Previous Question 82 of 219 Next

A woman develops winging of the scapula following a Patey mastectomy. What is the most likely
cause?

A. Division of pectoralis minor to access level 3 axillary nodes

B. Damage to the brachial plexus during axillary dissection

C. Damage to the long thoracic nerve during axillary dissection

D. Division of the thoracodorsal trunk during axillary dissection

E. Damage to the thoracodorsal trunk during axillary dissection

Next question

Theme from January 2012 exam

The serratus anterior muscle is supplied by the long thoracic nerve which runs along the surface of
serratus anterior and is liable to injury during nodal dissection. Although pectoralis minor is divided
during a Patey mastectomy (now seldom performed) it is rare for this alone to produce winging of
the scapula.

Long thoracic nerve

• Derived from ventral rami of C5, C6, and C7 (close to their emergence from intervertebral
foramina)
• It runs downward and passes either anterior or posterior to the middle scalene muscle
• It reaches upper tip of serratus anterior muscle and descends on outer surface of this
muscle, giving branches into it
• Winging of Scapula occurs in long thoracic nerve injury (most common) or from spinal
accessory nerve injury (which denervates the trapezius) or a dorsal scapular nerve injury

Previous Question 83 of 219 Next

Which of the following structures is not closely related to the posterior tibial artery?

A. Soleus posteriorly
 B. Tibial nerve medially

C. Deep peroneal nerve laterally

D. Flexor hallucis longus postero-inferiorly

E. Popliteus

Next question

The deep peroneal nerve lies in the anterior compartment. The tibial nerve lies medially. At its
termination it lies deep to the flexor retinaculum.

Posterior tibial artery

• Larger terminal branch of the popliteal artery

• Terminates by dividing into the medial and lateral plantar arteries
• Accompanied by two veins throughout its length
• Position of the artery corresponds to a line drawn from the lower angle of the popliteal
fossa, at the level of the neck of the fibula, to a point midway between the medial malleolus
and the most prominent part of the heel

Relations of the posterior

posterior tibial artery
Proximal to distal

Anteriorly Tibialis posterior

Flexor digitorum longus
Posterior surface of tibia and ankle joint

Posterior Tibial nerve 2.5 cm distal to its origin

Fascia overlying the deep muscular layer
Proximal part covered by gastrocnemius and soleus
Distal part covered by skin and fascia

Previous Question 84 of 219 Next

Which of the following is not closely related to the capitate bone?
 A. Lunate bone

B. Scaphoid bone

C. Ulnar nerve

D. Hamate bone

E. Trapezoid bone

Next question

The ulnar nerve and artery lie adjacent to the pisiform bone. The capitate bone articulates with the
lunate, scaphoid, hamate and trapezoid bones, which are therefore closely related to it.

Capitate bone

This is the largest of the carpal bones. It is centrally placed with a rounded head set into the cavities
of the lunate and scaphoid bones. Flatter articular surfaces are present for the hamate medially and
the trapezoid laterally. Distally the bone articulates predominantly with the middle metacarpal.

Previous Question 85 of 219 Next

An 82 year old lady with aortic stenosis is due to undergo an aortic valve replacement. Which of the
following is not a feature of the aortic valve?

A. The left coronary artery arises superior to the left posterior cusp

B. The right coronary artery arises superior to the right posterior cusp

C. It has 1 anterior cusp

D. It has no chordae

E. It has 3 cusps in total

Next question

The right posterior valve has a sinus but the right coronary artery does not arise from this. The
coronary arteries arise superior to the anterior and left posterior cusps.
Heart anatomy

The walls of each cardiac chamber comprise:

• Epicardium
• Myocardium
• Endocardium

Cardiac muscle is attached to the cardiac fibrous skeleton.

Relations
The heart and roots of the great vessels within the pericardial sac are related anteriorly to the
sternum, medial ends of the 3rd to 5th ribs on the left and their associated costal cartilages. The
heart and pericardial sac are situated obliquely two thirds to the left and one third to the right of the
median plane.

The pulmonary valve lies at the level of the left third costal cartilage.
The mitral valve lies at the level of the fourth costal cartilage.

Coronary
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 veins drain into the atria directly.

Aortic sinus
Right coronary artery arises from the right aortic sinus, the left is derived from the left aortic sinus
and no vessel emerges from the posterior sinus.

Right and left ventricles

Structure Left Ventricle

A-V Valve Mitral (double leaflet)

Walls Twice as thick as right

Trabeculae carnae Much thicker and more numerous

Right coronary artery
The RCA supplies:

• Right atrium
• Diaphragmatic part of the left 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.

Valves of the heart

Mitral valve Aortic valve Pulmonary valve Tricuspid valve

2 cusps 3 cusps 3 cusps 3 cusps

First heart sound Second heart sound Second heart sound First heart sound

1 anterior cusp 1 anterior cusp 2 anterior cusps 2 anterior cusps

Attached to chordae tendinae No chordae No chordae Attached to chordae tendinae

Previous Question 86 of 219 Next
Which of the following statements relating to the tympanic membrane is false?

A. The umbo marks the point of attachment of the handle of the malleus to the
tympanic membrane

B. The lateral aspect of the tympanic membrane is lined by stratified squamous

epithelium

C. The chorda tympani nerve runs medial to the pars tensa

D. The medial aspect of the tympanic membrane is lined by mucous membrane

E. The tympanic membrane is approximately 1cm in diameter

Next question

The chorda tympani runs medially to the pars flaccida. The relationship is shown from the medial
aspect in the dissection below.

Image sourced from Wikipedia

Ear-
Ear- anatomy
The ear is composed of three anatomically distinct regions.

External ear
Auricle is composed of elastic cartilage covered by skin. The lobule has no cartilage and contains fat
and fibrous tissue.

External auditory meatus is approximately 2.5cm long.

Lateral third of the external auditory meatus is cartilaginous and the medial two thirds is bony.

The region is innervated by the greater auricular nerve. The auriculotemporal branch of the
trigeminal nerve supplies most the of external auditory meatus and the lateral surface of the
auricle.

Middle
Middle ear
Space between the tympanic membrane and cochlea. The aditus leads to the mastoid air cells is the
route through which middle ear infections may cause mastoiditis. Anteriorly the eustacian tube
connects the middle ear to the naso pharynx.
The tympanic membrane consists of:

• Outer layer of stratified squamous epithelium.

• Middle layer of fibrous tissue.
• Inner layer of mucous membrane continuous with the middle ear.

The tympanic membrane is approximately 1cm in diameter.

The chorda tympani nerve passes on the medial side of the pars flaccida.

The middle ear is innervated by the glossopharyngeal nerve and pain may radiate to the middle ear
following tonsillectomy.

Ossicles
Malleus attaches to the tympanic membrane (the Umbo).
Malleus articulates with the incus (synovial joint).
Incus attaches to stapes (another synovial joint).

Internal ear
Cochlea, semi circular canals and vestibule
Organ of corti is the sense organ of hearing and is located on the inside of the cochlear duct on the
basilar membrane.

Vestibule accommodates the utricule and the saccule. These structures contain endolymph and are
surrounded by perilymph within the vestibule.

The semicircular canals lie at various angles to the petrous temporal bone. All share a common
opening into the vestibule.

Previous Question 87 of 219 Next

An injury to the spinal accessory nerve will affect which of the following movements?

A. Lateral rotation of the arm

B. Adduction of the arm at the glenohumeral joint

C. Protraction of the scapula

D. Upward rotation of the scapula

E. Depression of the scapula

Next question

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.

Shoulder joint

• Shallow synovial ball and socket type of joint.

• It is an inherently unstable joint, but is capable to a wide range of movement.
• Stability is provided by muscles of the rotator cuff that pass from the scapula to insert in the
greater tuberosity (all except sub scapularis-lesser tuberosity).

Glenoid labrum
 • Fibrocartilaginous rim attached to the free edge of the glenoid cavity
• Tendon of the long head of biceps arises from within the joint from the supraglenoid
tubercle, and is fused at this point to the labrum.
• The long head of triceps attaches to the infraglenoid tubercle

Fibrous capsule

• Attaches to the scapula external to the glenoid labrum and to the labrum itself (postero-
superiorly)
• Attaches to the humerus at the level of the anatomical neck superiorly and the surgical neck
inferiorly
• Anteriorly the capsule is in contact with the tendon of subscapularis, superiorly with the
supraspinatus tendon, and posteriorly with the tendons of infraspinatus and teres minor. All
these blend with the capsule towards their insertion.
• Two defects in the fibrous capsule; superiorly for the tendon of biceps. Anteriorly there is a
defect beneath the subscapularis tendon.
• The inferior extension of the capsule is closely related to the axillary nerve at the surgical
neck and this nerve is at risk in anteroinferior dislocations. It also means that proximally
sited osteomyelitis may progress to septic arthritis.

Movements and muscles

Flexion Anterior part of deltoid

Pectoralis major
Biceps
Coracobrachialis

Extension Posterior deltoid

Teres major
Latissimus dorsi

Adduction Pectoralis major

Latissimus dorsi
Teres major
Coracobrachialis

Abduction Mid deltoid

Supraspinatus
Medial rotation Subscapularis
Anterior deltoid
Teres major
Latissimus dorsi

Lateral rotation Posterior deltoid

Infraspinatus
Teres minor

Important anatomical relations

Anteriorly Brachial plexus

Axillary artery and vein

Posterior Suprascapular nerve

Suprascapular vessels

Inferior Axillary nerve

Circumflex humeral vessels

Previous Question 88 of 219 Next

Which of the following is not contained within the middle mediastinum?

