Anatomy Exam #2 PA

A surgeon is performing laparoscopic repair of a direct inguinal hernia. The preperitoneal space has been opened and the hernia reduced. A piece of mesh has been placed to reinforce the hernia defect. Where should the surgeon place sutures or stabilizing tacks? Above the pectineal ligament Below Cooper's ligament Below the inguinal triangle Below the medial umbilical fold Lateral to the semilunar line

Above the pectineal ligament Explanation: The regional nerves (lateral cutaneous nerve of thigh, anterior femoral cutaneous, femoral branch of the genitofemoral, and femoral nerve) and the two major vessels (external iliac artery and vein) all exit the pelvis under the pectineal ligament. By limiting placement of sutures or fixation tacks to the region above the pectineal ligament, all these vital structures are protected.

A 39-year-old man decides to start exercising to get in the best physical shape of his life before his 40th birthday. He starts a workout program that involves a lot of running, and he quickly progresses to running nearly every day. After 4 weeks of intense training he begins to experience leg and foot pain during and after his runs. The pain radiates from the anterolateral leg into the dorsal aspect of the foot. Extension of the toes and dorsiflexion at the ankle are performed only with pain. The leg appears to be swollen and red in the area of the pain. Which of the following arteries may have been directly compressed by the swelling? Popliteal Posterior tibial Anterior tibial Fibular Medial plantar

Anterior tibial Explanation: Extension of the toes and dorsiflexion at the ankle are performed only with pain indicates an anterior leg compartment problem. The main vascular supply of the anterior compartment of the leg is from the anterior tibial artery. The named branches of the anterior tibial artery are the anterior medial malleolar artery, anterior lateral malleolar artery, and the dorsalis pedis artery.

A soccer player gets kicked unintentionally in the lateral side of his leg. An opposing player kicked him at the proximal leg, just distal to the head of the fibula. The injured player gets up but is having difficulty walking. After hearing about the mechanism of the injury you hypothesize that a nerve has been injured and your patient will most likely have which of the following? An inability to dorsiflex the ankle Loss of the ability to invert the ankle Altered sensation in the skin of the medial aspect of the leg Altered sensation in the skin of the plantar aspect of the foot Weakened ability to flex the toes

An inability to dorsiflex the ankle Explanation: The common fibular nerve wraps superficially around the neck of the fibula and then branches as the superficial fibular (peroneal) nerve and the deep fibular (peroneal) nerve. The common fibular nerve is most likely damaged in this patient from being kicked in the lateral leg, just distal to the fibular head. This damage would affect both lateral and anterior compartment muscles. The deep fibular (peroneal) nerve innervates all four anterior leg compartment muscles including the extensor hallucis longus, extensor digitorum longus, tibialis anterior, and fibularis tertius. These muscles cross the ankle joint anteriorly, thus producing dorsiflexion of the foot at the ankle joint along with more specialized functions like extension of the digital phalanges and inversion and eversion of the foot. While the tibialis anterior muscle assists with inversion at the ankle, it is not the only inverter, so there would not be a complete loss of the ability to invert the ankle.

An 8-year-old boy suffers chest trauma in an automobile accident. He arrives at the emergency department unconscious and hypotensive. Repeated attempts to establish a percutaneous peripheral intravenous catheter to administer fluids have failed. The physician decides to perform a saphenous vein cutdown. In which location should she make her incision to find the great saphenous vein? Anterior and inferior to the lateral malleolus Anterior and inferior to the medial malleolus On the dorsum of the foot lateral to extensor hallucis longus tendon Posterior and inferior to the lateral malleolus Posterior and inferior to the medial malleolus

Anterior and inferior to the medial malleolus Explanation: The great saphenous vein passes approximately 1 cm anterior and 1 cm inferior to the medial malleolus. In cases of chest trauma the great saphenous is a good choice for vascular access because it is far removed from the site of injury, where other emergency procedures may need to be performed.

Conduction of electrical impulses in an isolated, perfused rat heart was studied using cellular electrophysiologic techniques. Assuming that the spread of electrical excitation in the rat heart is similar to that in the human heart, which part of the conducting system displayed the slowest speed of electrical conduction? Atrioventricular node (AV) Atrium Bundle branches Bundle of His Purkinje fibers Ventricular muscle

Atrioventricular node (AV) Explanation: Cells of the AV node are specialized for relatively slow electrical conduction to ensure that atrial contraction is complete before excitation of the ventricles.

A 53-year-old man arrives at the emergency department with severe chest pain and difficulty breathing. Physical examination and radiographic imaging reveal that the patient has an emergent case of cardiac tamponade, a fluid buildup outside the heart but within the pericardial sac. As the fluid fills the pericardial sac the heart gets compressed, stroke volume decreases, cardiac output goes down, and heart rate increases. A pericardiocentesis procedure is performed in which a needle is inserted to drain the fluid from within the pericardial sac. The needle is inserted to drain the fluid between which of the following two layers? Between the fibrous pericardium and the parietal pericardium Between the fibrous pericardium and the visceral pericardium Between the parietal pericardium and the visceral pericardium Between the fibrous pericardium and the myocardium Between the visceral pericardium and the myocardium

Between the parietal pericardium and the visceral pericardium Explanation: The potential space between the parietal and visceral pericardium is termed the pericardial space. This space is normally occupied by a serous fluid of capillary thinness that acts to reduce friction between the heart and pericardial sac. During a cardiac tamponade that space fills with an abnormal amount of fluid that cannot easily or efficiently be drained.

You are preparing to place a central venous catheter in the right internal jugular vein of a 45-year-old man. His BMI is 24. You have placed the patient in the Trendelenburg position and are preparing to cannulate the internal jugular vein via an anterior approach, placing the needle approximately 2 to 3 fingerbreadths above the clavicle and directing it toward the contralateral nipple. Where should the needle be placed to ensure greatest probability of success and least trauma to surrounding structures? Between the sternal and clavicular heads of the sternocleidomastoid muscle Lateral to the clavicular head of the sternocleidomastoid muscle Lateral to the anterior scalene muscle Medial to the sternal head of the sternocleidomastoid muscle Medial to the middle scalene muscle

Between the sternal and clavicular heads of the sternocleidomastoid muscle Explanation: The internal jugular vein lies just behind the sternocleidomastoid muscle and is most easily accessed at the apex of the triangle where the sternal and clavicular heads join. The needle should therefore be placed between these heads.

You are seeing an athletic, active 12-year-old girl with a chief complaint of heel pain during running. Upon further discussion with the patient, you find out that there was no specific injury involved; her heel becomes more painful with sprinting and after playing, and it feels a little better if she warms up. After the examination, you conclude that she has Sever's condition, caused by the frequent strong pulling of the tendon on the relatively weak growth plate of the calcaneus. Which of the following tendons is likely involved? Calcaneal tendon Fibularis longus tendon Flexor hallucis longus tendon Patellar tendon Flexor digitorum longus tendon

Calcaneal tendon Explanation: The calcaneal tendon (Achilles tendon) is the thickest and strongest tendon in the body that connects the gastrocnemius and soleus muscles to their bony insertion on the calcaneus. This tendon is implicated in Sever's condition (disease) especially in children or young adults because the calcaneus grows faster than the bones of the leg, and overuse can irritate this tendinous insertion.

A 44-year-old man accidentally cuts his leg below the knee with a box-cutter and is brought to the emergency department for evaluation. He has a 4 cm laceration that extends down to the bone distal to the head of his left fibula. Physical exam shows the patient now has no sensation in a 2 cm area on the dorsum of his foot between 1st and 2nd toes. Which nerve is most likely injured in this patient? Tibial Superficial fibular Sural Deep fibular Saphenous

Deep fibular Explanation: The common fibular nerve wraps anterolaterally around the neck of the fibula and then branches as the deep fibular (peroneal) nerve and the superficial fibular (peroneal) nerve. The deep fibular (peroneal) nerve innervates all anterior leg compartment muscles. The anterior compartment of the leg contains four muscles. These muscles cross the ankle joint anteriorly, thus producing dorsiflexion of the foot at the ankle joint. The deep fibular nerve is sensory to the ankle joint and the web of the great toe.

A 25-year-old female soccer player presents with symptoms of acute anterior compartment syndrome of her right leg several hours after sustaining a significant blow to her leg. Upon examination she displays footdrop, significant swelling and pain in region of the tibialis anterior, and a diminished dorsalis pedis pulse. Surgical intervention to relieve the pressure in the fascial compartment is indicated. Which of the following nerves is responsible for this patient's footdrop? Tibial nerve Deep fibular nerve Medial plantar nerve Sural nerve Lateral plantar nerve

Deep fibular nerve Explanation: The deep fibular nerve branches off the common fibular nerve and provides innervation within the anterior compartment of the leg. This nerve is responsible for the innervation of all of the muscles of this compartment, and damage to this nerve due to anterior compartment syndrome results in footdrop.

