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SECTION 7
Lower Limb

Question 1

A 42-year-old father is teaching one of his children how to ride a bike when his son
accidentally clips his father’s left leg with a pedal while riding by. The pedal struck just
distal to the head of the fibula, which leaves a large bruise and causes a lot of pain and loss
of function at the ankle joint. Which of the following muscles is most likely paralyzed?

A. Tibialis posterior
B. Extensor digitorum longus
C. Flexor digitorum longus
D. Soleus
E. Popliteus

Answer: B

A. Tibialis posterior
Explanation: The tibialis posterior muscle is located deep within the posterior compartment
of the leg, originating on the posterior borders of the tibia and fibula. It is innervated by
the tibial nerve, which would not normally be affected by an impact to the proximal fibula.

B. Extensor digitorum longus

Explanation: The extensor digitorum longus muscle is innervated by the deep branch of
the common fibular nerve. The common fibular nerve wraps anterolaterally around the
neck of the fibula, coinciding with the point of impact of the pedal, making it likely that
muscles innervated by this nerve would be paralyzed.

C. Flexor digitorum longus

Explanation: The flexor digitorum longus muscle is situated on the tibial side of the leg,
away from the point of impact. It is also innervated by the tibial nerve, which is situated
deep within the leg, most likely not affected by this impact trauma.

D. Soleus
Explanation: The soleus is a powerful posterior leg muscle that is innervated by the tibial
nerve, which is not located near the point of impact of the bike pedal.

E. Popliteus
Explanation: The popliteus muscle is not associated with the head of the fibula and is
innervated by the tibial nerve, which is not located near the point of impact of the bike
pedal.
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Question 2

A 54-year old man was lifting his suitcase up the stairs when he felt a sharp pain in his
upper groin region on the right side. Physical exam at the doctor’s office reveals a small
bulge at the top of the right thigh just below the groin skin crease, pointing to a femoral
hernia. As the small intestine herniates into the femoral canal, which of the following is
most likely compressed due to this herniation?

A. Femoral nerve
B. Femoral artery
C. Large intestine
D. Lymphatic vessel
E. Femoral vein

Answer: D

A. Femoral nerve
Explanation: The femoral nerve is the most lateral structure of the femoral triangle, the
farthest away from the femoral canal.

B. Femoral artery
Explanation: The femoral artery is just medial to the femoral nerve, not adjacent to the
femoral canal and thus not likely to herniate through it.

C. Large intestine
Explanation: The large intestine is not typically involved in hernia and is not located near
enough to the right femoral canal to herniate through in addition to the small intestine.

D. Lymphatic vessel
Explanation: The femoral canal is the medial compartment of the femoral sheath, which
contains several lymph vessels that travel back into the abdomen. The femoral canal is the
most common location for femoral hernias; thus the lymphatic vessels present there could
easily be compressed by the small intestines.

E. Femoral vein
Explanation: Although the femoral vein is close to the femoral canal, the femoral lymph
vessels still reside within the femoral canal, where most hernias occur, making the
lymphatics more likely to be compressed by a femoral herniation.

Question 3
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A 16-year-old female tennis player presents with Osgood-Schlatter disease, or apophysitis

of the tibial tuberosity. This condition is characterized by a painful lump located just below
the knee and is most often seen in active adolescents. Her parents are curious about what
has been causing their daughter’s knee pain and are concerned about a more serious injury.
They ask you to explain the etiology of this condition. Based on normal anatomy, identify
the most correct response to your patient’s parents.

A. Repeated contraction of the quadriceps muscles transmits stress through the patellar
tendon to its insertion on the tibial tuberosity.
B. Repeated contraction of the tibialis anterior muscle transmits stress through the patellar
tendon to its insertion on the tibial tuberosity.
C. Repeated contraction of the hamstrings (the semimembranosus, semitendinosus, and
biceps femoris muscles) transmits stress to its insertion on the tibial tuberosity.
D. Repeated blunt force trauma to the tibial tuberosity
E. Repeated contraction of the gastrocnemius and soleus muscles transmits stress to its
insertion on the tibial tuberosity.

Answer: A

A. Repeated contraction of the quadriceps muscles transmits stress through the patellar
tendon to its insertion on the tibial tuberosity.
Explanation: This is the major mechanism for apophysitis of the tibial tuberosity. The
quadriceps muscles come together at the patellar tendon (tendon of the quadriceps femoris)
and, after the patella, inserts on the tibial tuberosity. Repeated flexion of the quadriceps
keeps pulling on the insertion, leading to inflammation and irritation that is associated with
knee pain. Additionally, this occurs more frequently in younger patients who do not have
ossified growth plates at this location.

B. Repeated contraction of the tibialis anterior muscle transmits stress through the
patellar tendon to its insertion on the tibial tuberosity.
Explanation: The tibialis anterior muscle does not insert on the tibial tuberosity, and
therefore repetitive use of this muscle would not be implicated in this type of condition.