A. Main bronchi

B. Arch of the azygos vein

C. Thoracic duct

D. Pericardium

E. Aortic root

Next question

The thoracic duct lies within the posterior and superior mediastinum.

Mediastinum
Region between the pulmonary cavities.
It is covered by the mediastinal pleura. It does not contain the lungs.
It extends from the thoracic inlet superiorly to the diaphragm inferiorly.

Mediastinal regions

• Superior mediastinum
• Inferior mediastinum
• Posterior mediastinum
• Anterior mediastinum

Region Contents

Superior mediastinum • Superior vena cava

• Brachiocephalic veins
• Arch of aorta
• Thoracic duct
• Trachea
• Oesophagus
• Thymus
• Vagus nerve
• Left recurrent laryngeal nerve
• Phrenic nerve

Anterior mediastinum • Thymic remnants

• Lymph nodes
• Fat

Middle mediastinum • Pericardium

• Heart
• Aortic root
• Arch of azygos vein
• Main bronchi

Posterior mediastinum • Oesophagus

• Thoracic aorta
• Azygos vein
 • Thoracic duct
• Vagus nerve
• Sympathetic nerve trunks
• Splanchnic nerves

Previous Question 89 of 219 Next

A 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?

A. External iliac artery

B. Common iliac artery

C. Internal iliac artery

D. Inferior vesical artery

E. None of the above

Next question

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.

Prostate gland

The prostate gland is approximately the shape and size of a walnut and is located inferior to the
bladder. It is separated from the rectum by Denonvilliers fascia and its blood supply is derived from
the internal iliac vessels. The internal sphincter lies at the apex of the gland and may be damaged
during prostatic surgery, affected individuals may complain of retrograde ejaculation.

Summary of prostate gland

gland

Arterial supply Inferior vesical artery (from internal iliac)

Venous drainage Prostatic venous plexus (to paravertebral veins)

Lymphatic Internal iliac nodes
drainage

Innervation Inferior hypogastric plexus

Dimensions • Transverse diameter (4cm)

• AP diameter (2cm)
• Height (3cm)

Lobes • Posterior lobe: posterior to urethra

• Median lobe: posterior to urethra, in between ejaculatory ducts
• Lateral lobes x 2
• Isthmus

Zones • Peripheral zone: subcapsular portion of posterior prostate. Most prostate cancers
are here
• Central zone
• Transition zone
• Stroma

Relations

Anterior Pubic symphysis

Prostatic venous plexus

Posterior Denonvilliers fascia

Rectum
Ejaculatory ducts

Lateral Venous plexus (lies on prostate)

Levator ani (immediately below the puboprostatic ligaments)
Image sourced from Wikipedia

Question 90
Previous Next
of 219
Which nerve directly innervates the sinoatrial node?

A. Superior cardiac nerve

B. Right vagus nerve

C. Left vagus nerve

D. Inferior cardiac nerve

E. None of the above

Next question

Theme from September 2011 Exam

Theme from September 2012 Exam
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.

Sinoatrial node

• Located in the wall of the right atrium in the upper part of the sulcus terminalis from which it
extends anteriorly over the opening of the superior vena cava.
• In most cases it is supplied by the right coronary artery.
• It has a complicated nerve supply from the cardiac nerve plexus that takes both sympathetic
and parasympathetic fibres that run alongside the main vessels.

• Previous Question 91 of 219 Next

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?

A. S3 and S4

B. L4 and L5

C. L3 and L4

D. S1 and S2

E. S4 only

Next question

Theme from April 2012 Exam

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.

Previous Question 92 of 219 Next

Which of the following structures is not closely related to the piriformis muscle?
 A. Superior gluteal nerve

B. Sciatic nerve

C. Inferior gluteal artery

D. Inferior gluteal nerve

E. Medial femoral circumflex artery

Next question

Nerve supply of lateral hip rotators

Piriformis: ventral rami S1, S2

Obturator internus: nerve to obturator internus
Superior gemellus: nerve to obturator internus
Inferior gemellus: nerve to quadratus femoris
Quadrator femoris: nerve to quadrator femoris

The piriformis muscle is an important anatomical landmark in the gluteal region. The following
structures are closely related:

• Sciatic nerve
• Inferior gluteal artery and nerve
• Superior gluteal artery and nerve

The medial femoral circumflex artery runs deep to quadratus femoris.

Gluteal region

Gluteal muscles

• Gluteus maximus: inserts to gluteal tuberosity of the femur and iliotibial tract
• Gluteus medius: attach to lateral greater trochanter
• Gluteus minimis: attach to anterior greater trochanter
• All extend and abduct the hip
Deep lateral hip rotators

• Piriformis
• Gemelli
• Obturator internus
• Quadratus femoris

Nerves

Superior gluteal nerve (L5, S1) • Gluteus medius

• Gluteus minimis
• Tensor fascia lata

Inferior gluteal nerve Gluteus maximus

Damage to the superior gluteal nerve will result in the patient developing a Trendelenberg gait.
Affected patients are unable to abduct the thigh at the hip joint. During the stance phase, the
weakened abductor muscles allow the pelvis to tilt down on the opposite side. To compensate, the
trunk lurches to the weakened side to attempt to maintain a level pelvis throughout the gait cycle.
The pelvis sags on the opposite side of the lesioned superior gluteal nerve.

Previous Question 93 of 219 Next

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
examination the left eye cannot look downwards and medially. Which of the nerves listed below is
most likely to be responsible?

A. Facial

B. Oculomotor

C. Abducens

D. Trochlear

E. Trigeminal nerve
 Next question

Theme from September 2012 Exam

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. The affected eye
typically drifts upwards compared to the normal eye. A 4th nerve palsy is the commonest cause of a
vertical diplopia. Looking down and in is difficult and the patient notices diplopia on descending the
stairs.

Disorders of the oculomotor system

Nerve Path Nerve palsy features

Oculomotor • Large nucleus at the midbrain Ptosis

nerve • Fibres pass through the red nucleus and the pyramidal Eye down and out
tract; through the cavernous sinus into the orbit Unable to move the eye
superiorly, inferiorly,
medially
Pupil fixed and dilated

Trochlear • Longest intracranial course Vertical diplopia (diplopia

nerve • Only nerve to exit the dorsal aspect of brainstem on descending the stairs)
• Nucleus at midbrain, passes between the posterior Unable to look down and in
cerebral and superior cerebellar arteries, through the
cavernous sinus into the orbit

Abducens Nucleus lies in the mid pons Convergence of eyes in

nerve primary position
Lateral diplopia towards
side of lesion
Eye deviates medially

Previous Question 94 of 219 Next

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?

A. Extensor digitorum longus tendon

 B. Peroneus tertius tendon

C. Extensor hallucis longus tendon

D. Extensor digitorum brevis tendon

E. Flexor digitorum longus tendon

Next question

The extensor hallucis longus tendon lies medial to the dorsalis pedis artery.

Foot-
Foot- anatomy

Arches of the foot

The foot is conventionally considered to have two arches.

• The longitudinal arch is higher on the medial than on the lateral side. The posterior part of
the calcaneum forms a posterior pillar to support the arch. The lateral part of this structure
passes via the cuboid bone and the lateral two metatarsal bones. The medial part of this
structure is more important. The head of the talus marks the summit of this arch, located
between the sustentaculum tali and the navicular bone. The anterior pillar of the medial arch
is composed of the navicular bone, the three cuneiforms and the medial three metatarsal
bones.
• The transverse arch is situated on the anterior part of the tarsus and the posterior part of
the metatarsus. The cuneiforms and metatarsal bases narrow inferiorly, which contributes to
the shape of the arch.

Intertarsal joints

Sub talar joint Formed by the cylindrical facet on the lower surface of the body of the talus and the
posterior facet on the upper surface of the calcaneus. The facet on the talus is concave
anteroposteriorly, the other is convex. The synovial cavity of this joint does not
communicate with any other joint.

Talocalcaneonavicular The anterior part of the socket is formed by the concave articular surface of the
joint navicular bone, posteriorly by the upper surface of the sustentaculum tali. The talus
sits within this socket
Calcaneocuboid joint Highest point in the lateral part of the longitudinal arch. The lower aspect of this joint
is reinforced by the long plantar and plantar calcaneocuboid ligaments.

Transverse tarsal joint The talocalcaneonavicular joint and the calcaneocuboid joint extend across the tarsus
in an irregular transverse plane, between the talus and calcaneus behind and the
navicular and cuboid bones in front. This plane is termed the transverse tarsal joint.

Cuneonavicular joint Formed between the convex anterior surface of the navicular bone and the concave
surface of the the posterior ends of the three cuneiforms.

Intercuneiform joints Between the three cuneiform bones.

Cuneocuboid joint Between the circular facets on the lateral cuneiform bone and the cuboid. This joint
contributes to the tarsal part of the transverse arch.

