- The anterior triangle of the neck:
Is bounded posteriorly by the anterior border of sternocleidomastoid [T]
Contains the carotid sheath [T]
Contains the external jugular vein [F]
Is overlain by skin supplied by the transverse cervical nerve(s) [T
- Regarding the anterolateral abdominal wall:
The lumbar triangle (of Petit) is bounded by the posterior border of the external oblique
muscle, the anterior border of the latissimus dorsi muscle and the iliac crest [T]
The floor of the lumbar triangle (of Petit) is formed by the transversus abdominis
muscle [F]
During a landmark technique TAP block, two ‘pops’ are felt as the needle passes
through the thoracolumbar fascia and external oblique layer [F]
A subcostal TAP block can be used for surgery extending above the umbilicus [T]
The external oblique, internal oblique and transversus abdominis muscles all have the
same innervation, which is solely from the thoracoabdominal (T7–11) and subcostal
(T12) nerves [F]
The floor of the inferior lumbar triangle (of Petit) is formed by internal oblique muscle. The
two ‘pops’ felt during a TAP block are from the needle passing through the aponeuroses of
the external then internal oblique muscles. The internal oblique and transversus abdominis
muscles are also supplied by the iliohypogastric and ilioinguinal nerves (L1).
- At the ankle:
All of the deep nerves supplying the foot are branches of the sciatic nerve [T]
The deep peroneal nerve enters the dorsum of the foot between the tendons of extensor
hallucis longus and extensor digitorum longus [T]
The deep peroneal nerve is a hyperechoic structure on ultrasound [T]
The superficial peroneal nerve emerges between extensor digitorum longus and
peroneus brevis [T]
The sural nerve lies anterior to the medial malleolus [F]
The saphenous nerve is a branch of the femoral nerve. The sural nerve lies posterior to
the lateral malleolus and is associated with the short saphenous vein.
- Regarding the larynx and trachea:
In the adult, the narrowest part of the upper respiratory tract is at the level of the cricoid
cartilage [F]
In the child, the narrowest part of the upper respiratory tract is at the level of the (open)
vocal cords [F]
The position of the carina moves with respiration [T]
The trachea is in contact with the left vagus nerve in the thorax [F]
The trachea is in contact with the thoracic duct posteriorly [F]
The cricoid cartilage is the narrowest part of the upper respiratory tract in the child, in the
adult it is at the vocal cords. The left vagus nerve lies on the arch of the aorta (not the trachea)
and the thoracic duct lies behind and in contact with the oesophagus (not the trachea).
- The following is true of the ribs:
The sympathetic trunk is an anterior relation of the neck of the first rib [T]
Typical ribs have a head with two articular facets, for articulation with their own
vertebra and the one below [F]
Typical ribs have a tubercle with a smooth articular facet, which forms a synovial joint
with the transverse process of the corresponding vertebra [T]
Typical ribs have a tubercle with a rough non-articular facet, for attachment of the
lateral costotransverse ligament [T]
The costal cartilages of ribs 2–10 form primary cartilaginous joints with the sternum or
rib/costal cartilage above [F]
More specifically, the stellate/cervicothoracic ganglion lies on the anterior surface of the
neck of the first rib. Typical ribs do have two articular facets, but they articulate with the
corresponding vertebra and the one above. The costal cartilages of ribs 2–10 form a
synovial joint with the sternum or costal cartilage above.
- Regarding autonomic dysreflexia:
Excess sympathetic discharge occurs in response to stimuli below level of spinal cord
lesion [T]
Features are more pronounced with higher lesions and a stronger reaction is observed if
a more proximal dermatome is stimulated [F]
Patients develop tachycardia/arrhythmias, with severe hypotension and headache [F]
Below the level of the spinal cord lesion, patients exhibit sweating, pallor and muscle
contraction/spasticity [T]
Central neuroaxial blockade can be used to prevent and manage autonomic dysreflexia [T]
After a transecting injury of the spinal cord, stimulation of spinal cord reflexes below the
level of the injury are exaggerated due to the loss of descending inhibition from higher
centres. Features are more pronounced with stimulation of more distal/lower levels.
Patients typically develop severe hypertension with reflex bradycardia.
