A. Transverse Ligament: B. Ligamentum Teres

yomna92009@yahoo.
com - MRCS Part A - My account
Reference ranges End and review
Question 8 of 441 Question stats Score: 100%
1
A 11.4%
Which of the following ligaments contains the artery supplying the head of femur 2
B 53.3%
in children? 3
C 15.2%
D 11.4% 4
A. Transverse ligament E 8.7% 5
B. Ligamentum teres 6
53.3% of users answered this
C. Iliofemoral ligament question correctly
7
D. Ischiofemoral ligament
8
E. Pubofemoral ligament
Next question
Theme from 2010 Exam
Hip joint
Head of femur articulates with acetabulum of the pelvis

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

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

Extracapsular ligaments
Iliofemoral ligament: inverted Y shape. Anterior iliac spine to the

trochanteric line
Pubofemoral ligament: acetabulum to lesser trochanter
Ischiofemoral ligament: posterior support. Ischium to greater trochanter.
Blood supply
Medial circumflex femoral and lateral circumflex femoral arteries (Branches of
profunda femoris)
2 anastomoses: Cruciate and the trochanteric anastomoses (provides most of the

blood to the head of the femur) Hence the need for hemiarthroplasty when there
is a displaced femoral head fracture. These anastomoses exist between the
femoral artery or profunda femoris and the gluteal vessels.
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yomna92009@yahoo.com - MRCS Part A - My account
1
A 12.6%
Which of the following is not a branch of the posterior cord of the brachial plexus? 2
B 10.9%
C 9.1% 3
A. Thoracodorsal nerve D 11% 4
B. Axillary nerve E 56.4% 5
C. Radial nerve 56.4% of users answered this 6

question correctly
D. Lower subscapular nerve 7
E. Musculocutaneous nerve 8
9
Next question
10
11
Mnemonic branches off the posterior cord 12
13
S ubscapular (upper and lower)
T horacodorsal 14
A xillary 15
R adial
16
17
The musculocutaneous nerve is a branch off the lateral cord.
18
19
Brachial plexus
20
Origin Anterior rami of C5 to T1
Sections of the Roots, trunks, divisions, cords, branches

plexus Mnemonic:Real Teenagers Drink Cold Beer
Roots Located in the posterior triangle

Pass between scalenus anterior and medius
Trunks Located posterior to middle third of clavicle

Upper and middle trunks related superiorly to the subclavian
artery
Lower trunk passes over 1st rib posterior to the subclavian
artery
Divisions Apex of axilla
Cords Related to axillary artery
Diagram illustrating the branches of the brachial plexus

Cutaneous sensation of the upper limb
Question 13 of 441 Question stats Score: 92.3%
1
A 50.3%
Which of the following structures separates the subclavian artery from the 2
B 21.3%
subclavian vein? 3
C 7.5%
D 9.8% 4
A. Scalenus anterior E 11.1% 5
B. Scalenus medius 6
C. Sternocleidomastoid question correctly
7
D. Pectoralis major
8
E. Pectoralis minor
9
10
Next question
11
The artery and vein are separated by scalenus anterior. This muscle runs from 12
the the transverse processes of C3,4,5 and 6 to insert onto the scalene tubercle 13
of the first rib.
Subclavian artery
Path
The left subclavian comes directly off the arch of aorta

The right subclavian arises from the brachiocephalic artery (trunk) when it
bifurcates into the subclavian and the right common carotid artery.
From its origin, the subclavian artery travels laterally, passing between
anterior and middle scalene muscles, deep to scalenus anterior and
anterior to scalenus medius. As the subclavian artery crosses the lateral
border of the first rib, it becomes the axillary artery. At this point it is
superficial and within the subclavian triangle.
Branches
Vertebral artery
Internal thoracic artery
Thyrocervical trunk
Costocervical trunk
Dorsal scapular artery
1
A 7.9%
A motorcyclist is involved in a road traffic accident. He suffers a complex humeral 2
B 68.5%
shaft fracture which is plated. Post operatively he complains of an inability to
C 9.4%
extend his fingers. Which of the following structures is most likely to have been
D 6.7%
injured?
E 7.5%
A. Ulnar nerve 68.5% of users answered this

question correctly
B. Radial nerve
C. Median nerve
D. Axillary nerve
E. None of the above
Next question
Mnemonic for radial nerve muscles: BEST
B rachioradialis
E xtensors
S upinator
T riceps
The radial nerve is responsible for innervation of the extensor compartment of the
forearm.
Radial nerve
Continuation of posterior cord of the brachial plexus (root values C5 to T1)
Path
In the axilla: lies posterior to the axillary artery on subscapularis, latissimus

dorsi and teres major.
Enters the arm between the brachial artery and the long head of triceps
(medial to humerus).
Spirals around the posterior surface of the humerus in the groove for the
radial nerve.
At the distal third of the lateral border of the humerus it then pierces the
intermuscular septum and descends in front of the lateral epicondyle.
At the lateral epicondyle it lies deeply between brachialis and
brachioradialis where it then divides into a superficial and deep terminal
branch.
Deep branch crosses the supinator to become the posterior interosseous
nerve.
In the image below the relationships of the radial nerve can be appreciated
Regions innervated
Motor (main Triceps

nerve) Anconeus
Brachioradialis
Extensor carpi radialis
Motor Extensor carpi ulnaris