A detailed knowledge of the joints is not required for MRCS Part A. However, the contribution they
play to the overall structure of the foot should be appreciated

Muscles of the foot

Muscle Origin Insertion Nerve Action

supply

Abductor Medial side of the calcaneus, Medial side of Medial Abducts the great toe
hallucis flexor retinaculum, plantar the base of the plantar
aponeurosis proximal nerve
phalanx

Flexor Medial process of the Via 4 tendons Medial Flexes all the joints of
digitorum calcaneus, plantar into the middle plantar the lateral 4 toes except
brevis eponeurosis. phalanges of nerve for the interphalangeal
the lateral 4 joint.
toes.

Abductor From the tubercle of the Together with Lateral Abducts the little toe at
digit calcaneus and from the flexor digit plantar the metatarsophalangeal
minimi plantar aponeurosis minimi brevis nerve joint
into the lateral
side of the
base of the
 proximal
phalanx of the
little toe

Flexor From the medial side of the Into the Medial Flexes the
hallucis plantar surface of the cuboid proximal plantar metatarsophalangeal
brevis bone, from the adjacent part phalanx of the nerve joint of the great toe.
of the lateral cuneiform bone great toe, the
and from the tendon of tibialis tendon
posterior. contains a
sesamoid bone

Adductor Arises from two heads. The Lateral side of Lateral Adducts the great toe
hallucis oblique head arises from the the base of the plantar towards the second toe.
sheath of the peroneus longus proximal nerve Helps maintain the
tendon, and from the plantar phalanx of the transverse arch of the
surfaces of the bases of the great toe. foot.
2nd, 3rd and 4th metatarsal
bones. The transverse head
arises from the plantar surface
of the lateral 4
metatarsophalangeal joints
and from the deep transverse
metatarsal ligament.

Extensor On the dorsal surface of the Via four thin Deep Extend the
digitorum foot from the upper surface of tendons which peroneal metatarsophalangeal
brevis the calcaneus and its run forward joint of the medial four
associated fascia and medially toes. It is unable to
to be inserted extend the
into the medial interphalangeal joint
four toes. The without the assistance of
lateral three the lumbrical muscles.
tendons join
with hoods of
extensor
digitorum
longus.
Detailed knowledge of the foot muscles are not needed for the MRCS part A

Nerves in the foot

Lateral plantar nerve

Passes anterolaterally towards the base of the 5th metatarsal between flexor digitorum brevis and
flexor accessorius. On the medial aspect of the lateral plantar artery. At the base of the 5th
metatarsal it splits into superficial and deep branches.

Medial plantar nerve

Passes forwards with the medial plantar artery under the cover of the flexor retinaculum to the
interval between abductor hallucis and flexor digitorum brevis on the sole of the foot.

Plantar arteries
Arise under the cover of the flexor retinaculum, midway between the tip of the medial malleolus and
the most prominent part of the medial side of the heel.

• Medial plantar artery. Passes forwards medial to medial plantar nerve in the space between
abductor hallucis and flexor digitorum brevis.Ends by uniting with a branch of the 1st plantar
metatarsal artery.
• Lateral plantar artery. Runs obliquely across the sole of the foot. It lies lateral to the lateral
plantar nerve. At the base of the 5th metatarsal bone it arches medially across the foot on
the metatarsals

Dorsalis pedis artery

This vessel is a direct continuation of the anterior tibial artery. It commences on the front of the
ankle joint and runs to the proximal end of the first metatarsal space. Here is gives off the arcuate
artery and continues forwards as the first dorsal metatarsal artery. It is accompanied by two veins
throughout its length. It is crossed by the extensor hallucis brevis

Previous Question 95 of 219 Next

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 will not be present?

A. Weakness of thumb abduction

B. Loss of sensation on the dorsal aspect of the thenar eminence

C. Loss of power of opponens pollicis

D. Adduction and lateral rotation of the thumb at rest

E. Loss of power of abductor pollicis brevis

Next question

The median nerve may be injured proximal to the flexor retinaculum. This will result in loss of 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.

Median nerve

The median nerve is formed by the union of a lateral and medial root respectively from the lateral
(C5,6,7) and medial (C8 and T1) cords of the brachial plexus; the medial root passes anterior to the
third part of the axillary artery. The nerve descends lateral to the brachial artery, crosses to its
medial side (usually passing anterior to the artery). It passes deep to the bicipital aponeurosis and
the median cubital vein at the elbow.
It passes between the two heads of the pronator teres muscle, and runs on the deep surface of
flexor digitorum superficialis (within its fascial sheath).
Near the wrist it becomes superficial between the tendons of flexor digitorum superficialis and flexor
carpi radialis, deep to palmaris longus tendon. It passes deep to the flexor retinaculum to enter the
palm, but lies anterior to the long flexor tendons within the carpal tunnel.

Branches
Region Branch

Upper arm No branches, although the nerve commonly communicates with the musculocutaneous nerve

Forearm Pronator teres

Flexor carpi radialis
Palmaris longus
Flexor digitorum superficialis
Flexor pollicis longus
Flexor digitorum profundus (only the radial half)

Distal Palmar cutaneous branch

forearm

Hand Motor supply (LOAF)

(Motor)
• Lateral 2 lumbricals
• Opponens pollicis
• Abductor pollicis brevis
• Flexor pollicis brevis

Hand • Over thumb and lateral 2 ½ fingers

(Sensory) • On the palmar aspect this projects proximally, on the dorsal aspect only the distal regions
are innervated with the radial nerve providing the more proximal cutaneous innervation.

Patterns of damage
Damage at wrist

• e.g. carpal tunnel syndrome

• paralysis and wasting of thenar eminence muscles and opponens pollicis (ape hand
deformity)
• sensory loss to palmar aspect of lateral (radial) 2 ½ fingers

Damage at elbow, as above plus:

• unable to pronate forearm

• weak wrist flexion
• ulnar deviation of wrist
Anterior interosseous nerve (branch of median nerve)

• leaves just below the elbow

• results in loss of pronation of forearm and weakness of long flexors of thumb and index
finger

Previous Question 96 of 219 Next

The following muscles are supplied by the recurrent laryngeal nerve except:

A. Transverse arytenoid

B. Posterior crico-arytenoid

C. Cricothyroid

D. Oblique arytenoid

E. Thyroarytenoid

Next question

Innervates: all intrinsic larynx muscles (excluding cricothyroid)

The external branch of the superior laryngeal nerve innervates the cricothyroid muscle.

Recurrent laryngeal nerve

• Branch of the vagus nerve

Path

Right

• Arises anterior to the subclavian artery and ascends obliquely next to the trachea, behind
the common carotid artery
 • It is either anterior or posterior to the inferior thyroid artery

Left

• Arises left to the arch of the aorta

• Winds below the aorta
• Ascends along the side of the trachea

Then
Then both

• Pass in a groove between the trachea and oesophagus

• Enters the larynx behind the articulation between the thyroid cartilage and cricoid
• Distributed to larynx muscles

Branches to

• Cardiac plexus
• Mucous membrane and muscular coat of the oesophagus and trachea

Innervates

• Intrinsic larynx muscles (excluding cricothyroid)

Image sourced from Wikipedia

Previous Question 97 of 219 Next

From which embryological structure is the ureter derived?

A. Uranchus

B. Wolffian duct

C. Vitello-intestinal duct

D. Mesonephric duct

E. Cloaca

Next question

The ureter develops from the mesonephric duct.

Ureter

• 25-35 cm long
• Muscular tube lined by transitional epithelium
• Surrounded by thick muscular coat. Becomes 3 muscular layers as it crosses the bony pelvis
 • Retroperitoneal structure overlying transverse processes L2-L5
• Lies anterior to bifurcation of iliac vessels
• Blood supply is segmental; renal artery, aortic branches, gonadal branches, common iliac
and internal iliac
• Lies beneath the uterine artery

Previous Question 98 of 219 Next

A 16 year old boy is hit by a car and sustains a blow to the right side of his head. He is initially
conscious but on arrival in the emergency department is comatose. On examination his right pupil is
fixed and dilated. The neurosurgeons plan immediate surgery. What type of initial approach should
be made?

A. Left parieto-temporal craniotomy

B. Right parieto-temporal craniotomy

C. Posterior fossa craniotomy

D. Left parieto-temporal burr holes

E. None of the above

Next question

Theme from April 2012 Exam

A unilateral dilated pupil is a classic sign of transtentorial herniation. The medial aspect of the
temporal lobe (uncus) herniates across the tentorium and causes pressure on the ipsilateral
oculomotor nerve, interrupting parasympathetic input to the eye and resulting in a dilated pupil. In
addition the brainstem is compressed. As the ipsilateral oculomotor nerve is being compressed,
craniotomy (rather than Burr Holes) should be made on the ipsilateral side.

Head injury

• Patients who suffer head injuries should be managed according to ATLS principles and extra
cranial injuries should be managed alongside cranial trauma. Inadequate cardiac output will
compromise CNS perfusion irrespective of the nature of the cranial injury.
Types of traumatic brain injury

Extradural Bleeding into the space between the dura mater and the skull. Often results from
haematoma acceleration-deceleration trauma or a blow to the side of the head. The majority of extradural
haematomas occur in the temporal region where skull fractures cause a rupture of the middle
meningeal artery.

Features

• Raised intracranial pressure

• Some patients may exhibit a lucid interval

Subdural Bleeding into the outermost meningeal layer. Most commonly occur around the frontal and
haematoma parietal lobes. May be either acute or chronic.

Risk factors include old age and alcoholism.

Slower onset of symptoms than a extradural haematoma.