A 20-year-old member of a collegiate soccer team has been forced to leave several games because his right leg becomes so painful that he cannot continue playing. The pain subsides after he rests for about an hour. When examined after one particularly bad episode, his leg is pale, painful, and cool to touch. There is a loss of sensation in the web of skin between the great toe and second toe. A diagnosis of chronic anterior compartment syndrome is made. Fasciotomy is performed to reduce the tissue pressure in the compartment and reestablish adequate blood flow. Damage to which nerve is responsible for the observed loss of sensation between the toes in this patient? Deep fibular nerve Medial plantar nerve Superficial fibular nerve Sural nerve Tibial nerve

Deep fibular nerve Explanation: The deep fibular nerve supplies the muscles of the anterior compartment of the leg and is cutaneous to the skin between the great toe and second toe. The patient's anterior compartment syndrome is brought on by prolonged vigorous exercise, which causes a transient increase in muscle mass. This increases the pressure in the closed leg compartment, resulting in compression of the blood vessels and ischemia of muscles and nerves.

A 47-year-old woman presents to the emergency department complaining of sudden and severe tearing chest pain. CT imaging of her chest reveals an aortic dissection (DeBakey type III) from approximately the T9-T11 vertebral levels. Based on the vertebral levels identified in the CT scan, which of the following segments of the aorta does this dissection occur in? Ascending thoracic aorta Ascending abdominal aorta Aortic arch Descending thoracic aorta Descending abdominal aorta

Descending thoracic aorta Explanation: The descending thoracic aorta encompasses the entire aorta distal to the aortic arch (T3-T5) and before the aortic hiatus at the T12 level. Thus, the range of descending thoracic aorta is approximately T3-T12, which includes the identified area of aortic dissection in this patient.

A 62-year-old man has a small myocardial infarction involving the septum of the right atrium inferiorly and posteriorly near the ostium of the coronary sinus. Because of the location of the infarct, this patient will most likely Be free of any conduction defects Damage the sinoatrial (SA) node Develop atrioventricular (AV) block Develop mitral regurgitation Suffer cardiac arrest

Develop atrioventricular (AV) block Damage to the septum of the right atrium inferiorly and posteriorly near the ostium of the coronary sinus would affect the AV node. It is the only conduction pathway from atria to ventricles. Therefore, it is likely that damage to this area will result in AV block.

A 14-year-old boy sustains a deep laceration wound to the distal anterior left leg from falling while trying to climb a fence. You feel for a pulse slightly distal to the wound on the dorsal surface of the foot between the extensor hallucis longus and extensor digitorum longus tendons, but you cannot locate a pulse as compared with the right foot. From this finding, you would be concerned that there is damage to which vessel? Dorsalis pedis artery Popliteal artery Posterior tibial artery Lateral plantar artery Medial plantar artery

Dorsalis pedis artery Explanation: The dorsalis pedis artery is located on the dorsal surface (top) of the foot and is often the vessel used when testing for a distal pulse. Anatomically, it is located lateral to the extensor hallucis longus tendon and medial to the extensor digitorum longus tendon.

A 35-year-old man sustains a posterior dislocation of the knee in a motor vehicle crash. The dislocation is reduced, but there has been damage to the popliteal artery. A vascular repair is performed. Six hours after surgery, he complains of severe pain down the ipsilateral shin. On physical examination, severe pain is elicited when the ankle is passively plantar flexed. The pulse in the dorsalis pedis artery is diminished, and the posterior tibial artery pulse is normal. He has numbness to a pinprick in the space between the first two toes. A diagnosis of compartment syndrome due to prolonged ischemia is made. Which of the following is the most likely cause of these findings? Elevated pressure in the anterior compartment of the leg Elevated pressure in the lateral compartment of the leg Elevated pressure in the deep posterior compartment of the leg Elevated pressure in the superficial posterior compartment of the leg Elevated pressure in the medial compartment of the leg

Elevated pressure in the anterior compartment of the leg Explanation: The signs and symptoms described are classic for elevated pressure in the anterior compartment with compression of the anterior tibial artery and vein and the deep fibular nerve.

A 44-year-old woman is diagnosed with medial patellofemoral ligament (MPFL) damage following an acute lateral dislocation of the patella that occurred when she fell after sliding on a cheesesteak that was carelessly discarded in the road during the final mile of the Philadelphia marathon. Her fall caused the MPFL to tear away from its attachment to the adductor tubercle and a tendon attaching to the tubercle. This injury caused significant perimuscular and interstitial edema around the adductor tubercle and is associated with a great deal of pain when the main muscle attaching to the tubercle is contracted. Which of the following motions would be associated with the greatest pain in this patient? Flexion of the knee Extension of the knee Medial rotation of the femur on the tibia Adduction of the thigh at the hip joint Extension of the thigh at the hip joint

Extension of the thigh at the hip joint Explanation: The adductor magnus muscle has two separate muscle attachments. The hamstring portion of the adductor magnus muscle attaches proximally to the ischial tuberosity and ischiopubic ramus and attaches distally to the adductor tubercle of the femur. It functions to produce extension of the thigh at the hip joint, as well as medial rotation of the thigh (when the foot is in contact with the ground) and lateral rotation of the thigh (when the foot is raised off the ground) at that joint. Therefore, extension of the thigh at the hip joint would cause the greatest pain in this patient.

Police arrest a 22-year-old man who is wildly celebrating after the Boston Red Sox won the World Series. The man was resisting arrest and was highly intoxicated, so a police officer used a baton to hit him in the side of his leg to bring him to the ground. The man is brought to the emergency department after getting subdued by police and he has a significant bruise just distal to the head of the fibula. He is in a lot of pain and has some loss of function at the ankle joint. Which of the following muscles will most likely be significantly weakened or paralyzed in this patient from the baton hitting a nerve? Tibialis posterior Popliteus Gastrocnemius Extensor digitorum longus Flexor digitorum longus

Extensor digitorum longus Explanation: The common fibular nerve wraps superficially around the neck of the fibula and then branches as the superficial fibular (peroneal) nerve and the deep fibular (peroneal) nerve. The common fibular nerve is most likely damaged in this patient from the baton strike. This damage would affect both lateral and anterior compartment muscles. The deep fibular (peroneal) nerve innervates all four anterior leg compartment muscles, including extensor hallucis longus, extensor digitorum longus, tibialis anterior, and fibularis tertius. The superficial fibular (peroneal) nerve innervates both lateral leg compartment muscles: fibularis (peroneus) brevis and fibularis (peroneus) longus.

A 42-year-old father is teaching one of his children how to ride a bike when his son accidentally clips his father's left leg with a pedal while riding by. The pedal struck just distal to the head of the fibula, which leaves a large bruise and causes a lot of pain and loss of function at the ankle joint. Which of the following muscles is most likely paralyzed? Tibialis posterior Extensor digitorum longus Flexor digitorum longus Soleus Popliteus

Extensor digitorum longus Explanation: The extensor digitorum longus muscle is innervated by the deep branch of the common fibular nerve. The common fibular nerve wraps anterolaterally around the neck of the fibula, coinciding with the point of impact of the pedal, making it likely that muscles innervated by this nerve would be paralyzed.

A warehouse worker was operating a forklift and lowered a palate with four 55-gallon barrels onto an uneven surface. The palate got stuck and he tried to readjust the barrels by hand when one tipped over and fell on this leg. He was trapped under a barrel that weighed approximately 300 pounds until coworkers freed him. The crush injury to the anterior compartment of his leg is causing significant swelling. Which of the following muscles is most likely injured? Extensor hallucis brevis Rectus femoris Fibularis (peroneus) longus Extensor digitorum longus Flexor hallucis longus

Extensor digitorum longus Explanation: The muscles of the anterior compartment of the leg are the extensor hallucis longus, extensor digitorum longus, tibialis anterior, and fibularis tertius.

A 21-year-old female college volleyball player jumped to block an opposing player's hit and landed awkwardly with her foot inverted. The team trainer was worried about a fracture and sent her to the emergency department. Radiographic examination in the hospital revealed an avulsion fracture of the tuberosity of the 5th metatarsal. The radiograph shows part of the tuberosity is pulled off the 5th metatarsal, producing pain and edema. Which of the following muscles is pulling on the fractured fragment? Fibularis (peroneus) brevis Fibularis (peroneus) longus Tibialis posterior Extensor digitorum brevis Extensor digitorum longus

Fibularis (peroneus) brevis Explanation: The fibularis (peroneus) brevis muscle attaches distally to the base of the 5th metatarsal and proximally it attachesto the lateral surface of the fibula. This is the muscle that would be displacing the avulsed fracture.

A 39-year-old man presents with a significant laceration wound to his foot after stepping on a large piece of broken glass while playing Frisbee at the beach. Based on the depth and location of the laceration on the inferomedial aspect of the foot, you are concerned about damage or a complete severing of the medial plantar nerve. Which of the following muscles of the foot would be affected if this nerve were indeed severed? Flexor hallucis brevis Abductor digiti minimi Quadratus plantae Flexor digitorum longus Lateral lumbrical

Flexor hallucis brevis Explanation: The medial plantar nerve innervates the flexor hallucis brevis, the flexor digitorum brevis, the abductor hallucis, and the medial lumbrical muscle. Damage to the medial plantar nerve would affect this patient's flexor hallucis brevis muscle.

A 22-year-old woman consults her obstetrics and gynecology physician about a suspected pregnancy. She has noticed some swelling of her breasts that has caused some slight discomfort. Her breasts are bilaterally enlarged with no masses, and some darkening of the areolas is noted. She has also performed a home pregnancy test, which she reports as positive. A test at the office confirms this result, and she is estimated to be 5 weeks pregnant by the patient's self-reported last menstrual period. What is the most likely reason for the swelling in her breasts? Duct hypertrophy Gland hyperplasia Infiltrating ductal carcinoma Mastitis Phyllodes tumor

Gland hyperplasia Explanation: Prolactin and estrogen cause profound and prolonged hyperplasia of the breast acini.

