Sixth edition

APPLETON & LANGE REVIEW OF

ANATOMY
Royce Lee Montgomery, PhD
Professor
Department of Cell and Developmental Biology
School of Medicine
University of North Carolina
Chapel Hill, North Carolina

Kurt Ogden Gilliland, PhD

Department of Cell and Developmental Biology
School of Medicine
University of North Carolina
Chapel Hill, North Carolina

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Appleton & Lange Review of Anatomy, Sixth Edition
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Montgomery, Royce L.
Appleton & Lange review of anatomy / Royce L. Montgomery, Kurt Ogden
Gilliland.—6th ed.
p. ; cm.
Rev. ed. of: Appleton & Lange review of anatomy for the USMLE Step 1 / Royce L. Montgomery,
Gerald A. Montgomery. © 1995.
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ISBN 0-07-137727-1 (alk. paper)
1. Human anatomy—Examinations, questions, etc. 2. Physicians—Licenses—United States—Examinations—Study
guides. I. Title: Appleton & Lange review of anatomy. II. Title: Review of anatomy. III. Gilliland, Kurt Ogden. IV.
Montgomery, Royce L. Appleton & Lange review of anatomy for the USMLE Step 1. V. Title.
[DNLM: 1. Anatomy—Examination Questions. QS 18.2 M788a 2003]
QM32 .M65 2002
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2002016672
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Copyright © 2003. Exclusive rights by The McGraw-Hill Companies, Inc., for manufacture and export. This book cannot
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 CHAPTER 2

The Upper Limb

Questions

DIRECTIONS (Questions 1 through 83): Each of the (C) The acromion is superior to the glenoid
numbered items or incomplete statements in this cavity and projects anterolaterally.
section is followed by answers or by completions of (D) The scapula is fastened securely to the
the statement. Select the ONE lettered answer or thoracic cage at the scapulothoracic joint.
completion that is BEST in each case. (E) The acromioclavicular joint represents the
true shoulder joint.
1. Which of the following is NOT true regarding
the clavicle? 4. Which of the following is NOT included in the
(A) Its medial end is enlarged where it condyle of the humerus?
attaches to the sternum. (A) radial, coronoid, and olecranon fossae
(B) Its lateral end is flat where it articulates (B) epicondyles
with the humerus.
(C) trochlea
(C) The medial two-thirds of the shaft are
(D) capitulum
convex anteriorly.
(E) greater tubercle
(D) The clavicle transmits shock from the
upper limb to the axial skeleton.
5. Which of the following is NOT true in respect
(E) The clavicle is a “long bone” that has no to the ulna and radius?
medullary cavity.
(A) The brachialis attaches to the tuberosity of
2. The trapezius attaches to which of the follow- the ulna.
ing regions of the clavicle? (B) The ulnar styloid process is much larger
than the radial styloid process and
(A) lateral one-third of the clavicle
extends farther distally.
(B) conoid tubercle
(C) The head of the ulna lies distally, whereas
(C) subclavian groove the head of the radius articulates with the
(D) trapezoid line humerus.
(E) quadrangular tubercle (D) The ulna is medial to the radius in the
anatomical position.
3. Which of the following is true in respect to the (E) The bodies of these bones are firmly bound
scapula? together by the interosseous membrane.
(A) The spine of the scapula continues later-
ally as the coracoid process.
(B) The lateral surface of the scapula forms
the glenoid cavity.

11
12 2: The Upper Limb

6. Which of the following is true regarding the (D) subclavius

carpus? (E) serratus anterior
(A) The scaphoid articulates proximally with
the ulna and has a tubercle. 11. Which of the following best describes the action
of the pectoralis minor?
(B) The lunate articulates with the ulna and is
broader anteriorly than posteriorly. (A) stabilizes scapula by drawing it inferiorly
(C) The triquetrum articulates proximally and anteriorly against thoracic wall
with the articular disc of the distal (B) anchors and depresses clavicle
radioulnar joint. (C) adducts and medially rotates humerus
(D) The pisiform lies on the palmar surface of (D) rotates scapula
the trapezium. (E) flexes humerus
(E) It is composed of seven bones.
12. Which of the following muscles attaches to the
7. Which of the following describes the correct coracoid process of the scapula?
order of the distal row of carpals from lateral to
medial? (A) pectoralis minor
(B) triceps brachii
(A) triquetrum, trapezoid, capitate, hamate
(C) brachialis
(B) trapezoid, trapezium, capitate, hamate
(D) pectoralis major
(C) trapezium, trapezoid, capitate, hamate
(E) subclavius
(D) trapezium, triquetrum, capitate, hamate
(E) scaphoid, lunate, triquetrum, pisiform 13. All of the following are medial rotators of the
arm EXCEPT
8. Which of the following is actually a lateral cuta-
neous branch of an intercostal nerve, innervat- (A) latissimus dorsi
ing the skin of the medial surface of the arm? (B) teres major
(C) subscapularis
(A) intercostobrachial nerve
(D) infraspinatus
(B) superior lateral cutaneous nerve of the arm
(E) anterior part of deltoid
(C) inferior lateral cutaneous nerve of the arm
(D) medial cutaneous nerve of the arm 14. What muscles are necessary to raise the arm
(E) lateral pectoral nerve above the shoulder?

9. Which of the following is NOT a branch of the (A) first the supraspinatus, next the deltoid,
radial nerve? and then the serratus anterior
(B) first the deltoid, next the supraspinatus,
(A) posterior cutaneous nerve of the arm and then the serratus anterior
(B)posterior cutaneous nerve of the forearm (C) first the supraspinatus, next the serratus
(C) inferior lateral cutaneous nerve of the arm anterior, and then the deltoid
(D) superior lateral cutaneous nerve of the (D) first the serratus anterior, next the deltoid,
arm and then the supraspinatus
(E) posterior interosseous nerve (E) first the deltoid, next the serratus anterior,
and then supraspinatus
10. Which of the following is NOT an anterior tho-
racoappendicular muscle? 15. Which of the following is innervated by the
(A) pectoralis major dorsal scapular nerve?
(B) pectoralis minor (A) serratus anterior
(C) deltoid (B) rhomboid major and minor
 Questions: 6–23 13

(C) erector spinae (C) teres major

(D) subscapularis (D) subscapularis
(E) supraspinatus (E) levator scapulae

16. Which of the following is an extrinsic shoulder 21. Which of the following is NOT contained in the
muscle? axilla?
(A) deltoid (A) axillary blood vessels
(B) teres major (B) lymph nodes
(C) levator scapulae (C) trunks and divisions of the brachial
(D) teres minor plexus
(E) supraspinatus (D) axillary nerve
(E) lymph nodes
17. Which of the following is true in respect to the
trapezius? 22. Which of the following is most correct?
(A) It is innervated by the dorsal scapular (A) The subscapular artery arises from the
nerve. third part of the axillary artery and
(B) Its superior fibers retract the scapula. contributes to blood supply of muscles
(C) Its middle fibers elevate the scapula. near the scapula and humerus.
(D) Its inferior fibers retract the scapula. (B) The second part of the axillary artery typi-
cally contains two branches—the thora-
(E) Its superior and inferior fibers act together
coacromial artery and the superior
in rotating the scapula on the thoracic
thoracic artery.
wall.
(C) The first part of the axillary artery lies
18. A patient is asked to place the hands posteriorly posterior to the pectoralis minor.
on the hips and to push the elbows posteriorly (D) The thoracoacromial artery supplies the
against resistance. Which muscle is being tested? pectoral muscles, axillary lymph nodes,
and most importantly the lateral part of
(A) levator scapulae the mammary gland in women.
(B) rhomboid (E) The lateral thoracic artery divides into
(C) trapezius four branches, the acromial, deltoid, pec-
(D) latissimus dorsi toral, and clavicular.
(E) serratus anterior
23. Which of the following is NOT correct?
19. Which rotator cuff muscle does NOT rotate the (A) The brachial plexus is formed by the union
humerus? of the ventral rami of C5 through T1.
(A) supraspinatus (B) The roots of the brachial plexus and the
(B) infraspinatus subclavian artery pass through the gap
(C) teres minor between the anterior and middle scalene
muscles.
(D) subscapularis
(C) Gray rami contribute sympathetic fibers
(E) teres major
to each root.
20. The axillary nerve innervates which of the fol- (D) Each of the three trunks of the brachial
lowing muscles? plexus divide into anterior and posterior
divisions.
(A) coracobrachialis (E) The cords of the brachial plexus surround
(B) teres minor the brachial artery.
14 2: The Upper Limb

24. Which of the following is NOT a supraclavicu- (D) It is primarily innervated by the musculo-
lar branch of the brachial plexus? cutaneous nerve, but some of its lateral
part is innervated by a branch of the
(A) dorsal scapular nerve
radial nerve.
(B) lateral pectoral nerve
(E) It crosses two joints.
(C) long thoracic nerve
(D) nerve to the subclavius 29. A patient is asked to abduct the arm 90 degrees
(E) suprascapular nerve and then to extend the flexed forearm against
resistance. Which muscle is being tested?
25. Which of the following is true regarding the
(A) triceps brachii
quadrangular space?
(B) brachialis
(A) It is bounded superiorly by the teres (C) coracobrachialis
major.
(D) biceps brachii
(B) It is bounded inferiorly by the subscapu-
(E) supinator
laris and teres minor.
(C) It is bounded medially by the humerus 30. The deep artery of the arm accompanies which
and laterally by the long head of the of the following before passing around the
triceps. body of the humerus?
(D) It contains the posterior circumflex
humeral artery and the axillary nerve. (A) radial nerve
(E) Brachial plexus herniations occur here. (B) musculocutaneous nerve
(C) median nerve
26. Which of the following is NOT innervated by (D) ulnar nerve
the suprascapular nerve? (E) axillary nerve
(A) supraspinatus
31. Which muscle assists in extension of the fore-
(B) infraspinatus
arm, resists abduction of the ulna during prona-
(C) glenohumeral joint tion of the forearm, and tenses the capsule of
(D) skin over superior part of scapula the elbow joint so that it is not pinched when
(E) shoulder joint the joint is extended?
(A) anconeus
27. Which of the following is NOT a branch of the
posterior cord of the brachial plexus? (B) triceps brachii
(C) coracobrachialis
(A) upper and lower subscapular nerves
(D) brachialis
(B) thoracodorsal nerve
(E) biceps brachii
(C) axillary nerve
(D) radial nerve 32. Which of the following is a branch of the brachial
(E) long thoracic nerve artery?
(A) anterior and posterior circumflex humeral
28. Which of the following is NOT true in respect
arteries
to the brachialis?
(B) deltoid artery
(A) Its origin is the distal half of the anterior (C) superior and inferior ulnar collateral
surface of the humerus. arteries
(B) Its insertion is the coronoid process and (D) thoracoacromial artery
tuberosity of the ulna.
(E) anterior and posterior ulnar recurrent
(C) It flexes the forearm in all positions. arteries
 Questions: 24–42 15

33. Which of the following nerves supply NO 38. Which muscle does NOT cross the elbow joint?
branches to the arm?
(A) flexor pollicis longus
(A) musculocutaneous and median (B) pronator teres
(B) radial and ulnar (C) flexor carpi radialis
(C) median and ulnar (D) flexor carpi ulnaris
(D) median and radial (E) flexor digitorum superficialis
(E) musculocutaneous and radial
39. The ulnar nerve innervates which of the fol-
34. Which of the following nerves is correctly paired lowing muscles in the flexor compartment?
with its cutaneous branch?
(A) the medial part of the flexor digitorum
(A) median nerve and medial antebrachial superficialis
cutaneous nerve (B) flexor carpi radialis
(B) musculocutaneous nerve and lateral ante- (C) pronator quadratus
brachial cutaneous nerve (D) pronator teres
(C) ulnar nerve and posterior antebrachial (E) the medial part of flexor digitorum
cutaneous nerve profundus
(D) median nerve and medial brachial cuta-
neous nerve 40. The radial artery lies just lateral to the tendon of
(E) radial nerve and superior lateral brachial which muscle?
cutaneous nerve
(A) pronator teres
35. The cubital fossa does NOT contain which of the (B) flexor carpi radialis
following? (C) palmaris longus
(D) flexor carpi ulnaris
(A) terminal part of the brachial artery
(E) flexor digitorum superficialis
(B) deep accompanying veins of the arteries
(C) median nerve 41. The palmaris longus tendon is a useful guide to
(D) biceps brachii tendon which nerve at the wrist?
(E) ulnar nerve
(A) anterior interosseous nerve
36. A patient is unable to flex the arm and forearm. (B) posterior interosseous nerve
Where is the lesion likely to be? (C) median nerve
(D) ulnar nerve
(A) ventral rami of C3–C4
(E) radial nerve
(B) ventral rami of C5–C6–C7
(C) dorsal rami of C6–C7–C8 42. To pronate the forearm, which of the following
(D) ventral rami of C8–T1 must occur?
(E) dorsal rami of T1
(A) The pronator quadratus initiates prona-
tion, assisted later by the pronator teres.
37. The radial nerve innervates muscles in the exten-
sor compartment of the forearm, but it also in- (B) The pronator teres initiates pronation,
nervates the following flexor: assisted later by the pronator quadratus.
(C) The anconeus initiates pronation, assisted
(A) brachioradialis later by the pronator teres.
(B) pronator teres (D) The pronator quadratus initiates prona-
(C) palmaris longus tion, assisted later by the anconeus.
(D) pronator quadratus (E) The ulnar nerve must be used.
(E) palmaris longus
16 2: The Upper Limb

43. The extensor carpi radialis longus tendon is 47. Which of the following is true in respect to the
crossed by which two muscles? anatomical snuff box?
(A) abductor pollicis longus and extensor pol- (A) It is bounded anteriorly by the tendons of
licis longus the extensor pollicis longus.
(B) extensor indicis and extensor digitorum (B) It is bounded posteriorly by the tendons
(C) extensor digitorum and extensor pollicis of the abductor pollicis longus and exten-
brevis sor pollicis brevis.
(D) abductor pollicis longus and extensor pol- (C) The radial artery lies in the floor of the
licis brevis snuff box.
(E) extensor indicis and extensor carpi radi- (D) The scaphoid and triquetrum can be pal-
alis brevis pated within the snuff box.
(E) The snuff box is visible when the thumb is
44. Which of the following is true in respect to the fully flexed.
supinator?
48. Which of the following does NOT abduct the
(A) It is innervated by the ulnar nerve.
hand at the wrist joint?
(B) It supinates the forearm by rotating the
ulna. (A) flexor carpi radialis
(C) It forms the floor of the cubital fossa along (B) extensor carpi radialis longus
with the brachioradialis. (C) extensor carpi radialis brevis
(D) It supinates the forearm when the forearm (D) abductor pollicis longus
is already flexed. (E) palmaris longus
(E) It rotates the radius to turn the palm ante-
riorly. 49. Which of the following is derived from the
radial artery?
45. Which of the following does NOT take an ori-
(A) dorsal and palmar carpal arteries
gin from the lateral epicondyle of the humerus?
(B) common interosseous artery
(A) extensor carpi radialis brevis (C) anterior interosseous artery
(B) extensor carpi ulnaris (D) poster interosseous artery
(C) abductor pollicis longus (E) ulnar recurrent artery
(D) supinator
(E) extensor digiti minimi 50. The median nerve does which of the following?
(A) innervates the elbow joint with articular
46. Which of the following is correctly paired with
branches
its nerve?
(B) innervates the medial half of the flexor
(A) flexor pollicis longus and anterior digitorum profundus
interosseous nerve (C) innervates the hypothenar muscles
(B) flexor digitorum profundus and anterior (D) innervates lumbricals 3 and 4
interosseous nerve
(E) innervates the skin of the dorsum of the
(C) extensor carpi radialis longus and poste- hand
rior interosseous nerve
(D) brachioradialis and posterior interosseous 51. The ulnar nerve does NOT do which of the fol-
nerve lowing?
(E) abductor pollicis longus and anterior
(A) innervate the elbow joint with articular
interosseous nerve
branches
(B) innervate the flexor carpi ulnaris
 Questions: 43–59 17