Subarachnoid Usually occurs spontaneously in the context of a ruptured cerebral aneurysm but may be seen
haemorrhage in association with other injuries when a patient has sustained a traumatic brain injury

Pathophysiology

• Primary brain injury may be focal (contusion/ haematoma) or diffuse (diffuse axonal injury)
• Diffuse axonal injury occurs as a result of mechanical shearing following deceleration,
causing disruption and tearing of axons
• Intra-cranial haematomas can be extradural, subdural or intracerebral, while contusions may
occur adjacent to (coup) or contralateral (contre-coup) to the side of impact
• Secondary brain injury occurs when cerebral oedema, ischaemia, infection, tonsillar or
tentorial herniation exacerbates the original injury. The normal cerebral auto regulatory
processes are disrupted following trauma rendering the brain more susceptible to blood flow
changes and hypoxia
• The Cushings reflex (hypertension and bradycardia) often occurs late and is usually a pre
terminal event

Management
 • Where there is life threatening rising ICP such as in extra dural haematoma and whilst
theatre is prepared or transfer arranged use of IV mannitol/ frusemide may be required.
• Diffuse cerebral oedema may require decompressive craniotomy
• Exploratory Burr Holes have little management in modern practice except where scanning
may be unavailable and to thus facilitate creation of formal craniotomy flap
• Depressed skull fractures that are open require formal surgical reduction and debridement,
closed injuries may be managed non operatively if there is minimal displacement.
• ICP monitoring is appropriate in those who have GCS 3-8 and normal CT scan.
• ICP monitoring is mandatory in those who have GCS 3-8 and abnormal CT scan.
• Hyponatraemia is most likely to be due to syndrome of inappropriate ADH secretion.
• Minimum of cerebral perfusion pressure of 70mmHg in adults.
• Minimum cerebral perfusion pressure of between 40 and 70 mmHg in children.

Interpretation of pupillary findings in head injuries

Pupil size Light response Interpretation

Unilaterally dilated Sluggish or fixed 3rd nerve compression secondary to tentorial

herniation

Bilaterally dilated Sluggish or fixed • Poor CNS perfusion

• Bilateral 3rd nerve palsy

Unilaterally dilated or Cross reactive (Marcus - Optic nerve injury

equal Gunn)

Bilaterally constricted May be difficult to assess • Opiates

• Pontine lesions
• Metabolic encephalopathy

Unilaterally constricted Preserved Sympathetic pathway disruption

Previous Question 99 of 219 Next

Which of the following relationship descriptions regarding the scalene muscles is incorrect?

A. The brachial plexus passes anterior to the middle scalene muscle

 B. The phrenic nerve lies anterior to the anterior scalene muscle

C. The subclavian artery passes posterior to the middle scalene

D. The subclavian vein lies anterior to the anterior scalene muscle at the level of
the first rib

E. The anterior scalene inserts into the first rib

Next question

The subclavian artery passes anterior to the middle scalene.

Scalene muscles

The 3 paired muscles are:

• Scalenus anterior: Elevate 1st rib and laterally flex the neck to same side
• Scalenus medius: Same action as scalenus anterior
• Scalenus posterior: Elevate 2nd rib and tilt neck to opposite side

Innervation Spinal nerves C4-6

Origin Transverse processes C2 to C7

Insertion First and second ribs

Important • The brachial plexus and subclavian artery pass between the anterior and
relations middle scalenes through a space called the scalene hiatus/fissure.
• The subclavian vein and phrenic nerve pass anteriorly to the anterior
scalene as it crosses over the first rib.
 Image sourced from Wikipedia

Thoracic outlet syndrome

The scalenes are at risk of adhering to the fascia surrounding the brachial plexus or shortening
causing compression of the brachial plexus when it passes between the clavicle and 1st rib causing
thoracic outlet syndrome.
Previous Question 100 of 219 Next
A 56 year old man is having a long venous line inserted via the femoral vein into the right atrium for
CVP measurements. The catheter is advanced through the IVC. At which of the following levels does
this vessel enter the thorax?

A. L2

B. T10

C. L1
 D. T8

E. T6

Next question

Theme from 2010 Exam

Theme from September 2012 Exam
The IVC passes through the diaphragm at T8.

Inferior vena cava

Origin

• L5

Path

• Left and right common iliac veins merge to form the IVC.
• Passes right of midline
• Paired segmental lumbar veins drain into the IVC throughout its length
• The right gonadal vein empties directly into the cava and the left gonadal vein generally
empties into the left renal vein.
• The next major veins are the renal veins and the hepatic veins
• Pierces the central tendon of diaphragm at T8
• Right atrium
 Image sourced from Wikipedia

Relations

Anteriorly Small bowel, first and third part of duodenum, head of pancreas, liver and bile duct, right common
iliac artery, right gonadal artery

Posteriorly Right renal artery, right psoas, right sympathetic chain, coeliac ganglion

Levels

Level Vein

T8 Hepatic vein, inferior phrenic vein, pierces diaphragm

L1 Suprarenal veins, renal vein

L2 Gonadal vein

L1-5 Lumbar veins

L5 Common iliac vein, formation of IVC

Previous Question 101 of 219 Next

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?

A. Basilic vein

B. Radial artery

C. Extensor pollicis brevis

D. Abductor pollicis longus

E. Extensor pollicis longus

Next question

Theme from 2009 Exam

Theme from September 2012 Exam
Its 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

Previous Question 102 of 219 Next

A 62 year old man is undergoing a left hemicolectomy for carcinoma of the descending colon. The
registrar commences mobilisation of the left colon by pulling downwards and medially. Blood soon
appears in the left paracolic gutter. The most likely source of bleeding is the:

A. Marginal artery

B. Left testicular artery

C. Spleen

D. Left renal vein

E. None of the above

Next question

The spleen is commonly torn by traction injuries in colonic surgery. The other structures are
associated with bleeding during colonic surgery but would not manifest themselves as blood in the
paracolic gutter prior to incision of the paracolonic peritoneal edge.

Left colon

Position

• As the left colon passes inferiorly its posterior aspect becomes extraperitoneal, and the
ureter and gonadal vessels are close posterior relations that may become involved in disease
processes
• At a level of L3-4 (variable) the left colon becomes the sigmoid colon and wholly
intraperitoneal once again
• The sigmoid colon is a highly mobile structure and may even lie of the right side of the
abdomen
• It passes towards the midline, the taenia blend and this marks the transition between
sigmoid colon and upper rectum.

Blood supply

• Inferior mesenteric artery

 • However, the marginal artery (from the right colon) contributes and this contribution
becomes clinically significant when the IMA is divided surgically (e.g. During AAA repair)

Previous Question 103 of 219 Next

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?

A. Lingual artery

B. Occipital artery

C. Superior thyroid artery

D. Facial artery

E. External jugular vein

Next question

The high salivary viscosity of submandibular gland secretions favors stone formation.
Most stones are radio-opaque.

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.

Submandibular gland

Relations of the submandibular gland

Superficial Platysma, deep fascia and mandible

Submandibular lymph nodes
Facial vein (facial artery near mandible)
Marginal mandibular nerve
Cervical branch of the facial nerve

Deep Facial artery (inferior to the mandible)

Mylohoid muscle
 Sub mandibular duct
Hyoglossus muscle
Lingual nerve
Submandibular ganglion
Hypoglossal nerve

Submandibular duct (Wharton's duct)

• Opens lateral to the lingual frenulum on the anterior floor of mouth.

• 5 cm length
• Lingual nerve wraps around Wharton's duct. As the duct passes forwards it crosses medial to
the nerve to lie above it and then crosses back, lateral to it, to reach a position below the
nerve.

Innervation

• Sympathetic innervation- Superior Cervical ganglion via the Lingual nerve

• Parasympathetic innervation- Submandibular ganglion

Arterial supply
Branch of the Facial artery. The facial artery passes through the gland to groove its deep surface. It
then emerges onto the face by passing between the gland and the mandible.

Venous drainage
Anterior Facial vein (lies deep to the Marginal Mandibular nerve)

Lymphatic drainage
Deep cervical and jugular chains of nodes

2/3 Question 1-3 of 116 Next

Theme: Cranial nerves

A. Facial
B. Trigeminal
C. Vagus
D. Hypoglossal
E. Glossopharyngeal

For each of the following functions please select the most likely responsible cranial nerve. Each
option may be used once, more than once or not at all.

1. Supplies the motor fibres of styloglossus.

Hypoglossal

The hypoglossal nerve supplies motor innervation to all extrinsic and intrinsic muscles of the tongue.

2. Provides sensation to the anterior two thirds of the tongue.

Trigeminal

Taste to the anterior two thirds of the tongue is supplied by the facial nerve, the trigeminal supplies
general sensation.

3. Supplies general sensation to the posterior third of the tongue.

You answered Facial

The correct answer is Glossopharyngeal

The glossopharyngeal nerve supplies general sensation to the posterior third of the tongue and
contributes to the gag reflex.

