obturator nerve None of the above
D)
Contents
Nerves Sciatic Nerve Superior and Inferior Gluteal Nerves Pudendal Nerve Posterior Femoral Cutaneous Nerve Nerve to Quadratus Femoris Nerve to Obturator internus
Vessels
Superior Gluteal Artery and vein
Inferior Gluteal Artery and vein
Internal Pudendal Artery and vein
A 56 year old man is undergoing a right nephrectomy. The surgeons divide the renal artery. At what level does this usually branch off the abdominal aorta?
T9 L2 L3 T10 L4
B)
The renal arteries usually branch off the aorta on a level with L2.
A 23 year old man is shot in the chest during a robbery. The left lung is lacerated and is bleeding. An emergency thoracotomy is performed. The surgeons place a clamp over the hilum of the left lung. Which of the following structures lies most anteriorly at this level?
Vagus nerve Oesophagus Descending aorta Phrenic nerve Azygos vein
D) The phrenic nerve lies anteriorly at this point. The vagus passes anteriorly and then arches backwards immediately superior to the root of the left bronchus, giving off the recurrent laryngeal nerve as it does so.
Which of the following muscles does not adduct the shoulder?
Teres major Pectoralis major Coracobrachialis Supraspinatus Latissimus dorsi
D)
Supraspinatus is an abductor of the shoulder.
Which of these muscles is innervated by the cervical branch of the facial nerve?
Masseter Sternocleidomastoid Platysma Geniohyoid Sternothyroid
C) The cervical branch of the facial nerve innervates platysma.
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
D) Autonomic nerve injury is the most common cause.
A 73 year old man is due to undergo a radical prostatectomy for carcinoma of the prostate gland. To which of the following lymph nodes will the tumour drain primarily?
Para aortic Internal iliac Superficial inguinal Meso rectal None of the above
B) The prostate lymphatic drainage is primarily to the internal iliac nodes and also the sacral nodes. Although internal iliac is the first site.
Which of the following statements relating to the vertebral column is false?
There are 7 cervical vertebrae The cervical and lumbar lordosis are secondary curves developing after birth due to change in shape of the intervertebral discs The lumbar vertebrae do not have a transverse process foramina The lumbar vertebrae receive blood directly from the aorta The spinous process is formed by the junction of the pedicles posteriorly
D) The spinous process is formed by 2 laminae posteriorly.
A 78 year old lady falls over in her nursing home and sustains a displaced intracapsular fracture of the femoral neck. A decision is made to perform a hemi arthroplasty through a lateral approach. Which of these vessels will be divided to facilitate access?
Saphenous vein Superior gluteal artery Superficial circumflex iliac artery Profunda femoris artery Transverse branch of the lateral circumflex artery
E) During the Hardinge style lateral approach the transverse branch of the lateral circumflex artery is divided to gain access.
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
D) 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.
Which of the following structures is not closely related to the brachial artery?
Ulnar nerve Median nerve Cephalic vein Long head of triceps Median cubital vein
C) The cephalic vein lies superficially and on the contralateral side of the arm to the brachial artery.
A 38 year old man presents to the clinic with shoulder weakness. On examination he has an inability to initiate shoulder abduction. Which of the nerves listed below is least likely to be functioning normally?
Suprascapular nerve Medial pectoral nerve Axillary nerve Median nerve Radial nerve
A)
Which of the following statements relating to the Cavernous Sinus is false?
The pituitary gland lies medially The internal carotid artery passes through it The temporal lobe of the brain is a lateral relation The mandibular branch of the trigeminal and optic nerve lie on the lateral wall The ophthalmic veins drain into the anterior aspect of the sinus
D) The veins that drain into the sinus are important as sepsis can cause cavernous sinus thrombosis. The maxillary branch of the trigeminal and not the mandibular branches pass through the sinus
Which of the following is not a branch of the subclavian artery?
Superior thyroid artery Vertebral artery Thyrocervical trunk Internal thoracic artery Dorsal scapular artery
A) Mnemonic for the branches of the subclavian artery: VIT C & D
V ertebral artery
I nternal thoracic
T hyrocervical trunk
C ostalcervical trunk
D orsal scapular
Superior thyroid artery is a branch of the external carotid artery.
During the repair of an atrial septal defect the surgeons note that blood starts to leak from the coronary sinus. Which structure forms the largest tributary of the coronary sinus?
Thebesian veins Great cardiac vein Oblique vein Small cardiac veins None of the above
B) The great cardiac vein runs in the anterior interventricular groove, and is the largest tributary of the coronary sinus. The thebesian veins drain into the heart directly.
Coronary sinus
This lies in the posterior part of the coronary groove and receives blood from the cardiac veins. The great cardiac vein lies at its left and the middle and small cardiac veins lie on its right. The smallest cardiac vein (anterior cardiac vein) drains into the right atrium directly.
Which of the following vessels provides the greatest contribution to the arterial supply of the breast?
External mammary artery Thoracoacromial artery Internal mammary artery Lateral thoracic artery Subclavian artery
C) 60% of the arterial supply to the breast is derived from the internal mammary artery. The external mammary and lateral thoracic arteries also make a significant (but lesser) contribution. This is of importance clinically in performing reduction mammoplasty procedures.
Which of the following muscles is supplied by the external laryngeal nerve?
Transverse arytenoid Cricothyroid Thyro-arytenoid Posterior crico-arytenoid Oblique arytenoid
B) The others are all supplied by the recurrent laryngeal nerve.
A 28 year old man has sustained a non salvageable testicular injury to his left testicle. The surgeon decides to perform an orchidectomy and divides the left testicular artery. From which of the following does this vessel originate?
Abdominal aorta Internal iliac artery Inferior epigastric artery Inferior vesical artery External iliac artery
A) The testicular artery is a branch of the abdominal aorta.
During a carotid endarterectomy the internal carotid artery is cross clamped. Assuming that no shunt is inserted, which of the following vessels will not have diminished or absent flow as a result?
Anterior cerebral artery Ophthalmic artery Middle cerebral artery Maxillary artery None of the above
D) Mnemonic for branches of the cerebral portion of the internal carotid artery ‘Only Press Carotid Arteries Momentarily’
Only = Opthalmic Press = Posterior communicating Carotid = Choroidal Arteries = Anterior cerebral Momentarily = Middle cerebral
The maxillary artery is a branch of the external carotid artery.
