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Question 1 of 263

A 56 year old man is left impotent following an abdomino-perineal excision of the colon and rectum. What is the most likely
explanation?
A. Psychosexual issues related to an end colostomy
B. Damage to the sacral venous plexus during total mesorectal excision
C. Damage to the left ureter during sigmoid mobilisation
D. Damage to the hypogastric plexus during mobilisation of the inferior
mesenteric artery
E. Damage to the internal iliac artery during total mesorectal excision
Next question
Autonomic nerve injury is the most common cause.
Nerve lesions during surgery
A variety of different procedures carry the risk of iatrogenic nerve injury. These are important not only from the patients
perspective but also from a medicolegal standpoint.
The following operations and their associated nerve lesions are listed here:

Posterior triangle lymph node biopsy and accessory nerve lesion.

Lloyd Davies stirrups and common peroneal nerve.
Thyroidectomy and laryngeal nerve.
Anterior resection of rectum and hypogastric autonomic nerves.
Axillary node clearance; long thoracic nerve, thoracodorsal nerve and intercostobrachial nerve.
Inguinal hernia surgery and ilioinguinal nerve.
Varicose vein surgery- sural and saphenous nerves.
Posterior approach to the hip and sciatic nerve.
Carotid endarterectomy and hypoglossal nerve.

There are many more, with sound anatomical understanding of the commonly performed procedures the incidence of nerve
lesions can be minimised. They commonly occur when surgeons operate in an unfamiliar tissue plane or by blind placement of
haemostats (not recommended).

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Question 2 of 263
A 73 year old man is due to undergo a radical prostatectomy for carcinoma of the prostate gland. To which of the following
lymph nodes will the tumour drain primarily?

A. Para aortic
B. Internal iliac
C. Superficial inguinal
D. Meso rectal
E. None of the above
Next question
The prostate lymphatic drainage is primarily to the internal iliac nodes and also the sacral nodes. Although internal iliac is the
first site.
Prostate gland
The prostate gland is approximately the shape and size of a walnut and is located inferior to the bladder. It is separated from the
rectum by Denonvilliers fascia and its blood supply is derived from the internal iliac vessels. The internal sphincter lies at the
apex of the gland and may be damaged during prostatic surgery, affected individuals may complain of retrograde ejaculation.
Summary of prostate gland
Arterial supply

Inferior vesical artery (from internal iliac)

Venous drainage

Prostatic venous plexus (to paravertebral veins)

Lymphatic drainage

Internal iliac nodes

Innervation

Inferior hypogastric plexus

Dimensions

Transverse diameter (4cm)

AP diameter (2cm)
Height (3cm)

Lobes

Posterior lobe: posterior to urethra

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

Zones

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

Relations

Anterior

Pubic symphysis
Prostatic venous plexus

Posterior

Denonvilliers fascia
Rectum
Ejaculatory ducts

Lateral

Venous plexus (lies on prostate)

Levator ani (immediately below the puboprostatic ligaments)

Question
3 of 263

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Which of the following statements relating to the vertebral column is false?

A. There are 7 cervical vertebrae
B. The cervical and lumbar lordosis are secondary curves developing after birth
due to change in shape of the intervertebral discs
C. The lumbar vertebrae do not have a transverse process foramina
D. The lumbar vertebrae receive blood directly from the aorta
E. The spinous process is formed by the junction of the pedicles posteriorly
Next question
The spinous process is formed by 2 laminae posteriorly.
Vertebral column

There are 7 cervical, 12 thoracic, 5 lumbar, and 5 sacral vertebrae.

The spinal cord segmental levels do not necessarily correspond to the vertebral segments. For example, while the C1
cord is located at the C1 vertebra, the C8 cord is situated at the C7 vertebra. While the T1 cord is situated at the T1
vertebra, the T12 cord is situated at the T8 vertebra. The lumbar cord is situated between T9 and T11 vertebrae. The
sacral cord is situated between the T12 to L2 vertebrae.

Cervical vertebrae
The interface between the first and second vertebra is called the atlanto-axis junction. The C3 cord contains the phrenic nucleus.
The cervical cord innervates the deltoids (C4), biceps (C4-5), wrist extensors (C6-8), triceps (C7), wrist flexors (C8-T1), and
hand muscles (C8-T1).
Thoracic vertebrae
The thoracic vertebral segments are defined by those that have a rib. The spinal roots form the intercostal nerves that run on the
bottom side of the ribs and these nerves control the intercostal muscles and associated dermatomes.
Lumbosacral vertebrae
Form the remainder of the segments below the vertebrae of the thorax. The lumbosacral spinal cord, however, starts at about T9
and continues only to L2. It contains most of the segments that innervate the hip and legs, as well as the buttocks and anal
regions.
Cauda Equina
The spinal cord ends at L2 vertebral level. The tip of the spinal cord is called the conus. Below the conus, there is a spray of
spinal roots that is called the cauda equina. Injuries below L2 represent injuries to spinal roots rather than the spinal cord proper.

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Question 4 of 263

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The cephalic vein pierces the clavipectoral fascia to terminate in which of the veins listed below?
A. External jugular
B. Axillary
C. Internal jugular
D. Azygos
E. Brachial
Next question

Cephalic vein
Path

Dorsal venous arch drains laterally into the cephalic vein

Crosses the anatomical snuffbox and travels laterally up the arm

At the antecubital fossa connected to the basilic vein by the median cubital vein
Pierces deep fascia of deltopectoral groove to join axillary vein

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Question 5 of 263

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A 78 year old lady falls over in her nursing home and sustains a displaced intracapsular fracture of the femoral neck. A decision
is made to perform a hemi arthroplasty through a lateral approach. Which of these vessels will be divided to facilitate access?
A. Saphenous vein
B. Superior gluteal artery
C. Superficial circumflex iliac artery
D. Profunda femoris artery
E. Transverse branch of the lateral circumflex artery
Next question
During the Hardinge style lateral approach the transverse branch of the lateral circumflex artery is divided to gain access. The
vessels and its branches are illustrated below:

Image sourced from Wikipedia

Hip joint

Head of femur articulates with acetabulum of the pelvis

Both covered by articular hyaline cartilage
The acetabulum forms at the union of the ilium, pubis, and ischium
The triradiate cartilage (Y-shaped growth plate) separates the pelvic bones
The acetabulum holds the femoral head by the acetabular labrum
Normal angle between femoral head and femoral shaft is 130o

Ligaments

Transverse ligament: joints anterior and posterior ends of the articular cartilage

Head of femur ligament (ligamentum teres): acetabular notch to the fovea. Contains arterial supply to head of femur in
children.

Image sourced from Wikipedia

Image sourced from Wikipedia

Extracapsular ligaments

Iliofemoral ligament: inverted Y shape. Anterior iliac spine to the trochanteric line
Pubofemoral ligament: acetabulum to lesser trochanter
Ischiofemoral ligament: posterior support. Ischium to greater trochanter.

Blood supply
Medial circumflex femoral and lateral circumflex femoral arteries (Branches of profunda femoris)
2 anastomoses: Cruciate and the trochanteric anastomoses (provides most of the blood to the head of the femur) Hence the need
for hemiarthroplasty when there is a displaced femoral head fracture. These anastomoses exist between the femoral artery or
profunda femoris and the gluteal vessels.