C. Repeated contraction of the hamstrings (the semimembranosus, semitendinosus,

and biceps femoris muscles) transmits stress to its insertion on the tibial tuberosity.
Explanation: The hamstring muscles do not insert on the tibial tuberosity, and therefore
repetitive use of this group of muscles would not be implicated in this type of condition.

D. Repeated blunt force trauma to the tibial tuberosity

Explanation: Tibial tuberosity apophysitis, or Osgood-Schlatter’s disease is not due to
repeated blunt force trauma, rather, repetitive pulling of the tendon on the bony insertion
that causes irritation and inflammation.

E. Repeated contraction of the gastrocnemius and soleus muscles transmits stress to

its insertion on the tibial tuberosity.
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Explanation: The gastrocnemius and soleus are posterior leg muscles that insert on the
calcaneus, and therefore repetitive use of these muscles would not be implicated in this
type of condition.

Question 4

A 23-year-old football player presents with a knee hyperextension injury he incurred

during a football game. Physical examination of the knee reveals posterior laxity of the
knee joint during a posterior drawer test. Specifically, the tibial plateau deviates posteriorly
more than the normal joint laxity. Based on this information and the normal anatomical
functions of the ligaments of the knee, which ligament is most likely torn in this patient?

A. Posterior cruciate ligament

B. Medical collateral ligament
C. Lateral collateral ligament
D. Anterior cruciate ligament
E. Patellar ligament

Answer: A

A. Posterior cruciate ligament

Explanation: The posterior cruciate ligament is the most likely structure damaged in this
patient because this ligament functions to prevent the tibial plateau from deviating
posteriorly beyond normal limits. Additionally, hyperextension injuries often result in
posterior cruciate ligament damage and a positive posterior drawer tests also indicates
posterior cruciate ligament damage.

B. Medical collateral ligament

Explanation: The medial collateral ligament is most likely not the ligament damaged in
this patient because the mechanism of injury usually involves a strong force hitting the
outside of the knee, causing a valgus deviation. This ligament normally functions to resist
overextension of the knee medially. Additionally, a positive posterior drawer test does not
indicate a MCL injury.

C. Lateral collateral ligament

Explanation: The lateral collateral ligament is most likely not the ligament damaged in this
patient because the mechanism of injury usually involves a strong force hitting the medial
aspect of the knee, causing a varus deviation. This ligament normally functions to resist
overextension of the knee laterally. Additionally, a positive posterior drawer test does not
indicate a LCL injury.

D. Anterior cruciate ligament

Explanation: The anterior cruciate ligament normally prevents excessive anterior deviation
of the tibial plateau of the knee joint. A tear of this ligament would result in excessive
anterior deviation of the tibial plateau, as shown by a positive anterior drawer (or
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Lachman’s test).

E. Patellar ligament
Explanation: Tearing of the patellar ligament would not result in posterior knee joint laxity;
rather, it would prevent full extension of the knee and significant loss of joint strength due
to the detachment of the quadriceps femoris muscles from their point of insertion.

Question 5

A 19-year-old patient presents with an injury to his knee that resulted in a tibial collateral
ligament rupture. You are concerned about additional damage to cartilaginous structures
of his knee that often occur with this specific injury. What other cartilaginous structure that
is fused to the tibial collateral ligament should be checked in this patient, as it is often torn
in tibial collateral ligament ruptures?

A. Lateral meniscus
B. Fibular collateral ligament
C. Posterior cruciate ligament
D. Medial meniscus
E. Anterior collateral ligament

Answer: D

A. Lateral meniscus
Explanation: The lateral meniscus is one of the three structures involved with the “unhappy
triad” knee injury in which the tibial collateral ligament, the anterior cruciate ligament, and
the lateral meniscus are torn. The lateral meniscus, however, is not fused with the tibial
collateral ligament and therefore is not likely the structure affected by an isolated tibial
collateral ligament rupture.

B. Fibular collateral ligament

Explanation: The fibular collateral ligament is not fused with the tibial collateral ligament
and is not likely injured in a tibial collateral ligament rupture.

C. Posterior cruciate ligament

Explanation: The posterior cruciate ligament is not fused with the tibial collateral ligament
and is not often injured in a tibial collateral ligament rupture.

D. Medial meniscus
Explanation: The medial meniscus is fused with the tibial collateral ligament and thus can
often be torn when there is a significant rupture of the tibial collateral ligament.

E. Anterior cruciate ligament

Explanation: Although the anterior cruciate ligament and the tibial collateral ligament are
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often injured together as components of the “unhappy triad” knee injury, the anterior
cruciate ligament is not fused with the tibial collateral ligament and is not the structure
implicated in this case.