(posterior Extensor digitorum
interosseous Extensor indicis
branch Extensor digiti minimi
Extensor pollicis longus and brevis
Abductor pollicis longus
Sensory Dorsal aspect of lateral 3 1/2 fingers (N.B )only small area
between the dorsal aspect of the 1st and 2nd metacarpals is
unique to the radial nerve
Muscular innervation and effect of denervation

Anatomical Muscle affected Effect of paralysis
location
Shoulder Long head of triceps Minor effects on shoulder stability in

abduction
Arm Triceps Loss of elbow extension
Forearm Supinator Weakening of supination of prone hand

Brachioradialis and elbow flexion in mid prone position
Extensor carpi
radialis longus and
brevis
The cutaneous sensation of the upper limb- illustrating the contribution of the
radial nerve

1
A 22%
A 23 year old man falls and slips at a nightclub. A shard of glass penetrates the 2
B 14.9%
skin at the level of the medial epicondyle, which of the following sequelae is least 3
C 35.4%
likely to occur?
D 13.6% 4
E 14.1% 5
A. Atrophy of the first dorsal interosseous muscle
35.4% of users answered this 6
B. Difficulty in abduction of the the 2nd, 3rd, 4th and 5th fingers question correctly
7
C. Claw like appearance of the hand
8
D. Loss of sensation on the anterior aspect of the 5th finger
9
E. Partial denervation of flexor digitorum profundus
10
Next question
Injury to the ulnar nerve in the mid to distal forearm will typically produce a
claw hand. This consists of flexion of the 4th and 5th interphalangeal joints
and extension of the metacarpophalangeal joints. The effects are potentiated
when flexor digitorum profundus is not affected, and the clawing is more
pronounced.More proximally sited ulnar nerve lesions produce a milder
clinical picture owing to the simultaneous paralysis of flexor digitorum
profundus (ulnar half).
This is the 'ulnar paradox', due to the more proximal level of transection the hand
will typically not have a claw like appearance that may be seen following a more
distal injury. The first dorsal interosseous muscle will be affected as it is supplied
by the ulnar nerve.
Ulnar nerve
Origin
C8, T1
Supplies (no muscles in the upper arm)
Flexor carpi ulnaris

Flexor digitorum profundus
Flexor digiti minimi
Abductor digiti minimi
Opponens digiti minimi
Adductor pollicis
Interossei muscle
Third and fourth lumbricals
Palmaris brevis
Path
Posteromedial aspect of ulna to flexor compartment of forearm, then along

the ulnar. Passes beneath the flexor carpi ulnaris muscle, then superficially
through the flexor retinaculum into the palm of the hand.
Branches
Branch Supplies
Articular branch Flexor carpi ulnaris

Medial half of the flexor digitorum profundus
Palmar cutaneous branch (Arises near Skin on the medial part of the palm
the middle of the forearm)
Dorsal cutaneous branch Dorsal surface of the medial part of the hand
Superficial branch Cutaneous fibres to the anterior surfaces of the

medial one and one-half digits
Deep branch Hypothenar muscles

All the interosseous muscles
Third and fourth lumbricals
Adductor pollicis
Medial head of the flexor pollicis brevis
Effects of injury
Damage at the wrist Wasting and paralysis of intrinsic hand muscles (claw hand)
Wasting and paralysis of hypothenar muscles
Loss of sensation medial 1 and half fingers
Damage at the elbow Radial deviation of the wrist

Clawing less in 3rd and 4th digits
1
A 5.2%
A 20 year old man is hit with a hammer on the right side of the head. He dies on 2
B 17.9%
arrival in the emergency department. Which of the following features is most likely 3
C 57%
to be found at post mortem?
D 14% 4
E 5.9% 5
A. Hydrocephalus
57% of users answered this 6
B. Supra tentorial herniation question correctly
7
C. Laceration of the middle meningeal artery
D. Sub dural haematoma
E. Posterior fossa haematoma
Next question
Theme based on 2011 exam

This will account for the scenario given where there is a brief delay prior to death.
The other options are less acute and a supratentorial herniation would not occur
in this setting.
Head injury
Patients who suffer head injuries should be managed according to ATLS

principles and extra cranial injuries should be managed alongside cranial
trauma. Inadequate cardiac output will compromise CNS perfusion
irrespective of the nature of the cranial injury.
Types of traumatic brain injury

Extradural Bleeding into the space between the dura mater and the skull. Often results
haematoma from acceleration-deceleration trauma or a blow to the side of the head. The
majority of extradural haematomas occur in the temporal region where skull
fractures cause a rupture of the middle meningeal artery.
Features
Raised intracranial pressure

Some patients may exhibit a lucid interval
Subdural Bleeding into the outermost meningeal layer. Most commonly occur around
haematoma the frontal and parietal lobes. May be either acute or chronic.
Risk factors include old age and alcoholism.
Slower onset of symptoms than a extradural haematoma.
Subarachnoid Usually occurs spontaneously in the context of a ruptured cerebral

haemorrhage aneurysm but may be seen in association with other injuries when a patient
has sustained a traumatic brain injury
Pathophysiology
Primary brain injury may be focal (contusion/ haematoma) or diffuse

