CBME BASED QUESTIONS OF LOWER LIMB

Clinically oriented essays:

1. A 52-year-old woman observed a plum-sized bulge in her upper thigh, just inferior to the
inguinal ligament. A physical examination revealed that the swelling was in the femoral
triangle and that it was herniating through the saphenous opening.
Answer the flowing questions
 Which hernia gives rise to swelling below and lateral to pubic tubercle?
 Name the passage through which the hernia entered the thigh
 Give the name and the boundaries of the upper opening of the passage.
 Describe the direction of the hernia and the importance of this knowledge to the
surgeon.
 Is a femoral hernia found more frequently in women than in men? If so why?
 Define the terms: femoral ring, femoral canal, and femoral hernia
 In case of strangulation of this hernia how is the upper opening of the passage
enlarged?
 What do you know about the abnormal obturator artery?

2. A 78-year-old woman was not able to move her right lower limb after a minor fall. On
examination, it was noted that the toes of her right foot were pointing laterally. The right
limb was found to be shorter, on measuring the length. X-ray showed subcapital intra-
capsular fracture of femoral neck and general osteoporosis.
Answer the following questions
 How is the length of the lower limb measured?
 What is the reason for shortening of right lower limb in this patient?
 Which anatomical factors are responsible for the characteristic position of the right
foot?
 Draw a diagram to show the arterial supply of head and neck of femur.
 What are the anatomical reasons for avascular necrosis and non-union commonly
associated with these fractures?

3. A patient with 4 gm hemoglobin was given intramuscular injections of iron in the gluteal
region. After a few weeks, the patient complained of numbness in the intermediate part of
dorsum of foot and dorsum of all toes except lateral side of little toe. On examination, it
was noted that the patient was not able to dorsiflex and evert the right foot.
Answer the following questions
 Name the nerve that is injured.
 Name the two components of this nerve giving the root value of each.
 Based on the symptoms and signs, which component is injured?
 Give the origin and termination of the nerve.
 Give its surface marking.
 What is the peculiarity of its arterial supply?
 Intramuscular injection in which quadrant of gluteal region will cause injury to this
nerve?
 Name the structures that are its anterior relations in the gluteal region.
 Name the muscle that crosses it in the thigh from medial to lateral side.
4. A few days following the removal of plaster cast for fracture of the upper end of left
fibula, the patient complained of loss of sensation on the lateral and anterior aspect of leg
and on the intermediate area of the dorsum of foot including toes except the lateral side of
little toe and first interdigital cleft. On examination, the patient was unable to dorsiflex
and evert the left foot.
Answer the following questions
 Name the nerve that is injured in this patient.
 Give the site where this nerve is palpated.
 Name the deformity in which the foot cannot be dorsiflexed.
 Inability to dorsiflex the foot is due to loss of function of which nerve?
 Describe the course and distribution of this nerve.
 Describe the muscles that are the chief evertors of foot.

5. A young woman injured her ankle during a basketball game. A preliminary examination
by the trainer indicated that she had a severely sprained ankle. Tenderness was elicited
over the lateral aspect.
Answer the followings questions:
 What ankle ligament did she most likely tear?
 What are the parts of this ligament?
 What are the other ligaments of the joint?
 What bone might she have fractured?

6. A 50-year-old policeman with a history of chronic dull ache in both legs, came to the
hospital, when he noticed dilated and tortuous veins on the medial side of his both legs.
The skin on the medial malleolus was found to be discoloured, dry and scaly.
Answer the following Questions
 Name the clinical condition mentioning the vein involved.
 What is the relation of the vein to medial malleolus?
 Name closely related cutaneous nerves along its course.
 Name the vein that connect it to deep veins of lower limb.
 What is the direction of flow of blood in them?
 Name the perforating veins according to the position.
 Write briefly on saphenous opening.
 Name the terminal tributaries of this vein before it pierces cribriform fascia.
 Write a note on saphenous vein graft.
 What is the reason for dry scaly skin at medial malleous?

