HESHAM MRCS RECALLS

GENERAL ANATOMY
REVISION (RECALLS)
1. Which among the following statements regarding the functions of the extra ocular
muscles is incorrect?

A. The inferior oblique muscle abducts the eye and moves it upwards
B. The superior rectus muscle abducts the eyes and moves it laterally
C. The superior oblique muscle abducts the eye and moves it downwards
D. The medial rectus muscle moves the eye medially
E. The inferior rectus muscle adducts the eye and moves it downwards

1. Answer: B
There are six extra ocular muscles which act to rotate an eye about its vertical, horizontal, and
anteroposterior axes. They are
1) The inferior oblique (abducts the eye and moves it upwards)
2) The superior oblique (abducts the eye and moves the eye downwards)
3) The medial rectus (moves the eye medially)
4) The lateral rectus (moves the eye laterally)
5) The superior rectus (adducts the eyes and moves it upwards (not abduct the eye and move it laterally)
6) The inferior rectus (adducts the eye and moves it downwards)

2. A 45-year-old jockey falls off his horse and sustains a fracture of his distal tibia
involving the ankle joint. After initial resuscitation, a senior orthopedic review
determines that stability will be best achieved by external fixation with a quadrilateral
frame. This involves a pin placed in the proximal tibia, linked by rods to another pin
which is placed through the calcaneus. The distal pin is inserted from the medial aspect
of the calcaneus, about an inch (2.5 cm) superior and towards the toes, away from the
heel. Which local nerve is most likely to be damaged by improper pin placement?

A. Deep fibular (peroneal) nerve

B. Lateral plantar nerve
C. Medial plantar nerve
D. Saphenous nerve
E. Superficial fibular (peroneal) nerve

2. Answer: C
This patient has sustained a tibial plafond fracture (also known as a tibial pilon fracture) at the distal tibia
and involving the ankle joint. As is the case with tibial plateau fractures, these injuries occur close to the
joint surface and must be treated with the joint cartilage surface in mind.

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The various management options for tibial plafond fractures include casting, external fixation, limited
internal fixation, internal fixation, and ankle fusion.
In this case, external fixation is the treatment of choice and this involves insertion of a distal pin in the
region of the medial calcaneum, where the medial plantar nerve runs and this may potentially be damaged.
The medial plantar nerve is the larger of the two terminal divisions of the tibial nerve and accompanies the
medial plantar

3. A vascular surgeon considers the use of cerebrospinal fl uid drainage during thoracic
endovascular aneurysm repair, to reduce the risk of spinal cord ischaemia. Which of the
following statements regarding the blood supply of the spinal cord is true?

A. The artery of adamkiewicz commonly arises from a posterior intercostal artery

B. Between t3 and t7
C. The conus medullaris is the site of anastomosis of the anterior spinal artery with the
D. Posterior spinal arteries
E. The internal carotid arteries give rise to the anterior spinal artery
F. The paired anterior spinal arteries supply the anterior two-thirds of the spinal cord
G. The posterior spinal arteries supply the posterior two-thirds of the spinal cord

3. Answer: B
The artery of adamkiewicz (i.e. The ‘greater radicular artery’) usually arises from a left intercostal branch
of the aorta between t8 and t12, and supplies the anterior spinal artery and distal spinal cord.
The anterior spinal artery is an unpaired vessel that arises from the vertebral arteries (i.e. Not the carotids),
which unite below the foramen magnum to form a single anterior spinal artery. This artery then supplies the
pia mater and anterior two-thirds of the spinal cord, including the anterior and lateral columns (i.e. The
major motor tracts). It anastomoses with the posterior spinal arteries over the conus medullaris.
The posterior spinal arteries arise from the vertebral arteries. They pass down the spinal cord individually
and supply the posterior one-third of the spinal cord (i.e. Including the major sensory tracts).
The blood supply of the anterior and posterior spinal arteries is augmented by collateral radicular arteries the
most important of these are the branches of the posterior intercostal arteries at the sites of the cervical and
lumbar cord enlargements.

4. WHICH OF THE FOLLOWING IS TRUE ABOUT THE PAROTID GLAND?

A. The parotid gland is a mucus secreting gland contained within the parotid sheath
B. The gland is divided into two lobes in relation to the retromandibular vein
C. Its autonomic nerve supply is via the facial nerve, which passes through the gland
D. The mandibular branch of the facial nerve lies superficial to the parotid gland
E. The parotid duct drains into the buccal mucosa opposite the lower second molar

4. Answer: B
The parotid gland is a serous gland contained in the parotid sheath.
It has two lobes, superficial and deep in relation to the facial nerve and retromandibular vein.

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The facial nerve divides into its terminal motor branches within the substance of the parotid gland. The
salivary flow is regulated by the parasympathetic nervous system. The parotid gland receives autonomic
supply via the auriculotemporal nerve. Misdirected re-innervation of these autonomic nerve fibres after
superficial parotidectomy leads to frey’s syndrome. This typically develops about 6 months after surgery
and mainly features sweating and vasodilatation of the skin supplied by the auriculotemporal nerve.
The parotid duct drains in the buccal mucosa opposite the upper second molar tooth.

5. Which one of the following does not form a boundary of calot’s triangle?

A. Inferior border of the liver

B. Common hepatic duct
C. Cystic artery
D. Aberrant right hepatic artery
E. Cystic duct

5. Answer: C
Calot’s triangle is formed by the cystic duct inferiorly, the common hepatic duct medially, and the inferior
edge of the liver superiorly.
The triangle contains the cystic artery and a lymph node (lund's node or mascagni's lymph node).
An aberrant right hepatic artery running medial to the common hepatic duct and arising from the
superior mesenteric artery is seen in approximately 15% of patients.
Numerous anatomical variations and anomalies can occur in this region. Surgeons should therefore
appreciate that meticulous dissection of calot’s triangle and recognition

6. Which of the following tendons are contained in the second compartment of the
extensor retinaculum?

A. Extensor digitorum communis and extensor indicis proprius

B. Abductor pollicis longus and extensor pollicis brevis
C. Extensor carpi radialis longus and brevis
D. Extensor carpi ulnaris
E. Extensor digiti minimi

6. Answer: C
The fascia surrounding the extensors condenses at the wrist to form the extensor retinaculum.the space
below is divided into six compartments, as follows (radial to ulnar):

1. Abductor pollicis longus and extensor pollicis brevis (forming the radial border of the anatomical snuff
box)
2. Extensor carpi radialis longus and brevis through the floor of the anatomical snuff box
3. Extensor pollicis longus bends around the lister’s tubercle, which separates it from the second
compartment

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4. Extensor digitorum communis and extensor indicis proprius.

5. Extensor digiti minimi
6. Extensor carpi ulnaris.

7. An orthopaedic specialist registrar decides to revise the posterolateral approach to the

hip for her next total hip replacement. Which of the following muscles is not normally
divided to expose the joint capsule in this approach?

A. Inferior gemellus
B. Obturator externus
C. Obturator internus
D. Piriformis
E. Superior gemellus

7. Answer: B
The posterolateral approach to the hip involves dividing the short external rotators of the hip (i.e. From
superior to inferior) :
• Piriformis
• Gemellus superior
• Obturator internus
• Gemellus inferior
• Quadratus femoris to expose the joint capsule.
In contrast to these muscles, the obturator externus covers the outer surface of the anterior wall of the
pelvis and is part of the medial compartment of the thigh. The anterior approach (smith–petersen) and
anterolateral approach (watson–jones) are other methods of accessing the joint for procedures like the total
hip replacement.

8. Which one of the following structures lies parallel and immediately deep to the carotid
sheath in the neck?

A. Vagus nerve
B. Recurrent laryngeal nerve
C. Scalenus anterior
D. Trachea
E. Sympathetic trunk

8. Answer: E
Within the neck, the sympathetic trunk lies parallel and immediately deep to the carotid sheath, which
itself contains the common carotid (and cranially, the internal carotid) artery, internal jugular vein, vagus
nerve, and deep cervical lymph nodes.

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The sympathetic trunk lies ventral to the cervical muscles and transverse processes of the cervical vertebrae.
It travels downward from the skull, just lateral to the vertebral bodies, and communicates with the spinal
nerves (or their ventral roots) by means of rami communicantes.
The superior end of the trunk enters the skull via the carotid canal and forms a plexus on the internal carotid
artery. The inferior end descends in front of the coccyx, converging with the contralateral sympathetic trunk
at the ganglion impar. Paravertebral ganglia are present along the length of the sympathetic trunk.

9. A 23-year-old man is brought to the emergency department with a gunshot injury to

his right upper thigh. On examination, the wound lies about 4 cm below the inguinal
ligament. The vascular status of the limb Is normal. Local neurological examination
reveals numbness over the anterior thigh and medial aspect of his leg. Although he is
able to flex the hip, he is unable to extend the knee on the affected side. The knee jerk is
diminished but the ankle jerk is preserved. Which ne rve is most likely to be affected in
this patient?

A. Sciatic nerve
B. Tibial nerve
C. Saphenous nerve
D. Common peroneal nerve
E. Femoral nerve

9. Answer: E
The femoral nerve arises from the lumbar plexus (l2–l4). It exits the pelvis by passing beneath the medial
inguinal ligament to enter the femoral triangle after penetrating the psoas muscle. Within the femoral
triangle, it lies lateral to the femoral artery and vein. It may be injured by gunshot wounds, direct penetrating
wounds, traction during surgery, catheterization of the femoral artery, haematoma within the thigh, nerve
injury secondary to femoral nerve block, psoas abscess, fractured pelvis, or by dislocation of the hip. Apart
from trauma, it may be affected in patients with diabetes mellitus (diabetic neuropathy) and lumbar
spondylosis.
The femoral nerve innervates the iliopsoas, which helps in flexion of the hip, and the quadriceps, which
act to extend the knee.
The motor branch to the iliopsoas originates in the pelvis proximal to the inguinal ligament and injury at or
above this level leads to loss of hip flexion. The sensory branch of the femoral nerve, the saphenous nerve,
innervates the skin over the medial aspect of the thigh and the anteromedial aspect of the calf.
Hence, femoral nerve injury results in numbness over the medial aspect of the thigh and the
anteromedial aspect of the leg. Motor loss includes weakness of the quadriceps and decreased patellar refl
ex (knee jerk) (the ankle jerk is preserved since it is innervated by the tibial nerve (s1–s2)). In long-standing,
subacute injuries, the patient finds that the knee gives way on walking and has difficulty climbing stairs.

10. A 23-year-old student is referred to the urology clinic with unilateral testicular
enlargement and a dragging sensation in his left testis. Examination reveals a fi rm mass
in the body of the left testes. Together with preliminary blood results i ncluding an
elevated alpha fetoprotein level, a clinical diagnosis of testicular cancer is made. Staging
ct scans were performed of his chest, abdomen, and pelvis, indicating royal marsden

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classifi cation stage 2 disease. Which of the Following is the primary site of lymphatic
spread?

A. Axillary lymph nodes

B. Cervical lymph nodes
C. Pulmonary hilar lymph nodes
D. Inguinal lymph nodes
E. Para aortic lymph nodes

10. Answer: E
About 1 in 500 men develop testicular cancer in the UK. They usually present between 20–45 years of age.
These tumours can be classified into seminomas or non-seminomatous germ cell tumours (nsgcts). Nsgcts
include teratomas, yolk sac tumours, and choriocarcinomas. Occasionally leydig cell or sertoli cell tumours
can arise from sex cord stroma. Upon diagnosis, patients will have a staging CT of the chest, abdomen, and
pelvis. The primary site of lymphatic metastasis is the para-aortic lymph nodes. The extent of spread is
classified using the royal marsden staging system as follows:

• Stage 1: tumour confined to testis

• Stage 2: abdominal lymphadenopathy
• Stage 3: supra-diaphragmatic disease
• Stage 4: extralymphatic spread (e.g. Lungs, liver)

11. A 24-year-old construction worker was brought into the emergency department
having suff ered a crush injury to his left lower leg. Plain radiography performed on
admission excluded a fracture. However, his pain increased overnight, requiring a large
quantity of opioid analgesia. Examination revealed an erythematous, swollen, and shiny
leg that was Tender to palpation. Increased pain was elicited upon passive extension of
the foot and great toe. In which of the following compartments of the leg was raised
pressure most likely to have developed?

A. Anterior
B. Lateral
C. Deep posterior
D. Superfi cial posterior
E. Popliteal fossa

11. Answer: A
The bones, interosseous membranes, and fascia divide the lower leg into distinct compartments.

• Anterior compartment: lies between the deep fascia and the interosseous membrane, with the tibia
medially and the fibula laterally. It is also known as the extensor compartment as it contains tibialis
anterior, extensor hallucis longus, extensor digitorum longus, peroneus tertius, the deep peroneal
nerve and the anterior tibial vessels.
• Lateral compartment: lies between the deep fascia, peroneal surface of the fibula and the anterior
and posterior intermuscular septa. Within it lies peroneus longus, peroneus brevis and The superficial
peroneal nerve.

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• The posterior compartment is divided into deep and superficial compartments.

o The deep posterior compartment contains the tibialis posterior, flexor hallucis longus, flexor
digitorum longus, popliteus, posterior tibial vessels and the tibial nerve.

o The superficial posterior compartment contains the gastrocnemius, soleus and plantaris
muscles; and the medial sural cutaneous nerve.

12. A 29-year-old male was accidentally struck on the side of his head by a cricket bat.
On arrival at the emergency department he was unconscious, with bruising over the
region of his right pterion and an ipsilateral dilated pupil. Which of the following
arteries is most likely to have been damaged?

A. Anterior cerebral artery

B. Posterior cerebral artery
C. Middle cerebral artery
D. Middle meningeal artery
E. Internal carotid artery

12. Answer: D
The middle meningeal artery is a branch of the maxillary artery, which in itself is a terminal branch of the
external carotid artery. It supplies only the bones of the skull and not any intracranial structures.
The anterior branch of the middle meningeal artery lies beneath the pterion, which is formed at the site of
fusion of the frontal, parietal, temporal, and sphenoidal bones.
The surface marking for this is two finger breadths behind the zygomatic arch and a thumb’s breadth behind
the frontal process of the zygomatic bone. It is important to know this landmark as it is the site where an
emergency burr hole may be created to drain an extradural haematoma.

13. Which among the following statements concerning the lymphatic Drainage of the
colon is incorrect?

A. Lymph from the intermediate mesocolic lymph nodes drain to the principal nodes
B. Lymph from the caecum drains into the principal nodes at the origin of the inferior mesenteric artery
C. Lymph from the ascending colon passes to the superior mesenteric lymph nodes
D. Lymph from the descending colon passes to the intermediate colic lymph nodes along the left colic
artery
E. Lymph from the transverse colon passes to the lymph nodes that lie along the middle colic artery

13. Answer: B

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Regional lymph nodes are one of the important means of metastasis for colonic malignancy. Hence it is
essential to have a sound understanding of the lymphatic drainage of the colon. The lymphatics draining the
colon can be classified into four main groups:
(1) Epiploic nodes, (2) paracolic nodes, (3) intermediate mesocolic nodes, and (4) principal nodes.
The lymph thus drains from the epiploic to paracolic, then to the intermediate mesocolic, and finally to the
principal lymph nodes that lie at the root of mesocolon.
The pathways of nodal spread of the intermediate mesocolic and the principal lymph nodes follow the
course of the arterial supply and the venous drainage of the respective colonic segments.
Lymph from the caecum drains primarily to the ileocolic lymph nodes that lie along the ileocolic artery and
the efferent lymph nodes from here pass to the superior mesenteric lymph nodes.
The lymph from the ascending colon passes to the epiploic and paracolic lymph nodes, to the intermediate
nodes that lie along the right colic vessels, and from them to the superior mesenteric lymph nodes (that lie at
the root of thesuperior mesenteric artery).
The lymph from the transverse colon passes to the lymph nodes that lie along the middle colic artery (and
from them to the superior mesenteric lymph nodes).
The lymph from the descending colon passes to the intermediate colic lymph nodes along the left colic
artery and thence to the inferior mesenteric lymph nodes (that lie at the root of the inferior mesenteric
artery).

14. A 34-year-old secretary presents to the emergency department after sustaining

multiple penetrating injuries to her right upper limb . Careful examination reveals no
vascular injury to the limb, and sensory function remains intact. On examination of
motor function, however, finger extension is severely limited. Which nerve is most likely
to have been damaged?

A. Anterior interosseous nerve

B. Medial antebrachial cutaneous nerve
C. Musculocutaneous nerve
D. Posterior interosseous nerve
E. Radial nerve

14. Answer: D
The posterior (or dorsal) interosseous nerve of the forearm (c7–c8) is the continuation of the deep branch of
the radial nerve after the latter crosses the supinator muscle.
It provides purely motor innervation and is considerably smaller than the deep branch of the radial nerve.
It descends in front of extensor pollicis longus on the interosseous membrane.
It forms a gangliform enlargement behind the carpus, from which filaments are distributed to the carpal
ligaments and articulations.
The nerve supplies all the extensor muscles in the forearm, apart from anconeus, extensor carpi radialis
longus, and extensor carpi radialis brevis.

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Posterior interosseous neuropathy therefore affects only motor function, resulting in finger drop and
radial wrist deviation on extension.

15. A urologist performs a radical cystectomy for locally advanced bladder malignancy
in an elderly gentleman. Which of the following statements about the anatomy of the
urinary bladder is correct?

A. A peritoneal fold separates the bladder from the pubic symphysis

B. The bladder is related superomedially to the levator ani muscle
C. The external iliac veins drain the venous plexus of the bladder
D. The transitional cell epithelium of the bladder is derived from ectoderm
E. The bladder is located in the abdomen in young children
15. Answer: E
The urinary bladder is situated in the abdomen (i.e. Not the pelvic cavity) in infants and children, even
when empty. It is embryologically derived from two sources: the cloaca and mesonephric ducts. The
primitive cloaca is divided by the urorectal septum into the urogenital sinus and rectum.
The bladder develops mostly from the vesicular part of the urogenital sinus, and the bladder trigone is
formed from the mesonephric ducts being drawn into the bladder floor.
The transitional epithelium of the bladder is derived from the endoderm of the urogenital sinus, whereas the
epithelium of the ureters and renal pelvis are derived from mesoderm.
The venous drainage of the bladder is to the internal iliac veins, which drain the majority of pelvic viscera.
The vertex of the bladder is directed anteriorly towards the upper part of the symphysis pubis (i.e. Fascial
separation), and from it the median umbilical ligament (i.e. An unpaired remnant of the embryonic urachus)
continues upward on the deep surface of the anterior abdominal wall to the umbilicus.
The median umbilical ligament is covered by the median umbilical fold.

16. A 30-year-old male undergoes a right superfi cial parotidectomy. Eight months later
he presents to the outpatient department complaining of flushing and sweating of the
right side of his face on eating. He is diagnosed as having frey’s syndrome and is listed
for botulinum toxin injections. Misdirected re-innervation of which nerve is responsible
for this syndrome?

A. Greater auricular nerve

B. Facial nerve
C. Trigeminal nerve
D. Auriculotemporal nerve
E. Greater petrosal nerve

16. Answer: D
Frey’s syndrome is not an immediate complication of parotid surgery.

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It typically develops after 6 months and the main features are sweating and vasodilation of the skin supplied
by the auriculotemporal nerve.
The auriculotemporal branch of the trigeminal nerve carries sympathetic fibres to the sweat glands of the
scalp and parasympathetic fi bres to the parotid gland.
Misdirected re-innervation after surgery leads to gustatory sweating and flushing in the skin supplied by the
auriculotemporal nerve.
Other late complications after parotid surgery include the development of greater auricular nerve neuroma.
Facial nerve injury is more an intraoperative early complication of parotid surgery.

17. A 30-year-old man with a history of alcoholic liver cirrhosis and portal hypertension
presents with sudden-onset massive haematemesis. Gastroscopy reveals bleeding
oesophageal varices, which are then banded. Which one of the following is true about the
anatomy of the portal venous system?

A. The portal vein arises from the confluence of the splenic and the inferior mesenteric veins
B. The portal vein arises behind the neck of the pancreas.
C. Porto-systemic anastomoses are found only in the lower oesophagus and around the umbilicus.
D. The portal vein drains the gi tract from the upper oesophagus to the anorectal junction
E. The portal vein lies anterior to the common bile duct and hepatic artery in the lesser omentum

17. Answer: B
The portal vein arises from the confluence of the splenic and superior mesenteric veins behind the neck of
the pancreas, in front of the ivc between the vertebral levels l1 and l2.
It drains the GI tract from the lower oesophagus to the anorectal junction. Porto-systemic anastomoses are
seen at the umbilicus, lower oesophagus, retroperitoneum, and anorectal junction.
The portal vein lies behind the common bile duct and hepatic artery in the lesser omentum. The common
bile duct lies to the right of the hepatic artery.
The inferior mesenteric vein lies to the left of the inferior mesenteric artery in the left colonic mesentery and
drains into the splenic vein behind the tail of the pancreas.

18. A 45-year-old male presents to his gp with groin lumps on both sides. Examination
reveals fi rm bilateral inguinal lymphadenopathy. The gp attempts to recall the
lymphatic drainage of the region in order to suggest potential causes for this. Which one
of the following anatomical structures does not drain to the superficial inguinal lymph
nodes?

A. Perineum

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B. Feet
C. Scrotum
D. Testicle
E. Lower anal canal

18. Answer: D
There are two drainage patterns to the inguinal lymph nodes.

• The horizontal group of lymphatics drain along the inguinal ligament; infection and malignant cells
from the skin of the lower anterior abdominal wall, retroperitoneum, penis, scrotum, vulva, vagina,
gluteal region, lower anal canal, and perineum.

• The vertical group drains lymph from penis, scrotum, gluteal regions and the lower limbs along the
great saphenous vein. Testicular cancer spreads primarily to the para-aortic lymph nodes.

19. A 35-year-old-man is brought to the emergency department following a road traffi c

accident. He demonstrates signs and symptoms of a simple pneumothorax, which is confi
rmed on chest radiography. Which of the following anatomical landmarks is not useful
for delineating the 'safe triangle' for chest drain insertion in this patient?

A. Apex of axilla
B. Inferolateral border of pectoralis major
C. Anterior border of the latissimus dorsi
D. Nipple
E. Mid-clavicular line

19. Answer: E
Chest drains are commonly inserted to drain air, fluid or both from the pleural cavity. They should ideally be
inserted within the 'safe triangle' of the anterior chest wall.

• The safe triangle is bordered by

• The anterior border of the latissimus dorsi
• The lateral border of the pectoralis major muscle
• A line superior to the horizontal level of the nipple
• An apex below the axilla.
Within this safe triangle, the chest drain should be inserted by blunt dissection into the fifth intercostal
space, just above the superior border of the rib underneath (i.e. In order to avoid the neurovascular bundle
travelling along the inferior aspect of the rib above).

20. Before dissection of a gastric tumour, a surgeon identifi es the communicating cavity
between the greater and lesser sacs in the abdomen. Which of the following forms the
inferior boundary of this area?

A. Caudate lobe of the liver

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B. First part of duodenum

C. Gastroduodenal artery
D. Hepatic portal vein
E. Third part of the duodenum

20. Answer: B
The boundary between the greater (i.e. The general cavity of the abdomen) sac and lesser sac is known as
the epiploic foramen (or ‘omental foramen’; ‘foramen of winslow’).
This passage has the following borders:

• Anterior: the free border of the lesser omentum (i.e. The hepatoduodenal ligament). This has two
layers and within these layers are the common bile duct, hepatic artery and hepatic portal vein.
• Posterior: the peritoneum covering the inferior vena cava.
• Superior: the peritoneum covering the caudate lobe of the liver.
• Inferior: the peritoneum covering the first part of the duodenum and the hepatic artery, the latter
passing forward below the foramen before ascending between the two layers of the lesser omentum.
• Left lateral: gastrosplenic ligament and splenorenal ligament.

21. During open hepatobiliary surgery, the surgeon accidentally injures the structure
directly posterior to the second part of the duodenum whilst attempting to mobilize this
segment of bowel. Which one of the following structures is most likely to have been
injured?

A. Fundus of the gallbladder

B. Hepatic portal vein
C. Hilum of the right kidney
D. Superior mesenteric artery
E. Gastric pylorus

22. Answer: C
The second part of the duodenum (d2) lies along the transpyloric plane (of addison), at the level of the 1st
lumbar vertebra (l1). Other key structures at this point include the fundus of the gallbladder, splenic and
renal hila, neck of pancreas, origin of the superior mesenteric artery, origin of the hepatic portal vein, gastric
pylorus, the attachment of the transverse mesocolon and the tip of the 9th costal cartilage.
Posterior to d2 lies the right renal hilum; the other structures mentioned are not directly related to d2. It
should be noted that d2 begins at the superior.
Duodenal flexure, passing inferiorly to the level of the lower border of l3, before making a sharp turn
medially into the inferior duodenal flexure.
The pancreatic and common bile ducts enter the descending duodenum (known as the hepatopancreatic duct)
through the major duodenal papilla (ampulla of vater).
The minor duodenal papilla is also located here and serves as the outlet of the accessory pancreatic duct. The
junction between the embryological foregut and midgut lies just below the major duodenal papilla.

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23. Which of the following nerves does not arise from the posterior cord of brachial
plexus?

A. Upper subscapular nerve

B. Long thoracic nerve
C. Thoracodorsal nerve
D. Axillary nerve
E. Radial nerve

23. Answer: B

• The nerves which arise from the posterior cord of the brachial plexus include:
o The upper subscapular nerve (c5 and c6),
o Middle subscapular nerve (i.e. The thoracodorsal nerve, supplying latissimus dorsi; c6, c7, c8),
o Lower subscapular nerve (c5 and c6),
o Axillary nerve (c5 and c6)
o Radial nerve (c5, c6, c7, c8, t1)

• The long thoracic nerve (i.e. The nerve of bell, supplying serratus anterior), has a root value of c5, c6,
and c7. It arises from the roots of the brachial plexus; The other nerves arising from the roots include the
dorsal scapular nerve (c5) and the branches to scalene muscles (c5–c8).

24. A 45-year-old male presented to the emergency department complaining of a fish

bone stuck in his throat. Despite soft tissue radiographs of the neck confirming the
presence of the bone, it could not be detected during examination of th e larynx with a
laryngeal mirror. Eventually, endoscopic examination of the laryngopharynx allowed for
the bone to be visualized and retrieved. Which structure may have been injured if the
fish bone had pierced the mucous membrane?

A. Aryepiglottic fold
B. Internal laryngeal nerve
C. Larynx
D. Recurrent laryngeal nerve
E. Vocal cords

24. Answer: B
The fish bone is likely to have been stuck in the piriformis recess, which is a pear-shaped opening bounded
by the aryepiglottic folds medially; and the laryngopharynx, thyroid cartilage and hypothyroid membrane
laterally. Sharp objects may lodge in this recess and pierce the mucous membrane, injuring the internal
laryngeal nerve lying just beneath it. This nerve supplies sensation to the laryngeal mucosa above the vocal
folds. Damage to this nerve may therefore result in insensitivity of the mucous membrane of the superior
part of the larynx to food, resulting in a loss of cough impulse and increased risk of aspiration.

25. An 80-year-old osteoporotic female presents to the emergency department after

having slipped and fallen on her outstretched right arm. After she is diagnosed with a
colles’ fracture, she undergoes manipulation under anaesthesia and is eventually
discharged home in a cast. At her two-week follow-up in the fracture clinic, she is found
to be unable to move her thumb away from the rest of her hand (i.e. In the same plane as

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her hand), whilst her palm is resting flat on the table. Which of the following structures
is she most likely to have damaged?

A. Abductor pollicis longus

B. Extensor pollicis longus
C. Abductor pollicis brevis
D. Radial nerve
E. Median nerve

25. Answer: B
Rupture of the extensor pollicis longus tendon is a recognized complication of colles’ fractures. It may occur
either acutely, or more commonly, 2 weeks after the injury, when the blood supply to the tendon becomes
interrupted by repeated abrasions against the rough fracture edges. Other of colles' fractures include:

• Fracture malunion
• Subluxation of the radioulnar joint and fracture displacement
• Impingement on rotation caused by a prominent ulnar head
• Median nerve damage (which presents as pain and paraesthesia over the radial three-and-half digits
with sparing of sensation over the thenar eminence)
• Sudeck’s atrophy: reflex sympathetic dystrophy, which leaves the hand painful, stiff ,and
hypersensitive.

26. Which of the following arteries does not arise from the axillary artery?

A. Superior thoracic artery

B. Lateral thoracic (pectoral) artery
C. Thoraco-acromial artery
D. Costo-cervical trunk
E. Subscapular artery

26. Answer: D
The axillary artery is a large artery supplying the lateral aspect of the thorax, the axilla and the upper limb.
Its origin is at the lateral margin of the first rib (before which it is called the subclavian artery); after passing
the lower margin of teres major, it is known as the brachial artery.
❖ The axillary artery is divided into three parts by the pectoralis minor muscle

• The first part is between the outer border of the 1st rib and the pectoralis minor muscle,
✓ Has one branch (the superior thoracic artery)
• The second part is behind the pectoralis minor muscle,
✓ Has two branches ( the lateral thoracic (pectoral) artery and the thoraco-acromial artery)
• The third part is after the pectoralis minor muscle.
✓ Has three branches
o The subscapular artery (which divides into the circumflex scapular artery and the
thoraco-dorsal artery),
o The anterior circumflex humeral artery,

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o The posterior circumflex humeral artery.

The costo-cervical trunk arises from the second part of the subclavian artery.

27. A 75-year-old lady is scheduled for a total hip placement for severe osteoarthritis of
her hip. The surgeon’s preferred approach to the hip joint is the lateral approach, which
involves splitting the tensor fascia lata, followed by the gluteus medius and gluteus
minimus, to reach the hip joint. He explains to the patient that during this approach, the
nerve supply to the tensor fascia lata and gluteus medius is at risk. What nerve does the
surgeon specifically refer to in this case?

A. Femoral nerve
B. Inferior gluteal nerve
C. Lateral femoral cutaneous nerve of the thigh
D. Sciatic nerve
E. Superior gluteal nerve

27. Answer: E
There are several different approaches to the hip and different nerves may be damaged depending on which
approach is used.
The superior gluteal nerve arises from lumbosacral plexus (i.e. From the dorsal branches of l4, l5, and s1).
It exits the pelvis and enters the gluteal region through the upper margin of the greater sciatic notch, just
superior to the piriformis muscle.
It courses with the superior gluteal artery between gluteus medius and minimus, whilst supplying motor
branches to both these muscles, as well as the tensor fascia lata. The nerve is therefore at risk during the
lateral approach to the hip.
The posterior approach to the hip joint involves an incision through the deep fascia and gluteus maximus
and then division of the external rotators. The sciatic nerve is in danger with this approach.
The anterior approach involves the planes between tensor fascia lata and sartorius, followed by the rectus
femoris and gluteus medius. The lateral femoral cutaneous nerve of the thigh is in danger with the anterior
approach.

28. A thoracic surgeon carefully negotiates the axillary region during explorative surgery
for multiple gunshot wounds in a soldier. Which of the following statements regarding
the anatomy of the axillary region is most accurate?

A. Inadvertent damage to the thoracodorsal nerve during axillary dissection may result in winging of the
scapula
B. The lymph nodes lateral to pectoralis minor are considered as level iii nodes
C. The third part of the axillary artery is surrounded by cords of the brachial plexus
D. The intercostobrachial nerve is commonly sacrifi ced during axillary dissection
E. The third part of axillary artery gives off the subscapular artery

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28. Answer: E
The axillary artery originates at the lateral margin of the 1st rib (before which it is called the subclavian
artery) and ends at the lower margin of teres major (after which it is called the brachial artery). The fi rst,
second, and third parts of the axillary artery lie medial, behind and lateral to pectoralis minor respectively.
These parts of the axillary artery give off one, two and three branches respectively:
❖ First part: superior thoracic artery
❖ Second part: thoraco-acromial artery , lateral thoracic artery
❖ Third part: subscapular artery , anterior humeral circumfl ex artery , posterior humeral circumfl
ex artery.
Within the axillary region, level i lymph nodes lie lateral to pectoralis minor, level ii lie behind, and level iii
lie medial to the pectoralis minor.
If the intercostobrachial nerve is divided during axillary dissection, paraesthesia over the medial aspect of
the inner upper arm may result.
If the long thoracic nerve is divided, a winged scapula will result from denervation of serratus anterior.
However,
If the thoracodorsal nerve is divided there will be weakness of arm adduction, extension, and internal
rotation from denervation of latissimus dorsi.
The cords of the brachial plexus are anatomically related to the second part of the axillary artery: the lateral,
posterior, and medial cords lie laterally, posteriorly, and medially to this part of the artery, respectively.