A 72 year old lady with osteoporosis falls and sustains an intracapsular femoral neck fracture. The fracture is completely displaced. Which of the following vessels is the main contributor to the arterial supply of the femoral head?
Deep external pudendal artery Superficial femoral artery External iliac artery Circumflex femoral arteries Superficial external pudendal artery
D) The vessels which form the anastomoses around the femoral head are derived from the medial and lateral circumflex femoral arteries. These are usually derived from the profunda femoris artery.
A 21 year old man is hit with a hammer and sustains a depressed skull fracture at the vertex. Which of the following sinuses is at risk in this injury?
Superior sagittal sinus Inferior petrosal sinus Transverse sinus Inferior sagittal sinus Straight sinus
A) The superior sagittal sinus is at greatest risk in this pattern of injury. This sinus begins at the front of the crista galli and courses backwards along the falx cerebri. It becomes continuous with the right transverse sinus near the internal occipital protuberance.
A 44 year old man is stabbed in the back and the left kidney is injured. A haematoma forms, which of the following fascial structures will contain the haematoma?
Waldeyers fascia Sibsons fascia Bucks fascia Gerotas fascia Denonvilliers fascia
D) Waldeyers fascia- Posterior ano-rectum
Sibsons fascia- Lung apex
Bucks fascia- Base of penis
Gerotas fascia- Surrounding kidney
Denonvilliers fascia- Between rectum and prostate
A baby is found to have a Klumpke’s palsy post delivery. Which of the following is most likely to be present?
Loss of flexors of the wrist Weak elbow flexion Pronation of the forearm Adducted shoulder Shoulder medially rotated
A) Features of Klumpkes Paralysis
Claw hand (MCP joints extended and IP joints flexed)
Loss of sensation over medial aspect of forearm and hand
Horner’s syndrome
Loss of flexors of the wrist
A C8, T1 root lesion is called Klumpke’s paralysis and is caused by delivery with the arm extended.
A 22 year old man undergoes a superficial parotidectomy for a pleomorphic adenoma. The operation does not proceed well and a diathermy malfunction results in division of the buccal branch of the facial nerve. Which of the following muscles will not demonstrate impaired function as a result?
Zygomaticus minor Mentalis Buccinator Levator anguli oris Risorius
B)
At which of the following vertebral body levels does the common carotid artery typically bifurcate into the external and internal carotid arteries?
C4 C2 C1 C6 C7
A) It terminates at the upper border of the thyroid cartilage, Which is usually located at C4.
A man is stabbed in the chest to the right of the manubriosternal angle. Which structure is least likely to be injured in this case?
Right pleura The trachea Right phrenic nerve Right recurrent laryngeal nerve Brachiocephalic vein
D) The right recurrent laryngeal nerve branches off the right vagus more proximally and arches posteriorly round the subclavian artery. So of the structures given it is the least likely to be injured.
An 18 year old man is stabbed in the neck and has to undergo repair of a laceration to the internal carotid artery. Post operatively he is noted to have a Horners syndrome. Which of the following will not be present?
Apparent enopthalmos Loss of sweating on the entire ipsilateral side of the face Constricted pupil Mild ptosis Normal sympathetic activity in the torso
B)? The anhidrosis will be mild as this is a distal lesion and at worst only a very limited area of the ipsilateral face will be anhidrotic.
Which of the following types of epithelium lines the lumenal surface of the normal oesophagus?
Non keratinised stratified squamous epithelium Ciliated columnar epithelium Keratinised stratified squamous epithelium Non ciliated columnar epithelium None of the above
A) The oesphagus is lined by non keratinised stratified squamous epithelium. Changes to glandular type epithelium occur as part of metaplastic processes in reflux.
A 23 year old man is stabbed in the neck, in the region between the omohyoid and digastric muscles, the injury is explored surgically. At operation a nerve injury is identified immediately superior to the lingual artery as is branches off the external carotid artery. Which of the following is the most likely result of this injury?
Paralysis of the ipsilateral side of the tongue Abduction of the ipsilateral vocal cord Winging of the scapula Paralysis of the ipsilateral hemi diaphragm Inability to abduct the shoulder
A)
The hypoglossal nerve runs anterior to the external carotid, above the lingual arterial branch. If damaged then ipsilateral paralysis of the genioglossus, hyoglossus and styloglossus muscles will occur. If the patient is asked to protrude their tongue then it will tend to point to the affected side.
Which of the following structures is not directly related to the right adrenal gland?
Diaphragm posteriorly Kidney inferiorly Right renal vein Inferior vena cava Hepato-renal pouch
C)
The right renal vein is very short and lies more inferiorly.
Which of the following aortic branches leaves the aorta approximately 1cm below the coeliac axis?
Renal artery Inferior mesenteric artery Superior mesenteric artery Lumbar artery Gonadal artery
C) The SMA leaves the aorta approximately 1cm below the coeliac axis. This is usually a level of L1. It is crossed anteriorly by the splenic vein and the body of the pancreas. It runs downwards and forwards anterior to the uncinate process.
Through which of the structures listed below does the axillary nerve pass?
Quadrangular space Triangular space Subclavicular space Sub pectoral space Intercostal space
A)
The oesophagus is constricted at the following levels apart from:
Cricoid cartilage Arch of the aorta Lower oesophageal sphincter Left main stem bronchus Diaphragmatic hiatus
C) Constrictions of the oesophagus : ABCD A- Arch of the Aorta B- Left main Bronchus C- Cricoid Cartilage D- Diaphragmatic Hiatus
The oesophagus is not constricted at the level of the lower oesophageal sphincter.
A 19 year old man is playing rugby when he suddenly notices a severe pain at the posterolateral aspect of his right thigh. Which of the following muscle groups is most likely to have been injured?
Semimembranosus Semitendinosus Long head of biceps femoris Gastrocnemius Soleus
C) The biceps femoris is the laterally located hamstring muscle. The semitendinosus and semimembranosus are located medially. Rupture of gastrocnemius and soleus may occur but is less common.
Which of the following is a branch of the third part of the axillary artery?
Superior thoracic Lateral thoracic Dorsal scapular Thoracoacromial Posterior circumflex humeral
E) The other branches include:
Subscapular
Anterior circumflex humeral
Which of the following structures separates the intervertebral disks from the spinal cord?