An 18-year-old boy was playing football on wet turf when he planted his left foot to cut to his right and the left foot slipped out from under him. He fell awkwardly to the ground, and it appeared like he did a split with both legs pointed laterally. He immediately grabbed his left knee and was in considerable pain. Physical exam shows the anterior cruciate ligament intact, as well as both knee menisci and both medial and collateral knee ligaments. Palpation distal to the medial tibial condyle, just medial to the tibial tuberosity, elicited significant pain. An MRI scan confirms that a muscle inserting in this area has been damaged, with tearing of muscle fibers and interstitial edema resulting. The physician cautions the patient that this injury will take time to heal and that he should be especially careful with adduction of the thigh at the hip. Which of the following muscles is most likely damaged in this patient? Gracilis Sartorius Semitendinosus Adductor magnus Biceps femoris, long head

Gracilis Explanation: The area distal to the medial tibial condyle is the pes anserinus. Three muscles attach here: gracilis, semitendinosus, and sartorius. Of these three muscles, only the gracilis muscle produces adduction of the thigh at the hip joint.

Following surgery, a 67-year-old man must have an intravenous infusion, but no suitable veins of the upper extremity can be found. Which of the following vessels is the best choice for inserting a venous line into this patient? Cephalic vein Popliteal vein Femoral vein Great saphenous vein

Great saphenous vein Explanation: The great saphenous vein courses anterior to the medial malleolus and is usually the vein of choice for inserting a venous line. It is easy to identify and is readily accessible. Care must be taken to avoid the saphenous nerve, which parallels the vein See (see Plate 470).

A motor vehicle accident injures a 20-year-old man who was riding in the passenger seat. In the emergency department he is found to be hypotensive and complains of pelvic pain. Gentle bimanual compression and distraction of the pelvis reveals instability (pelvic springing) that suggests pelvic fracture. Anteroposterior radiographs show separation (diastasis) of the pubic symphysis and sacro-iliac joints, with external rotation of the hemipelves (open-book pelvis). Angiography reveals that the bleeding is caused by laceration of the branch of the internal iliac artery, which runs near the sacro-iliac joint and then ascends into the false (greater) pelvis. What is this branch of the internal iliac artery? Iliolumbar artery Inferior gluteal artery Internal pudendal artery Lateral sacral artery Obturator artery

Iliolumbar artery Explanation: The iliolumbar artery is a branch of the posterior trunk of the internal iliac artery. It crosses the sacro-iliac joint and ascends to supply muscles of the posterior abdominal wall. It is vulnerable to injury in cases of sacro-iliac joint separation

A 16-year-old female soccer player presents with a complaint of thigh pain. She is pain free with adduction and abduction of the thigh. However, flexion of the thigh (hip joint) causes pain. Which of the following has she most likely injured? Adductor longus and gracilis muscles Tensor fascia lata muscle and iliotibial band Adductor magnus muscle Iliopsoas and rectus femoris muscles Semitendinosus and semimembranosus muscles

Iliopsoas and rectus femoris muscles Explanation: Muscles producing flexion of the thigh at the hip joint include iliopsoas (psoas major and iliacus muscles common insertion into the lesser trochanter), rectus femoris, sartorius, and pectineus (weak flexor).

A 34-year-old man was hit by a car and sustained a fracture to the head and neck of his left fibula, damaging a major nerve to his leg. Identify the physical findings that would most accurately describe this patient's injury. Inability to extend his leg at the knee Inability to flex his leg at the knee The foot would remain inverted Inability to dorsiflex the foot Inability to plantar flex the foot

Inability to dorsiflex the foot Explanation: Injury to the head and neck of the fibula would likely damage the common fibular nerve, which wraps around the outside of these structures. The common fibular nerve branches into the deep fibular nerve, which supplies the muscles responsible for dorsiflexion of the foot, like the extensor digitorum longus and the extensor hallucis longus.

A 22-year-old runner has throbbing, unrelenting pain in her left leg along the anterior lateral border to the left of the tibia. There is some loss of dorsiflexion of the foot. Which condition could account for these symptoms? Compression of the tibial nerve Hemorrhage in the posterior compartment Increased tissue fluid in the anterior compartment of the leg Intermittent claudication of the lateral compartment Ischemia of the superficial fibular (peroneal) nerve

Increased tissue fluid in the anterior compartment of the leg Explanation: The condition described in this patient is known as anterior compartment syndrome, which manifests as a tense, tender, or swollen compartment on direct palpation. Increased pressure could compress the deep fibular (peroneal) nerve, which supplies the dorsiflexor muscles of the foot, and produce intense pain when the toes and foot are pointed upward, resulting in foot drop. The affected compartment may be decompressed through an anterior lateral incision of the crural fascia (see Plate 510).

A 40-year-old man with a long-term history of heavy alcohol consumption consults his physician because of persistent malaise and low-grade fever. The physician notes mild jaundice and hepatomegaly. The diagnosis is alcoholic hepatitis. To determine the presence or absence of cirrhosis, a liver biopsy is performed. Because the patient is thrombocytopenic, a transjugular biopsy procedure is used instead of percutaneous biopsy to minimize potentially dangerous bleeding. A catheter is inserted into the internal jugular vein and advanced into the heart via the superior vena cava. Through which aperture should the catheter leave the heart to reach the liver by the most direct route? Aortic valve Mitral valve Inferior vena cava Pulmonary valve Tricuspid valve

Inferior vena cava Explanation: From the superior vena cava (SVC) the catheter would reach the liver by passing through the right atrium into the IVC and then into a hepatic vein. Because the SVC, right atrium, and IVC are vertically aligned with one another, this represents a direct, uncomplicated approach to the liver.

In the course of performing an esophageal resection for carcinoma, a surgeon makes a radially oriented incision in the left diaphragm. This incision extends from the esophageal hiatus laterally to the costal margin. The incision in the diaphragm is repaired with heavy sutures at the conclusion of the operation. Postoperative examination reveals poor inspiratory effort on the left side. Radiographs taken at full inspiration and full expiration show that the left hemidiaphragm is high and is not moving with respiration. Which of the following is the most likely diagnosis? Injury to the left vagus nerve Injury to the left recurrent laryngeal nerve Injury to the left thoracodorsal nerve Injury to the left phrenic nerve Injury to the left long thoracic nerve

Injury to the left phrenic nerve Explanation: The injury described is characteristic of a division of the left phrenic nerve. The left phrenic nerve descends along the pericardium and then courses on the surface of the diaphragm. It may be divided if an incision in the diaphragm is not created carefully to avoid it. Because the left phrenic nerve innervates the diaphragm, injury would leave the left hemidiaphragm high and paralyzed (see Plate 195)

A 35-year-old man has a left supraclavicular lymph node removed for diagnostic purposes. It measures 3×4 cm and pathology returns a diagnosis of Hodgkin disease. He is seen 1 week later in a postoperative clinic and is found to have a fluctuant mass at the operative site. Aspiration yields 60 mL of milky fluid. Gram stain shows lymphocytes. No organisms are seen. What is the most likely diagnosis? Injury to apex of the lung Injury to the esophagus Injury to the thoracic duct Submandibular gland injury Wound infection

Injury to the thoracic duct Explanation: The thoracic duct carries lymph from the abdomen. It arches into the left lower neck in the supraclavicular region where it is susceptible to injury. Injury to the thoracic duct causes leakage of chyle, a milky fluid high in lymphocytes (see Plate 203).

A 21-year-old woman is injured while waterskiing. She falls forward with her knee fully extended, resulting in sudden forcible flexion of her thigh at the hip. After the injury movement of the hip and knee is painful and there is a feeling of weakness in the limb. Radiographs indicate that a bony site of muscle attachment has been avulsed. Which bony feature is involved in this injury? Anterior inferior iliac spine (AIIS) Anterior superior iliac spine (ASIS) Greater trochanter of the femur Ischial tuberosity Lesser trochanter of the femur

Ischial tuberosity Explanation: The force of this patient's fall caused a sudden but passive flexion of the thigh at the hip. This stretched and injured the hamstrings, which act as hip extensors and knee flexors, and led to avulsion of the ischial tuberosity, which is the origin of the hamstrings.

A 53-year-old man was cleaning fish when he accidentally dropped the knife, causing a deep laceration to the medial aspect of the knee. Examination in the emergency department reveals that he has a laceration of the medial aspect of the knee 10 cm long. The laceration is jagged and at least 2 cm deep in the midportion. There is concern about whether the wound penetrates the articular cavity of the knee joint, which would require surgical exploration and repair. To confirm or exclude such penetration, you are asked to inject methylene blue dye into the articular cavity of the knee. If the blue dye leaks from the wound, penetration is confirmed. To access this articular cavity by the most direct and least traumatic route, where should the physician place the needle? In the middle of the popliteal fossa, directed anteriorly In the middle of the popliteal fossa, directed medially In the middle of the popliteal fossa, directed laterally Just above and lateral to the patella, directed inferiorly and toward the midline behind the patella Just inferior and lateral to the patella, directed inferiorly and toward the midline

Just above and lateral to the patella, directed inferiorly and toward the midline behind the patella Explanation: This path leads to the suprapatellar synovial bursa, which communicates with the articular cavity and does not traverse any neurovascular structures. This bursa can also be accessed medial to the patella (see Plate 511).

