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1You are assisting your consultant with an emergency exploration of stab wound. The patient was stabbed in the left thigh. The consultant points out an anatomical structure that is bordered superiorly by the inguinal ligament, medially by the adductor longus and laterally by Sartorius and contains the femoral artery, femoral vein and femoral nerve.What anatomical structure is this?Femoral canalFemoral sheathFemoral triangle?? YOUR ANSWERHunters canalInguinal canalYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe femoral (Scarpa’s) triangle is a fascial space in the medial upper thigh. Its sides are formed superiorly by the inguinal ligament, medially by the adductor longus and laterally by the sartorius muscles. The floor is formed by the iliopsoas, pectineus and adductor longus muscles. The triangle contains the femoral vessels and nerve. Within the femoral triangle, the femoral artery divides into its deep and superficial branches; and the femoral vein receives deep femoral and saphenous tributaries.2In which of the following situations is amputation of the lower limb considered absolutely necessary?Absent plantar sensationMuscle loss in two or more compartmentsSegmental bone loss greater than 1/3 tibial lengthUncontrollable haemorrhage from an open tibial injury?? YOUR ANSWERWarm ischaemia time exceeding 4-6 hoursYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The AnswerA primary amputation is performed as a damage control procedure if there is uncontrollable haemorrhage from an open tibial injury, usually occurring in multi-level arterial / venous damage in blast injuries.All other answers fall into the “grey area” of limb salvage versus amputation. The decision to amputate should be made by two consultant surgeons with, if possible, patient and family input. Absent or reduced plantar sensation at time of presentation is not an indication for amputation, the tibial nerve and artery should be assessed intra-operatively.(See BAPRAS Guidelines for Primary Amputations)3The femoral canal is the most medial structure of the femoral triangle.What function does the femoral canal serve?Allows for expansion of the femoral vessels?? YOUR ANSWERContains and protects the femoral nerveForms the proximal part of the adductor canalIt forms a dead space and has no contentsPrevent herniation of the small bowelYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe femoral sheath is a fascial tube derived from extraperitoneal intra-abdominal fascia. It extends under the inguinal ligament to surround the femoral vessels. The canal is a small space between the medial part of the sheath and the femoral vein. It contains fat and Cloquet’s node. Femoral hernias can be differentiated from inguinal hernias by locating the neck of a femoral hernia below and lateral to the inguinal canal.4From lateral to medial what are the structures in the femoral triangleSingle best answer question – choose ONE true option onlyFemoral vein, femoral artery, femoral nerveFemoral nerve, femoral artery, femoral vein?? YOUR ANSWERFemoral nerve, femoral artery, femoral vein, long saphenous vein?? CORRECT ANSWERLong saphenous vein, femoral vein, femoral artery, femoral nerveShort saphenous vein, femoral vein, femoral artery, femoral nerveYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionFrom lateral to medial, the femoral triangle contains the femoral nerve and its branches, the femoral artery and its branches, including the profunda femoris and the femoral vein with its main tributary the long saphenous vein.The short saphenous vein enters the popliteal vein in the popliteal fossa.5Stability is very important to achieve a successful total hip replacement.Which factor restores tension of the abductor complex?Acetabular cup alignment?? YOUR ANSWERCementing the femoral stemFemoral stem alignmentFemoral stem neck length?? CORRECT ANSWERSmaller femoral head sizeYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe hip joint is a ball and socket synovial joint. The capsule is thicker and tighter than that of the shoulder joint. The acetabular labrum encloses the femoral head beyond its equator, increasing the stability of the joint.6Regarding blood supply to the lower limb.Which artery is typically palpated lateral to the tendon of Extensor Hallucis Longus?The dorsalis pedis?? CORRECT ANSWERThe peroneal arteryThe popliteal arteryThe posterior tibial artery?? YOUR ANSWERThe profunda femoris arteryYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe popliteal artery divides into the anterior and posterior tibial arteries below the knee. The peroneal artery arises from the posterior tibial artery. It runs in the posterior compartment between tibialis posterior and flexor hallicus longus and supplies the muscles of the lateral (peroneal) compartment of the leg. The pulse of the dorsalis pedis can be felt between the great and second toe.7A 54-year-old man presents as an emergency to casualty following a crush injury to his left femur sustained on a building site. On examination a diagnosis of compartment syndrome is suspected.Which signs might be expected on examination of this gentleman’s left lower limb to support this presumptive diagnosis?Select one answer onlyAbsent dorsalispedis pulseSensory loss before motor lossSevere pain on passive stretch of the affected group of muscles?? YOUR ANSWERGreatly prolonged capillary refillBlue or grey extremitiesYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The AnswerCompartment syndrome is defined as an increase in the interstitial fluid pressure within an osseofascial compartment of sufficient magnitude to cause microcirculatory compromise and later myoneural necrosis. It is a devastating early complication seen after long-bone fractures and crush injuries. It can also be caused by deep thermal burns, electrical injuries, restricting tourniquets and fluid extravasation (eg caused by iv regional anaesthesia).Early in its development, the peripheral pulses are normal, as are fingertip/toe colour, temperature and capillary refill, since it is the microvasculature that is initially affected. Loss of peripheral pulses is usually a late sign.Severe pain in response to passive stretch of the ischaemic muscles is by far the most dramatic and reliable clinical sign.Thin cutaneous nerve fibres are more susceptible to ischaemia than the motor fibres, and distal paraesthesias occurs before motor loss. The limb becomes tense and swollen, and if not treated, the muscle weakness progresses to paralysis. Alternatively, areas of muscle may infarct, giving rise to rhabdomyolysis, hyperkalaemia, hyperphosphataemia, high uric acid levels and metabolic acidosis.Classically, compartment pressures are measured using a slit-catheter device. The normal resting pressure within the compartment tissues is approximately 3–4 mm Hg. Compartment pressures in excess of 30–35 mm Hg in a normally perfused patient have previously been taken to indicate the need for open-compartment fasciotomy. Recent evidence, however, suggests that fasciotomy should be undertaken if the difference between the diastolic pressure and the measured compartment pressure is < 30 mm Hg.8A 47-year-old man sustained hip dislocation following a rugby injury, he presented with reduced sensation on the dorsum of the foot and weakness of foot dorsiflexion.Which nerve injury is responsible for this presentation?The femoral nerveThe sciatic nerve?? CORRECT ANSWERThe tibial nerveThe superficial peroneal nerve?? YOUR ANSWERThe sural nerveYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The AnswerThe femoral nerve supplies all the quadriceps muscles. Injury to the common peroneal nerve will cause foot drop and sensory loss to the dorsum of the foot. A branch of the common peroneal nerve is the superficial peroneal nerve, which supplies the lateral compartment of the leg, allowing foot eversion; and sensation over the dorsum of the foot, except the first web space between the great toe and the second toe. Another branch of the common peroneal nerve is the deep peroneal nerve, which supplies the anterior compartment of the leg, allowing for foot dorsiflexion; and sensation over the first dorsal webspace of the foot).The tibial nerve supplies the ankle flexors, the long digital flexors, the short (intrinsic) foot muscles and sensation to the sole of the foot. The sciatic nerve is closely related to the posterior aspect of the hip joint where it can be injured. In this case, sciatic nerve injury is likely due to the mechanism of injury, and also the mixed nature of the functional deficit.9Entrapment syndrome could affect the deepest content in the popliteal fossa causing calf cramps and toes tingling.Which of the following structures is the deepest content of the popliteal fossa?Genicular branch of the obturator nerveLong saphenous veinPosterior tibial arteryPopliteal artery?? YOUR ANSWERTibial nerveYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer28616411722147The popliteal fossa is a diamond-shaped space at the back of the knee. The superomedial border is formed by the semitendinous and semimembranous muscles and the superolateral border by biceps femoris muscle. The inferior borders are formed by the medial and lateral heads of gastrocnemius. The contents (from deep to superficial) include the popliteal artery, politeal vein, tibial nerve, common peroneal nerve, small saphenous vein, posterior cutaneous nerve of the thigh and the genicular branch of the obturator nerve. There are also lymph nodes and connective tissue.10A 21-year-old presents with pes planus and weak foot.Which Tendon, lying immediately posterior to the medial malleolus, is responsible for this presentation?Flexor Digitorum Longus?? YOUR ANSWERFlexor Hallucis LongusGastrocnemiusSoleusTibialis posterior?? CORRECT ANSWERYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe lateral malleolus is grooved by the peroneus brevis tendon; the medial malleolus by the tibialis posterior tendon. The superficial part of the deltoid ligament is attached to the sustentaculum tali of the calcaneus. Posterior to the medial malleolus, the tibial nerve lies posterior to the posterior tibial artery, and these lie between the flexor hallucis longus tendons posteriorly, and the flexor digitorum longus tendons anteriorly.11All of the following tests are used to examine children with developmental dysplasia of the hip, but which one causes the hip to give a distinctive click when the hip is flexed and then abducted?Barlow’s testDynamic hip ultrasound'Frog leg' x-rayMRIOrtolani’s test?? YOUR ANSWERYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionDevelopmental dysplasia of the hip (DDH) is due to underdevelopment of the acetabular roof anterolaterally. The hips can be held reduced in double nappies, a soft abduction pillow, a Von Rosen’s splint, a Pavlik harness or in a ‘frog-leg’ plaster. Later presentations or persistent dislocation require either closed reduction (e.g. gentle traction, or splintage) or open reduction. Operations in older age groups aim to bring the femoral head under the acetabulum or to increase the acetabular area. Barlow’s test is the clunk of dislocation as the hip is adducted; Ortolani’s test is the clunk of reduction as the hip is flexed and then abducted.?12A 57-year-old smoker undergoes a femoral-popliteal bypass procedure after complaining of intermittent claudication symptoms. The femoral artery is dissected from the adjacent tissues within the adductor canal of the thigh.What structure forms the anterolateral border of the canal?Adductor longusAdductor magnusSartorius?? YOUR ANSWERVastus lateralisVastus medialis?? CORRECT ANSWERYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe adductor canal is bordered by vastus medialis