29. What is the main arterial supply to the body of the pancreas?

A. Common hepatic artery

B. Left gastric artery
C. Superior mesenteric artery
D. Splenic artery
E. Right gastric artery

29. Answer: D
The blood supply to the pancreas is from the superior and inferior pancreaticoduodenal arteries and the
splenic artery.
The superior pancreaticoduodenal artery is a branch of the gastroduodenal artery, which is a branch of the
common hepatic artery of the coeliac axis.
The inferior pancreaticoduodenal artery is a branch of the superior mesenteric artery.

• The pancreaticoduodenal arteries supply the head of the pancreas.

• The body and tail are supplied by the pancreatic branches from the splenic artery.

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30. A 30-year-old lady is referred by her gp with a 3 -month history of a lump in her
neck. Examination reveals a fi rm lump in the anterior triangle on the right side of the
neck, which moves up with deglutition. Which of the following structures is responsible
for this upward movement on swallowing?

A. Pyramidal lobe
B. Berry’s ligament
C. Ligament of treitz
D. Thyroglossal duct
E. Cricothyroid membrane

30. Answer: B
In adults, the thyroid gland is a bilobed structure lying in the anterior neck.
The two lateral lobes are connected by the isthmus, which may have an associated pyramidal lobe extending
cephalad towards the base of the tongue the pretracheal fascia splits to enclose the thyroid gland.
The posteromedial aspect of the gland is attached to the side of the cricoid cartilage, and the fi rst and
second tracheal rings, by a condensation of the pretracheal fascia called the posterior suspensory ligament of
berry.
This is responsible for the upward movement of the thyroid gland on swallowing.
The ligament of treitz is the suspensory ligament of the duodenum, which arises from the right crus of the
diaphragm and inserts into the third and fourth parts of the duodenum (and frequently into the
duodenojejunal flexure).

31. A 24-year-old female has been in labour for more than 20 hours and the crown of the
foetal head is now visible through the vaginal orifi ce. The attending obstetrician decides
to perform a mediolateral episiotomy to enlarge the birth orifice and prevent tearing of
perineal structures. Which of the following structures is not incised during a
mediolateral episiotomy?

A. Perineal skin
B. Posterior wall of vagina
C. Perineal body
D. Attachment of bulbospongiosus muscle
E. Fascia around the urinary bladder

31. Answer: E
An episiotomy is performed when a perineal laceration seems to be inevitable, in order to protect the fascia
supporting the urinary bladder, urethra, external anal sphincter, levator ani and rectum. An uncontrolled tear
of these structures will result in poor perineal support of pelvic organs, resulting in prolapse of the urinary
bladder (cystocoele) and incontinence in later life.
An episiotomy therefore entails a clean cut that is made away from these important structures.

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32. A 25-year-old man presents to his gp with a painful swelling in the floor of his mouth
that becomes more painful during meals. Bimanual examination of the patient's mouth
suggests the presence of a stone in wharton’s duct. Which of the following provides the
best anatomical description of the opening of the wharton’s duct?

A. Buccal mucosa opposite the upper second molar

B. Buccal mucosa opposite the lower second molar
C. Either side of the frenulum of the tongue
D. Floor of the mouth
E. None of the above

32. Answer: C
The duct of the submandibular gland is also known as wharton’s duct. It runs along the floor of the mouth
and opens onto either side of the frenulum of the tongue.
In contrast, the parotid duct (stenson's duct) opens into the buccal mucosa opposite the second upper molar
tooth. The sublingual gland has about 8–20 ducts.
The smaller sublingual ducts (ducts of rivinus) either join the submandibular duct or open separately into the
mouth on the elevated crest of mucous membrane (plica sublingualis).
One or more of these join to form the major sublingual duct (duct of bartholin), which opens into the
submandibular duct.
Eighty percent of the calculi in salivary glands are found in the submandibular gland and the wharton’s duct
because of the primarily mucoid secretions of the submandibular gland, and the upward drainage angle of
wharton's duct.

33. A 34-year-old bowler presents with a gradual onset of right shoulder pain. He
specifically describes severe pain when he abducts and laterally rotates his arm.
Examination confirms severe pain on arm movement between 70–120 degrees of
abduction. Which structure is he not likely to have damaged?

A. Teres major
B. Teres minor
C. Supraspinatus
D. Infraspinatus
E. Subscapularis

33. Answer: A
The rotator cuff is a musculotendinous cuff formed by the tendons and insertions of the rotator cuff muscles
to reinforce the articular capsule of the glenohumeral joint. It holds the head of the humerus in the glenoid
cavity and stabilizes the joint through tonic contractions of the muscles.
Frequent microtrauma to the shoulder joint through activities such as bowling or throwing, which require
abduction of the arm, results in injuries and tears of the rotator cuff . As the supratendinous part of the

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rotator cuff is relatively avascular, this tears initially, resulting in severe pain and weakness when abducting
the arm from 70 to 120 degrees.
The reason that pain is not felt before and after this range of abduction is because the tendons of the rotator
cuff are not anatomically ‘impinged’ by the head of the humerus during this time. Of the options listed, only
teres major does not form part of the rotator cuff and cannot be implicated in the pain of such tendon
impingement.

34. Which of the following is the most superficial structure encountered whilst dissecting
into the popliteal fossa?

A. Tibial nerve
B. Posterior tibial artery
C. Superfi cial peroneal nerve
D. Popliteal artery
E. Sural nerve

34. Answer: A
The popliteal fossa is the shallow depression posterior to the knee joint, the boundaries of which are:
superomedial—semitendinosus; superolateral—biceps femoris; inferomedial—medial headof
gastrocnemius; and inferolateral—lateral head of gastrocnemius.
Its roof is formed by the skin, superficial fascia (containing the short saphenous vein), three cutaneous
nerves (terminal branch of posterior cutaneous nerve of thigh, posterior division of medial cutaneous nerve,
and peroneal or sural communicating nerve), and the deep (or popliteal) fascia.
The floor is formed by the popliteal surface of the femur, knee joint capsule, oblique popliteal ligament and
the strong fascia covering the popliteus muscle. During dissection within this fossa, the tibial nerve is the
most superficial structure encountered, followed by the popliteal vein, and lastly, the popliteal artery. Other
contents of the popliteal fossa include the common peroneal nerve and six or seven popliteal lymph nodes.

35. Which among the following statements about the inferior vena cava is correct?

A. It lies to the left of the abdominal aorta

B. It is contained in a groove on the posterior surface of the pancreas
C. It enters the diaphragm at the vertebral level t10
D. It is a retroperitoneal structure
E. It has three valves in the abdominal cavity before it enters the diaphragm

35. Answer: D
The inferior vena cava (ivc) conveys blood to the right atrium from all structures below the level of the
diaphragm. It is formed by the union of the common iliac veins anterior to the l5 vertebral body to the right
of the midline (note that the abdominal aorta bifurcates at the level of l4, just left of the ivc).
It ascends anterior to the vertebral column, lying to the right of the abdominal aorta.
Both the abdominal aorta and the ivc are retroperitoneal structures.

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The ivc is contained in a deep groove on the posterior surface of the liver.
It crosses the diaphragm at the level of t8, between its median and right leaves, and inclines slightly
anteromedially.
It then passes through the fi brous pericardium and opens into the inferoposterior aspect of the right atrium.
The abdominal part of the inferior vena cava is devoid of any valves.

36. A 63-year-old hyperthyroid patient notices a new prominent nodule within the right
lobe of her thyroid gland. A biopsy of the lump subsequently confi rms malignancy. She
then undergoes a total thyroidectomy. During the procedure, the surgeon’s fi eld of
vision is intermittently obscured by considerable bleeding from the gland. Which of the
following statements is correct regarding the vessels of the thyroid gland?

A. The inferior thyroid artery is usually the fi rst branch of the external carotid artery and supplies the
inferior poles of the gland
B. The superior thyroid artery is the fi rst branch of the internal carotid artery and descends to supply
the superior poles of the gland
C. The inferior thyroid artery is the largest branch of the thyrocervical trunk arising from the subclavian
artery
D. About 20% of people have an unpaired thyroid ima artery that usually arises directly from the
brachiocephalic trunk
E. The middle thyroid arteries supply the middle of the lobes

36. Answer: C
The thyroid gland is a highly vascular structure supplied by paired superior and inferior thyroid arteries.
The first branch of the external carotid artery is usually the superior thyroid artery, which descends
downwards to supply the superior pole.
It then divides into anterior and posterior branches, which anastomose in the midline.
The inferior thyroid artery is the largest branch of the thyrocervical trunk arising from the subclavian artery,
supplying the inferior poles of the gland. Around 10% of the population have a small unpaired thyroid ima
artery that usually arises directly from the brachiocephalic trunk. However, its origin may vary.
Although there is a middle thyroid vein, there is no middle thyroid artery.
The superior and middle thyroid veins drain into the internal jugular vein and the inferior thyroid veins drain
into the brachiocephalic veins.

37. A 26-year-old lady undergoes a high tie of the sapheno -femoral junction and
stripping of the long saphenous vein by the vascular sur geons. Prior to the operation the
surgeon counselled the patient regarding the possible complications of infection,
bleeding, bruising, scarring, and numbness along the medial aspect of the lower leg.
Which nerve supplies the sensation to the medial aspect of the lower leg?

A. Common peroneal nerve

B. Deep peroneal nerve
C. Superfi cial peroneal nerve

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D. Saphenous nerve
E. Sural nerve

37. Answer: D
The saphenous nerve is the largest cutaneous branch of the femoral nerve.
It is associated closely with the long saphenous vein and can be damaged easily during varicose vein
surgery.
The sural nerve runs on the posterolateral aspect of the leg along with the short saphenous vein to supply
sensation to the lateral aspect of the ankle, foot and 5th toe.
It is easily damaged during stripping of the short saphenous vein.
The superficial peroneal nerve supplies sensation to the dorsum of the foot except for the 1st dorsal web
space and innervates the peroneus longus and brevis muscles.
The deep peroneal nerve supplies sensation to the 1st dorsal web space and innervates tibialis anterior,
extensor hallucis longus and extensor digitorum longus muscles.
The common peroneal nerve supplies the biceps femoris and gastrocnemius muscles. Damage to this nerve
will result in failure to dorsifl ex and evert the foot and hence, foot drop.

38. Which of the following structures is unlikely to be damaged during a carotid

endarterectomy procedure?
A. Hypoglossal nerve
B. Buccal branch of the facial nerve
C. External laryngeal nerve
D. Ansa cervicalis
E. Pharyngeal branch of the vagus nerve

38. Answer: B
Many vital structures can be damaged during a carotid endarterectomy procedure.

• The hypoglossal nerve crosses the external carotid artery just above its bifurcation. Damage to this
nerve results in loss of normal motor function of the tongue (on protrusion, the tongue is pulled
towards the aff ected side)
• The buccal branch of the facial nerve does not run close to the field of surgery and, as such, is
unlikely to be damaged during a carotid endarterectomy procedure. However, the marginal
mandibular branch of the facial nerve can be damaged due to retraction of the nerve during the
procedure.
• The external laryngeal nerve runs close to the superior thyroid artery and supplies the cricothyroid
muscle. Damage to this nerve causes loss of phonation over prolonged periods of time.
• The ansa cervicalis lies within the carotid sheath and supplies the infrahyoid strap muscles.
• The pharyngeal branch of the vagus nerve is also at risk of injury at a higher level and paralysis of
this nerve causes difficulty in swallowing.

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39. A 55-year-old hypertensive man with a 60-pack-year smoking history is referred by

his gp to the vascular surgeon for the incidental fi nding of an expansile, pulsatile mass
in his left popliteal fossa. Further imaging confirms the presence of a popliteal artery
aneurysm. Whilst in clinic, the surgeon asks his surgical trainee to describe the anatomy
of the popliteal fossa. Which of the following structures is most likely to lie immediately
superfi cial to the popliteal artery aneurysm?

A. Common peroneal nerve

B. Small saphenous vein
C. Popliteal fascia
D. Popliteal vein
E. Sural nerve

39. Answer: D
The structures of the popliteal fossa (from superfi cial to deep) include the common peroneal nerve,
popliteal vein, popliteal artery (i.e. As a continuation of the femoral artery), tibial nerve, and the popliteal
lymph nodes. Such anatomy is especially useful when performing local anaesthetic blockade of the
common peroneal nerve, as the vein and artery are relatively protected from the needle.
The boundaries of the popliteal fossa are:

• Superolaterally: biceps femoris tendon

• Superomedially: semitendinosus and semimembranosus tendons
• Inferolaterally: plantaris muscle and lateral head of gastrocnemius
• Inferomedially: medial head of gastrocnemius.
The roof of the popliteal fossa (from superficial to deep) is comprised of skin; the superficial fascia (which
contains the small saphenous vein, the terminal branch of the posterior cutaneous nerve of the thigh, the
posterior division of the medial cutaneous nerve, the lateral sural cutaneous nerve and the medial sural
cutaneous nerve); and the deep (popliteal) fascia.
The floor of the popliteal fossa is formed by the popliteal surface of the femur, the knee joint capsule with
the oblique popliteal ligament, and the strong popliteus muscle fascia.

40. An orthopaedic surgeon performs an arthroscopic subacromial decompression on a

45-year-old woman suff ering from supraspinatus tendinopathy. Which of the following
statements regarding the anatomy of the shoulder joint is most accurate?

A. The shoulder joint most commonly dislocates in a posterior fashion

B. Weakness of teres major will result from trauma to the nerve related to the surgical neck of the
humerus
C. The shoulder joint capsule receives most support from its inferior aspect
D. The subacromial bursa usually communicates with the shoulder joint cavity
E. The origin of triceps lies within the shoulder joint capsule

40. Answer: B
The axillary nerve (c5, c6) arises from the posterior cord of the brachial plexus and passes through the
quadrilateral space just below the shoulder joint. This space is bound superiorly by subscapularis and teres

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minor; inferiorly by teres major; medially by the long head of triceps brachii; and laterally by the surgical
neck of the humerus.
It is important to note that the axillary nerve and the posterior circumfl ex humeral artery, both of which pass
through the quadrilateral space, may be damaged by trauma or space-occupying lesions in this region.
The axillary nerve then curves around the posterolateral surface of the humerus deep to the deltoid, dividing
into anterior and posterior branches, both of which supply the deltoid muscle. The posterior branch also
forms the upper lateral cutaneous nerve of the arm, which supplies the skin overlying the deltoid.
The axillary nerve also gives off a branch supplying the teres minor. The subacromial bursa is the synovial
membrane located just below the acromion; it does not usually communicate with the shoulder joint capsule,
and is often the site of pathology in shoulder impingement. The long head of triceps brachii originates at the
infraglenoid tubercle of the scapula, while the medial and lateral heads originate from the posterior aspect of
the humerus.
Therefore, no part of the triceps is considered to lie within the shoulder joint capsule (unlike the biceps
brachii, which has a long head that extends inside the capsule to attach to the supraglenoid tubercle of the
scapula).
The shoulder or ‘glenohumeral’ joint has a loose capsule that is lax inferiorly and is therefore at risk of
dislocation in an anteroinferior direction (>95%), potentially damaging the axillary artery. Posterior
dislocations are rarer and are usually due to electrocution or seizure activity (i.e. Causing unbalanced
contractions of the rotator cuff muscles, resulting in the humeral head dislocating posteriorly).

41. Which of the following is not true about the jejunum?

A. It is bright pink in appearance and is thin walled

B. It only has a sparse amount of lymphoid tissue
C. The mesentery of the jejunum has fat deposited near the root and is scanty at the intestinal end
D. The jejunal mesenteric vessels form only single or double arcades with long vasa recta
E. The jejunal mesentery is attached to the posterior abdominal wall to the left of the aorta

41. Answer: A
Beyond the duodenojejunal fl exure the small bowel is divided into the jejunum (proximal onethird) and
ileum (distal two-thirds). There are no defi ning features but the jejunum can be distinguished from the
ileum by the following features:

• The jejunum is of larger calibre, thick walled, and redder than the ileum, which is more purplish in
appearance. The jejunal wall feels thicker because of the permanent infoldings of the mucous
membrane, the plicae semilunaris are larger, more numerous, and closely set in the jejunum, whereas
in the upper part of the ileum they are smaller and more widely separated, and in the lower part they
are absent.
• The jejunal mesenteric vessels form single or double arterial arcades with long vasa recta while the
ileal vessels form multiple arcades with short vasa recta.
• Lymphoid tissue is sparse in the jejunum but numerous in the ileum in the form of peyer’s patches.
• The fat on the jejunal mesentery is abundant near the root and scant near the intestinal end while it is
deposited evenly throughout the ileal mesentery. The root of the mesentery extends 15 cm from

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duodenojejunal fl exure at the level of l2, inferomedially to the ileocecal junction in the right iliac
fossa.

42. A 30-year-old-man sustains a fall and presents with bleeding from his right nostril.
On examination, he looks well and is haemodynamically stable. Anterior rhinoscopy
reveals bleeding from the anterior part of the nasal septum corresponding to little’s
area. Which of the following arteries is not responsible for the epistaxis?

A. Sphenopalatine artery
B. Greater palatine artery
C. Anterior ethmoidal artery
D. Superior septal perforator artery
E. Superior labial artery

42. Answer: D
Little’s area is present in the anteroinferior part of the nasal septum and most bleeds (90%) originate here.It
is marked by the convergence of the anterior ethmoidal, superior labial, sphenopalatine and greater palatine
arteries. This is also known as kiesselbach’s plexus. In general, epistaxis is very common and has a bimodal
age distribution (i.e. 2-10 years and 50-80 years). In children, epistaxis is usually due to nose picking and
foreign bodies. Adult epistaxis is more likely to be idiopathic or traumatic in aetiology. In contrast, posterior
epistaxis is more common in the elderly and usually arises from the branches of the sphenopalatine artery.

43. A 12-year-old boy presents with a 3-day history of migratory abdominal pain and
vomiting. He is found to have localized peritonism in his right iliac fossa warranting an
appendicectomy. During the operation the appendix is felt to be retrocaecal and very
adherent to the surrounding structures. The surgeon extends the wound laterally to get
better Access. Which structure needs to be identifi ed and preserved when making this
transverse incision?

A. Iliohypogastric nerve
B. Ilioinginal nerve
C. Intercostobrachial nerve
D. Inferior epigastric artery
E. Superfi cial epigastric artery

43. Answer: A
The iliohypogastric nerve perforates the posterior part of the transversus abdominis muscle and divides
between this and the internal oblique muscle into lateral and anterior cutaneous branches, and muscular
branches to both these muscles.
This nerve may be cut during a transverse incision for appendicectomy, resulting in muscle weakness and a
subsequent predisposition to developing direct inguinal hernias.
Like the iliohypogastric nerve, the ilioinguinal nerve also arises from the l1 nerve root, but passes through
the 2nd and 3rd layers of abdominal wall musculature and passes through the inguinal canal. It lies inferior
to mcburney’s point and is therefore less likely to be damaged.

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44. Which of the following is not a remna nt of the wolffi an duct?

A. Hydatid cyst of morgagni

B. Appendix epididymis
C. Tunica vaginalis
D. Organ of giraldes
E. Ductulus aberrans

44. Answer: A
There are four types of testicular appendages:

• Appendix testis (hydatid cyst of morgagni)

• Appendix epididymis
• Paradidymis (organ of giraldes)
• Ductulus aberrans (vas aberrans of haller)
The commonest testicular appendage is the appendix testis, which is a remnant of the paramesonephric
(mullerian) duct. The rest are remnants of the mesonephric duct (wolffi an duct).
Torsion of the testicular appendage is the commonest cause of an acute scrotum in pre-pubertal boys.
Testicular appendages are present in 85–90% of testes but only a minority will develop torsion.
The tunica vaginalis (i.e. The serous covering of the testis) is a pouch of serous membrane derived from the
processus vaginalis.

45. A 14-year-old boy falls from a tree onto his right shoulder, in such a manner that his
shoulder is depressed, and his head and neck are forcefully flexed to the other side of the
body. Examination in the emergency department reveals paralysis of his right upper limb
as it hangs limply by his side. It is found to be abducted and medially rotated with an
extension of the elbow and pronation of the forearm so that th e palmar surface of the
hand is facing posteriorly. What is/are the most likely nerve root/s to have been injured?

A. C5 only
B. C5 and c6
C. C6 and c7
D. C7 and c8
E. C8 and t1

45. Answer: B
This type of trauma classically injures the upper brachial plexus, particularly the ventral rami of c5 and c6,
the consequences of which are in keeping with the clinical findings described.
The muscles supplied by the nerves arising from these rami and the superior trunk are paralysed. These
muscles are the deltoid, biceps brachii, brachialis, brachioradialis, supraspinatus, infraspinatus, teres minor
and supinator.

• Paralysis of teres minor and infraspinatus (lateral rotators) results in medial rotation of the arm.
• Paralysis of biceps (a secondary supinator), results in pronation of the forearm.

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• Paralysis of brachialis and biceps brachii results in weakness of elbow flexion.

• Inability of the patient to flex his upper arm results from paralysis of the deltoid, coracobrachialis
and the clavicular head of pectoralis major.
• Paralysis of the supraspinatus and deltoid muscles results in the loss of abduction at the shoulder
joint.

46. A 31-year-old motorcyclist is brought to the emergency department following a high-

speed road traffi c accident. On examination, he is noticed to have bruising on his right
arm. He is unable to actively extend his wrist or the fi ngers of this hand. Plain
radiography of the arm reveals a mid-shaft fracture of the humerus. Which of the
following nerves is most likely to be damaged following a midhumeral fracture?

A. Anterior interosseous nerve

B. Axillary nerve
C. Radial nerve
D. Median nerve
E. Musculocutaneous nerve

46. Answer: C
The clinical signs and the type of bony injury are consistent with an injury to the radial nerve.
The radial nerve (c5–t1) is the largest branch of the posterior cord of the brachial plexus and is most
frequently injured following a mid-shaft fracture of the humerus.
The course of this nerve is as follows: after leaving the axilla, the radial nerve gives three sensory branches
and innervates the three heads of the triceps muscle and the anconeus. It then winds down the humerus in the
spiral groove, after which it gives muscular branches to the brachioradialis, the extensor carpi radialis
longus, and the supinator muscles, before bifurcating into sensory and motor branches.
The sensory branch, the superficial radial nerve, travels along the radial aspect of the forearm and provides
sensation to the 1st web-space region. At the elbow, the motor branch of the radial nerve becomes the
posterior interosseous nerve and enters the extensor compartment through the supinator muscle under the
arcade of frohse. There it supplies the remaining extensors of the wrist, thumb and fi ngers.
If the nerve is injured in the region of the spiral groove, all the long extensors of the wrist and fi ngers are aff
ected, resulting in wrist drop.

47. Which of the following nerves does not pass through the superior orbital fissure?

A. Ophthalmic branch of the trigeminal nerve

B. Trochlear nerve
C. Optic nerve
D. Abducens nerve
E. Oculomotor nerve

47. Answer: C

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The middle cranial fossa communicates with the orbit via the superior orbital fi ssure. The orbital fissure is
bounded superiorly by the lesser wing of the sphenoid, inferiorly by the greater wing, and medially by the
body of the sphenoid. The fi ssure is wider on its medial aspect.
The superior orbital fissure transmits a number of structures including: the oculomotor, trochlear, and
abducent nerves; the frontal, lacrimal, and nasociliary branches of the trigeminal nerve; the internal carotid
sympathetic plexus; the ophthalmic vein; the orbital branch of the middle meningeal artery; and the
recurrent branch of the lacrimal artery.
The optic nerve, along with ophthalmic artery, passes through the optic canal which lies lateral to the
pituitary fossa.

48. A 22-year-old brick layer presents to his gp with altered sensation over the medial
aspect of his right hand and reduced hand function. He had sustained a fracture of the
medial epicondyle of the right humerus about 10 weeks ago. On examination, there is
wasting of the hypothenar eminence with loss of abduction and adduction of the fingers.
Which nerve do you think is most likely to have been injured in this patient?

A. Axillary nerve
B. Radial nerve
C. Ulnar nerve
D. Median nerve
E. Musculocutaneous nerve

48. Answer: C
The ulnar nerve (c8, t1) arises from the medial cord of the brachial plexus or, more specifi cally, the anterior
division of the lower trunk. This nerve is commonly damaged following injury to the medial epicondyle of
the humerus. It can also be injured in other types of humeral fractures.
Ulnar nerve injury may lead to paralysis of the small muscles of the hand; paralysis of the interossei results
in loss of adduction and abduction of the fingers.
Thumb adduction may be lost due to loss of innervation of adductor pollicis brevis (the other thenar
muscles are supplied by the median nerve). Clawing of the little and ring fingers, known as the ‘ulnar claw
hand’, is seen in low ulnar nerve injuries where the extension of the fi ngers is lost due to paralysis of the
medial two lumbricals but the figers become flexed due to the unopposed action of the long flexors (flexor
digitorum superficialis and flexor digitorum profundus).
High ulnar nerve lesions cause loss of action of the above flexors to the little and ring fingers and hence
there is no clawing of the hand.

49. A 45-year-old-male undergoes an elective inguinal hernia repair. Intraoperatively,

the junior surgical trainee is asked to identify if the hernia is a direct or an indirect
hernia. Which anatomical landmark is most likely to help her answer this question?

A. Mid-inguinal point
B. Midpoint of the inguinal ligament
C. Pubic tubercle
D. Spermatic cord

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E. Inferior epigastric artery

49. Answer: E
An inguinal hernia is the abnormal protrusion of the contents of the abdominal cavity through the inguinal
canal. The inguinal canal runs from the midpoint of the inguinal ligament (the deep inguinal ring) to a point
above and medial to the pubic tubercle (superficial inguinal ring).
The anterior wall of the canal is formed by the external oblique aponeurosis.
The posterior wall is formed by the conjoint tendon and transversalis fascia.
The floor is formed by the inguinal and lacunar ligaments and the roof is formed by the internal oblique and
transversus abdominis.
An indirect inguinal hernia protrudes through the deep ring due to a patent processus vaginalis. It is
therefore covered by the internal spermatic fascia and lies lateral to the inferior epigastric artery.
In contrast, a direct inguinal hernia occurs as a result of weakening of the transversalis fascia. It is therefore
not covered in spermatic fascia and lie medial to the inferior epigastric artery.

50. A 65-year-old presents to his gp with weakness along the right side of his mouth and
lower lip. He states that he has diffi culty in closing his mouth and is unable to move his
lower lip. On examination, there is loss of sensation over the mandible and the chin on
the right side. The patient states that he has noticed these symptoms since he underwent
excision of his right submandibular gland for a malignant tumour 2 weeks previously.
Which nerve is most likely to have been injured in this patient to cause these symptoms?

A. Mandibular branch of the trigeminal nerve

B. Glossopharyngeal nerve
C. Lingual nerve
D. Marginal mandibular branch of the facial nerve
E. Hypoglossal nerve

50. Answer: D
It is most likely that this patient has sustained an injury to the marginal mandibular branch of the facial
nerve during surgical removal of the submandibular gland. The submandibular gland occupies most of the
submandibular or the digastric triangle.
The marginal mandibular branch of the facial nerve courses between the deep surface of the platysma and
the superficial aspect of the fascia that overlies the submandibular gland.
The nerve supplies muscles of the lower lip and the chin. Injury to the nerve may thus result in difficulty in
closing the mouth and loss of sensation over the chin and mandible.
The facial artery and vein are located just deep to this nerve.
The lingual nerve and submandibular duct (wharton's duct) lie along the posterior border of the mylohyoid
muscle.

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The hypoglossal nerve courses deep to the tendon of the digastric muscle and then lies medial to the deep
cervical fascia.

51. In view of the possible operative damage to the recurrent laryngealnerve during
thyroid surgery, a patient is requested to undergo laryngoscopy as part of his
preoperative assessment to determine the baseline function of his vocal c ords. Which
muscle is primarily responsible for the abduction of the vocal cords?

A. Cricothyroid muscle
B. Lateral cricoarytenoid muscle
C. Posterior cricoarytenoid muscle
D. Thyroarytenoid muscle
E. Transverse arytenoid muscle

51. Answer: C
The posterior cricoarytenoid muscles are small, paired laryngeal muscles that extend from the posterior
cricoid cartilage to the arytenoid cartilages. By rotating the arytenoid cartilages laterally, these muscles
abduct the vocal cords and thereby open the rima glottidis.
Their action opposes the lateral cricoarytenoid muscles, which are primarily responsible for vocal cord
adduction. Both the posterior and lateral cricoarytenoid muscles are innervated by the recurrent laryngeal
nerve. Paralysis of the posterior cricoarytenoid muscles may lead to asphyxiation as they are the only
laryngeal muscles to open the true vocal folds, allowing inspiration and expiration.
The cricothyroid muscle originates from the anterolateral cricoid cartilage and inserts into the inferior cornu
and lamina of the thyroid cartilage. It is the only laryngeal muscle to be supplied by the external branch of
the superior laryngeal nerve (i.e. Instead of the recurrent laryngeal nerve).
Its contraction produces tension and elongation of the vocal folds, resulting in higher pitched phonation.
The thyroarytenoid is a broad, thin muscle lying parallel and lateral to the vocal fold. It functions to allow
fine tonal control of the vocal cords.
The transverse arytenoid muscle is an unpaired muscle that crosses transversely between the two arytenoids
cartilages, serving to adduct them.
Both of these muscles are supplied by the recurrent laryngeal nerve.

52. An obstetrician performs a pudendal nerve block to anaesthetize the perineum of a

pregnant woman in labour. Which of the following statements accurately describes the
pudendal nerve?

A. It arises from the posterior rami of nerve roots s2, s3, and s4
B. It crosses the ischial spine on the lateral side of the internal pudendal artery
C. It exists the pelvis through the lesser sciatic foramen

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D. It supplies the levator ani

E. It supplies the testes

52. Answer: D
The pudendal nerve is a somatosensory nerve in the pelvic region and is a large branch of the sacral plexus
(l4–l5, s1–s4). It originates in onuf’s nucleus in the sacral region of the spinal cord and arises from the
anterior rami of the 2nd–4th sacral roots.
The nerve passes between piriformis and coccygeus, leaving the pelvis through the lower part of the greater
sciatic foramen. It crosses the ischial spine and re-enters the pelvis through the lesser sciatic foramen.
It then accompanies the internal pudendal vessels upward and forward along the lateral wall of the
ischiorectal fossa, being contained in a sheath of the obturator fascia (i.e.The pudendal canal).
The pudendal nerve gives off the inferior rectal nerves before dividing into two terminal branches: the
perineal nerve, and the dorsal nerve of the penis (in males) or the dorsal nerve of the clitoris (in females).
The inferior rectal nerve innervates the external anal sphincter and the perianal skin.
The perineal nerve innervates the sphincter urethrae and other muscles of theanterior compartment via a
deep branch, and the skin of the perineum posterior to the clitoris via its superficial branch.
The dorsal nerves of the penis and clitoris innervate the skin of the penis and that surrounding the clitoris
respectively. The levator ani muscles are mostly innervated by the pudendal nerve, perineal nerve and
inferior rectal nerve in concert.
The testes are innervated by the spermatic (or ‘testicular’) plexus, which is derived from the renal plexus
(which itself receives branches from the aortic plexus).
As demonstrated by this case, it is important to remember the structures passing through the greater and
lesser sciatic foramina:
❖ Greater sciatic foramen:
• Above piriformis: superior gluteal vessels; superior gluteal nerve
• Below piriformis: inferior gluteal and internal pudendal vessels; inferior gluteal nerve;
pudendal nerve; sciatic nerve; posterior femoral cutaneous nerve; nerve to obturator internus;
nerve to quadratus femoris
❖ Lesser sciatic foramen:
• Tendon of obturator internus; internal pudendal vessels; pudendal nerve; nerve to the
obturator internus.

53. Which of the following is not true about coronary blood supply?

A. The sinoatrial (sa) node is usually supplied by the right coronary artery
B. 90% of human hearts are right dominant
C. The left coronary artery is usually smaller than the right coronary artery
D. The coronary arteries arise from the sinus of valsalva
E. 3% of hearts are codominant

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53. Answer: C
The right coronary artery arises form the anterior aortic sinus. It proceeds along the right atrioventricular
groove and gives rise to the marginal branch, which supplies the right ventricle.
The left coronary artery, which is usually larger than the right coronary artery, arises from the left posterior
aortic sinus and divides into the anterior interventricular branch and a circumflex Branch in the
atrioventricular groove. Dominance is based on the origin of the posterior interventricular artery. In right
dominance (90%) the posterior interventricular artery is a large branch of the right coronary artery.
Approximately 3% of hearts are co-dominant. The sinoatrial node is usually supplied by the right coronary
artery but sometimes by the left coronary artery. The AV node is consistently supplied by the right coronary
artery.

54. A 28-year-old woman undergoes a wide local excision of a right -sided breast lump
along with right axillary clearance. Postoperatively, she complains of numbness in her
inner arm and axilla. Which nerve injury has likely caused the patient’s symptoms?