You are asked to place an intravenous line into the greater saphenous vein at the ankle of a 25-year-old man. You will find the vein two fingerbreadths above and in what other relation to which anatomical landmark? Just anterior to the medial malleolus Just lateral to the medial malleolus Just medial to the lateral malleolus Just lateral to the lateral malleolus Midway between the medial and lateral malleoli anteriorly

Just anterior to the medial malleolus Explanation: The greater saphenous vein originates from veins of the foot, which coalesce into the dorsal venous arch, forming the greater saphenous vein. This vein is visible and palpable just above and anterior to the medial malleolus.

You are asked to place a chest tube (tube thoracostomy) to drain a traumatic hemopneumothorax in a 45-year-old man. You decide to pass the tube into the chest through the fifth intercostal space in the anterior axillary line. To minimize the risk of damage to the intercostal neurovascular bundle, care must be taken when inserting the trocar before passing the tube. What is the most favorable position to pass the trocar for this procedure? As far laterally as possible Just over the sixth rib Just under the fifth rib Through the fourth rather than the fifth interspace Through the sixth rather than the fifth interspace

Just over the sixth rib Explanation: The neurovascular bundle runs in a groove along the inferior aspect of each rib. Entering the chest just above a rib minimizes the chance of injury to the neurovascular bundle by maximizing the distance between the entry site and the structures of concern.

A 52-year-old man is in a car crash during which the dashboard was pushed back into his knees. He sustained a posterior dislocation of the hip joint, and paramedics stabilized his injuries while transporting him to the emergency department at a local hospital. A physician reduces (set the bone back in place) the dislocation, takes a follow up x-ray, and examines the lower extremity for any dysfunction. The dorsalis pedis, popliteal, and posterior tibial artery pulses are all easily palpable and strong. The patient is then examined for any weakness or paralysis of muscles. Knowing the patient had a posterior femoral head dislocation it is highly likely that a specific nerve may have been damaged. If this patient does have nerve damage from the dislocation, which of the following movements would most likely be affected? Hip abduction Hip adduction Hip flexion Knee extension Knee flexion

Knee flexion Explanation: A posterior hip dislocation has the greatest likelihood of directly damaging the sciatic nerve. The common fibular and tibial nerves are the two components of the sciatic nerve. The tibial nerve innervates the primary muscles producing flexion of the leg at the knee joint, including the semimembranosus, semitendinosus, and long head of biceps femoris. Therefore, if this nerve is damaged knee flexion would be weak.

A full-term male neonate presents 2 weeks after birth with fever, lethargy, and feeding difficulties. Physical examination reveals a bulging anterior fontanelle, causing the physician to suspect possible meningitis. The infant is started on an aggressive course of antibiotics while blood samples are collected and a lumbar puncture is performed to recover cerebrospinal fluid. Lumbar puncture must be carried out at a level inferior to the termination of the spinal cord. At which vertebral level does the neonatal spinal cord normally end? T11 L1 L3 S1 S3

L3 Explanation: Whereas the spinal cord of an adult normally ends at vertebral level L2, the spinal cord of a neonate is relatively longer, commonly extending to L3. The lower relative position of the neonatal cord must be kept in mind when selecting the level for lumbar puncture.

A 27-year-old man is stabbed in the fourth intercostal space, 3 cm to the left of the sternal border. After resuscitation, he is taken to the operating room where a left thoracotomy is performed. Blood is found in the pericardial cavity, and there is an injury to the anterior interventricular branch of the left coronary artery. There is a laceration to the underlying myocardium. What is the most likely diagnosis? Laceration of the intraventricular septum Laceration of the left atrium Laceration of the left ventricle Laceration of the right atrium Laceration of the right ventricle

Laceration of the right ventricle Explanation: The right ventricle forms much of the anterior surface of the heart. The anterior interventricular branch courses down the right side of the right ventricle. Traumatic injury to this vessel may occur with right ventricular injury, as in the case described (see Plate 219).

A 9-month-old boy is brought to the emergency department pale and listless and is having difficulty breathing. His mother thinks he may have swallowed something. An endoscopy shows a peanut in the right main bronchus, which was aspirated into the trachea. An object aspirated into the trachea would most likely end up in the right main bronchus because this bronchus is Larger in diameter than the left main bronchus Longer than the left main bronchus More acutely angled than the left main bronchus

Larger in diameter than the left main bronchus Explanation: Because the right lung is slightly larger than the left lung, its bronchus also has a slightly larger diameter. Aspirated objects more commonly find their way into the right main bronchus.

A 33-year-old security guard visits his family physician due to intermittent painful sensations along the anterolateral region of the thigh. The patient is 295 pounds and 5 feet, 10 inches tall. He has a large abdominal panniculus adiposus (extensive subcutaneous fat) that bulges over his belt. You hypothesize that this panniculus is responsible for his pain, with the abdominal fat compressing a nerve as it passes deep to the inguinal ligament. Which of the following nerves is most likely responsible for the pain described by this patient? Femoral branch of the genitofemoral Femoral Lateral femoral cutaneous Iliohypogastric Ilio-inguinal

Lateral femoral cutaneous Explanation: The lateral femoral cutaneous nerve (L2-L3) arises directly from the lumbar plexus to descend deep to the inguinal ligament medial to the anterior superior iliac spine. This nerve supplies the skin of the anterior and lateral aspects of the thigh, and when this nerve is compressed it can cause meralgia paresthetica, which is numbness or pain in the outer thigh.

A 17-year-old girl gets slide-tackled during a recent soccer practice and presents to the clinic with moderate pain in the back of her knee after hyperextending it. Physical examination reveals an acute injury to the popliteus muscle of her right leg. Which of the following actions will most likely be impaired due to the injury? Extension of the leg at the knee Adduction of the leg Lateral rotation of the femur Medial rotation of the femur Correct patellar tracking

Lateral rotation of the femur Explanation: When the knee is in full extension, the femur medially rotates on the tibia slightly to lock the knee joint in place. The popliteus muscle unlocks the knee by laterally rotating the femur on the tibia, allowing for knee flexion, and this motion would most likely be impaired.

Anteroposterior and lateral radiograph views in a 74-year-old woman show segmental pneumonia limited to the lingula region of her left lung. On auscultation, this region of the lung should have diminished breath sounds due to the presence of infection and atelectatic (collapsed) alveoli. Which of following locations would you place the stethoscope to best appreciate the diminished breathing sounds in the lingula? Left upper sternal border Left 5th intercostal space at the midclavicular line Left 2nd intercostal space at the midclavicular line Inferior to the left scapula on the back The left costovertebral angle on the back

Left 5th intercostal space at the midclavicular line Explanation: The breath sounds of the lingula would be best heard with this placement of the stethoscope because the lingula is located closest to this location, near the apex of the heart.

A 62-year-old man with mitral valve insufficiency is taken in for an echocardiogram to image his heart. Flow sensors on the echocardiogram equipment can pick up the acceleration of flow past the insufficient mitral valve. Which of the following chambers of the heart will the regurgitating blood reenter? Right atrium during systole Right atrium during diastole Left atrium during systole Left atrium during diastole Left ventricle during diastole

Left atrium during systole Explanation: During systole, the left ventricle contracts, the mitral valve closes, and blood is pushed into one of the outflow tracts of the heart. If the mitral valve is insufficient, the high pressure of blood during systole will leak through the weakly closed mitral valve into the left atrium from which it came.

A 64-year-old man with a history of several heart attacks undergoes an autopsy after death from a sudden stroke. Autopsy reveals the presence of a paradoxical embolus completely occluding the second major vessel branching off the aortic arch. If the patient has normal anatomy, which aortic arch vessel is likely occluded resulting in this patient's stroke? Left axillary artery Left common carotid artery Right brachiocephalic artery Right common carotid artery Left subclavian artery

Left common carotid artery Explanation: The second of the three major vessels branching off the aortic arch is the left common carotid artery. This vessel branches into the left internal and external carotid arteries, which are major vessels of the brain.

A 65-year-old man develops a worsening cough and shortness of breath associated with weakness, left shoulder pain, and a 30-pound weight loss. He has smoked two packs of cigarettes per day for 45 years. On physical examination, his left eyelid is observed to droop (i.e., ptosis), his left pupil is constricted (i.e., miosis), and the left side of his face does not sweat in response to heat (i.e., anhidrosis). A clinical diagnosis of Horner's syndrome is made. A chest radiograph shows a mass in the left lung consistent with a primary lung cancer. On the basis of the physical findings, which of the following is the most likely location of this tumor? Left hilum Left lower lobe Left middle lobe Left upper lobe Left mainstem bronchus

Left upper lobe Explanation: Tumors in the apex of the lung, in the upper lobe, that invade the superior sulcus (i.e., apical pleuropulmonary groove) and invade the cervicothoracic sympathetic ganglion produce the characteristic signs and symptoms of this patient (see Plates 203 and 228).

A runner comes to the sports medicine clinic. Her chief complaint concerns weakness when extending her thigh, which has dramatically reduced her running speed. As part of your patient's physical examination, your attending asks you to test the inferior gluteal nerve. What would you have the patient do? Lie prone (face down), flex the knee against resistance Lie prone (face down), flex the knee, and raise the thigh from the table Lie supine (face up), spread the legs against resistance While seated, raise the thigh While seated, raise the thigh and abduct the hip

Lie prone (face down), flex the knee, and raise the thigh from the table Explanation: The inferior gluteal nerve innervates the gluteus maximus muscle, which powerfully extends and laterally rotates the thigh at the hip joint. If a patient was to lie prone (face down), flex the knee, and raise the thigh from the table, the gluteus maximus muscle can be tested as a result of its powerful extension function.