Next question

Cranial nerves

Cranial nerve lesions

Olfactory nerve May be injured in basal skull fractures or involved in frontal lobe tumour extension. Loss of
olfactory nerve function in relation to major CNS pathology is seldom an isolated event and
thus it is poor localiser of CNS pathology.
Optic nerve Problems with visual acuity may result from intra ocular disorders. Problems with the blood
supply such as amaurosis fugax may produce temporary visual distortion. More important
surgically is the pupillary response to light. The pupillary size may be altered in a number
of disorders. Nerves involved in the resizing of the pupil connect to the pretectal nucleus of
the high midbrain, bypassing the lateral geniculate nucleus and the primary visual cortex.
From the pretectal nucleus neurones pass to the Edinger - Westphal nucleus, motor axons
from here pass along with the oculomotor nerve. They synapse with ciliary ganglion
neurones; the parasympathetic axons from this then innervate the iris and produce miosis.
The miotic pupil is seen in disorders such a Horner's syndrome or opiate overdose.
Mydriasis is the dilatation of the pupil in response to disease, trauma, drugs (or the dark!).
It is pathological when light fails to induce miosis. The radial muscle is innervated by the
sympathetic nervous system. Because the parasympathetic fibres travel with the oculomotor
nerve they will be damaged by lesions affecting this nerve (e.g. cranial trauma).
The response to light shone in one eye is usually a constriction of both pupils. This
indicates intact direct and consensual light reflexes. When the optic nerve has an afferent
defect the light shining on the affected eye will produce a diminished pupillary response in
both eyes. Whereas light shone on the unaffected eye will produce a normal pupillary
response in both eyes. This is referred to as the Marcus Gunn pupil and is seen in
conditions such as optic neuritis. In a total CN II lesion shining the light in the affected eye
will produce no response.

Oculomotor nerve The pupillary effects are described above. In addition it supplies all ocular muscles apart
from lateral rectus and superior oblique. Thus the affected eye will be deviated
inferolaterally. Levator palpebrae superioris may also be impaired resulting in impaired
ability to close the eye.

Trochlear nerve The eye will not be able to look down.

Trigeminal nerve Largest cranial nerve. Exits the brainstem at the pons. Branches are ophthalmic, maxillary
and mandibular. Only the mandibular branch has both sensory and motor fibres. Branches
converge to form the trigeminal ganglion (located in Meckels cave). It supplies the muscles
of mastication and also tensor veli palatine, mylohyoid, anterior belly of digastric and
tensor tympani. The detailed descriptions of the various sensory functions are described in
other areas of the website. The corneal reflex is important and is elicited by applying a
small tip of cotton wool to the cornea, a reflex blink should occur if it is intact. It is
mediated by: the naso ciliary branch of the ophthalmic branch of the trigeminal (sensory
component) and the facial nerve producing the motor response. Lesions of the afferent arc
will produce bilateral absent blink and lesions of the efferent arc will result in a unilateral
absent blink.

Abducens nerve The affected eye will have a deficit of abduction. This cranial nerve exits the brainstem
between the pons and medulla. It thus has a relatively long intra cranial course which
renders it susceptible to damage in raised intra cranial pressure.

Facial nerve Emerges from brainstem between pons and medulla. It controls muscles of facial
 expression and taste from the anterior 2/3 of the tongue. The nerve passes into the petrous
temporal bone and into the internal auditory meatus. It then passes through the facial canal
and exits at the stylomastoid foramen. It passes through the parotid gland and divides at this
point. It does not innervate the parotid gland. Its divisions are considered in other parts of
the website. Its motor fibres innervate orbicularis oculi to produce the efferent arm of the
corneal reflex. In surgical practice it may be injured during parotid gland surgery or
invaded by malignancies of the gland and a lower motor neurone on the ipsilateral side will
result.

Vestibulo-cochlear Exits from the pons and then passes through the internal auditory meatus. It is implicated in
nerve sensorineural hearing loss. Individuals with sensorineural hearing loss will localise the
sound in webers test to the normal ear. Rinnes test will be reduced on the affected side but
should still work. These two tests will distinguish sensorineural hearing loss from
conductive deafness. In the latter condition webers test will localise to the affected ear and
Rinnes test will be impaired on the affected side. Surgical lesions affecting this nerve
include CNS tumours and basal skull fractures. It may also be damaged by the
administration of ototoxic drugs (of which gentamicin is the most commonly used in
surgical practice).

Glossopharyngeal Exits the pons just above the vagus. Receives sensory fibres from posterior 1/3 tongue,
nerve tonsils, pharynx and middle ear (otalgia may occur following tonsillectomy). It receives
visceral afferents from the carotid bodies. It supplies parasympathetic fibres to the parotid
gland via the otic ganglion and motor function to stylopharyngeaus muscle. The sensory
function of the nerve is tested using the gag reflex.

Vagus nerve Leaves the medulla between the olivary nucleus and the inferior cerebellar peduncle. Passes
through the jugular foramen and into the carotid sheath. Details of the functions of the
vagus nerve are covered in the website under relevant organ sub headings.

Accessory nerve Exists from the caudal aspect of the brainstem (multiple branches) supplies trapezius and
sternocleidomastoid muscles. The distal portion of this nerve is most prone to injury during
surgical procedures.

Hypoglossal nerve Emerges from the medulla at the preolivary sulcus, passes through the hypoglossal canal. It
lies on the carotid sheath and passes deep to the posterior belly of digastric to supply
muscles of the tongue (except palatoglossus). Its location of the carotid sheath makes it
vulnerable during carotid endarterectomy surgery and damage will produce ipsilateral
defect in muscle function.

Previous Question 4 of 116 Next

The integrity of which muscle is assessed by the Trendelenberg test?
 A. Sartorius

B. Quadratus femoris

C. Semimembranosus

D. Gluteus medius

E. Piriformis

Next question

Theme from 2011 Exam

Trendelenberg test

Injury or division of the superior gluteal nerve results in a motor deficit that consists of weakened
abduction of the thigh by gluteus medius, a disabling gluteus medius limp and a compensatory list
of the body weakened gluteal side. The compensation results in a gravitational shift so that the body
is supported on the unaffected limb.
When a person is asked to stand on one leg the gluteus medius usually contracts as soon as the
contralateral leg leaves the floor, preventing the pelvis from dipping towards the unsupported side.
When a person with paralysis of the superior gluteal nerve is asked to stand on one leg, the pelvis
on the unsupported side descends, indicating that the gluteus medius on the affected side is weak
or non functional ( a positive Trendelenberg test).

Previous Question 5 of 116 Next

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?

A. Great saphenous vein

B. Deep circumflex iliac artery

C. Superficial circumflex iliac artery

D. Femoral vein
 E. Femoral branch of the genitofemoral nerve

Next question

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.

Previous Question 6 of 116 Next

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?

A. Right renal artery

B. Ureter

C. Right renal vein

D. Inferior vena cava

E. Right testicular vein

Next question

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.

Branches

• The renal arteries are direct branches off the aorta (upper border of L2)
• In 30% there may be accessory arteries (mainly left side). Instead of entering the kidney at
the hilum, they usually pierce the upper or lower part of the organ.
• Before reaching the hilum of the kidney, each artery divides into four or five segmental
branches (renal vein anterior and ureter posterior); which then divide within the sinus into
lobar arteries supplying each pyramid and cortex.
• Each vessel gives off some small inferior suprarenal branches to the suprarenal gland, the
ureter, and the surrounding cellular tissue and muscles.

• Previous Question 7 of 116 Next

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?

A. Palmaris brevis

B. Second and third interossei

C. Adductor pollicis

D. Abductor pollicis longus

E. Abductor pollicis brevis

Next question
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.

Previous Question 8 of 116 Next

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?

A. Middle cerebral artery

B. Internal carotid artery

C. Anterior cerebral artery

D. Maxillary artery

E. Mandibular artery

Next question

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")

Middle meningeal artery

 • Middle meningeal artery is typically the third branch of the first part of the maxillary artery,
one of the two terminal branches of the external carotid artery. After branching off the
maxillary artery in the infratemporal fossa, it runs through the foramen spinosum to supply
the dura mater (the outermost meninges) .
• The middle meningeal artery is the largest of the three (paired) arteries which supply the
meninges, the others being the anterior meningeal artery and the posterior meningeal
artery.
• The middle meningeal artery runs beneath the pterion. It is vulnerable to injury at this point,
where the skull is thin. Rupture of the artery may give rise to an extra dural hematoma.
• In the dry cranium, the middle meningeal, which runs within the dura mater surrounding the
brain, makes a deep indention in the calvarium.
• The middle meningeal artery is intimately associated with the auriculotemporal nerve which
wraps around the artery making the two easily identifiable in the dissection of human
cadavers and also easily damaged in surgery.

• Previous Question 9 of 116 Next

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?

A. T3

B. T7

C. T6

D. T10

E. T1

Next question

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)

Previous Question 10 of 116 Next

Which of the following regions of the male urethra is entirely surrounded by Bucks fascia?
 A. Preprostatic part

B. Prostatic part

C. Membranous part

D. Spongiose part

E. None of the above

Next question

Theme from 2010 Exam

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.

Image of penile cross section

Bucks fascia corresponds to the layer of deep fascia

Image sourced from Wikipedia

Urethral anatomy

Female urethra
The female urethra is shorter and more acutely angulated than the male urethra. It is an extra-
peritoneal structure and embedded in the endopelvic fascia. The neck of the bladder is subjected to
transmitted intra-abdominal pressure and therefore deficiency in this area may result in stress
urinary incontinence. Between the layers of the urogenital diaphragm the female urethra is
surrounded by the external urethral sphincter, this is innervated by the pudendal nerve. It ultimately
lies anterior to the vaginal orifice.

Male urethra
In males the urethra is much longer and is divided into four parts.