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Question 6 of 263

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A 73 year old man undergoes a sub total oesophagectomy with anastomosis of the stomach to the cervical oesophagus. Which
vessel will be primarily responsible for the arterial supply to the oesophageal portion of the anastomosis?
A. Superior thyroid artery
B. Internal carotid artery
C. Direct branches from the thoracic aorta
D. Inferior thyroid artery
E. Subclavian artery
Next question
The cervical oesophagus is supplied by the inferior thyroid artery. The thoracic oesophagus (removed in this case) is supplied
by direct branches from the thoracic aorta.
Oesophagus

25cm long
Starts at C6 vertebra, pierces diaphragm at T10 and ends at T11
Squamous epithelium

Constrictions of the oesophagus

Structure

Distance from incisors

Cricoid cartilage

15cm

Arch of the Aorta

22.5cm

Left principal bronchus

27cm

Diaphragmatic hiatus

40cm

Relations
Anteriorly

Trachea to T4
Recurrent laryngeal nerve
Left bronchus, Left atrium
Diaphragm

Posteriorly

Thoracic duct to left at T5

Hemiazygos to the left T8
Descending aorta
First 2 intercostal branches of aorta

Left

Thoracic duct
Left subclavian artery

Right

Azygos vein

Arterial, venous and lymphatic drainage of the oesophagus

Artery

Vein

Lymphatics

Muscularis externa

Upper third

Inferior thyroid

Inferior thyroid

Deep cervical

Striated muscle

Mid third

Aortic branches

Azygos branches

Mediastinal

Smooth & striated muscle

Lower third

Left gastric

Posterior mediastinal and coeliac

Gastric

Smooth muscle

Nerve supply

Upper half is supplied by recurrent laryngeal nerve

Lower half by oesophageal plexus (vagus)

Histology

Mucosa :Nonkeratinized stratified squamous epithelium

Submucosa: glandular tissue
Muscularis externa (muscularis): composition varies. See table
Adventitia

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Question 7 of 263

Which of the following structures is not closely related to the brachial artery?
A. Ulnar nerve
B. Median nerve
C. Cephalic vein
D. Long head of triceps
E. Median cubital vein
Next question
The cephalic vein lies superficially and on the contralateral side of the arm to the brachial artery. The relation of the ulnar
nerves and others are demonstrated in the image below:

Image sourced from Wikipedia

Brachial artery
The brachial artery begins at the lower border of teres major as a continuation of the axillary artery. It terminates in the cubital
fossa at the level of the neck of the radius by dividing into the radial and ulnar arteries.
Relations
Posterior relations include the long head of triceps with the radial nerve and profunda vessels intervening. Anteriorly it is
overlapped by the medial border of biceps.
It is crossed by the median nerve in the middle of the arm.
In the cubital fossa it is separated from the median cubital vein by the bicipital aponeurosis.
The basilic vein is in contact at the most proximal aspect of the cubital fossa and lies medially.

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Question 8 of 263

The following statements relating to the musculocutaneous nerve are true except?

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A. It arises from the lateral cord of the brachial plexus

B. It provides cutaneous innervation to the lateral side of the forearm
C. If damaged then extension of the elbow joint will be impaired
D. It supplies the biceps muscle
E. It runs beneath biceps
Next question
It supplies biceps, brachialis and coracobrachialis so if damaged then elbow flexion will be impaired.
Musculocutaneous nerve

Branch of lateral cord of brachial plexus

Path

It penetrates the Coracobrachialis muscle

Passes obliquely between the Biceps brachii and the Brachialis to the lateral side of the arm
Above the elbow it pierces the deep fascia lateral to the tendon of the Biceps brachii
Continues into the forearm as the lateral cutaneous nerve of the forearm

Innervates

Coracobrachialis
Biceps brachii
Brachialis

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Question 9 of 263

Which ligament keeps the head of the radius connected to the radial notch of the ulna?
A. Annular (orbicular) ligament
B. Quadrate ligament
C. Radial collateral ligament of the elbow
D. Ulnar collateral ligament

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E. Radial collateral ligament

Next question
The annular ligament connects the radial head to the radial notch of the ulna. This is illustrated below:

Image sourced from Wikipedia

Radius

Bone of the forearm extending from the lateral side of the elbow to the thumb side of the wrist

Upper end

Articular cartilage- covers medial > lateral side

Articulates with radial notch of the ulna by the annular ligament

Muscle attachment- biceps brachii at the tuberosity

Shaft

Muscle attachment-

Upper third of the body Supinator, Flexor digitorum superficialis, Flexor pollicis longus

Middle third of the body Pronator teres

Lower quarter of the body Pronator quadratus , tendon of supinator longus
Lower end

Quadrilateral

Anterior surface- capsule of wrist joint

Medial surface- head of ulna
Lateral surface- ends in the styloid process
Posterior surface: 3 grooves containing:

1. Tendons of extensor carpi radialis longus and brevis

2. Tendon of extensor pollicis longus
3. Tendon of extensor indicis

Image sourced from Wikipedia

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Question 10 of 263

A 38 year old man presents to the clinic with shoulder weakness. On examination he has an inability to initiate shoulder
abduction. Which of the nerves listed below is least likely to be functioning normally?
A. Suprascapular nerve
B. Medial pectoral nerve
C. Axillary nerve
D. Median nerve
E. Radial nerve
Next question
Theme from April 2012 Exam
Suprascapular nerve
The suprascapular nerve arises from the upper trunk of the brachial plexus. It lies superior to the trunks of the brachial plexus
and passes inferolaterally parallel to them. It passes through the scapular notch, deep to trapezius. It innervates both
supraspinatus and infraspinatus and initiates abduction of the shoulder. If damaged, patients may be able to abduct the shoulder
by leaning over the affected side and deltoid can then continue to abduct the shoulder.

I
Question
11 of 263

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Which of the following statements relating to the Cavernous Sinus is false?

A. The pituitary gland lies medially
B. The internal carotid artery passes through it
C. The temporal lobe of the brain is a lateral relation
D. The mandibular branch of the trigeminal and optic nerve lie on the lateral wall
E. The ophthalmic veins drain into the anterior aspect of the sinus
Next question

The veins that drain into the sinus are important as sepsis can cause cavernous sinus thrombosis. The maxillary branch of the
trigeminal and not the mandibular branches pass through the sinus
Cavernous sinus
The cavernous sinuses are paired and are situated on the body of the sphenoid bone. It runs from the superior orbital fissure to
the petrous temporal bone.
Relations
Medial

Lateral

Pituitary fossa Temporal lobe

Sphenoid sinus

Contents
Lateral wall components

(from top to bottom:)

Oculomotor nerve
Trochlear nerve
Ophthalmic nerve
Maxillary nerve

Contents of the sinus

(from medial to lateral:)

Internal carotid artery (and sympathetic plexus)
Abducens nerve

Blood supply
Ophthalmic vein, superficial cortical veins, basilar plexus of veins posteriorly.
Drains into the internal jugular vein via: the superior and inferior petrosal sinuses

Image sourced from Wikipedia

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Question 12 of 263

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Which of the following is not a branch of the subclavian artery?

A. Superior thyroid artery
B. Vertebral artery
C. Thyrocervical trunk
D. Internal thoracic artery
E. Dorsal scapular artery
Next question

Mnemonic for the branches of the subclavian artery: VIT C & D

V ertebral artery
I nternal thoracic
T hyrocervical trunk
C ostalcervical trunk
D orsal scapular

Superior thyroid artery is a branch of the external carotid artery.

Subclavian artery
Path

The left subclavian comes directly off the arch of aorta

The right subclavian arises from the brachiocephalic artery (trunk) when it bifurcates into the subclavian and the right
common carotid artery.
From its origin, the subclavian artery travels laterally, passing between anterior and middle scalene muscles, deep to
scalenus anterior and anterior to scalenus medius. As the subclavian artery crosses the lateral border of the first rib, it
becomes the axillary artery. At this point it is superficial and within the subclavian triangle.

Image sourced from Wikipedia

Branches

Vertebral artery

Internal thoracic artery

Thyrocervical trunk
Costocervical trunk
Dorsal scapular artery

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Question 13 of 263

During the repair of an atrial septal defect the surgeons note that blood starts to leak from the coronary sinus. Which structure
forms the largest tributary of the coronary sinus?
A. Thesbian veins
B. Great cardiac vein
C. Oblique vein
D. Small cardiac veins
E. None of the above
Next question
The great cardiac vein runs in the anterior interventricular groove, and is the largest tributary of the coronary sinus. The
Thesbian veins drain into the heart directly.
Heart anatomy

The walls of each cardiac chamber comprise:

Epicardium
Myocardium
Endocardium

Cardiac muscle is attached to the cardiac fibrous skeleton.