(C) innervate the skin on the lateral part of (B) adductor pollicis
the palm and dorsum of the hand (C) flexor pollicis brevis
(D) innervate the adductor pollicis (D) opponens pollicis
(E) innervate the dorsal and palmar interossei (E) The recurrent branch of the median nerve
innervates all of the above.
52. The radial nerve does NOT do which of the fol-
lowing? 56. Which of the following muscles is correctly
(A) give a superficial branch that innervates matched with the accompanying description?
the dorsum of the hand (A) lumbricals 1 and 2 . . . bipennate
(B) innervate the brachioradialis and extensor (B) lumbricals 3 and 4 . . . unipennate
carpi radialis longus (C) dorsal interossei 1–4 . . . bipennate
(C) give a deep branch that innervates the (D) palmar interossei 1–3 . . . bipennate
extensor carpi radialis brevis and
(E) deltoid . . . bipennate
supinator
(D) give a posterior interosseous branch that 57. The deep branch of the ulnar does NOT inner-
innervates all remaining extensor muscles vate which of the following?
in the posterior compartment of the fore-
arm (A) abductor digiti minimi
(E) innervate the glenohumeral joint (B) flexor digiti minimi brevis
(C) lumbricals 1 and 2
53. Which of the following is NOT true in respect (D) dorsal interossei 3 and 4
to the flexor pollicis brevis? (E) palmar interossei 1 and 2
(A) It is located medial to the abductor polli-
cis brevis. 58. The carpal tunnel does NOT contain which of
(B) It flexes the thumb at the carpometacarpal the following?
joint. (A) median nerve
(C) It flexes the thumb at the metacarpopha- (B) four tendons of the flexor digitorum
langeal joint. superficialis
(D) Its tendon typically contains a sesamoid (C) four tendons of the flexor digitorum pro-
bone. fundus
(E) It is innervated by C5–C6. (D) the tendon of the flexor pollicis longus
(E) ulnar nerve
54. Which of the following is true in respect to the
palmaris brevis? 59. The sternoclavicular joint . . .
(A) It aids the palmaris longus in tightening (A) . . . is a saddle-type synovial joint but
the palmar aponeurosis. functions as a ball-and-socket joint.
(B) It is innervated by the median nerve. (B) . . . is supplied by lateral thoracic and
(C) It is in the hypothenar compartment. thoracoacromial arteries.
(D) It covers and protects the radial artery. (C) . . . is innervated by the lateral and medial
(E) It wrinkles the skin of the hypothenar pectoral nerves.
eminence and deepens the hollow of the (D) . . . is the articulation of the clavicle and
palm. gladiolus of the sternum.
(E) . . . dislocates easily.
55. The recurrent branch of the median nerve does
NOT innervate which of the following?
(A) abductor pollicis brevis
18 2: The Upper Limb

60. Which of the following is true in respect to the (A) proximal and distal radioulnar joints . . .
acromioclavicular joint? condyloid type of synovial joint
(A) It is a saddle-type synovial joint. (B) radiocarpal joint . . . pivot type of synovial
joint
(B) It is strengthened by the coracohumeral
and transverse humeral ligaments. (C) intercarpal joints . . . plane type of syn-
ovial joints
(C) It is supplied by the lateral thoracic
arteries. (D) metacarpophalangeal joints . . . hinge type
of synovial joints
(D) It is innervated by the nerve to the sub-
clavius. (E) interphalangeal joints . . . condyloid type
of synovial joints
(E) When dislocated, it is often referred to as
a “separated shoulder.”
65. All carpometacarpal and intermetacarpal joints
are plane types of synovial joints EXCEPT for
61. Which of the following flexes the arm at the
glenohumeral joint? (A) the carpometacarpal joint of the thumb.
(A) deltoid (posterior part) (B) the carpometacarpal joint of the fifth
metacarpal.
(B) pectoralis major
(C) the carpometacarpal joint of the third
(C) latissimus dorsi
metacarpal.
(D) subscapularis
(D) the intermetacarpal joint of the 4th and
(E) infraspinatus 5th metacarpals.
(E) the intermetacarpal joint of the 1st and
62. In respect to movement of the arm at the gleno-
2nd metacarpals.
humeral joint, which of the following move-
ments is correctly paired with its prime mover?
66. Which of the following is NOT true in respect
(A) extension . . . deltoid (posterior part) to the clavicle?
(B) abduction . . . pectoralis major and latis- (A) The clavicle varies more in shape than
simus dorsi most other long bones.
(C) adduction . . . deltoid (B) The clavicle can be pierced by a branch of
(D) medial rotation . . . infraspinatus the supraclavicular nerve.
(E) lateral rotation . . . subscapularis (C) The clavicle is thicker and more curved in
manual workers.
63. Which of the following is true in respect to the (D) The right clavicle is stronger than the left
elbow joint? and is usually shorter.
(A) It is a plane type of synovial joint. (E) The clavicle is a compact bone.
(B) It is strengthened by the radial and ulnar
cruciate ligaments. 67. Fractures of the scapula typically involve
(C) It is supplied by the cephalic and basilic (A) the acromion.
arteries. (B) the coracoid process.
(D) It is innervated by the median and axil- (C) the spine.
lary nerves.
(D) the inferior angle.
(E) It is surrounded by the intratendinous ole-
(E) the suprascapular notch.
cranon bursa, the subtendinous olecranon
bursa, and the subcutaneous olecranon
68. Which of the following parts of the humerus is
bursa.
matched correctly with the nerve with which it
is in direct contact?
64. Which of the following joints is paired correctly
with its type?
 Questions: 60–76 19

(A) distal end of humerus . . . radial nerve (A) The teres major atrophies.
(B) surgical neck . . . musculocutaneous nerve (B) The rounded contour of the shoulder dis-
(C) radial groove . . . musculocutaneous nerve appears.
(D) medial epicondyle . . . ulnar nerve (C) A loss of sensation may occur in the
(E) scapular notch . . . suprascapular nerve lateral forearm.
(D) The patient may lose the ability to adduct
69. “Winging” of the scapula is most likely caused the arm.
by which of the following? (E) The patient may exhibit “wrist-drop.”
(A) a lesion to the long thoracic nerve
74. Which of the following is true regarding rotator
(B) a lesion to the thoracodorsal nerve cuff injuries?
(C) injury to the suprascapular nerve
(A) Injury or disease may damage the rotator
(D) damage to the dorsal scapular nerve
cuff, causing instability of the acromio-
(E) damage to the upper and lower subscapu- clavicular joint.
lar nerves
(B) The supraspinatus tendon is the most
commonly torn part of the rotator cuff.
70. Which of the following is correct regarding the
triangle of auscultation? (C) The teres major takes the longest to reha-
bilitate of the rotator cuff muscles.
(A) Its borders are the latissimus dorsi, (D) The injuries occur when the muscles pull
scapula, and trapezius. away from their origin on the acromion.
(B) It is a good location to hear heart murmurs. (E) Acute tears are common in young persons.
(C) The 8th and 9th ribs and the 8th inter-
costal space are subcutaneous here. 75. A patient has been thrown from a motorcycle,
(D) It is a location of back trauma. landing on the shoulder such that the neck and
(E) It is a location for dorsal rami to pass to shoulder are widely separated. You suspect an
the superficial back. upper brachial plexus injury. What signs do you
expect?
71. A patient cannot raise the trunk (as in climb- (A) “clawhand”
ing). What is most likely the problem?
(B) paralysis of flexor carpi ulnaris, flexor
(A) damage to the ventral rami of C5–C6–C7 digitorum superficialis, and flexor digito-
(B) paralysis of the latissimus dorsi rum profundus
(C) injury to the dorsal scapular nerve (C) adducted shoulder, medially rotated arm,
(D) damage to the dorsal rami of C8–T1 and extended elbow
(E) injury to the axillary nerve (D) loss of sensation in the medial forearm
(E) “wrist-drop”
72. The scapula on one side of a patient is located
farther from the midline than that on the nor- 76. A patient exhibits “clawhand.” What might
mal side. What might be the problem? have happened?
(A) paralysis of the rhomboids on one side (A) upper brachial plexus injury
(B) injury to the long thoracic nerve (B) acute brachial plexus neuritis
(C) a lesion of C7–C8 (C) compression of the cords of the brachial
(D) dislocated shoulder plexus
(E) separated shoulder (D) lower brachial plexus injury
(E) damage to dorsal rami that send fibers to
73. The axillary nerve is damaged. What is the the brachial plexus
likely result?
20 2: The Upper Limb

77. A patient receives a knife wound to the axilla. (D) amelia . . . long bones are absent, and
What problems do you expect? small hands or feet are attached to the
trunk by short, irregular bones
(A) damage to the axillary nerve
(E) cleft hand (lobster claw deformity) . . .
(B) paralysis of the coracobrachialis, biceps,
absent third metacarpal, fusion of digits
and brachialis
1–2 and 4–5
(C) inability to extend the wrist and digits at
the metacarpophalangeal joints 81. Syndactylyl involves
(D) loss of sensation on the medial surface of
the arm (A) extra fingers or toes.
(E) “clawhand” (B) absence of a digit or limb.
(C) abnormal fusion of fingers and toes.
78. A patient tries to make a fist, but digits 2 and (D) small hands or feet being attached to trunk
3 remain partially extended. What nerve is by short bones instead of long bones.
injured? (E) congenital dislocation of glenohumeral
(A) ulnar nerve joint.
(B) radial nerve
82. Which of the following is NOT correct?
(C) median nerve
(D) musculocutaneous nerve (A) During development, dorsal cells orga-
nize as the epimere and ventral cells orga-
(E) axillary nerve
nize as the hypomere.
79. Which of the following is true in respect to ulnar (B) Dorsal rami innervate muscles derived
nerve injuries? from the epimere.
(C) Ventral rami innervate muscles derived
(A) The injury often occurs where the nerve from the hypomere.
passes posterior to the medial epicondyle
(D) Myoblasts of the hypomere form the
of the humerus.
extensor muscles of the vertebral column.
(B) The patient experiences numbness and
(E) Somites and somitomeres form the mus-
tingling on the lateral part of the palm
culature of the limbs.
and the thumb.
(C) The patient may exhibit “waiter’s tip 83. A patient in surgery has no pectoralis major.
hand.” What do you suspect?
(D) Patients have difficulty because they can-
not flex their first, second, and third digits (A) trauma
at the DIP joints. (B) dominant pectoralis minor
(E) Power of abduction is impaired, and (C) drug-induced muscle hypoplasia
when the patient attempts to flex the (D) atrophy of the muscle
wrist, the flexor carpi ulnaris brings the (E) congenital absence of the muscle
hand to the medial side.

80. Which limb defect is correctly matched with its

definition?
(A) meromelia . . . complete absence of one or
more extremities
(B) phocomelia . . . all segments of extremities
are present but abnormally short
(C) micromelia . . . partial absence of one or
more extremities
 Questions: 77–93 21

DIRECTIONS (Questions 84 through 88): Identify the anatomical features indicated on the art below.

DIRECTIONS (Questions 89 through 93): Identify the anatomical features indicated on the art below.
22 2: The Upper Limb

DIRECTIONS (Questions 94 through 98): Identify the anatomical features indicated on the art below.
 Answers and Explanations

1. (B) The lateral end of the clavicle is flat where 7. (C) From lateral to medial, the four bones of the
it articulates with the acromion at the acromio- distal row of carpals are the trapezium, trape-
clavicular (AC) joint (Moore, pp 665–666). zoid, capitate, and hamate (Moore, p 674).

2. (A) The trapezius attaches to the lateral third of 8. (A) The intercostobrachial nerve is the lateral
the clavicle, acromion, and spine of the scapula. cutaneous branch of the second intercostal nerve
The deltoid attaches to the deltoid tubercle, the from T2, innervating the skin of the medial sur-
conoid ligament attaches to the conoid tubercle, face of the arm (Moore, p 684).
the subclavius attaches to the subclavian groove,
and the trapezoid ligament attaches to the trape- 9. (D) The posterior cutaneous nerve of the arm,
zoid line (Moore, pp 666, 691). posterior cutaneous nerve of the forearm, and
inferior lateral cutaneous nerve of the arm are
3. (B) The lateral surface of the scapula forms the branches of the radial nerve. The superior lateral
glenoid cavity, superior to which the coracoid cutaneous nerve is a branch of the axillary nerve
process projects anterolaterally. The glenohum- (Moore, p 684).
eral joint itself represents the true shoulder joint,
whereas the scapulothoracic joint, which is a con- 10. (C) The pectoralis major, pectoralis minor, sub-
ceptual joint, is a location where the scapula clavius, and serratus anterior are anterior tho-
moves easily on the thoracic wall. The spine of racoappendicular muscles. The deltoid is a
the scapula continues laterally as the acromion scapulohumeral (shoulder) muscle (Moore, pp
(Moore, pp 668–669). 688, 691).

4. (E) The condyle of the humerus (the distal end) 11. (A) The pectoralis minor stabilizes the scapula
includes the epicondyles, trochlea, capitulum, by drawing it inferiorly and anteriorly against
and the three fossae (radial, coronoid, and radial) the thoracic wall (Moore, p 688).
(Moore, p 670).
12. (A) The pectoralis minor, biceps brachii (short
5. (B) The radial styloid process is much larger head), and coracobrachialis attach to the cora-
than the ulnar styloid process and extends far- coid process of the scapula (Moore, p 688).
ther distally (Moore, p 671–672).
13. (D) The latissimus dorsi, teres major, and sub-
6. (C) The scaphoid articulates proximally with scapularis medially rotate the arm. The infra-
the radius and has a large tubercle. The lunate spinatus and teres minor rotate the arm laterally.
articulates with the radius and is broader anteri- The deltoid is unique in that its anterior part
orly than posteriorly. The triquetrum articulates rotates the arm medially, and its posterior part
proximally with the articular disc of the distal rotates the arm laterally (Moore, p 691).
radioulnar joint. The pisiform lies on the palmar
surface of the triquetrum (Moore, p 674). 14. (A) The supraspinatus initiates abduction of
the arm. The deltoid becomes fully effective as

23
24 2: The Upper Limb

an abductor following the initial 15 degrees of pass through the gap between the anterior and
abduction. The serratus anterior rotates the middle scalene muscles. Gray rami contribute
scapula, elevating its glenoid cavity so that the sympathetic fibers to each root. The roots of the
arm can be raised above the shoulder (Moore, brachial plexus form three trunks, each of which
pp 695, 696, 689). divides into anterior and posterior divisions.
The cords of the brachial plexus surround the
15. (B) The dorsal scapular nerve innervates the axillary artery (Moore, p 708).
levator scapulae, rhomboid major, and rhom-
boid minor (Moore, p 691). 24. (B) The dorsal scapular nerve, long thoracic
nerve, nerve to the subclavius, and supra-
16. (C) The trapezius, latissimus dorsi, levator scapular nerve are supraclavicular branches of
scapulae, and rhomboids are extrinsic shoulder the brachial plexus, whereas the lateral pectoral
muscles. The deltoid, teres major, supraspinatus, nerve is an infraclavicular branch, originating
infraspinatus, teres minor, and subscapularis are from the lateral cord (Moore, pp 708–709).
intrinsic shoulder muscles (Moore, pp 691–692).
25. (D) The quadrangular space is bounded superi-
17. (E) The trapezius, innervated by the spinal root orly by the subscapularis and teres minor, infe-
of the accessory nerve (XI), is composed of three riorly by the teres major, medially by the long
types of fibers. Its superior fibers elevate the head of triceps, and laterally by the humerus. It
scapula, its middle fibers retract the scapula, and contains the axillary nerve and the posterior cir-
its inferior fibers depress the scapula. Its superior cumflex humeral artery (Moore, p 711).
and inferior fibers act together in rotating the
scapula on the thoracic wall (Moore, p 694). 26. (D) The suprascapular nerve innervates the
supraspinatus, infraspinatus, and glenohumeral
18. (B) To test the rhomboids, the patient is asked (shoulder) joint (Moore, p 710).
to place the hands posteriorly on the hips and to
push the elbows posteriorly against resistance 27. (E) The posterior cord gives rise to the upper and
(Moore, p 695). lower subscapular nerves, thoracodorsal nerve,
axillary nerve, and radial nerve. The long tho-
19. (A) The supraspinatus is the only rotator cuff racic nerve originates from C5–C6–C7 (Moore,
muscle that does not rotate the humerus (Moore, pp 711).
pp 697–698).
28. (E) The brachialis originates from the distal half
20. (B) The axillary nerve innervates both the del- of the anterior surface of the humerus and inserts
toid and the teres minor (Moore, p 691). on the coronoid process and tuberosity of the
ulna. It crosses one joint, flexing the forearm in
21. (C) The axilla contains axillary blood vessels, all positions. While it is primarily innervated by
lymph nodes, the cords and branches of the the musculocutaneous nerve, some of its lateral
brachial plexus, and the axillary nerve. The part is innervated by a branch of the radial nerve
trunks and divisions are found superior to (Moore, p 722).
the axilla in the neck (Moore, p 699).
29. (A) To test the triceps brachii, the arm is abducted
22. (A) The subscapular artery arises from the third 90 degrees and then the flexed forearm is extended
part of the axillary artery and contributes to against resistance (Moore, p 724).
blood supply of muscles near the scapula and
humerus (Moore, p 701). 30. (A) The deep artery of the arm accompanies
the radial nerve through the radial groove and
23. (E) The brachial plexus is formed by the union passes around the body of the humerus (Moore,
of the ventral rami of C5 through T1. The roots p 728).
of the brachial plexus and the subclavian artery
 Answers and Explanations: 15–44 25

