EMRCS Flashcards
1
Q
Which of the following nerves supplies the skin on the palmar aspect of the thumb?
Ulnar Median Radial Musculocutaneous None of the above
A
Answer: B
The median nerve supplies cutaneous sensation to this region.
2
Q
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
A
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.
3
Q
Which of the following structures is not transmitted by the jugular foramen?
Hypoglossal nerve Accessory nerve Internal jugular vein Inferior petrosal sinus Vagus nerve
A
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
4
Q
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
A
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
5
Q
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
A
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.
6
Q
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
A
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.
7
Q
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
A
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.
8
Q
What is the lymphatic drainage of the ovaries?
Internal iliac nodes Common iliac nodes Para-aortic nodes Para uterine nodes Inguinal nodes
A
Ans: C
The lymphatic drainage of the ovary follows the gonadal vessels and drainage is therefore to the para-aortic nodes.
9
Q
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
A
Answer: E
There are six tunnels, each lined by its own synovial sheath.
10
Q
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
A
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.
11
Q
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
A
Ans: E
Adductor pollicis is innervated by the ulnar nerve.
Medial two lumbricals innervated by the ulnar nerve.
12
Q
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
A
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.
13
Q
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
A
Ans: C
The radial nerve supplies the extensor muscle group.
14
Q
What is the correct embryological origin of the stapes?
First pharyngeal arch Second pharyngeal arch Third pharyngeal arch Fourth pharyngeal arch Fifth pharyngeal arch
A
Ans: B
Embryological origin stapes = 2nd pharyngeal arch
The incus is most likely to arise from the first arch.
15
Q
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
A
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.
16
Q
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
A
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.
17
Q
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
A
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.
18
Q
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
A
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.
19
Q
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
A
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.
20
Q
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
A
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.
21
Q
What is the most important structure involved in supporting the uterus?
Round ligament Broad ligament Uterosacral ligaments Cardinal ligaments Central perineal tendon
A
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.
22
Q
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
A
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.
23
Q
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
A
Ans: C
Oxyphil cells are typically found in parathyroid glands
24
Q
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
A
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.
25
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.
26
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.
27
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.
28
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.
29
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.
30
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
31
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.
32
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.
33
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.
34
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.
35
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.
36
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.
37
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.
38
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.
39
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
40
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.
41
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
```
42
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.
43
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
44
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.
45
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.
46
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.
47
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.
48
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.
49
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
50
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.
51
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.
52
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
53
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.
54
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.
55
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.
56
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.
57
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.
58
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.
59
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.
60
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.
61
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.
62
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.
63
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
64
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)
65
What is the anatomical level of the transpyloric plane?
```
T11
T12
L1
L4
T10
```
Ans: C
66
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
67
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.
68
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).
69
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.
70
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.
71
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.
72
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.
73
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
74
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).
75
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.
76
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.
77
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.
78
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.
79
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.
80
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.
81
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.
82
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.
83
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.
84
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.
85
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.
86
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.
87
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.
88
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
89
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.
90
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.
91
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
```
92
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
93
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
94
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.
95
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.
96
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.
97
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.
98
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
99
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.
100
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
101
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.
102
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.
103
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.
104
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
105
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
106
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.
107
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.
108
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
1. Lateral ventricles (via foramen of Munro)
2. 3rd ventricle
3. Cerebral aqueduct (aqueduct of Sylvius)
4. 4th ventricle (via foramina of Magendie and Luschka)
5. Subarachnoid space
6. 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
```
109
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.
110
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.
111
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.
112
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.
113
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.
114
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.
115
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.
116
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.
117
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
```
118
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)
119
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.
120
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.
121
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.
122
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.
123
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.
124
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.
125
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.
126
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
127
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.
128
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
129
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.
130
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.
131
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.
132
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.
133
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
134
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
```
135
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.
136
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.
137
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
138
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
139
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
140
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.
141
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
142
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.
143
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.
144
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.
145
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.
146
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
147
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
148
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.
149
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
150
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.
151
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.
152
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)
```
153
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
154
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.
155
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.
156
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.
157
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.
158
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.
159
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.
160
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.
161
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.
162
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
163
Where is a gomphoses type of fibrous joint typically found?
```
Teeth
Skull
Manubriosternum
Ribs
Femur
```
Ans: A
164
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.
165
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
166
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
167
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.
168
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.
169
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
170
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
```
171
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.
172
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
173
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
174
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.
175
At which of the following levels does the inferior vena cava exit the abdominal cavity?
```
T6
T7
T10
T8
T12
```
Ans: D
176
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.