Relations
The heart and roots of the great vessels within the pericardial sac are related anteriorly to the sternum, medial ends of the 3rd to
5th ribs on the left and their associated costal cartilages. The heart and pericardial sac are situated obliquely two thirds to the left
and one third to the right of the median plane.
The pulmonary valve lies at the level of the left third costal cartilage.
The mitral valve lies at the level of the fourth costal cartilage.
Coronary sinus
This lies in the posterior part of the coronary groove and receives blood from the cardiac veins. The great cardiac vein lies at its
left and the middle and small cardiac veins lie on its right. The smallest cardiac veins drain into the atria directly.
Aortic sinus
Right coronary artery arises from the right aortic sinus, the left is derived from the left aortic sinus and no vessel emerges from
the posterior sinus.
Right and left ventricles

Structure

Left Ventricle

A-V Valve

Mitral (double leaflet)

Walls

Twice as thick as right

Trabeculae carnae

Much thicker and more numerous

Right coronary artery

The RCA supplies:

Right atrium
Diaphragmatic part of the left ventricle
Usually the posterior third of the interventricular septum
The sino atrial node (60% cases)
The atrio ventricular node (80% cases)

Left coronary artery

The LCA supplies:

Left atrium
Most of left ventricle
Part of the right ventricle
Anterior two thirds of the inter ventricular septum
The sino atrial node (remaining 40% cases)

Innervation of the heart

Autonomic nerve fibres from the superficial and deep cardiac plexus. These lie anterior to the bifurcation of the trachea,
posterior to the ascending aorta and superior to the bifurcation of the pulmonary trunk. The parasympathetic supply to the heart
is from presynaptic fibres of the vagus nerves.
Valves of the heart
Mitral valve

Aortic valve

Pulmonary valve

Tricuspid valve

2 cusps

3 cusps

3 cusps

3 cusps

First heart sound

Second heart sound

Second heart sound

First heart sound

1 anterior cusp

1 anterior cusp

2 anterior cusps

2 anterior cusps

Attached to chordae tendinae

No chordae

No chordae

Attached to chordae tendinae

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Question 14 of 263

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Which of the following vessels provides the greatest contribution to the arterial supply of the breast?
A. External mammary artery
B. Thoracoacromial artery
C. Internal mammary artery
D. Lateral thoracic artery
E. Subclavian artery
Next question
60% of the arterial supply to the breast is derived from the internal mammary artery. The external mammary and lateral thoracic

arteries also make a significant (but lesser) contribution. This is of importance clinically in performing reduction mammoplasty
procedures.
Breast
The breast itself lies on a layer of pectoral fascia and the following muscles:
1. Pectoralis major
2. Serratus anterior
3. External oblique
Image showing the topography of the female breast

Image sourced from Wikipedia

Breast anatomy
Nerve supply

Branches of intercostal nerves from T4-T6.

Arterial supply

Venous drainage

Superficial venous plexus to sub clavian, axillary and intercostal veins.

Lymphatic drainage

Previous

Internal mammary (thoracic) artery

External mammary artery (laterally)
Anterior intercostal arteries
Thoraco-acromial artery

70% Axillary nodes

Internal mammary chain
Other lymphatic sites such as deep cervical and supraclavicular fossa (later in disease)

Question 15 of 263

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Which of the following muscles is supplied by the external laryngeal nerve?

A. Transverse arytenoid
B. Cricothyroid
C. Thyro-arytenoid
D. Posterior crico-arytenoid
E. Oblique arytenoid
Next question

The others are all supplied by the recurrent laryngeal nerve.

Larynx
The larynx lies in the anterior part of the neck at the levels of C3 to C6 vertebral bodies. The laryngeal skeleton consists of a
number of cartilagenous segments. Three of these are paired; arytenoid, corniculate and cuneiform. Three are single; thyroid,
cricoid and epiglottic. The cricoid cartilage forms a complete ring (the only one to do so).
The laryngeal cavity extends from the laryngeal inlet to the level of the inferior border of the cricoid cartilage.
Divisions of the laryngeal cavity
Laryngeal vestibule

Superior to the vestibular folds

Laryngeal ventricle

Lies between vestibular folds and superior to the vocal cords

Infraglottic cavity

Extends from vocal cords to inferior border of the cricoid cartilage

The vocal folds (true vocal cords) control sound production. The apex of each fold projects medially into the laryngeal cavity.
Each vocal fold includes:

Vocal ligament
Vocalis muscle (most medial part of thyroarytenoid muscle)

The glottis is composed of the vocal folds, processes and rima glottidis. The rima glottidis is the narrowest potential site within
the larynx, as the vocal cords may be completely opposed, forming a complete barrier.
Muscles of the larynx
Muscle

Origin

Insertion

Innervation

Action

Posterior
cricoarytenoid

Posterior aspect of
lamina of cricoid

Muscular process of
arytenoid

Recurrent
Laryngeal

Abducts vocal fold

Lateral
cricoarytenoid

Arch of cricoid

Muscular process of
arytenoid

Recurrent
laryngeal

Adducts vocal fold

Thyroarytenoid

Posterior aspect of
thyroid cartilage

Muscular process of
arytenoid

Recurrent
laryngeal

Relaxes vocal fold

Transverse and
oblique arytenoids

Arytenoid cartilage

Contralateral arytenoid

Recurrent
laryngeal

Closure of
intercartilagenous part of
the rima glottidis

Vocalis

Depression between
lamina of thyroid
cartilage

Vocal ligament and

vocal process of
arytenoid cartilage

Recurrent
laryngeal

Relaxes posterior vocal

ligament, tenses anterior
part

Cricothyroid

Anterolateral part of
cricoid

Inferior margin and horn

of thyroid cartilage

External
laryngeal

Tenses vocal fold

Blood supply
Arterial supply is via the laryngeal arteries, branches of the superior and inferior thyroid arteries. The superior laryngeal artery
is closely related to the internal laryngeal nerve. The inferior laryngeal artery is related to the inferior laryngeal nerve. Venous
drainage is via superior and inferior laryngeal veins, the former draining into the superior thyroid vein and the latter draining
into the middle thyroid vein, or thyroid venous plexus.
Lymphatic drainage
The vocal cords have no lymphatic drainage and this site acts as a lymphatic watershed.
Supraglottic part

Upper deep cervical nodes

Subglottic part

Prelaryngeal and pretracheal nodes and inferior deep cervical nodes

The aryepiglottic fold and vestibular folds have a dense plexus of lymphatics associated with them and malignancies at these
sites have a greater propensity for nodal metastasis.

Topography of the larynx

Image sourced from Wikipedia

Question 1 of 248

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A 28 year old man has sustained a non salvageable testicular injury to his left testicle. The surgeon decides to perform an
orchidectomy and divides the left testicular artery. From which of the following does this vessel originate?
A. Abdominal aorta

B. Internal iliac artery

C. Inferior epigastric artery
D. Inferior vesical artery
E. External iliac artery
Next question
The testicular artery is a branch of the abdominal aorta.
Scrotal and testicular anatomy
Spermatic cord
Formed by the vas deferens and is covered by the following structures:
Layer

Origin

Internal spermatic fascia

Transversalis fascia

Cremasteric fascia

From the fascial coverings of internal oblique

External spermatic fascia

External oblique aponeurosis

Contents of the cord

Vas deferens

Transmits sperm and accessory gland secretions

Testicular artery

Branch of abdominal aorta supplies testis and epididymis

Artery of vas deferens

Arises from inferior vesical artery

Cremasteric artery

Arises from inferior epigastric artery

Pampiniform plexus

Venous plexus, drains into right or left testicular vein

Sympathetic nerve fibres

Lie on arteries, the parasympathetic fibres lie on the vas

Genital branch of the genitofemoral nerve

Supplies cremaster

Lymphatic vessels

Drain to lumbar and para-aortic nodes

Scrotum

Composed of skin and closely attached dartos fascia.