(diffuse axonal injury)
Diffuse axonal injury occurs as a result of mechanical shearing following
deceleration, causing disruption and tearing of axons
Intra-cranial haematomas can be extradural, subdural or intracerebral,
while contusions may occur adjacent to (coup) or contralateral (contre-
coup) to the side of impact
Secondary brain injury occurs when cerebral oedema, ischaemia, infection,
tonsillar or tentorial herniation exacerbates the original injury. The normal
cerebral auto regulatory processes are disrupted following trauma
rendering the brain more susceptible to blood flow changes and hypoxia
The Cushings reflex (hypertension and bradycardia) often occurs late and
is usually a pre terminal event
Management
Where there is life threatening rising ICP such as in extra dural haematoma
and whilst theatre is prepared or transfer arranged use of IV mannitol/
frusemide may be required.
Diffuse cerebral oedema may require decompressive craniotomy
Exploratory Burr Holes have little management in modern practice except
where scanning may be unavailable and to thus facilitate creation of formal
craniotomy flap
Depressed skull fractures that are open require formal surgical reduction
and debridement, closed injuries may be managed non operatively if there
is minimal displacement.
ICP monitoring is appropriate in those who have GCS 3-8 and normal CT
scan.
ICP monitoring is mandatory in those who have GCS 3-8 and Abnormal CT
scan.
Hyponatraemia is most likely to be due to syndrome of inappropriate ADH
secretion.
Minimum of cerebral perfusion pressure of 70mmHg in adults.
Minimum cerebral perfusion pressure of between 40 and 70 mmHg in
children.
Interpretation of pupillary findings in head injuries

Pupil size Light response Interpretation
Unilaterally dilated Sluggish or fixed 3rd nerve compression secondary to

tentorial herniation
Bilaterally dilated Sluggish or fixed Poor CNS perfusion

Bilateral 3rd nerve palsy
Unilaterally dilated Cross reactive (Marcus Optic nerve injury

or equal - Gunn)
Bilaterally May be difficult to Opiates

constricted assess Pontine lesions
Metabolic encephalopathy
Unilaterally Preserved Sympathetic pathway disruption

constricted
1
A 5.6%
A 60 year old female attends the preoperative hernia clinic. She reports some 2
B 13.4%
visual difficulty. On examination she is noted to have a homonymous hemianopia. 3
C 12.6%
Where is the lesion most likely to be?
D 31.4% 4
E 37.1% 5
A. Frontal lobe
B. Pituitary gland question correctly
7
C. Parietal lobe
8
D. Optic chiasm
9
E. Optic tract
10
Next question 11
12
13
Lesions before optic chiasm:
Monocular vision loss = Optic nerve lesion 14
Bitemporal hemianopia = Optic chiasm lesion 15
16
Lesions after the optic chiasm:
Homonymous hemianopia = Optic tract lesion 17
Upper quadranopia = Temporal lobe lesion 18

Lower quadranopia = Parietal lobe lesion
Theme from April 2012 exam
Unfortunately we thought as surgeons we could forget about visual field defects!

However the college seem to like them. Remember a homonymous hemianopia is
indicative of an optic tract lesion. Parietal lobe lesions tend to cause inferior
quadranopias and there is a bitemporal hemianopia with optic chiasm lesion or
pituitary tumours.
Visual field defects
Theme from January 2012 exam

Theme from April 2012 exam
left homonymous hemianopia means visual field defect to the left, i.e.
Lesion of right optic tract
homonymous quadrantanopias: PITS (Parietal-Inferior, Temporal-Superior)
incongruous defects = optic tract lesion; congruous defects = optic
radiation lesion or occipital cortex
Homonymous hemianopia
Incongruous defects: lesion of optic tract

Congruous defects: lesion of optic radiation or occipital cortex
Macula sparing: lesion of occipital cortex
Homonymous quadrantanopias
Superior: lesion of temporal lobe

Inferior: lesion of parietal lobe
Mnemonic = PITS (Parietal-Inferior, Temporal-Superior)
Bitemporal hemianopia
Lesion of optic chiasm

Upper quadrant defect > lower quadrant defect = inferior chiasmal
compression, commonly a pituitary tumour
Lower quadrant defect > upper quadrant defect = superior chiasmal
compression, commonly a craniopharyngioma
1
A 10.9%
What are the boundaries of the 'safe triangle' for chest drain insertion? 2
B 52.5%
C 22.7% 3
A. Bounded by trapezius, latissimus dorsi, and laterally by the vertebral D 6.9% 4

border of the scapula E 6.9% 5
B. Bounded by latissimus dorsi, pectoralis major, line superior to the
nipple and apex at the axilla
question correctly
7
C. Bounded by latissimus dorsi, serratus anterior, line superior to the
nipple and apex at the axilla 8
D. Bounded by trapezius, deltoid, rhomboid major and teres minor 9
E. Bounded by trapezius, deltoid and latissimus dorsi 10
11
Next question
12
13
Theme from April 2012 Exam
14
Chest drains 15
16
There are a number of different indications for chest drain insertion. In general
terms large bore chest drains are preferred for trauma and haemothorax
drainage. Smaller diameter chest drains can be used for pneumothorax or pleural
effusion drainage.
Insertion can be performed either using anatomical guidance or through