31. (A) The anconeus assists in extension of the fore- 36. (B) A patient who is unable to flex the arm and
arm, resists abduction of the ulna during prona- forearm is likely to have a lesion in the ventral
tion of the forearm, and tenses the capsule of the rami of C5, C6, and C7. The biceps brachii and
elbow joint so that it is not pinched when the brachialis receive fibers from C5 and C6, and the
joint is extended (Moore, p 724). coracobrachialis receives fibers from C5, C6, and
C7. C6 is the main source of fibers for each
32. (C) The axillary artery gives rise to the superior (Moore, p 722).
thoracic, thoracoacromial, lateral thoracic, sub-
scapular, and anterior and posterior circumflex 37. (A) The brachioradialis is a flexor of the forearm,
humeral arteries. The brachial artery gives rise to but it is located in the extensor compartment and
the deep artery of the arm, the nutrient humeral is innervated by the radial nerve (Moore, p 734).
artery, and the superior and inferior collateral
arteries. The ulnar artery gives rise to the anterior 38. (A) The superficial muscles (pronator teres,
and posterior ulnar recurrent, common inter- flexor carpi radialis, palmaris longus, flexor
osseous, anterior and posterior interosseous, and carpi ulnaris, and flexor digitorum superficialis)
dorsal and palmar carpal branch arteries (Moore, cross the elbow joint. The deep muscles (flexor
pp 699, 727–728, 750). digitorum profundus, flexor pollicis longus, and
pronator quadratus) do not (Moore, p 734).
33. (C) The median and ulnar nerves supply no
branches to the arm (Moore, p 730). 39. (E) All muscles in the anterior compartment
of the forearm are innervated by the median
34. (B) The median nerve gives rise to a palmar nerve, except for the flexor carpi ulnaris and the
cutaneous branch; the ulnar nerve as well has a medial part of the flexor digitorum profundus,
palmar cutaneous branch. The radial nerve gives which are innervated by the ulnar nerve (Moore,
rise to the posterior brachial cutaneous nerve, pp 736–737).
the posterior antebrachial cutaneous nerve, the
inferior lateral brachial cutaneous nerve, and a 40. (B) The radial artery lies lateral to the tendon of
superficial branch that innervates the dorsum of the flexor carpi radialis (Moore, p 737).
the hand and the digits. The musculocutaneous
nerve continues as the lateral antebrachial cuta- 41. (C) The palmaris longus tendon is a guide for
neous nerve. The axillary nerve gives rise to the locating the median nerve at the wrist (Moore,
superior lateral brachial cutaneous nerve. The p 737).
medial cord of the brachial plexus gives rise to
the medial brachial cutaneous nerve and the 42. (A) To pronate the forearm, the pronator quad-
medial antebrachial cutaneous nerve. The supra- ratus initiates pronation, assisted later by the
clavicular nerves (from C3–C4) and the inter- pronator teres (Moore, p 741).
costobrachial nerve (from T2) also contribute
to the cutaneous innervation of the arm (Moore, 43. (D) The extensor carpi radialis longus tendon
pp 684, 758–759). is crossed by the abductor pollicis longus and
extensor pollicis brevis (Moore, p 745).
35. (E) The cubital fossa contains the terminal part
of the brachial artery (and the beginning of the 44. (E) The supinator, which forms the floor of the
ulnar and radial arteries), deep accompanying cubital fossa along with the brachioradialis, is
veins, the median nerve, and the biceps brachii innervated by the deep branch of the radial
tendon. In the tissue superficial to the fossa are nerve. It supinates the forearm by rotating the
the median cubital vein and medial and lateral radius. The biceps brachii also supinates the
antebrachial cutaneous nerve. The deep and forearm when the forearm is already flexed
superficial branches of the radial nerve are (Moore, p 746).
within the floor of the fossa (Moore, pp 731–732).
26 2: The Upper Limb

45. (C) The abductor pollicis longus originates from ulnaris and medial half of the flexor digitorum
the posterior surfaces of the ulna, radius, and profundus. The palmar cutaneous branch inner-
interosseous membrane. The following muscles vates the skin of the medial part of the palm, and
take at least one of their origins from the lateral the dorsal cutaneous branch innervates the pos-
epicondyle of the humerus: extensor carpi radi- terior surface of the medial part of the hand and
alis brevis, extensor digitorum, extensor digiti digits. The deep branch innervates the hypo-
minimi, extensor carpi ulnaris, and supinator thenar muscles, adductor pollicis, interossei, and
(Moore, p 742). the 3rd and 4th lumbricals (Moore, pp 759–760).

46. (A) The flexor pollicis longus is innervated by 52. (E) The radial nerve gives a superficial branch
the anterior interosseous nerve from the median that innervates skin on the dorsum of the hand.
nerve (Moore, pp 736–737, 742–743). The radial nerve itself innervates the brachiora-
dialis and extensor carpi radialis longus. It then
47. (C) The snuff box is bounded anteriorly by the gives a deep branch that innervates the extensor
tendons of the abductor pollicis longus and ex- carpi radialis brevis and the supinator before
tensor pollicis brevis. Posteriorly it is bounded continuing as the posterior interosseous nerve,
by the tendon of the extensor pollicis longus. The which innervates the extensor digitorum, ex-
radial artery can be felt in the floor, along with tensor digiti minimi, extensor carpi ulnaris, ab-
the radial styloid process, first metacarpal, ductor pollicis longus, extensor pollicis brevis,
scaphoid, and trapezium (Moore, p 749). extensor pollicis longus, and extensor indicis
(Moore, pp 742, 761).
48. (E) The hand is abducted at the wrist joint by the
flexor carpi radialis, abductor pollicis longus, 53. (E) The flexor pollicis brevis is located medial to
extensor carpi radialis longus, and extensor carpi the abductor pollicis brevis. It flexes the thumb
radialis brevis (Moore, pp 736, 742). at the carpometacarpal and metacarpophalan-
geal joints and assists in opposition. Its tendon
49. (A) The radial artery gives rise to the radial typically contains a sesamoid bone. It is inner-
recurrent artery as well as dorsal and palmar vated by the recurrent branch of the median
carpal branches. The ulnar artery gives rise to the nerve (C8–T1) (Moore, p 767).
common interosseous artery, anterior and poste-
rior interosseous arteries, anterior and posterior 54. (E) The palmaris brevis, innervated by the ulnar
ulnar recurrent arteries, and dorsal and palmar nerve, wrinkles the skin of the hypothenar emi-
carpal branches (Moore, p 750). nence and deepens the hollow of the palm, assist-
ing the palmar grip. The muscle actually covers
50. (A) The median nerve assists in the innervation and protects the ulnar artery and the ulnar nerve,
of the elbow joint and gives muscular branches which innervates it. The muscle is not by defi-
to pronator teres, flexor carpi radialis, palmaris nition in the hypothenar compartment. The pal-
longus, and flexor digitorum superficialis. The maris longus, on the other hand, flexes the hand
median nerve also has an anterior interosseous at the wrist and tightens the palmar aponeuro-
branch that innervates the lateral part of the sis (Moore, p 768).
flexor digitorum profundus, flexor pollicis
longus, and pronator quadratus. The recurrent 55. (B) The recurrent branch of the median nerve
branch of the median nerve innervates the innervates the abductor pollicis brevis, flexor
thenar muscles, and the palmar cutaneous pollicis brevis, and opponens pollicis, but the
branch innervates the skin of the lateral part of deep branch of the ulnar nerve innervates adduc-
the palm (Moore, pp 757–759). tor pollicis (Moore, pp 769–770).

51. (C) The ulnar nerve gives rise to articular 56. (C) Lumbricals 1–2 and palmar interossei 1–3
branches that innervate the elbow joint and mus- are unipennate muscles. Lumbricals 3–4 and dor-
cular branches that innervate the flexor carpi sal interossei 1–4 are bipennate muscles. The del-
toid is multipennate (Moore, p 770).
 Answers and Explanations: 45–70 27

57. (C) The deep branch of the ulnar nerve inner- anastomosis around the elbow and is inner-
vates the adductor pollicis, abductor digiti min- vated by the musculocutaneous, radial, and
imi, flexor digiti minimi brevis, opponens digiti ulnar nerves. It is surrounded by the intratendi-
minimi, lumbricals 3 and 4, dorsal interossei 1–4, nous olecranon bursa, the subtendinous olec-
and palmar interossei 1–3. The median nerve ranon bursa, and the subcutaneous olecranon
innervates lumbricals 1 and 2 (Moore, p 770). bursa (Moore, pp 795–798).

58. (E) The carpal tunnel contains the median nerve, 64. (C) The proximal and distal radioulnar joints
the four tendons of the flexor digitorum superfi- are pivot-type synovial joints. The radiocarpal
cialis, the four tendons of the flexor digitorum (wrist) joint is a condyloid type of synovial joint.
profundus, and the tendon of the flexor pollicis Intercarpal joints are plane-type synovial joints.
longus (Moore, p 774). Metacarpophalangeal joints are condyloid types
of synovial joints. Interphalangeal joints are
59. (A) The sternoclavicular joint, which does not hinge-type synovial joints (Moore, pp 800, 803,
dislocate easily, is a saddle-type synovial joint 807, 809).
but functions as a ball-and-socket joint. It is the
articulation of the sternal end of the clavicle with 65. (A) All carpometacarpal and intermetacarpal
the manubrium of the sternum. The joint is sup- joints are the plane-type synovial joints except
plied by the internal thoracic and suprascapular for the carpometacarpal joint of the thumb,
arteries and is innervated by branches of the which is a saddle joint (Moore, p 809).
medial supraclavicular nerve and the nerve to
the subclavius (Moore, pp 781–782). 66. (E) The clavicle varies more in shape than most
other long bones and is thicker and more curved
60. (E) The acromioclavicular joint is a plane-type in manual workers. The right clavicle is stronger
synovial joint and is strengthened by the AC lig- than the left and is usually shorter. The clavicle
ament and the coracoclavicular ligament, which can also be pierced by a branch of the supracla-
is composed of the conoid and trapezoid liga- vicular nerve. The clavicle is a long bone with no
ments. It is supplied by the suprascapular and medullary cavity. It consists of spongy (cancel-
thoracoacromial arteries and is innervated by lous) bone with a shell of compact bone (Moore,
the supraclavicular, lateral pectoral, and axillary p 667).
nerves. When dislocated, it is referred to as a
“separated shoulder” (Moore, pp 784, 787). 67. (A) Fractures of the scapula typically involve the
protruding subcutaneous acromion. The remain-
61. (B) The pectoralis major (clavicular head) and der of the scapula is well protected by muscles
deltoid (anterior part) flex the arm at the gleno- and the thoracic wall itself (Moore, p 669).
humeral joint. The coracobrachialis and the bi-
ceps brachii assist (Moore, p 792). 68. (D) The surgical neck of the humerus is in direct
contact with the axillary nerve, the radial nerve
62. (A) The posterior portion of the deltoid causes runs in the radial groove, the distal end of the
extension of the arm at the glenohumeral joint. humerus is in direct contact with the median
The deltoid (as a whole, but especially the cen- nerve, and the medial epicondyle is in contact
tral part) causes abduction, whereas the pec- with the ulnar nerve (Moore, p 670).
toralis major and latissimus dorsi cause adduc-
tion. The subscapularis causes medial rotation, 69. (A) Damage to the long thoracic nerve results
whereas the infraspinatus causes lateral rota- in “winging” of the scapula (Moore, p 689).
tion (Moore, p 792).
70. (A) The triangle of auscultation, a good place to
63. (E) The elbow is a hinge type of synovial joint, examine lung sounds, is bounded by the supe-
strengthened by radial and ulnar collateral liga- rior horizontal border of the latissimus dorsi, the
ments. It is supplied by arteries derived from the medial border of the scapula, and the inferolat-
28 2: The Upper Limb

eral border of the trapezius. The 6th and 7th ribs ened. The patient would also lose sensation on
and the 6th intercostal space is subcutaneous the lateral surface of the forearm (Moore, p 731).
(Moore, p 693).
78. (C) When the median nerve is injured, the pa-
71. (B) With paralysis of the latissimus dorsi, the tient often exhibits the “hand of benediction.”
patient is unable to raise the trunk as necessary When the patient tries to make a fist, digits 2 and
for climbing. The cause could be injury to the 3 remain partially extended because flexion of
thoracodorsal nerve (C6–C7–C8) (Moore, p 693). the PIP joints is lost in digits 1–3 and weakened
in digits 4–5. Flexion of the DIP joints is lost in
72. (A) Injury to the dorsal scapular nerve (C4–C5) digits 2–3 but maintained in digits 4–5 (since the
can paralyze the rhomboids, causing the scapula ulnar nerve controls the medial part of the flexor
on one side to be located farther from the midline digitorum profundus). Flexion of the MCP joints
than that on the normal side (Moore, p 695). of digits 2-3 will also be affected due to a loss of
the lumbricals 1 and 2 (Moore, pp 757, 774, 776).
73. (B) The deltoid atrophies when the axillary
nerve (C5–C6) is damaged. Therefore, the 79. (A) The ulnar nerve is often injured where it
rounded contour of the shoulder often dis- passes posterior to the medial epicondyle of the
appears. A loss of sensation may occur on the humerus. The patient experiences loss of sensa-
lateral side of the proximal part of the arm tion in the medial part of the palm as well as in
(Moore, pp 696–697). the medial 11⁄2 digits. Most intrinsic hand mus-
cles are paralyzed, and the patient loses the
74. (B) Injury or disease may damage the rotator ability to adduct the hand at the wrist. Patients
cuff, causing instability of the glenohumeral cannot make a fist since they are unable to flex the
joint. The supraspinatus tendon is the most 4th and 5th digits at the DIP joints. The result-
commonly torn part of the rotator cuff. Acute ing deformity is known as “clawhand” (Moore,
tears are uncommon in young persons (Moore, pp 761, 776–777).
pp 698–699).
80. (E) Amelia is the complete absence of one or
75. (C) In an upper brachial plexus injury causing more extremities while meromelia is the partial
Erb-Duchenne palsy, one would expect damage absence of one or more extremities. All segments
to C5–C6, resulting in “waiter’s tip position” of extremities are present but abnormally short
(adducted shoulder, medially rotated arm, and in micromelia. In phocomelia, long bones are
extended elbow). This results from paralysis of absent, and small hands or feet are attached to
the deltoid, biceps, brachialis, and brachioradi- the trunk by short, irregular bones. In cleft hand
alis. The lateral aspect of the upper limb also (lobster claw deformity), the third metacarpal is
experiences loss of sensation (Moore, p 716). absent and digits 1–2 and 4–5 are fused (Sadler,
p 179).
76. (D) Damage to the inferior trunks of the brachial
plexus (C8–T1) affects the short muscles of the 81. (C) Syndactyly involves abnormal fusion of fin-
hand, resulting in “clawhand.” The patient might gers and toes. Cleft hand (lobster claw defor-
have grabbed a tree limb to catch himself while mity) consists of an abnormal cleft between the
falling to cause this injury. “Clawhand” may also 2nd and 4th metacarpal bones, with the 3rd
be caused by an injury to the ulnar nerve (Moore, metacarpal and phalangeal bones being absent
pp 716–717, 761). and with digits 1–2 and 4–5 being fused. Poly-
dactyly involves extra fingers or toes, while
77. (B) A knife wound to the axilla would dam- ectrodactyly involves the absence of a digit.
age the musculocutaneous nerve and result in Mutations in HOXA13 result in hand-foot-geni-
paralysis of the coracobrachialis, biceps, and tal syndrome, where carpals and short digits are
brachialis. Therefore, flexion of the elbow joint fused and the genitalia have altered structures
and supination of the forearm would be weak- (Sadler, p 181).
 Answers and Explanations: 71–98 29

82. (D) During development, dorsal cells organize 87. brachial artery
as the epimere and ventral cells organize as the
hypomere. Dorsal rami innervate muscles de- 88. median nerve
rived from the epimere, whereas ventral rami
innervate muscles derived from the hypomere. 89. lateral cord
Myoblasts of the epimere form the extensor
muscles of the vertebral column, and those of the 90. musculocutaneous nerve
hypomere give rise to muscles of the limbs and
body wall. Somites and somitomeres form the 91. medial antebrachial cutaneous nerve
musculature of the limbs (Sadler, pp 189–190).
92. ulnar nerve
83. (E) Partial or complete absence of one or more
muscles is rather common. One of the best- 93. lateral pectoral nerve
known examples is total or partial absence of the
pectoralis major (Poland anomaly). Similarly, 94. coracobrachialis
the palmaris longus, serratus anterior, and quad-
ratus femoris may be partially or entirely absent 95. brachialis
(Sadler, p 192).
96. ulna
84. biceps brachii
97. long head of triceps brachii
85. cephalic vein
98. lateral head of triceps brachii
86. radial nerve
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 CHAPTER 3