Arterial supply from the anterior and posterior scrotal arteries

Lymphatic drainage to the inguinal lymph nodes
Parietal layer of the tunica vaginalis is the innermost layer

Testes

The testes are surrounded by the tunica vaginalis (closed peritoneal sac). The parietal layer of the tunica vaginalis
adjacent to the internal spermatic fascia.
The testicular arteries arise from the aorta immediately inferiorly to the renal arteries.
The pampiniform plexus drains into the testicular veins, the left drains into the left renal vein and the right into the
inferior vena cava.
Lymphatic drainage is to the para-aortic nodes.

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Question 2 of 248

During a carotid endarterectomy the internal carotid artery is cross clamped. Assuming that no shunt is inserted, which of the
following vessels will not have diminished or absent flow as a result?
A. Anterior cerebral artery
B. Ophthalmic artery
C. Middle cerebral artery
D. Maxillary artery
E. None of the above
Next question

Mnemonic for branches of the cerebral portion of the internal carotid artery 'Only Press Carotid Arteries Momentarily'
Only = Opthalmic
Press = Posterior communicating
Carotid = Choroidal
Arteries = Anterior cerebral
Momentarily = Middle cerebral

The maxillary artery is a branch of the external carotid artery.

Internal carotid artery
The internal carotid artery is formed from the common carotid opposite the upper border of the thyroid cartilage. It extends

superiorly to enter the skull via the carotid canal. From the carotid canal it then passes through the cavernous sinus, above
which it divides into the anterior and middle cerebral arteries.
Relations in the neck
Posterior

Longus capitis
Pre-vertebral fascia
Sympathetic chain
Superior laryngeal nerve

Medially

External carotid (near origin)

Wall of pharynx
Ascending pharyngeal artery

Laterally

Internal jugular vein (moves posteriorly at entrance to skull)

Vagus nerve (most posterolaterally)

Anteriorly

Sternocleidomastoid
Lingual and facial veins
Hypoglossal nerve

Relations in the carotid canal

Internal carotid plexus

Cochlea and middle ear cavity

Trigeminal ganglion (superiorly)
Leaves canal lies above the foramen lacerum

Path and relations in the cranial cavity

The artery bends sharply forwards in the cavernous sinus, the aducens nerve lies close to its inferolateral aspect. The
oculomotor, trochlear, opthalmic and, usually, the maxillary nerves lie in the lateral wall of the sinus. Near the superior orbital
fissure it turns posteriorly and passes postero-medially to pierce the roof of the cavernous sinus inferior to the optic nerve. It
then passes between the optic and oculomotor nerves to terminate below the anterior perforated substance by dividing into the
anterior and middle cerebral arteries.
Branches

Anterior and middle cerebral artery

Ophthalmic artery
Posterior communicating artery
Anterior choroid artery

Meningeal arteries

Hypophyseal arteries

Image demonstrating the internal carotid artery and its relationship to the external carotid artery

Image sourced from Wikipedia

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Question 3 of 248

A 72 year old lady with osteoporosis falls and sustains an intracapsular femoral neck fracture. The fracture is completely
displaced. Which of the following vessels is the main contributor to the arterial supply of the femoral head?
A. Deep external pudendal artery
B. Superficial femoral artery
C. External iliac artery
D. Circumflex femoral arteries
E. Superficial external pudendal artery
Next question
Theme from 2010 Exam

The vessels which form the anastomoses around the femoral head are derived from the medial and lateral circumflex femoral
arteries. These are usually derived from the profunda femoris artery.
Hip joint

Head of femur articulates with acetabulum of the pelvis

Both covered by articular hyaline cartilage

The acetabulum forms at the union of the ilium, pubis, and ischium
The triradiate cartilage (Y-shaped growth plate) separates the pelvic bones
The acetabulum holds the femoral head by the acetabular labrum
Normal angle between femoral head and femoral shaft is 130o

Ligaments

Transverse ligament: joints anterior and posterior ends of the articular cartilage
Head of femur ligament (ligamentum teres): acetabular notch to the fovea. Contains arterial supply to head of femur in
children.

Image sourced from Wikipedia

Image sourced from Wikipedia

Extracapsular ligaments

Iliofemoral ligament: inverted Y shape. Anterior iliac spine to the trochanteric line
Pubofemoral ligament: acetabulum to lesser trochanter
Ischiofemoral ligament: posterior support. Ischium to greater trochanter.

Blood supply
Medial circumflex femoral and lateral circumflex femoral arteries (Branches of profunda femoris)
2 anastomoses: Cruciate and the trochanteric anastomoses (provides most of the blood to the head of the femur) Hence the need
for hemiarthroplasty when there is a displaced femoral head fracture. These anastomoses exist between the femoral artery or
profunda femoris and the gluteal vessels.

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Question 4 of 248

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A 21 year old man is hit with a hammer and sustains a depressed skull fracture at the vertex. Which of the following sinuses is
at risk in this injury?
A. Superior sagittal sinus
B. Inferior petrosal sinus
C. Transverse sinus

D. Inferior sagittal sinus

E. Straight sinus
Next question
Theme in September 2011 Exam
The superior sagittal sinus is at greatest risk in this pattern of injury. This sinus begins at the front of the crista galli and courses
backwards along the falx cerebri. It becomes continuous with the right transverse sinus near the internal occipital protuberance.
Cranial venous sinuses
The cranial venous sinuses are located within the dura mater. They have no valves which is important in the potential for
spreading sepsis. They eventually drain into the internal jugular vein.
They are:
Superior sagittal sinus
Inferior sagittal sinus
Straight sinus
Transverse sinus
Sigmoid sinus
Confluence of sinuses
Occipital sinus
Cavernous sinus
Topography of cranial venous sinuses

Image s

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Question 5 of 248

A 44 year old man is stabbed in the back and the left kidney is injured. A haematoma forms, which of the following fascial
structures will contain the haematoma?
A. Waldeyers fascia
B. Sibsons fascia
C. Bucks fascia
D. Gerotas fascia
E. Denonvilliers fascia
Next question
Waldeyers fascia- Posterior ano-rectum
Sibsons fascia- Lung apex
Bucks fascia- Base of penis
Gerotas fascia- Surrounding kidney
Denonvilliers fascia- Between rectum and prostate
Renal anatomy
Each kidney is about 11cm long, 5cm wide and 3cm thick. They are located in a deep gutter alongside the projecting verterbral
bodies, on the anterior surface of psoas major. In most cases the left kidney lies approximately 1.5cm higher than the right. The
upper pole of both kidneys approximates with the 11th rib (beware pneumothorax during nephrectomy). On the left hand side
the hilum is located at the L1 vertebral level and the right kidney at level L1-2. The lower border of the kidneys is usually
alongside L3.
The table below shows the anatomical relations of the kidneys:
Relations
Relations

Right Kidney

Left Kidney

Posterior

Quadratus lumborum, diaphragm, psoas major,

transversus abdominis

Quadratus lumborum, diaphragm, psoas major,

transversus abdominis

Anterior

Hepatic flexure of colon

Stomach, Pancreatic tail

Superior

Liver, adrenal gland

Spleen, adrenal gland

Fascial covering
Each kidney and suprarenal gland is enclosed within a common and layer of investing fascia that is derived from the
transversalis fascia into anterior and posterior layers (Gerotas fascia).

Renal structure
Kidneys are surrounded by an outer cortex and an inner medulla which usually contains between 6 and 10 pyramidal structures.
The papilla marks the innermost apex of these. They terminate at the renal pelvis, into the ureter.
Lying in a hollow within the kidney is the renal sinus. This contains:
1. Branches of the renal artery
2. Tributaries of the renal vein
3. Major and minor calyces's
4. Fat
Structures at the renal hilum
The renal vein lies most anteriorly, then renal artery (it is an end artery) and the ureter lies most posterior.