A. Medial cutaneous nerve of arm

B. Long thoracic nerve
C. Thoracodorsal nerve
D. Intercostobrachial nerve
E. Axillary nerve

54. Answer: D
After performing the wide local incision, a second transverse incision is made in the axilla. Dissection
progresses through the subcutaneous fat and the clavipectoral fascia down to the lateral border of the
pectoralis major. The axillary vein and thoracodorsal pedicle are identified and preserved.
The intercostobrachial nerve (t2) is also protected if possible, but if it gets in the way of the complete
excision of lymph nodes then it can be divided.
The long thoracic nerve is also preserved.
The intercostobrachial nerve is the lateral cutaneous branch of the second intercostal nerve.
The medial cutaneous nerve of the arm (c8, t1) arises from the medial cord and is the smallest branch of the
brachial plexus.
The long thoracic nerve of bell arises from the c5–c7 nerve roots and supplies the serratus anterior. The
thoracodorsal nerve arises from the posterior cord of the brachial plexus and supplies the latissimus dorsi.

55. A 65-year-old male is admitted to hospital with abdominal pain, back pain and
collapse. Physical examination reveals an expansile, pulsatile mass in his abdomen and
weak femoral pulses. As he is haemodynamically stable, he undergoes a ct scan to
confirm the suggestion of a ruptured abdominal aortic aneurysm. After a decision to
operate is made, emergency repair of his 10 cm aneurysm with a dacron graft requires
extensive mobilization of the aorta and ligation of several segmental vessels. After the
operation, he is found to be paraplegic, impotent, and incontinent o f urine and faeces.
What is the single most likely structure to have been damaged during surgery?

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A. Inferior intercostal artery

B. Lumbar artery
C. Posterior spinal artery
D. Great anterior segmental medullary artery
E. Spinal cord

55. Answer: D
Three main longitudinal arteries supply blood to the spinal cord it. These comprise an anterior spinal artery
and two posterior spinal arteries that are unlikely to be damaged during the procedure.
The spinal cord also receives arterial supply from branches of the vertebral (directly off the aorta), ascending
cervical, deep cervical, intercostal, lumbar and lateral sacral arteries. The circulation to much of the inferior
portion of the spinal cord is supplied by the anterior and posterior segmental medullary arteries which are
located chiefly at the cervical and lumbosacral enlargements. They enter the canal through the intervertebral
foramina.
The great anterior medullary artery (i.e. Artery of adamkiewicz) supplies blood to the inferior two-thirds of
the spinal cord and is found on the left side in 65% of people. The accidental ligation of this artery may
result in a loss of function of the lower limbs, bladder and intestines, although patients commonly remain
asymptomatic due to adequate collateral blood supply to these areas.

56. A surgeon wishes to obtain access into the popliteal fossa. Of the options listed, which
is the first structure to be encountered whilst operating in this region?

A. Common peroneal nerve

B. Popliteal artery
C. Popliteal vein
D. Posterior femoral cutaneous nerve
E. Sural nerve

56. Answer: E
The popliteal fossa is a diamond-shaped region on the posterior aspect of the knee. It is bounded
superomedially by the semimembranosus and semitendinosus muscles; superolaterally by the biceps femoris
muscle; and inferolaterally and inferomedially by the lateral and medial heads of the gastrocnemius muscle
respectively. The fossa is overlain by the popliteal fascia, which is perforated by the short saphenous vein
and the sural nerve. The sural nerve is the most superfi cial structure and is thus most likely to be
encountered when the popliteal fossa is explored during surgery. The important contents of the fossa include
the popliteal artery and vein, tibial and common peroneal nerves, short saphenous vein, sural nerve,
posterior femoral cutaneous nerve, and obturator nerve.

57. A 60-year-old man is referred to the head and neck clinic with a lump in his cheek 2
cm anterior to the tragus of his right ear. He describes rapid growth of the swelling over
the previous 2 months, associated with right-sided facial droop. Assuming that the lump
is a parotid tumour, the surgeon proceeds to examine for regional lymphadenopathy.
Which of the following nodes are lymphatic metastases from the parotid most likely to
reach?

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A. Submandibular nodes
B. Superfi cial cervical nodes
C. Deep cervical nodes
D. Posterior cervical nodes
E. Supraclavicular nodes

57. Answer: C
Malignant parotid tumours would metastasize to the deep cervical nodes. These nodes form a chain along
the course of the internal jugular vein from the skull to the root of the neck.
Lymph node group anatomical sites drained

• Submandibular>>>>> oral cavity

• Preauricular>>>> scalp and skin
• Posterior cervical>>>> scalp, neck, upper thoracic skin
• Deep cervical >>>(to jugular trunk)
• Superficial cervical>>> larynx, tongue, oropharynx, anterior neck
• Supraclavicular >>>gastrointestinal tract, genitourinary tract and pulmonary regions

58. Which of the following groups of lymph nodes is not involved in the lymphatic
drainage of the thyroid gland?

A. Brachiocephalic lymph nodes

B. Thoracic duct (directly)
C. Deep cervical lymph nodes
D. Paratracheal lymph nodes
E. Pectoral lymph nodes

58. Answer: E
There are numerous lymphatic vessels that drain lymph from the thyroid gland. Due to this, there is a high
propensity for metastasis of thyroid malignancies. The lymph from the thyroid gland is drained by:
1) The pre-laryngeal nodes (that lie above thyroid isthmus) via the tracheal plexus;
2) The pre-tracheal nodes (that lie along the recurrent laryngeal nerve);
3) The paratracheal nodes (that also lie along the recurrent laryngeal nerve);
4) The brachiocephalic nodes (that lie in the superior mediastinum);
5) The deep cervical nodes via the superior thyroid vessels; and
6) The thoracic duct (directly).
The pectoral nodes, which lie along the inferior border of the pectoralis minor, drain most of the breast (and
not the thyroid).

59. A 63-year-old lady undergoes a parathyroidectomy for the treatment of primary

hyperparathyroidism under the care of the endocrine surgeons. Intraoperatively, she is
found to have a right inferior parathyroid adenoma, which is excised. On the ward round
the following morning, she complains of hoarseness in her voice which she did not
experience prior to the operation. What is the most likely cause for her symptoms ?

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A. Intubation
B. Unilateral damage to the external laryngeal nerve
C. Unilateral damage to the recurrent laryngeal nerve
D. Bilateral damage to the recurrent laryngeal nerve
E. Haematoma of the neck

59. Answer: C
The recurrent laryngeal nerve (rln) is a branch of the vagus nerve. It is described as recurrent due to its
roundabout route: it descends down into the thorax before ascending to supply the larynx. It provides motor
innervation to all the laryngeal muscles (except for the cricothyroid) and sensation to the larynx.
In the neck, it is found behind the thyroid towards the inferior pole, In close association with the inferior
thyroid artery.
The nerve can pass above, below, or through the branches of this artery. The rln can be easily damaged
during thyroid and parathyroid surgery.
Unilateral damage to the rln will result in unilateral paralysis of the vocal cords and hoarseness of voice.
Bilateral damage will present as marked dysphonia and difficulty in breathing.
The right rln lies more medially than the left and is therefore more likely to be damaged. The external
laryngeal nerve is a small bra+nch of the superior laryngeal nerve, which descends on the larynx to supply
the cricothyroid muscle.
Damage to this nerve will present with difficulty in producing high pitched sounds and alteration in the
fundamental speaking frequency, especially in women or professional singers.
Many surgeons recommend that patients undergoing parathyroid and thyroid surgery routinely undergo
preoperative laryngoscopy to assess the vocal cords.

60. A 69-year-old gentleman presents to his gp with weakness of his rightshoulder. Three
months previously, he underwent a right cervical lymph node sampling for suspected
metastasis of a squamous cell carcinoma of the floor of his mouth. Examination reveals
muscle wasting in his right shoulder and neck, with associated ri ght shoulder droop. The
patient is unable to shrug the shoulder and his scapula appears prominently when he
attempts to externally rotate his shoulder against resistance. Which of the following
nerves is most likely to have been injured in this patient?

A. Long thoracic nerve

B. Median pectoral nerve
C. Transverse cervical nerve
D. Supraclavicular nerve
E. Spinal accessory nerve

60. Answer: E
This patient has the classical features of injury to the spinal accessory nerve. The superficial course of the
spinal accessory nerve in the posterior cervical triangle makes it susceptible to both trauma and surgical
injuries.

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Iatrogenic injury to the nerve can result from surgery to this region such as during radical neck dissection
(for removal of pathological lymph nodes), cervical lymph node Biopsy, cannulation of the internal jugular
vein, and carotid endarterectomy.
The spinal accessory nerve provides motor innervation to the sternocleidomastoid and the upper part of the
trapezius muscles. The sternocleidomastoid muscle helps in the side-to-side movement of the neck, and tilts
and rotates the head, whilst the trapezius muscle elevates, laterally rotates and retracts the scapula.
Patients with injury to the spinal accessory nerve (and subsequent dysfunction of the trapezius) present with
an asymmetric neckline, drooping shoulder and winging of the scapula (also seen in serratus anterior muscle
palsy due to weakness or paralysis of the long thoracic nerve). However, long thoracic nerve injury does not
cause drooping of the shoulder.

61. A 25-year-old diabetic man presents to his gp with a 48 -hour history of neck swelling
and dysphagia. He also describes a longstanding history of dental pain originating from
his left lower second molar. Examination reveals bilateral, tense neck swellings with
overlying erythema, and an elevated and protruding tongue. Which of the following
fascial compartments is most likely to be infected?

A. Prevertebral space
B. Retropharyngeal space
C. Parapharyngeal space
D. Submandibular space
E. Carotid sheath

61. Answer: D
Ludwig’s angina describes infection within the submandibular space. It is most common caused by
odontogenic infections (>90%). Once developed, it can spread to the retropharyngeal space.
The most life-threatening complication of ludwig’s angina is airway obstruction and therefore airway
management is the foundation of its treatment. In the era prior to the development of antibiotics, mortality
from this condition exceeded 50%.
The submandibular space lies between the floor of the mouth and the investing layer of fascia, bounded by
the mandible superiorly till the mastoid process and the two bellies of the digastric muscle. The
submandibular space is divided by the mylohyoid muscle into the sublingual space superiorly and
submaxillary space inferiorly.
The retropharyngeal space lies between the prevertebral fascia and the fascia covering the pharynx.
Abscesses in the retropharyngeal space can cause oedema and dysphagia.
The prevertebral space lies between the prevertebral fascia and the vertebral bodies. An abscess in this space
can extend as far down as the thoracic vertebrae.

62. A male patient undergoes an elective open inguinal hernia repair. The surgeon opens
the spermatic cord to identify the hernia sac. Which structure is is unlikely to be found
within the spermatic cord?

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A. Artery to the vas deferens

B. Genital branch of the genitofemoral nerve
C. Ilioinguinal nerve
D. Testicular artery
E. Vas deferens

62. Answer: C
The inguinal canal contains the spermatic cord and the ilioinguinal nerve. The spermatic cord is ensheathed
in the following three layers:
• External spermatic fascia (extension of the innominate fascia overlying the aponeurosis of
The external oblique)
• Cremasteric muscle (extension of the internal oblique and transversus abdominis)
• Internal spermatic fascia (continuation of the transversalis fascia)
The spermatic cord contains the following structures:
• Arteries: testicular artery, artery to the vas deferens, cremasteric artery__nerves: genital branch
of the genitofemoral nerve and sympathetics (note that the Ilioinguinal nerve runs within the
inguinal canal but lies outside of the spermatic cord)
• Other structures: vas deferens, pampiniform plexus, and lymphatics

63. Which of the following nerves does not arise from the medial cord of the brachial
plexus?

A. Medial cutaneous nerve of the forearm

B. Medial pectoral nerve
C. Musculocutaneous nerve
D. Ulnar nerve
E. Median cutaneous nerve of the arm

63. Answer: C
The following nerves arise from the medial cord of brachial plexus:

• The medial cutaneous nerve of the forearm (c8 and t1);

• The median cutaneous nerve of the arm (c8 and t1);
• The medial root of the median nerve (c8 and t1);
• The medial pectoral nerve (c8 and t1); and
• The ulnar nerve (c8 and t1).
The musculocutaneous nerve (c5, c6, and c7) arises from the lateral cord of the Brachial plexus. The other
nerves which arise from the lateral cord of the brachial plexus are the lateral pectoral nerve (c5, c6, c7) and
the lateral root of the median nerve (c5, c6, c7).

64. An adolescent boy is seen in the emergency department after experiencing a sharp
pain in his throat after ea ting bony fi sh. The ent surgical registrar on call manages to
retrieve the fi sh bone nonsurgically but is unsure if there may have been damage to the

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mucosa of the piriform fossa. Which nerve constitutes the aff erent (sensory) supply to
the piriform fossa?

A. External laryngeal nerve

B. Glossopharyngeal nerve
C. Hypoglossal nerve
D. Internal laryngeal nerve
E. Recurrent laryngeal nerve

64. Answer: D
The piriform fossae are recesses on either side of the laryngeal orifi ces, which are involved in speech. They
are bounded medially by the aryepiglottic fold, and laterally by the thyroid cartilage and thyrohyoid
membrane.
The internal laryngeal nerve (a branch of the superior laryngeal nerve) supplies sensory innervation to the
area (and also the mucous membrane to the rest of the larynx), and may become damaged if the mucous
membrane is inadvertently punctured.
The nerve ends by anastomosing with branches of the recurrent laryngeal nerve behind (or within) the
posterior cricoarytenoid muscle; and the connection may pierce the inferior constrictor of the pharynx.
In contrast, the external laryngeal nerve is the smaller, external branch of the superior laryngeal Nerve. It
descends on the larynx beneath the sternothyroid muscle, to supply the cricothyroid muscle.
It also gives branches to the pharyngeal plexus and the superior portion of the inferior pharyngeal
constrictor, and communicates with the superior cardiac nerve behind the common carotid artery. The
commonest modes of damage to the external laryngeal nerve include thyroidectomy and cricothyroidotomy,
as the nerve lies immediately deep to the superior thyroid artery.
The glossopharyngeal nerve generally provides sensory innervation to the skin of the external ear, the
internal surface of the tympanic membrane, the walls of the upper pharynx, and the posterior third of the
tongue.
The recurrent laryngeal nerve provides sensory innervation to the larynx, while the hypoglossal nerve does
not carry a sensory component.

65. A patient presents with left -sided facial weakness, loss of sensation to the anterior
two-thirds of the tongue, and hyperacusis. Tear production is normal in both eyes and
there is no vestibular dysfunction. At which of the following regions would a lesion to the
facial nerve result in the symptoms described?

A. Left stylomastoid foramen

B. Left parotid gland
C. Left facial canal
D. Left geniculate ganglion
E. Left cerebellopontine angle

66. Answer: C

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The facial nerve (vii) serves primarily as a motor nerve to the muscles of facial expression, although it also
transmits sensory fibres from the external acoustic meatus, fibres controlling salivation (i.e. To the
submandibular and sublingual glands), and taste fibres from the anterior two-thirds of the tongue (via the
chorda tympani) (figure 6.1). As it also supplies stapedius, complete nerve lesions may alter auditory acuity
on the aff ected side. From the facial nerve nucleus in the brainstem, fibres loop around the nucleus of the
abducens nerve before leaving the pons medial to the vestibulocochlear nerve, and passing through the
internal acoustic meatus. The facial nerve then passes through the facial canal (of the petrous temporal
bone), widens to form the geniculate ganglion (which mediates taste and salivation) on the medial side of the
middle ear. At this point, it deviates sharply (giving off the chorda tympani) to emerge through the
stylomastoid foramen, to supply all of the muscles of facial expression (including the platysma).
It is important to remember that in partial facial nerve paralysis, the lower face is generally aff ected to a
greater degree; in severe paralysis, there is often demonstrable loss of taste over the front of the tongue and
intolerance to high-pitched or loud noises. This may cause mild dysarthria and diffi culty with eating. Lower
motor neuron lesions of the facial nerve may be differentiated from upper motor neuron lesions as follows:

• In a lower motor neuron lesion, the patient generally cannot wrinkle his/her forehead, as the final
common pathway to the muscles is defunct. Such lesions must be either in the pons or outside the
brainstem (e.g. Posterior fossa, bony canal, middle ear or outside skull).
• In an upper motor neuron lesion, the patient should be able to wrinkle his/her forehead (unless there
is a bilateral lesion), since the upper facial muscles are partially spared due to alternative pathways in
the brainstem.

67. A 52-year-old lady presents with a ‘band like’ across her upper abdomen, at the level
of l1. While examining her abdomen, the surgical trainee attempts to remember all the
organs found at this level. Which one of the following structures is not found in this
plane?

A. Neck of the pancreas

B. Pylorus of the stomach
C. Origin of the coeliac trunk
D. Fundus of the gallbladder
E. Origin of the superior mesenteric artery

67. Answer: E
The transpyloric plane lies at the level of the l1 vertebra and bisects the line joining the Suprasternal notch
and the pubic symphysis.
Numerous important abdominal structures lie along this plane, making it a vital anatomical landmark. These
structures include the l1 vertebral body, gastric pylorus, hila of the kidneys, duodenojejunal fl exure, fundus
of the gallbladder, neck of the pancreas, origin of the hepatic portal vein, transverse mesocolon, second part
of the duodenum, origin of the superior mesenteric artery, hilum of the spleen, 9th costal cartilage, and the
end of the spinal cord (i.e. At the level of l1/l2). Note that coeliac trunk originates at the level of t12, and the
inferior mesenteric artery originates at the level of l3.

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68. A 50-year-old man undergoes open carpal tunnel decompression for carpal tunnel
syndrome. After his operation, he complain s of diffi culty in moving his thumb. Which
nerve is likely to have been injured to cause this?

A. Anterior interosseous branch of the median nerve

B. Recurrent branch of the median nerve
C. Palmar cutaneous branch of the median nerve
D. Superfi cial branch of ulnar nerve
E. Deep branch of ulnar nerve

68. Answer: B
Weakness of thumb movements after carpal tunnel decompression is related to paralysis of the thenar
muscles. The thenar muscles of the hand are supplied by the recurrent branch of the median nerve, which
usually lies just distal to the transverse carpal ligament. It is therefore at risk of damage during carpal tunnel
decompression. The palmar cutaneous nerve is also at risk of injury during this operation as it can be
damaged while placing the distal part of the skin incision.
It is the commonest nerve to be injured during carpal tunnel decompression. Injury can lead to neuroma
formation, which in turn leads to pain. Care is therefore taken to avoid injury to this nerve during surgery.
The superfi cial branch of the ulnar nerve passes superfi cially to the Carpal tunnel.
The deep branch of the ulnar nerve enters the hand through guyon’s canal (or the ‘ulnar canal’). The ulnar
nerve supplies all the intrinsic muscles of the hand except for the thenar muscles and the fi rst two
lumbricals.

69. A 55-year-old female presents with pain in her right inner thigh and a swelling in her
right groin. Examination reveals this swelling to be inferior to the medial third of the
inguinal ligament, and lateral to the pubic tubercle (i.e. Over the femoral ring). Which of
the following statements regarding the femoral canal is incorrect?

A. It is a short and blind-ending potential space in the medial compartment of the femoral sheath
B. The femoral sheath is an extension of the transversalis fascia and fascia iliaca
C. It contains lymphatic vessels and the node of cloquet
D. It is bounded by the femoral nerve laterally
E. It is bounded by the lacunar ligament medially

69. Answer: D
The femoral sheath contains three main compartments.

• The lateral compartment contains the femoral artery,

• The intermediate compartment contains the femoral vein, and
• The medial compartment contains the femoral canal.
The femoral canal is a short, 0.5 cm wide blind-ending potential space containing loose areolar tissue,
lymphatics and the node of cloquet.
It allows for the expansion of the femoral vein when there is increased venous return from the lower limbs
or increased intra-abdominal pressure.

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The femoral canal has the following boundaries:

o Anteriorly: inguinal ligament
o Posteriorly: pectineal ligament
o Medially: lacunar ligament
o Laterally: femoral vein
The femoral nerve lies lateral to the femoral artery, and is considered to be external to the femoral sheath.

70. When interpreting a ct scan of the abdomen, which of the following structures is
usually seen as a posterior relation of the first part of the duodenum?

A. Cystic artery
B. Hilum of the right kidney
C. Hepatic portal vein
D. Superior mesenteric vessels
E. Transverse colon

70. Answer: C
Traditional anatomy describes the duodenum as being divided into four sections.
The posterior relations of the first part of the duodenum include the portal vein, common bile duct and
gastroduodenal artery (behind which lies the inferior vena cava).
The abdominal aorta crosses behind the third part of the duodenum, whilst the superior mesenteric vessels
are related anteriorly to the third part of the duodenum. The main pancreatic duct opens into the second part
of the duodenum at the ampulla of vater. The second part of the duodenum is crossed by the transverse
colon.

71. Which of the following statements is true regarding the anatomy of the parotid
gland?

A. The parotid duct emerges from the anterior border of the gland and pierces the buccinator to enter the
buccal cavity at the level of the second lower molar tooth
B. The external carotid artery gives off its branches prior to passing through the gland
C. The facial nerve lies within the superfi cial lobe of the parotid gland
D. The retromandibular vein passes through the gland
E. Facial nerve palsy from lesions within the parotid gland results in sensory loss to the affected side of
the face

71. Answer: D
The parotid gland is the largest salivary gland in humans. The gland extends from the zygomatic arch to the
angle of the mandible.

• Superior to it lie the external auditory meatus and the temporomandibular joint;
• Inferiorly, the posterior belly of the digastric muscle;
• Medially, the styloid process;
• And posteriorly, the masseter and sternocleidomastoid muscles.

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The facial nerve runs through the parotid gland, dividing it into superficial and deep lobes. The superficial
lobe is larger and is the site of a greater proportion of tumours.
The facial nerve supplies the muscles of facial expression, rather than facial sensation, which is supplied by
the trigeminal nerve.
The retromandibular vein and the internal carotid artery pass through the parotid gland, where the latter
divides into its terminal branches (maxillary and superfi cial temporal arteries).
The parotid duct (or stensen’s duct) opens within the buccal cavity opposite to the second upper molar.

72. A 6-year-old boy is brought to the emergency department with a painful and swollen
right elbow after falling awkwardly from a bouncy castle. Examination reveals an
obviously deformed and tender elbow, and a weak radial pulse. The boy is unable to fl ex
his right index fi nger and has loss of sensation over the thenar eminence and thumb.
Plain radiography of the limb reveals a supracondylar fracture of the right humerus with
the proximal fragment penetrating the sk in. Which nerve is most likely to be injured in
this child?

A. Radial nerve
B. Median nerve
C. Posterior interosseous nerve
D. Ulnar nerve
E. Musculocutaneous nerve

72. Answer:B
The nerve that is most likely to be injured in this child is the median nerve.
The median nerve is derived from the c5–c7 roots from the lateral cord of the brachial plexus and from the
c8 and t1 roots from the medial cord.
In the arm, it runs in close proximity to the brachial artery and may be injured following supracondylar
fractures of the humerus. Thus the radial pulse may be feeble or absent with such injuries.
In the cubital fossa, the median nerve passes between the two heads of the pronator teres. It then travels
between the muscle bellies of flexor digitorum superfi cialis and fl exor digitorum profundus before
emerging between flexor digitorum superficialis and flexor pollicis longus.
The median nerve then passes through the carpel tunnel, where it may be compressed to cause carpal tunnel
syndrome.

73. A previously fit and healthy 37-year-old lady undergoes a prolonged laparoscopic
cholecystectomy due to multiple equipment -related complications. In the immediate
postoperative period, she develops biphasic stridor and cyanosis upon extubation, and is
therefore immediately re-intubated. The surgical registrar present at the time diagnoses
this as possible bilateral vocal cord paralysis and prepares to perform an open
tracheostomy. Which of the following structures are not encountered during this
procedure?

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A. Deep investing fascia

B. Platysma
C. Strap muscles (sternothyroid and sternohyoid)
D. Superior thyroid artery
E. Thyroid isthmus

73. Answer: D
The commonest reason for an open tracheostomy is the need for long-term mechanical ventilation.
To perform an open tracheotomy, the patient should be positioned supine with their neck extended. The neck
is prepared and draped, and a 2–3 cm transverse incision is made 2 cm above the sternal notch in the midline
(i.e. At the level of the 3rd tracheal ring).
The skin, deep fascia and the platysma are divided and the strap muscles retracted to expose the thyroid
isthmus.
The thyroid isthmus is then either pushed down or divided and ligated to achieve haemostasis.
The trachea is incised either between the 2nd and 3rd or the 3rd and 4th tracheal rings.
The anaesthetist is then asked to withdraw the endotracheal tube until above this level. The incision is
widened and a tracheostomy tube is inserted and secured.

74. A 43-year-old man is referred by his gp to the ophthalmol ogy outpatient clinic with a
2-month history of intermittently blurred vision. This symptom occurred immediately
after a head injury, for which the patient did not seek medical attention. Examination
reveals head-tilt towards the left shoulder and normal bilateral visual acuity with the
snellen chart. Although no nystagmus is observed when testing eye movements, the
patient reports double vision when looking downwards and outwards. Further
examination reveals vertical and torsional diplopia. Which of the following extraocular
muscles is most likely affected?

A. Superior oblique muscle

B. Inferior oblique muscle
C. Superior rectus muscle
D. Inferior rectus muscle
E. Lateral rectus muscle

74. Answer: A
This patient experiences diplopia on downward and outward gaze (vertical and torsional diplopia—torsional
rotation of the eye refers to keeping the eye oriented straight up and down when the head tilts from side to
side), and thus the superior oblique muscle is most likely to be aff ected.
The muscle is probably affected due to paralysis of the trochlear nerve (from the head injury). The long
course of the nerve makes it especially susceptible to injury in association with severe head injury.
The superior oblique muscle abducts the eye and moves the eye downwards (it intorts, depresses and
abducts the globe).

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It originates from the posterior orbit and travels along the superomedial wall of the orbit to the trochlea.
Its tendon passes through a pulley-like structure at the superior orbital rim and then courses back toward the
globe, inserting upon the posterosuperior quadrant of the eye.

75. A 48-year-old lady with central invasive breast cancer underwent a mastectomy and
axillary clearance of level i and level ii nodes. On the postoperative ward round, she
complained of numbness in the medial aspect of the upper arm. Which nerve is most
likely to have been damaged to cause the described symptoms?

A. Intercostobrachial nerve
B. Long thoracic nerve
C. Thoracodorsal nerve
D. Axillary nerve
E. Musculocutaneous nerve

75. Answer: A
Patients should be specifically warned of neurovascular damage prior to surgery. In particular they should be
consented for possible numbness on the medial aspect of the upper arm.
The long thoracic nerve supplies the serratus anterior muscle and damage to this will result in winging of the
scapula.
Thoracodorsal nerve innervates the latissimus dorsi muscle and should be preserved particularly in those
who are undergoing latissimus dorsi flap reconstructions.
Axillary nerve supplies the deltoid and teres minor muscles and the small patch of skin on the lateral aspect
of the upper arm, called the ‘regimental badge patch’.
Musculocutaneous nerve supplies sensation to the skin on the lateral aspect of the forearm.

76. A 35-year-old woman undergoes a laparoscopic cholecystectomy for recurrent biliary

colic. During the operation, the surgeon seeks to identify calot’s triangle. Which
structure is not bound by, or does not lie within, calot’s triangle?

A. Common hepatic duct

B. Common bile duct
C. Cystic duct
D. Cystic artery
E. Inferior edge of the liver

76. Answer: B
Calot’s triangle is formed by the inferior border of the liver, the cystic duct, and the common hepatic duct.
Within it lies the cystic artery, which is usually a branch of the right hepatic artery.
By identifying this triangle, the surgeon is able to safely dissect and ligate the cystic duct and cystic artery
without damaging the common bile duct.

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The famous lymph node that lies within Calot’s triangle is named mascagni’s lymph node (or node of lund),
and is the sentinel lymph node of the gallbladder.

77. Which of the following tendons form the ulnar border of the anatomical snuff box?

A. Tendon of extensor digitorum longus

B. Tendon of extensor indicis proprius
C. Tendon of extensor pollicis longus
D. Tendon of abductor pollicis longus
E. Tendon of extensor pollicis brevis

77. Answer: C
The anatomical snuff box lies distal to the styloid process of the radius. The fl oor of the snuff box is formed
by the scaphoid and the trapezium. Three tendons form the ulnar (medial) and radial (lateral) boundaries of
the anatomical snuff box.
The tendon of extensor pollicis longus forms the ulnar border while the tendons of abductor pollicis longus
and extensor pollicis brevis form the radial border.
The radial artery lies in the snuff box and runs in the space between the 1st and 2nd metacarpals to
contribute to the superficial and deep palmar arches.
The cephalic vein arises within the anatomical snuff box, while the dorsal cutaneous branch of the radial
nerve can be palpated by stroking along the extensor pollicis longus tendon.

78. A vascular surgeon attempts to palpate the femoral pulse prior to femoral artery
cutdown for an endovascular aneurysm repair. What is the posterior relation of the
femoral artery against which the surgeon compresses the artery to feel its pulsation?

A. Adductor longus
B. Iliac bone
C. Inguinal ligament
D. Psoas tendon
E. Superior pubic ramus

78. Answer: D
The femoral artery is palpated at the mid-inguinal point, which is midway between the anterior superior iliac
spine and the pubic symphysis. This is not to be confused with the midpoint of the inguinal ligament, which
is located midway between the anterior superior iliac spine and the pubic tubercle, and signifies the surface
anatomy of the deep inguinal ring.
The femoral artery is located within the femoral triangle, which is bounded superiorly by the inguinal
ligament, medially by the medial border of adductor longus, and laterally by the medial border of sartorius.
The floor of the femoral triangle is composed laterally of psoas major and iliacus, and medially by pectineus
and adductor longus. The fascia lata forms the roof of the triangle.

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The contents of the femoral triangle (from lateral to medial) include the femoral nerve and its branches (i.e.
The femoral branch of the genitofemoral nerve and lateral cutaneous nerve of the thigh); the femoral artery,
femoral vein, and femoral canal (which contains lymphatic vessels and deep inguinal lymph nodes).

79. An upper gastrointestinal surgeon dissects around the oesophageal hiatus of the
diaphragm during a minimally invasive oesophagectomy for an early oesophagogastric
tumour. Which of the following statements is correct regarding the thoracic diaphragm?

A. It has an oesophageal hiatus at vertebral level t8

B. It has a central tendon that transmits the right phrenic nerve
C. It is partly derived from the pleuroperitoneal membranes
D. It originates partly from the body of the sternum
E. The intercostal nerves supply it with accessory motor innervation

79. Answer: C
The diaphragm develops from the dorsal oesophageal mesentery, pleuroperitoneal membranes, lateral body
walls and the septum transversum (i.e. Which forms the central tendon).

• The sternal attachments of the diaphragm include two muscular slips from the back of the xiphoid
process (i.e. Not the sternal body).
• The costal attachments include the inner surfaces of the lower six ribs and costal cartilages on either
side (interdigitating with the transversus abdominis).
• The lumbar attachments include the medial and lateral arcuate ligaments and the crura, which are
attached to the upper three lumbar vertebrae on the right and upper two on the left.
The motor innervation to the diaphragm is from the cervical roots c3, c4 and c5, via the phrenic nerves.
The lower intercostal nerves merely provide proprioceptive supply to the periphery of the diaphragm.
The right phrenic nerve leaves the thorax by passing through the caval opening of the diaphragm, while the
left phrenic nerve pierces the muscular left dome of the diaphragm separately.
The caval opening lies within the central tendon at the level of t8 and transmits the inferior vena cava and
branches of the right phrenic nerve.
The oesophageal hiatus lies at the level of t10, in the right crus of the diaphragm, and transmits the
oesophagus, vagus nerves, and the oesophageal branch of the left gastric artery.
At the level of t12, the aorta (with the azygos vein and thoracic duct to the right of the aorta) passes through
the diaphragm in the midline.
The abdominal surface of the diaphragm is mainly perfused by the right and left inferior phrenic arteries
(from the aorta), while its costal margins are supplied by the lower fi ve costal and intercostal arteries.

80. A 47-year-old male presents to hospital with perianal pain and swelling. Physical
examination reveals a tender, erythematous swelling in his right ischioanal fossa. The
junior surgical trainee attempts to perform an incision and drainage of abscess. Which of
the following structures is most vulnerable to injury during this surgery?

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A. Superfi cial perineal nerve

B. Pudendal nerve
C. Nerve to obturator internus
D. Perineal branch of s4
E. Deep perineal nerve

80. Answer: B
Infection may spread through a small crack or lesion in the anal canal into the ischioanal fossa and form an
ischiorectal abscess.
The following are the boundaries of the ischioanal fossa:

• Medial: anal canal and levator ani

• Lateral: ischium and the inferior part of the obturator internus
• Posterior: sacrotuberous ligament and gluteus maximus
• Anterior: external urethral sphincter, deep transverse perineal muscle and fascia
The fossa contains mainly fat, the pudendal nerve and the internal pudendal vessels, which pass in the
pudendal canal lying in the lateral wall of the ischioanal fossa.
Posteriorly, these nerves and vessels become the inferior rectal nerve and vessels respectively.
Damage to the inferior rectal nerve results in impairment of this voluntary anal sphincter.