Question 6

A 44-year-old woman is diagnosed with medial patellofemoral ligament (MPFL) damage

following an acute lateral dislocation of the patella that occurred when she fell after sliding
on a cheesesteak that was carelessly discarded in the road during the final mile of the
Philadelphia marathon. Her fall caused the MPFL to tear away from its attachment to the
adductor tubercle and a tendon attaching to the tubercle. This injury caused significant
perimuscular and interstitial edema around the adductor tubercle and is associated with a
great deal of pain when the main muscle attaching to the tubercle is contracted. Which of
the following motions would be associated with the greatest pain in this patient?

A. Flexion of the knee

B. Extension of the knee
C. Medial rotation of the femur on the tibia
D. Adduction of the thigh at the hip joint
E. Extension of the thigh at the hip joint

Answer: E

A. Flexion of the knee

Explanation: The muscle attaching to the adductor tubercle is the adductor magnus, and it
does not cross the knee joint and therefore has no action at the knee.

B. Extension of the knee

Explanation: The muscle attaching to the adductor tubercle is the adductor magnus, and it
does not cross the knee joint and therefore has no action at the knee.

C. Medial rotation of the femur on the tibia

Explanation: The muscle attaching to the adductor tubercle is the adductor magnus, and it
does not cause medial rotation of the femur on the tibia.

D. Adduction of the thigh at the hip joint

Explanation: The muscle attaching to the adductor tubercle is the adductor magnus and,
while it does adduct the hip, the main portion of the muscle that accomplishes this attaches
to the linea aspera and gluteal tuberosity of the femur and not the adductor tubercle.

E. Extension of the thigh at the hip joint

Explanation: The adductor magnus muscle has two separate muscle attachments. The
hamstring portion of the adductor magnus muscle attaches proximally to the ischial
tuberosity and ischiopubic ramus and attaches distally to the adductor tubercle of the femur.
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It functions to produce extension of the thigh at the hip joint, as well as medial rotation of
the thigh (when the foot is in contact with the ground) and lateral rotation of the thigh
(when the foot is raised off the ground) at that joint. Therefore, extension of the thigh at
the hip joint would cause the greatest pain in this patient.

Question 7

A 52-year-old woman visits her obstetrician for abdominal cramping and muscle weakness
in her right thigh. Physical examination shows atrophy of right thigh muscles when
compared with the patient’s left thigh. Muscle tests determined weakness in adduction of
the right thigh. A pelvic exam reveals a mass growing on the lateral wall of the right pelvis.
Which of the following nerves is most likely being compressed by the mass in this patient?

A. Obturator
B. Femoral
C. Sciatic
D. Superior gluteal
E. Perineal

Answer: A

A. Obturator
Explanation: In this patient the mass would be compressing the obturator nerve within the
pelvis before it emerges through the obturator canal into the thigh. Adduction of the thigh
is accomplished predominantly by medial compartment muscles. The innervation of the
medial compartment of the thigh is primarily through the obturator nerve, with minor
innervations derived from the femoral nerve and the tibial division of the sciatic nerve. The
obturator nerve innervates the gracilis, adductor longus, adductor brevis, and the adductor
portion of adductor magnus.

B. Femoral
Explanation: The femoral nerve innervates most of the anterior thigh muscles.

C. Sciatic
Explanation: The sciatic nerve innervates the posterior thigh muscles.

D. Superior gluteal
Explanation: The superior gluteal nerve innervates gluteal muscles.

E. Perineal
Explanation: The perineal nerve does not innervate medial thigh compartment muscles.
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Question 8

A 21-year-old female college volleyball player jumped to block an opposing player’s hit
and landed awkwardly with her foot inverted. The team trainer was worried about a fracture
and sent her to the emergency department. Radiographic examination in the hospital
revealed an avulsion fracture of the tuberosity of the 5th metatarsal. The radiograph shows
part of the tuberosity is pulled off the 5th metatarsal, producing pain and edema. Which of
the following muscles is pulling on the fractured fragment?

A. Fibularis (peroneus) brevis

B. Fibularis (peroneus) longus
C. Tibialis posterior
D. Extensor digitorum brevis
E. Extensor digitorum longus

Answer: A

A. Fibularis (peroneus) brevis

Explanation: The fibularis (peroneus) brevis muscle attaches distally to the base of the 5th
metatarsal and proximally it attaches to the lateral surface of the fibula. This is the muscle
that would be displacing the avulsed fracture.

B. Fibularis (peroneus) longus

Explanation: The fibularis (peroneus) longus muscle tendon travels along the plantar
surface of the foot to attach on the base of the 1st metatarsal and medial cuneiform. This
muscle could not be displacing the avulsed fracture.

C. Tibialis posterior
Explanation: The tibialis posterior muscle tendon attaches on the tuberosity of the
navicular, cuneiform, cuboid, and sustentaculum tali of the calcaneus—bases of the 2nd,
3rd, and 4th metatarsals. This muscle could not be displacing the avulsed fracture.