ultrasound guidance. In the exam, the anatomical method is usually tested.
It is advised that chest drains are placed in the 'safe triangle'. The triangle is
located in the mid axillary line of the 5th intercostal space. It is bordered by:
Anterior edge latissimus dorsi, the lateral border of pectoralis major, a line
superior to the horizontal level of the nipple, and the apex below the axilla.
Another triangle is situated behind the scapula. It is bounded above by the

trapezius, below by the latissimus dorsi, and laterally by the vertebral border of
the scapula; the floor is partly formed by the rhomboid major. If the scapula is
drawn forward by folding the arms across the chest, and the trunk bent forward,
parts of the sixth and seventh ribs and the interspace between them become
subcutaneous and available for auscultation. The space is therefore known as
the triangle of auscultation.
References
Prof Harold Ellis. The applied anatomy of chest drains insertions. British Journal
of hospital medicine 2007; 68: 44-45
Laws D, Neville E, Duffy J. BTS guidelines for insertion of chest drains.

Thorax,May 2003; 58: ii53-ii59.
1
A 23%
During an Ivor Lewis Oesophagectomy for carcinoma of the lower third of the 2
B 36.9%
oesophagus which structure is divided to allow mobilisation of the oesophagus? 3
C 13.6%
D 8.7% 4
A. Vagus nerve E 17.7% 5
B. Azygos vein 6
C. Right inferior lobar bronchus question correctly
7
D. Phrenic nerve
8
E. Pericardiophrenic artery
9
10
Next question
11
The azygos vein is routinely divided during an oesophagectomy to allow 12

mobilisation. It arches anteriorly to insert into the SVC on the right hand side. 13
14
Treatment of oesophageal cancer
15
16
In general resections are not offered to those patients with distant
17
metastasis, and usually not to those with N2 disease.
Local nodal involvement is not in itself a contra indication to resection. 18
Surgical resection is the mainstay of treatment. 19
Neoadjuvent chemotherapy is given in most cases prior to surgery.
In situ disease may be managed by endoscopic mucosal resection,
although this is still debated.
In patients with lower third lesions an Ivor - Lewis type procedure is most
commonly performed. Very distal tumours may be suitable to a transhiatal
procedure. Which is an attractive option as the penetration of two visceral
cavities required for an Ivor- Lewis type procedure increases the morbidity
considerably.
More proximal lesions will require a total oesphagectomy (Mckeown type)
with anastomosis to the cervical oesophagus.
Patients with unresectable disease may derive benefit from local ablative
procedures, palliative chemotherapy or stent insertion.
Operative details of Ivor- Lewis procedure
Combined laparotomy and right thoracotomy
Indication
Lower and middle third oesophageal tumours
Preparation
Staging with a combination of CT chest abdomen and pelvis- if no

metastatic disease detected then patients will undergo a staging
laparoscopy to detect peritoneal disease.
If both these modalities are negative then patients will finally undergo a
PET CT scan to detect occult metastatic disease. Only in those whom no
evidence of advanced disease is detected will proceed to resection.
Patients receive a GA, double lumen endotracheal tube to allow for lung
deflation, CVP and arterial monitoring.
Procedure
A rooftop incision is made to access the stomach and duodenum.

Laparotomy To mobilize the stomach
The greater omentum is incised away from its attachment to the right
gastroepiploic vessels along the greater curvature of the stomach.
Then the short gastric vessels are ligated and detached from the greater
curvature from the spleen.
The lesser omentum is incised, preserving the right gastric artery.
The retroperitoneal attachments of the duodenum in its second and third
portions are incised, allowing the pylorus to reach the oesophageal hiatus.
Some surgeons perform a pyloroplasty at this point to facilitate gastric
emptying.
The left gastric vessels are then ligated, avoiding any injury to the common
hepatic or splenic arteries. Care must be taken to avoid inadvertently
devascularising the liver owing to variations in anatomy.
Right Thoracotomy Oesophageal resection and oesophagogastric anastomosis
Through 5th intercostal space

Dissection performed 10cm above the tumour
This may involve transection of the azygos vein.
The oesophagus is then removed with the stomach creating a gastric tube.
An anastomosis is created.
The chest is closed with underwater seal drainage and tube drains to the
abdominal cavity.
Post operatively
Patients will typically recover in ITU initially.