81 . A 30-year-old lady with symptomatic varicose veins undergoes a right leg sapheno-popliteal
ligation and stripping of the short saphenous vein. Which nerve is at risk of injury in this
procedure?

A. Saphenous nerve
B. Sural nerve
C. Common peroneal nerve
D. Superficial peroneal nerve
E. Deep peroneal nerve

81. Answer: B
The sural nerve is formed by the union of the medial (branch of the tibial nerve) and lateral (branch of the
common peroneal nerve) sural cutaneous nerves. It runs with the short saphenous vein in the posterior aspect
of the leg and supplies the lateral aspect of the foot.
In symptomatic varicose vein disease involving the short saphenous system, the short saphenous vein is
usually ligated at the sapheno-popliteal junction.
It is rarely stripped out due to potential damage to the sural nerve. Injury to the saphenous nerve causes loss
of sensation in the medial aspect of the leg and can be a complication of long saphenous vein stripping.

82. A 14-year-old gymnast sustains a deep laceration to her distal forearm during a
training-related accident. Examination of the injured hand and wrist reveal intermittent
spurts of blood from the lateral aspect of her wound, which are easily controlled with

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pressure. Closer examination reveals two transected tendons. She is able to adduct her
thumb but is unable to oppose it. She is unable to produce fi ne movements of her 2nd
and 3rd digits, and she describes diminished sensation over the lateral aspect of her palm
and digits. Further examination reveals weakened wrist fl exion, with associated ulnar
deviation. Which one of the following structures is unlikely to have been damaged in the
scenario described?

A. Palmaris longus tendon

B. Tendon of the fl exor carpi radialis
C. Radial artery
D. Superficial palmar branch of the radial artery
E. Median nerve
F. Ulna nerve

82. Answer: C
All structures that are vulnerable to injury from an incision at the distal transverse wrist crease are listed as
follows (from radial to ulnar):

• Superfi cial branch of the radial nerve

• Abductor pollicis longus
• Radial artery
• Superfi cial palmar branch of the radial artery
• Flexor carpi radialis
• Flexor pollicis longus
• Median nerve with its palmar cutaneous branch
• Palmaris longus
• Flexor digitorum superfi cialis
• Ulna artery
• Ulna nerve
• Flexor carpi ulnaris
• Dorsal/deep branch of the ulna nerve
In this clinical scenario, small spurts of blood that are easily controlled with pressure suggest a cut to the
small superficial palmar branch of the radial artery.
A cut to the radial artery would have resulted in more severe bleeding.
The median nerve supplies sensation to the radial three and- a-half digits and motor supply to the first two
lumbricals, opponens pollicis, abductor pollicis brevis and flexor pollicis brevis.
Therefore, numbness of the lateral aspect of the hand, weakness in fine movements of the 2nd and 3rd digits
and inability to oppose the thumb indicate potential njury to the median nerve.
As the posterior interosseous nerve, which is a branch of the radial nerve, is preserved, the patient is still
able to abduct her thumb using the abductor pollicis longus.
As the deep branch of the ulna nerve supplying the adductor pollicis is preserved, the patient remains able to
adduct her thumb.

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Cutting the palmaris longus and the fl exor carpi radialis wound weaken the wrist flexion and produce an
ulna deviation upon attempted flexion, due to the contraction of flexor carpi ulnaris, since ulnar nerve
function is preserved.

83. A 5-year-old girl presents to the emergency department after falling off her bed and
landing on her left upper limb. Plain radiographs of her left elbow demonstrate a
displaced supracondylar fracture of the humerus. Which of the following nerves is most
likely to be injured with this mechanism of fracture?

A. Anterior interosseous
B. Musculocutaneous
C. Medial cutaneous
D. Posterior interosseous
E. Ulnar nerve

83. Answer: A
The anterior interosseous nerve (‘volar interosseous’ nerve) is a branch of the median nerve that supplies the
deep muscles on the front of the forearm, except the ulnar half of the fl exor digitorum profundus. It
accompanies the anterior interosseous artery along the front of the interosseous membrane of the forearm, in
the interval between the fl exor pollicis longus and flexor digitorum profundus, supplying the whole of the
former and the radial half of the latter, and ending below in the pronator quadratus and wrist joint.
The anterior interosseous nerve is the most likely nerve in the upper limb to be damaged in supracondylar
fractures of the humerus. The functional status of the nerve may be tested by asking the patient to make an
‘o’ shape with their thumb and index fi nger. It is important to remember that displaced fractures of the
supracondylar humerus can cause compromise to the vascular supply of the forearm by injuring the brachial
artery.

84. A 65-year-old female presents to the endocrine clinic with an 8 -week history of
anorexia, nausea, constipation, polydipsia, polyuria and symptoms of intermittent renal
colic. Investigations reveal the presence of a parathyroid adenoma, which the patient
wishes to be removed. During surgical exploration of the patient's neck, the surgeon
promptly locates the two superior parathyroid glands and one inferior parathyroid
gland, which appear to be normal. He systematically searches the anterior part of the
neck for the 4th parathyroid gland. Which of the following statements is false regarding
the parathyroid glands?

A. The superior parathyroid glands are derived from the 3rd pair of the pharyngeal pouches while the
inferior ones are derived from the 4th pair
B. The inferior glands are more likely to be ectopic
C. Ectopic parathyroid glands are commonly found in association with the thymus
D. 5% of patients have more than four parathyroid glands

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E. If the gland cannot be found in the neck, the surgeon should explore the superior mediastinum
following dyed or imaged localization

84. Answer: A
Humans typically have four parathyroid glands. The superior parathyroid glands are derived from the 4th
pair of pharyngeal pouches and the inferior glands are derived from the 3rd pair, as is the thymus.
As the embryo develops, the thymus separates from the inferior parathyroid glands and descends. This
migration is extremely variable; the inferior glands are therefore more likely to be in an ectopic position.
15–20% of patients will have ectopic glands. Ectopic parathyroid glands are usually found in association
with the thymus or embedded in the inferior aspect of the thyroid gland.
If the glands are not found within the neck, the surgeon may have to explore the mediastinum (as guided by
dyed or imaged localization) as they may be as low down as the aortopulmonary window, anterior
mediastinum, posterior mediastinum, retro-oesophageal or prevertebral regions.
However, even when the inferior parathyroid glands are ectopic, they tend to be bilaterally symmetrical
making localization easier.
This suggests that the 4th parathyroid gland of this patient is likely to be found within the neck, rather than
in the mediastinum.

85. A 63-year-old gentleman undergoes a repair of his right poplitealartery aneurysm by

the vascular surgeons. The popliteal fossa is opened during the procedure to gain access
to the popliteal artery. He has an uneventful postoperative recovery but shortly before
discharge, he complains of diminished sensation over the lateral aspect of his right ankle,
foot, and the lateral aspect of his little toe. His knee jerk and ankle jerk refl exes are
normal. He has full range of movement of his leg. Which nerve is most likely to have
been injured causing the described symptoms?

A. Tibial nerve
B. Posterior femoral cutaneous nerve
C. Saphenous nerve
D. Common peroneal nerve
E. Sural nerve

85. Answer: E
The poplite al fossa is a diamond-shaped region in the posterior aspect of the knee. It is bounded
superomedially by semimembranosus and semitendinosus, superolaterally by biceps femoris, inferolaterally
by the lateral head of gastrocnemius, and inferomedially by the medial head of gastrocnemius.
The important contents of the popliteal fossa include the popliteal artery and Vein, tibial nerve, common
peroneal nerve, short saphenous vein, sural nerve, and the posterior femoral cutaneous nerve.
The fossa is covered by the popliteal fascia, which is perforated by the short saphenous vein and the sural
nerve.

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• The sural nerve is the most superficial structure that is likely to be encountered when the popliteal
fossa is explored during surgery.
• The sural nerve is Formed by union of the medial sural cutaneous, and the peroneal anastomotic
branch of the lateral sural cutaneous nerves.
• It then runs along the posterolateral aspect of the leg along with the short saphenous vein, lies lateral
to the tendo calcaneus and lies in the area between the lateral malleolus and the calcaneus. It then
runs forward below the lateral malleolus and continues as the lateral dorsal cutaneous nerve, along
the lateral side of the foot and little toe, communicating on the dorsum of the foot with the
intermediate dorsal cutaneous nerve, a branch of the superficial peroneal nerve.
• The sural nerve is the sensory nerve to the lateral aspect of the ankle, foot, and the lateral side of the
5th toe, so damage to the nerve may result in diminished sensation to these areas.

86. A 58-year-old man, who is on chemotherapy for metastatic gastric cancer, is brought
into the emergency department with acute gener al deterioration. On examination, he is
found to be confused, with a blood pressure of 80/45 mmhg and pulse rate of 110/min.
Chest examination reveals an elevated jugular venous pressure, normal breath sounds
and muffl ed heart sounds with no cardiac murmurs. Which of the following procedures
is likely to be most benefi cial to the patient?

A. Insertion of a large-bore needle in the 2nd intercostal space, along the mid-clavicular line
B. Large-bore needle insertion between the xiphoid process and the left 7th costal cartilage, aiming
towards the left shoulder tip
C. Inserting a needle through the cricothyroid membrane, attached to a bag valve device
D. Inserting a chest drain in the left 5th intercostal space, along the mid-axillary line
E. Large-bore needle insertion in the 4th intercostal space, aiming towards the right shoulder tip

86. Answer: B
The pericardium is a bilayered sac of connective tissue that invests the heart.
The fibrous pericardium is a tough, non-distensible sac that encloses the heart and great vessels, fusing
superiorly and blending into the central tendon of the diaphragm inferiorly.
The serous pericardium, which consists of the visceral and parietal pericardium, reflects over the entire
surface of the heart, Forming a sac in which the heart can move as it beats. Where the serous pericardium
invaginates between the left and right pulmonary veins and the inferior vena cava, it forms a blind ending
sac called the oblique sinus. Similarly, it forms a transverse sinus when it drapes over the pulmonary trunk
and the aorta on one side, and pulmonary veins and superior vena cava on the other.
The surface markings of the right border of the fibrous pericardium run from the 3rd costal cartilage to the
6th costal cartilage on the right, behind the right lateral edge of the sternum.
The inferior border extends from here to the left 5th intercostal space in the mid-axillary line (i.e. Over the
apex beat).
The left border extends from the apex to the lower border of the 2nd left costal cartilage, 2 cm lateral to the
left sternal edge.
The potential space between the two layers of parietal pericardium may fill with exudate, transudate, blood
or metastases to result in a pericardial effusion. Cardiac tamponade is an emergency condition in which the

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eff usion limits the contractile ability of the heart. If such patients in cardiogenic shock are left untreated,
they will soon arrest (with a rhythm such as pea—pulseless electrical activity) and die.

87. A 17-year-old male is brought to the emergency department after having sustained
blunt trauma to his chest. On examination, he is tachypnoeic with a respiratory rate of
36/min, heart rate of 120/min and systolic blood pressure of 70 mmhg. Chest examination
reveals bruising over his right lower ribs, tracheal deviation to the left, with right-sided
hyper-resonance to percussion and decreased breath sounds. The surgical registrar
diagnoses a tension pneumothorax and prepares to perform needle decompression.
Whilst attempting to locate the second intercostal space, he palpates for the
manubriosternal junction. Which of the following anatomical structures does not lie at
this level?

A. The hemiazygos vein passing from left to right to join the azygos vein
B. Between the t4 and t5 vertebral bodies
C. Bifurcation of the trachea
D. Entry of the azygos vein into the superior vena cava
E. Beginning and end of the aortic arch

87. Answer: A
The azygos vein is located on the right side of the body, it originates in the abdominal cavity and passes
upwards through the diaphragm to drain into the superior vena cava at the level of t4/5.
It drains the posterolateral thoracic and abdominal walls, parts of the right lung, mediastinum, and mid-
oesophagus.
The hemiazygos vein is located on the left side of the body. It ascends from the abdomen through the left
crus of the diaphragm at t12 and crosses over to the right side to drain into the azygos vein at the level of
t8/9. The hemiazygos vein drains the right posterior thorax, lumbar regions, lower oesophagus and parts of
the mediastinum.
The accessory hemiazygos vein is the venous confl uence of right posterior 4–8th intercostal veins. It passes
Posterior to the oesophagus and thoracic duct to merge with the azygos vein at t8/9. It drains the right
posterior thoracic cage and part of the left lung.

88. A 45-year-old lady is awaiting a mastectomy and axillary node clearance for a
central, invasive breast tumour. After careful consideration, the surgeon decides to
excise the level i and level ii nodes during the procedure. Which of the following
structures best defines the level of axillary clearance?

A. Clavicle
B. Axillary artery
C. Axillary vein
D. Pectoralis minor
E. Pectoralis major

88. Answer: D

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The axilla is the space between the upper arm and the thoracic wall. Its anterior wall consists of pectoralis
major, pectoralis minor, subclavius and clavipectoral fascia. It is bounded posteriorly by subscapularis, teres
major and the tendon of latissimus dorsi.
The medial wall is formed by the superior part of serratus anterior, and the lateral wall, by the medial border
of the humerus.
The floor is formed by the axillary fascia running from the serratus anterior to the deep fascia of the
humerus.
Within the axilla lie several important structures that may be encountered during surgery. These include the
axillary artery, axillary vein, cords of the brachial plexus, lymph nodes and fat.
Breast carcinoma spreads via lymphatics, and this lymphatic spread has been shown to be the single most
important factor in the management of breast cancer.
Several methods have been used to obtain information regarding the lymph node status, ranging from
sentinel node biopsy, to sampling and axillary clearance.
Anatomically, the nodes are said to be at one of three levels. Depending on their relationship to the
pectoralis minor muscle:
❖ Level i: all nodes inferior to the inferolateral border of pectoralis minor. This usually comprises the
lateral, anterior and posterior nodes. It is useful to note that the sentinel node (i.e. The fi rst node to
drain from that portion of the breast) is usually an anterior node.
❖ Level ii: all nodes posterior to pectoralis minor. This includes the central nodes and some apical
nodes.
❖ Level iii: all nodes beyond the superior border of pectoralis minor. This includes the remaining
apical nodes and infraclavicular nodes.

89. A 45-year-old hypothyroid lady presents to the orthopaedic clinic with pain and
paraesthesia over the lateral three-and-a-half digits of her right hand. Her symptoms are
often worse at night. Examination reveals wasting of the thenar eminence and a positive
tinel's sign, suggesting carpal tunnel syndrome. Which of the following structures does
not pass through the carpel tunnel?

A. Tendon of flexor digitorum superficialis

B. Tendon of flexor digitorum profundus
C. Tendon of flexor pollicis longus
D. Median nerve
E. Palmar cutaneous branch of the median nerve

89. Answer: E
The carpel tunnel is an osteofascial compartment formed by the concavity of the carpel bones and the
flexor retinaculum.
The flexor retinaculum attaches to the scaphoid and trapezium on the radial side, and the hamate and
pisiform on the ulnar side.
The contents of the carpel tunnel include options a–d and the tendon of the flexor carpi radialis.

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The palmar cutaneous branch arises from the median nerve at a point proximal to the flexor retinaculum,
and supplies sensation to the thenar eminence.
As it passes outside the tunnel, it is not compressed under the flexor retinaculum, thereby preserving the
sensation to the thenar eminence, if the median nerve lesion is truly within the carpel tunnel and not
located more proximally.

UPPER LIMB

1. Which one of the following muscles in the hand is supplied by the median nerve?

A. Radial two interossei

B. Abductor pollicis brevis
A. Ulnar two lumbricales
B. Adductor pollicis
C. Extensor pollicis

ANSWER: B

The median nerve supplies the following structures in the hand:

• The abductor pollicis brevis,

• Flexor pollicis brevis,
• Opponens pollicis ,
• The radial two lumbricales .
• The skin of the lateral three and half fingers
The ulnar nerve supplies all the interossei and the rest of the hand muscles.

2. A motor cyclist involved in a road traffic accident sustained an injury to the brachial
plexus on the right side. He is found to have weakness of right shoulder abduction and
forearm flexion, as well as some sensory loss over the lateral aspect of his upper arm.
The right biceps and brachioradialis reflexes are absent.W hat is the likely level of
maximal plexus injury? .

A. C4,5 root
B. C5,6 root
C. C6,7 root
D. C7,8 root

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E. C8, t1 root

ANSWER: B

A c5/c6 lesion, erb’s palsy, produces sensory loss over the lateral aspect of the upper arm (deltoid paralysis),
With loss of shoulder abduction, and paralysis of the biceps, brachialis and coracobrachialis. In addition to
loss of Elbow flexion, the biceps is also a powerful supinator of the forearm, so the forearm assumes a
pronated position.
T1 lesion produces a claw hand, (klumke’s palsy).
Sympathetic chain injury results in a horner’s syndrome, with ptosis of the upper eyelid and constriction of
the pupil (meiosis) on the affected side.

3. An 82-year-old woman with atrial fibrillation develops a sudden arterial occlusion of

her right arm due to a brachial embolism. Which statement pertaining to the arterial
system of the upper limb best accords with usual clinical findings?

A. The brachial artery bifurcates into the ulnar and radial arteries just below the level of the elbow
crease
B. The brachial artery is crossed by the median nerve immediately above the elbow
C. A large single brachial vein accompanies the artery on its medial side
D. Profunda brachii arises from the brachial artery a hand’s breadth above the elbow
E. A brachial artery embolus is especially serious because of the poor collateral circulation around the
elbow joint

ANSWER: A

The median nerve crosses from lateral to medial at the mid-humerus.

The artery is accompanied by two vena Comitantes and gives off its profunda branch near the upper end of
the humeral shaft, where it accompanies the Radial nerve.
As with all joints, there is an excellent circulation around the elbow joint.

4. A 38-year-old builder’s labourer sustained a severe fracture of his left elbow, which
damaged the ulnar nerve behind the medial epicondyle of the humerus. A month later, he
still has a total ulnar nerve paralysis. Which Clinical sign is most likely to be present on
examination? .

A. Sensory loss over the ulnar 3½ digits on the ulnar side of the hand your answer
B. Inability to grip a sheet of paper between his fingers when the hand is placed flat on the table
C. Excessive sweating over the ulnar border of the left hand
D. Index and middle fingers on the affected side are held in the claw position
E. Marked wasting of the thenar eminence

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ANSWER: B

The ulnar nerve (usually) supplies sensation to the skin of the fifth and the ulnar side of the fourth finger,
front and Back.
There is sympathetic interruption, with absence of sweating in the affected area.
The thenar muscles are Supplied by the median nerve and are therefore spared.
Although the fourth and fifth digits are held in the clawed Position when the nerve is injured at the wrist, a
high lesion paralyses the long flexors to these two fingers and results in the loss of this sign.
A test for paralysis of the palmar interossei, supplied by the ulnar nerve, is the Inability to adduct the fingers
and thus to be unable to grip a sheet of paper between them.

5. An anaesthetist performs a successful block of the median nerve at the elbow. Which
neurological sign is likely to be present on examination? .

A. Inability to flex the fingers

B. An obvious wrist drop deformity
C. The palm of the hand is totally anaesthetised
D. Inability to abduct and adduct the fingers
E. Loss of sensation over thenar eminence

ANSWER: E

The median nerve supplies all the muscles in the anterior compartment of the forearm, apart from the flexor
carpi Ulnaris and the flexor digitorum profundus to the ulnar two fingers: so these two fingers can still be
flexed.
The Radial nerve supplies the extensors hence no wrist drop.
The ulnar nerve supplies the skin of the ulnar side of The hand, hence no anaesthesia there. It also supplies
the interossei muscles of the hand, which effect abduction And adduction of the fingers.
Absence of thumb abduction, due to paralysis of abductor pollicis brevis, is a good Test for median nerve
paralysis.

6. A 78-year-old man had poliomyelitis as a child, which left him with total paralysis of
the left deltoid Muscle. Which feature is most likely to be present on clinical
examination? .

A. Anaesthesia over the ‘epaulette’ region of the left shoulder

B. The acromion process of the scapula forms the most lateral bony landmark of the left shoulder
C. Drooping of the left shoulder compared to the right side
D. Detectable weakness in drawing the arm forward and internally rotating the shoulder when this is
compared with the right side

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E. Some degree of abduction of the shoulder can be achieved by the action of the intact supraspinatus
muscle on the left side.

Answer: D

Poliomyelitis only affects the anterior horn cells of the spinal cord, so there is no sensory loss.
Although the Shoulder appears flattened, due to deltoid wasting, the greater tubercle of the humerus remains
the most lateral Bony landmark of the shoulder. It is paralysis of trapezius that results in shoulder drop.
Even if the supraspinatus is fully functional, it is far too weak a muscle to be able to abduct the whole
weight of the Arm.
The deltoid, in addition to being the powerful abductor of the humerus, also assists in flexion and medial
Rotation (and extension and lateral rotation) of the shoulder by means of its anterior and posterior fibres,
Respectively.
Weakness of these movements compared to the normal side can be detected on careful

7. A 28-year-old man, who is a keen bodybuilder, presents with a short history of left
upper limb discomfort and difficulty in moving his shoulder. On examination he is
noticed to have winging of the left scapula. There is no wasting of the shoulder girdle
muscles. With stabilisation of the scapula, he has a ful l range of movement and is able to
elevate the shoulder. Sensory testing is normal, as are upper limb reflexes. What is the
likely anatomical origin of his problem? .

A. C3,4 nerve root

B. Long thoracic nerve
C. Diffuse left brachial plexus injury
D. Spinal accessory nerve (cranial nerve xi)
E. C5,6 nerve root

ANSWER: B

Seven muscles attach the scapula (shoulder blade) to the chest wall and help maintain normal scapular
control.
These muscles are trapezius, levator scapulae, rhomboids major, rhomboids minor, pectoralis minor,
omohyoid and serratus anterior.
The latissimus dorsi has a small attachment at the base of the scapula but does not Significantly contribute to
scapular stability.
Of these muscles, the serratus anterior and the trapezius are the most important. A winging scapula is nearly
always associated with partial or complete paralysis of either of these muscles.
Weakness or paralysis of the Serratus anterior, secondary to palsy of the long thoracic nerve, is the
commonest cause of winging.

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The long Thoracic nerve (origin c5,6 motor roots, with sometimes a contribution from c4 +/- c7) is thin,
fragile and runs an anatomical course in the neck and upper thorax that makes it susceptible to damage by
compression or trauma.
Commoner causes include:

• Surgery (e.g. Radical mastectomy, lymph node biopsy from axilla);

• Stretch injury during Sports (as in this case);
• Viral/ post-infectious (brachial neuritis);
• Other causes of neuropathy (vascular, toxic etc.).
Accessory nerve (xi) damage can also produce scapular winging via weakness of trapezius, but this would
be Milder and would be expected to be associated with weakness of shoulder elevation, which this patient
does not Have.
The other options listed would tend to be associated with other symptoms and signs. Nerve conduction
Studies and electromyography would help confirm the diagnosis

8. Following a rock-climbing accident in which a foothold gave way, leaving him

suspended by one arm, a Young man develops weakness of his right hand. He can
manoeuvre his arm into any position but cannot use The hand effectively. What structure
is most likely to have been damaged in this accident? .

A. The c6 nerve root

B. The c7 nerve root
C. The t1 nerve root
D. The ulnar nerve
E. The radial nerve

ANSWER: C

He has sustained an injury to the brachial plexus, affecting the lowest roots (c8, t1), which provides the
motor supply to the intrinsic muscles of the hand and the long flexors and extensors of the fingers.
This deformity is Known as klumpke’s paralysis.
C6 and c7 mediate the movements of the shoulder and elbow, and c7 the Movements of the elbow and wrist.
The radial nerve is required for normal positioning of the arm.
A proximal ulnar Nerve lesion affects the small muscles of the hand and wrist flexion but not the positioning
of the arm.

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9. A 42-year-old man with a history of road traffic accident and injury to his back and
neck presents with global Muscle wasting of the left hand. Which is the nerve or nerve
root most likely to be involved? .

A. Radial nerve
B. Median nerve
C. Ulnar nerve
D. T1 nerve root
E. C7 nerve root

ANSWER: D

The median nerve supplies the lateral two lumbricals, opponens pollicis, abductor pollicis brevis and flexor
pollicis brevis; the remainder are served by the ulnar nerve.
Global muscle wasting of the hand indicates damage to both he median and ulnar nerves with damage to the
t1 nerve root.
Isolated wasting of abductor pollicis brevis occurs in association with median nerve damage from carpal
tunnel syndrome.
More extensive wasting may suggest a broader diagnosis such as syringomyelia or motor neurone disease.

10. A 49-year-old woman has been complaining of a tingling feeling in her right hand at
night and is under the impression that her hand is swollen although there is no obvious
oedema. In the last few days she has noticed numbness in her right index finger and the
tip of her thumb, especially while working. Which nerve is most likely to b e responsible
for her symptoms ?.

A. Ulnar nerve
B. Median nerve
C. Radial nerve
D. Nerve root c7
E. Nerve root c8

ANSWER : B

One of the most common lesions at this site is carpal tunnel syndrome, in which the median nerve is
compressed as it passes deep to the flexor retinaculum.
The usual presentation is with acroparaesthesias. This consists of numbness, tingling and burning sensations
felt in the hand and fingers; the pain sometimes radiates up the forearm as far as the elbow or even as high as
the shoulder or root of the neck. Although the paraesthesias are sometimes restricted to the radial fingers,
they may affect all the digits as some fibres from the median nerve are distributed to the fifth finger through
a communication with the ulnar nerve in the palm.

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The attacks of pain and paraesthesias are most common at night and often wake the patient from sleep. They
are then relieved by shaking the hand. The hand tends to feel numb and useless on waking in the morning
but recovers after it has been used for some minutes.
The symptoms may recur during the day following use, or at other times if the patient sits with the hands
immobile. Such symptoms of acroparaesthesias may persist for many years without the appearance of
symptoms of median nerve damage.
In other patients, weakness of the thenar muscles develops, particularly with abduction of the thumb, and is
associated with atrophy of the lateral aspect of the thenar eminence. Sensory loss may appear over the tips of
the median innervated fingers.

11.a patient undergoes mastectomy and axillary node clearance for her right sided breast
cancer. Post operatively she notices numbness in her axilla and upper inner arm. This is
because of the division of which nerve?

A. Internal thoracic nerve

B. Intercostobrachial nerve
C. Long thoracic nerve
D. Thoracodorsal nerve
E. Axillary nerve

ANSWER: B

During axillary node clearance the intercostobrachial nerve which gives the cutaneous innervations of the
axilla and the inner upper arm is encountered and is divided in many of the cases to ease the exposure to the
axilla.
The long thoracic nerve of bell (nerve to serratus anterior) and the thoracodorsal nerve to latissimus dorsi are
encountered during dissection and they are preserved.

12. A cut wound at the wrist affecting the median nerve will cause the following?.

A. The long flexors will be affected causing wasting the front of the forearm on the long run
B. Flexor polices longus will be affected
C. The hand is held typically with the index finger straight ‘pointing finger’
D. Abduction of the thumb is affected
E. Loss of sensation over the ulnar aspect of ring finger

ANSWER: D

All the answers, except e, are features of high median nerve injury (more at the level of elbow ), which
affects the long flexors of the forearm (except flexor carpi ulnaris and flexor digitorum profundus) and the
pronators.
Lesions at the wrist level affect the sensation in the radial 3 ½ fingers (but not the ulnar aspect of ring finger
which is supplied by ulnar nerve). Median nerve at wrist also supplies the three thenar muscles (abductor
and flexor polices brevis, and opponens polices) and the two radial lumbricals.

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13. In the breast the connective tissue that extends from deep layer of superficial fascia
to the epidermis is called?

A. Fibrous bands of halstead

B. Tubercles of montgomery
C. Retromammary bursa
D. Ligaments of cooper
E. Poupart’s ligament

ANSWER : D

The suspensory ligaments of the breast (ligaments of cooper) are fibrous bands of connective tissue that
interdigitate between the breast tissues and extend from the deep layers of the superficial fascia to the
dermis.
These ligaments provide some shape to the breast tissue and are partly responsible for the “peau d’orange”
appearance associated with lymphoedema of malignancy.
Tubercles of montgomery are small accessory glands on the areola. The retromammary bursa is the posterior
aspect of the breast between the deep layer of the superficial fascia and deep investing fascia of pectoralis
major.
Poupart’s ligament is the inguinal ligament

14. IN A FRACTURE OF THE SURGICAL NECK OF HUMERUS (NEER’S

CLASSIFICATION GROUP III) THE FOLLOWING IMPORTANT STRUCTURE
MIGHT BE AFFECTED?

A. The axillary artery

B. The axillary vein
C. The radial nerve
D. The axillary nerve
E. The profunda brachii artery

ANSWER: D

The important anatomical relationships to the humerus are the axillary nerve and circumflex humeral vessels
at the surgical neck, the ulnar nerve at the posterior aspect of the medial epicondyle, and the radial nerve and
the profunda brachii vessels at the surgical groove.
Fractures affecting those sites might affect the related structures. In proximal humeral fractures, surgical
neck fractures (neer group iii) might cause axillary nerve damage, anatomical neck fractures (neer group ii)
might result in avascular necrosis of the humeral head while greater tuberosity fractures (neer group iv)
might result in painful arc syndrome
.

15. The anatomical description of smith’s fracture is?

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A. It is an intra-articular distal radial fracture with volar displacement

B. It is an extra-articular proximal radial fracture with volar displacement
C. It is an extra-articular distal radial fracture with volar displacement c
D. It is an extra-articular fracture with dorsal and radial displacements of the distal fragment
E. It is an intra-articular distal radial fracture either volar or dorsal where the articular surface of the
distal radius subluxes from the carpals

ANSWER: C

The three commonest distal radial fractures are colles’, smith’s and barton’s. Colles’ and smith’s are
extraarticular
While barton’s is intra-articular. Answer d describes colles’ fracture while answer e describes barton’s
fracture.

16. IN AN ADULT FEMALE THE BREAST LIES OVER THESE STRUCTURES

EXCEPT?

A. Pectoralis major
B. Serratus anterior
C. Internal oblique **
D. External oblique
E. Rectus sheath

ANSWER: C

The breast extends from the second to the 6th rib overlying the pectoralis major muscle, extending over the
serratus anterior laterally, the rectus sheath inferomedially, the external oblique inferolaterally and the costal
cartilage medially.

17. The axillary artery is divided into three parts by which mu scle?

A. Teres major
B. Teres minor
C. Pectoralis major
D. Pectoralis minor
E. Latissimus dorsi

ANSWER: D

The axillary artery is the continuation of the subclavian artery starting from the outer part of the 1st rib to the
lower Border of teres minor. Along with the axillary vein and the brachial plexus it is enclosed in the
axillary sheath.
The vein is medial to the artery and the cords of the brachial plexus lie around it. Pectoralis major covers
most of the Artery except for its lateral edge…..

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The branches are;

• First part: superior thoracic artery

• Second part: acromiothoracic and lateral thoracic arteries
• Third part: subscapular, anterior circumflex humeral and posterior circumflex humeral arteries.

18. The following structure passes under the brachioradialis emerging distally on its
medial side. Distally it is covered only by skin and fascia and lies on the radius?

A. Ulnar artery
B. Radial artery
C. Median nerve
D. Profunda brachii artery
E. Radial nerve

ANSWER: B

This describes the course of the radial artery which starts at the level of the neck of the radius lying on the
tendon of the biceps. It passes under the brachioradialis as described reaching the wrist where its pulsations
are felt against the radius.
After that it winds laterally and enters the palm between the heads of the first dorsal interosseous muscle, it
ends as the deep palmar arch supplying the hand.
The ulnar artery on the other hand passes inferiorly and medially in the anterior compartment of the forearm.
It runs laterally to the ulnar nerve deep to the flexor carpi ulnaris and ends in the hand forming the
superficial palmar arch.

19. Which of the following structures passes through the canal of guyon?.

A. Ulnar nerve
B. Median nerve
C. Sciatic nerve
D. Accessory nerve
E. Sural nerve

ANSWER: A

The canal of guyon is a fibrous band of fascia covering both the ulnar artery and nerve at the level of the
wrist. Both the artery and nerve pass in front of the retinaculum lateral to the pisiform bone.
The ulnar artery lies lateral to the nerve at this level. The ulnar nerve might be occasionally compressed at
the canal of guyon.

20. A 23 year old presented with a humeral fracture on the left side affecting the area of
the spiral groove. The nerve most likely to be affected by this injury is?