Anterior longitudinal ligament Posterior longitudinal ligament Supraspinous ligament Interspinous ligament Ligamentum flavum
B) The posterior longitudinal ligament overlies the posterior aspect of the vertebral bodies. It also overlies the posterior aspect of the intervertebral disks.
At what level does the aorta bifurcate into the left and right common iliac arteries?
L1 L2 L3 L4 L5
D) The aorta typically bifurcates at L4. This level is usually fairly constant and is often tested in the exam.
A 23 year old man is due to undergo a mitral valve repair for mitral regurgitation. Which of the following is a feature of the mitral valve?
Its closure is marked by the first heart sound It has two anterior cusps The chordae tendinae attach to the anterior cusps only The chordae tendinae anchor the valve directly to the wall of the left ventricle It is best auscultated in the left third interspace
A) The mitral valve is best auscultated over the cardiac apex, where its closure marks the first heart sound. It has only two cusps. These are attached to chordae tendinae which themselves are linked to the wall of the ventricle by the papillary muscles.
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
A) The lingual nerve wraps around Whartons duct. The lingual nerve provides sensory supply to the anterior 2/3 of the tongue.
Which of the following is true in connection with the phrenic nerves?
They both lie anterior to the hilum of the lungs They are derived from spinal roots C 2,3,4 They pierce the diaphragm at the level of T7 They consist of motor fibres only None of the above
A) C3,4,5
Keeps the diaphragm alive!
They both lie anterior to the hilum of the lung. The phrenic nerves have both motor and sensory functions. For this reason sub diaphragmatic pathology may cause referred pain to the shoulder.
A 32 year old man presents with an inguinal hernia and undergoes an open surgical repair. The surgeons decide to place a mesh on the posterior wall of the inguinal canal to complete the repair, which of the following structures will lie posterior to the mesh?
Transversalis fascia External oblique Rectus abdominis Obturator nerve None of the above
A) Inguinal canal walls: ‘MALT: 2M, 2A, 2L, 2T’:
Starting from superior, moving around in order to posterior: Superior wall (roof): 2 Muscles:Internal oblique, transversus abdominis Anterior wall: 2 Aponeuroses: Aponeurosis of external oblique, Aponeurosis of internal oblique Lower wall (floor): 2 Ligaments: Inguinal Ligament, Lacunar Ligament Posterior wall: 2Ts: Transversalis fascia, Conjoint Tendon
A 22 year old man is involved in a fight and is stabbed in the posterior aspect of his right leg. The knife passes into the popliteal fossa. He sustains an injury to his tibial nerve. Which muscle is least likely to be compromised as a result?
Tibialis posterior Flexor hallucis longus Flexor digitorum brevis Soleus Peroneus tertius
E) Peroneus tertius is innervated by the deep peroneal nerve.
Which of the following overlies the outer muscular layer of the intrathoracic oesophagus?
Serosa Meissners plexus Auerbach's plexus Loose connective tissue None of the above
D) The oesophagus has no serosal covering and hence holds sutures poorly. The Auerbach’s and Meissner’s nerve plexuses lie in between the longitudinal and circular muscle layers and submucosally. The sub mucosal location of the Meissner’s nerve plexus facilitates its sensory role.
Which nerve lies medially on the thyroid gland, in the groove between the oesophagus and trachea?
Vagus nerve External laryngeal nerve Recurrent laryngeal nerve Ansa cervicalis Phrenic nerve
C) The recurrent laryngeal nerve may be injured at this site during ligation of the inferior thyroid artery.
Which of the following nerve roots contribute nerve fibres to the ansa cervicalis?
C1 only C1, C2 and C3 C2, C3 and C6 C2, C4 and C5 C4, C5 and C6
B)
The anterior interosseous nerve is a branch of which of the following?
Ulnar nerve Superficial branch of the radial nerve Axillary nerve Deep branch of the radial nerve Median nerve
E)
At which of the following anatomical locations does the common peroneal nerve bifurcate into the superficial and deep peroneal nerves?
Immediately anterior to the linea aspera At the lateral aspect of the neck of the fibula Within the substance of tibialis anterior muscle At the inferomedial aspect of the popliteal fossa Under the medial head of gastrocnemius
B)
A 48 year old motor cyclist sustains a complex lower limb fracture in a motor accident. For a time the popliteal artery is occluded and eventually repaired. Subsequently he develops a compartment syndrome and the anterior and superficial posterior compartments of the lower leg are decompressed. Unfortunately, the operating surgeon neglects to decompress the deep posterior compartment. Which of the following muscles is least likely to be affected as a result?
Flexor digitorum longus Plantaris Tibialis posterior Flexor hallucis longus None of the above
B) Muscles of the deep posterior compartment: Tibialis posterior Flexor hallucis longus Flexor digitorum longus Popliteus
The plantaris muscle lies within the superficial posterior compartment of the lower leg.
Considering the pituitary gland, which of the following is false?
The anterior pituitary secretes thyroid stimulating hormone The anterior pituitary develops from Rathkes pouch Patients with craniopharyngioma may develop bi temporal hemianopia The pituitary is in direct contact with the optic chiasm The posterior pituitary secretes oxytocin via a positive feedback loop
D) Although the optic chiasm is closely related to the pituitary, and craniopharyngiomas may compress this structure leading to bitemporal hemianopia, it is separated from the chiasm itself by a dural fold.
A 24 year old man is involved in a fight and his face is cut with a knife. The wound lies immediately anterior to the tragus of the ear and extends anteriorly. The wound is surgically explored and the laceration is found to be mainly superficial. It extends slightly more deeply immediately inferior to the main trunk of the facial nerve. Bleeding is observed, from which of the following is it most likely to originate?
External carotid artery Retromandibular vein Occipital artery Maxillary artery Ascending pharyngeal artery
B) The retromandibular vein lies slightly more deeply than the facial nerve in the parotid gland. It is formed from the maxillary and superficial temporal vein.
A 22 year old man is involved in a fight outside a nightclub. He is stabbed in the back, on the left side, approximately 3cm below the 12th rib in the mid scapular line. The structure most likely to be injured first as a result is the:
Spleen Left kidney Left adrenal gland Left ureter None of the above
B) The left kidney lies in this location and is the most likely structure to be injured. The Spleen lies more superiorly, and the left adrenal and ureter are unlikely to be injured in isolation.
A 28 year old man has a pleomorphic adenoma and the decision is made to resect this surgically. Which of the following structures is least likely to be encountered during surgical resection of the parotid gland?