The Thorax
Questions

DIRECTIONS (Questions 1 through 75): Each of the (C) venous drainage

numbered items or incomplete statements in this (D) poor imaging techniques
section is followed by answers or by completions of (E) complex lymphatic drainage
the statement. Select the ONE lettered answer or
completion that is BEST in each case. 5. Which of the following statements correctly
apply to the internal thoracic artery?
1. The articular part of a rib tubercle articulates
with which of the following structures? (A) It runs posterior to the transversus tho-
racis muscle.
(A) body of the vertebra
(B) It ends in the 6th intercostal space.
(B) costal cartilage
(C) It divides into the superior and inferior
(C) adjacent rib epigastric arteries.
(D) sternum (D) It runs posterior to the superior six ribs.
(E) transverse process (E) It gives rise to the posterior intercostal
arteries.
2. Where is the groove for the subclavian artery
located? 6. Which of the following statements concerning
(A) posterior to the scalene tubercle the sternal angle is correct?
(B) on the clavicle (A) It lies at the level of the intervertebral disk
(C) on the manubrium between T4/T5.
(D) at the sternal angle (B) It is flanked by the costal cartilage of the
(E) at the angle of the 1st rib 3rd pair of costal cartilages.
(C) It is crossed by the superior epigastric
3. The retromammary space is located between artery.
which of the following structures? (D) It lies in the epigastric fossa.
(A) skin and the areola (E) It is located 3 mm superior to the jugular
(B) pectoralis major and minor notch.
(C) breast and deep pectoral fascia
7. The pleural cavity contains which of the fol-
(D) suspensory ligament and the skin lowing?
(E) lactiferous sinus and the nipple
(A) lungs
4. The high death rate associated with breast can- (B) bronchi
cer is related to which of the following? (C) serous pleural fluid
(A) nerve supply (D) lymph nodes
(B) blood supply (E) pulmonary arteries and veins

31
32 3: The Thorax

8. The parietal pleura consists of all of the follow- (D) heart

ing parts EXCEPT (E) azygos vein
(A) costal
13. All of the following statements correctly apply
(B) pericardial
to the right atrium EXCEPT
(C) mediastinal
(D) diaphragmatic (A) It receives blood from the superior and
inferior vena cava and coronary sinus.
(E) cervical
(B) It forms the right side of the heart.
9. All of the following statements correctly apply (C) It contains the crista terminalis.
to the right lung EXCEPT (D) It contains the limbus fossae ovalis.
(A) The superior and oblique fissures divide it (E) It contains trabeculae carneae.
into three lobes.
14. The interventricular septum contains which of
(B) It is larger and heavier than the left lung.
the following structures?
(C) It is shorter and wider than the left lung.
(D) It contains a thin, tonguelike process (A) anterior papillary muscle
called the lingula. (B) fossa ovalis
(E) It has three surfaces. (C) sinus venarum
(D) sinoatrial node
10. All of the following statements correctly apply (E) conus arteriosus
to the left main bronchus EXCEPT
(A) It is wider, shorter, and runs more verti- 15. All of the following statements correctly apply
cally than the right main bronchus. to the right coronary artery EXCEPT
(B) It passes anterior to the esophagus. (A) Typically supplies the SA node in approx-
(C) It passes anterior to the thoracic aorta. imately 60% of people.
(D) It contains c-shaped rings of hyaline (B) Typically supplies the AV node in
cartilage. approximately 80% of people.
(E) It arises at the level of the sternal angle. (C) Arises from the arch of the aorta.
(D) Runs in the coronary sulcus.
11. All of the following statements correctly apply (E) Dominance is typical.
to a bronchopulmonary segment EXCEPT
(A) It is separated from adjacent segments by 16. Which of the following is the basic structural
connective tissue septa. unit for gas exchange in the lung?
(B) It is the largest subdivision of a lobe. (A) terminal bronchioles
(C) It is not resectable. (B) respiratory bronchioles
(D) It is named according to the segmental (C) alveolar ducts
bronchus supplying it. (D) alveoli
(E) It is a pyramid-shaped segment of the (E) bronchi
lung, with its apex facing the lung root
and its base at the pleural surface. 17. Which of the following structures carry highly
oxygenated blood from the lungs to the heart?
12. Which of the following structures is located in
the middle mediastinum? (A) pulmonary arteries
(B) pulmonary veins
(A) thoracic duct
(C) coronary arteries
(B) lungs
(D) cardiac veins
(C) esophagus
(E) ascending aorta
 Questions: 8–26 33

18. Which of the following structures is located in 22. All of the following veins drain into the coro-
the posterior mediastinum? nary sinus EXCEPT
(A) lungs (A) anterior cardiac
(B) heart (B) small cardiac
(C) azygos vein (C) middle cardiac
(D) superior vena cava (D) great cardiac
(E) right coronary artery (E) oblique vein of the left atrium

19. All of the following statements concerning spinal 23. All of the following statements concerning the
nerves are correct EXCEPT sinoatrial node are correct EXCEPT
(A) The dorsal and ventral rami are both (A) It is located near the superior end of the
motor and sensory. sulcus terminalis.
(B) The cutaneous branches include anterior, (B) It is located at the junction of the superior
lateral, and posterior branches. vena cava and the right atrium.
(C) The dorsal root is both sensory and motor. (C) It is known as the pacemaker of the heart.
(D) The ventral root is pure motor. (D) It is specialized cardiac muscle fiber.
(E) They supply a bandlike skin area known (E) It is avascular.
as a dermatome.
24. Which of the following structures is located in
20. Which of the following statements correctly the left ventricle?
applies to the tricuspid valve?
(A) fossa ovalis
(A) It guards the left atrioventricular orifice. (B) crista terminalis
(B)It guards the conus arteriosus. (C) opening of the coronary sinus
(C) It is also known as the mitral valve. (D) conus arteriosus
(D) Chordae tendineae attach to the free (E) posterior papillary muscle
edges of the cusps.
(E) The apex of each cusp attaches to the 25. Which of the following structures is located in
fibrous ring around the orifice. the left atrium?
(A) pectinate muscle
21. All of the following statements concerning the
pericardium are correct EXCEPT (B) pulmonary semilunar valves
(C) septomarginal trabeculae
(A) The external layer of the sac is fibrous.
(D) septal papillary muscle
(B) The internal layer is reflected onto the
(E) atrioventricular node
heart as the visceral serous layer (epi-
cardium).
26. Which of the following is NOT part of the chest?
(C) The internal layer of the fibrous sac is the
partietal serous layer. (A) 12 pairs of ribs
(D) The pericardial cavity is the potential (B) sternum
space between the parietal and visceral (C) costal cartilages
serous layers. (D) 12 thoracic vertebrae
(E) The fibrous pericardium is attached to (E) clavicle
the sternum by the pericardiacophrenic
ligament.
34 3: The Thorax

27. Which of the following is NOT likely to con- (C) internal intercostals
tribute to chest pain? (D) subcostals
(A) cardiac disease (E) serratus posterior inferior
(B) pulmonary disease
33. Which of the following do NOT elevate the
(C) thyroid disorders
ribs?
(D) gallbladder disorders
(E) intestinal disorders (A) serratus posterior superior
(B) serratus posterior inferior
28. Which of the following is a special feature of a (C) external intercostals
thoracic vertebra? (D) levatores costarum
(A) foramen for vertebral artery (E) subcostals
(B) dens for rotation
34. With which of the following does the intercos-
(C) short spinous processes
tobrachial nerve communicate?
(D) costal facets on bodies
(E) costal facets on spinous processes (A) medial brachial cutaneous nerve
(B) thoracodorsal nerve
29. Which of the following is a saddle-type synovial (C) long thoracic nerve
joint? (D) first intercostal nerve
(A) sternoclavicular joint (E) sympathetic trunk
(B) manubriosternal joint
35. The musculophrenic arteries give rise to which
(C) interchondral joint
of the following?
(D) intervertebral joint
(E) costochondral joint (A) anterior intercostal arteries for intercostal
spaces 7–9
30. The mammary glands are modified versions of (B) posterior intercostals arteries for inter-
which type of gland? costal spaces 3–11
(C) subcostal artery
(A) sebaceous gland
(D) inferior phrenic artery
(B) lymph gland
(E) lumbar arteries
(C) sweat gland
(D) tonsillar tissue 36. Anterior and posterior intercostals arteries pass
(E) endocrine gland between which two layers?

31. Which of the following does NOT supply the (A) skin and external intercostal muscles
breast with blood? (B) external and internal intercostal muscles
(C) internal and innermost intercostals
(A) lateral thoracic artery
muscles
(B) thoracoacromial artery
(D) innermost intercostal muscles and trans-
(C) posterior intercostals arteries versalis fascia
(D) internal thoracic artery (E) transversalis fascia and peritoneum
(E) costoclavicular artery
37. Of the bronchopulmonary segments in the supe-
32. Which of the following are innervated by dor- rior lobe of the left lung, which two are com-
sal rami? bined to form the lingula?
(A) levatores costarum (A) apical and posterior
(B) external intercostals (B) posterior and anterior
 Questions: 27–46 35

(C) anterior and superior 42. Which of the following is NOT a branch of the
(D) superior and inferior right coronary artery?
(E) apical and inferior (A) SA nodal
(B) right marginal
38. Which of the following areas do NOT receive
(C) posterior interventricular
visceral afferent fibers?
(D) AV nodal
(A) bronchial mucosa (E) circumflex
(B) bronchial muscles
(C) interalveolar connective tissue 43. Which of the following is NOT contained in the
(D) pulmonary arteries and veins superior mediastinum?
(E) diaphragm (A) thymus
(B) great vessels and their branches
39. Sympathetic nerves do NOT contribute to which
(C) azygos and hemiazygos veins
of the following?
(D) trachea
(A) diaphragm (E) esophagus
(B) bronchial muscle
(C) pulmonary vessels 44. The thymus is supplied by which of the fol-
(D) alveolar glands of the bronchial tree lowing?
(E) sweat glands of the chest (A) anterior intercostal branches of the inter-
nal thoracic artery
40. Which of the following is correct? (B) brachiocephalic artery
(A) While a person is supine, the arch of the (C) posterior intercostal arteries
aorta lies superior to the transverse tho- (D) left common carotid artery
racic plane. (E) pericardiacophrenic arteries
(B) While a person is supine, the bifurcation
of the trachea lies at the level of the 45. Which of the following is NOT a branch of the
xiphisternal junction and T9. aorta in the thorax?
(C) While a person is supine, the central ten-
(A) posterior intercostal arteries
don of the diaphragm is transected by the
transverse thoracic plane. (B) inferior phrenic artery
(D) While a person is standing, the arch of the (C) bronchial arteries
aorta lies inferior to the transverse tho- (D) esophageal arteries
racic plane. (E) superior phrenic arteries
(E) While a person is standing, the tracheal
bifurcation is transected by the transverse 46. The posterior mediastinum does NOT include
thoracic plane. which of the following?
(A) prevertebral muscles
41. The pericardium does NOT receive blood sup-
(B) thoracic aorta
ply from which of the following?
(C) thoracic duct
(A) pericardiacophrenic artery (D) thoracic sympathetic trunks
(B) musculophrenic artery (E) thoracic splanchnic nerves
(C) bronchial arteries
(D) esophageal arteries
(E) pectoral arteries
36 3: The Thorax

47. Which of the following may compress the (C) ganglion impar
esophagus? (D) superior cervical ganglia
(A) aortic arch (E) inferior cervical ganglia
(B) right main bronchus
53. Which of the following does NOT contain syn-
(C) left vagus
apses for the sympathetic nervous system?
(D) right brachiocephalic vein
(E) brachiocephalic trunk (A) prevertebral ganglia
(B) collateral ganglia
48. The azygos vein receives blood from which of (C) aortic plexus
the following? (D) celiac ganglia
(A) posterior intercostal veins (E) cardiac plexus
(B) anterior intercostal veins
54. Which of the following does NOT occur in the
(C) left internal jugular vein
sympathetic trunk?
(D) anterior jugular vein
(E) lateral thoracic vein (A) Presynaptic neurons synapse with post-
synaptic neurons immediately.
49. The hemiazygos vein does NOT receive blood (B) Fibers ascend and synapse.
from which of the following? (C) Fibers descend and synapse.
(A) left subcostal vein (D) Presynaptic fibers innervate immediately
surrounding blood vessels.
(B) ascending lumbar veins
(E) Fibers pass, without synapsing, into a
(C) inferior three posterior intercostal veins
splanchnic nerve.
(D) superior phrenic veins
(E) small mediastinal veins 55. Parasympathetic fibers stimulate secretion by
all glands except which of the following?
50. The accessory hemiazygos vein parallels the
vertebral column along which vertebral levels? (A) sweat glands
(B) lacrimal glands
(A) T1–4
(C) salivary glands
(B) T2–6
(D) nasal glands
(C) T5–8
(E) palatine glands
(D) T8–12
(E) L1–4 56. Vasoconstriction is sympathetically stimulated
with the exception of which arteries?
51. Which of the following is NOT contained in the
anterior mediastinum? (A) bronchial arteries
(B) coronary arteries
(A) fat
(C) esophageal arteries
(B) sternopericardial ligaments
(D) adrenal arteries
(C) branches of internal thoracic vessels
(E) renal arteries
(D) lymphatic vessels
(E) heart 57. Which of the following is a result of sympathetic
stimulation in the heart?
52. Which of the following is NOT part of the sym-
pathetic trunks? (A) decrease in the rate and strength of con-
traction
(A) prevertebral ganglia
(B) paravertebral ganglia
 Questions: 47–66 37

(B) inhibition of the effect of parasympathetic (A) cervical splanchnic nerves

system on coronary arteries, allowing (B) upper thoracic splanchnic nerves
them to dilate (C) lower thoracic splanchnic nerves
(C) production of atrial natriuretic factor (D) lumbar splanchnic nerves
(D) opening and closing of mitral valve (E) pelvic splanchnic nerves
(E) glandular secretion
63. The greater splanchnic nerve originates from
58. Which of the following is NOT a result of sym- which vertebral levels?
pathetic stimulation in the lungs?
(A) T1–4
(A) inhibition of parasympathetic system (B) T5–9
(B) bronchodilation (C) T10–11
(C) reduced secretion (D) T12
(D) maximum air exchange (E) L1–4
(E) surfactant production
64. The fibers of the greater splanchnic nerve syn-
59. Sympathetic fibers of the heart are accompanied apse in which ganglion?
by visceral afferent fibers that convey which type
of sensation? (A) celiac ganglion
(B) inferior mesenteric ganglion
(A) reflex
(C) paravertebral ganglia
(B) pain
(D) pulmonary plexus
(C) rate information
(E) adrenal cortex
(D) contraction feedback
(E) pressure sensation 65. The level of the domes of the diaphragm varies
according to various situations. Which of the fol-
60. The pulmonary plexus contains which of the lowing does NOT affect the level of the domes of
following? the diaphragm?
(A) cell bodies of visceral afferent fibers (A) phase of respiration
(B) cell bodies of postsynaptic sympathetic (B) posture
fibers (C) size of distention of abdominal viscera
(C) cell bodies of postsynaptic parasympa- (D) degree of distention of abdominal viscera
thetic fibers
(E) heart contractions
(D) somatic efferent fibers passing on to
diaphragm 66. Which of the following passes through the
(E) somatic afferent fibers from diaphragm caval opening of the diaphragm?

61. Visceral afferent fibers of the tenth cranial nerve (A) terminal branches of the right phrenic
are NOT distributed to which of the following? nerve
(B) thoracic duct
(A) bronchial mucosa
(C) greater thoracic splanchnic nerve
(B) bronchial muscles
(D) sympathetic trunk
(C) interalveolar connective tissue
(E) vagus
(D) pulmonary arteries and veins
(E) diaphragm

62. The greater, lesser, and least splanchnic nerves

are examples of what type of splanchnic nerves?
38 3: The Thorax

67. Which of the following does NOT pass through (C) mesoderm
the esophageal hiatus of the diaphragm? (D) ectoderm
(A) esophagus (E) notochord invagination
(B) branches of the left gastric vessels
73. Which of the following is NOT derived from
(C) lymphatic vessels
the original aortic arch system?
(D) vagal trunks
(E) lesser thoracic splanchnic nerve (A) carotid arteries
(B) arch of the aorta
68. Which of the following passes through the aortic (C) pulmonary artery
hiatus of the diaphragm? (D) right subclavian artery
(A) least thoracic splanchnic nerve (E) coronary arteries
(B) thoracic duct
74. The respiratory system is an outgrowth of what?
(C) branches of right gastric vessels
(D) sympathetic trunks (A) middle mediastinum
(E) terminal branches of the left phrenic nerve (B) ventral wall of foregut
(C) anterior abdominal wall
69. Ribs are formed from which of the following? (D) aortic arches
(A) sclerotome portion of paraxial mesoderm (E) pharyngeal arches
(B) lateral plate mesoderm
75. Which of the following correctly describes the
(C) ectodermal invagination
development of the lungs, in order?
(D) endodermal migration
(E) neural crest cell transitory development (A) pseudoglandular period, canalicular
period, terminal sac period, alveolar
70. The pleuropericardial membranes develop into period
what structures of the adult? (B) canalicular period, pseudoglandular
period, terminal sac period, alveolar
(A) fibrous pericardium period
(B) diaphragm (C) alveolar period, pseudoglandular period,
(C) parietal pleura canalicular period, terminal sac period
(D) visceral pleura (D) pseudoglandular period, terminal sac
(E) the membranes degenerate completely period, alveolar period, canalicular period
(E) terminal sac period, alveolar period,
71. The diaphragm is NOT derived from which of pseudoglandular period, canalicular
the following? period
(A) septum transversum
(B) pleuroperitoneal membranes
(C) muscular components from lateral and
dorsal body walls
(D) mesentery of esophagus
(E) anterior thoracic fascia

72. The entire cardiovascular system is derived from

which of the following?
(A) neural crest cells
(B) endoderm
DIRECTIONS (Questions 76 through 85): Identify the anatomical features indicated on the art below.

