emrcs anatomy Flashcards
1
Q
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
A
Posterior circumflex humeral vessels
The posterior circumflex humeral vessels which are branches of the axillary artery are related to the axillary nerve within the quadrangular space.
2
Q
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
A
In their upper half
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.
3
Q
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
A
Midgut
It is derived from the midgut which is why early appendicitis may present with periumbilical pain.
4
Q
Where are the reticulo-endothelial cells concentrated within the spleen?
Within the capsule Within the red pulp Within the trabeculae Within the white pulp Within the splenic cords
A
Within the white pulp
The reticuloendothelial cells are concerned with the immune functions of the spleen and these are therefore concentrated in the white pulp.
5
Q
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
A
Hypoglossal nerve
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.
6
Q
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 rin
A
1-2cm inferiorly to the mid inguinal point
The mid inguinal point is midway between the anterior superior iliac spine and the symphysis pubis
The mid inguinal point is the surface marking for the femoral artery.
7
Q
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
A
Damage to the vagus
Many of these nerves are at risk of injury during carotid surgery. However, only damage to the vagus would account for a hoarse voice.
8
Q
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
A
External oblique aponeurosis
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.
9
Q
Which muscle initiates abduction of the shoulder?
Infraspinatus Latissimus dorsi Supraspinatus Deltoid Teres major
A
Supraspinatus
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.
10
Q
Which of the following nerves is most commonly damaged during a superficial parotidectomy?
Greater auricular Facial Greater occipital Accessory Opthalmic branch of the trigeminal
A
Greater auricular
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.
11
Q
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
A
Common peroneal nerve
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
12
Q
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 be affected at this level?
Inferior mesenteric artery Superior mesenteric artery Coeliac axis Testicular artery None of the above
A
Superior mesenteric artery
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.
13
Q
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
A
Glossopharyngeal
The glossopharyngeal nerve supplies this area and the ear and otalgia may be the result of referred pain.
14
Q
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
A
Chorda tympani
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.
15
Q
What is the origin of the superior gluteal artery?
Internal iliac artery External iliac artery Femoral artery Common iliac artery Circumflex femoral artery
A
Internal iliac artery
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
16
Q
The first root of the brachial plexus commonly arises at which of the following levels?
C6 C5 C3 C2 C8
A
C5
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)
17
Q
What is the anatomical level of the transpyloric plane?
T11 T12 L1 L4 T10
A
L1
Transpyloric plane
Level of the body of L1
Pylorus stomach Left kidney hilum (L1- left one!) Right hilum of the kidney (1.5cm lower than the left) Fundus of the gallbladder Neck of pancreas Duodenojejunal flexure Superior mesenteric artery Portal vein Left and right colic flexure Root of the transverse mesocolon 2nd part of the duodenum Upper part of conus medullaris Spleen
18
Q
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
A
Inferior gluteal nerve
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
19
Q
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
A
Radial nerve
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
20
Q
During a neck dissection, a nerve is noted to pass posterior to the medial aspect of the first rib. Which of the nerves listed below is this most likely to be?
Medial cord of the brachial plexus Long thoracic nerve Nerve to subclavius Medial pectoral nerve Phrenic nerve
A
Phrenic nerve
The key point is that the phrenic nerve runs posterior to the medial aspect of the first rib. Superiorly, it lies on the surface of scalenus anterior.
21
Q
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
A
Subclavian vein
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).
22
Q
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
A
Obturator internus
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.
23
Q
Where are the greatest proportion of musculi pectinati found?
Right ventricle Left ventricle Right atrium Pulmonary valve Aortic valve
A
Right atrium
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.
24
Q
What is the lymphatic drainage of the upper ureter?
Common iliac nodes Para aortic nodes External iliac nodes Internal iliac nodes Meso colic nodes
A
Para aortic nodes
The upper ureter drains to the para-aortic nodes, the lower ureter drains to the common iliac nodes
25
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
```
Lateral nasal branches of the ethmoidal nerve
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.
26
Which of the following structures separates the subclavian artery and vein?
```
Digastric muscle
Prevertebral fascia
Anterior scalene muscle
Middle scalene muscle
Omohyoid
```
Anterior scalene muscle
The anterior scalene muscle is an important anatomical landmark and separates the subclavian vein (anterior) from the subclavian artery (posterior).
27
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
```
Azygos vein
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.
28
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
```
Axillary vein
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.
29
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
Via the coronary sinus
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.
30
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
```
Median
This is a common injury in children. In this case the angulation and displacement have resulted in median nerve injury.
31
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
```
Ulnar
The interossei are supplied by the ulnar nerve.
32
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
```
Lesser omentum
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.
33
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
```
Anterior tibial artery
The dorsalis pedis is a continuation of the anterior tibial artery.
34
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
```
Inferior gluteal artery
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.
35
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
```
Ileo-colic artery
The appendicular artery is a branch of the ileocolic artery.
36
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
```
Median sacral artery
The median sacral artery leaves the aorta a little above its bifurcation. It descends in the midline anterior to L4 and L5.
37
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
```
Gastroduodenal artery
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.
38
Which of the following nerves is responsible for the cremasteric reflex?