177
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)
178
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.
179
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
180
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
181
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.
182
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
```
183
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
```
184
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.
185
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.
186
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.
187
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.
188
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.
189
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
190
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.
191
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.
192
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.
193
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
194
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.
195
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
196
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.
197
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.
198
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.
199
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.
200
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.
201
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.
202
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
203
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.
204
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
205
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.
206
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.
207
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.
208
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.
209
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
210
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
211
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
212
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
213
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
214
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
215
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.
216
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.
217
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.
218
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.
219
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
220
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.
221
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.
222
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.
223
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.
224
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.
225
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.
226
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.
227
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
```
228
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.
229
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.
230
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
231
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.
232
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
233
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.
234
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.
235
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.
236
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.
237
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).
238
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.
239
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
```
240
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
241
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.
242
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.
243
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)
244
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.
245
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
246
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
247
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.
248
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.
249
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)
250
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.
251
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)
252
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).
253
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.
254
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.
255
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.
256
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.
257
Where is the vomiting centre located?
```
Medulla oblongata
Substantia nigra
Antrum of stomach
Pons
Midbrain
```
A)
258
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.
259
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.
260
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.
261
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
262
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.
263
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.
264
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.
265
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
266
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.
267
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.
268
Which muscle is supplied by the superficial peroneal nerve?
```
Peroneus tertius
Sartorius
Adductor magnus
Peroneus brevis
Gracilis
```
D)
269
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.
270
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:
1. Two flexors (flexor pollicis brevis and flexor pollicis longus)
2. Two extensors (extensor pollicis brevis and longus)
3. Two abductors (abductor pollicis brevis and longus)
4. One adductor (adductor pollicis)
5. 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.
271
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.
272
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.
273
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.
274
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.
275
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.
276
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.
277
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.
278
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.
279
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.
280
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.
281
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)
282
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.
283
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).
284
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.
285
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.
286
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.
287
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
288
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.
289
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.
290
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.
291
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.
292
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.
293
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.
294
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.
295
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.
296
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.
297
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.
298
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)
299
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
300
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.
301
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.
302
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.
303
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.
304
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.
305
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.
306
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.
307
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.
308
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
309
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.
310
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)
311
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.
312
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.
313
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.
314
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.
315
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.
316
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.
317
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.
318
Through which of the structures listed below does the axillary nerve pass?
```
Quadrangular space
Triangular space
Subclavicular space
Sub pectoral space
Intercostal space
```
A)
319
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.
320
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.
321
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
322
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.
323
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.
324
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.
325
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.
326
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.
327
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
```
328
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.
329
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.
330
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.
331
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)
332
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)
333
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)
334
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.
335
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.
336
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.
337
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.
338
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.
339
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.
340
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.
341
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.
342
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.
343
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.
344
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.
345
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.
346
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.
347
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.
348
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.
349
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
350
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.
351
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.
352
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.
353
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
354
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.
355
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.
356
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.
357
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.
358
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).
359
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)
360
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.
361
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.
362
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.
363
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.
364
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.
365
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.
366
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.
367
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.
368
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.
369
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.
370
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)
371
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.
372
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
373
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.
374
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):
1. Skin
2. Dartos fascia and muscle
3. External spermatic fascia
4. Cremasteric muscle and fascia
5. Internal spermatic fascia
6. Parietal layer of the tunica vaginalis
375
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.
376
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
377
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.
378
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.
379
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.
380
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)
381
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)
382
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.
383
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.
384
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.
385
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
386
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.
387
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.
388
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.
389
The cephalic vein pierces the clavipectoral fascia to terminate in which of the veins listed below?
```
External jugular
Axillary
Internal jugular
Azygos
Brachial
```
B)
390
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.
391
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.
392
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.
393
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.
394
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.
395
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).
396
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).
397
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.
398
Which nerve supplies sensation to the nail bed of the index finger?
```
Median
Ulnar
Radial
Musculocutaneous
Axillary
```
A)
399
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.
400
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.
401
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.
402
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.
403
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.
404
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.
405
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.
406
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.
407
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.
408
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.
409
What is the level of the hyoid bone?
```
C1
C2
C3
C4
C5
```
C)
410
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.
411
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.
412
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.
413
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
414
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.
415
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)
416
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.
417
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.
418
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.
419
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
420
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.
421
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")
422
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)
423
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.
424
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.
425
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.
426
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.
427
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.
428
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.
429
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)
430
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.
431
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.
432
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)
433
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.
434
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.
435
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.
436
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)
437
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.
438
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.
439
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)
440
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
441
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.
442
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.
443
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.
P