DIRECTIONS (Questions 86 through 90): Identify the anatomical features indicated on the art below.
40 3: The Thorax

DIRECTIONS (Questions 91 through 95): Identify the anatomical features indicated on the art below.
 Answers and Explanations

1. (E) The tubercle has a smooth articular part for intervertebral disc between T4 and T5 vertebrae
articulating with the corresponding transverse (Moore, p 66).
process of the vertebra and a rough nonarticu-
lar part for attachment of the costotransverse 7. (C) The pleural cavity, the potential space be-
ligament (Moore, p 63). tween the layers of pleura, contains a capillary
layer of serous pleural fluid. It provides the lubri-
2. (A) The surface of the 1st rib has two trans- cation and cohesion that keep the lung surface in
versely directed shallow grooves, anterior and contact with the thoracic wall (Moore, p 95).
posterior to the scalene tubercle, for the subcla-
vian vein and the subclavian artery respectively 8. (B) The parietal pleura includes costal, mediasti-
(Moore, pp 63–64). nal, diaphragmatic, and cervical parts (Moore,
pp 95–96).
3. (C) Between the breast and deep pectoral fas-
cia is a loose connective tissue plane or poten- 9. (D) The right lung has three lobes, the left two.
tial space known as the retromammary space The right lung is larger and heavier than the left,
(Moore, p 73). but it is shorter and wider, because the right
dome of the diaphragm is higher and the heart
4. (E) Because the axillary lymph nodes are the and pericardium bulge more to the left. The ante-
most common site of metastases from a breast rior margin of the right lung is relatively straight,
cancer, enlargement of the palpable nodes in a whereas the margin of the left lung has a deep
woman suggests the possibility of breast cancer cardiac notch. The cardiac notch primarily in-
and may be key to early detection. However, the dents the anteroinferior aspect of the superior
absence of enlarged axillary nodes is no guaran- lobe of the left lung. This often creates a thin,
tee that metastasis from a breast cancer has not tongue-like process of the superior lobe, called
occurred, because the malignant cells may have the lingula (Moore, p 101).
passed to other nodes, such as the infraclavicu-
lar and supraclavicular lymph nodes (Moore, 10. (A) The right main bronchus is wider and
p 78). shorter, running more vertically than the left
main bronchus as it passes directly to the hilum
5. (B) After descending past the 2nd costal carti- of the lung. The left main bronchus passes infer-
lage, the internal thoracic artery runs anterior to olaterally, inferior to the arch of the aorta and
the transversus thoracis muscle. It ends in the anterior to the esophagus and thoracic aorta, to
6th intercostal space, where it divides into the reach the hilum of the lung (Moore, p 104).
superior epigastric and musculophrenic arteries
(Moore, p 91). 11. (C) A bronchopulmonary segment is a pyramid-
shaped segment of the lung with its apex facing
6. (A) The sternal angle is located opposite the the lung root and its base at the pleural surface.
2nd pair of costal cartilages at the level of the 4th It is the largest subdivision of a lobe and is sepa-

41
42 3: The Thorax

rated from adjacent segments by connective tis- 20. (D) The tricuspid valve guards the right AV
sue. It is surgically resectable (Moore, p 104). orifice. The bases of the valve cusps are attached
to the fibrous ring around the orifice. Chordae
12. (D) The middle mediastinum contains the heart tendineae attach to the free edges and ventricu-
(Moore, p 114). lar surfaces of the anterior, posterior, and septal
cusps (Moore, p 127).
13. (E) The right border of the heart is formed by
the right atrium; it receives venous blood from 21. (E) The fibrous pericardium is attached to the
the SVC, IVC, and coronary sinus. It contains posterior surface of the sternum by the sterno-
both the crista terminalis and the limbus fossae pericardial ligaments (Moore, p 116).
ovalis. The interior of the ventricles contains
irregular muscular elevations called trabeculae 22. (A) The coronary sinus receives the great and
carneae (Moore, pp 125–127). small cardiac veins, middle cardiac vein, left pos-
terior ventricular vein, and left marginal vein.
14. (E) The interventricular septum is composed The anterior cardiac veins begin over the ante-
of membranous and muscular parts. The conus rior surface of the right ventricle and cross over
arteriosus leads into the pulmonary trunk. A the coronary groove to end directly in the right
thick muscular ridge, the supraventricular crest, atrium (Moore, pp 136–137).
separates the ridged muscular wall of the inflow
part of the right ventricle from the smooth wall 23. (E) The SA node is located anterolaterally just
of the conus arteriosus or outflow part (Moore, deep to the epicardium at the junction of the SVC
p 127). and right atrium, near the superior end of the
sulcus terminalis. The SA node, a small collec-
15. (C) Typically, the right coronary artery supplies tion of nodal tissue and specialized cardiac mus-
the right atrium, most of the right ventricle, part cle fibers, is the pacemaker of the heart. The SA
of the left ventricle, part of the AV septum, and node is supplied by a branch of the right coro-
the SA node in approximately 60% of people and nary artery in about 60% of individuals (Moore,
the AV node in approximately 80% of people p 137).
(Moore, p 135).
24. (E) The interior of the left ventricle includes
16. (D) The alveolus is the basic unit of gas exchange anterior and posterior papillary muscles (Moore,
in the lung (Moore, p 104). p 131).

17. (B) The pulmonary veins, two on each side, 25. (A) The interior of the left atrium has a large-
carry well-oxygenated (“arterial”) blood from walled part and a smaller muscular auricle con-
the lungs to the left atrium of the heart (Moore, taining pectinate muscles (Moore, p 129).
p 107).
26. (E) The chest consists of 12 pairs of ribs, the ster-
18. (C) The posterior mediastinum contains the tho- num, costal cartilages, and 12 thoracic vertebrae
racic aorta, thoracic duct, azygos and hemiazy- (Moore, p 60).
gos veins, esophagus, and thoracic sympathetic
trunks (Moore, pp 150–151). 27. (C) Chest pain may result from cardiac disease,
pulmonary disease, intestinal problems, gall-
19. (C) The dorsal and ventral rami are both motor bladder disorders, and musculoskeletal dis-
and sensory. The cutaneous branches include orders (Moore, p 61).
anterior, lateral, and posterior branches. The dor-
sal root is sensory and the ventral root is motor. 28. (D) Thoracic vertebrae have costal facets or
The spinal nerves supply a band-like skin area demifacets on their bodies, costal facets on the
known as a dermatome (Moore, p 85). transverse processes (for the first 9 or 10 thoracic
vertebrae), and long spinous processes (Moore,
p 65).
 Answers and Explanations: 12–51 43

29. (A) The sternoclavicular joint is a saddle-type 42. (E) The branches of the right coronary artery
synovial joint (Moore, p 69). include the SA nodal, right marginal, posterior
interventricular, and AV nodal arteries (Moore,
30. (C) The mammary glands are modified sweat p 134).
glands (Moore, p 74).
43. (C) The superior mediastinum contains the thy-
31. (E) The breast is supplied by the internal tho- mus, great vessels and their branches, vagus
racic, lateral thoracic, thoracoacromial, and pos- nerves, phrenic nerves, cardiac plexus, left recur-
terior intercostal arteries (Moore, p 75). rent laryngeal nerve, trachea, esophagus, thora-
cic duct, and prevertebral muscles (Moore, p 142).
32. (A) The levatores costarum are innervated by
the dorsal primary rami of C8–T11. (Moore, p 84). 44. (A) The thymus is supplied by the anterior
intercostal and anterior mediastinal branches of
33. (B) The serratus posterior inferior depresses the the internal thoracic artery (Moore, p 142).
ribs (Moore, p 84).
45. (B) Branches of the aorta in the thorax include
34. (A) The intercostobrachial nerve communicates the posterior intercostal, bronchial, esophageal,
with the medial brachial cutaneous nerve (Moore, and superior phrenic arteries (Moore, p 145).
p 87).
46. (A) The posterior mediastinum includes the
35. (A) The musculophrenic artery gives rise to thoracic aorta, thoracic duct, posterior mediasti-
anterior intercostal arteries for intercostal spaces nal lymph nodes, azygos and hemiazygos veins,
7–9 (Moore, p 88). esophagus, esophageal plexus, thoracic sympa-
thetic trunks, and thoracic splanchnic nerves
36. (C) Anterior and posterior intercostal arteries (Moore, pp 150–151).
pass between the internal and innermost inter-
costal muscles (Moore, p 88). 47. (A) The esophagus is compressed by the aortic
arch, left main bronchus, and diaphragm (Moore,
37. (D) The superior and inferior bronchopulmo- p 152).
nary segments of the superior lobe of the left lung
combine to form the lingula (Moore, p 106). 48. (A) The azygos vein receives blood from the
posterior intercostal veins, vertebral venous
38. (E) Visceral afferent fibers are distributed to plexuses, mediastinal veins, esophageal veins,
bronchial mucosa, bronchial muscles, interalve- and bronchial veins (Moore, p 155).
olar connective tissue, and pulmonary arteries
and veins (Moore, p 111). 49. (D) The hemiazygos vein receives blood from
the left subcostal vein, ascending lumbar veins,
39. (A) The diaphragm receives somatic efferent the inferior three posterior intercostal veins, infe-
and afferent innervation—not sympathetic in- rior esophageal veins, and small mediastinal
nervation (Moore, p 113). veins (Moore, p 155).

40. (A) While a person is supine, the arch of the 50. (C) The accessory hemiazygos descends on the
aorta lies superior to the transverse thoracic left side of the vertebral column from T5 through
plane (Moore, p 115). T8 (Moore, p 155).

41. (E) The pericardium receives blood supply from 51. (E) The anterior mediastinum contains fat, ster-
the pericardiacophrenic artery, musculophrenic nopericardial ligaments, branches of internal
artery, bronchial arteries, esophageal arteries, thoracic vessels, and lymphatic vessels (Moore,
superior phrenic arteries, and coronary arteries p 156).
(Moore, p 120).
44 3: The Thorax

52. (A) The sympathetic trunk contains the supe- receptors) and veins (as chemoreceptors) (Moore,
rior, middle, and inferior cervical ganglia; par- p 111).
avertebral ganglia; and the ganglion impar
(Moore, p 46). 62. (C) The greater, lesser, and least splanchnic
nerves are lower thoracic splanchnic nerves
53. (E) The cardiac plexus does not contain syn- (Moore, p 301).
apses for sympathetic fibers, as these fibers
have already synapsed in the sympathetic 63. (B) The greater thoracic splanchnic nerve orig-
trunk (Moore, p 150). inates from vertebral levels T5–9 (Moore, p 301).

54. (D) In the synaptic trunk, presynaptic neurons 64. (A) The fibers of the greater splanchnic nerve
synapse with postsynaptic neurons immedi- synapse in the celiac ganglion (Moore, p 302).
ately. Some fibers ascend and synapse, while
other fibers descend and synapse. Some fibers 65. (E) The level of the domes of the diaphragm
pass into a splanchnic nerve without synapsing varies according to phase of respiration, posture,
(Moore, p 46). and size and degree of distention of abdominal
viscera (Moore, p 289).
55. (A) With the exception of sweat glands, glan-
dular secretion is parasympathetically stimu- 66. (A) The inferior vena cava, terminal branches
lated (Moore, p 51). of the right phrenic nerve, and lymphatics pass
through the caval opening of the diaphragm
56. (B) With the exception of coronary arteries, (Moore, p 294).
vasoconstriction is sympathetically stimulated
(Moore, p 51). 67. (E) The esophagus, anterior and posterior vagal
trunks, esophageal branches of the left gastric
57. (B) Sympathetic stimulation of the heart in- vessels, and lymphatic vessels pass through the
creases the rate and strength of contraction and esophageal hiatus (Moore, p 294).
inhibits the effect of the parasympathetic sys-
tem on coronary arteries, allowing them to 68. (B) The aorta, thoracic duct, and azygos vein
dilate (Moore, p 51). (sometimes) pass through the aortic hiatus
(Moore, p 295).
58. (E) Sympathetic stimulation of the lungs results
in inhibition of the parasympathetic system, 69. (A) Ribs form from costal processes of thoracic
bronchodilation, reduced secretion, and maxi- vertebrae and thus are derived from the sclero-
mum air exchange (Moore, p 51). tome of paraxial medoderm (Sadler, p 184).

59. (B) Sympathetic fibers of the heart are accom- 70. (A) The pleuropericardial membranes develop
panied by visceral afferent fibers, which convey into the fibrous pericardium (Sadler, p 201).
pain information (Moore, p 52).
71. (E) The diaphragm is derived from the septum
60. (C) The pulmonary plexus contains cell bodies transversum and pleuroperitoneal membranes.
of postsynaptic parasympathetic fibers (Moore, Muscular components stem from lateral and
p 110). dorsal body walls and mesentery of the esoph-
agus (Sadler, p 206).
61. (E) Visceral afferent fibers of the tenth cranial
nerve are distributed to bronchial mucosa (for 72. (C) The entire cardiovascular system is derived
cough reflex), bronchial muscles (for stretch from mesoderm. (Sadler, p 256)
reception), interalveolar connective tissue (for
Hering-Breuer reflexes, limiting respiratory ex- 73. (E) The carotid arteries, arch of the aorta, pul-
cursions), and pulmonary arteries (as pressure monary artery, and right subclavian artery are
 Answers and Explanations: 52–95 45

derived from the original aortic arch system 83. ligamentum arteriosum
(Sadler, p 257).
84. left vagus nerve
74. (B) The respiratory system is an outgrowth of
the ventral wall of the foregut (Sadler, p 268) 85. left internal jugular vein

75. (A) The lungs develop in the following periods: 86. pulmonary arteries
pseudoglandular period, canalicular period, ter-
minal sac period, and alveolar period (Sadler, 87. aorta
p 266).
88. superior vena cava
76. inferior thyroid vein
89. left inferior pulmonary vein
77. right brachiocephalic vein
90. inferior vena cava
78. phrenic nerve and pericardiacophrenic vessels
91. manubrium of sternum
79. right pulmonary artery
92. oblique fissure
80. left auricle
93. costal cartilage
81. lingula
94. xiphoid process
82. left pulmonary vein
95. copula
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 CHAPTER 6

The Lower Limb

Questions

DIRECTIONS (Questions 1 through 100): Each of the (A) pecten pubis

numbered items or incomplete statements in this (B) pubic crest
section is followed by answers or by completions of (C) lunate surface
the statement. Select the ONE lettered answer or
(D) ala
completion that is BEST in each case.
(E) ramus
1. All of the following statements concerning the
femur are correct EXCEPT 5. A fracture of which of the following bones is
among the most troublesome and problematic
(A) It is the longest bone in the body. of all fractures?
(B) It is the heaviest bone in the body.
(A) tibia
(C) Its length is approximately a quarter of
(B) fibula
the person’s height.
(C) patella
(D) The distal end of the femur undergoes
ossification just before birth. (D) femoral neck
(E) Its average adult length is 36 inches. (E) medial malleolus

2. The adductor tubercle is located on which of 6. When it is said that an elderly person has a
the following bones? “broken hip,” the usual injury is a fracture of
which of the following structures?
(A) femur
(A) acetabulum
(B) tibia
(B) neck of the femur
(C) fibula
(C) pelvic rami
(D) ischium
(D) ischial tuberosity
(E) ilium
(E) ilium
3. The margin of the acetabulum is deficient infe-
riorly at which of the following structures? 7. The medial and lateral malleoli articulate with
which of the following bones?
(A) ischial tuberosity
(A) femur
(B) obturator foramen
(B) calcaneus
(C) linea aspera
(C) talus
(D) acetabular notch
(D) cuboid
(E) ischial spine
(E) fibula
4. A deficiency in the smooth articular surface of
the acetabulum is known as which of the fol-
lowing?