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Question 6 of 248

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A baby is found to have a Klumpke's palsy post delivery. Which of the following is most likely to be present?
A. Loss of flexors of the wrist
B. Weak elbow flexion
C. Pronation of the forearm
D. Adducted shoulder
E. Shoulder medially rotated
Next question

Features of Klumpkes Paralysis

Claw hand (MCP joints extended and IP joints flexed)

Loss of sensation over medial aspect of forearm and hand
Horner's syndrome
Loss of flexors of the wrist

A C8, T1 root lesion is called Klumpke's paralysis and is caused by delivery with the arm extended.
Brachial plexus

Origin
Sections of the plexus

Anterior rami of C5 to T1

Roots, trunks, divisions, cords, branches

Mnemonic:Real Teenagers Drink Cold Beer

Roots

Located in the posterior triangle

Pass between scalenus anterior and medius

Trunks

Located posterior to middle third of clavicle

Upper and middle trunks related superiorly to the subclavian artery
Lower trunk passes over 1st rib posterior to the subclavian artery

Divisions

Apex of axilla

Cords

Related to axillary artery

Diagram illustrating the branches of the brachial plexus

Image sourced from Wikipedia

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Question 7 of 248

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A 22 year old man undergoes a superficial parotidectomy for a pleomorphic adenoma. The operation does not proceed well and
a diathermy malfunction results in division of the buccal branch of the facial nerve. Which of the following muscles will not
demonstrate impaired function as a result?
A. Zygomaticus minor

B. Mentalis
C. Buccinator
D. Levator anguli oris
E. Risorius
Next question
Buccal branch supplies
Zygomaticus minor

Elevates upper lip

Risorius

Aids smile
Pulls corner of mouth backward and compresses cheek

Buccinator
Levator anguli oris

Pulls angles of mouth upward and toward midline

Orbicularis

Closes and tightens lips together

Nasalis

Flares nostrils and compresses nostrils

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

Face: muscles of facial expression

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

Path
Subarachnoid path

Origin: motor- pons, sensory- nervus intermedius

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

Facial canal path

The canal passes superior to the vestibule of the inner ear

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

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

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

Face
Enters parotid gland and divides into 5 branches:

Temporal branch

Zygomatic branch
Buccal branch
Marginal mandibular branch
Cervical branch

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Question 8 of 248

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At which of the following vertebral body levels does the common carotid artery typically bifurcate into the external and internal
carotid arteries?
A. C4
B. C2
C. C1
D. C6
E. C7
Next question
It terminates at the upper border of the thyroid cartilege, Which is usually located at C4.
Common carotid artery

The right common carotid artery arises at the bifurcation of the brachiocephalic trunk, the left common carotid arises from the
arch of the aorta. Both terminate at the level of the upper border of the thyroid cartilage (the lower border of the third cervical
vertebra) by dividing into the internal and external carotid arteries.
Left common carotid artery
This vessel arises immediately to the left and slightly behind the origin of the brachiocephalic trunk. Its thoracic portion is 2.53.5 cm in length and runs superolaterally to the sternoclavicular joint.
In the thorax
The vessel is in contact, from below upwards, with the trachea, left recurrent laryngeal nerve, left margin of the oesophagus.
Anteriorly the left brachiocephalic vein runs across the artery, and the cardiac branches from the left vagus descend in front of
it. These structures together with the thymus and the anterior margins of the left lung and pleura separate the artery from the
manubrium.
In the neck
The artery runs superiorly deep to sternocleidomastoid and then enters the anterior triangle. At this point it lies within the
carotid sheath with the vagus nerve and the internal jugular vein. Posteriorly the sympathetic trunk lies between the vessel and
the prevertebral fascia. At the level of C7 the vertebral artery and thoracic duct lie behind it. The anterior tubercle of C6
transverse process is prominent and the artery can be compressed against this structure (it corresponds to the level of the
cricoid).
Anteriorly at C6 the omohyoid muscle passes superficial to the artery.
Within the carotid sheath the jugular vein lies lateral to the artery.
Right common carotid artery
The right common carotid arises from the brachiocephalic artery. The right common carotid artery corresponds with the cervical
portion of the left common carotid, except that there is no thoracic duct on the right. The oesophagus is less closely related to
the right carotid than the left.
Summary points about the carotid anatomy
Path
Passes behind the sternoclavicular joint (12% patients above this level) to the upper border of the thyroid cartilage, to divide
into the external (ECA) and internal carotid arteries (ICA).
Relations

Level of 6th cervical vertebra crossed by omohyoid

Then passes deep to the thyrohyoid, sternohyoid, sternomastoid muscles.

Passes anterior to the carotid tubercle (transverse process 6th cervical vertebra)-NB compression here stops
haemorrhage.
The inferior thyroid artery passes posterior to the common carotid artery.
Then : Left common carotid artery crossed by thoracic duct, Right common carotid artery crossed by recurrent
laryngeal nerve

Previous

Question 9 of 248

Next

A man is stabbed in the chest to the right of the manubriosternal angle. Which structure is least likely to be injured in this case?
A. Aortic arch
B. The trachea
C. Right phrenic nerve
D. Right recurrent laryngeal nerve
E. Brachiocephalic vein
Next question
The right recurrent laryngeal nerve branches off the right vagus more proximally and arches posteriorly round the subclavian
artery. So of the structures given it is the least likely to be injured.
Mediastinum
Region between the pulmonary cavities.
It is covered by the mediastinal pleura. It does not contain the lungs.
It extends from the thoracic inlet superiorly to the diaphragm inferiorly.
Mediastinal regions

Superior mediastinum

Inferior mediastinum
Posterior mediastinum
Anterior mediastinum

Region
Superior mediastinum

Contents

Superior vena cava

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

Anterior mediastinum

Thymic remnants
Lymph nodes
Fat

Middle mediastinum

Pericardium
Heart
Aortic root
Arch of azygos vein
Main bronchi

Posterior mediastinum

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

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Question 10 of 248

Next

An 18 year old man is stabbed in the neck and has to undergo repair of a laceration to the internal carotid artery. Post
operatively he is noted to have a Horners syndrome. Which of the following will not be present?
A. Apparent enopthalmos
B. Loss of sweating on the entire ipsilateral side of the face
C. Constricted pupil
D. Mild ptosis
E. Normal sympathetic activity in the torso
Next question
The anhidrosis will be mild as this is a distal lesion and at worst only a very limited area of the ipsilateral face will be
anhidrotic.
Horners syndrome
Horners syndrome, clinical features:

Ptosis

Miosis
Enopthalmos
Anhydrosis

Primarily a disorder of the sympathetic nervous system. Extent of symptoms depends upon the anatomical site of the lesion.
Proximal lesions occur along the hypothalamospinal tract
Distal lesions are usually post ganglionic e.g. at level of internal carotid artery or beyond.
In contrast to a 3rd nerve palsy the ptosis is more mild and the pupil constricted rather than dilated.
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Question 11 of 248

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Which of the following types of epithelium lines the lumenal surface of the normal oesophagus?
A. Non keratinised stratified squamous epithelium
B. Ciliated columnar epithelium
C. Keratinised stratified squamous epithelium
D. Non ciliated columnar epithelium
E. None of the above
Next question
The oesphagus is lined by non keratinised stratified squamous epithelium. Changes to glandular type epithelium occur as part of
metaplastic processes in reflux.
Oesophagus