A nasogastric tube will have been inserted intraoperatively and must
remain in place during the early phases of recovery.
Post operatively these patients are at relatively high risk of developing
complications:
* Atelectasis- due to the effects of thoracotomy and lung collapse

* Anastomotic leakage. The risk is relatively high owing to the presence of a
relatively devascularised stomach. Often the only blood supply is from the
gastroepiploic artery as all others will have been divided. If a leak does occur then
many will attempt to manage conservatively with prolonged nasogastric tube
drainage and TPN. The reality is that up to 50% of patients developing an
anastomotic leak will not survive to discharge.
* Delayed gastric emptying (may be avoided by performing a pyloroplasty).
1
A 15.2%
A 56 year old lady is referred to the colorectal clinic with symptoms of pruritus ani. 2
B 13.2%
On examination a polypoidal mass is identified inferior to the dentate line. A 3
C 14.4%
biopsy confirms squamous cell carcinoma. To which of the following lymph node
D 52.2% 4
groups will the lesion potentially metastasise?
E 5% 5

A. Internal iliac
question correctly
B. External iliac
C. Mesorectal
D. Inguinal
Next question
Theme from September 2011 Exam

Lesions distal to the dentate line drain to the inguinal nodes. Occasionally this will
result in the need for a block dissection of the groin.
Rectum
The rectum is approximately 12 cm long. It is a capacitance organ. It has both

intra and extraperitoneal components. The transition between the sigmoid colon is
marked by the disappearance of the tenia coli.The extra peritoneal rectum is
surrounded by mesorectal fat that also contains lymph nodes. This mesorectal
fatty layer is removed surgically during rectal cancer surgery (Total Mesorectal
Excision). The fascial layers that surround the rectum are important clinical
landmarks, anteriorly lies the fascia of Denonvilliers. Posteriorly lies Waldeyers
fascia.
Extra peritoneal rectum
Posterior upper third

Posterior and lateral middle third
Whole lower third
Relations
Anteriorly (Males) Rectovesical pouch
Bladder
Prostate
Seminal vesicles
Anteriorly (Females) Recto-uterine pouch (Douglas)

Cervix
Vaginal wall
Posteriorly Sacrum
Coccyx
Middle sacral artery
Laterally Levator ani

Coccygeus
Arterial supply
Superior rectal artery
Venous drainage
Superior rectal vein
Lymphatic drainage
Mesorectal lymph nodes (superior to dentate line)

Internal iliac and then para-aortic nodes
Inguinal nodes (inferior to dentate line)
1
A 28.9%
A 48 year old lady is undergoing an axillary node clearance for breast cancer. 2
B 29.6%
Which of the structures listed below are most likely to be encountered during the 3
C 14.6%
axillary dissection?
D 18.9% 4
E 7.9%
A. Cords of the brachial plexus
B. Thoracodorsal trunk question correctly
C. Internal mammary artery
D. Thoracoacromial artery
Next question
Beware of damaging the thoracodorsal trunk if a latissimus dorsi flap

reconstruction is planned.
Theme from 2009 Exam

The thoracodorsal trunk runs through the nodes in the axilla. If injured it may
compromise the function and blood supply to latissimus dorsi, which is significant
if it is to be used as a flap for a reconstructive procedure.
Axilla
Boundaries of the axilla

Medially Chest wall and Serratus anterior
Laterally Humeral head
Floor Subscapularis
Anterior aspect Lateral border of Pectoralis major
Fascia Clavipectoral fascia
Content:
Long thoracic Derived from C5-C7 and passes behind the brachial plexus to enter
nerve (of Bell) the axilla. It lies on the medial chest wall and supplies serratus
anterior. Its location puts it at risk during axillary surgery and damage
will lead to winging of the scapula.
Thoracodorsal Innervate and vascularise latissimus dorsi.

nerve and
thoracodorsal
trunk
Axillary vein Lies at the apex of the axilla, it is the continuation of the basilic vein.
Becomes the subclavian vein at the outer border of the first rib.
Intercostobrachial Traverse the axillary lymph nodes and are often divided during axillary
nerves surgery. They provide cutaneous sensation to the axillary skin.
Lymph nodes The axilla is the main site of lymphatic drainage for the breast.
1
A 18.7%
A 53 year old lady is recovering following a difficult mastectomy and axillary nodal 2
B 67.8%
clearance for carcinoma of the breast. She complains of shoulder pain and on 3
C 2.9%
examination has obvious winging of the scapula. Loss of innervation to which of
D 5% 4
the following is the most likely underlying cause?
E 5.5% 5
A. Latissimus dorsi 67.8% of users answered this

question correctly
B. Serratus anterior
C. Pectoralis minor
D. Pectoralis major
E. Rhomboids
Next question

Winging of the scapula is most commonly the result of long thoracic nerve injury
or dysfunction. Iatrogenic damage during the course of the difficult axillary
dissection is the most likely cause in this scenario. Damage to the rhomboids may
produce winging of the scapula but would be rare in the scenario given.
Long thoracic nerve
Derived from ventral rami of C5, C6, and C7 (close to their emergence from
intervertebral foramina)
It runs downward and passes either anterior or posterior to the middle
scalene muscle
It reaches upper tip of serratus anterior muscle and descends on outer
surface of this muscle, giving branches into it
Winging of Scapula occurs in long thoracic nerve injury (most common) or
from spinal accessory nerve injury (which denervates the trapezius) or a
dorsal scapular nerve injury
1
A 7.4%
You are assisting in an open right adrenalectomy for a large adrenal adenoma. B 15.1%
The consultant is distracted and you helpfully pull the adrenal into the wound to
C 36.6%
improve the view. Unfortunately this is followed by brisk bleeding. The vessel
D 8.9%
responsible for this is most likely to be:
E 32.1%
A. Portal vein 32.1% of users answered this