External carotid artery Retromandibular vein Auriculotemporal nerve Mandibular nerve Zygomatic branch of the facial nerve
D) Structures passing through the parotid gland
Facial nerve and branches
External carotid artery (and its branches; the maxillary and superficial temporal)
Retromandibular vein
Auriculotemporal nerve
The mandibular nerve is well separated from the parotid gland.
The maxillary vein joins to the superficial temporal vein and they form the retromandibular vein which then runs through the parotid gland.
The auriculotemporal nerve runs through the gland. Following a parotidectomy this nerve may be damaged and during neuronal regrowth may then attach to sweat glands in this region. This can then cause gustatory sweating (Freys Syndrome).
The facial nerve branch is the marginal mandibular branch and this is related to the gland.
A 23 year old man is undergoing a hernia repair and the mesh is to be sutured to the inguinal ligament. From which of the following does the inguinal ligament arise?
Transversus abdominis fascia Internal oblique Rectus sheath Rectus abdominis muscle External oblique aponeurosis
E) The inguinal ligament is formed by the external oblique aponeurosis. It runs from the pubic tubercle to the anterior superior iliac spine.
A 56 year old man is undergoing a carotid endarterectomy. The internal carotid artery is mobilised. How many branches does this vessel give off in the neck?
0 1 2 3 6
A) The internal carotid does not have any branches in the neck.
Which of the following is a content of the adductor canal?
Saphenous nerve Sural nerve Femoral nerve Profunda branch of the femoral artery Saphenous vein
A) It contains the saphenous nerve and the superficial branch of the femoral artery.
A 56 year old man is undergoing a high anterior resection. Which of the following structures is at greatest risk of injury in this procedure?
Superior mesenteric artery Left ureter External iliac vein External iliac artery Inferior vena cava
B) A careless surgeon may damage all of these structures. However, the structure at greatest risk and most frequently encountered is the left ureter.
From which of these foraminae does the opthalmic branch of the trigeminal nerve exit the skull?
Foramen ovale Foramen rotundum Foramen spinosum Superior orbital fissure Foramen magnum
D) Mnemonic:
Standing Room Only -Exit of branches of trigeminal nerve from the skull
V1 -Superior orbital fissure
V2 -foramen Rotundum
V3 -foramen Ovale
The opthalmic branch of the trigeminal nerve exits the skull through the superior orbital fissure.
A 56 year old lady with metastatic breast cancer develops an oestolytic deposit in the proximal femur. One morning whilst getting out of bed she notices severe groin pain. X-rays show that the lesser trochanter has been avulsed. Which muscle is the most likely culprit?
Vastus lateralis Psoas major Piriformis Gluteus maximus Gluteus medius
B) The psoas major inserts into the lesser trochanter and contracts when raising the trunk from the supine position. When oestolytic lesions are present in the femur the lesser trochanter may be avulsed.
Which of the following nerves is responsible for the motor innervation of the sternocleidomastoid muscle?
Ansa cervicalis Accessory nerve Hypoglossal nerve Facial nerve Vagus nerve
B) The motor supply to the sternocleidomastoid is from the accessory nerve. The ansa cervicalis supplies sensory information from the muscle.
A 42 year old lady undergoes a difficult cholecystectomy and significant bleeding is occurring. The surgeons place a vascular clamp transversely across the anterior border of the epiploic foramen. Which of the following structures will be occluded in this manoeuvre?
Cystic artery Cystic duct Left gastric artery Portal vein None of the above
D) The portal vein, hepatic artery and common bile duct are occluded.
Which of the nerves listed below is at greatest risk of injury with a laceration to the upper lateral margin of the popliteal fossa?
Common peroneal nerve Sural nerve Sciatic nerve Saphenous nerve Tibial nerve
A) The sural nerve exits at the lower infero-lateral aspect of the fossa and is more at risk in short saphenous vein surgery. The tibial nerve lies more medially and is even less likely to be injured in this location.
Which option is false in relation to the trigeminal nerve?
The nerve originates at the pons The posterior scalp is supplied by the trigeminal nerve The maxillary nerve exits via the foramen rotundum The maxillary nerve is purely sensory The motor root is not in the trigeminal ganglion
B) The posterior scalp is supplied by C2-C3.
A 45 year old man is undergoing a lymph node biopsy from the posterior triangle of his neck. Which structure forms the posterior border of this region?
Trapezius muscle Diagastric muscle External jugular vein Omohyoid muscle Sternocleidomastoid muscle
A) Posterior triangle of the neck
Boundaries
Apex
Sternocleidomastoid and the Trapezius muscles at the Occipital bone
Anterior Posterior border of the Sternocleidomastoid
Posterior Anterior border of the Trapezius
Base Middle third of the clavicle
A 42 year old lady has had an axillary node clearance for breast malignancy. Post operatively she reports weakness of the shoulder. She is unable to push herself forwards from a wall with the right arm and the scapula is pushed out medially from the chest wall. What is the most likely nerve injury?
C5, C6 C8, T1 Axillary nerve Long thoracic nerve Spinal accessory nerve
D) The patient has a winged scapula caused by damage to the long thoracic nerve (C5,6,7) during surgery. The long thoracic nerve innervates serratus anterior. Serratus anterior causes pushing out of the scapula during a punch.
A 36 year old male is admitted for elective surgery for a lymph node biopsy in the supraclavicular region. Post operatively the patient has difficulty shrugging his left shoulder. What is the most likely reason?
Phrenic nerve lesion Axillary nerve lesion C5, C6 root lesion C8, T1 root lesion Accessory nerve lesion
E) The accessory nerve lies in the posterior triangle and may be injured in this region. Apart from problems with shrugging the shoulder, he may also have difficulty lifting his arm above his head.
How many fissures are present within the right lung?
One Three Two Four Five
C) The right lung has an oblique and horizontal fissure. The upper oblique fissure separates the inferior from the middle and upper lobes. The short horizontal fissure separates the superior and middle lobes.
Which of the following muscles is supplied by the musculocutaneous nerve?
Brachialis Latissimus dorsi Flexor carpi ulnaris Teres minor Triceps
A) Muscles innervated by the musculocutaneous nerve BBC:
Biceps brachii
Brachialis
Coracobrachialis
Which cranial nerve supplies the motor fibres of styloglossus?