25cm long

Starts at C6 vertebra, pierces diaphragm at T10 and ends at T11

Squamous epithelium

Constrictions of the oesophagus

Structure

Distance from incisors

Cricoid cartilage

15cm

Arch of the Aorta

22.5cm

Left principal bronchus

27cm

Diaphragmatic hiatus

40cm

Relations
Anteriorly

Trachea to T4
Recurrent laryngeal nerve
Left bronchus, Left atrium
Diaphragm

Posteriorly

Thoracic duct to left at T5

Hemiazygos to the left T8
Descending aorta
First 2 intercostal branches of aorta

Left

Thoracic duct
Left subclavian artery

Right

Azygos vein

Arterial, venous and lymphatic drainage of the oesophagus

Artery

Vein

Lymphatics

Muscularis externa

Upper third

Inferior thyroid

Inferior thyroid

Deep cervical

Striated muscle

Mid third

Aortic branches

Azygos branches

Mediastinal

Smooth & striated muscle

Lower third

Left gastric

Posterior mediastinal and coeliac

Gastric

Smooth muscle

Nerve supply

Upper half is supplied by recurrent laryngeal nerve

Lower half by oesophageal plexus (vagus)

Histology

Mucosa :Nonkeratinized stratified squamous epithelium

Submucosa: glandular tissue
Muscularis externa (muscularis): composition varies. See table
Adventitia

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Question 12 of 248

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A 23 year old man is stabbed in the neck, in the region between the omohyoid and digastric muscles, the injury is explored
surgically. At operation a nerve injury is identified immediately superior to the lingual artery as is branches off the external
carotid artery. Which of the following is the most likely result of this injury?
A. Paralysis of the ipsilateral side of the tongue
B. Abduction of the ipsilateral vocal cord
C. Winging of the scapula
D. Paralysis of the ipsilateral hemi diaphragm
E. Inability to abduct the shoulder
Next question
The hypoglossal nerve runs anterior to the external carotid, above the lingual arterial branch. If damaged then ipsilateral
paralysis of the genioglossus, hyoglossus and styloglossus muscles will occur. If the patient is asked to protrude their tongue
then it will tend to point to the affected side.
Anterior triangle of the neck

Boundaries
Anterior border of the Sternocleidomastoid
Lower border of mandible
Anterior midline

Sub triangles (divided by Digastric above and Omohyoid)

Muscular triangle: Neck strap muscles

Carotid triangle: Carotid sheath

Submandibular Triangle (digastric)

Contents of the anterior triangle

Digastric triangle

Submandibular gland
Submandibular nodes
Facial vessels
Hypoglossal nerve

Muscular triangle

Strap muscles
External jugular vein

Carotid triangle

Carotid sheath (Common carotid, vagus and internal jugular vein)

Ansa cervicalis

Nerve supply to digastric muscle

Anterior: Mylohyoid nerve

Posterior: Facial nerve

Image sourced from Wikipedia

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Question 13 of 248

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Which of the following structures is not directly related to the right adrenal gland?
A. Diaphragm posteriorly
B. Bare area of the liver anteriorly
C. Right renal vein
D. Inferior vena cava
E. Hepato-renal pouch
Next question
The right renal vein is very short and lies more inferiorly.
Adrenal gland anatomy
Anatomy

Location

Superomedially to the upper pole of each kidney

Relationships of the right

adrenal

Diaphragm-Posteriorly, Kidney-Inferiorly, Vena Cava-Medially, Hepato-renal pouch and

bare area of the liver-Anteriorly

Relationships of the left

adrenal

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

Arterial supply

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

Venous drainage of the right

adrenal

Via one central vein directly into the IVC

Venous drainage of the left

adrenal

Via one central vein into the left renal vein

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Question 14 of 248

With respect to the basilic vein, which statement is false?

A. Its deep anatomical location makes it unsuitable for use as an arteriovenous
access site in fistula surgery
B. It originates from the dorsal venous network on the hand
C. It travels up the medial aspect of the forearm
D. Halfway between the shoulder and the elbow it lies deep to muscle
E. It joins the brachial vein to form the axillary vein
Next question
It is used in arteriovenous fistula surgery during a procedure known as a basilic vein transposition.
Basilic vein
The basilic and cephalic veins both provide the main pathways of venous drainage for the arm and hand. It is continuous with
the palmar venous arch distally and the axillary vein proximally.
Path

Originates on the medial side of the dorsal venous network of the hand, and passes up the forearm and arm.
Most of its course is superficial.
Near the region anterior to the cubital fossa the vein joins the cephalic vein.
Midway up the humerus the basilic vein passes deep under the muscles.
At the lower border of the teres major muscle, the anterior and posterior circumflex humeral veins feed into it.
Joins the brachial veins to form the axillary vein.

Previous

Question 15 of 248

Next

Mobilisation of the left lobe of the liver will facilitate surgical access to which of the following?
A. Abdominal oesophagus
B. Duodenum
C. Right colic flexure
D. Right kidney
E. Pylorus of stomach
Next question
The fundus of the stomach is a posterior relation. The pylorus lies more inferolaterally. During a total gastrectomy division of
the ligaments holding the left lobe of the liver will facilitate access to the proximal stomach and abdominal oesophagus. This
manoeuvre is seldom beneficial during a distal gastrectomy.
Liver
Structure of the liver
Right lobe

Supplied by right hepatic artery

Contains Couinard segments V to VIII (-/+Sg I)

Left lobe

Supplied by the left hepatic artery

Contains Couinard segments II to IV (+/- Sg1)

Quadrate lobe

Part of the right lobe anatomically, functionally is part of the left

Couinard segment IV
Porta hepatis lies behind
On the right lies the gallbladder fossa
On the left lies the fossa for the umbilical vein

Caudate lobe

Supplied by both right and left hepatic arteries

Couinard segment I
Lies behind the plane of the porta hepatis
Anterior and lateral to the inferior vena cava
Bile from the caudate lobe drains into both right and left hepatic ducts

Detailed knowledge of Couinard segments is not required for MRCS Part A

Between the liver lobules are portal canals which contain the portal triad: Hepatic Artery, Portal Vein, tributary of Bile
Duct.

Relations of the liver

Anterior

Postero inferiorly

Diaphragm

Oesophagus

Xiphoid process

Stomach
Duodenum
Hepatic flexure of colon
Right kidney
Gallbladder
Inferior vena cava

Porta hepatis
Location

Transmits

Postero inferior surface, it joins nearly at right angles with the left sagittal fossa, and separates the caudate lobe
behind from the quadrate lobe in front

Common hepatic duct

Hepatic artery
Portal vein
Sympathetic and parasympathetic nerve fibres
Lymphatic drainage of the liver (and nodes)

Ligaments
Falciform ligament

2 layer fold peritoneum from the umbilicus to anterior liver surface

Contains ligamentum teres (remnant umbilical vein)
On superior liver surface it splits into the coronary and left triangular ligaments

Ligamentum teres

Joins the left branch of the portal vein in the porta hepatis

Ligamentum venosum

Remnant of ductus venosus

Arterial supply

Hepatic artery

Venous

Hepatic veins
Portal vein

Nervous supply

Sympathetic and parasympathetic trunks of coeliac plexus

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Question 16 of 248

Next

The following statements relating to the ankle joint are true except?
A. Three groups of ligaments provide mechanical stability
B. The sural nerve lies medial to the Achilles tendon at its point of insertion
C. Eversion of the foot occurs at the sub talar joint
D. The flexor hallucis longus tendon is the most posterior structure at the medial
malleolus
E. The saphenous nerve crosses the ankle joint.
Next question
The sural nerve lies behind the distal fibula. Inversion and eversion are sub talar movements. The structures passing behind the
medial malleolus from anterior to posterior include: tibialis posterior, flexor digitorum longus, posterior tibia vein, posterior
tibial artery, nerve, flexor hallucis longus.