```
Lateral femoral cutaneous nerve
Femoral nerve
Obturator nerve
Genitofemoral nerve
None of the above
```
Genitofemoral nerve
The motor and sensory fibres of the genitofemoral nerve are tested in the cremasteric reflex. A small contribution is also played by the ilioinguinal nerve and thus the reflex may be lost following an inguinal hernia repair.
39
Which of the structures listed below are not located within the mediastinum?
```
Thymus
Heart
Great vessels
Arch of azygos vein
Vertebral bodies
```
Vertebral bodies
The vertebral bodies lie outside of the mediastinum, as do the lungs.
40
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
```
Aortic arch
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.
41
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
```
Pudendal nerve
Structures passing through the lesser and greater sciatic foramina (medial to lateral): PIN
Pudendal nerve
Internal pudendal artery
Nerve to obturator internus
42
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
```
Obturator nerve
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.
43
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
Elongation of the transverse processes of the 7th cervical vertebra
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.
44
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
```
Recurrent laryngeal nerve
```
Contents of carotid sheath:
Common carotid artery
Internal carotid artery
Internal jugular vein
Vagus nerve
```
45
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
```
Axillary
This patch of skin is supplied by the axillary nerve
46
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
```
Spinothalamic tract
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
47
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
```
L3
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.
48
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
```
Conus arteriosus
The conus arteriosus (infundibulum) is the smooth walled outflow tract of the right ventricle leading to the pulmonary trunk.
49
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
```
Parietal pleura
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.
50
In which space is a lumbar puncture performed?
```
Subdural space
Epidural space
Subarachnoid space
Extradural space
Intraventricular space
```
Subarachnoid space
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.
51
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
```
Median nerve
The median nerve is formed by the union of a lateral and medial root respectively from the lateral (C5,6,7) and medial (C8 and T1) cords of the brachial plexus; the medial root passes anterior to the third part of the axillary artery. The nerve descends lateral to the brachial artery, crosses to its medial side (usually passing anterior to the artery). It passes deep to the bicipital aponeurosis and the median cubital vein at the elbow.
52
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
```
Tibial nerve
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.
53
A 43 year old man is undergoing a right hemicolectomy and the ileo-colic artery is ligated. From which of the following vessels is it derived?
```
Inferior mesenteric artery
Superior mesenteric artery
Coeliac axis
Aorta
None of the above
```
Superior mesenteric artery
The ileocolic artery is a branch of the SMA and supplies the right colon and terminal ileum. The transverse colon is supplied by the middle colic artery. As veins accompany arteries in the mesentery and are lined by lymphatics, high ligation is the norm in cancer resections. The ileo-colic artery branches off the SMA near the duodenum.
54
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
```
Splenic artery
There is an arterial watershed in the supply between the head and tail of the pancreas. The head is supplied by the pancreaticoduodenal artery and the tail is supplied by branches of the splenic artery.
55
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
```
Saphenous nerve injury
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.
56
Which of the following muscles does not attach to the radius?
```
Pronator quadratus
Biceps
Brachioradialis
Supinator
Brachialis
```
Brachialis
The brachialis muscle inserts into the ulna. The other muscles are all inserted onto the radius.
57
A 1 year old boy is referred because of an impalpable testis in the left scrotum. Which of the following positions describes an ectopic testis?
```
Intracanalicular
At the superficial ring
At the base of the penis
Upper scrotum
At the deep inguinal ring
```
At the base of the penis
A testis at the base of the penis is ectopic, not listed is the superficial inguinal pouch (one of the commonest ectopic sites). A testis located at deep or superficial rings or intra canalicular is not ectopically located.
58
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
```
Median nerve
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.
59
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
```
Lateral to anterior to medial
The median nerve descends lateral to the brachial artery, it usually passes anterior to the artery to lie on its medial side. It passes deep to the bicipital aponeurosis and the median cubital vein at the elbow. It enters the forearm between the two heads of the pronator teres muscle.
60
Which of the following is not a content of the cavernous sinus?
```
Oculomotor nerve
Internal carotid artery
Opthalmic nerve
Abducens nerve
Optic nerve
```
Optic nerve
The optic nerve lies above and outside the cavernous sinus.
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)
TOTOM=lateral wall components
CA= components within sinus
```
61
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
```
Portal vein
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.
62
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
A transversely orientated incision 3cm below the mandible
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.
63
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
```
Aqueduct of Sylvius
The CSF flows from the 3rd to the 4th ventricle via the Aqueduct of Sylvius.
64
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
```
External oblique aponeurosis
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.
65
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
```
Ilioinguinal nerve
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.
66
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
Loss of extension at the knee joint
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.
67
Where does the spinal cord terminate in neonates?
```
L1
L2
L3
L4
L5
```
L3
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.
68
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
```
Waldeyers fascia
Waldeyers fascia separates the mesorectum from the sacrum and will need to be divided.
69
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
```
Stratified squamous
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.
70
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
```
L1
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.
71
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
If damaged, then extension of the elbow joint will be impaired
It supplies biceps, brachialis and coracobrachialis. If damaged then elbow flexion will be impaired.
