EMRCS ANATOMY 2 Flashcards
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
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
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
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
The iliacus lies posterior to the femoral nerve in the femoral triangle. The femoral sheath lies anterior to the iliacus and pectineus muscles.
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
It drains directly via a very short vessel. If the sutures are not carefully tied then it may be avulsed off the IVC. An injury best managed using a Satinsky clamp and a 6/0 prolene suture
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
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
The radial nerve is responsible for innervation of the extensor compartment of the forearm.
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
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
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 53 year old lady is recovering following a difficult mastectomy and axillary nodal clearance for carcinoma of the breast. She complains of shoulder pain and on examination has obvious winging of the scapula. Loss of innervation to which of the following is the most likely underlying cause?
Latissimus dorsi Serratus anterior Pectoralis minor Pectoralis major Rhomboids
Serratus anterior
Winging of the scapula is most commonly the result of long thoracic nerve injury or dysfunction. Iatrogenic damage during the course of the difficult axillary dissection is the most likely cause in this scenario. Damage to the rhomboids may produce winging of the scapula but would be rare in the scenario given.
How many phalanges are there in the hand?
14 12 13 10 8
Each digit has 3 phalanges, the thumb has two the total is therefore 14.
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
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.
A 20 year old man is hit with a hammer on the right side of the head. He dies on arrival in the emergency department. Which of these features is most likely to be found at post mortem?
Hydrocephalus Supra tentorial herniation Laceration of the middle meningeal artery Sub dural haematoma Posterior fossa haematoma
Laceration of the middle meningeal artery
This will account for the scenario given where there is a brief delay prior to death. The other options are less acute and a supratentorial herniation would not occur in this setting.
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
Head of femur ligament (ligamentum teres): acetabular notch to the fovea. Contains arterial supply to head of femur in children.
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
The tunica vaginalis is derived from peritoneum, it secretes the fluid that fills the hydrocele cavity.
Internal spermatic fascia Transversalis fascia
Cremasteric fascia From the fascial coverings of internal oblique
External spermatic fascia External oblique aponeurosis
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 anterior scalene muscle On the right side it leaves the mediastinum via the vena cava hiatus at a level of T8 The right phrenic nerve passes over the right atrium
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.
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
The renal veins lie most anteriorly, then artery and ureter lies posteriorly.
What is the sensory nerve supply to the skin overlying 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
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
The interclavicular ligament lies at the upper end of a median sternotomy and is routinely divided to provide access. The pleural reflections are often encountered and should not be intentionally divided, if they are, then a chest drain will need to be inserted on the affected side as collections may then accumulate in the pleural cavity. Other structures encountered include the pectoralis major muscles, again if the incision is truly midline then these should not require formal division. The close relationship of the brachiocephalic vein should be borne in mind and it should be avoided, iatrogenic injury to this structure will result in considerable haemorrhage.
A 42 year old woman complains of a burning pain of her anterolateral 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
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
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
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 man undergoes a high anterior resection for carcinoma of the upper rectum. Which of the following vessels will require ligation?
Superior mesenteric artery Inferior mesenteric artery Coeliac axis Perineal artery Middle colic artery
The IMA is usually divided during anterior resection. Not only is this borne out of oncological necessity but it also permits sufficient colonic mobilisation for anastomosis.
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
The clavipectoral fascia is situated under the clavicular portion of pectoralis major. It protects both the axillary vessels and nodes. During an axillary node clearance for breast cancer the clavipectoral fascia is incised and this allows access to the nodal stations. The nodal stations are; level 1 nodes inferior to pectoralis minor, level 2 lie behind it and level 3 above it. During a Patey Mastectomy surgeons divide pectoralis minor to gain access to level 3 nodes. The use of sentinel node biopsy (and stronger assistants!) have made this procedure far less common.
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
It is advised that chest drains are placed in the ‘safe triangle’. The triangle is located in the mid axillary line of the 5th intercostal space. It is bordered by:
Anterior edge latissimus dorsi, the lateral border of pectoralis major, a line superior to the horizontal level of the nipple, and the apex below the axilla.
Where is a gomphoses type of fibrous joint typically found?