Ankle joint
The ankle joint is a synovial joint composed of the tibia and fibula superiorly and the talus inferiorly.
Ligaments of the ankle joint

Deltoid ligament (medially)

Lateral collateral ligament

Talofibular ligaments (both anteriorly and posteriorly)

The calcaneofibular ligament is separate from the fibrous capsule of the joint. The two talofibular ligaments are fused with it.
The components of the syndesmosis are

Antero-inferior talofibular ligament

Postero-inferior talofibular ligament
Inferior transverse talofibular ligament
Interosseous ligament

Movements at the ankle joint

Plantar flexion (55 degrees)

Dorsiflexion (35 degrees)

Inversion and eversion movements occur at the level of the sub talar joint

Nerve supply
Branches of deep peroneal and tibial nerves.
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Question 17 of 248

Next

A 78 year old man is lifting a heavy object when a feels a pain in his forearm and is unable to continue. He has a swelling over
his upper forearm. An MRI scan shows a small cuff of tendon still attached to the radial tuberosity consistent with a recent tear.
Which of the following muscles has been injured?
A. Pronator teres
B. Supinator
C. Aconeus
D. Brachioradialis
E. Biceps brachii
Next question
Biceps inserts into the radial tuberosity. Distal injuries of this muscle are rare but are reported and are clinically more important
than more proximal ruptures.
Radius

Bone of the forearm extending from the lateral side of the elbow to the thumb side of the wrist

Upper end

Articular cartilage- covers medial > lateral side

Articulates with radial notch of the ulna by the annular ligament
Muscle attachment- biceps brachii at the tuberosity

Shaft

Muscle attachment-

Upper third of the body Supinator, Flexor digitorum superficialis, Flexor pollicis longus
Middle third of the body Pronator teres
Lower quarter of the body Pronator quadratus , tendon of supinator longus
Lower end

Quadrilateral
Anterior surface- capsule of wrist joint
Medial surface- head of ulna
Lateral surface- ends in the styloid process
Posterior surface: 3 grooves containing:

1. Tendons of extensor carpi radialis longus and brevis

2. Tendon of extensor pollicis longus
3. Tendon of extensor indicis

Image sourced from Wikipedia

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Question 18 of 248

The oesophagus is constricted at the following levels apart from:

A. Cricoid cartilage
B. Arch of the aorta
C. Lower oesophageal sphincter
D. Left main stem bronchus
E. Diaphragmatic hiatus

Next

Next question
The oesophagus is not constricted at the level of the lower oesophageal sphincter.
Previous
Next
Question 19 of 248
A 19 year old man is playing rugby when he suddenly notices a severe pain at the posterolateral aspect of his right thigh. Which
of the following muscle groups is most likely to have been injured?
A. Semimembranosus
B. Semitendinosus
C. Long head of biceps femoris
D. Gastrocnemius
E. Soleus
Next question
Theme from April 2012 Exam
The biceps femoris is the laterally located hamstring muscle. The semitendinosus and semimembranosus are located medially.
Rupture of gastrocnemius and soleus may occur but is less common.
Biceps femoris
The biceps femoris is one of the hamstring group of muscles located in the posterior upper thigh. It has two heads.
Long head
Origin

Ischial tuberosity

Insertion

Fibular head

Action

Knee flexion, lateral rotation tibia, extension hip

Innervation

Tibial nerve (L5, S1, S2)

Arterial supply

Profunda femoris artery, inferior gluteal artery, and the superior muscular branches of popliteal artery

Image demonstrating the biceps femoris muscle, with the long head outlined

Image sourced from Wikipedia

Short head
Origin

Lateral lip of linea aspera, lateral supracondylar ridge of femur

Insertion

Fibular head

Action

Knee flexion, lateral rotation tibia

Innervation

Common peroneal nerve (L5, S1, S2)

Arterial supply

Profunda femoris artery, inferior gluteal artery, and the superior muscular branches of popliteal artery

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Question 20 of 248

Next

Which of the following is a branch of the third part of the axillary artery?
A. Superior thoracic
B. Lateral thoracic
C. Dorsal scapular
D. Thoracoacromial
E. Posterior circumflex humeral
Next question
The other branches include:

Subscapular
Anterior circumflex humeral

Axilla
Boundaries of the axilla
Medially

Chest wall and Serratus anterior

Laterally

Humeral head

Floor

Subscapularis

Anterior aspect

Lateral border of Pectoralis major

Fascia

Clavipectoral fascia

Content:
Long thoracic nerve (of
Bell)

Derived from C5-C7 and passes behind the brachial plexus to enter the axilla. It lies on the
medial chest wall and supplies serratus anterior. Its location puts it at risk during axillary
surgery and damage will lead to winging of the scapula.

Thoracodorsal nerve and

thoracodorsal trunk

Innervate and vascularise latissimus dorsi.

Axillary vein

Lies at the apex of the axilla, it is the continuation of the basilic vein. Becomes the subclavian
vein at the outer border of the first rib.

Intercostobrachial nerves

Traverse the axillary lymph nodes and are often divided during axillary surgery. They
provide cutaneous sensation to the axillary skin.

Lymph nodes

The axilla is the main site of lymphatic drainage for the breast.

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Question 21 of 248

Which of the following structures separates the intervertebral disks from the spinal cord?
A. Anterior longitudinal ligament
B. Posterior longitudinal ligament
C. Supraspinous ligament

Next

D. Interspinous ligament
E. Ligamentum flavum
Next question
The posterior longitudinal ligament overlies the posterior aspect of the vertebral bodies. It also overlies the posterior aspect of
the intervertebral disks.
Intervertebral discs

Consist of an outer annulus fibrosus and an inner nucleus pulposus.

The anulus fibrosus consists of several layers of fibrocartilage.

The nucleus pulposus contains loose fibres suspended in a mucoprotein gel with the consistency of jelly. The nucleus
of the disc acts as a shock absorber.
Pressure on the disc causes posterior protrusion of the nucleus pulposus. Most commonly in the lumbrosacral and lower

cervical areas.
The discs are separated by hyaline cartilage.
There is one disc between each pair of vertebrae, except for C1/2 and the sacrococcygeal vertebrae.

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Question 22 of 248

Next

At what level does the aorta bifurcate into the left and right common iliac arteries?
A. L1
B. L2
C. L3
D. L4
E. L5
Next question
The aorta typically bifurcates at L4. This level is usually fairly constant and is often tested in the exam.
Levels
Transpyloric plane
Level of the body of L1

Pylorus stomach
Left kidney hilum (L1- left one!)
Right hilum of the kidney (1.5cm lower than the left)

Fundus of the gallbladder

Neck of pancreas
Duodenojejunal flexure
Superior mesenteric artery
Portal vein
Left and right colic flexure
Root of the transverse mesocolon
2nd part of the duodenum
Upper part of conus medullaris
Spleen

Can be identified by asking the supine patient to sit up without using their arms. The plane is located where the lateral border of
the rectus muscle crosses the costal margin.
Anatomical planes
Subcostal plane

Lowest margin of 10th costal cartilage

Intercristal plane

Level of body L4 (highest point of iliac crest)

Intertubercular plane

Level of body L5

Common level landmarks

Inferior mesenteric artery

L3

Bifurcation of aorta into common iliac arteries

L4

Formation of IVC

L5 (union of common iliac veins)

Diaphragm apertures

Previous

Vena cava T8
Oesophagus T10
Aortic hiatus T12

Question 23 of 248

Next

A 23 year old man is due to undergo a mitral valve repair for mitral regurgitation. Which of the following is a feature of the
mitral valve?
A. Its closure is marked by the first heart sound
B. It has two anterior cusps
C. The chordae tendinae attach to the anterior cusps only

D. The chordae tendinae anchor the valve directly to the wall of the left ventricle
E. It is best auscultated in the left third interspace
Next question
The mitral valve is best auscultated over the cardiac apex, where its closure marks the first heart sound. It has only two cusps.
These are attached to chordae tendinae which themselves are linked to the wall of the ventricle by the papillary muscles.
Heart anatomy
The walls of each cardiac chamber comprise:

Epicardium
Myocardium
Endocardium

Cardiac muscle is attached to the cardiac fibrous skeleton.