D. Extensor digitorum brevis

Explanation: The extensor digitorum brevis muscle attaches distally to the long extensor
tendons. This muscle could not be displacing the avulsed fracture.

E. Extensor digitorum longus

Explanation: The extensor digitorum longus muscle attaches distally to the middle and
distal phalanges of lateral four digits. This muscle could not be displacing the avulsed
fracture.

Question 9

A 52-year-old woman is referred to a neurologist by her primary care physician due to

chronic pain in her right lower limb for nearly a year. She tells her neurologist that the pain
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has gotten more persistent but that she’s be experiencing the pain intermittently for as long
as she can remember. She recently took a job as a security guard where she sits for most of
an 8-hour shift and observes security camera monitors. The pain is mainly confined to the
thigh, leg, and gluteal region. The neurologist documents reduced sensation on the dorsum
of her right foot and between the first and second toes and a motor deficit with some
weakness in foot eversion. The neurologist diagnoses piriformis entrapment syndrome with
compression of the fibular division of the sciatic nerve. What else did the neurologist most
likely document during the physical exam?

A. Weakness of plantar flexion

B. Quadriceps weakness
C. Loss of sensation of the medial thigh
D. Spasms of the adductor musculature of the thigh
E. Weakness extending toes

Answer: E

A. Weakness of plantar flexion

Explanation: Plantar flexion is a function of the tibial nerve and would not be a significant
problem in this patient.

B. Quadriceps weakness
Explanation: Quadriceps weakness is a function of the femoral nerve and would not be a
significant problem in this patient.

C. Loss of sensation of the medial thigh

Explanation: Loss of sensation of the medial thigh is a function of the obturator and
femoral nerves and would not be a significant problem in this patient.

D. Spasms of the adductor musculature of the thigh

Explanation: Spasms of the adductor musculature of the thigh is a function of the obturator
nerve and would not be a significant problem in this patient.

E. Weakness extending toes

Explanation: This patient shows symptoms of deep and superficial fibular nerve problems.
Therefore, muscles in the lateral and anterior compartments will be affected. The extensor
digitorum longus, extensor hallucis longus, extensor hallucis brevis, and extensor
digitorum brevis muscles are all innervated by the deep fibular nerve, and therefore this
patient would have trouble extending the toes.

Question 10

A 67-year-old woman visits her primary care physician due to a growth in the anterior
compartment of her leg. Using ultrasound the physician approximated the growth to be a 3
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cm ovoid solid tumor deep to the deep fascia. The concern is that this may be a malignant
osteosarcoma (bone cancer). The physician is worried about metastatic spread of the cancer
cells along lymphatic channels and elects to palpate the nodes that would most likely be
affected (the ones receiving lymph directly from this region). Which of the following
lymph nodes would normally receive lymph flow from this location directly?

A. Deep inguinal nodes

B. External iliac nodes
C. Popliteal nodes
D. Superficial inguinal nodes
E. Internal iliac nodes

Answer: C

A. Deep inguinal nodes

Explanation: Deep lymphatic vessels accompany the anterior tibial veins in the anterior
compartment of the leg. These lymphatic channels drain into the popliteal lymph nodes
first, then through the deep lymphatic vessels of the thigh to the deep inguinal lymph nodes,
then into the external iliac lymph nodes, the common iliac lymph nodes, and ultimately the
lumbar lymphatic trunks.

B. External iliac nodes

Explanation: Deep lymphatic vessels accompany the anterior tibial veins in the anterior
compartment of the leg. These lymphatic channels drain into the popliteal lymph nodes
first, then through the deep lymphatic vessels of the thigh to the deep inguinal lymph nodes,
then into the external iliac lymph nodes, the common iliac lymph nodes, and ultimately the
lumbar lymphatic trunks.

C. Popliteal nodes
Explanation: Deep lymphatic vessels accompany the anterior tibial veins in the anterior
compartment of the leg. These lymphatic channels drain into the popliteal lymph nodes
first, then through the deep lymphatic vessels of the thigh to the deep inguinal lymph nodes,
then into the external iliac lymph nodes, the common iliac lymph nodes, and ultimately the
lumbar lymphatic trunks.

D. Superficial inguinal nodes

Explanation: Deep lymphatic vessels accompany the anterior tibial veins in the anterior
compartment of the leg. These lymphatic channels drain into the popliteal lymph nodes
first, then through the deep lymphatic vessels of the thigh to the deep inguinal lymph nodes,
then into the external iliac lymph nodes, the common iliac lymph nodes, and ultimately the
lumbar lymphatic trunks. Lymph from the anterior compartment would not normally flow
through the superficial inguinal nodes.