Facial Trigeminal Vagus Hypoglossal Glossopharyngeal
D) The hypoglossal nerve supplies motor innervation to all extrinsic and intrinsic muscles of the tongue. The only possible exception to this is palatoglossus, which is jointly innervated by the vagus and accessory nerves.
What is the most inferior anterior aortic branch?
Median sacral artery Inferior mesenteric artery Lumbar artery Superior mesenteric artery Gonadal artery
B) The IMA leaves the front of the aorta usually about 3 to 4cm superior to its bifurcation. The median sacral is not an anterior branch.
Which of the following statements relating to the posterior cerebral artery is false?
It supplies the visual cortex It is closely related to the 3rd cranial nerve It is a branch of the basilar artery It is connected to the circle of Willis via the superior cerebellar artery When occluded may result in contralateral loss of field of vision
D) The posterior cerebral arteries are formed by the bifurcation of the basilar artery and is connected to the circle of Willis via the posterior communicating artery.
The posterior cerebral arteries supply the occipital lobe and part of the temporal lobe.
An elderly lady falls and lands on her hip. On examination, her hip is tender to palpation and x-rays are taken. There are concerns that she may have an intertrochanteric fracture. What is the normal angle between the femoral neck and the femoral shaft?
90o 105o 80o 130o 180o
D) The normal angle between the femoral head and shaft is 130o. Changes to this angle may occur as a result of disease or pathology and should be investigated.
A 22 year old man suffers a compound fracture of the tibia. During attempted surgical repair the deep peroneal nerve is divided. Which of the following muscles will not be affected as a result?
Tibialis anterior Peroneus longus Extensor hallucis longus Extensor digitorum longus Peroneus tertius
B) Peroneus longus is innervated by the superficial peroneal nerve (L4, L5, S1).
A 17 year old male presents to the clinic. He complains of difficulty using his left hand. It has been a persistent problem since he sustained a distal humerus fracture as a child. On examination, there is diminished sensation overlying the hypothenar eminence and medial one and half fingers. What is the most likely nerve lesion?
Anterior interosseous nerve Posterior interosseous nerve Ulnar nerve Median nerve Radial nerve
C)
An 18 year old athlete attends orthopaedic clinic reporting pain and swelling over the medial aspect of the knee joint. The pain occurs when climbing the stairs, but is not present when walking on flat ground. Clinically there is pain over the medial, proximal tibia and the McMurray test is negative. What is the most likely cause of this patient’s symptoms?
Anterior cruciate ligament tear Prepatellar bursitis Medial meniscus injury Pes Anserinus Bursitis Fracture of tibia
D) Pes anserinus: GOOSE’S FOOT
Combination of sartorius, gracilis and semitendinous tendons inserting into the anteromedial proximal tibia.
Pes Anserinus Bursitis is common in sportsmen due to overuse injuries. The main sign is of pain in the medial proximal tibia. As the McMurray test is negative, medial meniscal injury is excluded.
Which of the following structures lies most posteriorly at the porta hepatis?
Cystic artery Common hepatic artery Left hepatic artery Portal vein Common bile duct
D) The portal vein is the most posterior structure at the porta hepatis.The common bile duct is a continuation of the common hepatic duct and is formed by the union of the common hepatic duct and the cystic duct.
Which of the following nerves innervates the long head of the biceps femoris muscle?
Inferior gluteal nerve Tibial division of sciatic nerve Superior gluteal nerve Common peroneal division of sciatic nerve Obturator nerve
B) The short head of biceps femoris, which may occasionally be absent, is innervated by the common peroneal component of the sciatic nerve. The long head is innervated by the tibial division of the sciatic nerve.
A 28 year old man is shot in the right chest and develops a right haemothorax necessitating a thoracotomy. The surgeons decide to place a vascular clamp across the hilum of the right lung. Which of the following structures will lie most anteriorly at this point?
Thoracic duct Phrenic nerve Vagus nerve Pulmonary artery Pulmonary vein
B) The phrenic nerve lies anteriorly at the root of the right lung.
A 56 year old man is undergoing a pancreatectomy for carcinoma. During resection of the gland which of the following structures will the surgeon not encounter posterior to the pancreas itself?
Left crus of the diaphragm Superior mesenteric vein Common bile duct Portal vein Gastroduodenal artery
E) The gastroduodenal artery divides into the gastro-epiploic and pancreaticoduodenal arteries at the superior aspect of the pancreas.
From which structure is the central tendon of the diaphragm derived?
Septum transversum Pleuroperitoneal folds Diaphragmatic crura Dorsal mesocardium Oropharyngeal membrane
A) The septum transversum is a thick ridge of mesodermal tissue in the developing embryo that separates the thoracic and abdominal cavities and forms the central tendon of the diaphragm.
Where does Stensens duct primarily open?
Immediately lateral to the foramen caecum Floor of mouth Opposite the second molar tooth Opposite the fifth molar tooth Into the post nasal space
C) Stensens duct conveys secretions from the parotid gland and these enter the oral cavity at the level of the second molar tooth.
Which of the following nerves is responsible for the innervation of the posterior belly of the digastric muscle?
Facial nerve Hypoglossal nerve Trigeminal nerve Ansa cervicalis Mylohoid nerve
A) The posterior belly of digastric is innervated by the facial nerve and the anterior belly by the mylohoid nerve.
Which of the following carpal bones is a sesamoid bone in the tendon of flexor carpi ulnaris?
Triquetrum Lunate Pisiform Scaphoid Capitate
C) This small bone has a single articular facet. It projects from the triquetral bone at the ulnar aspect of the wrist where most regard it as a sesamoid bone lying within the tendon of flexor carpi ulnaris.
A 43 year old woman is due to undergo an axillary node clearance following a positive sentinel node biopsy. Which of the nerves below is at greatest risk?
Accessory nerve Thoracodorsal Upper trunk of the brachial plexus Medial pectoral Axillary
B) The long thoracic nerve is also at risk. The thoracodorsal nerve traverses the level 2 axillary nodes to supply latissimus dorsi and may be divided or damaged with diathermy.
Which of the muscles listed below would be affected if the radial nerve were injured in a humeral shaft fracture?
Supinator Flexor digitorum profundus Brachialis Abductor pollicis brevis Abductor digiti minimi
A)
A 73 year old lady is hit by a car. She suffers a complex fracture of the distal aspect of her humerus with associated injury to the radial nerve. Which of the following movements will be most impaired as a result?