anterolaterally, by adductor longus and magnus posteriorly, and by sartorius superomedially. It contains the femoral artery and vein, and the saphenous nerve.13All of the following muscles are found in the anterior compartment of the leg except:Single best answer question – choose ONE true option onlyTibialis anteriorExtensor hallucis longusExtensor digitorum longusPeroneus tertiusPeroneus brevis?? YOUR ANSWERYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe muscles of the anterior compartment of the leg are:tibialis anteriorextensor Hallucis longusextensor Digitorum longusperoneus TertiusThey are all supplied by the deep peroneal nerve and receive their blood supply from the anterior tibial artery.Peroneus brevis is found in the lateral compartment of the leg, along with peroneus longus.14A 31-year-old basketball player felt a pop and sustained a non-contact pivoting injury to his knee. Immediate clinical examination shows haemoarthrosis.What is the most likely structure to have been damaged?Anterior cruciate ligament?? YOUR ANSWERLateral collateral ligamentMedial meniscus tearPosterior cruciate ligamentQuadriceps tendon ruptureYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe knee joint is a synovial and a hinge joint. The capsule of the knee joint is thin anteriorly and posteriorly but reinforced on either side by strong collateral ligaments. Both the anterior and posterior cruciate ligaments are intracapsular, but extrasynovial. The medial and lateral menisci are C shaped, with their anterior and posterior horns attached to the intercondylar eminence of the tibia and their outer borders to the joint capsule. The meniscofemoral ligament is adjacent to the posterior cruciate ligament and attaches the posterior border of the lateral meniscus close to the femoral attachment of the posterior cruciate ligament. It stabilises the meniscus during rotation of the femur on the tibia. The oblique popliteal ligament is a lateral expansion from the insertion of semimembranosus which slopes up to the popliteal surface of the femur. The obliquity of this ligament limits rotation-extension in the ‘screw-home’ or locked position.The anterior cruciate ligament, running upwards and backwards from the anterior part of the tibial plateau towards the lateral condyle of the femur, prevents backward displacement of the femur on the tibial plateau. It also limits extension of the lateral condyle of the femur, which then causes medial rotation of the femur in the ‘screw-home’ position of full extension. It is commonly injured in pivoting injuries, and often a pop is heard. The middle geniculate artery has branches within the ligament and therefore rupture results in an immediate haemarthrosis. The posterior cruciate ligament, running obliquely from the posterior part of the tibia towards the medial condyle of the femur, prevents the femur from sliding forwards off the tibial plateau. In the weight-bearing, flexed knee it is the only stabilising factor for the femur and its attached quadriceps. The suprapatellar bursa is continuous with the synovial cavity of the joint, and therefore it provides a route for injecting or withdrawing fluid into or from the joint. After injuries to the joint, fluid accumulates (effusion) in the suprapatellar bursa, causing typical fullness around the knee. The pre- and infrapatellar bursae, however, do not communicate with the joint.15Club foot deformity (Congential Talipes Equino Varus) is the most common birth defect.Which of the following is responsible for the hind foot equinus deformity?Achilles tendon?? CORRECT ANSWERPeroneus brevis?? YOUR ANSWERPeroneus tertiusTibialis anteriorTibialis posteriorYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionPeroneus tertius dorsiflexes and everts the foot. The extensor digitorum longus and brevis, extensor hallucis longus and tibialis anterior muscles are also in the anterior compartment of the leg. Tibialis posterior plantarflexes and inverts the foot. Soleus is also in the posterior compartment of the leg and plantarflexes the foot at the ankle joint. Peroneus longus and brevis are in the lateral compartment of the leg. They both plantarflex and evert the foot.16A 42-year-old female felt a pop at the back of her leg while playing tennis. She presented with weakness. On examination, she has a positive Thompson/Simmonds test.What is the likely diagnosis?Achilles tendon rupture?? YOUR ANSWERAnkle fractureAnkle sprainCalcaneal fractureTabialis anterior tendon ruptureYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionRupture of the Achilles tendon usually occurs in middle-aged men. The history frequently follows the pattern of tendon rupture following a trivial stumble. Dorsiflexion is exaggerated as it is normally limited by the Achilles tendon. Plantar flexion is limited and the patient is unable to stand on tiptoe, but some plantar flexion is still possible owing to the action of the long flexors of the toes, tibialis posterior and peronei. Thompson test is positive in Achillis tendon rupture, which is lack of plantar flexion when calf is squeezed.17During a posterior approach to the right hip joint, you are asked to identify the gluteal muscles, you correctly identify the most superficial gluteal muscle which is innervated by the inferior gluteal nerve, what movements does this muscle produce?Hip Adduction and medial rotationHip extension and knee flexionHip Extension and lateral rotation?? YOUR ANSWERHip Flexion aloneHip flexion and knee extensionYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionGluteus maximus is supplied by the inferior gluteal nerve, and extends and laterally rotates the hip. The superior and inferior gluteal arteries supply gluteus maximus and are branches off the internal iliac artery. The gluteus minimus and gluteus medius are supplied by the superior gluteal nerve and arteries.18A 23-year-old male is involved in a road traffic accident, he has multiple wounds over his lower limbs. An ATLS survey is undertaken and his primary survey is unremarkable. Long limb radiographs show no long bone trauma. A 10cm deep laceration is noted over the lateral aspect of the right calf. On neurological testing he has sensory loss to the dorsum of the foot except for the first web space (between the great and second toe), there is reduced power to eversion of right foot.Which nerve has been injured?Deep Peroneal nerveMedial dorsal cutaneous nerveMedial plantar nerveSuperfical Peroneal nerve?? YOUR ANSWERTibial nerveYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe superficial branch of the peroneal nerve supplies sensation to the dorsum of the foot, except for the 1st web space (supplied by deep peroneal nerve) and the lateral aspect of the foot including the lateral 1 ? toes (supplied by the sural nerve). It travels through the lateral compartment of the leg and is most likely to be injured as there are motor and sensory disturbances to its distribution.19You are examining the anatomy of the back of the knee; the popliteal fossa.?What are the contents of the popliteal fossa?The deep peroneal nerveThe deepest structure is the popliteal veinThe popliteal artery and vein and the tibial nerve?? YOUR ANSWERThe saphenous nerveThe Sciatic nerveYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe roof of the popliteal fossa is formed by the fascia lata. Within the apex of the fossa the sciatic nerve divides into common peroneal and tibial branches (but may divide higher), the former lying either against or under the medial edge of the biceps femoris muscle. The deepest structure is the popliteal artery. The sural nerve pierces the deep fascia halfway down the leg. The roof is pierced by the short saphenous vein.20The greater trochanter is part of the proximal femur and serves as attachment to several muscles.Which muscle is attached to the lateral surface of the greater trochanter?The external rotators of the hipThe gluteus maximus?? YOUR ANSWERThe gluteus medius?? CORRECT ANSWERThe psoas major attach to itThe obturator externusYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The AnswerThe gluteus medius and minimus (abductors) insert into the greater trochanter on the lateral side. The obturators and piriformis insert into the greater trochanter on the medial side. The psoas major attaches to the lesser trochanter. The greater trochanter is palpable.The growth plate for the head of the femur is intracapsular, while that of the lesser trochanter and most of the growth plate for the greater trochanter are extracapsular.21Your consultant asks you to consent a patient for sclerotherapy for varicose veins. They have had previous varicose vein surgery, but the varicose veins have recurred.The complications you should make the patient aware of specific to this treatment include which of the following?Choose the single best answer from the available cominations of complications shown below:1. Trash Foot2. Brown discoloration of the skin3. Deep vein thrombosis4. Skin ulceration5. Sudeck’s dystrophy1 & 22, 3 & 4?? CORRECT ANSWER1, 3 & 5All of the above?? YOUR ANSWERNone of the aboveYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The AnswerExtravasation of the sclerosing agent may cause skin damage and ulceration. Patients should be warned about the possibility of brown pigmentation of the skin. Trash foot can be a complication of arterial procedures, with emboli occluding the blood supply to the foot.Sudeck's atrophy is a recognised complication of trauma. It is another name for complex regional pain syndrome type 1 (CRPS 1), a poorly understood condition which may be an exaggeration of the normal sympathetic response to injury. It occurs in both upper and lower limbs and is see in as many of 30% of cases after distal radial fracture.Sclerotherapy is indicated for residual and recurrent varicosities after varicose vein surgery.22A 17-year-old female skier presents with an acutely painful and swollen ankle joint after falling at speed. She is diagnosed with a bi-malleolar ankle fracture and undergoes open reduction and internal fixation.Which ligament attaches to the medial malleolus?Anterior talofibular ligamentCalcaneofibular ligamentDeltoid ligament?? YOUR ANSWERPosterior talofibular ligamentSyndesmotic ligamentYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe deltoid ligament attaches to the medial malleolus of the tibia, and inserts via four separate parts into the sustentaculumtali of the oscalcis, the calcaneonavicular ligament, the navicular tuberosity and the medial surface of the talus.?23The knee is a hinge joint, but it does move is three planes.Which function of the knee allows increased flexion?External rotation of tibia on femur in flexionPosterior roll back of femur on tibia?? CORRECT ANSWERThe absence of posterior sloping of the proximal tibia?? YOUR ANSWERThe presence of ACLTightness of the extensor mechanismYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionJust before full extension the lateral condyle of the femur stops moving before the medial so that extension stops on the lateral side. As a result, the femur medially rotates on the tibia. In full extension the anterior cruciate ligament and posterior cruciate ligament are taut. To unlock the knee the popliteus contracts and laterally rotates the femur on the tibia. The knee joint can flex to about 135 degrees.24The femoral triangle of Scarpa in the thigh contains some important structures.What are the contents of the femoral triangle?The femoral canal lies lateral to the femoral veinThe femoral canal which is the most lateral structure in the femoral sheathThe femoral sheath which contains the femoral vessels?? YOUR ANSWERThe long saphenous veinThe pubic branch of the inferior epigastric veinYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The