E. Internal iliac nodes

Explanation: Deep lymphatic vessels accompany the anterior tibial veins in the anterior
compartment of the leg. These lymphatic channels drain into the popliteal lymph nodes
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first, then through the deep lymphatic vessels of the thigh to the deep inguinal lymph nodes,
then into the external iliac lymph nodes, the common iliac lymph nodes, and ultimately the
lumbar lymphatic trunks. Lymph from the anterior compartment would not normally flow
through the internal iliac nodes.

Question 11

A 78-year-old woman fell at home and was brought to the emergency department. She is
unable to bear weight on her right leg and her right foot is positioned in lateral rotation. A
plain film radiograph shows a fracture of the neck of the femur. The decision to reduce and
cast the fracture or recommend a hip replacement depends on the likelihood of avascular
necrosis of the head of the femur. An arteriogram is ordered to visualize the vascular supply
to the hip joint and head of femur. If the primary arterial supply to the hip is compromised,
the patient will need a new hip. When interpreting the arteriogram which of the following
arteries is the most important for the radiologist to visualize to help make this treatment
decision?

A. Artery to head of femur

B. Inferior gluteal
C. Superior gluteal
D. Medial circumflex femoral
E. Lateral circumflex femoral

Answer: D
A. Artery to head of femur
Explanation: The artery to the head of femur is a branch of the obturator artery and it
traverses the ligament of the head. The artery to the head of femur does not normally supply
enough arterial blood to prevent necrosis of the head of the femur if the medial circumflex
artery is compromised.

B. Inferior gluteal
Explanation: The inferior gluteal artery enters the gluteal region through the greater sciatic
foramen inferior to the piriformis muscle. It supplies the gluteus maximus, obturator
internus, quadratus femoris, and superior parts of the hamstrings. It does not supply the
head of the femur.

C. Superior gluteal
Explanation: The superior gluteal artery enters the gluteal region through the greater sciatic
foramen superior to the piriformis muscle. It divides into superficial and deep branches.
The superficial branch supplies the gluteus maximus muscle, and the deep branch transits
between the gluteus medius and minimus muscles and supplies them both before supplying
the tensor fasciae latae. It anastomoses with the inferior gluteal artery and the medial
circumflex femoral arteries, but it does not provide the primary vascular supply to the head
of the femur.
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D. Medial circumflex femoral

Explanation: The medial circumflex femoral artery originates from the profunda femoris
artery. It is the principal blood supply to the head of the femur, and if this blood supply is
severed it can lead to avascular necrosis of the femoral head. It passes medially and
posteriorly between pectineus and iliopsoas muscles before supplying the head and neck
of the femur.

E. Lateral circumflex femoral

Explanation: The lateral circumflex femoral artery originates from the profunda femoris
artery and passes laterally deep to sartorius and rectus femoris muscles. It supplies the
inferior gluteal region and the descending branch joins the genicular periarticular
anastomosis around the knee.

Question 12

A 70-year-old man recently returned from an international vacation that required three
flights and 16 hours on airplanes. With about an hour to go before landing he started to get
muscle cramping in his right hamstring. He did not think much of it at the time, but it got
progressively worse by the time he and his wife got home. She convinced him to go to the
emergency department, and upon arrival he was quickly taken back for examination. The
posterior compartment of his thigh was swollen, red, and very painful. A deep vein
thrombosis due to blood stasis is likely. Ultrasound is used to inspect the thigh with a focus
on veins that are normally responsible for the major drainage of the posterior compartment
of the thigh. Which of the following veins is normally most important for directly draining
the affected compartment?

A. Great saphenous vein

B. Lateral circumflex femoral vein
C. Perforating branches of profunda femoris vein
D. Profunda femoris vein
E. Inferior gluteal veins

Answer: C

A. Great saphenous vein

Explanation: The great saphenous vein drains very little of the posterior thigh
compartment.

B. Lateral circumflex femoral vein

Explanation: The lateral circumflex femoral vein drains very little of the posterior thigh
compartment.

C. Perforating branches of profunda femoris vein

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Explanation: The perforating branches of profunda femoris vein are tributaries of (drain
into) the profunda femoris vein and drain the large majority of blood from the posterior
compartment of the thigh. The profunda femoris vein originates midthigh in the medial
compartment and travels through the femoral triangle to the anterior compartment of the
thigh to empty into the femoral vein. It does not drain the posterior compartment directly.
The great saphenous vein drains very little of the posterior thigh compartment, nor does
the lateral circumflex femoral vein. The inferior gluteal veins travel on either side of the
inferior gluteal artery and drain blood from the superficial aspect of the gluteal region.

D. Profunda femoris vein

Explanation: The profunda femoris vein originates midthigh in the medial compartment
and travels through the femoral triangle to the anterior compartment of the thigh to empty
into the femoral vein. It does not drain the posterior compartment directly.

E. Inferior gluteal veins

Explanation: The inferior gluteal veins travel on either side of the inferior gluteal artery
and drain blood from the superficial aspect of the gluteal region.