87
88 6: The Lower Limb

8. Which of the following bones is the most com- (C) crural fascia
mon site for a compound fracture? (D) fascia lata
(A) femur (E) plantar fascia
(B) tibia
14. Which of the following structures covers the
(C) fibula
saphenous opening in the fascia lata?
(D) ilium
(E) ischium (A) lateral intermuscular septum
(B) medial intermuscular septum
9. Which of the following bones is the largest and (C) crural fascia
strongest bone of the foot? (D) cribriform fascia
(A) talus (E) iliotibial tract
(B) calcaneus
15. Which of the following structures passes
(C) cuboid
through the saphenous opening?
(D) navicular
(E) lateral cuneiform (A) femoral artery
(B) femoral vein
10. The sustentaculum tali projects from the supe- (C) femoral nerve
rior surface of which of the following bones? (D) obturator nerve
(A) intermediate cuneiform (E) great saphenous vein
(B) talus
16. The small saphenous vein empties into which
(C) cuboid
of the following veins?
(D) navicular
(E) calcaneus (A) femoral
(B) tibial
11. Which of the following bones articulates with (C) peroneal
the fibula, tibia, calcaneus, and navicular? (D) popliteal
(A) talus (E) great saphenous
(B) lateral cuneiform
17. Which of the following statements correctly
(C) intermediate cuneiform
applies to the iliopsoas muscle?
(D) medial cuneiform
(E) cuboid (A) It is a flat quadrangular muscle.
(B) It is the chief flexor of the thigh.
12. Which of the following statements applies to (C) It is enclosed between two layers of
the 2nd metatarsal bone? fascia lata.
(A) It is the shortest. (D) It inserts into the iliotibial tract.
(B) It is the strongest. (E) It is located in the posterior compart-
ment of the thigh.
(C) It is the longest.
(D) Its base has a large tuberosity. 18. All of the following statements concerning the
(E) Its base articulates with the navicular sartorius muscle are correct EXCEPT
bone.
(A) It is known as the “tailor’s muscle.”
13. The deep fascia of the thigh is known as which (B) It is the longest muscle in the body.
of the following? (C) It acts across two joints.
(A) Scarpa’s fascia (D) It extends the hip.
(B) Colles’ fascia
 Questions: 8–25 89

(E) It is located in the anterior compartment (C) It has adductor and hamstring parts.
of the thigh. (D) It is a composite, triangular muscle with
two parts that differ in nerve supply.
19. All of the following statements concerning the (E) Its main action is to adduct the thigh.
quadriceps femoris are correct EXCEPT
(A) Collectively constitutes the largest and 23. Which of the following statements correctly
most powerful muscle group in the applies to the adductor hiatus?
body. (A) It is an opening in the aponeurotic distal
(B) It is the great extensor of the thigh. attachment of the adductor longus.
(C) It inserts onto the tibia. (B) It transmits the femoral nerve, artery and
(D) It forms the main bulk of the anterior vein.
thigh muscles. (C) The opening is located just inferior to the
(E) The patella provides additional leverage adductor tubercle of the femur.
for the quadriceps. (D) It extends from the adductor canal in the
thigh to the popliteal fossa.
20. Which of the following statements concerning (E) The great saphenous vein passes
the components of the quadriceps femoris is through the adductor hiatus.
correct?
(A) The rectus femoris is considered the 24. All of the following statements concerning the
“kicking muscle.” femoral triangle are correct EXCEPT
(B) The vastus lateralis is the smallest com- (A) Its superior border is the inguinal
ponent of the quadriceps. ligament.
(C) The articularis genus is a derivative of (B) Its lateral border is the sartorius.
the vastus lateralis. (C) It is bisected by the femoral artery and
(D) The rectus femoris lies deep to the vastus vein.
intermedius. (D) The saphenous nerve passes through the
(E) The vastus intermedius is the chief flexor femoral triangle.
of the thigh. (E) Its medial border is the adductor
magnus.
21. Which of the following statements concerning
the gracilis muscle is correct? 25. All of the following statements concerning the
(A) It passes through the lesser sciatic femoral sheath are correct EXCEPT
foramen. (A) It extends 3 to 4 cm inferior the inguinal
(B) It crosses the knee joint. ligament.
(C) It lies deep to the pectineus and adductor (B) It is formed by an inferior prolongation
longus muscles. of transversalis and iliopsoas fascia.
(D) It is located in the anterior compartment (C) It encloses the femoral nerve.
of the thigh. (D) Its medial wall is pierced by the great
(E) It is a short, fan-shaped muscle. saphenous vein and lymphatic vessels.
(E) It ends by becoming continuous with the
22. All of the following statements concerning the adventitia of the femoral vessels.
adductor magnus are correct EXCEPT
(A) It is the largest muscle in the adductor
group.
(B) It is located in the posterior compart-
ment of the thigh.
90 6: The Lower Limb

26. All of the following statements concerning the (D) It exits the adductor canal through the
femoral canal are correct EXCEPT adductor hiatus.
(A) It contains the femoral nerve. (E) It passes through the obturator foramen.
(B) It is the medial compartment of the
30. Which of the following arteries supplies most
femoral sheath.
of the blood to the head and neck of the femur?
(C) It allows the femoral vein to expand
when venous return from the lower limb (A) medial circumflex femoral
is increased. (B) obturator
(D) It extends distally to the level of the (C) lateral circumflex femoral
proximal edge of the saphenous (D) external pudendal
opening. (E) deep circumflex iliac
(E) It contains loose connective tissue, fat, a
few lymphatic vessels, and sometimes a 31. All of the following statements concerning the
deep inguinal lymph node (Cloquet’s adductor canal are correct EXCEPT
node).
(A) It is approximately 15 cm long.
27. All of the following statements concerning the (B) It extends from the apex of the femoral
femoral ring are correct EXCEPT triangle to the adductor hiatus.
(C) It contains the saphenous nerve.
(A) The lacunar ligament forms its medial
boundary. (D) Is is bounded posteriorly by the sartorius
muscle.
(B) The anterior boundary is formed by the
inguinal ligament. (E) It contains the femoral artery and vein.
(C) The femoral artery forms its lateral
32. Which of the following statements concerning
boundary.
the lesser sciatic foramen is correct?
(D) Its proximal end is closed by extraperi-
toneal fatty tissue that forms the femoral (A) It is the passageway for structures enter-
septum. ing or leaving the pelvis.
(E) It lies anterior to the pectineus muscle. (B) It is the passageway for structures enter-
ing or leaving the perineum.
28. Which of the following statements concerning (C) All lower limb arteries and nerves leave
the femoral artery is correct? the pelvis through this foramen.
(A) It enters the femoral canal. (D) The femoral nerve passes through the
lesser sciatic foramen.
(B)It enters the adductor canal.
(E) The obturator nerve enters the adduc-
(C) It passes dorsal to the inguinal ligament.
tor compartment via the lesser sciatic
(D) It gives rise to the inferior epigastric foramen.
artery.
(E) It passes through the obturator canal. 33. All of the following structures pass through
the greater sciatic foramen EXCEPT
29. Which of the following statements concerning
the deep artery of the thigh is correct? (A) piriformis muscle
(B) sciatic nerve
(A) It is the largest branch of the femoral
(C) superior gluteal vessels
artery.
(D) inferior gluteal vessels
(B) It passes through the adductor canal.
(E) pudendal nerve
(C) It gives rise to the deep circumflex iliac
branch.
34. All of the following statements concerning the
gluteus maximus are correct EXCEPT
 Questions: 26–42 91

(A) It is used very little during casual 39. All of the following muscles are lateral rota-
walking. tors of the thigh EXCEPT
(B) It assists in making the knee stable. (A) quadratus femoris
(C) It is used very little in climbing upstairs. (B) obturator internus
(D) It is used in running. (C) obturator externus
(E) It is used when rising from the sitting (D) gluteus medius
position.
(E) inferior gemellus
35. The ischial bursa separates the inferior part of
40. All of the following statements concerning the
which of the following muscles from the ischial
inferior clunial nerves are correct EXCEPT
tuberosity?
(A) They are gluteal branches of the poste-
(A) gluteus maximus
rior cutaneous nerve of the thigh.
(B) gluteus minimus
(B) These nerves curl around the inferior
(C) gluteus medius border of the gluteus maximus.
(D) piriformis (C) They are derivatives of the sacral plexus
(E) obturator internus S1–S3.
(D) They supply the inferior half of the
36. All of the following statements concerning buttock.
the gluteus medius and minimus are correct
(E) They are dorsal primary rami.
EXCEPT
(A) They all have the same nerve supply. 41. All of the following nerves are ventral primary
(B) They have the same actions. rami EXCEPT
(C) They are supplied by the same blood (A) posterior cutaneous nerve of the thigh
vessels. (B) inferior gluteal
(D) They abduct the thigh and rotate it (C) pudendal
laterally.
(D) sciatic
(E) They are largely responsible for prevent-
(E) superior cluneal
ing sagging of the unsupported side of
the pelvis during walking.
42. All of the following statements concerning the
sciatic nerve are correct EXCEPT
37. The positive Trendelenburg sign is associated
with injuries to which of the following? (A) It is the largest nerve in the body.
(A) quadriceps femoris (B)It is really two nerves.
(B) adductor muscles (C) It supplies all leg and foot muscles.
(C) abductors of the thigh (D) It receives its blood supply from the
superior gluteal nerve.
(D) hamstring muscles
(E) It passes inferolaterally under cover of
(E) piriformis muscle
the gluteus maximus, midway between
the greater trochanter and the ischial
38. Which of the following muscles is part of the
tuberosity.
triceps coxae?
(A) obturator externus
(B) gemelli muscles
(C) piriformis
(D) gluteus medius
(E) quadratus femoris
92 6: The Lower Limb

43. The piriformis syndrome involves which of 48. A line drawn from the anterior superior iliac
the following nerves? spine to the ischial tuberosity (Nelaton’s line),
passing over the lateral aspect of the hip,
(A) sciatic
normally passes over which of the following
(B) obturator structures?
(C) femoral
(A) sciatic nerve
(D) ilioinguinal
(B) ischial spine
(E) inferior gluteal
(C) obturator canal
44. All of the following statements concerning the (D) pudendal nerve
internal pudendal artery are correct EXCEPT (E) greater trochanter
(A) It does not supply any structures in the
49. All of the following statements concerning the
gluteal region.
popliteal fossa are correct EXCEPT
(B) It passes to the perineum with the
pudendal nerve. (A) The biceps femoris forms the superolat-
(C) It supplies the external genitalia. eral border.
(D) It crosses the ischial tuberosity. (B) The semimembranosus forms the super-
omedial border.
(E) It re-enters the pelvis through the lesser
sciatic foramen. (C) It contains both the tibial and common
fibular nerves.
45. Which of the following muscles is located in (D) The lateral and medial heads of the gas-
the posterior aspect of the thigh? trocnemius form the inferolateral and
inferomedial borders.
(A) semitendinosus
(E) It contains the great saphenous vein.
(B) gluteus maximus
(C) piriformis 50. The floor of the popliteal fossa includes which
(D) internal obturator of the following structures?
(E) superior gemellus (A) oblique popliteal ligament
(B) patella
46. All of the following statements concerning the
hamstring muscles are correct EXCEPT (C) lateral meniscus
(D) anterior cruciate ligament
(A) They are extensors of the thigh.
(E) posterior cruciate ligament
(B) They are flexors of leg.
(C) A person with paralyzed hamstrings 51. The lateral sural nerve is a branch of which of
tends to fall backwards. the following nerves?
(D) Most take origin from the ischial
(A) femoral
tuberosity.
(B) common fibular
(E) Most are innervated by the tibial divi-
sion of the sciatic nerve. (C) tibial
(D) obturator
47. The innervation for the short head of the biceps (E) posterior cutaneous nerve of the thigh
is provided by which of the following nerves?
52. Which of the following muscles dorsiflexes the
(A) obturator
ankle?
(B) femoral
(C) tibial division of the sciatic (A) extensor digitorum longus
(D) fibular division of the sciatic (B) fibularis longus
(E) sartorius (C) soleus
 Questions: 43–62 93

(D) plantaris (D) extensor digitorum longus

(E) gastrocnemius (E) extensor hallucis longus

53. Muscles that evert the foot include which of the 58. Which of the following muscles is the power-
following muscles? ful “push-off” muscle?
(A) gastrocnemius (A) gastrocnemius
(B) soleus (B) soleus
(C) tibialis posterior (C) tibialis anterior
(D) fibularis brevis (D) flexor hallucis longus
(E) flexor digitorum longus (E) plantaris

54. All of the following statements correctly apply 59. Which of the following muscles contract to
to the inferior extensor retinaculum EXCEPT assist the posterior cruciate ligament in pre-
venting anterior displacement of the femur on
(A) It passes from the fibula to the tibia prox-
the tibia?
imal to the malleoli.
(B) It is a Y-shaped band of deep fascia. (A) plantaris
(C) It attaches laterally to the anterosuperior (B) popliteus
surface of the calcaneus. (C) soleus
(D) It forms a strong loop around the ten- (D) gastrocnemius
dons of the fibularis tertius. (E) tibialis posterior
(E) It forms a strong loop around the ten-
dons of the extensor digitorum longus. 60. Which of following muscles is included in the
triceps surae?
55. Which of the following muscles is the strongest
(A) gastrocnemius
dorsiflexor and invertor of the foot?
(B) tibialis anterior
(A) extensor digitorum longus (C) tibialis posterior
(B) tibialis anterior (D) popliteus
(C) fibularis tertius (E) fibularis brevis
(D) extensor hallucis longus
(E) flexor hallucis longus 61. The lateral compartment of the foot contains
which of the following muscles?
56. All of the following muscles are located in the
(A) abductor digiti minimi brevis
deep muscle group of the posterior compart-
ment EXCEPT (B) flexor hallucis brevis
(C) quadratus plantae
(A) flexor digitorum longus
(D) flexor hallucis longus
(B) popliteus
(E) abductor hallucis
(C) plantaris
(D) flexor hallucis longus 62. The central compartment of the foot contains
(E) tibialis posterior all of the following muscles EXCEPT
(A) flexor digitorum brevis
57. Which of the following muscles is a flexor of
the knee joint? (B) flexor digitorum longus
(C) quadratus plantae
(A) popliteus
(D) abductor hallucis
(B) tibialis anterior
(E) lumbricals
(C) fibularis longus
94 6: The Lower Limb

63. The medial plantar nerve is a terminal branch (C) It contains a small nerve.
of which of the following nerves? (D) Usually it contains a small artery.
(A) femoral (E) Its wide end attaches to the margins of
(B) tibial the acetabular notch and the transverse
ligament.
(C) fibular
(D) obturator 68. Which of the following arteries provides the
(E) sural main blood supply for the hip joint?

64. All of the following statements concerning the (A) obturator

saphenous nerve are correct EXCEPT (B) medial circumflex
(C) lateral circumflex
(A) It is the largest cutaneous branch of the
femoral nerve. (D) common iliac
(B) It passes anterior to the medial malleolus (E) internal iliac
to the dorsum of the foot.
69. Which of the following muscles is the most
(C) It supplies skin along the medial side of
important muscle in stabilizing the knee?
the foot.
(D) It supplies skin on the anterior and (A) biceps femoris
medial side of the leg. (B) adductor magnus
(E) It innervates the muscles of the foot in (C) obturator internus
the medial compartment of the foot. (D) quadriceps femoris
(E) piriformis
65. Which of the following ligaments prevents
hyperextension of the hip joint during stand- 70. Which of the following muscles passes out of
ing? the knee joint to reach the tibia?
(A) iliofemoral (A) plantaris
(B) ischiofemoral (B) popliteus
(C) pubofemoral (C) sartorius
(D) ligament of head of femur (D) gracilis
(E) transverse acetabular (E) tibialis anterior

66. A synovial protrusion beyond the free margin 71. All of the following statements concerning the
of the fibrous capsule onto the posterior aspect fibular collateral ligament are correct EXCEPT
of the femoral neck forms a bursa for which of
these muscle tendons? (A) It splits the tendon of the biceps femoris.
(B) It is superficial to the tendon of the
(A) piriformis
popliteus.
(B) obturator internus
(C) It is connected to the lateral meniscus.
(C) obturator externus
(D) It is rounded and cordlike.
(D) superior gemellus
(E) It extends from the lateral epicondyle of
(E) quadratus femoris the femur to the head of the fibula.