AnswerThe femoral sheath is a downward continuation of the abdominal fascia about 2.5 cm below the inguinal ligament. It is believed to allow for femoral vessel movement in the inguinal region during movement of the hip. The mnemonic ‘NAVEL’ describes some of the key structures in this region (from lateral to medial): femoral nerve, artery, vein, empty space, lymphatics (Cloquet’s). Apart from the femoral nerve, that lies most laterally, all the other structures in the mnemonic are encased in the femoral sheath. The mentioned empty space and lymphatic compartments form the ‘femoral canal’, where femoral hernias may occur. Therefore, the femoral canal is in the most medial portion of the femoral sheath. The femoral ring is the abdominal opening into the femoral canal. At 2–3 cm below the inguinal ligament, the femoral sheath fuses with the adventitia of the femoral vessels. The pubic branch of the inferior epigastric artery replaces the obturator artery in about 30% of cases, and may be at risk in a femoral hernia repair.25A young man sprains his ankle while playing basketball. His ankle went into eversion and external rotation.Which ligament complex is likely to be damaged with this mechanism of injury??The anterior and posterior talofibular ligamentsThe calcaneofibular ligamentThe calcaneonavicular ligamentThe deltoid ligament?? YOUR ANSWERThe syndesmosis ligaments complexYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe deltoid ligament is attached above to the medial malleolus and below to the talus, sustentaculum tali and the spring ligament. In an inversion injury the lateral malleolus is fractured due to traction and the medial malleolus by compression force. An eversion injury can rupture the deltoid due to traction force and the compression force can fracture the lower end of the fibula. Maximal stability is dorsiflexion because the anterior surface of the talus is wider anteriorly. The ankle joint is best aspirated anteriorly, entering between the tendons of the tibialis anterior and extensor hallicus longus.26When performing arthroscopic examination of the knee, the posterolateral portal could be used to visualise the posterior cruciate ligament and posterior horn of later meniscus.Which structure is at particular risk of being damaged through this portal?The common peroneal nerve?? CORRECT ANSWERPatellar tendonThe popliteal arteryThe saphenous nerve and veinThe tibial nerve?? YOUR ANSWERYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe saphenous nerve and vein pass along the posteriomedial border of the knee. The common peroneal nerve winds round the neck of the fibula. The knee joint is supplied by branches of the femoral nerve, tibial nerve, common peroneal nerve and obturator nerve.27Osteochondritis of the navicular bone is known as K?hler’s disease and occurs in children of 3 – 5 years old.What is the main pathological process thought to cause this condition?Avascular necrosis?? CORRECT ANSWERInflammatory arthropathy?? YOUR ANSWERLigamentous strainLisfranc fractureOsteoarthritisYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionOsteochondritis of the navicular bone is known as K?hler’s disease and affects children age 3–5 years. They complain of pain over the medial side of the foot and noticeably limp. It is thought to be due to a disturbance of the blood supply causing avascular necrosis and delay in ossification. Normally symptoms disappear after a few weeks of strapping the foot and restricting activity, but, rest in a cast may be necessary if there is severe pain. Eventually the foot becomes normal clinically and radiologically over a period of months.28A 14-year-old footballer presents with severe pain and swelling of the left ankle. Plain radiographs confirm a bimalleolar ankle fracture.The distal tibia articulates with which bone?CuboidMedial cuneiformNavicular?? YOUR ANSWEROs calcisTalus?? CORRECT ANSWERYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe ankle joint is formed of the distal tibia and fibula, articulating with the talus. The cuboid, cuneiform and navicular bones form the midfoot, with the oscalcis (or calcaneum) forming part of the hindfoot.29You are assisting your consultant in open reduction and internal fixation of a pelvic fracture via the kocher langhenbeck (posterior) approach. Your consultant indicated an anatomical structure and you correctly identify the structures passing through it, which are the superior and inferior gluteal nerves and vessels, the sciatic nerve, the pudendal nerve, the posterior cutaneous nerve of the thigh and the nerve to obturator internus. The consultant then asks you what foramen it is?Greater sciatic foramen?? YOUR ANSWERInfrapiriform foramenLesser sciatic foramenObturator foramenSuprapiriform foramenYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The AnswerThe greater sciatic notch is converted into the greater sciatic foramen by the sacrospinous ligament. This foramen transmits many structures between the gluteal and pelvic regions including superior and inferior gluteal vessels and nerves; sciatic nerve; posterior cutaneous nerve of the thigh; the nerve to obturator internus and quadratus femoris; the pudendal nerve; and the internal pudendal vessels. 17802641479853The lesser sciatic foramen is the space between the sacrospinous and sacrotuberous ligaments. It contains: the pudendal nerve; the nerve and tendon to obturator internus; and the internal pudendal vessels. The pudendal nerve and the internal pudendal vessels exit the pelvis via the greater sciatic foramen and enter the perineum through the lesser sciatic foramen. Similarly, the nerve to the obturator internus leaves the pelvis via the greater sciatic foramen and soon re-enters the pelvis through the lesser sciatic foramen.30A 28-year-old man presents with a painful swollen right calf 14 days following an intramedullary tibial nail for a closed midshaft tibial fracture. The calf circumference is 3.5cm greater on this side.What is the MOST sensitive test of a deep vein thrombosis (DVT)?CTPAD-dimer blood testDuplex venous ultrasonography?? YOUR ANSWERLower limb arteriogramLower limb venography?? CORRECT ANSWERYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The AnswerVenography remains the most sensitive investigation for deep vein thrombosis (DVT) but is used less commonly than Doppler ultrasound as it involves the use of contrast and it is invasive. Significant complications are uncommon but do occur – local sepsis, thrombosis due to the contrast medium is the most likely and worrying complication. Discomfort is experienced in approximately 60% of cases. Venography is limited by the effects of obliteration and recanalisation of veins, leading to impaired visualisation of diagnostic features such as constant intraluminal filling defects. CTPA is an investigation for pulmonary embolism. The D-dimer will be raised in the patient in the above scenario, as there are multiple factors, which can lead to a raised D-dimer, such as trauma and surgery.?31Acute limb compartment syndrome is characterised by increased pressure within an unyielding osseo-fascial compartment, resulting in local tissue hypoxia.Of the following symptoms, which one is a late sign of compartment syndrome indicating a poor prognosis?Anaesthesia?? CORRECT ANSWERParaesthesia within distribution sensory nerves?? YOUR ANSWERPulses presentSevere pain on passive muscle stretchSwollen limbYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionCompartment syndrome is the term used to describe the condition in which the tissue pressure in an enclosed fascial compartment rises above the capillary pressure, thus reducing blood flow to the distal tissues. The earliest sign is pain out of proportion with the injury, and other early signs are pink shiny shin, pain in the affected muscles on passive stretching, and a feeling of pressure. Distal pulses and capillary refill may be present even in the presence of significant increases in compartmental pressure. Although direct measurement of compartmental pressures can be made, the condition should be treated on clinical grounds with removal of any occlusive dressings and elevation followed by fasciotomy if needed. Paraesthesia is a relatively late sign. Complete anaesthesia is a late sign which indicates a poor prognosis.32The medial and lateral femoral circumflex arteries are usually direct branches of the:Single best answer question – choose ONE true option onlyObturator arteryPopliteal arteryProfunda femoris artery?? CORRECT ANSWERExternal iliac artery?? YOUR ANSWERFirst perforating arteryYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The AnswerThe profunda femoris artery (deep femoral artery) is a large vessel arising from the lateral and back part of the femoral artery, from 2 to 5 cm below the inguinal ligament. At first it lies lateral to the femoral artery; it then runs behind it and the femoral vein to the medial side of the femur and, passing downward behind the adductor longus, ends at the lower third of the thigh in a small branch which pierces the adductor magnus and is distributed on the back of the thigh to the hamstring muscles. The terminal part of the profunda is sometimes known as the fourth perforating artery.33A 46-year-old taxi driver presents with severe right hip pain and deformity following a road traffic accident. He is diagnosed with a right posterior hip dislocation.Which fracture is associated with this injury?Acetabulum?? YOUR ANSWERFemoral shaftIntertrochanteric femoral neckSacrumInferior pubic ramusYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionHip dislocation is usually posterior and may cause sciatic nerve injury and later, avascular necrosis of the femoral head ± secondary degenerative change. It is frequently associated with a fracture of the posterior rim of the acetabulum. Car drivers or motorcyclists who are sitting with hip and knee flexed and then hit their knee hard are likely to sustain a dislocation. Most are then treated by prompt closed reduction and traction. Subsequent open exploration of the joint may be required to remove any loose fragments of bone or soft tissue from within the joint. Central dislocation is uncommon and usually associated with a fracture of the pelvis ± pre-existing protrusion.34A 36-year-old male presents with pain radiating down the leg, worse in the anterior leg distal to the knee. On physical exam, he is unable to extend his knee and his patellar reflex is absent.Which nerve injury would produce these symptoms?A common peroneal nerve injuryA lesion of L3 nerve root?A lesion of S1L4 nerve root compression?? YOUR ANSWERSciatic nerve injuryYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionLesions affecting L3/4 also result in a decreased knee reflex, and sensory loss over the anterior thigh and medial part of the leg. S1 lesions result in weak plantar flexion, loss of ankle reflex and sensory loss over the sole of the foot. Common peroneal nerve injuries often occur from pressure from plaster casts and lateral knee ligament injuries. Superficial peroneal nerve injuries impair eversion but not dorsiflexion, as this action is subserved by the deep peroneal nerve.?35With regard to the adductor muscle group of the medial fascial compartment of the thigh ...Which muscle has a different nerve supply to the rest of the group?Adductor brevisAdductor longusAdductor magnusGracilisPectineus?? YOUR ANSWERYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The AnswerThe medial fascial compartment of the thigh contains adductor longus, adductor brevis, adductor portion of adductor magnus, gracilis, pectineus and obturator externus. They are all supplied by the obturator nerve except the pectineus, which is supplied by the femoral nerve. Sartorius lies in the anterior fascial