question correctly
B. Phrenic vein
C. Right renal vein
D. Superior mesenteric vein
E. Inferior vena cava
Next question
It drains directly via a very short vessel. If the sutures are not carefully tied then it
may be avulsed off the IVC. An injury best managed using a Satinsky clamp and a
6/0 prolene suture.
Adrenal gland anatomy
Anatomy
Location Superomedially to the upper pole of each kidney
Relationships of Diaphragm-Posteriorly, Kidney-Inferiorly, Vena Cava-Medially, Hepato-

the right adrenal renal pouch and bare area of the liver-Anteriorly
Relationships of Crus of the diaphragm-Postero- medially, Pancreas and splenic

the left adrenal vessels-Inferiorly, Lesser sac and stomach-Anteriorly
Superior adrenal arteries- from inferior phrenic artery, Middle adrenal

Arterial supply arteries - from aorta, Inferior adrenal arteries -from renal arteries
Venous drainage Via one central vein directly into the IVC
of the right
adrenal
Venous drainage Via one central vein into the left renal vein
of the left adrenal
1
A 8.9%
What is the sensory nerve supply to the angle of the jaw? 2
B 37%
C 9% 3
A. Maxillary branch of the trigeminal nerve D 34.3% 4
B. Mandibular branch of the trigeminal nerve E 10.8% 5
C. C3-C4 34.3% of users answered this 6

question correctly
D. Greater auricular nerve (C2-C3) 7
E. Buccal branch of the facial nerve 8
9
Next question
10
11
The trigeminal nerve is the major sensory nerve to the face except over the angle
of the jaw. The angle of the jaw is innervated by the greater auricular nerve. 12
Trigeminal nerve
The trigeminal nerve is the main sensory nerve of the head. In addition to its
major sensory role, it also innervates the muscles of mastication.
Distribution of the trigeminal nerve
Sensory Scalp
Face
Oral cavity (and teeth)
Nose and sinuses
Dura mater
Motor Muscles of mastication

Mylohyoid
Anterior belly of digastric
Tensor tympani
Tensor palati
Autonomic connections (ganglia) Ciliary

Sphenopalatine
Otic
Submandibular
Path
Originates at the pons

Sensory root forms the large, crescentic trigeminal ganglion within Meckel's
cave, and contains the cell bodies of incoming sensory nerve fibres. Here
the 3 branches exit.
The motor root cell bodies are in the pons and the motor fibres are
distributed via the mandibular nerve. The motor root is not part of the
trigeminal ganglion.
Branches of the trigeminal nerve

Ophthalmic nerve Sensory only
Maxillary nerve Sensory only
Mandibular nerve Sensory and motor
Sensory
Ophthalmic Exits skull via the superior orbital fissure
Sensation of: scalp and forehead, the upper eyelid, the conjunctiva and cornea
of the eye, the nose (including the tip of the nose, except alae nasi), the nasal
mucosa, the frontal sinuses, and parts of the meninges (the dura and blood
vessels).
Maxillary Exit skull via the foramen rotundum
nerve Sensation: lower eyelid and cheek, the nares and upper lip, the upper teeth
and gums, the nasal mucosa, the palate and roof of the pharynx, the maxillary,
ethmoid and sphenoid sinuses, and parts of the meninges.
Mandibular Exit skull via the foramen ovale

nerve Sensation: lower lip, the lower teeth and gums, the chin and jaw (except the
angle of the jaw), parts of the external ear, and parts of the meninges.
Motor
Distributed via the mandibular nerve.
The following muscles of mastication are innervated:
Masseter
Temporalis
Medial pterygoid
Lateral pterygoid
Other muscles innervated include:
Tensor veli palatini

Mylohyoid
Anterior belly of digastric
Tensor tympani
1
A 13.5%
A 43 year old lady is due to undergo an axillary node clearance as part of 2
B 7.8%
treatment for carcinoma of the breast. Which of the following fascial layers will be 3
C 11%
divided during the surgical approach to the axilla?
D 58.9% 4
E 8.7% 5
A. Sibsons fascia
B. Pre tracheal fascia question correctly
7
C. Waldayers fascia
8
D. Clavipectoral fascia
9
10
Next question 11
12
The clavipectoral fascia is situated under the clavicular portion of pectoralis 13
major. It protects both the axillary vessels and nodes. During an axillary node
14
clearance for breast cancer the clavipectoral fascia is incised and this allows
access to the nodal stations. The nodal stations are; level 1 nodes inferior to 15
pectoralis minor, level 2 lie behind it and level 3 above it. During a Patey
Mastectomy surgeons divide pectoralis minor to gain access to level 3 nodes. The
use of sentinel node biopsy (and stronger assistants!) have made this procedure
far less common.
Axilla
Boundaries of the axilla

Medially Chest wall and Serratus anterior
Laterally Humeral head
Floor Subscapularis
Anterior aspect Lateral border of Pectoralis major
Fascia Clavipectoral fascia
Content:
Long thoracic Derived from C5-C7 and passes behind the brachial plexus to enter
nerve (of Bell) the axilla. It lies on the medial chest wall and supplies serratus
anterior. Its location puts it at risk during axillary surgery and damage
will lead to winging of the scapula.
Thoracodorsal Innervate and vascularise latissimus dorsi.