- The following are true of the internal auditory meatus/auditory canal:
It transmits the vestibulocochlear nerve and the facial nerve [T]
It is directed laterally in the petrous bone [T]
It connects the middle cranial fossa to the inner ear [F]
It contains only the motor component of CN 7 [F]
The vestibular ganglion lies within the internal auditory meatus [T]
The internal auditory meatus/auditory canal connects the posterior cranial fossa and
inner ear. The vestibular ganglion (equivalent to the DRG of a spinal nerve) lies within
the IAM
- Regarding the rectus abdominis:
The rectus abdominis muscle lies superficial to the external oblique aponeurosis [F]
The superior epigastric artery is a branch of the internal thoracic artery [T]
The arcuate line of the rectus sheath lies approximately halfway between the pubic
symphysis and umbilicus [T]
Motor supply of the rectus abdominis is partly by the iliohypogastric nerve [F]
Perforation of the inferior epigastric artery is a common complication of rectus sheath
block [F]
The external oblique aponeurosis contributes to the anterior layer of the rectus sheath,
hence the rectus abdominis muscle lies deep to it. Motor supply to rectus abdominis is
from the thoracoabdominal (T7–11) and subcostal (T12) nerves. Perforation of the
inferior epigastric artery is a minor risk of rectus sheath block, especially when per-
formed at or below the level of the umbilicus.
- The following is true of the lower limb vasculature:
The femoral artery lies in the adductor (subsartorial/Hunter’s) canal [T]
The inferior epigastric artery is a branch of the femoral artery [F]
The femoral vein lies medial to the femoral artery initially, but lies posteriorly to it at
the apex of the femoral triangle [T]
The popliteal vein is the deepest structure in the popliteal fossa [F]
The peroneal artery provides little or no arterial supply to the foot [T]
The inferior epigastric artery arises from the external iliac artery, just before the latter
passes beneath the inguinal ligament to become the femoral artery. The popliteal artery
is the deepest structure in the popliteal fossa, making it difficult to palpate. The peroneal
(fibular) artery arises from the tibioperoneal trunk, along with the posterior tibial
artery, and supplies the lateral compartment of the leg. The foot is supplied by the
anterior and posterior tibial arteries, the former becoming the dorsalis pedis artery as it
crosses the ankle joint into the foot.
- Regarding the scalp block:
The infraorbital nerve is targeted [F]
The transverse cervical nerves are targeted [F]
The third occipital nerve is targeted [F]
A scalp block can be the sole technique used for awake craniotomy, without
sedation or general anaesthesia, as the brain itself is not sensitive to painful
stimuli [T]
Intra-arterial injection into the superficial temporal artery is possible when targeting
the auriculotemporal nerve [T]
The supraorbital (not infraorbital) nerve is targeted (although the infratrochlear nerve
may be affected due to its proximity). The greater and lesser occipital nerves are
targeted, whilst the third occipital usually supplies posterior skin further down the neck.
However, since the greater and third occipital nerves often communicate (being derived
from the dorsal rami of C2 and C3, respectively), the spread of local anaesthetic mayinadvertently block the third occipital nerve. The auriculotemporal nerve travels with
the superficial temporal artery, which can be damaged (or injected) when performing a
scalp block.
- Regarding the lungs and pleura:
The pulmonary ligament consists of pleura [T]
The visceral pleura has no sensory innervation [F]
At the midpoint between full inspiration and expiration, the inferior border of the lung
lies at the level of the sixth rib in the midclavicular line [T]
The horizontal fissure of the right lung lies at the level of the fourth costal cartilage
and runs horizontally backwards to meet the oblique fissure in the midaxillary
line [T]
The blunt posterior border of the lung lies in the paravertebral gutter, either side of the
midline [T]
The pulmonary ligament is a fold/cuff of pleura at the lung root, formed by the
reflection/continuity of the parietal and visceral layers, which provides dead space for
lung root to descend during inspiration and permits expansion of the pulmonary vessels.
The visceral pleura receives nociceptive innervation via sympathetic nerves of the
pulmonary plexus (which enter/leave the lung via the root). The inferior border of the
lung lies behind the 6th rib in the midclavicular line, 8th rib in midaxillary line, 10th rib
in midscapular line (lateral border of erector spinae) and from there passes horizontally
to the lower border of the T10 vertebra. The oblique fissure of both lungs starts
posteriorly at the level of the spinous process of T3, then runs downwards and forwards
to lie behind the 6th rib in the midclavicular line (roughly in line with the 5th rib). The
sharp anterior and inferior borders lie in the costomediastinal and costodiaphragmatic
recesses respectively.
- Regarding Brown–Séquard syndrome:
It typically results after complete transection of the spinal cord [F]
It results in an ipsilateral upper motor neurone lesion (spastic paralysis) below the level
of the injury [T]
It results in an ipsilateral lower motor neurone lesion (flaccid paralysis) below the level
of the injury [F]
It results in ipsilateral loss of vibration sensation and proprioception (dorsal column)
below the level of the injury [T]
It results in contralateral loss of pain and temperature sensation (spinothalamic tract)
below the level of the injury [T]
Brown–Séquard syndrome follows hemisection of the spinal cord, resulting in a lower
motor neurone lesion at the level of the injury (damage to the anterior grey horn).