A. Ulnar nerve
B. Radial nerve

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C. Axillary nerve
D. Median nerve
E. Posterior interosseous nerve

ANSWER: B

The radial nerve runs in the spiral groove and injury at that level will affect the extensors of the wrist and
fingers resulting in ‘wrist drop’. Sensory loss will be localised to the back of the radial side of the hand.

21. A seven-year-old boy presents with a displaced supracondylar fracture of his right
humerus. On examination there is no distal sensory deficit, but he is unable to flex his
thumb and index finger to make the “ok” sign. Which nerve has been damaged?

A. Median nerve
B. Radial nerve
C. Posterior interosseous nerve
D. Ulnar nerve
E. Anterior interosseous nerve

ANSWER: E

The anterior interosseous nerve is a branch of the median nerve.

It does not have a sensory component and supplies both flexor pollicis longus and flexor digitorum
profundus to the index and middle fingers.
Both of these muscles are required to make an “ok” sign. It is the most commonly injured nerve in
supracondylar fractures of the elbow.

22. The first compartment under the extensor retinaculum of the wrist contains which of
the following tendons?

A. Extensor carpi radialis longus and extensor carpi radialis brevis

B. Extensor pollicis longus
C. Extensor pollicis brevis and abductor pollicis longus
D. Extensor carpi ulnaris
E. Extensor digiti minimi

ANSWER: C

There are six extensor compartments in the extensor retinaculum on the dorsum of the wrist.
They contain in order:

• 1st - extensor pollicis brevis and abductor pollicis longus

• 2nd - extensor carpi radialis longus and extensor carpi radialis brevis
• 3rd - extensor pollicis longus
• 4th - extensor digitorum and extensor indicis
• 5th - extensor digiti minimi

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• 6th - extensor carpi ulnaris

The second and third compartments are separated by lister’s tubercle.

23. A man is treated with a right sided intercostal chest drain for haemothorax after an
rtc. He subsequently develops a winged scapula on the right side. Which nerve has been
damaged?

A. Dorsal scapular nerve

B. Long thoracic nerve
C. Suprascapular nerve
D. Musculocutaneous nerve
E. Thoracodorsal nerve

ANSWER: B

The long thoracic nerve arises from the roots of c5, c6 and c7.
The nerve passes just posterior to the midaxillary line deep to the fascia of serratus anterior and supplies this
muscle in a segmental fashion.
Serratus nterior protracts the scapula in punching and pushing and keeps the vertebral border of the scapula
in firm apposition with the chest wall.
The nerve is potentially damaged by malpositioned chest drains.

24. An 18-year-old falls out of a tree and injures his ar m by stretching it to break his
fall. Subsequently his hand appears clawed. On examination, his hand is extended at all
the mcp joints and all the interphalangeal joints are in fixed flexion. The wrist flexors
appear to be slightly weaker. What is likely t o be the injury?.

A. Ulnar nerve injury

B. C8, t1 root injury
C. Median nerve injury
D. C5, c6 root injury
E. Radial nerve injury

ANSWER: B

This is a classical history for a “klumpke’s palsy”. It is produced by a traction type injury to the lower
brachial plexus nerve roots.
It is commonly associated with traction to the arm when it is in an extended overhead position.
Occasionally damage to t1 may also cause a horner’s syndrome.

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All the intrinsic muscles of the hand are affected as opposed to an ulnar nerve lesion producing a claw hand
affecting only the little and ring fingers.
In ulnar nerve injuries, the index and middle fingers are spared as the radial 2 lumbricals are supplied by the
median nerve.

25. A 79-year-old lady suffers a displaced transverse fracture of her left olecranon. The
fracture is treated conservatively in a cast. Which function is she most likely to have
difficulty with?

A. Brushing her hair

B. Fastening buttons
C. Pouring a kettle
D. Pushing to standing from an armchair
E. Reaching into a high cupboard

ANSWER: D

Triceps attaches to the olecranon and is responsible for extension of the elbow.
If olecranon fractures are treated conservatively, an excellent range of movement can be achieved, however
functional outcome is impaired due to lack of power of extension.
This would be most apparent pushing up against gravity as you have to do when pushing out of a chair.
Brushing hair, reaching into cupboards and pouring kettles are functions mainly achieved by movements of
the shoulder, whilst fastening buttons requires dexterity and may be adversely affected by injuries to the
wrist or hand.

26. A patient with a dislocated shoulder is thought to have an associated axillary nerve
injury. What would you expect to find on examination?

A. No sensory loss and weakness of shoulder abduction

B. Sensory loss over the anterior aspect of the arm but no motor loss
C. Sensory loss over the anterior aspect and weakness of shoulder abduction
D. Sensory loss over the lateral aspect and inability to initiate abduction
E. Sensory loss over the lateral aspect of the arm and weakness of shoulder abduction

ANSWER: E

The axillary nerve supplies the “regimental patch” area of skin over the upper lateral aspect of the arm. Its
motor component is to deltoid and to teres minor.
The motor deficit resulting from an axillary nerve injury is weakness of these muscles.
The most noticeable is abduction, since flexion and extension are assisted by pectoralis major and latissimus
dorsi respectively. There is not complete loss of abduction as supraspinatus will still be intact which mainly
initiates abduction.

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27. Which of the structures below is not contained within the carpal tunnel at th e wrist?

A. Flexor carpi radialis tendon

B. Palmaris longus tendon
C. Median nerve
D. Flexor digitorum profundus tendons
E. Flexor pollicis longus tendon

ANSWER: B

Palmaris longus lies anterior to the flexor retinaculum, partly adherent to the retinaculum. The tendons of
flexor pollicis longus and flexor carpi radialis lie within their own synovial sheaths within the carpal tunnel

28. Which tendon can be seen during routine arthroscopy of the shoulder joint?

A. Short head of biceps

B. Pectoralis major
C. Long head of biceps
D. Pectoralis minor
E. Latissimus dorsi

ANSWER: C

Long head of biceps passes through the shoulder joint and is invested in a synovial sleeve.
As such it will be the only tendon visible during arthroscopy of the shoulder other than the tendons of the
rotator cuff.

29. A patient has a fall onto his shoulder and is unable to internally rotate the shoulder
against resistance. Other movements are relatively well preserved. X -rays taken show no
bony injury. Which of the following muscles is likely to be injured?

A. Supraspinatus
B. Infraspinatus
C. Teres minor
D. Deltoid
E. Subscapularis

ANSWER: E

Subscapularis produces internal rotation of the shoulder joint. It arises from the costal surface of the scapula
and inserts into the lesser tubercle.
Pectoralis major and latissimus dorsi contribute to internal rotation so there is not a complete loss of internal
rotation if only subscapularis has been injured. Supraspinatus initiates abduction and helps in abducting the
shoulder joint between 90° and 120°.

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Teres minor along with infraspinatus externally rotates the shoulder. Deltoid flexes and abducts the
shoulder.

30. A patient attends clinic complaining of pins and needles affecting t he radial (lateral)
3 digits of his hand. The symptoms are worse at night, and also after driving long
distances. Which of the following motor signs would confirm the likely diagnosis?.

A. Inability to flex the radial 3 digits

B. Inability to adduct all the fingers of his hand
C. Inability to abduct all the fingers of his hand
D. Weakness of opposition of the thumb

ANSWER: D

The likely diagnosis would not cause a motor deficit

The history described above is typical of carpal tunnel syndrome. Entrapment of the median nerve at the
carpal tunnel affects the muscles of the thenar eminence.
These are abductor pollicis brevis, flexor pollicis brevis andvopponens pollicis. The nerve supply of flexor
pollicis brevis is extremely variable however, so the best test to perform would be to see if opposition is
affected. In addition the motor branch of the median nerve after the level of the carpal tunnel also innervates
the radial 2 lumbricals.
Flexion would not be affected as the nerve supply to the long flexors comes off the median nerve proximal
to the carpal tunnel. Abduction and adduction of the fingers is produced by the interossei, which are
supplied by the ulnar nerve.

31. While performing a radical mastectomy, the surgeon injured the long thoracic
nerve.which one of the following muscles will be affected due to injury to the long
thoracic nerve?

A. Anterior scalene
B. Middle scalene
C. Serratus anterior
D. Subscapularis
E. Teres major

ANSWER: C

Serratus anterior is innervated by the long thoracic nerve. Serratus anterior keeps the scapula held forward,
balancing trapezius and the rhomboids, which retract the scapula.
If the long thoracic nerve is injured (which is common in surgery, because the long thoracic nerve is on the
superficial side of serratus anterior), you may see a ‘winged scapula’ protruding posteriorly.
The anterior scalene muscle is innervated by c5-c7 and the middle scalene muscle is innervated by c3-c8.
Teres major is innervated by the lower subscapular nerve from the posterior cord of the brachial plexus.

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Subscapularis is innervated by the upper and lower subscapular nerves from the posterior cord of the
brachial plexus.

32. A motorcyclist fell from his bike. On arrival in a&e, it was noticed that extension of
his right humerus was severely limited.he has sustained injury to the:

A. Long thoracic nerve

B. Medial pectoral nerve
C. Suprascapular nerve
D. Thoracodorsal nerve
E. Upper subscapular nerve

ANSWER: D

The thoracodorsal nerve, a branch of the posterior cord of the plexus, derives its fibres from the fifth, sixth
and seventh cervical nerves.
It follows the course of the subscapular artery, along the posterior wall of the axilla to the latissimus dorsi, in
which it can be traced as far as the lower border of the muscle.
Latissimus dorsi is responsible for extension of the humerus and in this scenario it is the affected muscle due
to injury to the thoracodorsal nerve.

33. A young boy fell from his skateboard, twisted his forearm and sprained his annular
ligament.The annular ligament in the forearm:

A. Encircles the head of the radius

B. Encircles the head of the ulna
C. Encircles the styloid process of the radius
D. Goes from the olecranon fossa to the olecranon process
E. Spans the space between the ulna and radius

ANSWER: A

The annular ligament is a strong band of fibres, which encircles the head of the radius and retains it in
contact with the radial notch of the ulna.
It forms about four-fifths of the osteofibrous ring and is attached to the anterior and posterior margins of the
radial notch. A few of its lower fibres are continued around below the radial notch and form at this level a
complete fibrous ring.
Its upper border blends with the anterior and posterior ligaments of the elbow, while from its lower border a
thin, loose membrane passes to be attached to the neck of the radius. A thickened band that extends from the
inferior border of the annular ligament below the radial notch to the neck of the radius is known as the
‘quadrate ligament’.

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The superficial surface of the annular ligament is strengthened by the radial collateral ligament of the elbow
and affords origin to part of the supinator.
Its deep surface is smooth and lined by synovial membrane, which is continuous with that of the elbow joint.

34. A young gymnast sustained injury to a muscle that acts to depress the glenoid fossa
directly. Which one of the following is a muscle that acts to depress the glenoid fossa
directly?

A. Pectoralis minor
B. Serratus anterior
C. Pectoralis major
D. Latissimus dorsi
E. Supraspinatus

ANSWER: A

The pectoralis minor is a thin, triangular muscle, situated at the upper part of the thorax, beneath the
pectoralis major. It arises from the upper margins and outer surfaces of the third, fourth and fifth ribs, near
their cartilage and from the aponeurosis covering the intercostals.
The fibres pass upward and lateralward and converge to form a flat tendon, which is inserted into the medial
border and upper surface of the coracoid process of the scapula.
The pectoralis minor receives its fibres from the eighth cervical and first thoracic nerves through the medial
anterior thoracic nerve. The pectoralis minor depresses the point of the shoulder (glenoid fossa), drawing the
scapula downward and medialward toward the thorax and throwing the inferior angle backward.

35. A rugby player sustained spinal cord injury at spinal lev el c8. What is likely to be
seen in this patient?

A. The brachialis muscle will be paralysed

B. The muscles innervated by the radial nerve that would most likely be affected would be the most
proximal ones
C. The hypothenar muscles would be completely paralysed
D. Innervation to the deltoid muscle would be affected
E. The patient would be unable to flex their humerus

ANSWER: C

The hypothenar muscles include the palmaris brevis, opponens digiti minimi, abductor digiti minimi and
flexor digiti minimi brevis.
All the muscles of this group are supplied by the eighth cervical nerve through the ulnar nerve and will be
completely paralysed in a lesion at spinal level c8.

36. Which one of the following statements is correct regarding the extensor ret inaculum
of the wrist?

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A. It is a direct extension of the axillary fascia

B. The median nerve runs deep to it
C. The tendon of the brachioradialis muscle runs through it
D. It contains a compartment for the thenar muscles
E. It prevents the tendons of the posterior compartment of the forearm from ‘bowstringing’ when the
hand is extended at the wrist

ANSWER: E

The extensor tendons are held closely applied to the dorsal surface of the distal radius and ulna by the
extensor retinaculum. This is a ribbon-like fascial band, 2.5 cm wide, that extends obliquely from the
anterolateral surface of the radius across the dorsum of the wrist, inserting into the pisiform and triquetral
bones, but not directly into the ulna.
The radius and carpus are free to rotate about the ulna without affecting tension in the extensor retinaculum.
The extensor retinaculum prevents bowstringing of the extensor tendons with wrist extension and bony
attachments of the retinaculum produce six extensor compartments that control the tendons with wrist
movement.

37. To draw some blood from a patient’s median cubital vein you will insert the needle in
the:

A. Posterior aspect of the knee

B. Femoral triangle
C. Dorsal surface of the hand
D. Anterior aspect of the elbow
E. Deltopectoral triangle

ANSWER: D

The veins of the arm carry blood from the extremities of the limb, as well as drain the arm itself. The two
main veins are the basilic and the cephalic veins.
There is a connecting vein between the two, the median cubital vein, which passes through the cubital fossa
on the anterior aspect of the elbow and is clinically important for venepuncture (withdrawing blood). The
median nerve and brachial artery are the deep relations of the median cubital vein and can be damaged
during venous access.

38. What sort of a synovial joint is the elbow?

A. Ellipsoid
B. Hinge
C. Ball and socket
D. Plane
E. Bicondylar

ANSWER: B

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The elbow joint is a ginglymus or hinge joint. The trochlea of the humerus is received into the semilunar
notch of the ulna and the capitulum of the humerus articulates with the fovea on the head of the radius.
The articular surfaces are connected by a capsule, which is thickened medially and laterally and, to a lesser
extent, in front and behind.
These thickened portions are usually described as distinct ligaments under the following names: anterior
ligament, posterior ligament, ulnar collateral ligament and radial collateral ligament.

39. A road traffic accident victim injured a nerve, which resulted in loss of action of the
muscle inserting on to the crest of the lesser tubercle of the humerus. Which nerve is
damaged?

A. Radial
B. Long thoracic
C. Median
D. Lower subscapular
E. Axillary

ANSWER:D

The lower subscapular nerve supplies the lower part of the subscapularis, which inserts onto the crest of the
lesser tubercle of the humerus and ends in the teres major.
The latter muscle is sometimes supplied by a separate branch.

40. Which one of the following statements regarding the suprascapular nerve is correct?

A. It courses superior to the suprascapular ligament en route to the supraspinatus muscle

B. It contains nerve fibres from c5 and c6 spinal cord segments
C. It innervates the teres minor muscle
D. It provides cutaneous innervation to the posterolateral surface of the shoulder
E. It branches from the middle trunk of the brachial plexus

ANSWER: B

The suprascapular nerve arises from the trunk formed by the union of the fifth and sixth cervical nerves.
It runs lateralward beneath the trapezius and the omohyoid and enters the supraspinatus fossa through the
suprascapular notch, below the superior transverse scapular ligament.
It then passes beneath the supraspinatus and curves around the lateral border of the spine of the scapula to
the infraspinatus fossa.

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In the supraspinatus fossa, it gives off two branches to the supraspinatus muscle and an articular filament to
the shoulder joint; and in the infraspinatus fossa it gives off two branches to the infraspinatus muscle, as
well as some filaments to the shoulder joint and scapula.

LOWER LIMB

1.AN 84-YEAR-OLD MAN HAD HIS LEFT SCIATIC NERVE COMPLETELY

TRANSECTED JUST INFERIOR TO THE BUTT OCK CREASE BY A PIECE OF
SHRAPNEL DURING THE D-DAY LANDINGS IN 1944.WHICH SIGN IS LIKELY TO
BE PRESENT ON CURRENT NEUROLOGICAL EXAMINATION?

A. Complete anaesthesia below the knee

B. Spastic paralysis of the lower limb, with increased ankle jerk
C. Plantar flexed and everted foot
D. Paralysed quadriceps femoris
E. Unimpaired hip abduction

ANSWER: E

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The saphenous branch of the femoral nerve ( the longest cutaneous nerve in the body ) is intact, so there is
retention of Normal sensation along the medial side of the anterior aspect of the leg down to the base of the
hallux.
Peripheral nerve Injuries result in flaccid paralysis, with loss of stretch reflexes of the paralysed muscles.
The foot is plantar flexed due to gravity, (foot drop). However, it is not everted (eversion is produced by the
peroneus longus and brevis, which are paralysed), nor is it Inverted, a function of the paralysed long flexors
of the foot.
The quadriceps is innervated by the intact femoral nerve, and hip Abduction, effected by the gluteus medius
and minimus, supplied by the intact superior gluteal nerve, is unaffected.

2. A 75-year-old man has gangrene of the left hallux. There are no pulses to feel below
the rather weak femoral pulse on that side. A duplex scan reveals a block in the
superficial femoral artery. Which statement pertaining to the arterial system of the
lower limb best accords with usual clinical findings?

A. The common femoral artery divides into its superficial and profunda branches a hand’s breadth
below the inguinal ligament
B. The femoral vein lies on the lateral side of the common femoral artery at the groin
C. The femoral artery passes into the popliteal fossa, as the popliteal artery, by passing between the
adductor longus and magnus
D. The popliteal artery lies against the popliteal surface of the femur deep to the popliteal vein, which
itself lies deep to the tibial nerve
E. The pulse of the posterior tibial artery is felt behind the lateral malleolus

ANSWER:D

The common femoral artery lies on the lateral side of the vein and divides 3 cm distal to the inguinal
ligament.
The superficial femoral artery becomes the popliteal by passing through the hiatus in the adductor magnus.
The posterior tibial pulse is sought behind the medial malleolus.

3. Intervertebral disc prolapse in the lumbar spine most oft en affects the l4/l5 and l5/s1
discs. In a man presenting with acute back pain following an episode of lifting a heavy
weight, reduced force of which of the following movements would most suggest an l5/s1
(l.5 root) rather than an l4/5 disc lesion (l.4 roo t)?

A. Ankle plantar flexion

B. Eversion of the foot
C. Extension of great toe
D. Inversion of the foot
E. Knee extension

ANSWER: C

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In the lumbar spine (in contrast to the cervical spine) nerve roots emerge below their respective vertebrae:
thus an l4/5 disc
Lesion would be expected to affect the l4 root and an l5/s1 disc lesion to affect the l.5 nerve root.
Knee extension is mediated by l2, 3 and 4; ankle dorsiflexion by l4 and 5; inversion of the foot by l4 alone;
eversion of the foot by s1, and ankle plantar Flexion by s1 and 2.
Although l5 contributes to hip abduction and extension, knee flexion and ankle dorsiflexion, weakness is
often minimal because of the contribution of other roots to these movements and tends to be maximal in
extension of the toes, Particularly the great toe.

4. What would be consistent with femoral nerve damage in a patient with pelvis trauma?

A. Preserved knee reflex

B. Loss of sensation over the anterior femur
C. Loss of power in the biceps femoris muscle
D. Loss of power in the peroneus muscle
E. Reduced power on adduction

ANSWER: B

The femoral nerve may be damaged from fractures of the pelvis or femur, or dislocations of the hip, and hip
or hernia surgery.
It can also be involved in psoas abscesses, thigh wounds and frequently in large psoas haematomas in
patients with haemophilia and diabetic amyotrophy.
Partial lesions are common from thigh wounds with the nerve to the quadriceps most Frequently involved
and causing great problems in walking with the knee often giving way, especially when descending stairs.
It Leads to a loss of power in the knee extension.
In addition there is quadriceps wasting, loss of knee jerk and impaired sensation Over the front of the thigh.

5. A patient presents with pins and needles on the lateral and anterior aspect of his left
thigh. On examination, there is no motor deficit. There is no history of trauma. Which of
the following is likely to be causing the problem?

A. Single best answer question – choose one true option only

B. Lateral cutaneous nerve of the thigh lesion
C. L2 root lesion
D. L3 root lesion
E. Femoral nerve lesion
F. Saphenous nerve lesion

ANSWER: B

The lateral cutaneous nerve of the thigh supplies the antero-lateral aspect of the thigh. It has no motor
branches. Meralgia

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Paraesthetica is a condition which where there is irritation of the nerve causing sensory changes in the
distribution of the lateral Cutaneous nerve of the thigh without any motor changes.
L2 and l3 supply part of the dermatome described but both have motor branches.
The femoral nerve supplies the quadriceps muscle, and the saphenous nerve runs with the saphenous vein to
supply an area of skin below the knee on the medial aspect of the leg.

6. A patient develops common peroneal nerve palsy after treatment with a below knee
cast for 6 weeks for an undisplaced ankle fracture. Which of the following is true ?

A. The patient is unable to stand on tip toe

B. There would be complete sensory loss below the knee
C. There would be no dorsiflexion of the foot
D. The patient would complain of complete sensory loss on the sole of the foot
E. Sensation would be normal on the dorsum of the foot

ANSWER: C

The common peroneal nerve (also known as the common fibular nerve) can be compressed by a below knee
cast at the level of the fibula neck. It supplies the muscles of the anterior and lateral compartments of the leg,
producing dorsiflexion of the foot, Ankle and toes, as well as eversion of the foot.
The superficial peroneal nerve gives sensory supply to most of the dorsum of the foot. The deep peroneal
nerve supplies the first web space.
The action of standing on tip-toes is produced by ankle plantar flexion ie. Gastrocnemius and soleus,
supplied by the tibial Nerve.
The lower leg also receives sensory innervation from the saphenous and tibial nerves which would be
unaffected, therefore sensory loss would be incomplete.

7. A PATIENT PRESENTS WITH VARICOSITIES AROUND THE LATERAL

MALLEOLUS AND FURTHER VARICOSITIES ON THE PO STERO-LATERAL
ASPECT OF THE LEG UP TO THE LEVEL OF THE KNEE JOINT. WHICH OF THE
FOLLOWING IS CORRECT?

A. The patient has varicosities of the long saphenous vein

B. There is an incompetence at the sapheno-femoral junction
C. The incompetent valve is unlikely to be in the popliteal fossa
D. Both short and long saphenous veins are affected
E. The patient has varicosities of the short saphenous system

ANSWER: E

The short saphenous system passes posterior to the lateral malleolus and ascends the leg lateral to the
achilles tendon.

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It usually perforates the popliteal fossa and terminates in the popliteal vein. The incompetent valve is likely
to be at this junction.
The great saphenous passes above the medial malleolus, ascending obliquely across the inferior third of the
patella and passes a hands breadth posterior to the patella on the medial side of the knee.
It passes through the superficial fascia and the Saphenous opening in the fascia lata, ending at the sapheno-
femoral junction.

8. From lateral to medial what are the structures in the femoral triangle

A. Femoral vein, femoral artery, femoral nerve

B. Femoral nerve, femoral artery, femoral vein
C. Femoral nerve, femoral artery, femoral vein, long saphenous vein
D. Long saphenous vein, femoral vein, femoral artery, femoral nerve
E. Short saphenous vein, femoral vein, femoral artery, femoral nerve

ANSWER: C

From lateral to medial, the femoral triangle contains the femoral nerve and its branches, the femoral artery
and its branches, Including the profunda femoris and the femoral vein with its main tributary the long
saphenous vein.
The short saphenous vein enters the popliteal vein in the popliteal fossa.

9. All of the following muscles are found in the anterior compartment of the leg except:

A. Tibialis anterior
B. Extensor hallucis longus
C. Extensor digitorum longus
D. Peroneus tertius
E. Peroneus brevis

ANSWER: E

The muscles of the anterior compartment of the leg are:

Tibialis anterior, extensor hallucis longus ,extensor digitorum longus ,peroneus tertius
They are all supplied by the deep peroneal nerve and receive their blood supply from the anterior tibial
artery.
Peroneus brevis is found in the lateral compartment of the leg, along with peroneus longus.

10. A footballer suffers a knee injury in a heavy tackle with immediate swelling of the
knee. He is unable to weight bear. X-rays show an avulsion fracture of the tibial spine.
Which of the following is likely to be true?

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A. There will be impaired resistance to valgus stressing of the knee joint

B. There will be impaired resistance to varus stressing of the knee joint
C. There will be impaired resistance to anterior translation of the tibia on the femur**
D. The patient will be unable to maintain a straight leg raise
E. There will be mal positioning of the patella

Answer: C

The tibial spine is the origin of the anterior cruciate ligament (acl). This provides resistance to anterior
translation of the tibia on the femur as well as resistance to hyperextension of the knee.
Avulsion of the tibial spine is likely to defunction the acl.
The collateral ligaments of the knee attach to the medial proximal tibia and the head of the fibula and are
unlikely to be Affected, hence there will be normal resistance to varus and valgus stressing of the knee joint.
The extensor mechanism of the knee is anterior to the tibial spine and is unlikely to be affected.
Patella tracking and straight leg raising should not be impaired.

11. A patient undergoes intra-medullary nailing for a mid-shaft fracture of tibia 3 hours
ago. The ward nurses are concerned as he is in a lot of pain. On examination, he has no
neurovascular deficit. He complains of excruciating pain on passive dorsif lexion of the
big toe, but not on passive plantar flexion. Passive dorsiflexion and plantar flexion of the
ankle do not cause as much pain. What is the likely diagnosis?

A. Compartment syndrome of the deep posterior compartment of the leg

B. Compartment syndrome of the superficial posterior compartment of the leg
C. Compartment syndrome of the anterior compartment of the leg
D. Compartment syndrome of the lateral compartment of the leg
E. Compartment syndrome of the medial compartment of the leg

ANSWER: A

In compartment syndrome, pain is worsened by passive stretching of the affected compartment. In this case
the muscle being stretched is flexor hallucis longus. This muscle is in the deep posterior compartment of the
leg, along with flexor digitorum Longus and tibialis posterior.

• The anterior compartment contains tibialis anterior, extensor hallucis longus, extensor digitorum
longus and peronius tertius.
• The superficial posterior compartment contains gastrocnemius. Plantaris and soleus.
• The lateral compartment contains peroneus longus and brevis. There is no medial compartment of
the leg.

12. A patient presents with a history of back pain which developed 3 months ago when he
got up suddenly from a seated position. The pain radiates down the l eg to the ankle. On

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examination he has weakness of the quadriceps, reduced knee jerk reflex and reduced
sensation over the patella. Where is the lesion likely to be?

A. Sciatic nerve compression

B. Ilioinguinal nerve
C. L3 nerve root
D. L5 nerve root
E. Compression of the femoral nerve at the inguinal ligament

ANSWER: C

The history suggest a prolapsed intervertebral disc. The quadriceps are supplied by the femoral nerve whose
root value is l2-l4. The skin over the patella is usually part of the l3 dermatome, and the root value of the
knee jerk is l3/l4.
The sciatic nerve innervates the muscles of the posterior compartment of the thigh and the muscles of the
leg. It provides Sensory innervation for the posterior thigh, the leg and the foot.
The ilioinguinal nerve supplies a small area of skin on the medial aspect of the upper thigh as well as the
scrotum and penis.
Femoral nerve compression at the level of the inguinal ligament is unlikely given the history of injury and
back pain.

13. Following open reduction internal fixation of both the distal tibia and the distal
fibula, a patient complains of numbness along the lateral side of the foot. Which nerve is
likely to have been injured?

A. Sural nerve
B. Saphenous nerve
C. Deep peroneal nerve
D. Superficial peroneal nerve
E. Tibial nerve

ANSWER: A

The sural nerve arises from the tibial nerve. It is purely sensory and supplies the lateral border of the leg and
the lateral border of the foot. It lies approximately 1cm posterior to the distal fibula and may be damaged
during operations on the distal fibula.
The saphenous nerve supplies the medial aspect of the leg up to the medial malleolus.
The deep peroneal nerve supplies the First web space whilst the superficial peroneal nerve usually supplies
the rest of the dorsum of the foot.
The tibial nerve supplies the heel and branches into the medial and lateral plantar nerves to innervate the
sole of the foot.

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14. A patient with known vascular disease develops erectile dysfunction he denies any leg
pain. On examination he has marked wasting of the right buttock area. Which vessel is
likely to be affected?

A. Single best answer question – choose one true option only

B. Superficial femoral artery
C. Internal iliac artery
D. Profunda femoris
E. External iliac artery
F. Common iliac artery

ANSWER: C

The internal iliac artery divides into two branches, the posterior division and the anterior division.
The posterior division gives off the superior gluteal artery which supplies gluteus medius and minimis.
The anterior division gives off the inferior gluteal artery which supplies gluteus maximus.
All the muscles of the buttock are therefore supplied by the internal iliac artery, so Compromise of this
vessel would lead to visible buttock wasting.
As there is no leg pain the lesion is unlikely to be affecting either the common iliac artery or any branches of
the external iliac Artery.
The superficial femoral artery is a continuation of the external iliac artery and this gives off the profunda
femoris.

15. A patient has paralysis of the quadriceps femoris muscle. Which one of the following
movements will be affected in this Patient?

A. Single best answer question – choose one true option only

B. Extension of the leg**
C. Flexion of the leg
D. Flexion of the thigh
E. Adduction of the thigh
F. Abduction of the thigh

ANSWER:

The quadriceps femoris is the great extensor muscle of the leg, forming a large fleshy mass that covers the
front and sides of the femur. It is subdivided into separate portions, which have received distinctive names.
One, occupying the middle of the thigh and connected above with the ilium, is called from its straight course
the rectus femoris.
The other three lie in immediate Connection with the body of the femur, which they cover from the
trochanters to the condyles.
The portion on the lateral side of the femur is the vastus lateralis; that covering the medial side, the vastus
medialis; and that in front, the vastus intermedius.

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16. A young man was stabbed on the lateral aspect of the knee. Identify the correct
superficial-to-deep sequence of structures traversed by the knife :

A. Single best answer question – choose one true option only

B. Skin, tibial collateral ligament, lateral meniscus
C. Skin, fibular collateral ligament, popliteus muscle tendon, lateral meniscus
D. Skin, popliteus muscle tendon, tibial collateral ligament, lateral meniscus
E. Skin, popliteus tendon, fibular collateral ligament, lateral meniscus
F. Skin, anterior cruciate ligament, popliteus muscle tendon

ANSWER: C

The correct order of superficial to deep structures on the lateral aspect of the knee joint is skin, fibular
collateral ligament, Popliteus muscle tendon and lateral meniscus.

17. The medial and lateral femoral circumflex arteries are usually direct branches of the:
single best answer question – choose one true option only

A. Obturator artery
B. Popliteal artery
C. Profunda femoris artery
D. External iliac artery
E. First perforating artery

ANSWER: C

The profunda femoris artery (deep femoral artery) is a large vessel arising from the lateral and back part of
the femoral artery, from 2 to 5 cm below the inguinal ligament.
At first it lies lateral to the femoral artery; it then runs behind it and the femoral vein to the medial side of
the femur and, passing downward behind the adductor longus, ends at the lower third of the thigh in a small
branch which pierces the adductor magnus and is distributed on the back of the thigh to the hamstring
muscles.
The terminal part of the profunda is sometimes known as the fourth perforating artery.

18. The short head of the biceps femoris muscle is innervated by: single best answer
question – choose one true option only

A. The common peroneal part of the sciatic nerve

B. The same nerve as the pectineus muscle
C. The same nerve as the piriformis muscle
D. The tibial part of the sciatic nerve

ANSWER: A

The same portion of the sciatic nerve as innervates the semitendinosus muscle the short head of biceps
femoris arises from the lateral lip of the linea aspera, between the adductor magnus and vastus Lateralis,

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extending up almost as high as the insertion of the gluteus maximus; from the lateral prolongation of the
linea aspera to within 5 cm of the lateral condyle; and from the lateral intermuscular septum.
The fibres of the short head merge into the aponeurosis formed by the long head; this aponeurosis becomes
gradually contracted into a tendon, which is inserted into the Lateral side of the head of the fibula and by a
small slip into the lateral condyle of the tibia.
At its insertion, the tendon of biceps femoris divides into two portions, which embrace the fibular collateral
ligament of the knee joint. From the posterior border of the tendon, a thin expansion is given off to the
fascia of the leg. The tendon of insertion of this biceps forms the lateral hamstring; the common peroneal
nerve descends along its medial border. The nerve to the short head of the biceps femoris is derived from the
common peroneal part of the sciatic nerve.