Elbow extension Elbow flexion Shoulder abduction Wrist extension None of the above
D) The triceps will not be affected so elbow extension will be preserved. Loss of wrist extension will be the most obvious effect.
Which of the following is not a content of the rectus sheath?
Pyramidalis Superior epigastric artery Inferior epigastric vein Internal iliac artery Rectus abdominis
D) The rectus sheath also contains:
superior epigastric vein
inferior epigastric artery
Which of the following vessels does not drain directly into the inferior vena cava?
Superior mesenteric vein Right common iliac Right hepatic vein Left hepatic vein Right testicular vein
A) The superior mesenteric vein drains into the portal vein. The right and left hepatic veins drain into it directly, this can account for major bleeding in more extensive liver shearing type injuries.
A 17 year old male has a suspected testicular torsion and the scrotum is to be explored surgically. The surgeon incises the skin and then the dartos muscle. What is the next tissue layer that will be encountered during the dissection?
Visceral layer of the tunica vaginalis Cremasteric fascia Parietal layer of the tunica vaginalis External spermatic fascia Internal spermatic fascia
D) The layers that will be encountered are (in order):
- Skin
- Dartos fascia and muscle
- External spermatic fascia
- Cremasteric muscle and fascia
- Internal spermatic fascia
- Parietal layer of the tunica vaginalis
A well toned weight lifter attends clinic reporting weakness of his left arm. There is weakness of flexion and supination of the forearm. Which of the following nerves is likely to have been affected?
Axillary Suprascapular Medial Radial Musculocutaneous
E) Musculocutaneous nerve compression due to entrapment of the nerve between biceps and brachialis. Elbow flexion and supination of the arm are affected. This is a rare isolated injury.
A 25 year old man is stabbed in the groin and the area, which lies within the femoral triangle is explored. Which structure forms the lateral wall of the femoral triangle?
Adductor longus Pectineus Adductor magnus Sartorius Conjoint tendon
D) The sartorius forms the lateral wall of the femoral triangle
An 18 year old man develops a severe spreading sepsis of the hand. The palm is explored surgically and the flexor digiti minimi brevis muscle is mobilised to facilitate drainage of the infection. Which of the following structures is not closely related to this muscle?
The hook of hamate Median nerve Superficial palmar arterial arch Digital nerves arising from the ulnar nerve None of the above
B) The flexor digiti minimi brevis originates from the Hamate, on its under- surface lie the ulnar contribution to the superficial palmar arterial arch and digital nerves derived from the ulnar nerve. The median nerve overlies the flexor tendons.
A 19 year old man undergoes an open inguinal hernia repair. The cord is mobilised and the deep inguinal ring identified. Which of the following structures forms its lateral wall?
External oblique aponeurosis Transversalis fascia Conjoint tendon Inferior epigastric artery Inferior epigastric vein
B) The transversalis fascia forms the superolateral edge of the deep inguinal ring. The epigastric vessels form its inferomedial wall.
A 22 year old man develops an infection in the pulp of his little finger. What is the most proximal site to which this infection may migrate?
The metacarpophalangeal joint The distal interphalangeal joint The proximal interphalangeal joint Proximal to the flexor retinaculum Immediately distal to the carpal tunnel
D) The 5th tendon sheath extends from the little finger to the proximal aspect of the carpal tunnel. This carries a significant risk of allowing infections to migrate proximally.
Which of the following muscles is not innervated by the deep branch of the ulnar nerve?
Adductor pollicis Hypothenar muscles All the interosseous muscles Opponens pollicis Third and fourth lumbricals
D)
Which of the following muscles is not innervated by the deep branch of the ulnar nerve?
Adductor pollicis Hypothenar muscles All the interosseous muscles Opponens pollicis Third and fourth lumbricals
D)
During an inguinal hernia repair the surgeon identifies a small nerve whilst mobilising the cord structures at the level of the superficial inguinal ring. Which nerve is this most likely to be?
Subcostal Iliohypogastric Ilioinguinal Obturator Pudendal
C) Ilioinguinal nerve entrapment may be a cause of neuropathic pain following inguinal hernia surgery.
A 25 year old man undergoes an excision of a pelvic chondrosarcoma, during the operation the obturator nerve is sacrificed. Which of the following muscles is least likely to be affected as a result?
Adductor longus Pectineus Adductor magnus Sartorius Gracilis
D) Sartorius is supplied by the femoral nerve. In approximately 20% of the population, pectineus is supplied by the accessory obturator nerve. Adductor magnus has a composite supply from the obturator and sciatic nerves.
During an arch aortogram the brachiocephalic artery is entered with an angiography catheter. The radiologist continues to advance the catheter. Into which of the following vessels is it likely to enter?
Left subclavian artery Left axillary artery Right subclavian artery Right axillary artery None of the above
C) The axillary artery is a branch of the subclavian artery and although developmental anomalies may occur they are rare. The catheter may also enter the right carotid. There is no brachiocephalic artery on the left side.
Into which of the following structures does the superior part of the fibrous capsule of the shoulder joint insert?
The surgical neck of the humerus The body of the humerus The bicipital groove Immediately distal to the greater tuberosity The anatomical neck of the humerus
E) The shoulder joint is a shallow joint, hence its great mobility. However, this comes at the expense of stability. The fibrous capsule attaches to the anatomical neck superiorly and the surgical neck inferiorly
What is the lymphatic drainage of the membranous urethra?
Deep inguinal nodes Superficial inguinal nodes Internal iliac nodes External iliac nodes Para-aortic nodes
C) The prostatic and membranous urethra drain to the internal iliac nodes.
A 34 year old lady presents with symptoms of faecal incontinence. Ten years previously she gave birth to a child by normal vaginal delivery. Injury to which of the following nerves is most likely to account for this process?
Genitofemoral Ilioinguinal Pudendal Hypogastric autonomic nerve Obturator
C) S2,3,4 keeps the poo up off the floor - POOdendal nerve
Damage to the pudendal nerve is classically associated with faecal incontinence and it is for this reason that sacral neuromodulation is a popular treatment for the condition. Injury to the hypogastric autonomic nerves is an aetiological factor in the development of constipation.
During a difficult thyroidectomy haemorrhage is noted from the thyroidea ima vessel. From which structure does this vessel usually arise?
External carotid artery Internal carotid artery Brachiocephalic artery Axillary artery Superior thyroid artery
C) Rhyme isthmus location:
Rings 2,3,4 make the isthmus floor
This accessory vessel which usually lies at the inferior aspect of the gland is derived either from the brachiocephalic artery or the arch of the aorta.