7. A football player, on receiving a blow on the lateral side of the right knee, felt a sharp pain
on the medial aspect and was not able to extent the leg. His right knee was swollen
especially above the patella. Drawer signs were negative. Radiological examination did
not show any fracture.
Answer the following Questions
 Which intra-articular structure is torn in this patient?
 Name the type of tear that usually occurs in it in the sports injury.
 Give the shape, attachments and nutrition of this structure.
 What is the ‘unhappy triad’ of knee joint?
  What is suprapatellar bursa? Which muscle is inserted in it?
 What is housemaid’s knee?
 Write short note on the muscle that originates inside the capsule of knee joint.

8. A 50 year old policeman came to the surgical O.P with complaints of dull aching pain on
the legs. On examination, dilated tortuous veins were seen on the front of thigh and legs.
Using your knowledge in Anatomy, answer the following question:
 Name the probable clinical condition and the structure involved here.
 Mention the formation and termination of the above structure.
 Give the course and tributaries of the structure.
 Name one clinical test used in this patient.
 Mention the common site for its puncture for intravenous infusion and name the
nerve closely related to it at this site

9. A 12 year old boy following an inadvertent intramuscular injection in the gluteal region
developed certain neurological deficits including difficulty to dorsiflex the foot. With your
knowledge of Anatomy answer the following question:
 Mention briefly the structures under cover of gluteus maximus.
 Name the structure which is affected in this case. Give its origin, course and
distribution in thigh.
 Give the cutaneuous innervations of lower limb below knee.
 Name the muscles responsible for dorsiflexion and eversion of the foot

10. During a football game, a 20 year old player was knocked by another player on the lateral
aspects of his knee. He felt severe pain on his Right Knee and was unable to extend his
Right Knee joint. With your knowledge in Anatomy, answer the following question:-
 Name the most probable structures of knee joint that can be injured in this case.
 Write briefly about intra articular structures of knee joint.
 Name the movements of the knee joint
 What is meant by unlocking of the knee joint and name the muscles producing it?

11. A 50 year old woman had a complaint of a swelling in the right groin. On examination, the
swelling was found to be below and lateral to the pubic tubercle. It was also found that the
swelling increased in size during coughing the swelling was diagnosed as the herniation of
the abdominal contents. Based on anatomical knowledge.
Answer the following questions:
 Name the canal through which the herniation occurred and give the normal
contents of the canal.
 Give the boundaries of the upper opening of the canal to abdomen and clinical
significance of the medial boundary.
 Give the anatomical reason for the common occurrence of this herniation in
females.
 Name the structures lying in the compartments lateral to the canal.
 Give the formation of the sheath enveloping the canal

12. A 30-years old man was brought to the casualty following a road traffic accident. On
examination, his right lower limb was shorted, flexed and internally rotated. X-ray of his
 right hip showed posterior displacement of head of femur. Following surgical correction
of dislocation of hip, the patient was not able to dorsiflex his right foot. Based on
yourknowledge in anatomy answer the following questions.
 Injury to which nerve in posterior dislocation of hip, can produce inability to
dorsiflex thefoot.
 Briefly describe the articular surfaces, capsule and ligaments, blood supply
andnerve supply of the hip joint.
 Name the muscles acting at the hip joint and mention the appropriate movements
produced by them
 Mention the anatomical features render this joint prone to dislocation.

13. While driving a car, a 30 years old man was accidently hit against a tree. He was rushed to
the hospital. His chief complaint was that, he could not stand up because of severe pain.
Physical examination revealed, his lower limb was slightly flexed, adducted, medially
rotated and appeared shorter than the other limb. X-rays were taken. Posterior dislocation
of the right hip with fracture of the posterior margin of acetabulum was diagnosed. With
your knowledge in anatomy, answer the following:
 Mention the type and articular surfaces of hip joint.
 Describe the ligaments
 Describe the blood supply of the joint giving its clinical importance
 Which nerve is prone to get injured in this case? What is its origin and root value?
 Enumerate the movements of the hip joint and the muscles producing them.

14. A 35 years old lady admitted to the hospital with pain abdomen and vomiting: on
examination a small lemon sized swelling was noticed on upper medial aspect of right
thigh, inferolateral to the public tubercle. The patient told she is having the swelling for
the last four months. With your knowledge in anatomy answer the following questions.