67. All of the following statements concerning the 72. Which of the following statements concerning
ligament of the head of the femur are correct the tibial collateral ligament is correct?
EXCEPT
(A) It is attached to the lateral meniscus.
(A) It is a weak ligament.
(B) It is stronger than the fibular collateral
(B) It is of little importance in strengthening ligament.
the hip.
 Questions: 63–79 95

(C) It is less frequently damaged than the (C) They are wedge-shaped in transverse
fibular collateral ligament. section.
(D) The tibial collateral ligament and medial (D) Their external margins attach to the
meniscus are commonly torn during fibrous capsule of the knee joint.
contact sports such as football. (E) The transverse ligament of the knee joins
(E) It is an expansion of the tendon of the the posterior edges of the menisci.
adductor magnus.
77. Which of the following statements correctly
73. The oblique popliteal ligament is an expan- applies to the lateral meniscus?
sion of the tendon of which of the following
(A) It is larger and less movable than the
muscles?
medial meniscus.
(A) popliteus (B) It is in contact with the fibular collateral
(B) plantaris ligament.
(C) adductor magnus (C) It is attached to the posterior cruciate lig-
(D) semimembranosus ament by the posterior meniscofemoral
(E) gastrocnemius ligament.
(D) It adheres to the deep surface of the tib-
74. All of the following ligaments of the knee are ial collateral ligament.
intra-articular EXCEPT (E) It acts like a shock absorber.
(A) anterior cruciate
78. Which of the following genicular branches sup-
(B) lateral meniscus plies the cruciate ligaments?
(C) patellar
(A) femoral
(D) posterior cruciate
(B) popliteal
(E) medial meniscus
(C) anterior recurrent branches of the ante-
75. Which of the following statements concerning rior tibial recurrent
the anterior cruciate ligament is correct? (D) circumflex fibular
(E) posterior recurrent branches of the ante-
(A) It is the stronger of the two cruciate liga-
rior tibial recurrent
ments.
(B) It has a relatively poor blood supply. 79. Which of the following three ligaments are
(C) It is the main stabilizing factor for the damaged in the “unhappy triad” of knee in-
femur when one is walking downhill. juries?
(D) It tightens during flexion of the knee
(A) ACL, tibial collateral, and medial
joint, preventing anterior displacement
meniscus
of the tibia on the femur.
(B) PCL, fibular collateral, and lateral
(E) It attaches to the anterior part of the lat-
meniscus
eral surface of the medial condyle of the
femur. (C) ACL, fibular collateral, and medial
meniscus
76. All of the following statements concerning the (D) PCL, tibial collateral, and lateral
menisci of the knee joint are correct EXCEPT meniscus
(E) ACL, tibial collateral, and lateral
(A) They are thicker at their external
meniscus
margins.
(B) They taper to thin, unattached edges in
the interior of the joint.
96 6: The Lower Limb

80. Pain on lateral rotation of the tibia on the femur (C) The calcaneus is the keystone of this arch.
indicates damage to which of the following (D) The tibialis anterior helps strengthen this
structures? arch.
(A) anterior cruciate ligament (E) The fibularis longus tendon also supports
(B) posterior cruciate ligament this arch.
(C) lateral meniscus
85. Which of the following conditions is associ-
(D) medial meniscus ated with lateral deviation of the great toe?
(E) posterior meniscofemoral ligament
(A) hallux valgus
81. All of the following ligaments reinforce the (B) hammer toe
fibrous capsule on the medial side of the ankle (C) claw toe
EXCEPT (D) pes planus
(A) tibiocalcaneal (E) club foot
(B) posterior tibiotalar
86. All of the following statements concerning the
(C) anterior tibiotalar
transverse tarsal joint are correct EXCEPT
(D) tibionavicular
(E) calcaneofibular (A) It occurs where the talus rests on and
articulates with the calcaneus.
82. Which of the following groups of muscles pro- (B) It is formed by the combined talonavicu-
duce dorsiflexion of the ankle? lar part of the talocalcaneonavicular and
calcaneocuboid joints.
(A) anterior compartment of the leg
(C) Transection across this joint is a standard
(B) posterior compartment of the leg method for surgical amputation of the
(C) medial compartment of the foot foot.
(D) lateral compartment of the leg (D) It is two separate joints aligned trans-
(E) lateral compartment of the foot versely.
(E) Dorsiflexion and plantarflexion of the
83. All of the following statements concerning the foot are the main movements involving
plantar calcaneonavicular ligament are correct this joint.
EXCEPT
(A) It extends from the sustentaculum tali to 87. Which of the of the following areas is involved
the navicular. in tibial nerve entrapment?
(B) It is also known as the spring ligament. (A) medial malleolus to the calcaneus
(C) It lies deep to the plantar aponeurosis. (B) lateral malleolus to the navicular bone
(D) It plays an important role in maintaining (C) medial malleolus to the calcaneal tendon
the longitudinal arch of the foot. (D) lateral malleolus to the fibularis brevis
(E) It forms a tunnel for the tendon of the (E) long plantar ligament to the tendon of
fibularis longus. the fibularis longus

84. All of the following statements concerning the 88. Which of the following major joints is the most
medial longitudinal arch of the foot are correct frequently injured?
EXCEPT
(A) shoulder
(A) It is higher and more important than the (B) elbow
lateral longitudinal arch.
(C) hip
(B) It is composed of the calcaneus, talus,
(D) knee
navicular, cuneiforms, and three
metatarsals. (E) ankle
 Questions: 80–98 97

89. Which of the following statements correctly 94. Which of the following muscles is the strongest
applies in Pott’s fracture-dislocation? flexor of the hip joint?
(A) The foot is forcibly dorsiflexed. (A) semitendinosus
(B) The foot is forcibly plantar flexed. (B) iliopsoas
(C) The foot is forcibly inverted. (C) gluteus medius
(D) The foot is forcibly everted. (D) gracilis
(E) The calcaneus is usually fractured. (E) pectineus

90. The grip of the malleoli on the trochlea is 95. All of the following muscles are lateral rota-
strongest during which of the following move- tors of the hip joint EXCEPT
ments of the ankle?
(A) obturator externus
(A) plantarflexion (B) superior gemellus
(B) dorsiflexion (C) piriformis
(C) eversion (D) gluteus minimus
(D) inversion (E) quadratus femoris
(E) lateral rotation
96. Which of the following arteries is usually eval-
91. Which of the following statements correctly uated during a physical examination of the
applies to genu valgum? peripheral vascular system?
(A) The tibia is diverted medially. (A) lateral plantar
(B) The tibia is diverted laterally. (B) dorsalis pedis
(C) The medial side of the knee takes all the (C) popliteal
pressure. (D) fibular
(D) This deformity causes wear and tear of (E) posterior tibial
the medial meniscus.
(E) This deformity does not influence 97. The tendon of the biceps femoris and the neck
weight distribution. of the fibula may be used as a guide for locat-
ing which of the following nerves?
92. Which of the following knee support struc-
(A) saphenous
tures is considered to be the most important in
the stabilization of the joint? (B) sural
(C) common fibular
(A) lateral and medial menisci
(D) medial plantar
(B) anterior and posterior cruciate ligaments
(E) tibial
(C) medial and lateral collateral ligaments
(D) fibrous capsule 98. Which of the following muscle tendons is com-
(E) quadriceps femoris monly removed for grafting without causing
disability?
93. Which of the following fractures is the most
(A) extensor hallucis brevis
troublesome and problematic?
(B) fibularis tertius
(A) medial malleolus of tibia (C) plantaris
(B) lateral malleolus of fibula (D) flexor digitorum brevis
(C) sustentaculum of calcaneus (E) tendons of the flexor digitorum longus
(D) femoral neck
(E) adductor tubercle
98 6: The Lower Limb

99. Shin splints usually involve muscles in which 100. The strongest dorsiflexor of the foot is which
of the following compartments? of the following muscles?
(A) anterior (A) fibularis tertius
(B) lateral (B) extensor digitorum longus
(C) posterior (C) tibialis anterior
(D) medial plantar (D) gastrocnemius
(E) lateral plantar (E) extensor hallucis brevis

DIRECTIONS (Questions 101 through 105): Identify DIRECTIONS (Questions 106 through 110): Identify
the anatomical features indicated on the art below. the anatomical features indicated on the art below.
 Questions: 99–115 99

DIRECTIONS (Questions 111 through 115): Identify the anatomical features indicated on the art below.
 Answers and Explanations

1. (E) The femur is the longest and heaviest bone 6. (B) Elderly people fracture the neck of the
in the body. In the average adult, its length femur and refer to the injury as a “broken hip”
is approximately one-quarter of the person’s (Moore, p 511).
height (108 cm or 18 in.). The distal end of the
femur undergoes ossification just before birth 7. (C) The lateral surface of the medial malleolus
(Moore, p 509). articulates with the talus, and the lateral malle-
olus helps hold the talus in its socket (Moore,
2. (A) The medial surface of the medial condyle p 513).
has a large and prominent medial epicondyle,
superior to which is another elevation, the 8. (B) The body of the tibia is the most common
adductor tubercle (Moore, p 509). site for a compound fracture—one in which the
skin is perforated and blood vessels are torn
3. (D) The margin of the acetabulum is deficient (Moore, p 513).
inferiorly at the acetabular notch, which makes
the fossa resemble a cup with a piece of its lip 9. (B) The calcaneus is the largest and strongest
missing (Moore, p 508). bone in the foot. The calcaneus transmits most
of the body weight from the talus to the ground
4. (C) The acetabular notch and fossa comprise (Moore, p 515).
a deficiency in the smooth articular lunate sur-
face of the acetabulum, which actually articu- 10. (E) The shelf-like sustentaculum tali projects
lates with the head of the femur (Moore, p 508). from the superior border of the medial surface
of the calcaneus and supports the talar head
5. (D) A fracture of the femoral neck is among the (Moore, p 515).
most troublesome and problematic of all frac-
tures because of the instability of the fracture 11. (A) The talus articulates with the fibula, cal-
site. Furthermore, the periosteum covering the caneus, navicular, and tibia (Moore, p 515).
femoral neck is exceedingly thin and has ex-
tremely limited powers of osteogenesis (bone 12. (C) The 1st metatarsal is shorter and stouter
formation). Because the retinacular arteries than the others. The 2nd metatarsal is the
arise from the medial circumflex femoral arter- longest. The bases of the metatarsals articulate
ies and run parallel to the femoral neck on their with the cuneiform and cuboid bones. The base
way to supply the femoral head, they are vul- of the 5th metatarsal has a large tuberosity
nerable to injury when the neck of the femur (Moore, p 515).
fractures. Rupture of these vessels cause de-
generation (necrosis) of the femoral head and 13. (D) The deep fascia of the thigh is called fas-
bleeding into the hip joint (Moore, p 511). cia lata and the deep fascia of the leg is called

100
 Answers and Explanations: 1–25 101

crural fascia. Scarpa’s fascia is the membra- most powerful muscles in the body. The qua-
nous fascia of the lower abdominal wall and driceps is the great extensor of the leg, and all
Colles’ fascia is located in the perineum (Moore, four of its parts combine to from a tendinous
p 522). attachment to the tibia. The patella also pro-
vides additional leverage for the quadriceps
14. (C) The saphenous opening in the fascia lata (Moore, pp 532–534).
is a deficiency in the deep fascia lata inferior
to the medial part of the inguinal ligament, 20. (A) The rectus femoris is considered to be the
approximately 4 cm inferolateral to the pubic “kicking muscle.” The vastus lateralis is the
tubercle. The medial margin of the saphenous largest component of the quadriceps. The vas-
opening is smooth, but its superior, lateral, tus intermedius lies deep to the rectus femoris,
and inferior margins form a sharp crescentic and the articular muscle is considered to be a
edge, the falciform margin. The sickle-shaped derivative of the vastus intermedius (Moore,
margin of the saphenous opening is joined at p 534).
its medial margin by fibrofatty tissue—the
cribriform fascia (Moore, p 524). 21. (B) The long, strap-like muscle lies along the
medial side of the thigh and knee. It is the only
15. (E) The great saphenous vein passes through muscle of the adductor group that crosses the
the saphenous opening and cribriform fascia knee. It is the most superficial of the adduc-
to enter the femoral vein. Some efferent lym- tor group and is the weakest member (Moore,
phatic vessels from the superficial inguinal p 538).
lymph nodes also pass through the saphenous
opening and cribriform fascia to enter the deep 22. (B) The adductor magnus is the largest mus-
inguinal lymph nodes (Moore, p 524). cle in the adductor group. It is located in the
medial compartment of the thigh. This large
16. (D) The small saphenous vein ascends poste- adductor is a composite, triangular muscle that
rior to the lateral malleolus and passes along has adductor and hamstring parts. The two
the lateral border of the calcaneal tendon. It parts differ in their attachments, nerve supply,
then ascends between the heads of the gastroc- and main actions (Moore, p 538).
nemius muscle and empties into the popliteal
vein in the popliteal fossa (Moore, p 526). 23. (D) The adductor hiatus is an opening in the
aponeurotic distal attachment of the adductor
17. (B) The iliopsoas is the chief flexor of the thigh, magnus. It transmits the femoral artery and
and when the thigh is fixed, it flexes the trunk vein from the adductor canal in the thigh to the
on the hip. Its broad lateral part, the iliacus, and popliteal fossa posterior to the knee. The open-
its long medial part, the psoas major, arise from ing is just superior to the adductor tubercle of
the iliac fossa and lumbar vertebrae, respec- the femur (Moore, p 541).
tively. It is an anterior thigh muscle (Moore,
p 531). 24. (E) The femoral triangle is bounded superi-
orly by the inguinal ligament, medially by the
18. (D) The sartorius is known as the “tailor’s adductor longus, and laterally by the sarto-
muscle.” It is the longest muscle in the body rius. The femoral triangle is bisected by the
and acts across two joints. It flexes the hip femoral artery and vein, which leave and enter
joint and participates in flexion of the knee. It the adductor canal at its apex. The saphenous
is located in the anterior compartment of the nerve descends through the femoral triangle
thigh (Moore, p 531). (Moore, p 541).

19. (B) The quadriceps femoris forms the main 25. (C) The femoral sheath extends 3 to 4 cm in-
bulk of the anterior thigh muscles and collec- ferior to the inguinal ligament and encloses
tively constitutes the largest and one of the proximal parts of the femoral vessel and the
102 6: The Lower Limb

femoral canal. The sheath is formed by an infe- deep or posterior to the middle third of the sar-
rior prolongation of transversalis and iliopsoas torius, the adductor canal provides an inter-
fascia. The femoral sheath does not enclose the muscular passage through which the femoral
femoral nerve. The sheath ends by becoming vessels pass to reach the popliteal fossa. The
continuous with the adventitia of the femoral contents of the adductor canal include the
vessels (Moore, p 542). femoral vessels, saphenous nerve, and nerve to
the vastus medialis (Moore, p 549).
26. (A) The medial compartment of the femoral
sheath is the femoral canal. It extends distally to 32. (B) The greater sciatic foramen is the passage-
the level of the proximal edge of the saphenous way for structures entering or leaving the pel-
opening. It allows the femoral vein to expand vis, whereas the lesser sciatic foramen is the
when venous return from the lower limb is in- passageway for structures entering or leaving
creased. It contains loose connective tissue, fat, the perineum. The greater sciatic foramen is the
a few lymphatic vessels, and sometimes a deep opening for all lower limb arteries and nerves
inguinal lymph node (Cloquet’s node) (Moore, leaving the pelvis and entering the gluteal
pp 542–543). region (Moore, p 550).