Question 13

A 57-year-old woman has thyroid surgery to remove a cancerous nodule. The nodule was
removed successfully, but the surgeon cut the recurrent laryngeal nerve during the
procedure, causing the woman to talk with a hoarse voice. A second surgery is scheduled
to graft a lower limb cutaneous nerve to replace the damaged segment of the recurrent
laryngeal nerve. Months after the procedure, results look promising regarding the patient’s
voice. She has one minor complaint about a lack of sensation on the back of her leg laterally
and along the lateral side of her foot. Which nerve was harvested during the grafting
procedure?

A. Saphenous
B. Sural
C. Superficial fibular
D. Tibial
E. Lateral plantar

Answer: B

A. Saphenous
Explanation: A saphenous nerve harvest cannot explain lack of sensation on the back of
her leg laterally and along the lateral side of her foot. The saphenous nerve (L3-L4) arises
as a cutaneous branch of the femoral nerve in the femoral triangle. It descends with the
femoral artery and vein in the adductor canal, but before reaching the adductor hiatus the
saphenous nerve pierces the fascia lata and innervates the skin of the medial crural region
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and the ankle.

B. Sural
Explanation: The sural nerve (S1-S2) forms as the union of the medial sural cutaneous
branch of the tibial nerve and the lateral sural cutaneous nerve of the common fibular
(peroneal) nerve superficial to the crural fascia. The sural nerve supplies the skin of the
back of the leg laterally and along the lateral side of the foot.

C. Superficial fibular
Explanation: A superficial fibular nerve harvest cannot explain lack of sensation on the
back of her leg laterally and along the lateral side of her foot. The superficial fibular nerve
provides the primary nerve supply to the skin of the dorsum of the foot.

D. Tibial
Explanation: A tibial nerve harvest cannot explain lack of sensation on the back of her leg
laterally and along the lateral side of her foot. Furthermore, the tibial nerve is a mixed
nerve, and therefore motor deficits would accompany the sensory loss.

E. Lateral plantar
Explanation: A lateral plantar nerve harvest cannot explain lack of sensation on the back
of her leg laterally and along the lateral side of her foot. The lateral plantar nerve is a branch
of the tibial nerve and carries no sensory fibers originating from the back of the leg.

Question 14

An 8-year-old boy suffers chest trauma in an automobile accident. He arrives at the

emergency department unconscious and hypotensive. Repeated attempts to establish a
percutaneous peripheral intravenous catheter to administer fluids have failed. The
physician decides to perform a saphenous vein cutdown. In which location should she make
her incision to find the great saphenous vein?

A. Anterior and inferior to the lateral malleolus

B. Anterior and inferior to the medial malleolus
C. On the dorsum of the foot lateral to extensor hallucis longus tendon
D. Posterior and inferior to the lateral malleolus
E. Posterior and inferior to the medial malleolus

Answer: B

A. Anterior and inferior to the lateral malleolus

Explanation: The great saphenous vein passes anterior and inferior to the medial malleolus,
not the lateral malleolus.
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B. Anterior and inferior to the medial malleolus

Explanation: The great saphenous vein passes approximately 1 cm anterior and 1 cm
inferior to the medial malleolus. In cases of chest trauma the great saphenous is a good
choice for vascular access because it is far removed from the site of injury, where other
emergency procedures may need to be performed.

C. On the dorsum of the foot lateral to extensor hallucis longus tendon

Explanation: The dorsalis pedis artery passes just lateral to the tendon of extensor hallucis
longus on the dorsum of the foot. Its pulse can be palpated in this location.

D. Posterior and inferior to the lateral malleolus

Explanation: The small saphenous vein rather than the great saphenous vein passes
posterior to the lateral malleolus.

E. Posterior and inferior to the medial malleolus

Explanation: The great saphenous vein passes anterior and inferior to the medial malleolus
rather than posterior and inferior. Structures posterior to the medial malleolus include the
tendons of tibialis posterior, flexor digitorum longus, and flexor hallucis longus, along with
the tibial nerve and posterior tibial artery.

Question 15

A heart murmur is detected in a 2-month-old infant. Left-side and right-side cardiac

catheterizations are performed to evaluate possible multiple congenital defects. To gain
direct access to the right side of the heart, the catheter is placed in a large vessel in the
groin region. The vessel used for right-side catheterization is found in which location?

A. Lateral to the femoral artery in the femoral triangle

B. Lateral to the femoral vein in the femoral triangle
C. Medial to the femoral artery in the femoral triangle
D. Medial to the femoral vein in the femoral triangle
E. Superior to the inguinal ligament and lateral to the inferior epigastric vessels

Answer: C

A. Lateral to the femoral artery in the femoral triangle

Explanation: The vessel required for right-side catheterization is the femoral vein. The
structure that lies lateral to the femoral artery in the femoral triangle is the femoral nerve.