19. A patient complains of defici t in the cutaneous field halfway down the anterior
surface of the thigh. This: single best answer question – choose one true option only

A. Is due to damage to the sciatic nerve

B. Would result from compression of the ventral roots of l5 to s2
C. Would result from damage to a nerve accompanying the artery in the adductor canal
D. Could be the result of nerve damage during surgical procedures in the femoral sheath
E. Would result from damage to the nerve that innervates the pectineus muscle

ANSWER: E

The pectineus is supplied by the second, third and fourth lumbar nerves through the femoral nerve and by
the third lumbar through the accessory obturator when this exists. Occasionally it receives a branch from the
obturator nerve.
The anterior surface of the thigh receives its innervation from, the femoral nerve as well so that is the nerve
most likely to be injured. In the thigh, the anterior division of the femoral nerve gives off anterior cutaneous
branches. The anterior cutaneous branches comprise the intermediate and medial cutaneous nerves.
The intermediate cutaneous nerve pierces the fascia lata (and generally the sartorius) about 7.5 cm below the
inguinal ligament and divides into two branches that descend in immediate proximity along the forepart of
the thigh to supply the skin as low as the front of the knee. Here they communicate with the medial
cutaneous nerve and the infrapatellar branch of the saphenous, to form the patellar plexus. In the upper part
of the thigh, the lateral branch of the intermediate cutaneous communicates with the lumboinguinal branch
of the genitofemoral nerve.

20. Innervation to the peroneus brevis muscle: choose one true option only

A. Could be damaged by a fracture of the tibia

B. Is by a nerve that is a direct branch of the femoral nerve
C. Is by a nerve that is accompanied by an artery in the same compartment
D. Is by the same distal nerve that innervates the peroneus tertius muscle
E. Could be damaged by a fracture of the neck of the fibula

ANSWER: E

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The peroneus brevis is supplied by the fourth and fifth lumbar and first sacral nerves through the superficial
peroneal nerve.
The superficial peroneal nerve is one of the two terminal branches of the common peroneal nerve. The
common peroneal nerve winds around the neck of the fibula and can be injured in cases of fracture neck of
fibula.
Such an injury can result in paralysis or paresis of peroneus brevis due to indirect involvement of the
superficial peroneal nerve.

21. Which one of the following muscles is attached to the tibial tuberosity? Choose one
true option only

A. Pectineus
B. Vastus intermedius
C. Tensor fascia lata
D. Short head of the biceps femoris
E. Adductor brevis

ANSWER: B

The tuberosity of the tibia gives attachment to the ligamentum patellae (which is the single strong tendon of
the quadriceps Femoris, including rectus femoris, vasti medialis, intermedius and lateralis).
A bursa intervenes between the deep surface of the Ligament and the part of the bone immediately above the
tuberosity.

22. Following a stab injury a patient has his sciatic nerve cut as it exits the pelvis. Which
one of the following statements is correct regarding this patient? Choose one true option
only

A. Extension of the knee would be eliminated

B. The long head of the biceps femoris muscle would be affected but not the short head
C. There would still be cutaneous sensation over the anteromedial surface of the thigh
D. The muscles in the anterior compartment of the leg would still be functional
E. The sartorius and gracilis muscles would not be able to contract

ANSWER: C

The sciatic nerve is a large nerve that runs down the lower limb. It is the longest single nerve in the body.
The sciatic nerve supplies nearly the whole of the skin of the leg, the muscles of the back of the thigh and
those of the leg and foot.
A transection of the sciatic nerve at its exit from the pelvis will affect all the above-mentioned functions
except cutaneous sensation over the anteromedial surface of the thigh, which comes from the femoral nerve.

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23. The lateral compartment of the leg containing the peroneus longus and brevi s
muscles is innervated by the: Choose one true option only

A. Tibial nerve
B. Common peroneal nerve
C. Superficial peroneal nerve
D. Deep peroneal nerve
E. Sural nerve

ANSWER: C

The superficial peroneal nerve supplies the peronei longus and brevis and the skin over the greater part of
the dorsum of the Foot.
It passes forward between the peronei and the extensor digitorum longus, pierces the deep fascia at the lower
third of the Leg and divides into a medial and an intermediate dorsal cutaneous nerve.
In its course between the muscles, the nerve gives off muscular branches to the peronei longus and brevis
and cutaneous filaments to the skin of the lower part of the leg.

24. A footballer fell awkwardly because of a rash challenge. He sustained a blow to his
left knee and was stretchered off the playing field. On examination of his injured knee
the physiotherapist found excessive posterior movement of the tibia on the femur. The
chief ligament preventing posterior sliding of the tibia on the femur is the :

A. Tibial collateral
B. Fibular collateral
C. Oblique popliteal
D. Posterior cruciate
E. Anterior cruciate

ANSWER: D

The posterior cruciate ligament (pcl) is stronger, but shorter and less oblique in its direction, than the
anterior. It is attached to the posterior intercondyloid fossa of the tibia and to the posterior extremity of the
lateral meniscus and passes upward, forward and medialward, to be fixed into the lateral and front part of the
medial condyle of the femur.
This configuration allows the pcl to resist forces pushing the tibia posteriorly relative to the femur.

HEAD & NECK

1. The supratrochlear nerve is a terminal branch of which nerve ?

A. Ophthalmic

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B. Frontal
C. Nasociliary
D. Lacrimal
E. Maxillary

ANSWER: B

The supratrochlear nerve, the smaller of the two branches of the frontal nerve, passes above the pulley of the
superior oblique and gives off a descending filament to join the infratrochlear branch of the nasociliary
nerve. It then escapes From the orbit between the pulley of the superior oblique and the supraorbital
foramen, curves up onto the forehead close to the bone, ascends beneath the corrugator and frontalis and
dividing into branches which pierce these Muscles, it supplies the skin of the lower part of the forehead
close to the midline and sends filaments to the Conjunctiva and skin of the upper eyelid.

2. Which of the following statements is correct regarding the muscles of facial

expression?

A. The digastric muscle is a muscle of facial expression

B. Some muscles of facial expression are innervated by the long buccal nerve
C. They are in the same subcutaneous plane as the platysma muscle
D. Some muscles of facial expression receive their motor supply via the zygomaticofacial nerve
E. All muscles of facial expression are attached to bone

ANSWER: C

The facial muscles are subcutaneous (just under the skin, in the same plane as the platysma) muscles that
control facial expression. They generally originate on bone and insert on the skin of the face.
The facial muscles are innervated by cranial nerve vii, also known as the facial nerve. The facial muscles are
derived from the second Pharyngeal arch.

3. The olfactory foramina:

A. Are located in the middle cranial fossa

B. Are located in the anterior cranial fossa
C. Are located immediately inferior to the optic foramen
D. Have motor neurones running through them
E. Are located in the sphenoid bone

ANSWER: B

The olfactory foramina are located in the anterior cranial fossa. These foramina are in the cribriform plate of
the Ethmoid bone for the passage of olfactory nerves.

4.The inferior sagittal sinus:

A. Drains directly into the confluence of sinuses

B. Is found in the falx cerebelli

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C. Is formed between two layers of meningeal dura

D. Drains into the superior petrosal sinus
E. Contains valves, unlike the other venous dural sinuses

ANSWER: C

The inferior sagittal sinus is enclosed in the posterior half or two thirds of the free margin of the falx cerebri.
It is Cylindrical in shape. It increases in size as it passes backward and ends in the straight sinus. It receives
several veins From the falx cerebri and occasionally receives a few veins from the medial surfaces of the
hemispheres.

5. Which of the following structures separates the anterior and posterior chambers in the
eyeball?

A. The lens
B. The cornea
C. The iris
D. The pupil
E. The ciliary processes

ANSWER: C

The iris has received its name from its various colours in different individuals. It is a thin, circular,
contractile disc, Suspended in the aqueous humour between the cornea and lens and perforated a little to the
nasal side of its centre by a circular aperture, the pupil.
At its periphery it is continuous with the ciliary body and is also connected to the posterior Elastic lamina of
the cornea by means of the pectinate ligament. Its surfaces are flattened and look forward and Backward,
the anterior toward the cornea, the posterior toward the ciliary processes and lens.
The iris divides the Space between the lens and the cornea into an anterior and a posterior chamber. The
anterior chamber of the eye is bounded in front by the posterior surface of the cornea; behind by the front of
the iris and the central part of the lens.The posterior chamber is a narrow chink behind the peripheral part of
the iris and in front of the suspensor ligament of the lens and the ciliary processes.
In the adult, the two chambers communicate through the pupil, but in the fetus up to the seventh month they
are separated by the membrana pupillaris.

6. A patient who had surgery in the left carotid triangle complained to his physician that
he has little sense of touch to the skin over the left side of his n eck and difficulty
swallowing. The patient’s hyoid bone is deviated to the right side. The patient’s tongue is
not affected. The physician suspects that the cervical plexus of nerves to the left side of
this patient’s neck was harmed during the surgical pr ocedure. Of the following nerves,
which is embedded in the carotid sheath and therefore vulnerable to injury during
surgical procedures to the carotid artery?

A. Spinal accessory nerve

B. Ansa cervicalis

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C. Cervical sympathetic chain

D. Phrenic nerve
E. Suprascapular nerve

ANSWER: B

The ansa cervicalis (or ansa hypoglossi in older literature) is a loop of nerves that are part of the cervical
plexus.
Branches from the ansa cervicalis innervate the sternohyoid, sternothyroid and the inferior belly of the
omohyoid. Two Roots make up the ansa cervicalis. The superior root of the ansa cervicalis is formed by a
branch of spinal nerve c1.
These nerve fibres travel in the hypoglossal nerve before leaving to form the superior root. The superior root
goes around the occipital artery and then descends embedded in the carotid sheath. It sends a branch off to
the superior Belly of the omohyoid muscle and is then joined by the inferior root. The inferior root is formed
by fibres from spinal Nerves c2 and c3.

7. Postganglionic sympathetic fibres innervating the dilator pupillae muscle begin in the:

A. Ciliary ganglion
B. Superior cervical ganglion
C. Brain
D. Trigeminal ganglion
E. Spinal cord (t1-l2)

ANSWER : B

The cervical portion of the sympathetic trunk consists of three ganglia, named according to their positions as
the Superior, middle and inferior ganglia and connected by intervening cords.
This portion receives no white rami Communicantes from the cervical spinal nerves.
Its spinal fibres are derived from the white rami of the upper thoracic nerves and enter the corresponding
thoracic ganglia of the sympathetic trunk, through which they ascend into the neck.
The superior cervical ganglion, the largest of the three, is located opposite the second and third cervical
vertebrae. It is Reddish-grey in colour and usually fusiform in shape. It is thought to be formed by the
coalescence of four ganglia, Corresponding to the upper four cervical nerves.
It is related anteriorly to the sheath of the internal carotid artery and the internal jugular vein and posteriorly
to the longus capitis muscle.
It contains neurones that supply sympathetic innervation to the face (including the dilator pupillae muscle of
the iris).

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8. THE OPHTHALMIC ARTERY EMERGES THROUGH WHICH OF THE

FOLLOWING FORAMINA TO REACH THE EYE?

A. Optic canal
B. Foramen spinosum
C. Superior orbital fissure
D. Foramen rotundum
E. Inferior orbital fissure

ANSWER: A

The ophthalmic artery arises from the internal carotid, just as that vessel is emerging from the cavernous
sinus, on the medial side of the anterior clinoid process and enters the orbital cavity through the optic
foramen (canal), below and lateral to the optic nerve.
It then passes over the nerve to reach the medial wall of the orbit and thence horizontally Forward, beneath
the lower border of the superior oblique and divides it into two terminal branches, the frontal and dorsal
nasal. As the artery crosses the optic nerve it is accompanied by the nasociliary nerve and is separated from
the Frontal nerve by the rectus superior and levator palpebrae superioris.

9. The sphenopalatine artery:

A. Accompanies the infraorbital nerve to its termination

B. Enters the infratemporal fossa through the pterygomaxillary fissure
C. Supplies blood to the lateral nasal wall and nasal septum
D. Is a terminal branch of the middle superior alveolar artery
E. Sends a branch into the pharyngeal canal

ANSWER: C

The sphenopalatine artery, a branch of the third part of the internal maxillary artery, passes through the
sphenopalatine foramen into the cavity of the nose, at the back part of the superior meatus. Here it gives off
its posterior lateral nasal branches, which spread forward over the conchae and meatuses, anastomose with
the ethmoidal arteries and the Nasal branches of the descending palatine and assist in supplying the frontal,
maxillary, ethmoidal and sphenoidal Sinuses.
Crossing the undersurface of the sphenoid, the sphenopalatine artery ends on the nasal septum as the
Posterior septal branches; these anastomose with the ethmoidal arteries and the septal branch of the superior
labial.
One branch descends in a groove on the vomer to the incisive canal and anastomoses with the descending
palatine Artery.

10. The submandibular duct opens:

A. Near the maxillary second molar

B. Near the mandibular first molar
C. From the incisive foramen
D. Near the midline in the anterior aspect of the floor of the mouth

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E. Into the buccal vestibule near the mandibular ramus

ANSWER: D

The submandibular duct (wharton’s duct) is about 5 cm long and its wall is much thinner than that of the
parotid duct.
It begins from numerous branches from the deep surface of the gland and runs forward between the
mylohyoid and the hyoglossus and genioglossus, then between the sublingual gland and the genioglossus
and opens by a narrow orifice on the summit of a small papilla, at the side of the frenulum linguae, near the
midline in the anterior aspect of the floor of the mouth.
On the hyoglossus it lies between the lingual and hypoglossal nerves, but at the anterior border of themuscle
it is crossed laterally by the lingual nerve. The terminal branches of the lingual nerve ascend on its medial
side.

11. Of the following intrinsic muscles of the larynx, which tenses (stretches) the vocal
folds?

A. Posterior cricoarytenoid
B. Lateral cricoarytenoid
C. Thyroarytenoid
D. Transverse arytenoid
E. Cricothyroid muscle

ANSWER : E

The cricothyroid, triangular in form, arises from the front and lateral part of the cricoid cartilage; its fibres
diverge and Are arranged in two groups. The lower fibres constitute a pars obliqua and slant backward and
lateralward to the anterior border of the inferior cornu.
The anterior fibres, forming pars recta, run upward, backward and lateralward to The posterior part of the
lower border of the lamina of the thyroid cartilage.
The external laryngeal branch of the Superior laryngeal nerve supplies the cricothyroid.
The cricothyroids produce tension and elongation of the vocal folds by drawing up the arch of the cricoid
cartilage and tilting back the upper border of its lamina.
The distance between the Vocal processes and the angle of the thyroid is so increased and the folds are
consequently elongated.

12. The nasolacrimal duct empties into the:

A. Sphenoethmoidal recess
B. Inferior meatus
C. Middle meatus

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D. Maxillary sinus
E. Infundibulum

ANSWER: B

The nasolacrimal duct is a membranous canal, about 18 mm in length, which extends from the lower part of
the Lacrimal sac to the inferior meatus of the nose, where it ends by a somewhat expanded orifice, provided
with an Imperfect valve, the plica lacrimalis (hasner’s fold), formed by a fold of the mucous membrane.
It is contained in an osseous canal, formed by the maxilla, the lacrimal bone and the inferior nasal concha. It
is narrower in the middle than at either end and is directed downward, backward and a little lateralward.
The mucous lining of the lacrimal sac and Nasolacrimal duct is covered with columnar epithelium, which in
places is ciliated.

13. In surgery of the thyroid gland, the external laryngeal nerve may be injured and
must be identified before ligating the:

A. Inferior thyroid artery

B. Superior thyroid artery
C. Superior pharyngeal artery
D. Inferior laryngeal artery
E. Ascending palatine artery

ANSWER: B

The external laryngeal nerve is the smaller, external branch (ramus externus) of the superior laryngeal nerve.
It descends on the larynx, beneath the sternothyroid muscle, to supply the cricothyroid muscle.
It gives branches to the Pharyngeal plexus and the superior portion of the inferior pharyngeal constrictor and
communicates with the superior Cardiac nerve behind the common carotid artery.
The external branch is susceptible to damage during thyroidectomy, As it lies immediately deep to the
superior thyroid artery.

14. Directing the gaze downward when the eye is abducted requires the:

A. Lateral rectus muscle

B. Inferior rectus muscle
C. Superior oblique muscle
D. Inferior oblique muscle
E. Medial rectus muscle

ANSWER: B

The inferior rectus muscle is an extraocular muscle that depresses, adducts and rotates the eye laterally.
As with most of the muscles of the orbit (exceptions are the lateral rectus and superior oblique), it is
innervated by the oculomotor Nerve (cranial nerve iii).

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15. What structure divides the posterior triangle of the neck further into an upper and
lower triangle?

A. Anterior belly of the digastric

B. Inferior belly of the omohyoid
C. Posterior belly of the digastric
D. Scalenus anterior muscle
E. Superior belly of the omohyoid

ANSWER: B

The posterior triangle is bounded in front by the sternocleidomastoid; behind, by the anterior margin of the
trapezius; its base is formed by the middle third of the clavicle; its apex, by the occipital bone.
The space is crossed, about 2.5 cm above the clavicle, by the inferior belly of the omohyoid, which divides it
into two triangles, an upper or occipital and a Lower or subclavian.
It contains the accessory nerve, which crosses the triangle from the upper third of Sternocleidomastoid to the
lower two-thirds of trapezius.
It is particularly vulnerable to damage during lymph node Biopsy, when damage results in an inability to
shrug the shoulders or raise the arm above the head (brushing hair).

16. What structure divides the posterior triangle of the neck further into an upper and
lower triangle?

A. Anterior belly of the digastric

B. Inferior belly of the omohyoid
C. Posterior belly of the digastric
D. Scalenus anterior muscle
E. Superior belly of the omohyoid

ANSWER: B

The posterior triangle is bounded in front by the sternocleidomastoid; behind, by the anterior margin of the
trapezius; its Base is formed by the middle third of the clavicle; its apex, by the occipital bone.
The space is crossed, about 2.5 cm above the clavicle, by the inferior belly of the omohyoid, which divides it
into two triangles, an upper or occipital and a lower or subclavian. It contains the accessory nerve, which
crosses the triangle from the upper third of Sternocleidomastoid to the lower two-thirds of trapezius.
It is particularly vulnerable to damage during lymph node Biopsy, when damage results in an inability to
shrug the shoulders or raise the arm above the head (brushing hair).

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17.the name of the bone that the internal carotid artery enters to reach the intracranial
cavity is the:

A. Frontal
B. Occipital
C. Sphenoid
D. Temporal
E. Maxillary

ANSWER: D

The internal carotid artery supplies the anterior part of the brain, the eye and its appendages and the forehead
and Nose. In the adult it is the same size as the external carotid, but in the child it is larger than the external
carotid.
It is Remarkable for the number of curvatures that it presents in different parts of its course. It occasionally
has one or two Curvatures near the base of the skull, while in its passage through the carotid canal in the
petrous part of the temporal Bone and along the side of the body of the sphenoid bone it describes a double
curvature and resembles an italic letter ‘s’.
The carotid canal is found on the inferior surface of the petrous part of the temporal bone. It ascends
vertically at First and then bends and runs horizontally forward and medially. It transmits the internal carotid
artery and the carotid Plexus of nerves into the cranium.

18. A 25-year-old woman with history of high-grade fever, gradual-onset loss of

consciousness and a petechial rash is suspected of ha ving bacterial meningitis. As part of
the diagnostic procedure, a lumbar puncture is to be performed. To avoid injury to the
spinal cord and nerves you must insert the spinal needle just below the spine of the
fourth lumbar vertebra. What anatomical landmark would you use to identify the spine
of the fourth lumbar vertebra?

A. Pubic symphysis
B. Iliac crest
C. Xiphoid process
D. Iliac tuberosity
E. Umbilicus

ANSWER: B

The fourth lumbar vertebra (l4) is a relatively safe level for performing a lumbar puncture. Since the conus
medullaris Is at the inferior border of l1 or the superior border of l2, it should be safe to insert a needle either
above or below l4.
The anatomical landmark used to identify l4 is the top of the iliac crest.

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The line connecting the top of the two iliac Crests, the supracrestal line, passes through the spinous process
of the l4 vertebra. Therefore, by finding the tops of The iliac crests, you should be able to identify l4.

19. An 85-year-old man with prostatic cancer is most likely to have metastatic spread of
cancer through which of the following veins?

A. Testicular vein
B. Cephalic vein
C. Basilic vein
D. External iliac vein
E. Internal vertebral venous plexus

ANSWER: E

The veins of the internal vertebral venous plexus are clinically significant because they are valveless and can
serve as A route for metastases.
Cancerous cells can travel freely in vertebral veins and lodge somewhere else in the body.
The Other veins all have valves that would direct the flow of blood and stop some of the metastatic spread.

20. Itching sensation from the skin immediately over the base of the spine of your
scapula is mediated through the:

A. Accessory nerve
B. Dorsal primary ramus of c7
C. Dorsal root of t2
D. Ventral primary ramus of c7
E. Ventral root of t2

ANSWER: B

Dorsal and ventral primary rami are the first branches off spinal nerves.

• Dorsal rami provide sensory innervation to the Skin over the back and give motor innervation to the
true back muscles;
• ventral rami supply sensory innervation to the Skin over the limbs and the skin over the ventral side
of the trunk. Ventral rami also give motor innervation to the Skeletal muscles of the neck, trunk and
extremities.
Therefore, if the skin over the spine of your scapula began to itch, the sensation of that area would be
transmitted by the dorsal primary ramus of c7.
The accessory nerve, which Innervates the trapezius, is not responsible for any sensory innervation. The
dorsal and ventral roots of spinal nerves are not directly responsible for any sensory innervation to the skin.

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Dorsal and ventral rootlets emerge from the spinal Cord to form the dorsal and ventral roots. The ventral
roots contain efferent motor fibres to skeletal muscles, while the Dorsal roots contain afferent sensory fibres.
These roots combine to form the spinal nerve, which then gives off the Primary rami.

21.which of the following effects is most likely to be seen if the right dorsal scapular
nerve is injured near its origin?

A. Skin of the upper back on the right side would be numb

B. The point of the right shoulder would droop
C. Scapular retraction on the right would be weakened
D. Extension of the right arm would be weakened
E. Inability to adduct the right arm

ANSWER: C

The dorsal scapular nerve is a motor nerve off the c5 nerve root that innervates the rhomboids and levator
scapulas. These muscles help to retract and elevate the scapula, so these movements would be weakened
following that Damage.
The skin of the upper back on the right side is innervated by the dorsal primary rami of a spinal nerve.
The Point of the right shoulder, the acromion, is elevated by the trapezius. The trapezius is innervated by the
accessory Nerve, so the point of the shoulder would droop if the accessory nerve was damaged.
Latissimus dorsi, innervated by the thoracodorsal nerve, allows for extension and adduction of the arm.

22. The transverse cervical artery is severed in a road traffic accident. Which muscle
would be affected the most?

A. Levator scapulas
B. Rhomboideus minor
C. Rhomboideus major
D. Trapezius
E. Latissimus dorsi

ANSWER: D

The transverse cervical artery supplies blood to the trapezius. Levator scapulas and the rhomboids receive
blood from The dorsal scapular artery.
Latissimus dorsi receives blood from the thoracodorsal artery.

23. Which of the following statements regarding the spinal arachnoid mater is correct?

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A. It is very thick compared with the cranial part

B. It is separated from the dura by the subarachnoid space
C. It forms the denticulate ligaments
D. It invests the cauda equina
E. It has a rich plexus of nerves derived from the vagus

ANSWER: D

The spinal part of the arachnoid is a thin, delicate, tubular membrane loosely investing the spinal cord.
Above, it is Continuous with the cranial arachnoid.
Below, it widens out and invests the cauda equina and the nerves proceeding From it. It is separated from
the dura mater by the subdural space, but here and there this space is traversed by isolated connective-tissue
trabeculae, which are most numerous on the posterior surface of the spinal cord.
The Arachnoid surrounds the cranial and spinal nerves and encloses them in loose sheaths as far as their
points of exit from the skull and vertebral canal. The arachnoid consists of bundles of white fibrous and
elastic tissue intimately blended together. Its outer surface is covered with a layer of low cuboidal
mesothelium.
The inner surface and the Trabeculae are likewise covered by a somewhat low type of cuboidal
mesothelium, which in places is flattened to a Pavement type.
Vessels of considerable size, but few in number, and a rich plexus of nerves derived from the motor Root of
the trigeminal, the facial and the accessory nerves, are found in the arachnoid.

24. Each branchial (pharyngeal) arch has a cartilaginous bar, a muscle component that
differentiates from the cartilaginoustissue, an artery and a cranial nerve. The first
pharyngeal (branchial) arch:

A. Gives rise to the styloid process and hyoid bone

B. Gives rise to the palatine tonsil
C. Gives rise to the muscles of facial expression
D. Gives rise to the sphenomandibular ligament
E. Is innervated by the glossopharyngeal nerve

ANSWER: D

The first pharyngeal arch or mandibular arch is involved with development of the face.
It develops two processes, Maxillary and mandibular, which form the upper and lower jaws respectively.
Bones and muscles of this region are Developed from mesoderm in the arch.
Meckel’s cartilage is the first arch cartilage. It ossifies to form the malleus and Incus in the middle ear.
The sphenomandibular ligament is derived from its perichondrium.
The rest of the cartilage Disappears after the mandible forms around it by intramembranous ossification.

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The muscles derived from the first arch Include temporalis, masseter, medial and lateral pterygoids, anterior
belly of the digastric, mylohyoid, tensor tympani And tensor palati.
The trigeminal nerve is the motor supply of the mandibular arch.

ABDOMEN

1. A 64-year-old man is admitted with a severe haematemesis. Upper gi endoscopy

identifies a posterior gastric ulcer. Bleeding is most likely to having occurred from which
main vessel?

A. Splenic artery
B. Left gastroepiploic artery
C. Inferior pancreaticoduodenal artery
D. Oesophageal branch of the left gastric artery
E. Gastroduodenal branch of the right gastric artery

ANSWER: A

A posterior gastric ulcer may adhere to, and ulcerate, the splenic artery as this runs along the upper border of
the pancreas, Resulting in a drenching haemorrhage. A lesser curve gastric ulcer may implicate the left
gastric artery – the gastroepiploic Vessels lie along the greater curve of the stomach.
A posterior duodenal ulcer may erode the gastroduodenal branch of the Right gastric artery – ‘the ulcer of
duodenal haemorrhage’ – the inferior pancreaticoduodenal artery supplies the lower part of the second part
of the duodenum, well clear of the site of ulceration.
Oesophageal varices commonly extend into the upper Stomach and are, of course, venous in origin.

2. A 50-year-old woman has a suspected right renal artery stenosis. A transfemoral

aortogram has been performed. Which one of the following is likely to be correct?

A. The femoral artery at the groin is situated halfway between the anterior superior iliac spine and the
Pubic tubercle
B. The catheter passes through the common femoral artery into first the external iliac artery and then the
Aorta at its bifurcation
C. The right renal artery also gives off the right ovarian and suprarenal arteries
D. The right and left renal arteries lie in the transpyloric plane at the level of the first lumbar vertebra
E. The aorta passes through the diaphragm at the level of the tenth thoracic vertebra

ANSWER: D

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The femoral artery at the groin constantly lies halfway between the anterior superior iliac spine and the
midline (the pubic Symphysis).
The catheter continues proximally through the external and then the common iliac artery to reach the aorta.
The Aorta gives off the suprarenal and the gonadal (ovarian or testicular) arteries as separate branches,
respectively above and Below the origins of the renal arteries on each side.
The aorta gives off its renal branches at l1 and passes through the Diaphragm at t12.

3.you review a 54-year-old man with a history of alcoholism; you are concerned tha t
there may be evidence of portal hypertension. Which of the following stems best
describes blood flow to the liver?

A. The hepatic artery supplies 75% of the total liver blood flow
B. The normal portal vein pressure is 8–12 mmhg
C. The portal vein supplies 75% of liver blood flow
D. The caudate lobe of the liver does not have it’s own branch of the hepatic vein
E. Only the portal vein enters the liver via the porta hepatis

ANSWER: C

The blood supply of the liver is around 25% of the resting cardiac output and arises from two main vessels.
The hepatic artery, A branch of the coeliac axis supplies 25% of the total liver blood flow. Autoregulation of
blood flow by the hepatic artery ensures Constant liver blood flow.
The portal vein drains most of the gastrointestinal (gi) tract and the spleen and constitutes 75% of Liver
blood flow. Normal portal pressure is 5–8 mmhg, but blood flow increases after meals. Both vessels enter
the liver via the Porta hepatis.
The caudate lobe receives an independent blood supply from the hepatic portal vein and artery and its
branch of The hepatic vein drains directly into the inferior vena cava.

4. Which organ lies anterior in direct contact with the left kidney without separation by
visceral peritoneum?

A. Spleen
B. Left suprarenal
C. Tail of the pancreas
D. Left psoas muscle
E. Splenic flexure

ANSWER: C

A small area along the upper part of the medial border of the left kidney is in relation with the left suprarenal
gland, and close to the lateral border is a long strip in contact with the renal impression on the spleen.

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A somewhat quadrilateral field, about the Middle of the anterior surface, marks the site of contact with the
body of the pancreas, on the deep surface of which are the Lienal vessels.
Above this is a small triangular portion, between the suprarenal and splenic areas, in contact with the
posteroinferior Surface of the stomach. Below the pancreatic area, the lateral part is in relation with the left
colic flexure, the medial with The small intestine.
The areas in contact with the stomach and spleen are covered by the peritoneum of the omental bursa,While
that in relation to the small intestine is covered by the peritoneum of the general cavity; behind the latter are
some branches of the left colic vessels.
The suprarenal, pancreatic, and colic areas are devoid of peritoneum.

5. The psoas major muscle:

A. Flexes the thigh at the hip joint

B. Extends the thigh at the hip joint
C. Adducts the thigh at the hip joint
D. Abducts the thigh at the hip joint
E. Assists in the full contraction of the diaphragm

ANSWER: A

The psoas major muscle joins the iliacus muscle which orginates broadly over the inner aspect of the iliac
wing of the pelvis. This becomes the iliopsoas muscle and inserts on the lesser trochanter of the femur and
thus flexes the thigh at the hip joint.

6. In a subcostal flank approach to the ki dney, which of the following may be incised to
increase upward mobility of the 12th rib?

A. The latissimus dorsi muscle

B. The lumbodorsal fascia
C. The quadratus lumborum muscle
D. The costovertebral ligament
E. The intercoastal muscles between ribs 11 and 12

ANSWER: D

The costovertebral ligament is a strong fascial attachment between the transverse process of the first and
second lumbar Vertebrae and the inferior margin of the 12th rib. It is encountered only in posterior
approaches to the kidney and it can be Incised to produce a greater degree of mobility of the 12th rib thus
providing greater exposure and access to the structures Which reside within the upper portion of the
retroperitoneum.

7. The descending duodenum:

A. Is a retroperitoneal structure
B. Receives the common bile duct
C. Lies lateral to the head of the pancreas

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D. Lies anterior to the hilum of the right kidney

E. All of the above

ANSWER: E

The descending part of the duodenum (the second part) descends vertically, directly anterior to the hilum of
the right kidney,
And as a result is intimately related on its posterior aspect to the medial margin of the right kidney, renal
pelvis, pelviureteric Junction, and often the right proximal ureter.
The common bile duct also lies posterior and drains into the descending Duodenum. Directly medial and
intimately related to the descending duodenum lies the pancreatic head.

8. Which of the vessels listed below drain(s) into the inferior vena cava?

A. Renal veins
B. Inferior mesenteric vein
C. Superior mesenteric vein
D. Splenic vein
E. All of the above

ANSWER: A

The renal veins drain into the inferior vena cava (remember the renal vein is longer on the left). The superior
and inferior Mesenteric veins, along with the splenic vein join to form the portal vein and drain proximally
into the liver rather than directly into the inferior vena cava.

9. A 45 year old man was admitted with right sided abdominal pain and his
investigations include an abdominal ultrasound scan. The ultrasound reveals a right
sided hydronephrosis with a dilated right ureter. Which of the inflammatory processes
listed below might impinge upon the right ureter and cause obstruction?

A. Acute appendicitis
B. A perforated caecal carcinoma
C. Crohn’s disease affecting the terminal ileum
D. All of the above
E. None of the above

ANSWER: D

Although one should think of a calculus in the distal right ureter as the cause of his pain.One must consider
acute appendicitis, Crohns disease, and a perforated caecal carcinoma as possible causes of his symptoms
and ultrasonic findings of a right sided Hydronephrosis and hydroureter. This is because anteriorly the right
ureter is related to the terminal ileum, caecum, appendix, And ascending colon and their mesenteries.