 What is the swelling in the front of thigh?

 Why did the patient present with abdomen pain and vomiting
 Describe the boundaries and contents of femoral triangle

15. A footballer is suffering from sustained injury to his right knee while kicking. His leg got
forcefully abducted in a slightly flexed position.
 Which is the likely meniscus has injured in this case.
 Why this meniscus is more prone to injury as compared to the other one
 Enumerate the other intra capsular structures of the knee joint
 Briefly describe the process of locking and unlocking at the knee joint

16. A 35 years old male patient was brought to the casualty with a swollen right knee and a
history of a fall during mountain climbing. There was severe pain and restricted mobility
at the joint. Answer the following based on the anatomical knowledge:
 Describe the attachments and relations of the ligaments of this joint
 What are the movements at this joint and which muscles are involved?

17. A 40 years old shopkeeper whose job requires standing up to 15 hours per day developed
abnormally swollen (Varicose) veins in left leg leading to non-healing ulcers above left
 medial malleolus. The condition was diagnosed by a surgeon as dilated and incompetent
great saphenous vein and the associated incompetent perforators. Based on your basic
knowledge of anatomy answer the following questions
 Describe the course and relations of great saphenous vein
 Name the tributaries of great saphenous vein
 What are perforating veins and what is its function.
 Describe the various perforating veins in lower limb.
 Name the tests performed for observing competence of superficial veins

18. A 50 year old traffic police man came to a surgeon with complaint of swollen vessels in
the leg which appears prominent on standing for long periods. On examination, it was
found to be superficial veins of lower limb involved.
 What is the name of this condition and which are vessels involved?
 What is the test performed in this condition?
 Describe the origin, course and termination of these vessels.
 What is the communication between superficial and deep veins and their role in
venous drainage of lower limb?

19. An 18 year old boy was hit down by a car while walking on the road and sustained injury
to his right knee joint. He visited the orthopaedic clinic with complaints of pain, swelling
and while walking his right knee is giving out (instability). On examination, soft tissue
swelling and tenderness present around knee joint. Lachman test was performed and
shows abnormal forward & backward movement of right tibia. With your anatomical
knowledge, answer the following questions related to knee joint:
 Describe the articular surfaces of knee joint.
 Describe the ligaments of knee joint.
 Name the structure(s) that maintain the anteroposterior stability of knee joint.
 What is locking of knee joint?
 Nerves that supply the knee joint. (2+3+5+3+2=15)
(2019 scheme – March 2021)

20. Describe the intracapsular structures of knee joint. Explain the clinical importance of any
two of them. (9+6)
(2019 scheme – March 2021)

Structured essays:

1. Describe the Hip joint under the following headings:

 Type & Articular surfaces.
 Capsule &Ligaments
 Movements & muscles producing them
 Relations with aid of diagram
 Blood supply & its clinical importance
 Applied Aspects

2. Describe the femoral artery under following headings:

  Extent
 Course & relations
 Branches
 Surface marking.
 Applied anatomy

3. Describe the femoral nerve under the following headings:

 Root Value
 Course & relations
 Branches and distribution
 Applied aspects.

4. Describe the femoral triangle under the following headings:

 Boundaries
 Contents
 Applied aspects

5. Describe the sciatic nerve under the following headings.

 Origin & root value
 Course & relations
 Branches & distribution
 Surface marking.
 Applied aspects.

6. Describe the tibial nerve under the following headings.

 Origin & root value
 Course & relations
 Branches & distribution
 Applied aspects

7. Describe the popliteal artery under the following headings:

 Extent
 Course& relations
 Branches& distribution
 Applied aspects

8. Describe the common peroneal nerve under the following headings:

 Origin & root value
 Course &relations
 Branches &distribution
 Applied aspects.

9. Describe the knee joint under the following heads:

 Type of joint, formation & articular surfaces
 Capsule & ligaments
 Movements & muscles taking part
 Applied aspects
10. Describe the ankle joint under the following heads:
 Bones taking part
 Type of joint
 Capsule& ligaments
 Movements& muscles producing them
 Applied aspects.