compartment and the hamstring portion of adductor magnus lies in the posterior fascial compartment of the thigh.36A 32-year-old skier presents with an acutely painful and swollen knee joint and is noted to have a positive Lachman’s test.Which ligament has been injured?Anterior cruciate ligament?? YOUR ANSWERDeltoid ligamentLateral collateral ligamentMedial collateral ligamentPosterior cruciate ligamentYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe anterior cruciate ligament provides stability to the knee joint. High impact sports that involve rapid changes of direction or direct lower limb trauma are often associated with injuries to the ligament. The ligament originates from the lateral femoral condyle to insert into the intercondyloidtibial eminence. Lachman’s test requires the knee to be slightly flexed, and is positive when the tibia can be pulled abnormally anteriorly from a fixed femur. The deltoid ligament stabilises the ankle joint.37The popliteal fossa forms the posterior aspect of the kneeWhich structure forms the floor of the popliteal fossa?The biceps femorisThe gastrocnemiusThe knee joint capsule?? YOUR ANSWERThe semimembranosusThe semitendenosusYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The AnswerThe popliteal fossa lies behind the knee and is diamond shaped. It is bound above laterally by the biceps femoris and above medially by the semimembranosus. It is bound by the two heads of the gastrocnemius below. In addition to lymph nodes the fossa contains (from superficial to deep) branches of the sciatic nerve, the popliteal vein, popliteal artery. The sciatic nerve divides into the tibial and common peroneal nerves. The floor of the popliteal fossa is formed by the posterior surface of the knee joint capsule, and by the posterior surface of the femur.38What is the most common complication of total hip arthroplasty?Asymptomatic Deep Vein Thrombosis?? CORRECT ANSWERDislocationHeterotropic ossificationLeg length discrepancy with Trendelenburg Gait?? YOUR ANSWERUrinary retentionYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The AnswerThromboembolism occurs in 50% of cases of hip replacement, despite prophylaxis, but these rarely progress to fatal pulmonary embolism. Heterotopic ossification affects approximately 10% of cases. Dislocation occurs in 2–5% instances. Urinary retention is a particular problem especially in elderly men.39A 24-year-old soldier sustained a gunshot wound to the right proximal thigh. Neurological examination revealed he had an absent knee jerk reflex, numbness over the medial and anterior thigh, and medial malleolus. The cremasteric reflex is intact.Which is the most likely nerve to have been injured?Femoral nerve?? YOUR ANSWERGenitofemoral nerveLateral cutaneous nerve of the thighL2 nerve rootSaphenous nerveYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionFemoral nerve injury is rare and usually secondary to stab or gunshot wounds. Motor fibres supply the quadraceps femoris muscle, the contracting fibres of which elicit the knee jerk. The nerve supplies the L2–L4 dermatomes over the anterior skin of the thigh. The genitofemoral nerve mediates the cremasteric reflex. The saphenous nerve (L4), a branch of the femoral nerve, innervates the skin over the medial malleolus. The lateral cutaneous nerve of the thigh, and the genitofemoral nerve, both branches of the lumbar plexus, also supply the L2 dermatome.40Avascular necrosis of the femoral head is most commonly seen following which one of these injuries?Anterior dislocation of the hipDisplaced mid shaft femoral fractureIntertrochanteric fracture of the femoral neckIntracapsular fracture of the femoral neck?? YOUR ANSWERPosterior dislocation of the hipYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe vascular supply to the proximal femur is tenuous and provided largely by two sources. Branches of the medial and lateral circumflex femoral arteries, usually branches of the deep femoral artery, ascend on the posterior aspect of the femoral neck in the retinacula (reflections of the capsule along the neck of the femur toward the head). The branches of the medial and lateral circumflex arteries perforate the bone just distal to the head of the femur where they anastomose with branches from the foveal artery and with medullary branches located within the shaft of the femur.From proximal to distal, femoral neck fractures can be delineated as subcapital, transcervical, and basicervical, all of which are intracapsular and associated with potential disruption of the vascular supply. The incidence of avascular necrosis (AVN) is up to 15% in nondisplaced fractures and increases to nearly 90% with untreated, completely displaced fractures.41A 30-year-old man complains of having to swing his body to help him walk after a long session of exercise in the gym. A Trendelenburg test is performed.What is the positive right-side Trendelenburg test associated with?A shortened right femurAn injury to the left abductor muscles?? CORRECT ANSWERAn injury to the left pectineus muscleAn injury to the right gluteus medius muscle?? YOUR ANSWERbilateral hip dysplasiaYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The AnswerThe Trendelenburg test is used to assess stability of the hip. A positive Trendelenburg test is seen with any painful disorder of the hip. It is also present with a dislocated or subluxed hip and in other conditions where the proximal femoral anatomy is abnormal (short femoral neck with high riding trochanter). Weak abductor muscles will also lead to a positive test. The abductors of the hip include piriformis, gluteus medius and minimis. Pectineus adducts the hip. The other adductors of the hip are gracilis, and adductor longus, brevis and magnus.42A 10-year-old girl is treated for a tibia and fibula fracture with above knee plaster.What early clinical signs of compartment syndrome in the leg do you look for?Loss of the dorsalis pedis pulseMottling of the overlying skinPain out of proportion to injury on passive dorsiflexion of the foot?? YOUR ANSWERParalysis of the footReduced sensation in the footYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionA high index of suspicion is required to diagnose compartment syndrome. Early signs include pain out of proportion to the injury on passively stretching the muscles in the effected compartment. Late signs include pallor of the foot, paralysis, paresthesia (early loss of vibratory sensation) and loss of distal pulses.43A patient presents with pins and needles on the lateral and anterior aspect of his left thigh. On examination, there is no motor deficit. There is no history of trauma.?Which of the following is likely to be causing the problem?Single best answer question – choose ONE true option onlyLateral cutaneous nerve of the thigh lesion?? YOUR ANSWERL2 root lesionL3 root lesionFemoral nerve lesionSaphenous nerve lesionYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The AnswerThe lateral cutaneous nerve of the thigh supplies the antero-lateral aspect of the thigh. It has no motor branches. Meralgia Paraesthetica is a condition which where there is irritation of the nerve causing sensory changes in the distribution of the lateral cutaneous nerve of the thigh without any motor changes.L2 and L3 supply part of the dermatome described but both have motor branches. The femoral nerve supplies the quadriceps muscle, and the saphenous nerve runs with the saphenous vein to supply an area of skin below the knee on the medial aspect of the leg.44Which one of the following statements about the hip joint is false?it is a hinge joint?? CORRECT ANSWERa thick and tight fibrous capsule increases stabilitythe quadratus femoris is a lateral rotator of the hip?? YOUR ANSWERthe iliofemoral ligament prevents overextension of the hip jointthe rim of the acetabular labrum increases hip stabilityYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The AnswerThe hip joint is a ball and socket synovial joint. The capsule is thicker and tighter than that of the shoulder joint. The acetabular labrum encloses the femoral head beyond its equator, increasing the stability of the joint.45The greater trochanter of the femur is a bony prominence of the proximal femur that serves as insertional muscle attachment.Which muscle is attached to the greater trochanter of the femur?Gluteus maximusPiriformis?? YOUR ANSWERPsoasSartoriusVastus lateralisYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The AnswerPiriformis, gluteus medius, gluteus minimus, obturator internus, obturator externus, quadratus femoris and the gemelli are all attached to the greater trochanter of the femur. Psoas and iliacus both insert on the lesser trochanter.46A 25-year-old man sustained a low-velocity bullet wound to the lateral aspect of the thigh. The bullet can be visualised, lodged 6cm lateral to the mid-inguinal point.What is the most appropriate next step in his management?Bullet fragment removalWound closure in the accident & Emergency departmentPatient can be discharged without the need for any interventionSurgical exploration of the femoral vesselsTetanus prophylaxis, antibiotics and wound care?? YOUR ANSWERYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The AnswerTetanus should always be given after any penetrating injury if the patient has not been immunised in the past ten years. None of the other options are appropriate in this case as the injury is in the lateral aspect of the thigh and anatomically not a concern for major blood-vessel trauma.?47A 25-year-old man sustained a low-velocity bullet wound to the lateral aspect of the thigh. The bullet can be visualised, lodged 6cm lateral to the mid-inguinal point.What is the most appropriate next step in his management?Bullet fragment removalWound closure in the accident & Emergency departmentPatient can be discharged without the need for any interventionSurgical exploration of the femoral vesselsTetanus prophylaxis, antibiotics and wound care?? YOUR ANSWERYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionTetanus should always be given after any penetrating injury if the patient has not been immunised in the past ten years. None of the other options are appropriate in this case as the injury is in the lateral aspect of the thigh and anatomically not a concern for major blood-vessel trauma.?48The femoral artery is the terminal branch of the external iliac artery behind the inguinal ligament.Which branch of the femoral artery supplies the femoral head?Deep external pudendal arteryProfunda femoris artery?? YOUR ANSWERSuperficial circumflex iliac arterySuperficial external pudendal arterySuperficial epigastric arteryYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The AnswerThe surface marking of the femoral artery is the mid-inguinal point, which lies just medial to the position of the deep inguinal ring, which is at the midpoint of the inguinal ligament. The lateral and medial circumflex femoral arteries are branches of the profunda femoris artery, and they contribute to the trochanteric anastomosis, feeding the femoral head via their subretinacular branches. The femoral artery is subcutaneous in the femoral triangle, separated from skin by the fascia lata49The lateral compartment of the leg containing the peroneus longus and brevis muscles is innervated by the:Single best answer question – choose ONE true option onlyTibial nerveCommon peroneal nerveSuperficial peroneal nerve?? YOUR ANSWERDeep peroneal nerveSural nerveYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe superficial peroneal nerve supplies the peronei longus and brevis and the skin over the greater part of the dorsum of the foot. It passes forward between the peronei and the extensor digitorum longus, pierces the deep fascia at the lower third of the leg and divides into