10. During an inguinal hernia repair in a 54 year man, the ilioinguinal nerve is injured in
the inguinal canal, this will most likely result in:

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A. Paraesthesia over the dorsum of the penis

B. Paraesthesia over the pubis and scrotum, and loss of cremasteric contraction
C. Paraesthesia over the pubis and anterior scrotum only
D. Paraesthesia over the anterior and medial thigh
E. Paraesthesia over the pubis only

ANSWER: C

An injury to the ilioinguinal nerve within the inguinal canal may result in parasthesia over the pubis and
anterior scrotum. The Ilioinginal nerve (l1) passes through the internal oblique muscle to enter the inguinal
canal laterally. It passes anterior to the Cord and exits the superficial ring to provide sensation to the mons
pubis and anterior scrotum in the male and labia majora in The female.

11. The blade of a retractor has rested on the psoas muscle during a lengthy operative
procedure. This has resulted in a femoral nerve palsy. In the post -operative period the
patient will experience:

A. Inability to flex the knee only

B. Inability to flex the knee and numbness over the thigh
C. Numbness over the anterior thigh only
D. Inability to extend the knee and numbness over the anterior thigh
E. Inability to flex the hip and numbness over the anterior thigh

ANSWER: D

The femoral nerve is the largest branch of the lumbar plexus (l2-4). It forms in the abdomen within the
substance of the psoas Major muscle and descends posterolaterally through the pelvis to the midpoint of the
inguinal ligament.
It supplies the anterior Thigh muscles – the quadriceps group extend the leg at the knee, it also supplies
other anterior thigh muscles - iliacus and Sartorius which allow flexion of the thigh at the hip joint.
The femoral nerve also gives several branches to the skin on the Anteriomedial side of the lower limb.

12. The femoral sheath:

A. Surrounds the femoral canal and encloses the femoral nerve

B. The medial wall is pierced by the great saphenous vein
C. Is divided by two ventral septa into two compartments
D. The lateral compartment contains the femoral vein
E. The femoral sheath ends about 1 cm inferior to the inguinal ligament

ANSWER: B

The femoral sheath is an oval, funnel shaped fascial tube which encloses the proximal parts of the femoral
vessels, which Inferior to the inguinal ligament.

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It also surrounds the femoral canal, but it does not enclose the femoral nerve. The femoral Sheath ends about
4 cm inferior to the inguinal ligament. The medial wall of the femoral sheath is pierced by the great
Saphenous vein and lymphatic vessels.
The sheath is divided by two vertical septa into three compartments: i. Lateral (containing the femoral
artery), ii. Intermediate (containing the femoral vein, and iii. Medial compartment or space called the
Femoral canal.

13. The transpyloric plane:

A. Is situated midway between the jugular notch and the pubic tubercle
B. Passes through the superior border of l1
C. Passes through the head of the pancreas
D. Passes through the neck of the pancreas
E. Passes through the second part of the duodenum

ANSWER: D

The transpyloric plane is situated midway between the jugular notch in the manubrium of the sternum and
the pubic symphysis. It passes through the inferior border of l1, the pylorus of the stomach, the anterior parts
of the 9th costal cartilages, the Duodenojejunal junction, the neck of the pancreas, and the renal hila.

14. During a left radical nephrectomy performed via a transabdominal route, excessive
traction on which of the following structures might be expected to produce a si gnificant
injury to the spleen?

A. Left adrenal gland

B. Splenorenal and splenocolic ligaments
C. Splenorenal ligament
D. Splenocolic ligament
E. None of the above

ANSWER : B

There is typically a peritoneal extension running from the perirenal fascia which covers the upper pole of the
left kidney to the Inferior splenic capsule. This peritoneal extension is known as the splenorenal or
lienorenal ligament.
Just as with the adjacent Splenocolic ligament one must take care not to exert undue tension on the
splenorenal ligament during a left radical Nephrectomy, and thus avoid any inadvertent tearing of the spleen.

15. The boundaries of the omental foramen (epiploic foramen or foramen of winslow)
are:

A. Anteriorly the hepatic artery

B. Posteriorly the hepatic vein
C. Superiorly the quadrate lobe of the liver
D. Inferiorly the hepatic vein
E. None of the above

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ANSWER: A

The boundaries of the omental foramen are: anteriorly, the portal vein, hepatic artery, and bile duct (all in
the free edge of the Lesser omentum); posteriorly, the inferior vena cava and right crus of the diaphragm;
superiorly, the caudate lobe of the liver; And inferiorly, the superior part of the duodenum, portal vein,
hepatic artery, and bile duct.

16.which of the following arteries branches directly from the coeliac trunk?

A. The right gastric artery

B. The left gastric artery Correct answer
C. The superior pancreaticoduodenal artery
D. The superior mesenteric artery
E. The inferior mesenteric artery

ANSWER:

The short coeliac trunk arises from the aorta at t12. It trifurcates into the common hepatic, left gastric, and
splenic arteries. The Right gastric artery branches from the common hepatic artery.
The superior pancreaticoduodenal artery is a branch of the Gastroduodenal artery.
The superior and inferior mesenteric arteries are branches of the aorta arising from the aorta at l1 and L3
respectively.

17. A 40 year old man presents to the a&e department with a penile fracture. If the
buck’s fascia remains intact, the haematoma will be visible in:

A. The perineum in a butterfly pattern

B. The penis, scrotum, and perineum tracking up the anterior abdominal wall
C. The penis and scrotum only
D. The penile shaft only
E. The shaft and the glans penis only

ANSWER: D

A penile fracture is a result of a tear in the tunica albuginea, which is a dense white fibrous capsule
enclosing the corporal Bodies.
Such a tear leads to bleeding which is usually contained by buck’s fascia.
Given the fact that buck’s fascia (the deep Fascia of the penis) remains intact the haematoma is therefore
limited to the shaft of the penis only.

18. When making an incision for an inguinal hernia repair, the vessels which may be
encountered beneath camper’s fascia are:

A. The accessory obturator vein

B. The gonadal vein

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C. The superficial inferior epigastric artery and vein

D. The superficial circumflex iliac artery and vein
E. None of the above

ANSWER: C

The superficial fascia just superior to the inguinal ligament can be divided into two layers: i. A superficial
fatty layer (camper’s Fascia) and ii.
A membranous deep layer (scarpa’s fascia). The superficial vessels and nerves are located between these
two Layers of superficial fascia.
One should be mindful of the superficial inferior epigastric vessels when cutting through camper’s as failure
to do so can lead To troublesome bleeding.

19. In the normal ureter the diameter of its lumen narrows at:

A. The pelviureteric junction

B. The vesicoureteric junction
C. The point at which the iliac vessels cross it
D. All of the above
E. None of the above

ANSWER: D

The lumen of the ureter is not of equal diameter throughout the ureters entire length. It has three distinct
narrowings, these are The pelviureteric junction proximally, then the crossing of the iliac vessels, and
distally the vesicoureteric junction in the pelvis. These are possible sites of ureteric calculus impaction.

20. The first arterial branch or branches arising from the abdominal aorta is (are)?

A. The renal arteries

B. The right adrenal artery
C. The left adrenal artery
D. The inferior phrenic arteries
E. The superior mesenteric artery

ANSWER: D

The abdominal aorta is a continuation of the thoracic aorta, it begins at the aortic hiatus in the diaphragm
between t12/l1 and Ends at l4 by dividing into two common iliac arteries.
The first arteries to come off the aorta are the inferior phrenic arteries Which arise just inferior to the
diaphragm and pass superolaterally over the crura of the diaphragm.

21. Concerning the portal vein:

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A. It carries blood from three major veins, the superior and inferior mesenteric vein and the left gastric
Vein
B. It is formed posterior to the head of the pancreas
C. It lies posterior to the bile duct in the free edge of the lesser omentum
D. At the porta hepatis the portal vein divides into four branches
E. It lies anterior to the hepatic artery in the free edge of the lesser omentum

ANSWER: C

The portal vein is the main channel of the portal system of veins. It carries blood from three major veins: the
superior and Inferior mesenteric veins and the splenic veins.
The portal vein is formed posterior to the neck of the pancreas. The portal vein Ascends in the free edge of
the lesser omentum to the liver (posterior to the hepatic artery and bile duct).
At the porta hepatis the portal vein divides into right and left branches, which empty their blood into the
hepatic sinusoids.

22. Concerning the uterine artery:

A. It lies anterior and inferior to the ureter near the lateral portion of the fornix
B. It lies anterior and superior to the ureter near the lateral portion of the fornix
C. The right ureter is more vulnerable because it is very close to the lateral aspect of the cervix
D. Usually arises from the umbilical artery
E. The point at which it crosses the ureter is 4cm superior to the ischial spine

ANSWER: B

The uterine artery usually arises separately from the internal iliac artery, but it may also arise from the
umbilical artery. The Uterine artery crosses anterior and superior to the ureter near the lateral portion of the
fornix.
This is of surgical importance as The ureter is in danger of being damaged at the time of a hysterectomy.
The point of crossing of the uterine artery and ureter is Approximately 2 cm superior to the ischial spine.
The left ureter is particularly vulnerable as it lies very close to the lateral Aspect of the cervix.

23. Concerning the uterus:

A. The uterine wall consists of two layers: the myometrium and the endometrium
B. The uterus is frequently retroverted in older women
C. The body of the uterus is enclosed between the layers of the round ligament
D. The principal support of the uterus is the uterosacral ligament
E. Peritoneum covers only the superior aspect of the uterus

ANSWER: B

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The uterus is normally bent anteriorly between the cervix and the body of the uterus, and the entire uterus is
as a general rule Inclined anteriorly (anteverted).
However, the uterus is frequently retroverted (inclined posteriorly) in older women. The wall of The uterus
consists of three layers: the perimetrium, the myometrium, and the endometrium. The body of the uterus is
enclosed between the layers of the broad ligament and is freely mobile. The uterus is covered by peritoneum
anteriorly and superiorly Except for the vaginal part of the cervix, and the principal support of the uterus is
the pelvic floor.

24. Concerning the pelvis:

A. The male pelvis has a larger superior pelvic aperture than the female pelvis
B. The obturator foramina are round in the female
C. The male sacrum is less curved than that of the female
D. The ischial tuberosities are farther apart in the female pelvis
E. The male pelvis is shallower that that of the female

ANSWER: D

The general structure of the male pelvis is heavier and thicker than the female pelvis and has more
prominent bone markings.
The female pelvis is wider, shallower, and has both a larger superior and inferior pelvic aperture.
The ischial tuberosities are Farther apart in the female pelvis because of the wider pubic arch, and the
sacrum is less curved in the female pelvis.
In Addition to this the obturator foramina are round in the male and oval in the female.

25. You are called to the delivery room with your registrar to see a baby because the
midwife says he has “no abdominal wall ”.When you get there you find a baby with an
abdominal defect with loops of bowel outside the abdomen, and no covering Layers.
Which one of the following statements is true?

A. The child has an umbilical hernia

B. The child has gastroschisis
C. The child has an exomphalos
D. The mortality rate of this condition is 50%
E. The condition is often associated with other congenital anomalies

ANSWER: B

An umbilical hernia is covered by skin. The defect is herniation of the abdominal contents through the
umbilical fibromuscular Ring.
Umbilical hernias usually occur in infants and reach their maximal size by the first month of life. Most
hernias of this type Close spontaneously by the first year of life, with only a 2-10% incidence in children
older than 1 year.

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An exomphalos always Has a sac – which may be intact or ruptured. The sac has three layers peritoneum,
wharton’s jelly, and amnion. The sac may Contain intestinal loops, bladder, and liver. Unlike gastroschisis it
is often associated with other congenital anomalies.
Gastroschisis has no sac, and is rarely associated with congenital defects, but it may be associated with
intestinal atresia.
Management initially consists of covering the defect with clingfilm to prevent heat and moisture loss, while
establishing iv Access for iv fluids.

26. The narrowest part of the urethra is?

A. The navicular fossa

B. At the site of seminal colliculus
C. At the membranous urethra
D. The external urethral orifice
E. The bulbous urethra

ANSWER: D

The male urethra is approximately 20 cm long and the narrowest parts are the external urethral orifice,
bladder neck & just Proximal to navicular fossa.
The seminal colliculus are present in the prostatic urethra at the verumontanum. The prostatic Urethra is the
widest and most dilatable part of the entire male urethra.

27. Which one of the following structures is not encountered during a right
hemicolectomy?

A. The right ureter

B. The right gonadal artery
C. The inferior mesenteric artery
D. The second part of the duodenum
E. The middle colic artery

ANSWER: C

The inferior mesenteric artery supplies the large bowel from the transverse colon distally and is not
encountered in a right Hemicolectomy which involves excision of the caecum, ascending colon and the
middle third of the transverse colon.
The Transverse colon crosses the second part of the duodenum. The right ureter and gonadal vessels
although both retroperitoneal, Are both posteriorly related to the ascending colon and are easily injured
during dissection.

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The middle colic artery is the Terminal branch of the superior mesenteric artery and it’s right branch is
usually included in the excision during a right Hemicolectomy.

28. What is the normal location of the major duodenal papilla?

A. Superior part of the duodenum

B. Ascending part of the duodenum
C. Descending part of the duodenum Correct answer
D. Horizontal part of the duodenum
E. Duodenal bulb

ANSWER: C

The major duodenal papilla is situated at the medial side of the descending portion of the duodenum, a little
below its middle And about 7 to 10 cm from the pylorus.
The common bile and pancreatic ducts unite and open by a common orifice on the Summit of the duodenal
papilla.

29. In a patient with gastric carcinoma, the radiologist reported that the lymph nodes
around the coeliac trunk are enlarged. The coeliac trunk:

A. Is the arterial supply to the embryonic mid-gut

B. Is accompanied by the coeliac vein
C. Arises from the lateral surface of the abdominal aorta, at about the level of the first lumbar vertebra
D. Gives rise to the splenic, left gastric and common hepatic arteries
E. Is surrounded by the aorticorenal ganglion

ANSWER: D

The coeliac trunk is a short thick trunk, about 1.25 cm in length, which arises from the front of the aorta, just
below the aortic Hiatus of the diaphragm and, passing nearly horizontally forward, divides into three large
branches, the left gastric, the hepatic And the splenic.
It occasionally gives off one of the inferior phrenic arteries. It is covered by the lesser omentum. On the
right Side it is in relation to the right coeliac ganglion and the caudate process of the liver; on the left side, to
the left coeliac ganglion And the cardiac end of the stomach. Below, it is in relation to the upper border of
the pancreas and the splenic vein.

30. The ejaculatory duct opens into the:

A. Membranous urethra
B. Prostatic urethra
C. Spongy urethra
D. Lateral lobes of the prostate gland

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E. Duct of the bulbourethral glands

ANSWER: B

The ejaculatory ducts are two in number, one on either side of the middle line. Each is formed by the union
of the duct from the Seminal vesicles with the ductus deferens and is about 2 cm long.they commence at the
base of the prostate and run forward And downward between its middle and lateral lobes and along the sides
of the prostatic utricle, to end by separate slit-like Orifices close to or just within the margins of the utricle in
the prostatic urethra. The ducts diminish in size and also converge, Toward their terminations.

31. The cremasteric muscle is an extension of the:

A. External abdominal oblique muscle

B. Transverse abdominal muscle
C. Internal abdominal oblique muscle
D. Pyramidalis muscle
E. Dartos muscle

ANSWER: C

The cremaster is a thin muscular layer that is composed of a number of fasciculi, which take origin from the
middle of the Inguinal ligament. At its origin its fibres are continuous with those of the internal oblique and
also occasionally with the Transverses abdominis. It passes along the lateral side of the spermatic cord and
descends with it through the superficial Inguinal ring on the front and sides of the cord. It forms a series of
loops that differ in thickness and length in different people. At the upper part of the cord the loops are short,
but they become successively longer and longer, the longest reaching down As low as the testis, where a few
are inserted into the tunica vaginalis.
These loops are united together by areolar tissue and Form a thin covering over the cord and testis called the
cremasteric fascia. The fibres ascend along the medial side of the cord And are inserted by a small pointed
tendon into the pubic tubercle and crest, as well as into the front of the sheath of the rectus Abdominis.

32. A builder falls from the second storey of a building under construction. The patient is
conscious but complains of not feeling his ‘legs’. Neurological assessment in a&e suggests
that he has no cutaneous sensation from h is umbilicus to his toes. The patient has
sustained a spinal cord injury at which spinal cord level?

A. T6
B. T8
C. T10
D. L2
E. E

ANSWER: C

The umbilicus is an important landmark on the abdomen, because its position is relatively consistent among
humans. The skin Around the waist at the level of the umbilicus is supported by the tenth thoracic spinal

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nerve (t10 dermatome). The umbilicus is At the level of the fibrocartilage between the third and fourth
lumbar vertebrae.

33. While performing a laparoscopic inguinal hernia repair in a 68 -year-old man with a
direct inguinal hernia, the surgeon asked the specialist registrar to look at the medial
inguinal fossa to identify the direct inguinal hernia. To do so, the specialist registrar
would have to look at the area between the:

A. Inferior epigastric artery and urachus

B. Medial umbilical ligament and urachus
C. Inferior epigastric artery and lateral umbilical fold
D. Medial umbilical ligament and inferior epigastric artery
E. Median umbilical ligament and medial umbilical ligament

ANSWER: D

Remember: the medial umbilical fold is made by the medial umbilical ligament (the obliterated portion of
the umbilical artery), While the lateral umbilical fold is a fold of peritoneum over the inferior epigastric
vessels. The median umbilical fold is a midline Structure made by the median umbilical ligament
(obliterated urachus). The medial inguinal fossa is the space on the inner Abdominal wall between the
medial umbilical fold and the lateral umbilical fold. This is the place in the abdominal wall where there is an
area of weak fascia called the inguinal triangle - direct inguinal hernias can break through this space. The
lateral Inguinal fossa is a space lateral to the lateral umbilical fold - indirect inguinal hernias push through
the deep inguinal ring in this Space.

34. A specialist registrar while performing inguinal hernia repair made an incision
parallel to and 5 cm (2 inches) above the inguinal ligament. The supervising consultant
warned him to look out for the inferior epigastric vessels. The specialist registrar is most
likely to find the inferior epigastric vessels between which layers of the abdominal wall?

A. Camper’s fascia and scarpa’s fascia

B. External abdominal oblique and internal abdominal oblique muscles
C. Internal abdominal oblique and transversus abdominis muscles
D. Skin and deep fascia of the abdominal wall
E. Transversus abdominis muscle and peritoneum

ANSWER: E

The inferior epigastric vessels lie on the inner surface of the transversus abdominis and are covered by
parietal peritoneum.
Remember: the peritoneum lies over the inferior epigastric vessels to make the lateral umbilical fold.
Camper’s fascia and Scarpa’s fascia are two layers of the superficial fascia - camper’s is the fatty layer and
scarpa’s is the membranous layer.

35. While reviewing the abdominal aortogram of a 67 -year-old man with an abdominal
aortic aneurysm, a radiologist noticed an occluded inferior mesenteric artery. However,

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on enquiry, the patient denied having any abdominal symptoms. Occlusion of the inferior
mesenteric artery is seldom symptomatic because its territory may be supplied by
branches of the:

A. Gastroduodenal artery
B. Ileocolic artery
C. Middle colic artery Correct answer
D. Right colic artery
E. Splenic artery

ANSWER: C

The middle colic artery is the branch from the superior mesenteric artery that supplies the transverse colon.
This is the most Distal part of the colon that receives blood from the sma. Branches from the middle colic go
to the marginal artery, which would Be able to supply the descending colon, sigmoid colon and rectum if the
inferior mesenteric artery was occluded.
The ileocolic And right colic arteries are also branches of the sma that supply the colon (and contribute to
the marginal artery), but the Middle colic, which serves a more distal part of the colon, is a better answer.
The gastroduodenal artery is a branch off the Common hepatic artery, which supplies parts of the duodenum,
pancreas and stomach.
The splenic artery is one of the three Branches of the coeliac trunk. It supplies the spleen, pancreas and
curvature of the stomach.

36. The spleen normally does not descend below the costal margin. However, it pushes
downward and medially when pathologically enlarged. What structure limits the
straight-vertical-downward movement?

A. Left colic flexure

B. Left suprarenal gland
C. Ligament of treitz
D. Pancreas
E. Stomach

ANSWER: A

The left colic flexure, also called the splenic flexure, is the point where the colon takes a sharp downward
turn.
This flexure is the point where the transverse colon ends and the descending colon begins. It is located
immediately inferior to the spleen, so an enlarged spleen must move medially to avoid this colic flexure.
The left suprarenal gland is a retroperitoneal structure, which Sits superior to the kidney.
The suspensory muscle of the duodenum or ligament of treitz is a thin sheet of muscle derived from the right
crus of the diaphragm - it suspends the fourth part of the duodenum from the posterior abdominal wall.

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Both the Pancreas and stomach lie medial to the spleen. These organs would not prevent the spleen from
descending inferiorly.

37. The coeliac branch of the posterior vagal trunk sustained iatrogenic injury during
repair of a hiatus hernia. The damage to this nerve would affect the muscular
movements, as well as somesecretory activities, of the gastrointestinal tract.Which
segment is least likely to be affected by the nerve damage?

A. Ascending colon
B. Caecum
C. Jejunum
D. Ileum
E. Sigmoid colon

ANSWER: E

The vagus nerve supplies parasympathetic fibres to all of the abdominal organs, which receive blood from
the coeliac trunk or Superior mesenteric artery. This means that the vagus supplies parasympathetics to the
entire gastrointestinal tract, up to the Last part of the transverse colon.
The end of the transverse colon and all gastrointestinal structures distal to that point receive Parasympathetic
innervation from the pelvic splanchnic nerves and blood from the inferior mesenteric artery. So, the
ascending Colon, caecum, jejunum and ileum would all be affected by damage to the vagus nerve.
The sigmoid colon, which receives nParasympathetic innervation from the pelvic splanchnics, would not be
affected.

38. A 55-year-old man executive who had a history of a chronic duodenal ulcer was
admitted to the casualty department exhibiting signs of a severe internal haemorrhage.
He was quickly diagnosed with perforation of the posterior wall of the first part of the
duodenum and erosion of an artery behind it by the gastric expellant. The involved
artery is most likely to be the:

A. Common hepatic
B. Gastroduodenal
C. Left gastric
D. Proper hepatic
E. Superior mesenteric

ANSWER: B

The gastroduodenal artery is a branch of the common hepatic artery; it descends behind the first part of the
duodenum. Therefore, if an ulcer destroyed the posterior wall of the duodenum, gastric juices could escape
and destroy the Gastroduodenal artery.
The common hepatic artery is a branch of the coeliac trunk found superior to the duodenum.
The left Gastric artery is a branch of the coeliac trunk, which supplies the left side of the lesser curvature of
the stomach.

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The proper Hepatic artery is a branch of the common hepatic artery; it travels superiorly from the common
hepatic artery to give off the Right, middle and left hepatic arteries.
Finally, the superior mesenteric artery originates from the aorta at the bottom of the l1 Level, posterior to the
pancreas. It travels over the third part of the duodenum and supplies the intestines, up to the last third of The
transverse colon.

39. During a difficult vaginal delivery, the sho on call was asked to come and make an
episiotomy. She made a median episiotomy and in doing so cut too far through the
perineal body into the structure immediately posterior. Which structure did she cut?

A. External anal sphincter

B. Bulbospongiosus muscle
C. Ischiocavernosus muscle
D. Sphincter urethrae
E. Sacrospinous ligament

ANSWER: A

An episiotomy is an incision made in the perineum to enlarge the distal end of the birth canal and to prevent
serious damage to The perineal structures. This procedure is often performed when there is a risk of tearing
the birth canal during a breech or Forceps delivery.
When performing a median episiotomy, a cut is made immediately posterior to the vagina, through the
Perineal body. If this cut went too far, the physician might cut through the external anal sphincter or the
rectum.
It is important To remember that episiotomies are usually made in the posterolateral direction, not on the
midline. If the incision tears further During the delivery, a median incision is more likely than a
posterolateral incision to extend posteriorly through the external anal Sphincter and the rectum. A
posterolateral incision is much safer!
The bulbospongiosus muscle, ischiocavernosus muscle and Sphincter urethrae are anterior to the area that is
cut during an episiotomy. The sacrospinous ligament extends from the Sacrum to the ischial tuberosity - it is
deep to the perineum and should not be involved in this procedure.

40. A young man developed a boil on his scrotum. Which of the following lymph nodes
are most likely to enlarge in this patient due to lymphati c spread of infection?

A. Internal iliac nodes

B. Sacral nodes
C. Superficial inguinal nodes
D. Lumbar nodes
E. External iliac nodes

ANSWER: C

The perineum and the external genitalia, including the scrotum and labia majora, drain to the superficial
inguinal lymph nodes. However, in men, remember that the testes do not drain to the superficial inguinal

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lymph nodes! The lymphatic vessels for the Testes travel in the spermatic cord and drain the testes into the
lumbar nodes (ovaries also drain to lumbar nodes).
The internal Iliac nodes drain the pelvis and gluteal region. The lumbar nodes drain the internal pelvic
organs. The sacral nodes drain the Prostate gland, uterus, vagina, rectum and posterior pelvic wall; the
external iliac nodes drain the lower limb.

41. A 38-year-old woman was seen in the out-patient clinic complaining of a boil located
on her labia majora. Lymphatic spread of the infection would most likely enlarge which
nodes?

A. Lumbar
B. Sacral
C. External iliac
D. Superficial inguinal
E. Internal iliac

ANSWER: D

The perineum and the external genitalia, including the labia majora and scrotum, drain to the superficial
inguinal lymph nodes. However, in the male, remember that the testes do not drain to the superficial inguinal
lymph nodes! The lymphatic vessels for Testes travel in the spermatic cord and drain the testes into the
lumbar nodes (ovaries also drain to lumbar nodes).
The lumbar Nodes drain the internal pelvic organs; the sacral nodes drain the prostate gland, uterus, vagina,
rectum and posterior pelvic Wall; the external iliac nodes drain the lower limb; the internal iliac nodes drain
the pelvis and gluteal region.

42. While performing a hysterectomy the surgeon ligated the uterine artery on either
side. The uterine artery arises from the:

A. Abdominal aorta
B. External iliac artery
C. Inferior rectal artery
D. Internal iliac artery
E. Ovarian artery

ANSWER: D

The uterine artery arises from the anterior division of the internal iliac artery and runs medially on the
levator ani toward the Uterine cervix. It crosses above and in front of the ureter, to which it supplies a small
branch, about 2 cm from the cervix.
Reaching the side of the uterus, it ascends in a tortuous manner between the two layers of the broad ligament
to the junction of The fallopian tube and uterus. It then runs laterally toward the hilum of the ovary and ends
by joining with the ovarian artery.
It Supplies branches to the uterine cervix and others that descend on the vagina. The branches descending
on the vagina Anastomose with branches of the vaginal arteries and form with them two median longitudinal

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vessels, the azygos arteries of The vagina, one of which runs down in front of and the other behind the
vagina.
It supplies numerous branches to the body of The uterus and from its terminal portion branches are
distributed to the fallopian tube and the round ligament of the uterus.

43. A 38-year-old woman with an extensive malignant growth in the anterior wall of the
vagina is most likely to have involvement of which adjacent structure?

A. Anal canal
B. Fundus of the bladder
C. Perineal body
D. Rectum
E. Rectovesical fascia

ANSWER: B

The anterior surface of the vagina is related to the fundus of the bladder and the urethra. A growth in the
anterior wall is therefore most likely to involve the fundus of the urinary bladder and/or the urethra.
The posterior surface is separated from the Rectum by the rectouterine pouch in its upper quarter and by the
rectovesical fascia in its middle two quarters, while the lower Quarter is separated from the anal canal by the
perineal body. Its sides are enclosed between the levatores ani muscles.
As the Terminal portions of the ureters pass forward and medially to reach the fundus of the bladder, they
run close to the lateral Fornices of the vagina and as they enter the bladder they are slightly anterior to the
anterior fornix.

44. The ovum is the largest cell in the human body, typically visible to the naked eye
without the aid of a microscope or other magnification device. The ova:

A. Are developed from the primitive germ cells, which are embedded in the substance of the ovaries
B. Are released by the rupture of the corona radiata at the time of ovulation
C. Give rise to oogonia
D. Measure about 2 mm in diameter
E. Undergo routine further development after liberation

ANSWER: A

The ova are developed from the primitive germ cells, which are embedded in the substance of the ovaries.
Each primitive germ Cell gives rise, by repeated divisions, to a number of smaller cells called oogonia, from
which the ova or primary oocytes are Developed.
Human ova are extremely small, measuring about 0.2 mm in diameter and are enclosed within the egg
follicles of The ovaries. By the enlargement and subsequent rupture of a follicle at the surface of the ovary,
an ovum is liberated and Conveyed by the uterine tube to the cavity of the uterus.

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Unless it is fertilised it undergoes no further development and is Discharged from the uterus, but if
fertilisation take place it is retained within the uterus and develops into a new being.

45. A 26-year-old primigravida aborted a 4-week-old embryo. On gross examination:

A. Differentiation of the limbs into their segments has occurred

B. The cerebral hemispheres appear as hollow buds
C. The cloacal tubercle is evident
D. The embryo is less curved and the head is relatively large
E. The nose forms a short, flattened projection

ANSWER: B

During the fourth week the embryo is markedly curved on itself and when viewed in profile is almost
circular in outline. The Cerebral hemispheres appear as hollow buds and the elevations that form the
rudiments of the auricula are visible. The limbs Now appear as oval flattened projections.

46. A 26-year-old primigravida aborted a 5-week-old embryo. On gross examination:

A. The embryo is markedly curved on itself

B. The elevations that form the rudiments of the auricula are visible
C. The primitive segments number about 30
D. The limbs appear as oval flattened projections
E. The cloacal tubercle is evident

ANSWER: E

During the fifth week the embryo is less curved and the head is relatively large. Differentiation of the limbs
into their segments Occurs. The nose forms a short, flattened projection. The cloacal tubercle is evident.

47. A 25-year-old primigravida aborted a 2-month-old embryo. On gross examination:

A. The eyelids are present in the shape of folds above and below the eye
B. The different parts of the auricula are not distinguishable
C. The lower lip is completed
D. The neck is fully developed
E. The palate is completely developed

ANSWER: A

During the second month of development the flexure of the head is gradually reduced and the neck is
somewhat lengthened.
The upper lip is completed and the nose is more prominent.
The nostrils are directed forward and the palate is not completely Developed.
The eyelids are present in the shape of folds above and below the eye and the different parts of the auricula
are Distinguishable.

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By the end of the second month, the fetus measures from 28 to 30 mm in length.

48. A full-term baby boy is born with incomplete fusion of the embryonic endocardial
cushions in the heart. The baby is most likely to have:

A. An atrioventricular septal defect

B. Coarctation of the aorta
C. Pulmonary stenosis
D. Tetralogy of fallot
E. Transposition of the great arteries

ANSWER: A

The terms endocardial cushion defect, atrioventricular septal defect and common atrioventricular canal
defect, are Interchangeable in describing defects in the formation of the atrioventricular valves, the anterior
portion of the atrial septum and the posterior portion of the ventricular septum.
Endocardial cushions are masses of mesenchymal tissue that form components of the arteriovenous valves,
atrial septum and ventricular septum.
Defects range from incomplete (also called partial, such as Ostium primum atrial septal defect with ‘cleft
mitral valve’) to transitional (large ostium primum defect and small ‘inlet’ or Posterior ventricular septal
defect) to complete (large ostium primum atrial septal defect, large inlet ventricular septal defect, Common
arteriovenous valve).

49. A 2-year-old boy is brought to the paediatric emergency department because he has
had several episodes of rectal bleeding. On evaluation he is diagnosed to have a 3 -cm
ileal outpouching located 0.6 m (2 ft) from the ileocaecal valve. This structure most
commonly contains which type of ectopic tissue?

A. Duodenal
B. Gastric Correct answer
C. Hepatic
D. Jejunal
E. Oesophageal

ANSWER: B

This child has a meckel’s diverticulum. Meckel’s diverticulum is present in about 2-4% of the population.
Typically, it is a blindly Ending pouch a few centimetres long on the antimesenteric border of the ileum
within 100 cm of the ileocaecal junction.

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It is a Remnant of an embryological structure called the vitelline duct, which once connected the yolk sac
with the developing mid-gut. Usually the vitelline duct disappears completely.
Meckel’s diverticulum may produce no symptoms. However, sometimes it can Become inflamed, or it might
have ectopic gastric or pancreatic cells in its walls leading to ulceration. In some cases, a fibrous Strand
connects the diverticulum to the inner aspect of the umbilicus and a loop of small intestine can become
twisted around this (volvulus) causing obstruction.
The symptoms may closely mimic those of appendicitis.
It is useful to remember the ‘rule of Twos’ associated with meckel’s diverticulum: present in 2% of the
population, occurs within 0.6 m (2 ft) of the ileocaecal valve, Contains two types of ectopic mucosa (gastric
and pancreatic) and is usually symptomatic by the age of 2 years.

THORAX

1.A hypertensive, heavy smoking, 73 -year-old man suffers a massive cardiac infarct
following occlusion of his anterior interventricular artery, (anterior descending artery).
Angiography is performed to demonstrate the coronary vessels. Which anatomical
relationship of these vessels should be borne in mind?