72
Which of the following structures does not pass through the foramen ovale?
```
Lesser petrosal nerve
Accessory meningeal artery
Maxillary nerve
Emissary veins
Otic ganglion
```
Maxillary nerve
Mnemonic: OVALE
```
O tic ganglion
V3 (Mandibular nerve:3rd branch of trigeminal)
A ccessory meningeal artery
L esser petrosal nerve
E missary veins
```
73
An elderly man develops a squamous cell carcinoma affecting the lobule of his ear. To which lymph node is the lesion most likely to metastasize?
```
Deep cervical nodes
Mastoid nodes
Superficial parotid nodes
Superficial cervical nodes
Deep parotid nodes
```
Superficial cervical nodes
The lobule drains to the superficial cervical nodes.
74
Which of the cranial nerves listed below is least likely to carry parasympathetic fibres?
```
III
VII
IX
X
II
```
II
The parasympathetic functions served by the cranial nerves include:
III (oculomotor) Pupillary constriction and accommodation
VII (facial) Lacrimal gland, submandibular and sublingual glands
IX (glossopharyngeal) Parotid
X (vagus) Heart and abdominal viscera
The optic nerve carries no parasympathetic fibres.
75
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
```
Left renal vein
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.
76
At which of the following levels does the inferior thyroid artery enter the thyroid gland?
```
C6
C2
C4
C3
C5
```
C6
It enters the gland at C6.
77
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
```
Brocas area is usually supplied by branches from the middle cerebral artery.
78
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
```
Spongy urethra
The spongy urethra is around 15cm long and is the longest part of the male urethra.
79
Parasympathetic fibres innervating the parotid gland originate from which of the following?
```
Submandibular ganglion
Otic ganglion
Ciliary ganglion
Pterygopalatine ganglion
None of the above
```
Otic ganglion
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.
80
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
```
Serosa
The wall lacks a serosa which can make the wall hold sutures less securely.
81
Which of the following structures suspends the spinal cord in the dural sheath?
```
Filum terminale
Conus medullaris
Ligamentum flavum
Denticulate ligaments
Anterior longitudinal ligament
```
Denticulate ligaments
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.
82
Where is the centre of 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
5th intercostal space, mid axillary line
'Safe Triangle' for chest drain insertion:
5th intercostal space, mid axillary line
83
Which of the muscles listed below is attached to the anterior aspect of the fibrous capsule that encases the elbow joint?
```
Pronator teres
Biceps
Brachialis
Triceps
Extensor carpi radialis longus
```
Brachialis
The brachialis inserts some of its fibres into the fibrous joint of the elbow capsule and when it contracts, it helps to flex the joint.
84
A 75-year-old man presents with hepatomegaly and ascites. A CT scan shows evidence of post hepatic portal hypertension. The inferior vena cava passes through the diaphragm at which vertebral level?
```
T5
T8
T9
T10
T11
```
T8
It passes through the diaphragm at T8.
85
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
```
Brachial trunks C5-6
The patient has an Erb's palsy involving brachial trunks C5-6.
86
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
```
T12
87
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
```
Trapezius
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.
88
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
```
Ulnar
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.
89
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
```
Taste sensation from anterior two thirds of the tongue
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.
90
Which cranial nerve supplies general sensation to the posterior third of the tongue?
```
Facial
Trigeminal
Vagus
Hypoglossal
Glossopharyngeal
```
Glossopharyngeal
The glossopharyngeal nerve supplies general sensation to the posterior third of the tongue and contributes to the gag reflex.
91
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
```
Ligamentum flavum
92
Which of the following does not pass through the superior orbital fissure?
```
Lacrimal nerve
Abducens nerve
Opthalmic artery
Trochlear nerve
Superior opthalmic vein
```
Opthalmic artery
The opthalmic artery arises from the internal carotid immediately after it has pierced the dura and arachnoid. It runs through the optic canal below the optic nerve and within its dural and arachnoid sheaths. It terminates as the supratrochlear and dorsal nasal arteries.
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
```
93
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
```
External palatine vein
The external palatine vein lies immediately lateral to the tonsil and if damaged may be a cause of reactionary haemorrhage following tonsillectomy.
94
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
```
Inferior alveolar nerve
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.
95
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
```
Inferior mesenteric artery
Only the IMA is likely to affect the left side of the colon and originate at L3.
96
At which level does the aorta traverse the diaphragm?
```
T10
T9
T8
T11
T12
```
Memory aid:
T8 (8 letters) = vena cava
T10 (10 letters) = oesophagus
T12 (12 letters) = aortic hiatus
97
What is the arterial blood supply to the lacrimal apparatus?
```
Nasociliary artery
Supra orbital artery
Internal carotid artery
Ophthalmic artery
Supra trochlear artery
```
Ophthalmic artery
The ophthalmic artery supplies the gland
98
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
```
Superior gluteal nerve
Damage to the superior gluteal nerve will result in a Trendelenburg gait.
99
At which level is the hilum of the left kidney located?
```
L1
L2
T12
T11
L3
```
L1
Remember L1 ('left one') is the level of the hilum of the left kidney
100
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
```
Pretracheal fascia
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