nerve and
thoracodorsal
trunk
Axillary vein Lies at the apex of the axilla, it is the continuation of the basilic vein.
Becomes the subclavian vein at the outer border of the first rib.
Intercostobrachial Traverse the axillary lymph nodes and are often divided during axillary
nerves surgery. They provide cutaneous sensation to the axillary skin.
Lymph nodes The axilla is the main site of lymphatic drainage for the breast.
1
A 14%
The vertebral artery traverses all of the following except? 2
B 15.5%
C 24.4% 3
A. Transverse process of C6 D 17.1% 4
B. Transverse process of the axis E 29% 5
C. Vertebral canal 29% of users answered this 6

question correctly
D. Foramen magnum 7
E. Intervertebral foramen 8
9
Next question
10
11
The vertebral artery passes through the foramina which lie within the foramina of
the transverse processes of the cervical vertebral, not the intervertebral foramen. 12
13
Vertebral artery
14
15
The vertebral artery is the first branch of the subclavian artery. Anatomically it is
divisible into 4 regions: 16
17
The first part runs to the foramen in the transverse process of C6. Anterior
to this part lies the vertebral and internal jugular veins. On the left side the
thoracic duct is also an anterior relation.
The second part runs superiorly through the foramina of the the transverse
processes of the upper 6 cervical vertebrae. Once it has passed through
the transverse process of the axis it then turns superolaterally to the atlas.
It is accompanied by a venous plexus and the inferior cervical sympathetic
ganglion.
The third part runs posteromedially on the lateral mass of the atlas. It
enters the sub occipital triangle, in the groove of the upper surface of the
posterior arch of the atlas. It then passes anterior to the edge of the
posterior atlanto-occipital membrane to enter the vertebral canal.
The fourth part passes through the spinal dura and arachnoid, running
superiorly and anteriorly at the lateral aspect of the medulla oblongata. At
the lower border of the pons it unites to form the basilar artery.
1
A 25.3%
A 56 year old lady is due to undergo a left hemicolectomy for carcinoma of the 2
B 18.9%
splenic flexure. The surgeons decide to perform a high ligation of the inferior 3
C 8.3%
mesenteric vein. Into which of the following does this structure usually drain?
D 6.9% 4
E 40.6% 5
A. Portal vein
B. Inferior vena cava question correctly
7
C. Left renal vein
8
D. Left iliac vein
9
E. Splenic vein
10
Next question 11
12
13
Beware of ureteric injury in colonic surgery.
14
The IMV drains into the splenic vein.
Left colon
Position
As the left colon passes inferiorly its posterior aspect becomes

extraperitoneal, and the ureter and gonadal vessels are close posterior
relations that may become involved in disease processes
At a level of L3-4 (variable) the left colon becomes the sigmoid colon and
wholly intraperitoneal once again
The sigmoid colon is a highly mobile structure and may even lie of the right
side of the abdomen
It passes towards the midline, the taenia blend and this marks the transition
between sigmoid colon and upper rectum.
Blood supply
Inferior mesenteric artery

However, the marginal artery (from the right colon) contributes and this
contribution becomes clinically significant when the IMA is divided surgically
(e.g. During AAA repair)
1
A 49.1%
A 72 year old man develops a hydrocele which is being surgically managed. As 2
B 13.4%
part of the procedure the surgeons divide the tunica vaginalis. From which of the 3
C 11.6%
following is this structure derived?
D 20.2% 4
E 5.7% 5
A. Peritoneum
B. External oblique aponeurosis question correctly
7
C. Internal oblique aponeurosis
8
D. Transversalis fascia
9
E. Rectus sheath
Next question
The tunica vaginalis is derived from peritoneum, it secretes the fluid that fills the
hydrocele cavity.
Scrotal and testicular anatomy
Spermatic cord
Formed by the vas deferens and is covered by the following structures:
Layer Origin
Internal spermatic fascia Transversalis fascia
Cremasteric fascia From the fascial coverings of internal oblique
External spermatic fascia External oblique aponeurosis
Contents of the cord

Vas deferens Transmits sperm and accessory gland secretions
Testicular artery Branch of abdominal aorta supplies testis and

epididymis
Artery of vas deferens Arises from inferior vesical artery
Cremasteric artery Arises from inferior epigastic artery
Pampiniform plexus Venous plexus, drains into right or left testicular vein
Sympathetic nerve fibres Lie on arteries, the parasympathetic fibres lie on the
vas
Genital branch of the genitofemoral Supplies cremaster

nerve
Lymphatic vessels Drain to lumbar and para-aortic nodes
Scrotum
Composed of skin and closely attached dartos fascia.