a medial and an intermediate dorsal cutaneous nerve. In its course between the muscles, the nerve gives off muscular branches to the peronei longus and brevis and cutaneous filaments to the skin of the lower part of the leg.50A variety of fracture patterns result from injurious forces upon the patella.Which is the most common following a direct blow (compressive force) to the patella?MarginalOsteochondral (sleeve) fracturesStellate?? CORRECT ANSWERTransverse?? YOUR ANSWERVerticalYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The AnswerIndirect trauma such as knee flexion injuries usually cause a transverse fracture of the patella. Stellate (comminuted) fractures are more frequently seen with direct trauma. Undisplaced fractures are treated with a straight cylinder cast, displaced transverse fractures need internal fixation to repair the extensor mechanism, and comminuted fractures can be treated conservatively, but patellectomy may be required to prevent damage to the patellofemoral joint. However, complete patellectomy should be avoided when possible.51Dislocation of the hip joint in young adults is an orthopaedic emergency. Which of these complications increases its incidence the longer the hip remains dislocated?Avascular necrosis of the femoral head?? CORRECT ANSWEROsteoarthritisPulmonary embolismRecurrent hip dislocationSciatic nerve injury?? YOUR ANSWERYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The AnswerAfter the first year of life, hip dislocation is usually due to pyogenic arthritis, muscle imbalance (e.g. cerebral palsy) or commonly trauma (e.g. the impact of a dashboard to the knee during a road traffic accident). Hip dislocation occurs when the hip is flexed and adducted. Posterior dislocation is the commonest direction of dislocation. An acetabular fracture may accompany the hip dislocation in about 50% of cases. Complications are (1) injury to the sciatic nerve (causing foot-drop), (2) damage to the femoral head, (3) avascular necrosis of the femoral head, (4) post-traumatic ossification (5) osteoarthritis.Avascular necrosis of the femoral head occurs in 2-17% of patients. This can occur with pure dislocations but is more common with fracture-dislocations of the femoral head. Numerous studies suggest that the risk of AVN rises proportional to the time to relocation. The longer it takes to relocate a hip, the higher the risk of AVN. Early relocation of a hip can make the difference between a healthy joint and a chronically disabled joint.?52A footballer suffers a knee injury in a heavy tackle with immediate swelling of the knee. He is unable to weight bear. X-rays show an avulsion fracture of the tibial spine.?Which of the following is likely to be true??Single best answer question – choose ONE true option onlyThere will be impaired resistance to valgus stressing of the knee jointThere will be impaired resistance to varus stressing of the knee jointThere will be impaired resistance to anterior translation of the tibia on the femur?? YOUR ANSWERThe patient will be unable to maintain a straight leg raiseThere will be mal positioning of the patellaYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe tibial spine is the origin of the anterior cruciate ligament (ACL). This provides resistance to anterior translation of the tibia on the femur as well as resistance to hyperextension of the knee. Avulsion of the tibial spine is likely to defunction the ACL.?The collateral ligaments of the knee attach to the medial proximal tibia and the head of the fibula and are unlikely to be affected, hence there will be normal resistance to varus and valgus stressing of the knee joint. The extensor mechanism of the knee is anterior to the tibial spine and is unlikely to be affected. Patella tracking and straight leg raising should not be impaired.`53A 58-year-old lady with a past medical history of deep vein thrombosis presents with a longstanding ulcer on the medial side of her leg. A biopsy is taken from the edge of the ulcer and shows malignant change.What is this type of ulcer called?Curlings ulcerCushings ulcerMarjolin ulcer?? YOUR ANSWERMartorell ulcerVenous ulcerYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The AnswerVaricose ulcers are commonly found on the medial side of the lower limb. Venous hypertension secondary to venous stasis leads to extravasation of fibrin from hyper-permeable capillaries. This fibrin sheath is thought to block the oxygen diffusion, so the skin is relatively ischaemic and ultimately necroses. Women are more commonly affected than men, usually >40 years of age. Malignant change (Marjolin’s ulcer) does occur on the edge of chronic ulcers.A curlings ulcer is a duodenal ulcer in burns patients. A cushings ulcer is a gastric ulcer seen in patients with head injuries and raised intracranial pressure. A Martorells ulcer is a painful lower leg ulcer secondary to arterial hypertension.54A 75-year-old man has gangrene of the left hallux. There are no pulses to feel below the rather weak femoral pulse on that side. A duplex scan reveals a block in the superficial femoral artery.Which statement pertaining to the arterial system of the lower limb best accords with usual clinical findings? Single best answer question – choose ONE true option onlyThe common femoral artery divides into its superficial and profunda branches a hand’s breadth below the inguinal ligament? YOUR ANSWERThe femoral vein lies on the lateral side of the common femoral artery at the groinThe femoral artery passes into the popliteal fossa, as the popliteal artery, by passing between the adductor longus and magnusThe popliteal artery lies against the popliteal surface of the femur deep to the popliteal vein, which itself lies deep to the tibial nerve? CORRECT ANSWERThe pulse of the posterior tibial artery is felt behind the lateral malleolusYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe common femoral artery lies on the lateral side of the vein and divides 3 cm distal to the inguinal ligament. The superficial femoral artery becomes the popliteal by passing through the hiatus in the adductor magnus. The posterior tibial pulse is sought behind the medial malleolus.55An 18-year-old football player sustains a twisting injury to his knee and complains of medial side knee pain and locking. An MRI shows medial mesical tear.What is the main function of the menisci?Decrease friction and stress shielding?? YOUR ANSWERIncrease moment arm of quadricepsJoint proprioceptionPrimary knee stabilizationShock absorption?? CORRECT ANSWERYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The AnswerMenisci are shock absorbers and secondary stabilizers to the knee, the primary stabilizers are the ligaments which also help in joint proprioception.The quadriceps and patellar tendons increase the moment arm of the quadriceps and the joint articular cartilage provides stress shielding and lubrication of the joint movements due to its high water content.56The arches of the foot are formed by the tarsal and metatarsal bones. The ligaments and fascia of the foot help to support the foot arches.Which ligament supports the medial longitudinal arch?Flexor retinaculum of footDorsal interosseous ligamentThe middle plantar ligamentThe plantar calcaneonavicular ligament?? YOUR ANSWERTransverse metatarsal ligamentYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The AnswerThere are three arches in the foot: the medial longitudinal arch, the lateral longitudinal arch the transverse arch. Ligaments that support the medial longitudinal arch include the long plantar ligament, short plantar ligament (plantar calcaneocuboid ligament), spring ligament (plantar calcaneonavicular ligament), interosseous ligament (talocalcaneal ligament), deltoid ligament (medial collateral ankle ligament) and the plantar aponeurosis (deep plantar fascia).57The femoral triangle contains the femoral nerve and femoral canal.Which structure forms the lateral boundary of the femoral triangle?The adductor longus muscle?? YOUR ANSWERThe fascia lataThe inguinal ligamentThe pectineus muscleThe Sartorius muscle?? CORRECT ANSWERYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe femoral triangle is bounded by the inguinal ligament superiorly, sartorius laterally and adductor longus medially. Its floor is formed by the iliopsoas and pectineus. Its roof is formed by the fascia lata. It contains the femoral vein, artery and nerve from medial to lateral and also contains the deep inguinal nodes.58A 45-year-old woman sustained a hip dislocation following a road traffic accident. She presented with reduced sensation on the dorsum of the foot and weakness of foot dorsiflexion.Which nerve injury is responsible for this presentation?The femoral nerveThe sciatic nerve?? YOUR ANSWERThe superficial peroneal nerveThe sural nerveThe tibial nerveYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionPosterior hip dislocation is a common injury often occurring when the hip is flexed e.g. a road traffic accident. The two main complications are sciatic nerve damage and avascular necrosis. Sciatic nerve damage occurs because the sciatic nerve lies in close proximity to the posterior aspect of the joint capsule so is at risk in posterior dislocation. Avascular necrosis occurs due to tearing of the joint capsule, causing a disturbance of the blood supply to the femoral head.59The adductor (subsartorius) canal lies in the middle third of the thigh.Which structure runs through the adductor canal?Common peroneal nerveFemoral nerveFemoral vein?? YOUR ANSWERNerve to vastus intermediusProfunda femoris arteryYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The AnswerThe adductor canal (Hunter’s or subsartorial canal) extends from the apex of the femoral triangle to the opening in adductor magnus. It contains the femoral artery and vein, saphenous nerve and the nerve to vastus medialis.60A 25-year-old female sustained a non-contact twisting injury and dislocated her patella.Which anatomical structure contributes to the dynamic stability of the patella?Distal femoral trochlea?? YOUR ANSWERLateral femoral trochleaMedial patella femoral ligamentQuadriceps tendonVastus medialis muscle?? CORRECT ANSWERYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe patella dislocates laterally due to the pull of the quadriceps. The vastus medialis is attached to the medial border. A transverse fracture can occur without displacement. The patella is stabilised against displacement by greater prominence of the lateral femoral condyle. Active extension is still possible if displacement of fragments is minimal.61A 39-year-old female sustains a displaced intracapsular fracture of neck of femur following a fall from a horse.What is the most common complication of this injury?Avascular necrosis?? YOUR ANSWERChondrolysisHip instabilityNon-unionPost traumatic arthritisYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionPosteriorly the capsule is attached half-way along the neck. The intertrochanteric crest lies posteriorly. A fracture of the neck of the femur causes lateral rotation of the thigh. The blood supply to the head of the femur passes through the retinacula on the neck. The obturator externus winds round the inferior aspect of the neck. Nonunion rate is around 20%, whereas AVN is about 30%62When operating on a femoral hernia in the femoral triangle, care should be taken to avoid damage to which structure?Large bowels could become incarcerated in the herniaThe cribriform fascia transmits the superficial branches of the femoral arteryThe deep inguinal nodes those lie lateral to the femoral veinThe femoral vein which lies medial to the femoral nerve?? YOUR ANSWERThe profunda femoris artery which lies medial to the femoral arteryYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The AnswerThe superficial