B. Lateral to the femoral vein in the femoral triangle

Explanation: The vessel required for right-side catheterization is the femoral vein. The
structure that lies lateral to the femoral vein in the femoral triangle is the femoral artery. A
catheter inserted into the femoral artery would reach the left side of the heart via the aorta.

C. Medial to the femoral artery in the femoral triangle

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Explanation: The vessel required for right-side catheterization is the femoral vein, which
lies medial to the femoral artery in the femoral triangle. A catheter inserted into the femoral
vein will enter the right atrium via the inferior vena cava.

D. Medial to the femoral vein in the femoral triangle

Explanation: The vessel required for right-side catheterization is the femoral vein. The
femoral canal lies medial to the femoral vein in the femoral triangle and contains lymph
nodes and lymphatic vessels.

E. Superior to the inguinal ligament and lateral to the inferior epigastric vessels
Explanation: The deep ring of the inguinal canal lies superior to the inguinal ligament and
lateral to the inferior epigastric vessels. The vessel required for right-side catheterization
is the femoral vein, which is located inferior to the inguinal ligament.

Question 16

A full-term male neonate presents 2 weeks after birth with fever, lethargy, and feeding
difficulties. Physical examination reveals a bulging anterior fontanelle, causing the
physician to suspect possible meningitis. The infant is started on an aggressive course of
antibiotics while blood samples are collected and a lumbar puncture is performed to recover
cerebrospinal fluid. Lumbar puncture must be carried out at a level inferior to the
termination of the spinal cord. At which vertebral level does the neonatal spinal cord
normally end?

A. T11
B. L1
C. L3
D. S1
E. S3

Answer: C

A. T11
Explanation: Whereas the spinal cord of an adult normally ends at vertebral level L2, the
spinal cord of a neonate is relatively longer, commonly extending to L3. A lumbar puncture
carried out at T11 would endanger the spinal cord of a neonate or an adult.

B. L1
Explanation: Whereas the spinal cord of an adult normally ends at vertebral level L2, the
spinal cord of a neonate is relatively longer, commonly extending to L3. A lumbar puncture
carried out at L1 would endanger the spinal cord of a neonate or an adult.

C. L3
Explanation: Whereas the spinal cord of an adult normally ends at vertebral level L2, the
spinal cord of a neonate is relatively longer, commonly extending to L3. The lower relative
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position of the neonatal cord must be kept in mind when selecting the level for lumbar
puncture.

D. S1
Explanation: Although the spinal cord initially extends to sacral vertebral levels in the
fetus, by the final 15 weeks of in utero development it has already ascended to lumbar
vertebral levels.

E. S3
Explanation: Although the spinal cord initially extends to sacral vertebral levels in the
fetus, by the final 15 weeks of in utero development it has already ascended to lumbar
vertebral levels.

Question 17

A 35-year-old woman has been on prolonged bed rest after a pelvic fracture. She has a
genetic deficiency of protein C, resulting in a hypercoagulable state. Localized swelling
develops below her left knee, and she experiences leg pain, which worsens with
dorsiflexion of the foot (Homan’s sign). A diagnosis of deep vein thrombosis (DVT) is
made. Magnetic resonance imaging (MRI) studies reveal a clot in one of the paired fibular
veins accompanying the fibular artery. If the clot embolizes, which vein will the embolus
directly enter as it leaves the fibular vein?

A. Anterior tibial vein

B. Great saphenous vein
C. Lateral plantar vein
D. Popliteal vein
E. Posterior tibial vein

Answer: E

A. Anterior tibial vein

Explanation: The fibular veins are deep veins in the posterior compartment of the leg and
are direct tributaries to the posterior tibial vein rather than the anterior tibial vein.

B. Great saphenous vein

Explanation: The fibular veins are deep veins that lie in the posterior compartment of the
leg, while the great saphenous vein is a superficial vein. Deep veins communicate with
superficial veins via perforating veins, but blood normally flows from superficial to deep
veins rather than vice versa. In addition, the fibular veins lie on the lateral side of the
posterior compartment, while the great saphenous vein is located on the anteromedial
aspect of the leg.

C. Lateral plantar vein

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Explanation: The lateral plantar veins on the sole of the foot and the fibular veins in the
posterior compartment of the leg are both tributaries to the posterior tibial vein. An embolus
in a fibular vein would therefore directly enter the posterior tibial vein rather than the lateral
plantar vein.

D. Popliteal vein
Explanation: The fibular veins are deep veins in the posterior compartment of the leg.
Blood from the fibular veins reaches the popliteal vein indirectly by first draining into the
posterior tibial vein. The posterior tibial vein then unites with the anterior tibial vein to
form the popliteal vein.