A 32-year-old female soccer player presents with significant hip pain when running. Physical examination and radiographic imaging reveal that she has a sustained a tear in her hip joint capsule, which is composed of a combination of ligaments including the iliofemoral, ischiofemoral, and pubofemoral ligaments. Which of the following ligaments also contributes to the hip joint capsule? Sacrotuberous ligament Ligamentum teres Sacrospinous ligament Sacro-iliac ligaments Superior pubic ligament

Ligamentum teres Explanation: The ligamentum teres spans between the fovea capitis and the acetabular notch, where it blends with the transverse ligament and the hip joint capsule.

A 54-year old man was lifting his suitcase up the stairs when he felt a sharp pain in his upper groin region on the right side. Physical exam at the doctor's office reveals a small bulge at the top of the right thigh just below the groin skin crease, pointing to a femoral hernia. As the small intestine herniates into the femoral canal, which of the following is most likely compressed due to this herniation? Femoral nerve Femoral artery Large intestine Lymphatic vessel Femoral vein

Lymphatic vessel Explanation: The femoral canal is the medial compartment of the femoral sheath, which contains several lymph vessels that travel back into the abdomen. The femoral canal is the most common location for femoral hernias; thus the lymphatic vessels present there could easily be compressed by the small intestines.

A 78-year-old woman fell at home and was brought to the emergency department. She is unable to bear weight on her right leg and her right foot is positioned in lateral rotation. A plain film radiograph shows a fracture of the neck of the femur. The decision to reduce and cast the fracture or recommend a hip replacement depends on the likelihood of avascular necrosis of the head of the femur. An arteriogram is ordered to visualize the vascular supply to the hip joint and head of femur. If the primary arterial supply to the hip is compromised, the patient will need a new hip. When interpreting the arteriogram which of the following arteries is the most important for the radiologist to visualize to help make this treatment decision? Artery to head of femur Inferior gluteal Superior gluteal Medial circumflex femoral Lateral circumflex femoral

Medial circumflex femoral Explanation: The medial circumflex femoral artery originates from the profunda femoris artery. It is the principal blood supply to the head of the femur, and if this blood supply is severed it can lead to avascular necrosis of the femoral head. It passes medially and posteriorly between pectineus and iliopsoas muscles before supplying the head and neck of the femur.

A 46-year-old woman presents to the clinic with some throbbing pain in her left thigh and leg, accompanied by swelling and engorgement in some of her superficial thigh veins. After ultrasound of the vessels in her thigh region, it is determined that she has a thrombus in her proximal profunda femoris (deep femoral) artery. Which of the following downstream vessels would receive reduced blood flow due to this arterial clot? Posterior tibial artery Medial plantar artery Medial femoral circumflex Popliteal artery Femoral artery

Medial femoral circumflex Explanation: The medial femoral circumflex artery is a direct branch off the deep femoral artery. Thus, occlusion of the deep femoral artery would significantly decrease the blood flow in this downstream vessel.

A 19-year-old patient presents with an injury to his knee that resulted in a tibial collateral ligament rupture. You are concerned about additional damage to cartilaginous structures of his knee that often occur with this specific injury. What other cartilaginous structure that is fused to the tibial collateral ligament should be checked in this patient, as it is often torn in tibial collateral ligament ruptures? Lateral meniscus Fibular collateral ligament Posterior cruciate ligament Medial meniscus Anterior collateral ligament

Medial meniscus Explanation: The medial meniscus is fused with the tibial collateral ligament and thus can often be torn when there is a significant rupture of the tibial collateral ligament.

A heart murmur is detected in a 2-month-old infant. Left-side and right-side cardiac catheterizations are performed to evaluate possible multiple congenital defects. To gain direct access to the right side of the heart, the catheter is placed in a large vessel in the groin region. The vessel used for right-side catheterization is found in which location? Lateral to the femoral artery in the femoral triangle Lateral to the femoral vein in the femoral triangle Medial to the femoral artery in the femoral triangle Medial to the femoral vein in the femoral triangle Superior to the inguinal ligament and lateral to the inferior epigastric vessels

Medial to the femoral artery in the femoral triangle Explanation: The vessel required for right-side catheterization is the femoral vein, which lies medial to the femoral artery in the femoral triangle. A catheter inserted into the femoral vein will enter the right atrium via the inferior vena cava.

A 35-year-old man is brought to the emergency department directly from the scene of an accident. The paramedics report that he was the unrestrained driver of a car going highway speed. His vehicle was struck by another car that crossed the median. The driver of the second car was dead at the scene. The patient was ejected and thrown 15 feet. Obvious injuries include facial fractures and bilateral open tibia-fibula fractures. At arrival in the emergency department, his pulse is 150 and weak and blood pressure is 80 mmHg by palpation. His veins are collapsed, and out of necessity the physician attempts to place a femoral vein intravenous line. Which of the landmarks below best describes how to access this vein? Inferior to the femoral pulse Lateral to the femoral pulse Medial to the femoral pulse Superficial to the femoral pulse Superior to the femoral pulse

Medial to the femoral pulse Explanation: The femoral vein lies parallel to and immediately medial to the femoral artery. The femoral pulse is a reliable landmark for femoral vein line placement.

A 45-year-old woman is admitted with a subarachnoid hemorrhage caused by a ruptured intracranial aneurysm. Despite attempts to occlude the aneurysm angiographically and neurosurgical intervention, her condition deteriorates and she is declared brain dead. The family gives consent for organ donation, and you are told to harvest a superficial femoral lymphnode for tissue crossmatching in preparation for donation. Where do you harvest this tissue? Deep to the transversalis fascia In Hesselbach's triangle Lateral to the femoral artery Medial to the femoral vein Superior (cephalad) to the inguinal ligament

Medial to the femoral vein Explanation: The superficial femoral lymph nodes surround the femoral vein and are found most easily just medial to the femoral vein (see Plate 472).

A 55-year-old man develops burning pain in his groin after an open inguinal hernia repair. During this surgical repair, the floor of the inguinal canal was reinforced with a piece of surgical mesh, which was sutured to the borders of the hernia defect. The pain causes him to limit his activities significantly. He rates the pain as 8 on a scale of 10. On examination, he has hyperalgesia along the incision site radiating down the groin into the lateral aspect of the ipsilateral scrotum. What is the most likely diagnosis? Mesh entrapment of the femoral nerve Mesh entrapment of the genitofemoral nerve Mesh entrapment of the iliohypogastric nerve Mesh entrapment of the lateral cutaneous nerve of thigh Mesh entrapment of the obturator nerve

Mesh entrapment of the genitofemoral nerve Explanation: The genital branch of the genitofemoral nerve passes through the inguinal canal, where it is vulnerable to injury during inguinal hernia repair. Entrapment causes hyperalgesia in the distribution described.

A 16-year-old boy breaks his fibula after falling from his tree house. The emergency department physician refers him to an orthopaedic specialist who ensures that the broken bone is aligned properly and the leg is casted. Weeks later the cast is removed and the fracture has healed nicely. The boy complains of numbness on the top of his foot, and he cannot lift his toes or foot. Further examination reveals that he cannot evert his foot, and there are sensory deficits along the anterolateral leg and dorsum of the foot. A nerve has most likely been damaged from long-term compression from the cast. Which of the following is the most probable site of nerve compression that caused the patient's symptoms? Neck of the fibula Lateral compartment of leg Anterior compartment of leg Medial malleolus Posterior compartment of leg

Neck of the fibula Explanation: Problems with dorsiflexion and eversion indicate both anterior and lateral compartment problems, and therefore the site of compression would have to affect the common fibular (peroneal) nerve before it splits into superficial and deep branches. The common fibular nerve wraps anterolaterally around the neck of the fibula and then branches as the deep fibular (peroneal) nerve and the superficial fibular (peroneal) nerve. The deep fibular (peroneal) nerve innervates all anterior leg compartment muscles. The anterior compartment of the leg contains four muscles. These muscles cross the ankle joint anteriorly, thus producing dorsiflexion of the foot at the ankle joint. The deep fibular nerve is sensory to the ankle joint and the web of the great toe. The superficial fibular (peroneal) nerve innervates the two lateral leg compartment muscles: fibularis (peroneus) longus and fibularis (peroneus) brevis. These muscles cross the ankle joint laterally and posteriorly, thus producing eversion of the foot and plantar flexion of the foot at the ankle joint. It is also sensory to the lateral ankle and dorsum of the foot, except the web of the great toe

A 52-year-old woman visits her obstetrician for abdominal cramping and muscle weakness in her right thigh. Physical examination shows atrophy of right thigh muscles when compared with the patient's left thigh. Muscle tests determined weakness in adduction of the right thigh. A pelvic exam reveals a mass growing on the lateral wall of the right pelvis. Which of the following nerves is most likely being compressed by the mass in this patient? Obturator Femoral Sciatic Superior gluteal Perineal

Obturator Explanation: In this patient the mass would be compressing the obturator nerve within the pelvis before it emerges through the obturator canal into the thigh. Adduction of the thigh is accomplished predominantly by medial compartment muscles. The innervation of the medial compartment of the thigh is primarily through the obturator nerve, with minor innervations derived from the femoral nerve and the tibial division of the sciatic nerve. The obturator nerve innervates the gracilis, adductor longus, adductor brevis, and the adductor portion of adductor magnus

An 85-year-old woman complains of pain along the medial thigh. On examination, she is cachectic and frail. There is an ovoid patch of decreased sensation to pinprick on the medial thigh that is approximately 20 cm long and 15 cm in the transverse diameter. The remainder of the physical examination is negative, with the exception of a tender mass detected on the ipsilateral wall of the vagina on pelvic examination. Which of the following is the most likely diagnosis? Femoral hernia Lumbar hernia Obturator hernia Indirect inguinal hernia Direct inguinal hernia

Obturator hernia Explanation: An obturator hernia may be felt as a mass on vaginal examination. Pressure on the obturator nerve causes characteristic numbness and pain in the distribution of this nerve.