A. The anterior interventricular artery arises above the left posterior aortic cusp
B. The anterior interventricular artery supplies almost all of the left ventricle
C. There is a rich collateral circulation between the right and left coronary arteries
D. The circumflex artery is the major branch of the right coronary artery
E. The posterior interventricular artery is a branch of the circumflex artery

ANSWER: B

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The left coronary artery arises above the left posterior aortic cusp. After a short course it divides into an
anterior interventricular and a circumflex branch.
The former is the main arterial supply to the left ventricle.
Unfortunately, there is only a poor collateral Supply between the branches of the two coronary arteries.
The posterior interventricular artery arises from the right coronary Artery.

2. In the clinical examination of the chest, accurate knowledge of the surface markings of
the lungs is essential. Which of the following corr esponds to the clinical situation?

A. The apex of the lung corresponds precisely to the upper border of the medial third of the clavicle
B. The oblique fissure of the lung corresponds to the medial border of the scapula when the arm is fully
Abducted
C. The transverse (horizontal) fissure of the right lung corresponds to the right fifth intercostal space
D. The lower border of the lung on each side corresponds to the tenth rib in the mid-axillary line
E. The lower border of the lung reaches the twelfth rib posteriorly

ANSWER:B

The apex of the lung extends about 4 cm above the medial one-third of the clavicle.
The oblique fissure does indeed Correspond closely to the medial border of the scapula when the arm is fully
abducted.
The transverse fissure of the right lung Corresponds to the level of the fourth rib.
The lower border of the lung on each side corresponds to the eighth rib in the midaxillary Line and the tenth
rib posteriorly.

3. WHICH OF THE FOLLOWING STRUCTURES IS LOCATED IN THE ANTERIOR

MEDIASTINUM ON COMPUTED TOMOGRAPHY (CT)?

A. Thymus
B. Oesophagus
C. Aorta
D. Heart
E. Trachea

ANSWER: A

The anterior mediastinum is bordered anteriorly by the sternum and posteriorly by the great vessels. It
contains the thymus, Lymph nodes, fat, and vessels.
Disorders of the anterior mediastinum are generally thymic, thyroid (substernal goitre), teratoma (and other
germ cell tumors), and lymphomas ( hodgkin's disease, non-hodgkin's lymphoma).

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4. You have performed a liver biopsy, and shortly after the procedure the patient
develops pain on the tip of his right shoulder. Which nerve is most likely to be
responsible for his pain? Single best answer - choose one true option only

A. Right phrenic nerve

B. Axillary nerve
C. Right vagus
D. Right sympatheticus
E. Intercostobrachial nerve

ANSWER: A

The phrenic nerve on both sides originates from the ventral rami of the third to fifth cervical nerves.
It passes inferiorly down the Neck to the lateral border of the scalenus anterior, then it passes medially
across the border of scalenus anterior parallel to the Internal jugular vein that lies inferomedially.
The right phrenic nerve pierces the diaphragm in its tendinous portion just slightly lateral to the inferior vena
caval foramen. It then forms three branches on the inferior surface of the diaphragm: anterior, lateral and
posterior. These ramify out in a radial Manner from the point of perforation to supply all but the periphery of
the muscle.

5. You are reviewing a 52-year-old man who has suffered a myocardial infarction. You
suspect occlusion of the posterior descending coronary artery. In this case, which region
of myocardium would you expect to be most affected? Single best answer - choose one
true option only

A. The right atrium

B. The right ventricle
C. The anterior septum
D. The anterior left ventricular wall
E. The posterior portion interventricular septum and the posterior left ventricular wall Correct answer

ANSWER: E

The coronary system consists of left and right coronary arteries, which arise immediately above the aortic
valve.
They are Unique in that they fill during diastole, when not occluded by valve cusps and when not squeezed
by myocardial contraction.
The right coronary artery arises from the right coronary sinus, giving off branches supplying the right atrium
and right ventricle.
It then continues as the posterior descending coronary artery, which supplies the posterior portion of the
interventricular Septum and the posterior left ventricular wall.
The left coronary artery divides into the left anterior descending (lad) and circumflex arteries.

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The lad runs in the anterior Interventricular groove and supplies the anterior septum and the anterior left
ventricular wall.
The left circumflex artery gives off Branches that supply the left atrium and left ventricle.
The sinus node is supplied by the right coronary artery in around 60% of people, the av node in around 90%.

6. You are asked to see a 45-year-old man who is haemodynamically compromised and
plan to insert a right subclavian line. He has a body mass index (bmi) of 38, where is the
correct position for central venous can nulation? Single best answer - choose one true
option only

A. 1 cm under the mid-point of the clavicle and 0.5 cm laterally

B. 2 cm under the mid-point of the clavicle and 1 cm laterally
C. 2.5 cm under the mid-point of the clavicle and 2 cm laterally
D. 0.5 cm under the mid-point of the clavicle and 1 cm laterally
E. 1 cm under the mid-point of the clavicle and 1 cm laterally

ANSWER: B

In obese patients, the standard position for right subclavian central venous cannulation is 2 cm under the
mid-point of the Clavicle and 1 cm laterally.
In thin patients the standard position for insertion is 1 cm under the mid-point of the clavicle and 0.5 Cm
laterally.
Jugular vein cannulation is now the prepared choice for central venous catheterisation, as insertion under
Ultrasound guidance is associated with a much lower rate of complications than subclavian insertion.
The major hazard of the Subclavian approach is arterial puncture, as the artery lies close to the vein.

7. Where would you visualise the azygous lobe on an antero -posterior (a-p) chest x-ray?
Single best answer - choose one true option only

A. Left lower zone

B. Left middle zone
C. Left upper zone
D. Right upper zone
E. Right lower zone

ANSWER: D

An azygous lobe is seen in about 0.5% of routine chest x-rays and is a normal variant. It is seen as a
‘reverse comma sign’ Behind the medial end of the right clavicle.

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8. A 60-year-old previously fit and well man dies suddenly after two separate syncopal
episodes. At post mortem examination, which one of the following congenital cardiac
defects that could be associated with his sudden death would you expect to find?

A. Dextrocardia with situs inversus

B. Patent foramen ovale
C. Bicuspid aortic valve
D. Ventricular septal defect
E. Single coronary artery

ANSWER: C

Whilst isolated dextrocardia can be associated with severe cardiac anomalies, dextrocardia with situs
inversus has a low Incidence of accompanying defects and the heart functions normally.
Isolated patent foramen ovale is of no haemodynamic Significance.
The relatively common (1-2% of people) bicuspid aortic valve leads to accelerated calcific stenosis, which is
Associated with syncope and sudden death.
Small ventricular septal defects are insignificant, whereas large defects lead to Massive left to right shunts.
A single coronary artery is not common, but does occur. When present, there is no clinical Consequence
unless disease (such as atheroma) affects the vessel.

9. In a 27-year-old restrained passenger from a high speed collision with a tree, you
suspect a deceleration injury to the aorta. Which feature on chest x -ray would most
reliably support your suspicion?

A. Obliteration of the aortic knuckle

B. Obscuration of the aorto-pulmonary window
C. Presence of a pleural cap
D. Depression of the left main stem bronchus
E. Widened mediastinum

ANSWER: E

All of the above can be associated with a traumatic aortic injury. However, they are non-specific signs with
high false positive and false negative rates. Occasionally, no chest x-ray changes are visible following
traumatic aortic injury.
In a trauma supine Cxr, a widened mediastinum is the most consistent feature of aortic disruption.
About 3% of these patients would prove to have aortic injury on contrast ct or aortic angiogram.

10. You suspect a lower respiratory tract infection in an elderly post operative patient
and request a chest x-ray. Which of the following chest x-ray appearances is most likely?

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A. Blunting of the costophrenic angles

B. Indistinct hemidiaphragms
C. Kerley b lines
D. Indistinct right heart border
E. Indistinct left heart border

ANSWER: B

Blunting of the costophrenic angles occurs when a (relatively) small volume of fluid has collected in the
pleural spaces.
This Can occur in a number of scenarios, but it is not the most likely appearance in the above patient.
Immobilisation puts such a Patient at risk of basal atelectasis, subsequent consolidation and therefore a less
distinct air-tissue interface at the diaphragm On chest x-ray.
Kerley b lines occur when there is interstitial oedema.
An indistinct right heart border occurs with right middle Lobe consolidation, and an indistinct left heart
border occurs when there is left upper lobe consolidation.
Both of these are less Likely sites for consolidation given the above history.

11. You are concerned about myocardial ischaemia in a post -operative patient who is
complaining of chest pain. The ecg shows tachycardia and isolated st-segment depression
in leads v1 and v2. Which coronary artery is most likely to be responsible?

A. Circumflex coronary artery

B. Left anterior descending coronary artery
C. Posterior descending coronary artery
D. Left main stem coronary artery
E. Right coronary artery

ANSWER: C

The coronary artery anatomy is variable, as are the relative territories of myocardium supplied by each of the
arteries. Stsegment Depression across all leads implies ischaemia (angina), whereas isolated st-segment
depression in leads v1 and v2 May indicate a posterior myocardial infarction.
The most likely involved artery in this case is therefore the posterior descending Artery.
Either the right coronary or circumflex arteries can supply the posterior descending artery, but it is not
possible to Identify which from the ecg alone.
Left main stem and left anterior descending artery lesions would cause changes over a Much larger area.

12. After a difficult right-sided subclavian central line insertion, which is the least likely
structure to be damaged?

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A. Thoracic duct
B. Brachial plexus
C. Subclavian vein
D. Subclavian artery
E. Lung apex

ANSWER: A

The thoracic duct has usually crossed over to the left side by the level of the 5th or 6th vertebral body, and is
therefore the Furthest structure from the advancing needle.
The brachial plexus, subclavian artery and lung can all be reached and damaged By a needle during
subclavian cannulation.
The subclavian vein, although the target vessel in this case (and therefore Intentionally punctured) can be
damaged (torn) during line insertion.

13. In a post-operative immunosuppressed transplant patient, some small vesicles have

formed on the chest wall, in a linear patch, approximately level with his xiphoid process.
Which dermatome is most likely to be affected?

A. C4
B. T4
C. T7
D. T10
E. L1

ANSWER: C

C4 corresponds to the lower neck just above the clavicle.

T4 corresponds to the level of the nipples.
T7 is the level of the Xiphoid process.
T10 corresponds to the level of the umbilicus, and l1 corresponds to the lower abdomen / inguinal region.

14. A pre-operative patient is on β-blockers. Where in the thoracic cage are the beta -1
adrenoceptors concentrated?

A. Ventricles
B. Atria
C. Aortic arch
D. Lungs
E. Carotid body

ANSWER: A

The beta-1 adrenoceptors are located within the ventricles of the heart.

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The atria contain cholinergic receptors.

The aortic arch Contains baroreceptors .
The lungs contain beta-2 adrenoceptors.
The carotid body contains baroreceptors.

15. A 62-year-old ex-smoker has been diagnosed with non -small cell lung carcinoma by
endobronchial biopsy. At standard mediastinoscopy, what is the least likely lymph node
station to be sampled?

A. Paratracheal nodes
B. Subcarinal nodes
C. Tracheobronchial nodes
D. Aortopulmonary nodes
E. Pretracheal nodes

ANSWER: D

During mediastinoscopy, the pretracheal fascia is incised and blunt dissection creates a tunnel inferiorly.
The linear passage of the mediastinoscope along this tunnel allows visualisation of the nodes lying to the
front (pretracheal) and sides (paratracheal) Of the trachea. The subcarinal and tracheobronchial nodes can
also be reached at the distal end of this tunnel.
The Aortopulmonary nodes, however, cannot easily be reached as the aorta is “in the way” of the advancing
finger or Mediastinoscope.

16. You are required to insert a chest drain in a patient with penetrating trauma. Which
anatomical landmark is least useful to you?

A. Anterior border of latissimus dorsi

B. The mid-clavicular line
C. The nipple
D. The mid-axillary line
E. Inferolateral border of pectoralis major

ANSWER: B

The “safe triangle” for the insertion of an intercostal drain is bounded anteriorly by the inferolateral border
of pectoralis major,
Posteriorly by the anterior border of latissimus dorsi and inferiorly by the axial plane at the level of the
nipple.
The mid-axillary Line may be used within this triangle to help guide placement of the incision.
The mid-clavicular line should not be used for Placement of an intercostal tube drain.

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17. A young man is about to undergo bronchoscopy for suspected inhaled peanut. Where
is the most likely site for the inhaled peanut?

A. Right middle lobe bronchus

B. Left inferior lobe bronchus
C. Right superior lobe bronchus
D. Left superior lobe bronchus
E. Right lower lobe bronchus

ANSWER: E

The right main bronchus is wider, shorter and runs more vertically than the left main bronchus.
Consequently, foreign bodies Small enough to be inhaled more commonly enter the right lung.
As a result of gravity, the right lower lobe is more likely to Receive such foreign bodies.

18. A patient presents with a right bundle branch block due to blockage in the
atrioventricular nodal artery. Part of the right bundle branch of the arteriovenous
bundle is carried by which structure?

A. Pectinate muscles
B. Anterior papillary muscle of the left ventricle
C. Moderator band (septomarginal trabecula)
D. Crista terminalis
E. Chordae tendineae

ANSWER: C

A muscular band, well marked in sheep and some other animals, frequently extends from the base of the
anterior papillary Muscle to the ventricular septum.
From its attachments it was thought to prevent overdistension of the ventricle and was Named the
‘moderator band’.
However, more recent research has indicated that it is more properly considered part of the
Electrical conduction system of the heart and in that capacity it is now called the septomarginal trabecula.

19.an sho has been asked to aspirate some pleural fluid for culture and sensitivity from
the left pleural space of a 65 -year-oldman who has postpneumonic effusion. If the sho
wants to aspirate the fluid with the patient sitting up in bed, where would the fluid tend
to accumulate?

A. Costodiaphragmatic recess
B. Costomediastinal recess
C. Cupola
D. Hilar reflection
E. Middle mediastinum

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ANSWER: A

The costodiaphragmatic recess is the lowest extent of the pleural cavity or sac.
It is the part of the pleural sac where the costal Pleura changes into the diaphragmatic pleura.
Because this is the inferior part of the pleural sac, fluid in the pleural sac will fall To this region when a
patient sits up.
The costodiaphragmatic recess is also the area into which a needle is inserted for
Thoracocentesis and it is found at different levels at different areas of the thorax.

At the mid-clavicular line, the Costodiaphragmatic recess is between ribs 6 and 8; at the mid-axillary line it
is between ribs 8 and 10; and at the paravertebral Line it is between ribs 10 and 12.
The costomediastinal recess is found where the costal pleura become the mediastinal pleura.
The cupola is the part of the pleural cavity that extends above the level of the first rib into the root of the
neck. The hilar Reflection is the point at the root of the lung where the mediastinal pleura is reflected and
becomes continuous with the visceral Pleura.
Finally, the middle mediastinum is the space in the mediastinum that contains the heart, pericardium, great
vessels and Bronchi (at the roots of the lung).

20. A victim of anterior chest stabbing received a stab in a structure that is in close
proximity to where the first rib articulates with the sternum. The structure most likely to
be injured is the:

A. Nipple
B. Root of the lung
C. Sternal angle
D. Sternoclavicular joint
E. Xiphoid process

ANSWER: D

The first rib articulates with the sternum directly below the sternoclavicular joint. The nipple is found in the
fourth intercostals Space, between the fourth and fifth ribs. The sternal angle is connected to the costal
cartilage of rib 2. Finally, the xiphoid Process is located just below the point where the costal cartilage of rib
7 articulates with the sternum. The root of the lung Consists of the main bronchus, pulmonary and bronchial
vessels, lymphatic vessels and nerves entering and leaving the lung.

21. A 25-year-old man was stabbed in the right supracla vicular fossa. The knife
punctured the portion of the parietal pleura that extends above the first rib. This portion
of the parietal pleura is called the:

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A. Costodiaphragmatic recess
B. Costomediastinal recess
C. Costocervical recess
D. Cupola
E. Endothoracic fascia

ANSWER: D

The cupola is the cervical parietal pleuron, which extends slightly above the level of the first rib into the root
of the neck.
The Costodiaphragmatic recess is the part of the pleural sac where the costal pleura changes into the
diaphragmatic pleura.
It is the Lowest extent of the pleural sac.
The costomediastinal recess is found where the costal pleura become the mediastinal pleura.
The endothoracic fascia is connective tissue between the inner chest wall and the costal parietal pleura.
The costocervical Recess is a made-up term.

22. During pericardiectomy, sudden bleeding was noticed due to accidental injury to a
major vascular structure in the pericardium. The surgeon inserted his left index finger
through the transverse pericardial sinus, pulled forward on the two large vessels lying
ventral to his finger and compressed these vessels with his thumb to control bleeding.
Which vessels were these?

A. Pulmonary trunk and brachiocephalic trunk

B. Pulmonary trunk and aorta
C. Pulmonary trunk and superior vena cava
D. Superior vena cava and aorta
E. Superior vena cava and right pulmonary artery

ANSWER: B

The transverse pericardial sinus is an area of the pericardial cavity located behind the aorta and pulmonary
trunk and anterior To the superior vena cava. Therefore, the two large vessels lying ventral to his finger are
the pulmonary trunk and aorta; the Large vessel lying dorsal to his finger is the superior vena cava.

23. A patient with a cystic swelling in his left chest underwent a computer tomography -
guided biopsy. The radiologist inserted the biopsy needle into the ninth intercostal space
along the mid-axillary line to aspirate the swelling and obtain tissue for histological
diagnosis. The swelling is most likely to be in which space?

A. Cardiac notch
B. Costodiaphragmatic recess
C. Costomediastinal recess
D. Cupola

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E. Oblique pericardial sinus

ANSWER: B

The costodiaphragmatic recess is the lowest extent of the pleural cavity or sac. It is the part of the pleural sac
where the costal Pleura changes into the diaphragmatic pleura. It is also the area into which a needle is
inserted for thoracocentesis and it is Found at different levels in different areas of the thorax.
At the mid-clavicular line, the costodiaphragmatic recess is between Ribs 6 and 8; at the mid-axillary line it
is between ribs 8 and 10; and at the paravertebral line it is between ribs 10 and 12.
Therefore, inserting the needle just above the ninth rib at the mid-axillary line should put you in the
costodiaphragmatic recess.
The cardiac notch is a structure on the left lung, which separates the lingula below from the upper portion of
the superior lobe Of the left lung.
The costomediastinal recess is found where the costal pleura become the mediastinal pleura.
The cupola is the Part of the pleural cavity, which extends above the level of the first rib into the root of the
neck.
The oblique pericardial sinus is An area of the pericardial cavity located behind the left atrium of the heart.

24. A patient with a malignant mesothelioma is to undergo pleuropneumonectomy, which

involves removal of the entire pleura and lung on the affected side. Which of the
following layers provides a natural cleavage plane for surgical separation of th e costal
pleura from the thoracic wall?

A. Deep fascia
B. Endothoracic fascia
C. Parietal pleura
D. Visceral pleura
E. Transversus thoracis muscle fascia

ANSWER: B

The endothoracic fascia is the connective tissue between the inner aspect of the chest wall and the costal
parietal pleura.
By Clearing the endothoracic fascia, it is easy to separate the costal pleura from the thoracic wall.
Deep fascia is a fascial layer That invests a muscle or muscle group - it is not present around the lungs.
The parietal pleura comprise the cupola or cervical Pleura, costal pleura, diaphragmatic pleura and
mediastinal pleura.
It lines the inner surfaces of the walls of the pleural cavity.
The visceral pleura are the serous membrane that covers the lungs.

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Finally, the transversus thoracis muscle fascia is onlyb Associated with the transversus thoracis - it would
not provide a natural cleavage plane for separating the costal pleura from The thoracic wall.

25. A 78-year-old man with pseudobulbar palsy, lying supine in bed, aspirates one of his
tablets into his lungs while swallowing. It would be most likely to end up in which of the
following bronchopulmonary segments?

A. Anterior segmental bronchus of the right superior lobe

B. Medial segmental bronchus of the right middle lobe
C. Superior segmental bronchus of the right inferior lobe
D. Medial basal segmental bronchus of the left inferior lobe
E. Inferior segmental bronchus of the lingular

ANSWER: C

Remember: inhaled material tends to go into the right bronchus because it is bigger and more vertically
orientated than the left!
The superior segmental bronchus branches posteriorly off the intermediate bronchus or the inferior lobe
bronchus, so it is the Segmental bronchus most likely to receive the foreign bodies that enter the right main
bronchus.

26. A 32-year-old man was shot in the chest. The bullet punctured a vessel that courses
across the mediastinum in an almost horizontal fashion. Which one of the following
vessels was injured?

A. Left subclavian artery

B. Left subclavian vein
C. Left brachiocephalic vein
D. Left internal jugular vein
E. Left common carotid artery

ANSWER: C

The left brachiocephalic vein joins with the right brachiocephalic vein to form the superior vena cava on the
right side of the Body.
Therefore, the left brachiocephalic vein must course across the mediastinum to reach its destination. The left
subclavian Artery and vein are lateral to the mediastinum, while the left jugular and common carotid travel
vertically.

27. While performing a surgical procedure in the mid -region of the thorax the surgeon
accidentally injured an important structure that lies immediately anterior to the thoracic
duct. Which one of the following structures was most likely to be injured?

A. Aorta
B. Azygos vein
C. Oesophagus

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D. Superior vena cava

E. Trachea

ANSWER: C

In the mid-thorax, the aorta, thoracic duct and azygos vein are all posterior to the oesophagus.
(they are in that order, from left To right.) The superior vena cava and the trachea are not located in the mid-
thorax - the superior vena cava terminates as it Feeds into the right atrium and the trachea ends as it splits
into the two main stem bronchi, which enter the lungs.

28. The sinus venosus is the large quadrangular cavity located between the two vena cava
vessels in the embryonic human heart. In the adult heart the sinus venosus gives rise to
the:

A. Aortic vestibule of the left ventricle

B. Coronary sinus Correct answer
C. Fossa ovalis
D. Trabeculated part of the right ventricle
E. Trabeculated portion of the right atrium

ANSWER: B

The derivatives of the embryonic sinus venosus include: the smooth part of the right atrium (sinus venarum),
the ‘valve’ of the Superior vena cava and the sinoatrial node from the right horn; the coronary sinus and the
valve of coronary sinus from the left Horn; the border of smooth part of right atrium (crista terminalis) from
the right half of the valve of the sinus venosus and part of The atrial septum from the left half of the valve of
the sinus venosus.

29. The human embryonic heart rate is nearly twice that of the adult. Which of the
following statements regarding the development of the human heart is correct?

A. In the second week, the endocardial tubes begin to fuse to form a single tube
B. The septum primum appears in the eighth week
C. The heart begins to beat in the fourth week
D. The primordium of the heart forms in the cardiogenic plate located at the caudal end of the embryo
E. The bulboventricular loop is formed in the sixth week

ANSWER: C

The primordium of the heart forms in the cardiogenic plate located at the cranial end of the embryo.
Angiogenic cell clusters, Which lie in a horseshoe-shaped configuration in the plate, coalesce to form two
endocardial tubes.
These tubes are then Forced into the thoracic region due to cephalic and lateral foldings, where they fuse
together forming a single endocardial tube during the third week.

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The heart begins to beat in the fourth week at about the same time that the septum primum appears and The
bulboventricular loop is formed.
From the fourth week onwards, septa begin to grow in the atria, ventricle and bulbus cordis To form right
and left atria, right and left ventricles and the two great vessels - the pulmonary artery and the aorta.
By the end of The eighth week, partitioning is completed and the fetal heart has formed.

30. Endoderm is one of the germ layers formed during embryogenesis. Which of the
following organs is a derivative of the endoderm?

A. Adrenal medulla
B. Dermis of the skin
C. Epithelial part of the tympanic cavity
D. Gonads
E. Lens

ANSWER: C

Derivatives of endoderm include the epithelium of the gastrointestinal tract and its associated glands as well
as glandular cells of the liver and pancreas, epithelium of the urachus and urinary bladder, epithelium of
respiratory passages (the pharynx, Trachea, bronchi and alveoli), epithelial parts of the tonsils, thyroid,
parathyroids, tympanic cavity and thymus and epithelial Parts of the anterior pituitary.

NEUROANATOMY

1. A YOUNG MAN SUSTAINS A SKULL -BASE FRACTURE AT THE MIDDLE

CRANIAL FOSSA WHICH INJURES HIS RIGHT ABDUCENT (VI) NERVE. WHICH
SIGNS ARE MOST LIKELY TO BE PRESENT ON CLINICAL EXAMINATION?

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A. There is ptosis on the right side

B. The pupil on the right side is constricted and fails to respond to light
C. The right eyelid is numb
D. The patient is unable to deviate his right eye medially
E. The patient is unable to deviate his right eye laterally

ANSWER: E

The abducent nerve innervates the lateral rectus muscle of the eye exclusively; the sole effect of damage to
this nerve is that The patient is unable to abduct (laterally deviate) the eye.

2. In performing a lumbar puncture, the operator needs to be familiar with the anatomy
involved. Which anatomical feature is relevant to this procedure?

A. In the newborn baby, the spinal cord occupies the full length of the dural sac
B. The dural sac in the adult terminates at the lower end of the sacral canal
C. The spinal cord in the normal adult terminates anywhere from opposite the body of t12 to the body of
D. L3; however, the commonest level is at the disc space between l1 and l2
E. The spinal cord in the average male is 12 inches (30 cm) in length
F. The extradural space comprises a thin layer of avascular connective tissue

ANSWER: D

The spinal cord in both adult men and women is 18 inches (45 cm) in length. In the newborn it terminates at
l3. The dural sac
In the adult extends to the level of the second sacral segment. The spinal extradural space contains loose fat
(which allows the Ready diffusion of local anaesthetic in an extradural block), together with the extensive
vertebral venous plexus of veins.

3. A cerebral angiogram is performed on a 37 -year-old woman, following a suspected

aneurysmal bleed. Which anatomical feature should be considered when interpreting the
angiogram?

A. The middle cerebral artery is the largest single component of the circle of willis
B. The posterior cerebral artery is clearly seen on a lateral carotid angiogram
C. The vertebral arteries meet at the foramen magnum to form the basilar artery
D. The middle cerebral artery courses over the lateral aspect of the temporal lobe of the cerebrum
E. The middle meningeal artery is an extracranial branch of the internal carotid artery

ANSWER: A

The middle meningeal artery is a branch of the maxillary artery, one of the terminal branches of the external
carotid.
The Posterior cerebral artery arises from the termination of the basilar artery, which itself arises from the
two vertebral arteries that Meet on the under surface of the brainstem – so the posterior cerebral artery can
only be visualised by vertebral angiography.

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The middle cerebral artery is indeed the largest component of the circle of willis, being, in effect, the
termination of the internal Carotid. It passes through the lateral sulcus of the cerebrum between the temporal
and frontal lobes.

4. You see in clinic a 36-year-old man referred by his gp with a feeling of numbness in
his left leg. On examination, he has decreased position sense and light touch and
vibration sensation affecting his left leg to the upper part of the thigh. No other
neurological deficit is demonstrable. Which of the following is the most likely cause of
this presentation?

A. Left dorsal column lesion

B. Left spinothalamic tract lesion
C. Peripheral polyneuropathy
D. Partial section of the spinal cord
E. Sensory root compression

ANSWER: A

The dorsal columns carry ipsilateral proprioreception, light touch and vibration sensation.
Spinothalamic tract lesions cause Contralateral loss of pain and temperature sensation.
Partial section of the cord tends to cause contralateral pain and temperature sensation and ipsilateral loss of
the modalities carried in the dorsal columns; there may also be upper motor ………Neurone weakness.
Sensory root compression typically causes pain in the dermatome supplied by the root; peripheral
Polyneuropathy is usually bilateral.

5. A 24-year-old woman attends the neurological clinic for review of multiple sclerosis,
diagnosed 2 years before. She had presented with blurring of vision and mild pain in her
left eye, which had resolved over a period of 3 months and had not recurred. On
examination now, the following observations are made: light shone in the left eye causes
constriction of the left and right pupils; light shone into the right eye causes constriction
of the right and left pupils but when the light is shone back into the left eye, the left
pupil dilates slightly. Which of the following is the most likely site of the lesio n
responsible?

A. Left ciliary ganglion

B. Left oculomotor nerve
C. Left optic nerve
D. Right ciliary ganglion
E. Right optic nerve

ANSWER: C

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The abnormal response is on the left; the right pupil shows a normal direct and consensual response.
The normal constriction Of the left pupil indicates that the efferent pathway (involving the edinger–westphal
nucleus, oculomotor nerve and ciliary Ganglion) is intact.
The defect is in the afferent pathway on the left, which involves fibres in the optic nerve.
The sign Demonstrated is a relative afferent pupillary defect (rapd), implying partial damage only to the
afferent pathway: if all function Is lost, neither the direct reflex nor consensual reflex (constriction of the
right pupil in response to light shone into the left eye) Will be present.

6. A patient has been diagnosed with a fast -growing pituitary adenoma. Magnetic
resonance image (mri) scanning reveals suprasellar extension. Which structure is most
likely affected?

A. Abducens nerve
B. Hypothalamus
C. Oculomotor nerve
D. Third ventricle
E. Optic nerve

ANSWER: E

The pituitary gland occupies the sella turcica, which is a cup-shaped depression in the basisphenoid bone.
The roof of the sella Is formed by the diaphragma sella, a fold of dura, which is perforated to allow passage
of the pituitary stalk.
Above the Diaphragma lie the suprasellar cistern, the optic chiasm and the anterior cerebral arteries.
The lateral walls of the pituitary fossa Are formed by the cavernous sinuses which contain the internal
carotid arteries and cranial nerves 3, 4, the first and second Divisions of 5, and 6. Behind the sella is the
pontine cistern containing the basilar artery.
The cavernous sinus, pituitary gland, And stalk and median eminence all show significant enhancement after
the administration of intravenous contrast medium.

7. A tumour in the medial wall of the body of the lateral ventricle will involve which of
the following structures?

A. Caudate nucleus of the corpus striatum

B. Stria terminalis
C. Posterior part of the septum pellucidum
D. Terminal vein
E. Undersurface of the corpus callosum

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ANSWER: C

The central part or body of the lateral ventricle extends from the interventricular foramen to the splenium of
the corpus Callosum.
It is an irregularly curved cavity, triangular on transverse section, with a roof, a floor and a medial wall.
The roof is Formed by the undersurface of the corpus callosum; the floor by the following parts, enumerated
in their order of position, from Before backward: the caudate nucleus of the corpus striatum, the stria
terminalis and the terminal vein, the lateral portion of the Upper surface of the thalamus, the choroid plexus
and the lateral part of the fornix; the medial wall is the posterior part of the Septum pellucidum, which
separates it from the opposite ventricle.
A tumour in the medial wall of the body of the lateral Ventricle will involve the posterior part of the septum
pellucidum.

8. A 65-year-old man developed a homonymous hemianopia following the stroke. This

visual field aneurysmal dilatation of the great cerebral vein on computed tomography.the
great cerebral vein defect is caused by a lesion of the:

A. Abducent nucleus
B. Oculomotor nucleus
C. Optic chiasma
D. Optic nerve
E. Optic radiation

ANSWER: E

Hemianopia indicates a loss of half of the visual field.

Homonymous hemianopia indicates that the same half of each visual Field is lost, that is, all the vision on
the left, or on the right, of the midline. Such a pattern of visual loss is caused by damage to The more distal
part of the optic radiation, most commonly by a stroke.

9. A patient with headache was found to have aneurysmal dilatation of the great cerebral
vein on computed tomography.

A. The great cerebral vein is formed by the union of the two:

B. Inferior sagittal sinuses
C. Internal cerebral veins
D. Middle cerebral veins
E. Striate veins

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F. Superficial cerebral veins

ANSWER: C

The great cerebral vein (great vein of galen), formed by the union of the two internal cerebral veins, is a
short median trunk
Which curves backward and upward around the splenium of the corpus callosum and ends in the anterior
extremity of the Straight sinus. It is prone to congenital defects, such as vein of galen aneurysmal
malformation and vein of galen aneurysmal Dilatation.

10. The superior cerebral veins drain into the:

A. Cavernous sinus
B. Great cerebral vein
C. Inferior petrosal sinus
D. Superior petrosal sinus
E. Superior sagittal sinus

ANSWER: E

The superior cerebral veins, eight to twelve in number, drain the superior, lateral and medial surfaces of the
cerebral Hemispheres and are mainly lodged in the sulci between the gyri, but some run across the gyri.
They open into the superior\ Sagittal sinus.
The anterior veins run nearly at right angles to the sinus.
The posterior and larger veins are directed obliquely Forward and open into the sinus in a direction more or
less opposed to the current of the blood contained within it.

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