E. Posterior tibial vein

Explanation: The fibular veins are companion vessels to the fibular artery and are located
in the posterior compartment of the leg. Fibular veins are direct tributaries to the posterior
tibial vein, which then unites with the anterior tibial vein to form the popliteal vein.

Question 18

A 17-year-old boy with a black belt in karate executes a kick without properly warming
up. He hears a popping sound and is unable to bear weight on his right leg. On examination
he is unable to actively plantar flex his foot, and passive dorsiflexion causes pain in his calf
and the back of his ankle. There is a palpable gap in the contour of the posterior ankle
above the calcaneal tuberosity. Which of the following is the most likely diagnosis?

A. Ruptured medial meniscus

B. Ruptured lateral meniscus
C. Ruptured talofibular ligament
D. Ruptured calcaneal tendon
E. Ruptured inferior extensor retinaculum

Answer: D

A. Ruptured medial meniscus

Explanation: The medial meniscus helps to cushion the knee joint. Injury may be
associated with a tendency of the knee to lock, and pain would be localized to the knee not
the ankle.

B. Ruptured lateral meniscus

Explanation: The lateral meniscus helps to cushion the knee joint, and injury may be
associated with a tendency of the knee to lock. Pain would be localized to the knee not the
ankle.

C. Ruptured talofibular ligament

Explanation: The talofibular ligament connects the distal fibula with the calcaneus. It may
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be injured when the ankle is sprained by forced inversion.

D. Ruptured calcaneal tendon

Explanation: This tendon connects the calcaneus with the body of the gastrocnemius
muscle. The pattern of signs and symptoms described is characteristic of a ruptured
calcaneal (Achilles) tendon (see Plate 506).

E. Ruptured inferior extensor retinaculum

Explanation: This retinaculum helps prevent bowing of extensor ankle tendons.

Question 19

A football player complains of severe knee pain after being tackled from the side. When
the knee is flexed, the tibia can be moved anteriorly relative to the femur. Which injury
most likely occurred?

A. Rupture of the fibular collateral ligament

B. Rupture of the patellar ligament
C. Tear of the anterior cruciate ligament (ACL)
D. Tear of the lateral meniscus
E. Tear of the posterior cruciate ligament

Answer: C

A. Rupture of the fibular collateral ligament

Explanation: The fibular collateral ligament usually is not torn because it is so strong.
Blows to the knee from the medial side are uncommon.

B. Rupture of the patellar ligament

Explanation: The patellar ligament, a continuation of the quadriceps femoris tendon, is not
ruptured by a blow to the lateral side of the knee. Injuries from the front, such as in an
automobile accident, may lead to rupture of the patellar ligament.

C. Tear of the anterior cruciate ligament (ACL)

Explanation: If the knee is hit hard from the lateral side while the foot is planted, the
“unhappy triad” may result: rupture of the tibial collateral ligament with tearing of the ACL
and the medial meniscus. An ACL tear or strain is the most common knee injury that occurs
while playing sports such as football (see Plate 496).

D. Tear of the lateral meniscus

Explanation: The lateral meniscus, which is more freely movable than the medial
meniscus, is less likely to be torn because it is not attached to the fibular collateral ligament.
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E. Tear of the posterior cruciate ligament

Explanation: A tear of the posterior cruciate ligament results in the posterior drawer sign,
which is movement of the tibia posteriorly when the knee is flexed. Automobile and
motorcycle accidents account for many tears of the posterior cruciate ligament.

Question 20

A 27-year-old professional cyclist develops a traumatic aneurysm of an artery in his lower

limb. A thromboembolus forms at the site of injury, breaks free, and travels into a distal
artery, where it blocks blood flow. A thromboembolus that lodges in the lateral plantar
artery would most likely come from an aneurysm located in which artery?

A. Anterior tibial
B. Deep artery of thigh (profunda femoris artery)
C. Fibular
D. Lateral femoral circumflex
E. Posterior tibial

Answer: E

A. Anterior tibial
Explanation: The anterior tibial artery ends on the dorsum of the foot as the dorsalis pedis
artery.

B. Deep artery of thigh (profunda femoris artery)

Explanation: The deep artery of thigh is a branch of the femoral artery that supplies the
adductor and hamstring muscles of the thigh.

C. Fibular
Explanation: The fibular (peroneal) artery arises from the posterior tibial artery and
supplies muscles in the deep posterior and lateral compartments of the leg.

D. Lateral femoral circumflex

Explanation: The lateral femoral circumflex artery is usually a branch of the profunda
femoris (deep femoral) artery, but it may also arise from the femoral. It participates in the
cruciate anastomosis around the hip but does not extend into the foot.

E. Posterior tibial
Explanation: The posterior tibial artery divides into the medial plantar and the lateral
plantar arteries. An aneurysm in the posterior tibial artery is uncommon; aneurysms in the
lower extremity most commonly occur in the popliteal or the femoral artery secondary to
atherosclerosis.
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