A 13-year-old boy presents to the emergency department after acute onset of right hip pain as he was preparing to kick a soccer ball. After feeling a pop, he was unable to bear weight on the leg, and the pain was described as being from the groin area. No bone or neurovascular deficits were found on examination; however, the pain was easily regenerated with any non-passive external rotation of the leg, suggesting a muscle strain or tear. Which of the following muscles is likely injured in this patient? Obturator internus Tensor fasciae latae Gluteus medius Gluteus minimus Coccygeus

Obturator internus Explanation: The obturator internus muscle is located in the groin region on the interior surface of the obturator membrane, coinciding with the location of the pain. This muscle inserts on the medial surface of the greater trochanter and provides external rotation when stimulated. Thus, when this muscle is injured, pain on external rotation of the thigh at the hip would be generated.

A 37-year-old woman is diagnosed with a lobular carcinoma of her right breast located in the superomedial aspect, close to the midline. Based on the staging and aggressiveness of her cancer, a lymph node biopsy has been indicated. Which of the following draining lymph nodes is located closest to the cancer and therefore needs to be biopsied? Axillary lymph nodes Subscapular lymph nodes Apical axillary lymph nodes Humeral (lateral) lymph nodes Parasternal lymph nodes

Parasternal lymph nodes Explanation: The parasternal lymph nodes drain lymph from the medial breast. These nodes should certainly be biopsied in this patient.

A 3-year-old girl was brought to the local free clinic for evaluation because her parents felt she was not "growing normally." Physical examination revealed tachycardia, bounding peripheral pulses, and widened pulse pressure. No cyanosis was noted. Cardiac auscultation revealed a continuous "machinery" murmur, heard most clearly at the left upper sternal border. A chest radiograph revealed enlargements of the pulmonary arteries, pulmonary veins, left atrium, and left ventricle. What congenital defect is the most likely cause of the signs and symptoms presented here? Atrial septal defect Coarctation of the aorta Mitral stenosis Patent ductus arteriosus Tetralogy of Fallot

Patent ductus arteriosus Explanation: Continuous, machinery-like murmur, bounding peripheral pulses, and failure to thrive are common features of patent ductus arteriosus.

A 35-year-old man arrives at the emergency department with a severe laceration to the upper medial thigh, close to the ischial ramus of the hip bone. Over the next day, the wound is closed and the patient is stabilized. A routine exam before discharge reveals that most of the muscles of the medial compartment of the thigh are completely paralyzed, pointing to a severing of the obturator nerve. He still can adduct the thigh at the hip slightly, but it is very weak. Which of the following muscles is most likely allowing this patient to still adduct his thigh? Adductor magnus Pectineus Gracilis Adductor brevis Adductor longus

Pectineus Explanation: The pectineus muscle is most often innervated by the obturator and femoral nerves and produces flexion and adduction of the thigh at the hip. Damage to the obturator nerve would still allow the pectineus to perform adduction at the hip joint due to the femoral nerve contributions. Therefore, some continued weak adduction of the thigh at the hip would still be possible.

A 70-year-old man recently returned from an international vacation that required three flights and 16 hours on airplanes. With about an hour to go before landing he started to get muscle cramping in his right hamstring. He did not think much of it at the time, but it got progressively worse by the time he and his wife got home. She convinced him to go to the emergency department, and upon arrival he was quickly taken back for examination. The posterior compartment of his thigh was swollen, red, and very painful. A deep vein thrombosis due to blood stasis is likely. Ultrasound is used to inspect the thigh with a focus on veins that are normally responsible for the major drainage of the posterior compartment of the thigh. Which of the following veins is normally most important for directly draining the affected compartment? Great saphenous vein Lateral circumflex femoral vein Perforating branches of profunda femoris vein Profunda femoris vein Inferior gluteal veins

Perforating branches of profunda femoris vein Explanation: The perforating branches of profunda femoris vein are tributaries of (drain into) the profunda femoris vein and drain the large majority of blood from the posterior compartment of the thigh. The profunda femoris vein originates midthigh in the medial compartment and travels through the femoral triangle to the anterior compartment of the thigh to empty into the femoral vein. It does not drain the posterior compartment directly. The great saphenous vein drains very little of the posterior thigh compartment, nor does the lateral circumflex femoral vein. The inferior gluteal veins travel on either side of the inferior gluteal artery and drain blood from the superficial aspect of the gluteal region.

A 67-year-old woman visits her primary care physician due to a growth in the anterior compartment of her leg. Using ultrasound the physician approximated the growth to be a 3 cm ovoid solid tumor deep to the deep fascia. The concern is that this may be a malignant osteosarcoma (bone cancer). The physician is worried about metastatic spread of the cancer cells along lymphatic channels and elects to palpate the nodes that would most likely be affected (the ones receiving lymph directly from this region). Which of the following lymph nodes would normally receive lymph flow from this location directly? Deep inguinal nodes External iliac nodes Popliteal nodes Superficial inguinal nodes Internal iliac nodes

Popliteal nodes Explanation: Deep lymphatic vessels accompany the anterior tibial veins in the anterior compartment of the leg. These lymphatic channels drain into the popliteal lymph nodes first, then through the deep lymphatic vessels of the thigh to the deep inguinal lymph nodes, then into the external iliac lymph nodes, the common iliac lymph nodes, and ultimately the lumbar lymphatic trunks.

A 23-year-old football player presents with a knee hyperextension injury he incurred during a football game. Physical examination of the knee reveals posterior laxity of the knee joint during a posterior drawer test. Specifically, the tibial plateau deviates posteriorly more than the normal joint laxity. Based on this information and the normal anatomical functions of the ligaments of the knee, which ligament is most likely torn in this patient? Posterior cruciate ligament Medical collateral ligament Lateral collateral ligament Anterior cruciate ligament Patellar ligament

Posterior cruciate ligament Explanation: The posterior cruciate ligament is the most likely structure damaged in this patient because this ligament functions to prevent the tibial plateau from deviating posteriorly beyond normal limits. Additionally, hyperextension injuries often result in posterior cruciate ligament damage and a positive posterior drawer tests also indicates posterior cruciate ligament damage.

A 27-year-old professional cyclist develops a traumatic aneurysm of an artery in his lower limb. A thromboembolus forms at the site of injury, breaks free, and travels into a distal artery, where it blocks blood flow. A thromboembolus that lodges in the lateral plantar artery would most likely come from an aneurysm located in which artery? Anterior tibial Deep artery of thigh (profunda femoris artery) Fibular Lateral femoral circumflex Posterior tibial

Posterior tibial Explanation: The posterior tibial artery divides into the medial plantar and the lateral plantar arteries. An aneurysm in the posterior tibial artery is uncommon; aneurysms in the lower extremity most commonly occur in the popliteal or the femoral artery secondary to atherosclerosis.

A 35-year-old woman has been on prolonged bed rest after a pelvic fracture. She has a genetic deficiency of protein C, resulting in a hypercoagulable state. Localized swelling develops below her left knee, and she experiences leg pain, which worsens with dorsiflexion of the foot (Homan's sign). A diagnosis of deep vein thrombosis (DVT) is made. Magnetic resonance imaging (MRI) studies reveal a clot in one of the paired fibular veins accompanying the fibular artery. If the clot embolizes, which vein will the embolus directly enter as it leaves the fibular vein? Anterior tibial vein Great saphenous vein Lateral plantar vein Popliteal vein Posterior tibial vein

Posterior tibial vein Explanation: The fibular veins are companion vessels to the fibular artery and are located in the posterior compartment of the leg. Fibular veins are direct tributaries to the posterior tibial vein, which then unites with the anterior tibial vein to form the popliteal vein.

A 25-year-old student sits with his right leg crossed over his left for approximately 30 minutes while working on a final examination. He states that he had his right leg crossed over the left just proximal to the knee, with the right foot dangling freely. He was concentrating so intently on the examination that he did not shift his posture. When he tried to get up from his chair, he was unable to elevate his toes and noted a sense of pins and needles in his lower leg. When he attempted to walk, he needed to lift his right leg higher than the left so that his toes would clear the floor. This lasted about 30 minutes and gradually resolved. What is the mostly likely explanation for these symptoms? Prolonged pressure to the common fibular nerve Prolonged pressure to the femoral nerve Prolonged pressure to the iliohypogastric nerve Prolonged pressure to the pudendal nerve Prolonged pressure to the sciatic nerve

Prolonged pressure to the common fibular nerve Explanation: The common fibular nerve passes over the head of the fibula in a relatively superficial location. It is therefore vulnerable to pressure from the position described. Injury to the common fibular nerve (in this case, a temporary injury from prolonged pressure) results in loss of eversion and dorsiflexion of the foot and some sensory disturbances as noted.