Teeth Skull Manubriosternum Ribs Femur
Sutures- skull
Gomphoses-Peg to socket e.g. teeth
Syndesmosis-tibiofibular joint
The vertebral artery traverses all of the following except?
Transverse process of C6 Transverse process of the axis Vertebral canal Foramen magnum Intervertebral foramen
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
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
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.
During an Ivor Lewis Oesophagectomy for carcinoma of the lower third of the oesophagus which structure is divided to allow mobilisation of the oesophagus?
Vagus nerve Azygos vein Right inferior lobar bronchus Phrenic nerve Pericardiophrenic artery
The azygos vein is routinely divided during an oesophagectomy to allow mobilisation. It arches anteriorly to insert into the SVC on the right hand side.
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
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
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 68 year old man with critical limb ischaemia is undergoing a femoro-distal bypass graft. During mobilisation of the proximal part of the posterior tibial artery which of the following is at greatest risk of injury?
Tibial nerve Sciatic nerve Saphenous nerve Common peroneal nerve Medial superior genicular artery
The tibial nerve is closely related to the posterior tibial artery. The tibial nerve crosses the vessel posteriorly approximately 2.5cm distal to its origin. At its origin the nerve lies medial and then lateral after it crosses the vessel as described.
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
The coeliac axis lies at T12, it takes an almost horizontal angle off the aorta. It has three major branches.
Which muscle does not insert on the medial surface of the greater trochanter?
Gemelli Obturator internus Piriformis Quadratus femoris Obturator externus
The quadratus femoris fibres pass laterally to be inserted into the quadrate tubercle on the intertrochanteric crest of the femur. The other muscles all insert on the trochanteric fossa lying medial to the greater trochanter.
What is the largest branch of the brachial artery?
Radial artery Ulnar artery Profunda brachii artery Humeral nutrient artery Ulnar collateral artery
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
The vessels supplying the omentum are the omental branches of the right and left gastro-epiploic arteries. The colonic vessels are not responsible for the arterial supply to the omentum. The left gastro-epiploic artery is a branch of the splenic artery and the right gastro-epiploic artery is a terminal branch of the gastroduodenal artery.
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
The common carotid artery is a lateral relation of the inferior parathyroid.
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
The common iliac veins fuse with the IVC at L5.
Following a carotid endarterectomy a man notices that he has a weakness of his tongue. Damage to which of the following nerves is the most likely explanation for this process?
Hypoglossal Accessory Ansa cervicalis Vagus Cervical plexus
The hypoglossal nerve innervates the tongue and is one of the structures more commonly at risk in carotid surgery.
At which of the following levels does the inferior vena cava exit the abdominal cavity?
T6 T7 T10 T8 T12
Vena cava T8
Oesophagus T10
Aortic hiatus T12
Which of the following structures lies deepest in the popliteal fossa?
Popliteal artery Popliteal vein Tibial nerve Common peroneal nerve Popliteal lymph nodes
From superficial to deep:
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
Which of the following nerves is responsible for innervation of the triceps muscle?
Radial Ulnar Axillary Median None of the above
The radial nerve innervates all three heads of triceps, with a separate branch to each head.
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
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
It lies anterior to the crura of the diaphragm and the aorta.
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
Adductor magnus is innervated by the obturator and sciatic nerve. The pectineus muscle is sometimes supplied by the obturator nerve but this is variable. Since the question states least likely, the correct answer is adductor magnus.
What is the nerve root value of the external urethral sphincter?
S4 S1, S2, S3 S2, S3, S4 L3, L4, L5 L5, S1, S2
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
The lack of valves in the IVC is important clinically when it is cannulated during cardiopulmonary bypass, using separate SVC and IVC catheters, such as when the right atrium is to be opened. Note that there is a non functional valve between the right atrium and inferior vena cava.
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
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 nerves listed below is responsible for providing voluntary control of the urethral sphincter?
Inferior hypogastric plexus Superior hypogastric plexus Obturator nerve Femoral nerve Pudendal nerve
The hypogastric plexuses provide autonomic control of the bladder. However, voluntary control of the urethral sphincter is provided by the pudendal nerve.