27. (C) The femoral ring is closed at the proxi- 33. (E) The greater sciatic foramen is the passage-
mal end by extraperitoneal fatty tissue, which way for the sciatic nerve, piriformis muscle,
forms the femoral septum. The boundaries of and gluteal vessels. The pudendal nerve
the femoral ring include the partition between enters the perineum through the lesser sciatic
the femoral canal and the femoral vein laterally. foramen (Moore, p 553).
Posteriorly, the superior ramus of the pubis is
covered by the pectineus muscle. Its medial 34. (C) The gluteus maximus is used when rising
boundary is the lacunar ligament; anteriorly, from the sitting position or straightening from
the boundary is the medial part of the inguinal the bending position. It is used in climbing
ligament (Moore, pp 543–545). steps and running. It also assists in making the
knee stable. It is used very little during casual
28. (B) The femoral artery is the chief artery of the walking and when one is standing motionless
lower limb and is the continuation of the exter- (Moore, p 552).
nal iliac artery. It bisects the femoral triangle at
its apex and enters the adductor canal deep to 35. (A) The ischial bursa separates the inferior
the sartorius muscle (Moore, p 545). part of the gluteus maximus from the ischial
tuberosity, which is often absent (Moore, p 552).
29. (A) The deep artery of the thigh is the largest
branch of the femoral artery and the chief artery 36. (D) The gluteus medius and minimus have the
of the thigh. It arises in the femoral triangle from same actions and nerve supply and are sup-
the lateral side of the femoral artery (Moore, plied by the superior gluteal arteries. Both mus-
p 545). cles abduct the thigh and rotate it medially.
They play an essential role during locomotion
30. (A) The medial circumflex femoral artery is and are largely responsible for preventing sag-
especially important because it supplies most ging of the unsupported side of the pelvis dur-
of the blood to the head and neck of the femur ing walking (Moore, p 554).
(Moore, p 545).
37. (C) When the weight is on both feet, the pelvis
31. (D) The adductor canal (Hunter’s canal) is is evenly supported and does not sag. When the
approximately 15 cm long and is a narrow fas- weight is borne by one foot, the muscles on the
cial tunnel in the thigh running from the apex same side hold the pelvis so the pelvis will not
of the femoral triangle to the adductor hiatus in sag on the side of the raised foot. When the glu-
the tendon of the adductor magnus. Located teus medius and minimus (abductors of the
 Answers and Explanations: 26–51 103

thigh) are inactive owing to injury of the supe- the lesser sciatic foramen. The artery passes to
rior gluteal nerve, the supporting and steady- the perineum with the pudendal nerve and
ing action of these muscles is lost and the pel- supplies the external genitalia and muscles in
vis falls on the side of the raised limb. This is the pelvic region. It does not supply any struc-
referred to as a positive Trendelenburg sign tures in the gluteal region (Moore, p 562).
(Moore, p 555).
45. (A) The three muscles in the posterior aspect
38. (B) The obturator internus and the superior of the thigh are the hamstrings, which include
and inferior gemelli form a tricipital (three- the semitendinosus, semimembranosus, and
headed) muscle that is sometimes called the biceps femoris (Moore, p 563).
triceps coxae (Moore, p 550).
46. (C) The hamstring muscles arise from the is-
39. (D) The gluteus maximus, piriformis, obtu- chial tuberosity and are innervated by the tib-
rator internus and externus, and superior and ial division of the sciatic nerve. The short
inferior gemelli are all lateral rotators of the head of the biceps does not meet these crite-
thigh. Both the gluteus medius and the glu- ria. The hamstrings are extensors of the thigh
teus minimus are medial rotators of the thigh and flexors of the leg. A person with paralyzed
(Moore, p 551). hamstrings tends to fall forward because the
gluteus maximus muscles cannot maintain the
40. (E) The inferior clunial nerves are gluteal necessary muscle tone to stand straight (Moore,
branches of the posterior cutaneous nerve of p 563).
the thigh, a derivative of the sacral plexus (ven-
tral rami S1 through S3). These nerves curl 47. (D) The long head of the biceps femoris is
around the inferior border of the gluteus max- innervated by the tibial division of the sciatic
imus and supply the inferior half of the buttock nerve and the short head of the biceps is inner-
(Moore, p 556). vated by the fibular division of the sciatic nerve
(Moore, p 563).
41. (E) The superior cluneal nerves are dorsal
rami of L1–L3 and the middle cluneal nerves 48. (E) A line drawn from the anterior superior
are dorsal rami of S1–S3. The sciatic, puden- iliac spine to the ischial tuberosity (Nélaton’s
dal, posterior cutaneous nerve of the thigh, line), passing over the lateral aspect of the hip
and the gluteal nerves are all ventral primary region, normally passes over or near the top of
rami (Moore, p 557). the greater trochanter (Moore, p 567).

42. (D) The sciatic nerve is the largest nerve in the 49. (E) The biceps femoris forms the superolat-
body. It is so large that it receives its own blood eral border and the semimembranosus muscle
supply from the inferior gluteal artery. It runs forms the superomedial border. The medial and
inferolaterally under cover of the gluteus max- lateral heads of the gastrocnemius form the
imus, midway between the greater trochanter inferolateral and inferomedial borders. The
and the ischial tuberosity. The sciatic nerve is contents of the fossa include the small saphe-
really two nerves, the tibial and common fibu- nous vein, popliteal arteries and veins, and tib-
lar (Moore, p 558). ial and common fibular nerves (Moore, p 571).

43. (A) A pain in the buttock may result from com- 50. (A) The floor of the popliteal fossa is formed by
pression of the sciatic nerve by the piriformis the popliteal surface of the femur, the oblique
muscle (piriformis syndrome) (Moore, p 559). popliteal ligament, and the popliteal fascia over
the popliteus (Moore, p 571).
44. (D) The internal pudendal artery leaves the
gluteal region immediately by crossing the is- 51. (B) The medial sural nerve is derived from the
chial spine and re-entering the pelvis through tibial nerve and the lateral sural nerve is
104 6: The Lower Limb

derived from the common fibular. The medial 62. (D) The central compartment of the foot con-
and lateral sural nerves unite to form the sural tains the flexor digitorum brevis, flexor digi-
nerve (Moore, p 590). torum longus, quadratus plantae, lumbricals,
proximal part of the tendon flexor hallucis
52. (A) Dorsiflexors of the ankle include the tibialis longus, and the lateral plantar nerve and ves-
anterior, extensors digitorum longus, hallucis sel (Moore, p 596).
longus, and fibularis tertius (Moore, p 577).
63. (B) The medial plantar nerve, the larger of
53. (D) Both the fibularis longus and brevis evert the two terminal branches of the tibial nerve,
the foot. The fibularis tertius also aids in ever- passes deep to the abductor hallucis and runs
sion of the foot (Moore, p 577). anteriorly between the muscles and the flexor
digitorum brevis on the lateral side of the
54. (A) The superior extensor retinaculum is a medial plantar artery (Moore, p 601).
strong, broad band of deep fascia passing from
the fibula to the tibia, proximal to the malleoli. 64. (E) The saphenous nerve is the largest cuta-
The inferior extensor retinaculum is a Y-shaped neous branch of the femoral nerve. In addition
band of deep fascia that attaches laterally to to supplying the skin and fascia on the ante-
the anterosuperior surface of the calcaneus. It rior and medial sides of the leg, the saphenous
forms a strong loop around the tendons of the nerve passes anterior to the medial malleolus to
fibularis tertius and the extensor digitorum the dorsum of the foot, where it supplies skin
longus muscle (Moore, p 579). along the medial side of the foot as far as the
head of the 1st metatarsal (Moore, p 601).
55. (B) The tibialis anterior is the strongest dorsi-
flexor and inverter of the foot (Moore, p 579). 65. (A) The fibrous capsule is reinforced anteriorly
by the strong, Y-shaped iliofemoral ligament
56. (C) The plantaris is located in the superficial (of Bigelow) which attaches to the anterior infe-
group of muscles in the posterior compartment rior iliac spine and the acetabular rim proxi-
(Moore, p 586). mally and the intertrochanteric line distally.
The iliofemoral ligament prevents hyperexten-
57. (A) The popliteus is a flexor of the knee joint sion of the hip during standing by screwing the
(Moore, p 588). femoral head into the acetabulum (Moore, p 611).

58. (D) The flexor hallucis longus is the powerful 66. (C) A synovial protrusion beyond the free
“push-off” muscle during walking, running, margin of the fibrous capsule onto the posterior
and jumping (Moore, p 589). aspect of the femoral neck forms a bursa for the
obturator externus tendon (Moore, p 611).
59. (B) When a person is standing with the knee
partly flexed, the popliteus contracts to assist 67. (C) The ligament of the head of the femur is
the posterior cruciate ligament in preventing weak and of little importance in strengthening
anterior displacement of the femur on the tibia the hip joint. Its wide end attaches to the mar-
(Moore, p 588). gins of the acetabular notch and the transverse
acetabular ligament. Its narrow end attaches
60. (A) Together, the two-headed gastrocnemius to the pit in the head of the femur. Usually the
and soleus form the three-headed triceps surae ligament contains a small artery to the head of
(Moore, p 586). the femur (Moore, p 611).

61. (A) The lateral compartment of the foot con- 68. (B) The main blood supply of the hip joint is
tains the abductor and flexor digiti minimi bre- from branches of the circumflex femoral arter-
vis (Moore, p 596). ies (especially the medial circumflex femoral
artery) that travel in the retinacula (reflections
 Answers and Explanations: 52–79 105

of the capsule along the neck of the femur to- joint. The popliteal tendon is also intra-articular
ward the head). These retinacular vessels may during part of its course (Moore, p 620).
be damaged in femoral neck fractures and re-
sult in avascular necrosis of the femoral head 75. (B) The anterior cruciate ligament (ACL), the
(Moore, p 613). weaker of the two cruciate ligaments, arises
from the anterior intercondylar area of the tibia,
69. (D) The most important muscle in stabilizing just posterior to the attachment of the medial
the knee joint is the large quadriceps femoris, meniscus. It extends superiorly, posteriorly, and
particularly inferior fibers of the vastus medi- laterally to attach to the posterior part of the
alis and lateralis. The knee joint will function medial side of the lateral condyle of the femur.
surprisingly well following a ligament strain The ACL has a relatively poor blood supply. It
if the quadriceps is well conditioned (Moore, is slack when the knee is flexed and taut when
pp 617–618). it is fully extended, preventing posterior dis-
placement. (Moore, p 620).
70. (B) The fibrous capsule of the knee is deficient
on the lateral condyle to allow the tendon of the 76. (E) The menisci are thicker at their external
popliteus to pass out of the joint to attach to the margins and taper to thin, unattached edges in
tibia (Moore, p 618). the interior of the joint. Wedge-shaped in trans-
verse section, the menisci are firmly attached at
71. (C) The fibular collateral ligament (lateral their ends to the intercondylar area of the tibia.
collateral ligament), rounded and cordlike, is Their external margins attach to the fibrous cap-
strong. It extends inferiorly from the lateral epi- sule of the knee joint. The transverse ligament
condyle of the femur to the lateral surface of of the knee, a slender, fibrous band, joins the
the head of fibula. The tendon of the popliteus anterior edges of the menisci, allowing them to
passes deep to the fibular collateral ligament, move together during knee movements (Moore,
separating it from the lateral meniscus. The ten- p 621).
don of the biceps femoris is also split into two
parts by this ligament (Moore, p 619). 77. (D) The lateral meniscus is nearly circular
and is smaller and more movable than the
72. (D) The tibial collateral ligament (medial col- medial meniscus. The tendon of the popliteus
lateral ligament) is a strong, flat band that ex- separates the lateral meniscus from the fibular
tends from the medial epicondyle of the femur collateral ligament. A strong tendinous slip,
to the medial surface of the tibia. At its mid- the posterior meniscofemoral ligament, joins
point, the deep fibers of the tibial collateral lig- the lateral meniscus to the posterior cruciate
ament are firmly attached to the medial me- ligament and the medial femoral condyle.
niscus. The tibial collateral ligament, weaker The lateral meniscus acts like a shock
than the fibular collateral ligament, is more absorber (Moore, p 621).
often damaged. As a result, the tibial collateral
ligament and medial meniscus are commonly 78. (B) The middle genicular branches of the pop-
torn during contact sports such as football liteal artery penetrate the fibrous capsule of the
(Moore, p 619). knee joint and supply the cruciate ligaments,
synovial membrane, and peripheral margins of
73. (D) The oblique popliteal ligament is an expan- the menisci (Moore, p 626).
sion of the tendon of the semimembranosus,
which strengthens the fibrous capsule posteri- 79. (A) The ACL may tear when the tibial collateral
orly (Moore, p 619). ligament ruptures. First, the tibial collateral lig-
ament ruptures, opening the joint on the medial
74. (C) The patellar ligament is extracapsular. The side and possibly tearing the medial meniscus
cruciate ligaments and menisci are classified as and ACL. This “unhappy triad of injuries” can
intra-articular and are found within the knee result from clipping in football (Moore, p 626).
106 6: The Lower Limb

80. (C) Pain on lateral rotation of the tibia on the tion across the transverse tarsal joint is a stan-
femur indicates injury of the lateral meniscus, dard method for surgical amputation of the
whereas pain on medial rotation of the tibia on foot. Inversion and eversion of the foot are the
the femur indicates injury of the medial menis- main movements involving these joints (Moore,
cus (Moore, p 628). p 637).

81. (E) The lateral ligament consists of the anterior 87. (A) The tibial nerve leaves the posterior com-
and posterior talofibular ligaments and the cal- partment of the leg by passing deep to the
caneofibular ligament. The three discrete liga- flexor retinaculum in the interval between
ments are collectively referred to as the lateral the medial malleolus and calcaneus. The area
ligament. The fibrous capsule is reinforced involved is from the medial malleolus to the
medially by the large, strong medial ligament calcaneus, and the heel pain results from com-
(deltoid ligament), which attaches proximally pression of the tibial nerve by the flexor reti-
to the medial malleolus. This ligament consists naculum (Moore, p 636).
of the tibionavicular, tibiocalcaneal, and ante-
rior and posterior tibiotalar ligaments (Moore, 88. (E) The ankle is the most frequently injured
pp 633–635). major joint in the body. Ankle sprains are most
common. A sprained ankle is nearly always an
82. (A) Dorsiflexion of the ankle is produced by inversion injury (Moore, p 636).
the muscles in the anterior compartment of the
leg (Moore, p 635). 89. (D) A Pott’s fracture-dislocation of the ankle
occurs when the foot is forcibly everted. This
83. (E) The plantar calcaneonavicular ligamentum action pulls on the extremely strong medial lig-
(spring ligament) extends from the sustentacu- ament, often tearing off the medial malleolus.
lum tali to the posteroinferior surface of the The talus then moves laterally, shearing off the
navicular. It plays an important role in main- lateral malleolus or, more commonly, breaking
taining the longitudinal arch of the foot (Moore, the fibula superior to the inferior tibiofibular
p 637). joint (Moore, p 636).

84. (C) The talar head is the keystone of the medial 90. (B) The grip of the malleoli on the trochlea is
longitudinal arch (Moore, p 640). strongest during dorsiflexion of the foot, be-
cause this movement forces the wider, anterior
85. (A) Hallux valgus is a foot deformity char- part of the trochlea posteriorly, spreading the
acterized by lateral deviation of the great toe. tibia and fibula slightly apart (Moore, p 632).
Hammertoe is a deformity in which the prox-
imal phalanx is permanently flexed at the 91. (B) Genu varum and genu valgum result in
metatarsophalangeal joint and the middle pha- deviation of the tibia from the midline. In genu
lanx is plantarflexed at the interphalangeal joint. varum, the tibia is diverted medially, and in
The distal phalanx is also flexed. Claw toes are genu valgum, the tibia is diverted laterally;
characterized by hyperextension of the metatar- these deformities cause unequal weight distri-
sophalangeal joints and flexion of the distal bution. In the varum deformity, the medial side
interphalangeal joints. Pes planus is flat feet, of the knee takes all the pressure, leading to
and clubfoot refers to a foot that is twisted. The wear and tear of the medial meniscus (Moore,
foot is inverted, the ankle is plantarflexed, and p 630).
the forefoot is adducted (Moore, pp 641–642).
92. (E) The stability of the knee joint depends on
86. (E) The transverse tarsal joint is formed by the the strength and actions of the surrounding
combined talonavicular part of the talocalca- muscles and their tendons. The ligaments that
neonavicular and calcaneocuboid joints, two connect the femur and tibia are also important.
separate joints aligned transversely. Transec- Of these supports, the muscles are most impor-
 Answers and Explanations: 80–115 107

tant; therefore, many sport injuries are pre- 98. (C) Because of its minor role, the plantaris
ventable through appropriate conditioning tendon can be removed for grafting without
and training. The most important muscle in causing any disability (Moore, p 586).
stabilizing the knee joint is the large quadri-
ceps femoris, particularly inferior fibers of the 99. (A) Shin splints commonly result from trau-
vastus medialis and lateralis. The knee joint matic injury or athletic overexertion of muscles
will function surprisingly well following a lig- in the anterior compartment—especially the
ament strain if the quadriceps is well condi- tibialis anterior (Moore, p 580).
tioned (Moore, pp 617–618).
100. (C) The tibialis anterior is the strongest dorsi-
93. (D) Fractures of the femoral neck are intracap- flexor and invertor of the foot (Moore, p 579).
sular, and realignment of the neck fragments
requires internal skeletal fixation. Femoral neck 101. deep peroneal nerve
fractures are among the most troublesome and
problematic of all fractures (Moore, p 614). 102. tibialis anterior

94. (B) The iliopsoas is the strongest flexor of the 103. extensor digitorum longus
hip joint (Moore, p 613).
104. extensor digitorum brevis
95. (D) Medial rotators of the hip joint include
anterior fibers of the gluteus medius, gluteus 105. dorsalis pedis artery
minimus, and tensor fascia lata; lateral rotators
include the obturator externus, obturator inter- 106. abductor digiti minimi
nus, superior gemellus, piriformis, quadratus
femoris, and gluteus maximus (Moore, p 613). 107. flexor digitorum brevis

96. (B) The pulse of the dorsalis pedis artery, or 108. lateral plantar nerve
dorsal artery of the foot, is evaluated during a
physical examination of the peripheral vascu- 109. medial plantar nerve
lar system. Dorsalis pedis pulses may be pal-
pated with the feet slightly dorsiflexed (Moore, 110. lumbrical
pp 603–604).
111. gluteus minimus
97. (C) The tendon of the biceps femoris may be
traced by palpating its distal attachment to the 112. sciatic nerve
lateral side of the head of the fibula. This tendon
and the neck of the fibula guide the examin- 113. semitendinosus
ing finger to the common fibular nerve (Moore,
p 592). 114. long head of biceps femoris

115. soleus