epigastric and superficial external pudendal arteries pass through the saphenous opening (the superficial circumflex and deep external pudendal arteries pierce the fascia lata). The femoral nerve, artery and vein lie in that order from lateral to medial. The profunda femoris artery is a lateral branch of the femoral artery. The deep inguinal nodes lie medial to the femoral vein. The femoral sheath encloses the femoral vessels for up to 3 cm beyond the inguinal ligament, where the sheath terminates by fusing with the adventitia of both vessels.63A 12-year-old child has a tibia and fibula fracture following a fall from a swing. The fracture is reduced and placed in above knee plaster in the accident & emergency department.What is the most reliable clinical test for compartment syndrome in this alert patient?Is diagnosed by compartment pressures in excess of 30–35 mmHg in a normally perfused patientLoss of dorsalis pedis and posterior tibial pulses on Doppler examinationPain with dorsiflexion of toes?? YOUR ANSWERPalpation of tense swollen compartmentSensory or motor nerve deficitYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionCompartment syndrome, a devastating early complication of lower limb fractures, occurs when the capillary perfusion pressure falls below the tissue perfusion pressure. This leads to necrosis of the muscles and nerves in the enclosed compartment. Up to 45% of all cases of compartment syndrome are caused by tibial fractures. It is more common in patients with open tibial fractures compared to closed tibial fractures (6% vs 1.2%), probably reflecting the severity of the injury. Although commonly caused by trauma, it can also occur following crush injury, massive haemorrhage, gun shot injuries, deep burns, electrical injuries, restricting tourniquets and fluid extravasation; chronic compartment syndrome has been reported following splints, casts and dressings, military antishock trousers, drug/alcohol abuse, coma, gastrocnemius or peroneus muscle tear and snake envenomation. Peripheral pulses including the dorsalis pedis and posterior tibial are normal during the early phases of development of compartment syndrome (since it is the microvasculature which is initially affected); loss of peripheral pulses is usually a late and sinister sign that suggests imminent tissue ischaemia. The most significant and reliable clinical sign, however, is severe pain in response to passive stretch of the ischaemic muscles. Pain is deep and aching in nature. The sensory nerve fibres are more susceptible to ischaemia than the motor fibres and hence there is loss of sensation before paralysis of the affected group of muscles. All muscles in the lower leg tolerate 4 h of ischemia well, but by 8 h the damage is often irreversible. Areas of muscle may infarct giving rise to rhabdomyolysis, hyperphosphataemia, hyperkalaemia, high uric acid levels and metabolic acidosis; acute renal failure is a well-recognised complication of untreated compartment syndrome. Many surgeons now use compartment pressures in excess of 30–35 mmHg in a normally perfused patient as an indication for open compartment fasciotomy. However, in a haemodynamically unstable or a shocked patient, a lower threshold is indicated: Fasciotomy should be undertaken if the difference between the diastolic pressure and the measured compartment pressure is less than 30 mmHg (eg, if the diastolic pressure falls to 50 mmHg, fasciotomy should be undertaken even if the compartment pressure is only 20 mmHg).64A 26-year-old man sustains a laceration to his foot just anterior to the medial malleolus on the dorsum of the foot.Which clinical structure is likely to be damaged in this injury?Inferior extensor retinaculum which loops under the medial longitudinal archThe deep peroneal nerve which lies medial to the dorsalis pedis arteryThe dorsalis pedis artery which lies medial to the extensor hallucis longus tendonThe extensor digitorum communis which is medial to tibialis anterior?? YOUR ANSWERThe great saphenous vein lies anterior to the medial malleolus?? CORRECT ANSWERYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The AnswerThe dorsalis pedis artery lies between the extensor hallucis longus tendon medially, and the deep peroneal nerve lies laterally. The L5 dermatome lies over the medial half of the dorsum of the foot. The great saphenous vein is found anterior to the medial malleolus, and the lower limb of the extensor retinaculum passes under the medial longitudinal arch and blends with the plantar aponeurosis.65The tibial nerve is a branch of the sciatic nerve that passes through the popliteal fossa.What is the main cutaneous branch of the tibial nerve in the popliteal fossa?Articular branch to the knee jointGives off the sural nerve as a branch?? CORRECT ANSWERThe common peroneal nerve is a branch of the tibial nerveThe medial plantar nerve is a branch of tibial nerve in the popliteal fossaThe posterior femoral cutaneous nerve?? YOUR ANSWERYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe tibial nerve is the large terminal branch of the sciatic nerve. It runs through the popliteal fossa, at first lying on the lateral side, then crossing medial to the popliteal artery. It leaves the fossa by passing deep to gastrocnemius and soleus. The tibial nerve supplies the knee joint, popliteus, and the posterior compartment muscles of the leg and the foot.66A 53-year-old male presents with intermittent shooting pain along the posterior aspect of the lower limb. On examination, the pain is exacerbated by flexing thehip, and relieved by subsequent knee flexion.The sciatic nerve divides to form which two nerves?Anterior cutaneous and lateral femoral cutaneous nervesAnterior cutaneous and sural nervesAnterior cutaneous and tibial nervesCommon fibular and anterior cutaneous nervesCommon fibular and tibial nerves?? YOUR ANSWERYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe sciatic nerve originates from the L4-S3 roots. It can be injured or compressed to give symptoms of pain and paraesthesia in the posterior aspect of the lower limb. The diagnosis can be confirmed if symptoms are exacerbated by passive extension of the knee (which can be combined with foot dorsiflexion to further provoke symptoms, so long as the knee is extended)and immediately relieved by knee flexion. The sciatic nerve divides to form the common fibular and tibial nerves.67An 87-year-old female is referred to an orthopaedic clinic with ongoing left hip pain which has persisted for the last year following a fractured hip. This was treated with cannulated screws and an x-ray shows changes consistent with avascular necrosis of the femoral head.Which of the following are at risk of avascular necrosis?Single best answer - select one answer onlyCalcaneus?? YOUR ANSWERNeck of femurOlecranonPatellaTalus?? CORRECT ANSWERYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The AnswerA scaphoid fracture often severs the proximal fragment from the blood supply entering the distal aspect of the bone. The head (not the neck) of the femur undergoes necrosis when the subretinacular arteries are severed following fractures of the neck. Dislocation of the talus ruptures the blood supply and avascular necrosis results after reduction.68A patient develops common peroneal nerve palsy after treatment with a below knee cast for 6 weeks for an undisplaced ankle fracture.?Which of the following is true??Single best answer question – choose ONE true option onlyThe patient is unable to stand on tip toe?? YOUR ANSWERThere would be complete sensory loss below the kneeThere would be no dorsiflexion of the foot?? CORRECT ANSWERThe patient would complain of complete sensory loss on the sole of the footSensation would be normal on the dorsum of the footYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe common peroneal nerve (also known as the common fibular nerve) can be compressed by a below knee cast at the level of the fibula neck. It supplies the muscles of the anterior and lateral compartments of the leg, producing dorsiflexion of the foot, ankle and toes, as well as eversion of the foot. The superficial peroneal nerve gives sensory supply to most of the dorsum of the foot. The deep peroneal nerve supplies the first web space.?The action of standing on tip-toes is produced by ankle plantar flexion ie. Gastrocnemius and soleus, supplied by the tibial nerve.The lower leg also receives sensory innervation from the saphenous and tibial nerves which would be unaffected, therefore sensory loss would be incomplete.69An 18-year-old male has come back from a camping holiday with his friends complaining of numb, swollen and blistered feet.What is the main cause of this trench foot condition?ChilblainsCold and damp conditions while wearing constricting foot wear?? YOUR ANSWERFoot infectionFrost biteGoutYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The AnswerTrench foot or cold immersion foot (or hand) is caused due to a non-freezing injury of the hands or feet. This is typically seen in soldiers, sailors, or fishermen, who are chronically exposed to wet conditions and temperatures just above freezing, i.e. 1.6°C to 10°C (35°F to 50°F). It occurs due to microvascular endothelial damage, stasis and vascular occlusion. Although the entire foot may appear black, deep tissue destruction may not be present. An alternating arterial vasospasm and vasodilatation occurs, with the affected tissue first cold and anaesthetic, progressing to hyperaemia in 24 to 48 h. This then leads to an intense painful burning and dysaesthesia, as well as tissue damage characterised by oedema, blistering, redness, ecchymosis, and ulcerations. Pruritic, red–purple skin lesions are a feature of chilblain or pernio. Complications of trench foot include local infection, cellulitis, lymphagitis, and gangrene.70A footballer fell awkwardly because of a rash challenge. He sustained a blow to his left knee and was stretchered off the playing field. On examination of his injured knee the physiotherapist found excessive posterior movement of the tibia on the femur.The chief ligament preventing posterior sliding of the tibia on the femur is the:Single best answer question – choose ONE true option onlyTibial collateralFibular collateralOblique poplitealPosterior cruciate?? YOUR ANSWERAnterior cruciateYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The AnswerThe posterior cruciate ligament (PCL) is stronger, but shorter and less oblique in its direction, than the anterior. It is attached to the posterior intercondyloid fossa of the tibia and to the posterior extremity of the lateral meniscus and passes upward, forward and medialward, to be fixed into the lateral and front part of the medial condyle of the femur. This configuration allows the PCL to resist forces pushing the tibia posteriorly relative to the femur.71A 50-year-old man was hit by a car, sustaining a proximal fibular fracture at the level of the fibular neck. Following the injury he had a foot drop gait, wasting and weakness of the anterior and lateral compartments of the calf but preservation of the posterior compartment muscles. There was loss of sensation over the dorsum of the foot including the 1st web space. Which nerve is the most likely to be damaged?Common peroneal nerve?? CORRECT ANSWERDeep peroneal nerve?? YOUR ANSWERSciatic nerveSuperficial peroneal nerveTibial nerveYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe common peroneal nerve winds round the fibular neck. It supplies the lateral and anterior muscular compartments of the calf as well as the skin over the anterior aspects of the calf and foot. With foot drop, the patient trips on walking, as the toes catch the ground. Cutaneous innervation of the sole of the foot is through the medial and lateral plantar branches