A 75-year-old man presents to the emergency department with significant lower abdomen pain and back pain. An arteriogram confirms the patient has an embolic occlusion of the posterior division of his internal iliac artery. It is hypothesized that the loss of blood flow to a given region is causing his pain. Which of the following structures would likely have a loss of blood flow? Vagina Bladder Quadriceps femoris Psoas major Rectum

Psoas major Explanation: The psoas major muscle receives its blood supply from the iliolumbar artery. This iliolumbar artery is a branch of the posterior division of the internal iliac artery; thus a clot in the posterior division would affect blood supply to this muscle.

A 21-year-old woman presents to the emergency department after a pole-vaulting injury. She hyperextended her torso after falling awkwardly on the landing mat. Examination and ultrasound imaging reveal a grade three tear of the rectus abdominis muscle away from its inferior attachment. Which of the following structures is the most likely attachment site that was injured in this patient? Costal cartilages of ribs 5-7 Pubic symphysis Xiphoid process Ischial tuberosity Anterior inferior iliac spine

Pubic symphysis Explanation: The origin of the rectus abdominis muscle is at the pubic symphysis, which is the structure that would be closest to her injury in this case.

After birth the ductus arteriosus begins to vasoconstrict and eventually becomes obliterated to form the ligamentum arteriosum. In utero this vessel is important to shunt blood away from the developing lungs. Occasionally, this vessel remains patent (open) after birth and can cause some cardiovascular problems. A mother of a premature infant is asking you to explain to her about the patent ductus arteriosus in her newborn. You reply that the ductus arteriosus connects which of the following two structures? Left anterior descending artery and great cardiac vein Subclavian artery and brachiocephalic vein Aorta and inferior vena cava Pulmonary artery and aorta Left atrium and right atrium

Pulmonary artery and aorta Explanation: The normal ductus arteriosus allows shunting to occur between the pulmonary artery and the aorta. This shunt is normally present in fetal circulation to decrease blood flow to the pulmonary bed, as the lungs are still developing in utero.

A 56-year-old man with congestive heart failure presents to the emergency department because of a rusty red-colored hemoptysis, or blood in the sputum. The color is caused by the phagocytosis of leaked erythrocytes by alveolar macrophages, and the hemoptysis associated with congestive heart failure is often attributed to increased intravascular pressure. Which of the following vessels are most likely responsible for the leakage of erythrocytes, causing blood in the sputum of this patient? Pulmonary veins Pulmonary capillaries Pulmonary trunk Pulmonary arteries Pulmonary lymphatics

Pulmonary capillaries Explanation: The pulmonary capillaries are located near the alveolar surface of the lung, as they are the location of gas exchange. Increased intravascular pressure due to congestive heart failure would cause these normally leaky vessels to leak erythrocytes near the surface of the airway, which can easily be coughed up.

A 16-year-old female tennis player presents with Osgood-Schlatter disease, or apophysitis of the tibial tuberosity. This condition is characterized by a painful lump located just below the knee and is most often seen in active adolescents. Her parents are curious about what has been causing their daughter's knee pain and are concerned about a more serious injury. They ask you to explain the etiology of this condition. Based on normal anatomy, identify the most correct response to your patient's parents. Repeated contraction of the quadriceps muscles transmits stress through the patellar tendon to its insertion on the tibial tuberosity. Repeated contraction of the tibialis anterior muscle transmits stress through the patellar tendon to its insertion on the tibial tuberosity. Repeated contraction of the hamstrings (the semimembranosus, semitendinosus, and biceps femoris muscles) transmits stress to its insertion on the tibial tuberosity. Repeated blunt force trauma to the tibial tuberosity Repeated contraction of the gastrocnemius and soleus muscles transmits stress to its insertion on the tibial tuberosity.

Repeated contraction of the quadriceps muscles transmits stress through the patellar tendon to its insertion on the tibial tuberosity. Explanation: This is the major mechanism for apophysitis of the tibial tuberosity. The quadriceps muscles come together at the patellar tendon (tendon of the quadriceps femoris) and, after the patella, inserts on the tibial tuberosity. Repeated flexion of the quadriceps keeps pulling on the insertion, leading to inflammation and irritation that is associated with knee pain. Additionally, this occurs more frequently in younger patients who do not have ossified growth plates at this location.

A 35-year-old construction worker complains of difficulty walking 2 days after falling off some low scaffolding and landing on his buttocks. He had a screwdriver in his back pocket, and although the fall was only about 4 feet, the landing was hard and drove the screwdriver handle into his gluteal region. You notice that when you ask the patient to stand on his right foot only (lift left foot off the ground), the iliac crest on the left side slumps (dips lower than the right iliac crest). Damage to which of the following nerves is the most likely cause of this phenomenon? Left superior gluteal nerve Right superior gluteal nerve Left inferior gluteal nerve Right inferior gluteal nerve Sciatic nerve

Right superior gluteal nerve Explanation: Damage to the superior gluteal nerve weakens the gluteal abductors of the thigh at the hip joint. Therefore, when the right superior gluteal nerve is damaged the ipsilateral muscles affected cause weakness of abduction on the right side. When the individual lifts his left foot, all the body weight is being supported by the right lower limb up through the pelvis. Since the right abductors are weak they cannot hold the pelvis horizontal with the left foot off the ground. Therefore, the iliac crest and lower limb slump on the right because the left hip abductors are not functioning properly. Muscles producing abduction of the thigh at the hip joint include gluteus medius, gluteus minimus, and tensor fascia latae. All are innervated by the superior gluteal nerve.

A 17-year-old boy with a black belt in karate executes a kick without properly warming up. He hears a popping sound and is unable to bear weight on his right leg. On examination he is unable to actively plantar flex his foot, and passive dorsiflexion causes pain in his calf and the back of his ankle. There is a palpable gap in the contour of the posterior ankle above the calcaneal tuberosity. Which of the following is the most likely diagnosis? Ruptured medial meniscus Ruptured lateral meniscus Ruptured talofibular ligament Ruptured calcaneal tendon Ruptured inferior extensor retinaculum

Ruptured calcaneal tendon Explanation: This tendon connects the calcaneus with the body of the gastrocnemius muscle. The pattern of signs and symptoms described is characteristic of a ruptured calcaneal (Achilles) tendon (see Plate 506).

A deep tendon reflex, also known as stretch reflex, is a useful clinical tool to determine the localized functionality of the neuromuscular structures. Characteristically, the deep tendon reflex usually involves only several spinal cord segments (and their afferent and efferent nerve fibers). During a test of a calcaneal tendon reflex, which of the following segmental level(s) are involved? L3 and L4 L1 and L2 S4 and S5 S1 and S2 L5

S1 and S2 Explanation: The S1 and S2 spinal levels have dermomyotomes that correspond with the calcaneal tendon reflex. This "ankle jerk reflex" is commonly tested in patients with suspected L5/S1 disc disease. When the reflex hammer strikes the calcaneal tendon just proximal to the calcaneus the normal result is plantarflexion of the ankle joint. If the S1 nerve root is injured or compressed, the ankle reflex is virtually absent.

To help manage postoperative pain, an anesthesiologist plans to administer caudal as well as general anesthesia to an 8-year-old girl undergoing abdominal surgery. The caudal anesthetic will be introduced via the sacral hiatus. Which landmark most reliably indicates the location of the sacral hiatus? Ischial spine Posterior sacral foramina Posterior superior iliac spine Sacral cornua Sacral promontory

Sacral cornua Explanation: The sacral cornua are the inferior articular processes of the sacrum. Because they are located just lateral to the sacral hiatus and are easily palpable, they are useful landmarks for locating the hiatus.

A patient was being prepared for surgical treatment of varicose veins in the lower extremities and had the great saphenous vein cannulated in the vicinity of the ankle. During the procedure, the patient experienced significant pain that radiated along the medial border of the foot. Which of the following nerves was accidentally included in a ligature during this procedure? Saphenous Medial plantar Superficial fibular Sural cutaneous Tibial

Saphenous Explanation: The saphenous nerve (L3-L4) arises as a cutaneous branch of the femoral nerve in the femoral triangle. It descends with the femoral artery and vein in the adductor canal, but before reaching the adductor hiatus the saphenous nerve pierces the fascia lata and innervates the skin of the medial crural region and the ankle. Additionally, near the ankle the saphenous nerve travels alongside the greater saphenous vein.

Pes anserine bursitis is an inflammatory condition of the medial knee, commonly associated with spontaneous pain of the inferomedial knee joint. The pes anserine bursa is associated with three muscle tendons that insert medial and distal to the tibial tuberosity of the tibia. Bursitis in this region can occur from acute medial knee trauma, overuse, or degenerative processes. Which combination of three muscles is most likely causing irritation of this bursa? Sartorius, gracilis, semitendinosus Sartorius, gracilis, vastus medialis Biceps femoris long head, vastus medialis, gracilis Tibialis anterior, semitendinosus, sartorius Tibialis anterior, sartorius, gracilis

Sartorius, gracilis, semitendinosus Explanation: The pes anserinus is the anatomical term for the location of the conjoined tendons of the sartorius, gracilis, and semitendinosus muscles. All three muscles insert on the anteromedial proximal tibia.