The cephalic vein pierces the clavipectoral fascia to terminate in which of the veins listed below?
External jugular Axillary Internal jugular Azygos Brachial
B)
A 43 year old lady develops a cerebello-pontine angle lesion. Which of the nerves listed below is likely to be affected first?
CN X CN III CN V CN IX CN XII
C) The most likely lesion to occur in the cerebello-pontine angle is an acoustic neuroma.
The trigeminal nerve has a broad base and involvement of at least part of this nerve is the most likely initial finding. The defect may be subtle such as loss of the ipsilateral corneal reflex. Ipsilateral hearing loss will also occur. Untreated, progressive lesions, may ultimately affect cranial nerve roots in this region.
Which of the following is not a branch of the abdominal aorta?
Inferior mesenteric artery Inferior phrenic artery Superior mesenteric artery Superior phrenic artery Renal artery
D) Mnemonic for the Descending abdominal aorta branches from diaphragm to iliacs:
‘Prostitutes Cause Sagging Swollen Red Testicles [in men] Living In Sin’:
Phrenic [inferior] Celiac Superior mesenteric Suprarenal [middle] Renal Testicular ['in men' only] Lumbars Inferior mesenteric Sacral
The superior phrenic artery branches from the aorta in the thorax.
A 23 year old man is admitted with a suspected ureteric colic. A KUB style x-ray is obtained. In which of the following locations is the stone most likely to be visualised?
The tips of the transverse processes between L2 and L5 The tips of transverse processes between T10-L1 At the crest of the ilium Over the S3 foramina Over the sacrococcygeal joint
A) The ureter lies anterior to L2 to L5 and stones may be visualised at these points, they may also be identified over the sacro-iliac joints.
In a patient with an ectopic kidney where is the adrenal gland most likely to be located?
In the pelvis On the contralateral side In its usual position Superior to the spleen It will be absent
C) Because the kidney is present, rather than absent, the adrenal will usual develop and in the normal location.
Which of the following structures is not closely related to the posterior tibial artery?
Soleus posteriorly Tibial nerve medially Deep peroneal nerve laterally Flexor hallucis longus postero-inferiorly Popliteus
C) The deep peroneal nerve lies in the anterior compartment. The tibial nerve lies medially. At its termination it lies deep to the flexor retinaculum.
Which cranial nerve provides general sensation to the anterior two thirds of the tongue?
Facial Trigeminal Hypoglossal Vagus Glossopharyngeal
B) Taste to the anterior two thirds of the tongue is supplied by the facial nerve, the trigeminal supplies general sensation, this is mediated by the mandibular branch of the trigeminal nerve (via the lingual nerve).
A 62 year old male complains of back pain. He has had a recent fall. Walking causes pain of the left lower leg. On examination, he is noted to have reduced sensation over the knee. Which of the spinal levels listed below is most likely to have been affected?
L1 L3 L2 L4 L5
B) Sensation over the knee is equivalent to the L3 dermatome. The four nerves involved include the infrapatellar branch of the saphenous nerve, the lateral cutaneous nerve of the thigh, anterior cutaneous nerve of the thigh (both lateral and medial branches).
Which of the following statements relating to the tympanic membrane is false?
The umbo marks the point of attachment of the handle of the malleus to the tympanic membrane The lateral aspect of the tympanic membrane is lined by stratified squamous epithelium The chorda tympani nerve runs medial to the pars tensa The medial aspect of the tympanic membrane is lined by mucous membrane The tympanic membrane is approximately 1cm in diameter
C) The chorda tympani runs medially to the pars flaccida.
Which nerve supplies sensation to the nail bed of the index finger?
Median Ulnar Radial Musculocutaneous Axillary
A)
An injury to the spinal accessory nerve will have the greatest affect on which of the following movements?
Lateral rotation of the arm Adduction of the arm at the glenohumeral joint Protraction of the scapula Upward rotation of the scapula Depression of the scapula
D) The spinal accessory nerve innervates trapezius. The entire muscle will retract the scapula. However, its upper and lower fibres act together to upwardly rotate it.
Which of the following is not contained within the middle mediastinum?
Main bronchi Arch of the azygos vein Thoracic duct Pericardium Aortic root
C) The thoracic duct lies within the posterior and superior mediastinum.
55 year old man is due to undergo a radical prostatectomy for carcinoma of the prostate gland. Which of the following vessels directly supplies the prostate?
External iliac artery Common iliac artery Internal iliac artery Inferior vesical artery None of the above
D) The arterial supply to the prostate gland is from the inferior vesical artery, it is a branch of the prostatovesical artery. The prostatovesical artery usually arises from the internal pudendal and inferior gluteal arterial branches of the internal iliac artery.
Which nerve directly innervates the sinoatrial node?
Superior cardiac nerve Right vagus nerve Left vagus nerve Inferior cardiac nerve None of the above
E) No single one of the above nerves is responsible for direct cardiac innervation (which those who have handled the heart surgically will appreciate).
The heart receives its nerves from the superficial and deep cardiac plexuses. The cardiac plexuses send small branches to the heart along the major vessels, continuing with the right and left coronary arteries. The vagal efferent fibres emerge from the brainstem in the roots of the vagus and accessory nerves, and run to ganglia in the cardiac plexuses and within the heart itself.
The background vagal discharge serves to limit heart rate, and loss of this background vagal tone accounts for the higher resting heart rate seen following cardiac transplant.
A 56 year old man suddenly develops severe back pain. His pain has a radicular pattern. On examination, he is unable to extend his great toe. Which of the spinal levels listed below is most likely to have been affected?
L5 L4 L3 L2 L1
A) Extensor hallucis longus is derived from L5 and loss of EHL function is a useful test to determine whether this level is involved.
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?
S3 and S4 L4 and L5 L3 and L4 S1 and S2 S4 only
D) Ankle reflex
The ankle reflex is elicited by tapping the Achilles tendon with a tendon hammer. It tests the S1 and S2 nerve roots. It is typically delayed in L5 and S1 disk prolapses.
Which of the following structures accompanies the posterior interventricular artery within the posterior interventricular groove?
Great cardiac vein Middle cardiac vein Small cardiac vein Anterior cardiac vein Coronary sinus
B) Coronary sinus
This lies in the posterior part of the coronary groove and receives blood from the cardiac veins. The great cardiac vein lies at its left and the middle and small cardiac veins lie on its right. The smallest cardiac vein (anterior cardiac vein) drains into the right atrium directly.