of the tibial nerve. Inversion is weakened because of paralysis of the tibialis anterior muscle. Muscle wasting is a sign of lower motor neurone damage. The peroneus longus tendon is one of the supports of the lateral arch; when this is paralysed, the arch is compromised.72What would be consistent with femoral nerve damage in a patient with pelvis trauma? Single best answer - choose ONE true option onlyPreserved knee reflexLoss of sensation over the anterior femur?? YOUR ANSWERLoss of power in the biceps femoris muscleLoss of power in the peroneus muscleReduced power on adductionYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe femoral nerve may be damaged from fractures of the pelvis or femur, or dislocations of the hip, and hip or hernia surgery. It can also be involved in psoas abscesses, thigh wounds and frequently in large psoas haematomas in patients with haemophilia and diabetic amyotrophy. Partial lesions are common from thigh wounds with the nerve to the quadriceps most frequently involved and causing great problems in walking with the knee often giving way, especially when descending stairs. It leads to a loss of power in the knee extension.?In addition there is?quadriceps wasting, loss of knee jerk and impaired sensation over the front of the thigh.73Which nerve is potentially at greatest danger of iatrogenic injury during Total Hip Arthroplasty via the posterior approach?Femoral NerveLateral Cutaneous Nerve of the ThighObturator NerveSciatic Nerve?? YOUR ANSWERSuperior Gluteal NerveYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionIatrogenic injury to the femoral or obturator nerves are rare, accounting for less than 10% of all nerve injuries following hip surgery. Schmalzreid et al conducted a large study documenting 3126 consecutive total hip replacements and found that 80% of nerve injuries occurred to the sciatic nerve (47% peroneal division alone, 30% to peroneal and tibial divisions, 3% to tibial division alone). Lateral skin incision should be planned to avoid the lateral cutaneous nerve of the thigh. The superior gluteal nerve is retracted with the muscle intra-op and is unlikely to be injured.74A patient presented with a Trendelenburg gait compensating for weakness in her hip abductors.Which of the following muscles abduct the hip?Biceps femorisGluteus maximusGluteus medius?? YOUR ANSWERPiriformisQuadratus femorisYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionBoth gluteus medius and gluteus minimus abduct and medially rotate the thigh at the hip joint. Gluteus maximus extends and laterally rotates the thigh at the hip joint. Quadratus femoris and piriformis both contribute to lateral rotation of the thigh.75During total hip arthroplasty via the posterior approach in the gluteal region you are asked to locate the sciatic nerve.Where is the sciatic nerve likely to be found??Deep in the upper outer quadrantDeep to the obturator internus muscleDeep to the piriformis muscle?? CORRECT ANSWERMedial to the inferior gluteal vessels?? YOUR ANSWEROn the capsule of the hip jointYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe sciatic nerve appears in the gluteal region below the lower border of the piriformis muscle in the vast majority of cases, deep to the lower medial quadrant, and lateral to the inferior gluteal vessels. In its descent, it is separated from the capsule of the hip joint anteriorly by the obturator internus tendon, and by the gemelli muscles.76The linea aspera is the bony ridge on the posterior aspect of the femurWhich muscle is attached to the linea aspera?Single best answer - select one answer onlyAdductor longus and brevis?? CORRECT ANSWERLong and short heads of biceps femorisPectineus and adductor magnusRectus femoris and vastus intermediusVastus lateralis and vastus intermedius?? YOUR ANSWERYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe linea aspera is a ridge running down the posterior aspect of the femur. It forms a point of attachment for the following muscles: vastus lateralis, vastus medialis, gluteus maximus, adductor magnus, adductor longus, adductor brevis and the short head of biceps femoris.77In pes planus, where the whole foot is everted around its longitudinal axis and the medial arch comes into contact with the ground when standing, which of these anatomical structures is the dynamic stabilizer of the medial plantar arch?Acetabulum pedisCalcaneo-navicular (spring) ligament?? YOUR ANSWERLisfranc jointPlantar fasciaTibialis Posterior?? CORRECT ANSWERYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionPes planus = pes valgus = flat foot. The whole foot is rotated into eversion around its longitudinal axis. It is asymptomatic in the vast majority of cases. There are two types: mobile and rigid. Rigid flat foot is often caused by synostosis between two of the tarsal bones: talocalcaneal and talonavicular.?The complex ligamentous support and congruent bony anatomy that surrounds the talonaviculocalcaneal joint have created comparisons to the ball-and-socket of the femoral head and acetabular articulation. This "acetabulum pedis" maintains the medial longitudinal arch and acts as an important static stabilizer. The spring-ligament complex is the most frequently affected static stabilizer in symptomatic pes planus.?The most frequently affected dynamic stabilizer in pes planus is the tibialis posterior tendon, and it is the most powerful inverter of the foot and serves as an important dynamic arch stabilizer. The tibialis posterior muscle and corresponding tendon are crucial to hindfoot position and foot flexibility during the gait cycle.?78A 43-year-old female presents with pain and paraesthesia of the medial aspect of the foot, exacerbated by walking. She is diagnosed with tarsal tunnel syndrome and receives appropriate management.Which nerve has been injured?Common peroneal nerveFemoral nerveLateral cutaneous nerveSural nerveTibial nerve?? YOUR ANSWERYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe tibial nerve originates from the sciatic nerve. It runs inferior to the flexor retinaculum of the foot alongside the tibial artery and vein, the tibialis posterior muscle, and the flexor hallucislongus and flexor digitorumlongus muscles. If the nerve is compressed within the tarsal tunnel, then the clinical syndrome described above can result.79The adductor (Hunter) canal runs behind the sartorius muscle is in danger during anteromedial approach to the femur.What passes through this canal?The deep femoral arteryThe femoral nerveThe nerve that supplies tensor fascia lataThe nerve to the vastus lateralisThe saphenous nerve?? YOUR ANSWERYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe adductor canal (also known as the subsartorial or Hunter’s canal) is a 15-cm long tunnel bounded by vastus medialis laterally, and adductor longus and magnus posteriorly. The canal serves as a passage for the superficial femoral artery, femoral vein, saphenous nerve and the nerve to vastus medialis to pass into the popliteal fossa. The adductor canal begins where the sartorius crosses over the adductor longus and ends at the adductor hiatus. The femoral artery gives off a descending genicular artery while in the adductor canal. The nerve to the tensor fascia lata is the superior gluteal nerve (L4–S1), which passes through the greater sciatic foramen.80You are in vascular clinic and are reviewing a pregnant patient with varicose veins. The registrar asks you about risk factors for varicose veins, which of the following is a risk factor:Male sexMediterranean originPrevious history of deep vein thrombosis?? CORRECT ANSWERProfessional cyclist?? YOUR ANSWERYoung ageYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionVaricose veins affect females of Northern European origin five times more commonly than men and are particularly associated with previous deep vein thrombosis (DVT). Veins are most pronounced in patients who stand for long periods. The incidence of varicose veins increases with increasing age.81You have reviewed a 42-year-old lady in the vascular clinic and your consultant asks you to consent her for a trendelenburgs operation.What condition is this procedure for?Abdominal aortic aneurysmArteriovenous fistulaDeep Vein Thrombosis (DVT) with varicose veins?Primary varicose vein surgery?? YOUR ANSWERVaricoceleYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The AnswerIn Trendelenburgs operation for varicose veins, the patient is usually placed supine with 30 degree of head-down tilt to allow emptying of the veins. The operation is not recommended if the long saphenous vein (LSV) is a collateral for obstructed deep veins, otherwise venous claudication may ensue. The LSV has approximately seven tributaries close to the sapheno-femoral junction (SFJ). The femoral vein does not receive any tributaries except the LSV.82Which of the following is correct regarding Developmental Dysplasia of the Hip (DDH)?Both hips are affected in the majority of patientsIn a newborn the femoral head will show on an ultrasound scan?? YOUR ANSWERIn the newborn the femoral head will show on a plain radiographIt affects about 1 in 1000 new bornsIt is equally common if boys and girlsYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe incidence of developmental dysplasia of the hip (DDH) is about 1 in 500 newborns; it is commoner in girls and both hips are affected in up to one-third of patients. There is a familial tendency related to acetabular dysplasia and joint laxity. Though the joint capsule is lax it is intact, but may fold into the joint space and prevent reduction. X-ray examination is of value in established cases, but in the newborn the femoral head is cartilagenous so does not show on a plain radiograph. However, ultrasound scanning will show both the position of the femoral head and the shape of the acetabulum.DDH can be described as:Subluxation – Incomplete contact between the articular surfaces of the femoral head and acetabulum.?Dislocation – Complete loss of contact between the articular surface of the femoral head and acetabulum.?Instability – Ability to subluxate or dislocate the hip with passive manipulation.?Teratologic dislocation – Antenatal dislocation of the hip.83A 68-year-old man presents with mechanical hip pain.What is the first radiographic sign to appear in osteoartritis?Narrowing joint space?? YOUR ANSWEROsteopeniaOsteophytesSoft tissue swellingSubchondral sclerosisYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The AnswerThe classic radiographic signs of osteoarthritis are: joint space narrowing, subchondral sclerosis, osteophytes and subchondral cysts. Osteopenia and soft tissue swelling are often associated with rheumatoid arthritis.84A patient with known vascular disease develops erectile dysfunction He denies any leg pain. On examination he has marked wasting of the right buttock area.?Which vessel is likely to be affected?Single best answer question – choose ONE true option onlySuperficial femoral arteryInternal iliac artery?? YOUR ANSWERProfunda femorisExternal iliac artery?Common Iliac arteryYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The AnswerThe internal iliac artery divides into two branches, the posterior division and the anterior division. The posterior division gives off the superior gluteal artery which supplies gluteus medius and minimis. The anterior division gives off the inferior gluteal artery which supplies gluteus maximus. All the muscles of the buttock are therefore supplied by the internal iliac artery, so compromise of this vessel would lead to visible buttock wasting.The blood supply of the penis is mainly derived from the pudendal artery (a branch of the internal iliac artery) and so this would also suggest the internal iliac artery was affected.As there is no leg pain the lesion is unlikely