However, the injury also transects the white matter columns:
Descending fibres of the corticospinal tract (upper motor neurones, which have already
decussated proximally)
Ascending fibres of the spinothalamic tract (second order sensory neurones, which
decussated at the level of entry of the first order sensory neurone in the peripheral
spinal nerve)Ascending fibres of the dorsal column–medial lemniscal pathway (first order neurones,
which are destined to synapse and then decussate more proximally)
This leads to paralysis and loss of vibration/proprioception below the level of the injury on
the same side of the body, but loss of pain/temperature sensation on the opposite side
- The following bones contribute to the pterion:
Sphenoid (greater wing) [T]
Frontal [T]
Temporal (squamous part) [T]
Parietal [T]
Occipital [F]
- Regarding the bronchial circulation:
The bronchial arteries supply the lung parenchyma with oxygenated blood [T]
The bronchial arteries arise from the corresponding pulmonary artery [F]
There are two bronchial arteries supplying the right lung [F]
The bronchial veins return deoxygenated blood directly to the inferior vena cava [F]
The bronchial and pulmonary circulations allow mixing of oxygenated and
deoxygenated blood [T]
Two bronchial arteries arise from the descending thoracic aorta to supply the left lung,
the single bronchial artery to the right lung arises from the third right posterior
intercostal artery. The superficial bronchial veins drain the surface of the lung to the
azygos system of veins; the deep bronchial veins drain the deeper tissue to either the
pulmonary veins or directly into the left atrium (and this contributes to the mixing of
oxygenated and deoxygenated blood; known as shunt*).
*N.B. The venae cordis minimae of the heart also contribute to shunt, as some of the venules
also drain directly into the left atrium
- Regarding the blood supply of the upper limb:
The axillary artery is a continuation of the subclavian artery at the lateral border of
scalenus anterior [F]
The cords of the brachial plexus are named according to their relationship to the second
part of the axillary artery [T]
The axillary artery gives rise to medial and lateral circumflex humeral arteries [F]
The ulnar artery gives rise to the common interosseous artery [T]
The superficial (palmar) branch of the radial artery travels into the hand deep to the
flexor retinaculum [F]
The subclavian artery becomes the axillary artery at the outer border of first rib. The
second part of the axillary artery lies behind pectoralis minor, surrounded by the cords
of the brachial plexus. The axillary artery gives rise to the anterior/posterior circumflex
humeral arteries (the femoral artery gives rise to medial/lateral circumflex femoral
arteries). The common interosseous artery divides into anterior and posterior interosse-
ous arteries, which travel with anterior (from the median) and posterior (from theradial) nerves respectively. The superficial (palmar) branch of the radial artery lies
superficial to the flexor retinaculum.
- The following is true regarding relations of the orbit:
The anterior cranial fossa is a superior relation of the orbit [T]
The ethmoid air sinuses are a medial relation of the orbit [T]
The sphenoid air sinus is a posterior relation of the orbit [F]
The maxillary air sinus is a medial relation of the orbit [F]
The infratemporal fossa and middle cranial fossa are posterolateral relations of the
orbit [T]
The anterior cranial fossa and frontal lobe lie above the orbit. The ethmoid sinuses and
upper part of the nasal cavity lie between the orbits. The maxillary air sinus lies below
the orbit. The sphenoidal sinus lies between the posterior extent of the orbits.
- Which of the following are boundaries of the paravertebral space?
The superior costotransverse ligament is a superior boundary [F]
The visceral pleura of the thorax is an anterolateral boundary [F]
The psoas muscle is an anterolateral boundary at the lumbar level [T]
The endothoracic fascia is a medial boundary [F]
The vertebral body is a medial boundary [T]
The superior costotransverse ligament is a posterior boundary and the parietal pleura is
an anterolateral boundary. The endothoracic fascia is found between the parietal pleura
and the ribs/innermost layer of intercostal muscles.
- Regarding central cord syndrome:
It is commonly due to a crush injury (without transection) of the spinal cord [T]
Hyperextension of the cervical spine is a common feature [T]
The upper limbs are affected more than the lower limbs [T]
The cervical fibres of the spinothalamic tract are more superficial than the sacral fibres [F]
The anterior horn of grey matter is not affected [F]
Since the cell bodies of the lower motor neurones to the upper limb muscles are located
more centrally in the anterior grey horn, the upper limbs are preferentially affected in
central cord syndrome.