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?
Facial Oculomotor Abducens Trochlear Trigeminal nerve
D) 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.
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 digitorum longus tendon Peroneus tertius tendon Extensor hallucis longus tendon Extensor digitorum brevis tendon Flexor digitorum longus
C) The extensor hallucis longus tendon lies medial to the dorsalis pedis artery.
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?
Posterior interosseous Anterior interosseous Median Ulnar Musculocutaneous
B) 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.
What is the level of the hyoid bone?
C1 C2 C3 C4 C5
C)
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 Loss of power of opponens pollicis Adduction and lateral rotation of the thumb at rest Loss of power of abductor pollicis brevia
B) 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.
The following muscles are supplied by the recurrent laryngeal nerve except:
Transverse arytenoid Posterior crico-arytenoid Cricothyroid Oblique arytenoid Thyroarytenoid
C) Innervates: all intrinsic larynx muscles (excluding cricothyroid)
The external branch of the superior laryngeal nerve innervates the cricothyroid muscle.
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 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
C) The subclavian artery passes anterior to the middle scalene.
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 posterior border of this structure?
Basilic vein Radial artery Extensor pollicis brevis Abductor pollicis longus Extensor pollicis longus
A) It’s boundaries are extensor pollicis longus, medially (posterior border) and laterally (anterior border) by the tendons of abductor pollicis longus and extensor pollicis brevis.
Anatomical snuffbox
Posterior border Tendon of extensor pollicis longus
Anterior border Tendons of extensor pollicis brevis and abductor pollicis longus
Proximal border Styloid process of the radius
Distal border Apex of snuffbox triangle
Floor Trapezium and scaphoid
Content Radial artery
Which of the following structures attaches periosteum to bone?
Sharpeys fibres Peripheral lamellae Elastic fibres Fibrolamellar bundles Purkinje fibres
A) 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.
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 Sciatic nerve Superior gluteal nerve Ilioinguinal nerve Genitofemoral nerve
A)
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?
Lingual artery Occipital artery Superior thyroid artery Facial artery External jugular vein
D) 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.
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 Superficial circumflex iliac artery Femoral vein Femoral branch of the genitofemoral nerve
B) 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.
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 axillary nerve Injury to the long thoracic nerve Injury to the intercostobrachial nerve Injury to the thoracodorsal nerve Injury to the median pectoral nerve
D) 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.
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?
Right renal artery Ureter Right renal vein Inferior vena cava Right testicular vein
B) The ureter is the most posterior structure at the hilum of the right kidney and would therefore be encountered first during a posterior approach.
Renal arteries
The right renal artery is longer than the left renal artery
The renal vein/artery/pelvis enter the kidney at the hilum
Relations
Right Anterior- IVC, right renal vein, the head of the pancreas, and the descending part of the duodenum
Left Anterior- left renal vein, the tail of the pancreas
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?
Palmaris brevis Second and third interossei Adductor pollicis Abductor pollicis longus Abductor pollicis brevis
E) 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.
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
D) 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”)
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?
T3 T7 T6 T10 T1
C) 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)
Which of the following regions of the male urethra is entirely surrounded by Bucks fascia?
Preprostatic part Prostatic part Membranous part Spongiose part None of the above
D) 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.
In the distal third of the upper arm, where is the musculocutaneous nerve located?
Between the biceps brachii and brachialis muscles Between the brachialis and brachioradialis muscles Between the brachioradialis and triceps muscles Between the brachialis and triceps muscles Between the humerus and brachialis muscles
A) The musculocutaneous nerve lies between the biceps and brachialis muscles.
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?
Left renal artery Inferior phrenic artery Aorta Splenic None of the above
B) The superior adrenal artery is a branch of the inferior phrenic artery.
Which of the following does not exit the pelvis through the greater sciatic foramen?
Superior gluteal artery Internal pudendal vessels Sciatic nerve Obturator nerve Inferior gluteal nerve
D) The obturator nerve exits through the obturator foramen.
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
E) 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.
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?
Ureter Inferior epigastric artery Internal iliac vein Femoral artery Lateral border of rectus abdominis
B) 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.
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 Ipsilateral deep cervical nodes Tonsil Ipsilateral superficial cervical nodes Contralateral deep cervical nodes
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?
Ulnar nerve Axillary nerve Medial cord of brachial plexus Lateral cord of brachial plexus Posterior cord of brachial plexus
E) 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.
Which of the muscles below does not cause lateral rotation of the hip?
Obturator internus Quadratus femoris Gemellus inferior Piriformis Pectineus
E) 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.
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
E)
Which of these openings transmits the facial nerve into the temporal bone?
Internal acoustic meatus Foramen lacerum Foramen spinosum Stylomastoid foramen Jugular foramen
A) It enters the temporal bone through the internal acoustic meatus and exits through the stylomastoid foramen.
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?
C8, T1 root lesion C5, C6 root lesion Radial nerve lesion Ulnar nerve lesion Axillary nerve lesion
B) 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.
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?
Middle colic artery Inferior mesenteric artery Superior mesenteric artery Ileo-colic artery None of the above
D) 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.
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?
Common peroneal nerve Lateral cutaneous nerve of the thigh L5 L3 L1
D)
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
E) It inserts into the medial aspect of the upper part of the tibia.
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 Internal iliac vein External iliac vein Gonadal vein Common iliac vein
A) 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.
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?
Superficial ulnar nerve Deep ulnar nerve Median nerve Radial nerve Recurrent branch of median nerve
B)
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 Coeliac axis Inferior mesenteric artery Aorta Left gastric artery
A) 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.
K
A 23 year old man has a cannula inserted into his cephalic vein. Through which structure does the cephalic vein pass?
Interosseous membrane Triceps Pectoralis major Clavipectoral fascia Tendon of biceps
D) 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 calvipectoral fascia (but not the pectoralis major) prior to terminating in the axillary vein.
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?
Internal oblique aponeurosis External oblique aponeurosis Transversalis fascia Rectus sheath Campers fascia
B) 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.
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?
Superior mesenteric artery Inferior mesenteric artery Middle colic artery Ileo-colic artery Superior rectal artery
C) The middle colic artery supplies the transverse colon and requires high ligation during cancer resections. It is a branch of the superior mesenteric artery.
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