Pre-prostatic Extremely short and lies between the bladder and prostate gland.It has a stellate lumen and is
urethra between 1 and 1.5cm long.Innervated by sympathetic noradrenergic fibres, as this region is
composed of striated muscles bundles they may contract and prevent retrograde ejaculation.

Prostatic This segment is wider than the membranous urethra and contains several openings for the
urethra transmission of semen (at the midpoint of the urethral crest).

Membranous Narrowest part of the urethra and surrounded by external sphincter. It traverses the perineal
urethra membrane 2.5cm postero-inferior to the symphysis pubis.

Penile urethra Travels through the corpus songiosum on the underside of the penis. It is the longest urethral
segment.It is dilated at its origin as the infrabulbar fossa and again in the gland penis as the
navicular fossa. The bulbo-urethral glands open into the spongiose section of the urethra 2.5cm
below the perineal membrane.

The urothelium is transitional in nature near to the bladder and becomes squamous more distally.

Previous Question 11 of 116 Next

Which of the following statements relating to the knee joint is false?

A. It is the largest synovial joint in the body

B. When the knee is fully extended all ligaments of the knee joint are taut

C. Rupture of the anterior cruciate ligament may result in haemarthrosis

D. The posterior aspect of the patella is extrasynovial

E. The joint is innervated by the femoral, sciatic and obturator nerves

Next question

The posterior aspect is intrasynovial and the knee itself comprises the largest synovial joint in the
body. It may swell considerably following trauma such as ACL injury. Which may be extremely
painful owing to rich innervation from femoral, sciatic and ( a smaller) contribution from the
obturator nerve. During full extension all ligaments are taut and the knee is locked.

Previous Question 12 of 116 Next

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?

A. Left renal artery

B. Inferior phrenic artery

C. Aorta

D. Splenic

E. None of the above

Next question

The superior adrenal artery is a branch of the inferior phrenic artery.

Adrenal gland anatomy

Anatomy

Location Superomedially to the upper pole of each kidney

Relationships of the right Diaphragm-Posteriorly, Kidney-Inferiorly, Vena Cava-Medially, Hepato-renal

adrenal pouch and bare area of the liver-Anteriorly

Relationships of the left Crus of the diaphragm-Postero- medially, Pancreas and splenic vessels-Inferiorly,
adrenal Lesser sac and stomach-Anteriorly

Superior adrenal arteries- from inferior phrenic artery, Middle adrenal arteries -
Arterial supply from aorta, Inferior adrenal arteries -from renal arteries

Venous drainage of the Via one central vein directly into the IVC
right adrenal
Venous drainage of the Via one central vein into the left renal vein
left adrenal

Previous Question 13 of 116 Next

Which of the following does not exit the pelvis through the greater sciatic foramen?

A. Superior gluteal artery

B. Internal pudendal vessels

C. Sciatic nerve

D. Obturator nerve

E. Inferior gluteal nerve

Next question

The obturator nerve exits through the obturator foramen.

Greater sciatic foramen

Contents

Nerves • Sciatic Nerve

• Superior and Inferior Gluteal Nerves
• Internal 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

Piriformis
The piriformis is a landmark for identifying structures passing out of the sciatic notch
 • Above piriformis: Superior gluteal vessels
• Below piriformis: Inferior gluteal vessels, sciatic nerve (10% pass through it, <1% above it),
posterior cutaneous nerve of the thigh

Greater sciatic foramen boundaries

Anterolaterally Greater sciatic notch of the ilium

Posteromedially Sacrotuberous ligament

Inferior Sacrospinous ligament and the ischial spine

Superior Anterior sacroiliac ligament

The greater sciatic foramen

Image sourced from Wikipedia

Structures passing between both foramina (Medial to lateral)

• Pudendal nerve
• Internal pudendal artery
• Nerve to obturator internus

Contents of the lesser sciatic foramen

• Tendon of the obturator internus

• Pudendal nerve
• Internal pudendal artery and vein
• Nerve to the obturator internus

• Previous Question 14 of 116 Next

Which statement is false about the foramina of the skull?

A. The hypoglossal canal transmits the hypoglossal nerve

B. The foramen spinosum is at the base of the medial pterygoid plate.

C. The jugular foramen transmits the accessory nerve

D. The foramen lacerum is located in the sphenoid bone

E. The stylomastoid foramen transmits the facial nerve

Next question

Foramina of the base of the skull

Foramen Location Contents

Foramen ovale Sphenoid Otic ganglion

bone V3 (Mandibular nerve:3rd branch of
trigeminal)
 Accessory meningeal artery
Lesser petrosal nerve
Emissary veins

Foramen Sphenoid Middle meningeal artery

spinosum bone Meningeal branch of the Mandibular nerve

Foramen Sphenoid Maxillary nerve (V2)

rotundum bone

Foramen lacerum Sphenoid Base of the medial pterygoid plate.

bone Internal carotid artery
Nerve and artery of the pterygoid canal

Jugular foramen Temporal Anterior: inferior petrosal sinus

bone 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.

Foramen Occipital Anterior and posterior spinal arteries

magnum bone Vertebral arteries
Medulla oblongata

Stylomastoid Temporal Stylomastoid artery

foramen bone Facial nerve

Superior orbital Sphenoid Oculomotor nerve (III)

fissure bone trochlear nerve (IV)
lacrimal, frontal and nasociliary branches of ophthalmic nerve (V1)
abducent nerve (VI)
Superior and inferior ophthalmic vein

Question 15
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of 116
An 80 year old lady with a caecal carcinoma is undergoing a right hemicolectomy performed through
a transverse incision. The procedure is difficult and the incision is extended medially by dividing the
rectus sheath. Brisk arterial haemorrhage ensues. From which of the following does the damaged
vessel originate?

A. Internal iliac artery

B. External iliac artery

 C. Superior vesical artery

D. Inferior vesical artery

E. None of the above

Next question

The vessel damaged is the epigastric artery. This originates from the external iliac artery (see
below).

Epigastric artery

The inferior epigastric artery arises from the external iliac artery immediately above the inguinal
ligament. It then passes along the medial margin of the deep inguinal ring. From here it continues
superiorly to lie behind the rectus abdominis muscle.

This is illustrated below:

Image sourced from Wikipedia

Question 16
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of 116
A 73 year old man has a large abdominal aortic aneurysm. During a laparotomy for planned surgical
repair the surgeons find the aneurysm is far more proximally located and lies near the origin of the
SMA. During the dissection a vessel lying transversely across the aorta is injured. What is this vessel
most likely to be?

A. Left renal vein

B. Right renal vein

C. Inferior mesenteric artery

D. Ileocolic artery

E. Middle colic artery

Next question

Theme from April 2012 Exam

The left renal vein runs across the surface of the aorta and may require deliberate ligation during
juxtarenal aneurysm repair.

Abdominal aorta

Abdominal aortic topography

Origin T12

Termination L4

Posterior relations L1-L4 Vertebral bodies

Anterior relations Lesser omentum

Liver
Left renal vein
Inferior mesenteric vein
Third part of duodenum
Pancreas
Parietal peritoneum
Peritoneal cavity

Right lateral relations Right crus of the diaphragm

 Cisterna chyli
Azygos vein
IVC (becomes posterior distally)

Left lateral relations 4th part of duodenum

Duodenal-jejunal flexure
Left sympathetic trunk

The abdominal aorta

Image sourced from Wikipedia

Question 17
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Which of the following is not a branch of the posterior cord of the brachial plexus?

A. Thoracodorsal nerve

B. Axillary nerve

C. Radial nerve
 D. Lower subscapular nerve

E. Musculocutaneous nerve

Next question

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.

Previous Question 18 of 116 Next

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?

A. Ureter

B. Inferior epigastric artery

C. Internal iliac vein

D. Femoral artery

E. Lateral border of rectus abdominis

Next question

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.

Image sourced from Wikipedia

Inguinal canal

Location

• Above the inguinal ligament

• The inguinal canal is 4cm long

Boundaries of the inguinal canal

Floor • External oblique aponeurosis

• Inguinal ligament
• Lacunar ligament
Roof • Internal oblique
• Transversus abdominis

Anterior wall External oblique aponeurosis

Posterior wall • Transversalis fascia

• Conjoint tendon

Laterally • Internal ring

• Fibres of internal oblique

Medially • External ring

• Conjoint tendon

Contents

Males Spermatic cord and ilioinguinal nerve As it passes through the canal the spermatic cord has 3
coverings:

• External spermatic fascia from external oblique

aponeurosis
• Cremasteric fascia
• Internal spermatic fascia

Females Round ligament of uterus and

ilioinguinal nerve

Related anatomy of the inguinal region

The boundaries of Hesselbachs triangle are commonly tested and illustrated below:
 Image sourced from Wikipedia

The image below demonstrates the close relationship of the vessels to the lower limb with the
inguinal canal. A fact to be borne in mind when repairing hernial defects in this region.

Image sourced from Wikipedia

Previous Question 19 of 116 Next
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?