Arterial supply from the anterior and posterior scrotal arteries
Lymphatic drainage to the inguinal lymph nodes
Parietal layer of the tunica vaginalis is the innermost layer
Testes
The testes are surrounded by the tunica vaginalis (closed peritoneal sac).
The parietal layer of the tunica vaginalis adjacent to the internal spermatic
fascia.
The testicular arteries arise from the aorta immediately inferiorly to the
renal arteries.
The pampiniform plexus drains into the testicular veins, the left drains into
the left renal vein and the right into the inferior vena cava.
Lymphatic drainage is to the para-aortic nodes.
1
A 17%
A 43 year old lady is donating her left kidney to her sister and the surgeons are 2
B 46.1%
harvesting the left kidney. Which of the following structures will lie most anteriorly 3
C 14.7%
at the hilum of the left kidney?
D 8.3% 4
E 13.9% 5
A. Left renal artery
B. Left renal vein question correctly
7
C. Left ureter
8
D. Left ovarian vein
9
E. Left ovarian artery
10
Next question 11
The renal veins lie most anteriorly, then artery and ureter lies posteriorly.
Renal arteries
The right renal artery is longer than the left renal artery
The renal vein/artery/pelvis enter the kidney at the hilum
Relations
Right:
Anterior- IVC, right renal vein, the head of the pancreas, and the descending part
of the duodenum.
Left:
Anterior- left renal vein, the tail of the pancreas.
Branches
The renal arteries are direct branches off the aorta (upper border of L2)
In 30% there may be accessory arteries (mainly left side). Instead of
entering the kidney at the hilum, they usually pierce the upper or lower part
of the organ.
Before reaching the hilum of the kidney, each artery divides into four or five
segmental branches (renal vein anterior and ureter posterior); which then
divide within the sinus into lobar arteries supplying each pyramid and
cortex.
Each vessel gives off some small inferior suprarenal branches to the
suprarenal gland, the ureter, and the surrounding cellular tissue and
muscles.
1
A 10.2%
An enthusiastic surgical registrar undertakes his first solo splenectomy. The 2
B 10.5%
operation is far more difficult than anticipated and the registrar leaves a tube 3
C 8.8%
drain to the splenic bed at the end of the procedure. Over the following 24 hours
D 59.2%
approximately 500ml of clear fluid has entered the drain. Biochemical testing of
E 11.2%
the fluid is most likely to reveal:

question correctly
A. Elevated creatinine
B. Elevated triglycerides
C. Elevated glucagon
D. Elevated amylase
Next question
During splenectomy the tail of the pancreas may be damaged. The pancreatic
duct will then drain into the splenic bed, amylase is the most likely biochemical
finding. Glucagon is not secreted into the pancreatic duct.
Splenic anatomy
The spleen is the largest lymphoid organ in the body. It is an intraperitoneal

organ, the peritoneal attachments condense at the hilum where the vessels enter
the spleen. Its blood supply is from the splenic artery (derived from the coeliac
axis) and the splenic vein (which is joined by the IMV and unites with the SMV).
Embryology: derived from mesenchymal tissue

Shape: clenched fist
Position: below 9th-12th ribs
Weight: 75-150g
Relations
Superiorly- diaphragm
Anteriorly- gastric impression
Posteriorly- kidney
Inferiorly- colon
Hilum: tail of pancreas and splenic vessels
Forms apex of lesser sac (containing short gastric vessels)

A. Transverse Ligament: B. Ligamentum Teres

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yomna92009@yahoo.

com - MRCS Part A - My account

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Question 8 of 441 Question stats Score: 100%

Theme from 2010 Exam

Head of femur articulates with acetabulum of the pelvis

Transverse ligament: joints anterior and posterior ends of the articular

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Iliofemoral ligament: inverted Y shape. Anterior iliac spine to the

2 anastomoses: Cruciate and the trochanteric anastomoses (provides most of the

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Question 20 of 441 Question stats Score: 75%

A. Thoracodorsal nerve D 11% 4

B. Axillary nerve E 56.4% 5

C. Radial nerve 56.4% of users answered this 6

Mnemonic branches off the posterior cord 12

Origin Anterior rami of C5 to T1

Sections of the Roots, trunks, divisions, cords, branches

Roots Located in the posterior triangle

Trunks Located posterior to middle third of clavicle

Divisions Apex of axilla

Cords Related to axillary artery

Diagram illustrating the branches of the brachial plexus

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Image sourced from Wikipedia

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Question 13 of 441 Question stats Score: 92.3%

The left subclavian comes directly off the arch of aorta

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Question 2 of 441 Question stats Score: 100%

A. Ulnar nerve 68.5% of users answered this

Mnemonic for radial nerve muscles: BEST

Continuation of posterior cord of the brachial plexus (root values C5 to T1)

In the axilla: lies posterior to the axillary artery on subscapularis, latissimus

Motor (main Triceps

Motor Extensor carpi ulnaris

Muscular innervation and effect of denervation

Shoulder Long head of triceps Minor effects on shoulder stability in

Arm Triceps Loss of elbow extension

Forearm Supinator Weakening of supination of prone hand

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Question 10 of 441 Question stats Score: 90%

Supplies (no muscles in the upper arm)

Flexor carpi ulnaris

Posteromedial aspect of ulna to flexor compartment of forearm, then along

Articular branch Flexor carpi ulnaris

Superficial branch Cutaneous fibres to the anterior surfaces of the

Deep branch Hypothenar muscles

Damage at the elbow Radial deviation of the wrist

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