- Regarding sutures of the cranium:
They are secondary cartilaginous joints [F]
They fuse at around 20–40 years of age [T]
The lambda represents the closed/ossified posterior fontanelle [T]
The anterior fontanelle closes/ossifies after the posterior fontanelle [T]
An extradural haematoma crosses lines of sutural intersection [T]
The sutures of the cranium are fibrous joints. The sutures fuse between ages 20 and
40 years, from the inside to out. Initially, the sutural joints provide mobility required
during parturition and then growth of the brain. The lambda represents the closed/
ossified posterior fontanelle – the point of intersection between the sagittal (between
parietal bones) and lambdoid (between parietal and occipital bones) sutures. Closure
occurs in the first year and can be as early as 6–8 weeks. The larger anterior
fontanelle closes at around 12–18 months to form the bregma – the point ofintersection between the coronal and sagittal sutures. An extradural haematoma can
cross lines of sutural intersection since it develops between the dura mater and the
endocranium* (periosteum of bone on the inner surface of the cranium). In com-
parison, a fracture-haematoma is limited by periosteal boundaries as the periosteum
of bone on inner and outer surfaces of the cranium is fused with the sutural joint.
This type of haematoma is therefore limited by sutural joints to the margins of the
involved bone.
- The following is true in relation to the right lung root:
The right upper lobe bronchus and accompanying artery are found above the main
bronchus [T]
The pulmonary arteries lie anterior to their respective bronchi [T]
Four pulmonary veins drain the lung [F]
Branches of the phrenic nerve supply the lung parenchyma [F]
Pulmonary lymphatics drain the lung via this route [T]
The eparterial bronchus (to the right upper lobe) branches off before the right main
bronchus reaches the hilum of the lung. Each lung drains by two pulmonary veins to the
left atrium. The lung parenchyma receives an autonomic supply; the parietal pleura
receives a somatic innervation from the intercostal (T1–6), thoracoabdominal (T7–11),
subcostal and phrenic nerves. Branches of the pulmonary plexus (autonomic) pass
through the hilum of the lung to innervate the lung parenchyma.
- Regarding the brachial plexus:
It comprises five roots, three trunks, five divisions and three cords [F]
The branching pattern of the brachial plexus often varies between the right and left
sides in the same individual [T]
The sheath surrounding the brachial plexus is at its smallest volume in the
supraclavicular fossa [T]
The roots lie anterior to the anterior scalene muscle [F]
It provides motor innervation to the serratus anterior muscle [T]
Each trunk of the brachial plexus gives anterior and posterior divisions (i.e. six in total).
The roots emerge between scalenus anterior (in front) and medius (behind). (N.B. The
posterior scalene muscle is part of the middle scalene, which continues down to attach to
the second rib.) The long thoracic nerve (C5/6/7), arising from the roots of the brachial
plexus, provides the motor innervation to serratus anterior (and therefore brachial
plexus injury can lead to winging of the scapula).
- The following bones contribute to the orbital margin/rim:
Frontal [T]
Zygomatic [T]
Maxilla [T]
Nasal [F]
Ethmoid [F]
The frontal, zygomatic bone and maxilla contribute approximately one-third each to the
orbital rim. The ethmoid contributes to the medial wall of the orbit, the nasal bone to
the bridge of the nose
- Concerning the oesophageal sphincters:
Atropine reduces lower oesophageal sphincter pressure [T]
The lower oesophageal sphincter is in a state of tonic contraction [T]
The upper oesophagus consists of skeletal muscle, but is not under voluntary
control [T]
Upper oesophageal sphincter tone is reduced by all intravenous anaesthetic induction
agents [F]
Upper oesophageal sphincter tone is reduced by both non-depolarising and
depolarising neuromuscular blocking drugs [T]
Upper oesophageal sphincter tone is not reduced by ketamine
- Regarding anterior spinal artery syndrome:
Proprioception is preserved below the level of the lesion [T]
Voluntary motor function is lost below the level of the lesion [T]
An upper motor neurone lesion (spastic paralysis) will develop below the level of the
lesion [T]
Pain and temperature sensation is preserved below the level of the lesion [F]
The lateral spinothalamic tract is typically affected [T]
Anterior spinal artery syndrome causes ischaemia/infarction of the anterior two-thirds
of the cord (and medulla), affecting the spinothalamic (pain/temperature) corticospinal
(motor) tracts. A lower motor neurone lesion is seen at the level of the lesion and an
upper motor neurone lesion below. Vibration sense and proprioception is conveyed in
the dorsal column-medial lemniscal pathway, which is preserved.