A. Sub mental nodes

B. Ipsilateral deep cervical nodes

C. Tonsil

D. Ipsilateral superficial cervical nodes

E. Contralateral deep cervical nodes

Next question

Lymphatic drainage of the tongue

• The lymphatic drainage of the anterior two thirds of the tongue shows only minimal
communication of lymphatics across the midline, so metastasis to the ipsilateral nodes is
usual.
• The lymphatic drainage of the posterior third of the tongue have communicating networks,
as a result early bilateral nodal metastases are more common in this area.
• Lymphatics from the tip of the tongue usually pass to the sub mental nodes and from there
to the deep cervical nodes.
• Lymphatics from the mid portion of the tongue usually drain to the submandibular nodes
and then to the deep cervical nodes. Mid tongue tumours that are laterally located will
usually drain to the ipsilateral deep cervical nodes, those from more central regions may
have bilateral deep cervical nodal involvement.

Previous Question 20 of 116 Next

A 78 year old man is undergoing a femoro-popliteal bypass graft. The operation is not progressing
well and the surgeon is complaining of poor access. Retraction of which of the following structures
will improve access to the femoral artery in the groin?
 A. Quadriceps

B. Adductor longus

C. Adductor magnus

D. Pectineus

E. Sartorius

Next question

At the lower border of the femoral triangle the femoral artery passes under the sartorius muscle.
This can be retracted to improve access.

Previous Question 21 of 116 Next

A builder falls off a ladder whilst laying roof tiles. He sustains a burst fracture of L3. The MRI scan
shows complete cord transection at this level as a result of the injury. Which clinical sign will not be
present?

A. Flaccid paralysis of the legs

B. Extensor plantar response

C. Sensory loss in the legs

D. Incontinence

E. Loss of patellar tendon reflex

Next question

In lower motor neuron lesions everything is reduced

The main purpose of this question is to differentiate the features of an UMN lesion and a LMN lesion.
The features of a LMN lesion include:
 • Flaccid paralysis of muscles supplied
• Atrophy of muscles supplied.
• Loss of reflexes of muscles supplied.
• Muscles fasciculation

For lesions below L1 LMN signs will occur. Hence in an L3 lesion, there will be loss of the patella
reflex but there will be no extensor plantar reflex.

Spinal cord

• Located in a canal within the vertebral column that affords it structural support.
• Rostrally is continues to the medulla oblongata of the brain and caudally it tapers at a level
corresponding to the L1-2 interspace (in the adult), a central structure, the filum terminale
anchors the cord to the first coccygeal vertebra.
• The spinal cord is characterised by cervico-lumbar enlargements and these, broadly
speaking, are the sites which correspond to the brachial and lumbar plexuses respectively.

There are some key points to note when considering the surgical anatomy of the spinal cord:

* During foetal growth the spinal cord becomes shorter than the spinal canal, hence the adult site of
cord termination at the L1-
L1-2 level.
level

* Due to growth of the vertebral column the spine segmental levels may not always correspond to
bony landmarks as they do in the cervical spine.

* The spinal cord is incompletely divided into two symmetrical halves by a dorsal median
sulcus and ventral median fissure.
fissure Grey matter surrounds a central canal that is continuous rostrally
with the ventricular system of the CNS.

* The grey matter is sub divided cytoarchitecturally into Rexeds laminae.

laminae

* Afferent fibres entering through the dorsal roots usually terminate near their point of entry but
may travel for varying distances in Lissauers tract.
tract In this way they may establish synaptic
connections over several levels
* At the tip of the dorsal horn are afferents associated with nociceptive stimuli. The ventral horn
contains neurones that innervate skeletal muscle.

The key point to remember when revising CNS anatomy is to keep a clinical perspective in mind. So
it is worth classifying the ways in which the spinal cord may become injured. These include:

• Trauma either direct or as a result of disc protrusion

• Neoplasia either by direct invasion (rare) or as a result of pathological vertebral fracture
• Inflammatory diseases such as Rheumatoid disease, or OA (formation of osteophytes
compressing nerve roots etc.
• Vascular either as a result of stroke (rare in cord) or as complication of aortic dissection
• Infection historically diseases such as TB, epidural abscesses.

The anatomy of the cord will, to an extent dictate the clinical presentation. Some points/ conditions
to remember:

• Brown- Sequard syndrome-Hemisection of the cord producing ipsilateral loss of

proprioception and upper motor neurone signs, plus contralateral loss of pain and
temperature sensation. The explanation of this is that the fibres decussate at different levels.
• Lesions below L1 will tend to present with lower motor neurone signs

Previous Question 22 of 116 Next

A 56 year old machinist has his arm entrapped in a steel grinder and is brought to the emergency
department. On examination, he is unable to extend his metacarpophalangeal joints and abduct his
shoulder. He has weakness of his elbow and wrist. What has been injured?

A. Ulnar nerve

B. Axillary nerve

C. Medial cord of brachial plexus

D. Lateral cord of brachial plexus

E. Posterior cord of brachial plexus

Next question
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)

Theme from September 2012 exam

This is a description of a posterior cord lesion. Remember that the posterior cord gives rise to the
axillary and radial nerve.

Cords of the brachial plexus

The brachial plexus cords are described according to their relationship with the axillary artery. The
cords pass over the 1st rib near to the dome of the lung and pass beneath the clavicle immediately
posterior to the subclavian artery.

Lateral cord

• Anterior divisions of the upper and middle trunks form the lateral cord
• Origin of the lateral pectoral nerve (C5, C6, C7)

Medial cord

• Anterior division of the lower trunk forms the medial cord

• Origin of the medial pectoral nerve (C8, T1), the medial brachial cutaneous nerve (T1), and
the medial antebrachial cutaneous nerve (C8, T1)

Posterior cord

• Formed by the posterior divisions of the 3 trunks (C5-T1)

• Origin of the upper and lower subscapular nerves (C7, C8 and C5, C6, respectively) and the
thoracodorsal nerve to the latissimus dorsi (also known as the middle subscapular nerve, C6,
C7, C8), axillary and radial nerve
Previous Question 23 of 116 Next
A 66 year old man with peripheral vascular disease is undergoing a below knee amputation. In
which of the lower leg compartments does peroneus brevis lie?

A. Lateral compartment

B. Anterior compartment

C. Superficial posterior compartment

D. Deep posterior compartment

E. None of the above

Next question

The interosseous membrane separates the anterior and posterior compartments. The deep and
superficial compartments are separated by the deep transverse fascia. The peroneus brevis is part of
the lateral compartment.

Fascial compartments of the leg

Compartments of the thigh

Formed by 3 septae passing from the femur to the fascia lata.

Compartment Nerve Muscles Blood supply

Anterior Femoral • Iliacus Femoral artery

compartment • Tensor fasciae latae
• Sartorius
• Quadriceps femoris

Medial Obturator • Adductor longus/magnus/brevis Profunda femoris artery and

compartment • Gracilis obturator artery
• Obturator externus

Posterior Sciatic • Semimembranosus Branches of Profunda femoris

compartment • Semitendinosus artery
 • Biceps femoris

Compartments of the lower leg

Separated by the interosseous membrane (anterior and posterior compartments), anterior fascial
septum (separate anterior and lateral compartments) and posterior fascial septum (separate lateral
and posterior compartments)

Compartment Nerve Muscles Blood supply

Anterior Deep peroneal • Tibialis anterior Anterior

compartment nerve • Extensor digitorum longus tibial artery
• Extensor hallucis longus
• Peroneus tertius

Posterior Tibial • Muscles: deep and superficial compartments Posterior

compartment (separated by deep transverse fascia) tibial
• Deep: Flexor hallucis longus, Flexor digitalis
longus, Tibialis posterior, Popliteus
• Superficial: Gastrocnemius, Soleus, Plantaris

Lateral Superficial • Peroneus longus/brevis Anterior

compartment peroneal tibial

Previous Question 24 of 116 Next

A 70 year old man is due to undergo an arterial bypass procedure for claudication and foot
ulceration. The anterior tibial artery will form the site of the distal arterial anastomosis. Which of the
following structures is not closely related to it?

A. Interosseous membrane

B. Deep peroneal nerve

C. Tibialis posterior
 D. Extensor hallucis longus

E. Dorsalis pedis artery

Next question

As an artery of the anterior compartment, the anterior tibial artery is closely related to tibialis
anterior.

Anterior tibial artery

• Begins opposite the distal border of popliteus

• Terminates in front of the ankle, continuing as the dorsalis pedis artery
• As it descends it lies on the interosseous membrane, distal part of the tibia and front of the
ankle joint
• Passes between the tendons of flexor digitorum and flexor hallucis longus distally
• It is related to the deep peroneal nerve, it lies anterior to the middle third of the vessel and
lateral to it in the lower third

• Previous Question 25 of 116 Next

Which of the muscles below does not cause lateral rotation of the hip?

A. Obturator internus

B. Quadratus femoris

C. Gemellus inferior

D. Piriformis

E. Pectineus

Next question

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.

Previous Question 26 of 116 Next

Which of the following is not a content of the posterior triangle of the neck?

A. Spinal accessory nerve

B. Phrenic nerve

C. External jugular vein

D. Occipital lymph nodes

E. Internal jugular vein

Next question

The IJV does not lie in the posterior triangle. However, the terminal branches of the external jugular
vein do.

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

 Image sourced from Wikipedia

Contents

Nerves • Accessory nerve

• Phrenic nerve
• Three trunks of the brachial plexus
• Branches of the cervical plexus: Supraclavicular nerve, transverse cervical nerve, great
auricular nerve, lesser occipital nerve

Vessels • External jugular vein

• Subclavian artery

Muscles • Inferior belly of omohyoid

• Scalene

Lymph • Supraclavicular
nodes • Occipital

Previous Question 27 of 116 Next

Which nerve is at risk during submandibular gland excision?