11. Describe the arches of foot under the following headings:

 Formation
 Supports
 Factors maintaining stability
 Functions
 Applied aspects
Short essays:
1. Gluteus maximus muscle and structures under cover of it
2. Hamstring muscles
3. Obturator nerve
4. Femoral sheath – formation, contents & applied aspects.
5. Femoral canal – boundaries, contents & applied aspects.
6. Femoral triangle – boundaries, contents and applied aspects
7. Inguinal lymph nodes
8. Great saphenous vein – formation, course and termination and applied aspects.
9. Adductor canal (Sub-sartorial canal/Hunter’s canal)
10. Profunda femoris artery
11. Popliteal fossa – boundaries, contents and applied anatomy
12. External ligaments of Knee joint
13. Intra articular structures of knee joint
14. Longitudinal arches of foot
15. Inversion & Eversion of foot.
16. Arches of foot
Short notes:
1. Fascia lata.
2. Iliotibial tract
3. Circumflex arteries
4. Cruciate anastomosis
5. Trochanteric anastomosis
6. Anastomosis at the back of thigh
7. Ligaments of hip joint
8. Iliofemoral ligament
9. Greater sciatic foramen
10. Head of femur
11. Gluteus medius
12. Gluteus minimus
13. Quadriceps femoris muscle
14. Piriformis muscle
15. Superior gluteal artery
16. Psoas major muscle
17. Inguinal ligament
18. Saphenous opening
19. Great saphenous vein
20. Varicose veins
21. Adductor longus muscle
22. Adductor magnus muscle
23. Linea aspera of femur
24. Lower end of femur
25. Locking and unlocking of the knee joint.
26. Anastomosis around knee joint
27. Tibial collateral ligament (Medial collateral ligament)
28. Menisci of knee joint
29. Cruciate ligaments
30. Bursae around the knee joint.
31. Popliteal Artery
32. Popliteal vein
33. Popliteus muscle
34. Soleus muscle (peripheral heart)
35. Tendocalcaneus
36. Tibialis posterior muscle
37. Tibialis anterior
38. Peroneus longus muscle
39. Superficial peroneal nerve
40. Deep peroneal nerve
41. Dorsalis pedis artery
42. Flexor/ Extensor retinacula of foot
43. Plantar aponeurosis
44. First layer of sole
45. Subtalar joints
46. Medial ligament of ankle joint (Deltoid ligament)
47. Spring ligament
48. Transverse arches
49. Medial longitudinal arch of foot.
50. Short saphenous vein
51. Sural nerve
52. Saphenous nerve
53. Cutaneous innervation of dorsum of foot
Write the anatomical basis of:
1. Explain the anatomical basis of psoas abscess.
2. Explain the anatomical basis of femoral hernia.
3. Describe the anatomical basis of sciatic nerve injury during gluteal intramuscular
injections.
4. Explain the anatomical basis of Trendelenburg sign.
5. Describe the anatomical basis of complications of fracture neck of femur.
6. Explain the anatomical basis of foot drop.
7. Explain the anatomical basis of locking and unlocking of the knee joint.
8. Explain the anatomical basis of osteoarthritis.
9. Explain the concept of “Peripheral heart”.
10. Explain the anatomical basis of rupture of calcaneal tendon.
11. Explain the anatomical basis of flat foot and club foot.
12. Explain the anatomical basis of metatarsalgia & plantar fasciitis.
13. Explain the anatomical basis of enlarged inguinal lymph nodes.
14. Explain the anatomical basis of varicose veins and deep vein thrombosis.
15. Anatomical basis of dilated veins of lower limb

Draw labelled diagrams of:

1. Structures around hip joint
2. Femoral triangle – boundaries and contents
3. Adductor canal
4. Transverse section at the level of middle of thigh
5. Transverse section through knee joint
6. Popliteal fossa
7. Transverse section through middle of leg
8. Longitudinal arches of foot.
9. Cutaneous innervation of dorsum of foot
Name the following
1. Nerve passing underneath the flexor retinaculum of foot.