Relations
The heart and roots of the great vessels within the pericardial sac are related anteriorly to the sternum, medial ends of the 3rd to
5th ribs on the left and their associated costal cartilages. The heart and pericardial sac are situated obliquely two thirds to the left
and one third to the right of the median plane.
The pulmonary valve lies at the level of the left third costal cartilage.
The mitral valve lies at the level of the fourth costal cartilage.
Coronary sinus
This lies in the posterior part of the coronary groove and receives blood from the cardiac veins. The great cardiac vein lies at its
left and the middle and small cardiac veins lie on its right. The smallest cardiac veins drain into the atria directly.
Aortic sinus
Right coronary artery arises from the right aortic sinus, the left is derived from the left aortic sinus and no vessel emerges from
the posterior sinus.
Right and left ventricles

Structure

Left Ventricle

A-V Valve

Mitral (double leaflet)

Walls

Twice as thick as right

Trabeculae carnae

Much thicker and more numerous

Right coronary artery

The RCA supplies:

Right atrium
Diaphragmatic part of the left ventricle
Usually the posterior third of the interventricular septum
The sino atrial node (60% cases)
The atrio ventricular node (80% cases)

Left coronary artery

The LCA supplies:

Left atrium

Most of left ventricle

Part of the right ventricle

Anterior two thirds of the inter ventricular septum

The sino atrial node (remaining 40% cases)

Innervation of the heart

Autonomic nerve fibres from the superficial and deep cardiac plexus. These lie anterior to the bifurcation of the trachea,
posterior to the ascending aorta and superior to the bifurcation of the pulmonary trunk. The parasympathetic supply to the heart
is from presynaptic fibres of the vagus nerves.
Valves of the heart
Mitral valve

Aortic valve

Pulmonary valve

Tricuspid valve

2 cusps

3 cusps

3 cusps

3 cusps

First heart sound

Second heart sound

Second heart sound

First heart sound

1 anterior cusp

1 anterior cusp

2 anterior cusps

2 anterior cusps

Attached to chordae tendinae

No chordae

No chordae

Attached to chordae tendinae

Previous 2 / 3

Question 24-26 of 248

Theme: Nerve lesions

A. Intercostobrachial
B. Median
C. Axillary
D. Radial

Next

E. Ulnar
F. Musculocutaneous
G. Brachial plexus upper cord
H. Brachial plexus lower cord
Please select the most likely nerve injury for the scenarios given. Each option may be used once, more than once or not at all.

24.

A 23 year old rugby player sustains a Smiths Fracture. On examination opposition of the thumb is markedly
weakened.
Median
This high velocity injury can often produce significant angulation and displacement. Both of these may impair the
function of the median nerve with loss of function of the muscles of the thenar eminence

25.

A 45 year old lady recovering from a mastectomy and axillary node clearance notices that sensation in her armpit is
impaired.
Intercostobrachial
The intercostobrachial nerves are frequently injured during axillary dissection. These nerves traverse the axilla and
supply cutaneous sensation.

26.

An 8 year old boy falls onto an outstretched hand and sustains a supracondylar fracture. In addition to a weak radial
pulse the child is noted to have loss of pronation of the affected hand.
You answered Ulnar
The correct answer is Median
This is a common injury in children. In this case the angulation and displacement have resulted in median nerve
injury.

Previou
s

Question 27 of 248

Next

A 23 year old lady with sialolithiasis of the submandibular gland is undergoing excision of the gland. Which of the following
nerves is at risk as the duct is mobilised?
A. Lingual nerve
B. Buccal nerve
C. Facial nerve

D. Glossopharyngeal
E. Vagus
Next question
The lingual nerve wraps around Whartons duct. The lingual nerve provides sensory supply to the anterior 2/3 of the tongue.
Submandibular gland
Relations of the submandibular gland
Superficial

Platysma, deep fascia and mandible

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

Deep

Facial artery (inferior to the mandible)

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

Submandibular duct (Wharton's duct)

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

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

Innervation

Sympathetic innervation- Superior Cervical ganglion via the Lingual nerve

Parasympathetic innervation- Submandibular ganglion

Arterial supply
Branch of the Facial artery. The facial artery passes through the gland to groove its deep surface. It then emerges onto the face
by passing between the gland and the mandible.
Venous drainage
Anterior Facial vein (lies deep to the Marginal Mandibular nerve)

Lymphatic drainage
Deep cervical and jugular chains of nodes
Previous

Question 28 of 248

Next

Which of the following is true in connection with the phrenic nerves?

A. They both lie anterior to the hilum of the lungs
B. They are derived from spinal roots C 2,3,4
C. They pierce the diaphragm at the level of T7
D. They consist of motor fibres only
E. None of the above
Next question

C3,4,5
Keeps the diaphragm alive!

They both lie anterior to the hilum of the lung. The phrenic nerves have both motor and sensory functions. For this reason sub
diaphragmatic pathology may cause referred pain to the shoulder.
Phrenic nerve
Origin

C3,4,5

Supplies

Diaphragm, sensation central diaphragm and pericardium

Path

The phrenic nerve passes with the internal jugular vein across scalenus anterior. It passes deep to prevertebral fascia of
deep cervical fascia.
Left: crosses anterior to the 1st part of the subclavian artery.
Right: Anterior to scalenus anterior and crosses anterior to the 2nd part of the subclavian artery.
On both sides, the phrenic nerve runs posterior to the subclavian vein and posterior to the internal thoracic artery as it
enters the thorax.

Right phrenic nerve

In the superior mediastinum: anterior to right vagus and laterally to superior vena cava
Middle mediastinum: right of pericardium
It passes over the right atrium to exit the diaphragm at T8

Left phrenic nerve

Passes lateral to the left subclavian artery, aortic arch and left ventricle

Passes anterior to the root of the lung

Pierces the diaphragm alone

Image showing the passage of the phrenic nerve in the neck

Image sourced from Wikipedia

Question 29
of 248

Previous

Next

A 32 year old man presents with an inguinal hernia and undergoes an open surgical repair. The surgeons decide to place a mesh
on the posterior wall of the inguinal canal to complete the repair, which of the following structures will lie posterior to the
mesh?
A. Transversalis fascia
B. External oblique
C. Rectus abdominis

D. Obturator nerve
E. None of the above
Next question

Inguinal canal walls: 'MALT: 2M, 2A, 2L, 2T':

Starting from superior, moving around in order to posterior:
Superior wall (roof): 2 Muscles:Internal oblique, transversus abdominis
Anterior wall: 2 Aponeuroses: Aponeurosis of external oblique, Aponeurosis of internal oblique
Lower wall (floor): 2 Ligaments: Inguinal Ligament, Lacunar Ligament Posterior wall: 2Ts: Transversalis fascia, Conjoint
Tendon

This is actually quite a straightforward question. It is simply asking for the structure that forms the posterior wall of the inguinal
canal. This is composed of the transversalis fascia, the conjoint tendon and more laterally the deep inguinal ring.
Inguinal canal
Location

Above the inguinal ligament

The inguinal canal is 4cm long

Boundaries of the inguinal canal

Floor

External oblique aponeurosis

Inguinal ligament
Lacunar ligament

Roof

Internal oblique
Transversus abdominis

Anterior wall

External oblique aponeurosis

Posterior wall

Transversalis fascia
Conjoint tendon

Laterally

Internal ring
Fibres of internal oblique

Medially

External ring
Conjoint tendon

Contents
Males

Spermatic cord and ilioinguinal nerve

As it passes through the canal the spermatic cord has 3 coverings:

Females

External spermatic fascia from external oblique

aponeurosis
Cremasteric fascia
Internal spermatic fascia

Round ligament of uterus and ilioinguinal

nerve

Related anatomy of the inguinal region

The boundaries of Hesselbachs triangle are commonly tested and illustrated below:

Image sourced from Wikipedia

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

Image sourced from Wikipedia