A. Maxillary nerve
 B. Buccal nerve

C. Zygomatic nerve

D. Marginal mandibular nerve

E. Cervical nerve

Next question

The marginal mandibular nerve lies deep to platysma. It supplies the depressor anguli oris and the
depressor labii inferioris. If injured it may lead to facial asymmetry and dribbling.

Submandibular gland

Relations of the submandibular gland

Superficial Platysma, deep fascia and mandible

Submandibular lymph nodes
Facial vein (facial artery near mandible)
Marginal mandibular nerve
Cervical branch of the facial nerve

Deep Facial artery (inferior to the mandible)

Mylohoid muscle
Sub mandibular duct
Hyoglossus muscle
Lingual nerve
Submandibular ganglion
Hypoglossal nerve

Submandibular duct (Wharton's duct)

• Opens lateral to the lingual frenulum on the anterior floor of mouth.

• 5 cm length
• Lingual nerve wraps around Wharton's duct. As the duct passes forwards it crosses medial to
the nerve to lie above it and then crosses back, lateral to it, to reach a position below the
nerve.

Innervation
 • Sympathetic innervation- Superior Cervical ganglion via the Lingual nerve
• Parasympathetic innervation- Submandibular ganglion

Arterial supply
Branch of the Facial artery. The facial artery passes through the gland to groove its deep surface. It
then emerges onto the face by passing between the gland and the mandible.

Venous drainage
Anterior Facial vein (lies deep to the Marginal Mandibular nerve)

Lymphatic drainage
Deep cervical and jugular chains of nodes

Previous Question 28 of 116 Next

In a patient with a carcinoma of the distal sigmoid colon, what is the most likely source of its blood
supply?

A. Ileocolic artery

B. External iliac artery

C. Internal iliac artery

D. Superior mesenteric artery

E. Inferior mesenteric artery

Next question

During a high anterior resection of such tumours, the inferior mesenteric artery is ligated. Note that
the branches (mainly middle rectal branch) of the internal iliac artery are important in maintaining
vascularity of the rectal stump and hence the integrity of the anastomoses.

Rectum

The rectum is approximately 12 cm long. It is a capacitance organ. It has both intra and
extraperitoneal components. The transition between the sigmoid colon is marked by the
disappearance of the tenia coli.The extra peritoneal rectum is surrounded by mesorectal fat that also
contains lymph nodes. This mesorectal fatty layer is removed surgically during rectal cancer surgery
(Total Mesorectal Excision). The fascial layers that surround the rectum are important clinical
landmarks, anteriorly lies the fascia of Denonvilliers. Posteriorly lies Waldeyers fascia.

Extra peritoneal rectum

• Posterior upper third

• Posterior and lateral middle third
• Whole lower third

Relations

Anteriorly (Males) Rectovesical pouch

Bladder
Prostate
Seminal vesicles

Anteriorly (Females) Recto-uterine pouch (Douglas)

Cervix
Vaginal wall

Posteriorly Sacrum
Coccyx
Middle sacral artery

Laterally Levator ani

Coccygeus

Arterial supply
Superior rectal artery

Venous drainage
Superior rectal vein

Lymphatic drainage

• Mesorectal lymph nodes (superior to dentate line)

• Internal iliac and then para-aortic nodes
 • Inguinal nodes (inferior to dentate line)

Previous Question 29 of 116 Next

Which of these openings transmits the facial nerve into the temporal bone?

A. Internal acoustic meatus

B. Foramen lacerum

C. Foramen spinosum

D. Stylomastoid foramen

E. Jugular foramen

Next question

It enters the temporal bone through the internal acoustic meatus and exits through the stylomastoid
foramen.

Facial nerve

The facial nerve is the main nerve supplying the structures of the second embryonic branchial arch.
It is predominantly an efferent nerve to the muscles of facial expression, digastric muscle and also
to many glandular structures. It contains a few afferent fibres which originate in the cells of its
genicular ganglion and are concerned with taste.

Supply - 'face, ear, taste, tear'

• Face: muscles of facial expression

• Ear: nerve to stapedius
• Taste: supplies anterior two-thirds of tongue
• Tear: parasympathetic fibres to lacrimal glands, also salivary glands

Path
Subarachnoid path

• Origin: motor- pons, sensory- nervus intermedius

 • Pass through the petrous temporal bone into the internal auditory meatus with the
vestibulocochlear nerve. Here they combine to become the facial nerve.

Facial canal path

• The canal passes superior to the vestibule of the inner ear

• At the medial aspect of the middle ear, it becomes wider and contains the geniculate
ganglion.

- 3 branches:
1. greater petrosal nerve
2. nerve to stapedius
3. chorda tympani

Stylomastoid foramen

• Passes through the stylomastoid foramen (tympanic cavity anterior and mastoid antrum
posteriorly)
• Posterior auricular nerve and branch to Posterior belly of Digastric and Stylohyoid muscle

Face
Enters parotid gland and divides into 5 branches:

• Temporal branch
• Zygomatic branch
• Buccal branch
• Marginal mandibular branch
• Cervical branch

Previous Question 30 of 116 Next

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?

A. C8, T1 root lesion

 B. C5, C6 root lesion

C. Radial nerve lesion

D. Ulnar nerve lesion

E. Axillary nerve lesion

Next question

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 and teres major)
• 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.

Previous Question 31 of 116 Next

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?

A. Middle colic artery

B. Inferior mesenteric artery

C. Superior mesenteric artery

D. Ileo-colic artery

E. None of the above

Next question
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.

Caecum

Location • Proximal right colon below the ileocaecal valve

• Intraperitoneal

Posterior relations • Psoas

• Iliacus
• Femoral nerve
• Genitofemoral nerve
• Gonadal vessels

Anterior relations Greater omentum

Arterial supply Ileocolic artery

Lymphatic drainage Mesenteric nodes accompany the venous drainage

• The caecum is the most distensible part of the colon and in complete large bowel obstruction
with a competent ileocaecal valve the most likely site of eventual perforation.

Previous Question 32 of 116 Next

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?

A. Common peroneal nerve

 B. Lateral cutaneous nerve of the thigh

C. L5

D. L3

E. L4

Next question

Prolapsed disc

A prolapsed lumbar disc usually produces clear dermatomal leg pain associated with neurological
deficits.

Features

• Leg pain usually worse than back

• Pain often worse when sitting

The table below demonstrates the expected features according to the level of compression:

L3 nerve root compression Sensory loss over anterior thigh/knee

Weak quadriceps
Reduced knee reflex
Positive femoral stretch test

L5 nerve root compression Sensory loss dorsum of foot

Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test

S1 nerve root compression Sensory loss posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexion of foot
Reduced ankle reflex
Positive sciatic nerve stretch test
Management

• Similar to that of other musculoskeletal lower back pain: analgesia, physiotherapy, exercises
• Persistent symptoms, muscular weakness, bladder or bowel dysfunction are indications for
urgent MRI scanning to delineate the disease extent to allow surgical planning
• Plain spinal x-rays have no useful role in establishing the extent of disk disease

Previous Question 33 of 116 Next

A 72 year old man is undergoing a repair of an abdominal aortic aneurysm. The aorta is cross
clamped both proximally and distally. The proximal clamp is applied immediately inferior to the renal
arteries. Both common iliac arteries are clamped distally. A longitudinal aortotomy is performed.
After evacuating the contents of the aneurysm sac a significant amount of ongoing bleeding is
encountered. This is most likely to originate from:

A. The coeliac axis

B. Testicular artery

C. Splenic artery

D. Superior mesenteric artery

E. Lumbar arteries

Next question

The lumbar arteries are posteriorly sited and are a common cause of back bleeding during aortic
surgery. The other vessels cited all exit the aorta in the regions that have been cross clamped.

Abdominal aortic branches

Branches Level Paired Type

Inferior phrenic T12 (Upper border) Yes Parietal

Coeliac T12 No Visceral

Superior mesenteric L1 No Visceral

Middle suprarenal L1 Yes Visceral

Renal L1-L2 Yes Visceral

Gonadal L2 Yes Visceral

Lumbar L1-L4 Yes Parietal

Inferior mesenteric L3 No Visceral

Median sacral L4 No Parietal

Common iliac L4 Yes Terminal

Previous Question 34 of 116 Next

Which of the following statements relating to sartorius is untrue?

A. It is supplied by the femoral nerve

B. It forms the lateral boundary of the femoral triangle

C. The middle third forms the roof of the adductor canal

D. It is a flexor of the hip and knee

E. It inserts into the medial femoral condyle

Next question

It inserts into the medial aspect of the upper part of the tibia.

Sartorius

• Longest strap muscle in the body

• Most superficial muscle in the anterior compartment of the thigh
Origin Anterior superior iliac spine

Insertion Medial surface of the of the body of the tibia (upper part). It inserts anterior to gracilis and
semitendinosus

Nerve Supply Femoral nerve (L2,3)

Action • Flexor of the hip and knee, slight abducts the thigh and rotates it laterally
• It assists with medial rotation of the tibia on the femur. For example it would play a
pivotal role in placing the right heel onto the left knee ( and vice versa)

Important The middle third of this muscle, and its strong underlying fascia forms the roof of the adductor
relations canal , in which lie the femoral vessels, the saphenous nerve and the nerve to vastus medialis.