A 42-year-old housewife visits her family doctor with a chief complaint of knee pain, which is made worse by extension of the thigh at the hip and flexion of the leg at the knee. Upon examination you localize the pain to the superior part of the anteromedial tibia. Which of the following muscles inserts in this area? Soleus Gastrocnemius (medial head) Semitendinosus Vastus medialis Vastus intermedius

Semitendinosus Explanation: The semitendinosus muscle attaches proximally to the ischial tuberosity and distally to the anteromedial aspect of the proximal tibia in the pes anserinus. It functions to produce extension of the thigh at the hip joint and flexion and medial rotation of the leg at the knee joint.

A 35-year-old man goes to his family doctor due to tingling in the fingers of his left hand and he complains that his left hand seems to frequently feel cooler than his right. He is a sheet-rock worker and he frequently works with his arms overhead for long periods of time. He tells his doctor that his left hand gets much worse after many hours of overhead work. You suspect thoracic outlet syndrome and hypothesize that an artery is being compressed as it exits the thorax. Therefore, the overhead work coupled with reduced vascular supply could cause the tingling in the hand and a reduction in skin temperature of the left hand. Which of the following is most likely compressed and therefore causing the symptoms in this patient? Subclavian artery Radial artery Superior vena cava Celiac trunk Lateral thoracic artery

Subclavian artery Explanation: The subclavian artery exits the superior thoracic outlet and passes between the anterior and middle scalene muscles as it continues out to supply blood to the arm. It is easily compressed in the scalene hiatus, which can cause the vascular symptoms experienced in this patient.

A 36-year-old man presents to the emergency department with a staple gun wound to the chest that occurred while remodeling his house. A staple was found to have pierced the external (deep) investing fascia anteriorly near his left 10th rib. Which of the following superficial structures has the staple most likely to have passed through before the external investing fascia? Internal investing fascia Subcutaneous layer Scarpa's fascia Pericardium Intercostal muscles

Subcutaneous layer Explanation: The external investing fascia lies superficial to the musculoskeletal wall, leaving only a few possibilities for structures that lie superficial to it. The skin and underlying subcutaneous layer would need to be pierced in this region of the thorax to reach this fascia.

A 46-year-old man comes to the emergency department. As a third year medical student you are the first to evaluate him. He was having an affair with his married neighbor when her husband came home unexpectedly. As he was running from the house the husband fired one shot from a gun, striking the patient in the right buttock. Upon examination the patient is able to walk a few steps and you notice a Trendelenburg gait. You confirm through physical findings that he has significant weakness with abduction at the hip joint. Which of the following nerves is most likely damaged? Inferior gluteal Sciatic Obturator Pudendal Superior gluteal

Superior gluteal Explanation: Muscles producing abduction of the thigh at the hip joint include gluteus medius, gluteus minimus, and tensor fascia latae. All are innervated by the superior gluteal nerve. A gluteus medius/minimus limp (Trendelenburg gait) occurs with an injury of the superior gluteal nerve, which weakens the gluteal abductors of the thigh at the hip joint and results in pelvic drop of the contralateral unsupported side of single limb stance. To overcome this deficiency, individuals must laterally flex their trunk over the supported limb, which keeps the unsupported side from dropping too far and hitting the ground during the swing phase of normal gait.

The Trendelenburg gait is a gait disturbance that is caused by weakness in the hip abductors. The clinical presentation of this gait occurs during the stance phase of walking, in which one foot is flat on the ground and the other is moving forward. Patients with a positive Trendelenburg sign have weakened gluteus medius and gluteus minimus muscles on the side of the planted foot, which causes the opposite hip to tilt inferiorly during the step. Which of the following nerves could be damaged or impinged and cause weakness in these muscles, causing the Trendelenburg gait? Inferior gluteal nerve Sciatic nerve Superior gluteal nerve Ilio-inguinal nerve Obturator nerve

Superior gluteal nerve Explanation: The superior gluteal nerve originates in the sacral plexus and exits the pelvis via the greater sciatic foramen to innervate both the gluteus medius and gluteus minimus. Damage or impingement of this nerve could weaken these muscles and cause a positive Trendelenburg sign.

A 57-year-old woman has thyroid surgery to remove a cancerous nodule. The nodule was removed successfully, but the surgeon cut the recurrent laryngeal nerve during the procedure, causing the woman to talk with a hoarse voice. A second surgery is scheduled to graft a lower limb cutaneous nerve to replace the damaged segment of the recurrent laryngeal nerve. Months after the procedure, results look promising regarding the patient's voice. She has one minor complaint about a lack of sensation on the back of her leg laterally and along the lateral side of her foot. Which nerve was harvested during the grafting procedure? Saphenous Sural Superficial fibular Tibial Lateral plantar

Sural Explanation: The sural nerve (S1-S2) forms as the union of the medial sural cutaneous branch of the tibial nerve and the lateral sural cutaneous nerve of the common fibular (peroneal) nerve superficial to the crural fascia. The sural nerve supplies the skin of the back of the leg laterally and along the lateral side of the foot.

A football player complains of severe knee pain after being tackled from the side. When the knee is flexed, the tibia can be moved anteriorly relative to the femur. Which injury most likely occurred? Rupture of the fibular collateral ligament Rupture of the patellar ligament Tear of the anterior cruciate ligament (ACL) Tear of the lateral meniscus Tear of the posterior cruciate ligament

Tear of the anterior cruciate ligament (ACL) Explanation: If the knee is hit hard from the lateral side while the foot is planted, the "unhappy triad" may result: rupture of the tibial collateral ligament with tearing of the ACL and the medial meniscus. An ACL tear or strain is the most common knee injury that occurs while playing sports such as football (see Plate 496).

A 2-year-old girl is suspected of aspirating the eye from one of her small stuffed animals and she is seen in the emergency department. Her mother reports consistent coughing but no displays of distress or pain. In which area of the airway would you expect to hear diminished breath sounds? Both the left and right lobe The carina The left inferior lobe The right inferior lobe The right superior lobe

The right inferior lobe Explanation: The right inferior lobe is the most likely location of diminished breath sounds because the right mainstem bronchus is more vertical compared to the left, allowing gravity to take effect and lodge the object in the lowest division of the bronchi.

A 41-year-old man visits a pain clinic to get an injection to relieve ischial tuberosity pain caused by a previous car accident. At his last visit an inexperienced physician attempted to inject a medication at the hamstring attachment to the ischial tuberosity. The patient felt a shock run down the back of his thigh and leg, all the way to the bottom of his foot. The needle was quickly removed and the patient stood to assess his injury. He now complains about weakness when flexing the knee and when attempting to stand on his toes. Additionally, he is concerned because he has been tripping frequently as a result of not feeling the ground under his foot. Which of the following nerves was most likely directly damaged by the injection? Common fibular (peroneal) nerve Posterior cutaneous nerve of the thigh Medial plantar nerve Obturator nerve Tibial nerve

Tibial nerve Explanation: The tibial nerve innervates all muscles of the posterior thigh and posterior leg, except for the short head of the biceps femoris (innervated by the common fibular nerve). Additionally, the tibial nerve carries sensory innervation from the posterior thigh, the posterolateral leg, and plantar surface of the foot. Therefore, damage to the tibial nerve would cause weakness in knee flexion and plantar flexion at the ankle and could cause cutaneous sensory problems on the soles of the feet.

A nurse is directed to give an intramuscular injection of 5 mL of gamma globulin to a 35-year-old man who will be traveling to a hepatitis-endemic part of the world. She chooses an injection site on the left buttock. To avoid injury to the sciatic nerve and any other major neurovascular structures in the vicinity, where should the nurse inject the gamma globulin? Exact center of the gluteus maximus muscle Lower inner quadrant of the gluteus maximus muscle Lower outer quadrant of the gluteus maximus muscle Upper inner quadrant of the gluteus maximus muscle Upper outer quadrant of the gluteus maximus muscle

Upper outer quadrant of the gluteus maximus muscle Explanation: Injection in the upper outer quadrant of the gluteus maximus muscle minimizes the risk of injury to the sciatic nerve, superior gluteal artery and nerve, and other structures in the vicinity.

A 52-year-old woman is referred to a neurologist by her primary care physician due to chronic pain in her right lower limb for nearly a year. She tells her neurologist that the pain has gotten more persistent but that she's be experiencing the pain intermittently for as long as she can remember. She recently took a job as a security guard where she sits for most of an 8-hour shift and observes security camera monitors. The pain is mainly confined to the thigh, leg, and gluteal region. The neurologist documents reduced sensation on the dorsum of her right foot and between the first and second toes and a motor deficit with some weakness in foot eversion. The neurologist diagnoses piriformis entrapment syndrome with compression of the fibular division of the sciatic nerve. What else did the neurologist most likely document during the physical exam? Weakness of plantar flexion Quadriceps weakness Loss of sensation of the medial thigh Spasms of the adductor musculature of the thigh Weakness extending toes

Weakness extending toes Explanation: This patient shows symptoms of deep and superficial fibular nerve problems. Therefore, muscles in the lateral and anterior compartments will be affected. The extensor digitorum longus, extensor hallucis longus, extensor hallucis brevis, and extensor digitorum brevis muscles are all innervated by the deep fibular nerve, and therefore this patient would have trouble extending the toes.