to be affecting either the common iliac artery or any branches of the external iliac artery. The superficial femoral artery is a continuation of the external iliac artery and this gives off the profunda femoris.85In the anatomy of the bony pelvis, several bony landmarks have important clinical relevance.Which statement is correct?Femoral canals lie medial to the lacunar ligamentsIschial spines are palpable per vaginam?? CORRECT ANSWERPubic tubercles are palpable lateral to the external ring of the inguinal canalSacral cornua are palpable per rectumTranstubercular plane passes through the spinous process of the L3 vertebra?? YOUR ANSWERYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The AnswerIn the natal cleft, the sacral cornua are important surface markings for the sacral hiatus, through which a needle is passed for epidural anaesthesia. A direct inguinal hernia protrudes above and medial to the pubic tubercle. The external inguinal ring is palpable superolateral to the pubic tubercle. The femoral canal has the lacunar ligament as its medial wall. The ischial spine guides a needle to the pudendal canal for per vaginam pudendal nerve block. The transtubercular plane is an important landmark for lumbar puncture and transects the L5 vertebra (the supracristal plane, which passes through the L4 lumbar spine, can also be used).86Whilst in a vascular clinic you suspect a patient has varicose veins, and your consultant asks you to test for valvular incompetence and gives you the Doppler ultrasound machine. With the probe over the saphenofemoral junction as you squeeze the calf what sound signifies valvular incompetence?Negative A Sound?? CORRECT ANSWERNegative B Sound?? YOUR ANSWERPositive A SoundPositive B SoundNone of the aboveYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionIn Doppler ultrasound (U/S), the A sound is produced by squeezing the calf. When pressure is released there is no sound if the valves are competent, this is termed a positive A sound. Doppler U/S has a sensitivity of up to 97%; 87% of perforating veins are localised by ascending phlebography.87A 13-year-old female falls from a horse and presents with a swollen, painful foot. She is given analgesia and proceeds to the radiology department where she is noted to have a fracture of the talus.Which bone articulates with the anterior aspect of the talus?CuboidLateral cuneiformMedial cuneiformNavicular?? YOUR ANSWEROs calcisYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe talus articulates with the navicular bone anteriorly and the oscalcis inferiorly. The cuneiform bones are anterior to the navicular, with the cuboid lying laterally.88Following open reduction internal fixation of both the distal tibia and the distal fibula, a patient complains of numbness along the lateral side of the foot.?Which nerve is likely to have been injured??Single best answer question – choose ONE true option onlySural nerve?? CORRECT ANSWERSaphenous nerveDeep peroneal nerveSuperficial peroneal nerveTibial nerveYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe sural nerve arises from the tibial nerve. It is purely sensory and supplies the lateral border of the leg and the lateral border of the foot. It lies approximately 1cm posterior to the distal fibula and may be damaged during operations on the distal fibula.?The saphenous nerve supplies the medial aspect of the leg up to the medial malleolus. The deep peroneal nerve supplies the first web space whilst the superficial peroneal nerve usually supplies the rest of the dorsum of the foot. The tibial nerve supplies the heel and branches into the medial and lateral plantar nerves to innervate the sole of the foot.89The tibial nerve is a peripheral branch of the sacral plexus in the leg.Which muscle gets its motor supply from the tibial nerve?Extensor digitorum longusExtensor hallucis longusGastrocnemius?? YOUR ANSWERPeroneus longusTibialis anteriorYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe sural nerve branches off the tibial nerve in the popliteal fossa. It is usually joined by the sural communicating branch of the common peroneal nerve and supplies the back of the leg and the lateral foot. The tibial nerve enters the popliteal fossa lateral to the popliteal artery and then passes posterior then medial to the artery. Damage to the tibial nerve results in loss of plantar flexion of the feet. The tibial nerve is superficial to both popliteal vein and artery in the popiteal fossa.90A patient presents with a history of back pain which developed 3 months ago when he got up suddenly from a seated position. The pain radiates down the leg to the ankle. On examination he has weakness of the quadriceps, reduced knee jerk reflex and reduced sensation over the patella.?Where is the lesion likely to be??Single best answer question – choose ONE true option onlySciatic nerve compressionIlioinguinal nerveL3 nerve root?? YOUR ANSWERL5 nerve rootCompression of the femoral nerve at the inguinal ligamentYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe history suggest a prolapsed intervertebral disc. The quadriceps are supplied by the femoral nerve whose root value is L2-L4. The skin over the patella is usually part of the L3 dermatome, and the root value of the knee jerk is L3/L4.?The sciatic nerve innervates the muscles of the posterior compartment of the thigh and the muscles of the leg. It provides sensory innervation for the posterior thigh, the leg and the foot.?The ilioinguinal nerve supplies a small area of skin on the medial aspect of the upper thigh as well as the scrotum and penis.?Femoral nerve compression at the level of the inguinal ligament is unlikely given the history of injury and back pain.91There are several approaches that could be used for hip joint exposure.Which approach risks injury to the superior gluteal nerve while splitting the gluteus medius muscle?The anterior Smith Peterson approachThe anterolateral Watson Jones approachThe anteromedial Ludloff approachThe lateral Hardinge approach?? CORRECT ANSWERThe posterior approach?? YOUR ANSWERYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe superior gluteal nerve runs between gluteus medius and minimus 5 cm above the tip of greater trochanter.The gluteus maximus is split in the direction of its fibres in the posterior approach. The anterolateral approach is usually through the interval between the gluteus medius and tensor fascia lata. The sciatic nerve lies posterior to the hip joint separated by the short lateral rotators. The sciatic nerve is at risk when the femoral head is dislocated in order to remove it for the prosthesis. The short lateral rotators lie on the posterior surface of the hip joint.92A young man was stabbed on the lateral aspect of the knee.Identify the correct superficial-to-deep sequence of structures traversed by the knife:Single best answer question – choose ONE true option onlySkin, tibial collateral ligament, lateral meniscusSkin, fibular collateral ligament, popliteus muscle tendon, lateral meniscus?? CORRECT ANSWERSkin, popliteus muscle tendon, tibial collateral ligament, lateral meniscus?? YOUR ANSWERSkin, popliteus muscle tendon, fibular collateral ligament, lateral meniscusSkin, anterior cruciate ligament, popliteus muscle tendonYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe correct order of superficial to deep structures on the lateral aspect of the knee joint is skin, fibular collateral ligament, popliteus muscle tendon and lateral meniscus.93A patient undergoes intra-medullary nailing for a mid-shaft fracture of tibia 3 hours ago. The ward nurses are concerned as he is in a lot of pain. On examination, he has no neurovascular deficit. He complains of excruciating pain on passive plantar flexion of the big toe, but not on passive dorsiflexion.?What is the likely diagnosis?Single best answer question – choose ONE true option onlyCompartment syndrome of the deep posterior compartment of the legCompartment syndrome of the superficial posterior compartment of the leg?? YOUR ANSWERCompartment syndrome of the anterior compartment of the leg?? CORRECT ANSWERCompartment syndrome of the lateral compartment of the legCompartment syndrome of the medial compartment of the legYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The AnswerIn compartment syndrome, pain is worsened by passive stretching (i.e. extension) of the affected compartment. In this case the muscle being stretched is the extensor hallucis longus. This muscle is in the anterior compartment which also contains tibialis anterior, extensor digitorum longus and peronius tertius.The superficial posterior compartment contains gastrocnemius. plantaris and soleus.The lateral compartment contains peroneus longus and brevis.The deep posterior compartment of the leg contains the flexor hallucis longus along with flexor digitorum longus and tibialis posterior.There is no medial compartment of the leg.94Innervation to the peroneus brevis muscle:Single best answer question – choose ONE true option onlyCould be damaged by a fracture of the tibiaIs by a nerve that is a direct branch of the femoral nerveIs by a nerve that is accompanied by an artery in the same compartmentIs by the same distal nerve that innervates the peroneus tertius muscleCould be damaged by a fracture of the neck of the fibula?? YOUR ANSWERYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe peroneus brevis is supplied by the fourth and fifth lumbar and first sacral nerves through the superficial peroneal nerve. The superficial peroneal nerve is one of the two terminal branches of the common peroneal nerve. The common peroneal nerve winds around the neck of the fibula and can be injured in cases of fracture neck of fibula. Such an injury can result in paralysis or paresis of peroneus brevis due to indirect involvement of the superficial peroneal nerve.95The lumbosacral plexus is formed from the ventral rami of T12-S3,and lies on the anterior surface of the quadratus lumborum.What is the biggest branch of this plexus?Common peroneal nerveFemoral nerve (L2, L3, L4)Ilioinguinal nerveObturator nerve (L3, L4, L5)Sciatic nerve?? YOUR ANSWERYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The AnswerThe sciatic nerve (sacral plexus – L4, L5, S1, S2, S3) divides into the common peroneal (L4, L5, S1, S2) and tibial (L4, L5, S1, S2, S3) nerves. The obturator and femoral nerves are both derived from the lumbar plexus and have the same root values (L2, L3, L4).96Intervertebral disc prolapse in the lumbar spine most often affects the L4/L5 and L5/S1 discs. In a man presenting with acute back pain following an episode of lifting a heavy weight, reduced force of which of the following movements would most suggest an L4/L5 rather than an L5/S1 disc lesionSingle best answer question – choose ONE true option onlyAnkle plantar flexionEversion of the footExtension of great toe?? CORRECT ANSWERInversion of the footKnee extension?? YOUR ANSWERYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The AnswerIn the lumbar spine (in contrast to the cervical spine) nerve roots emerge below their respective vertebrae: thus the majority of L4/5 disc prolapses would be expected to affect the L5 root and the majority of L5/S1 disc prolapses would affect the S1 nerve root. Knee extension is mediated primarily by L3/4ankle dorsiflexion by L4/L5inversion of the foot by L4 aloneeversion of the foot by S1, and ankle plantar flexion by S1 and 2. Although L5 contributes to hip abduction and extension, knee flexion and ankle dorsiflexion, weakness is often minimal because of the contribution of other roots to these movements and tends to be maximal in extension of the toes, particularly the great toe.97A 28-year-old pregnant woman presents with bilateral painful lower limbs with varicosities in the long saphenous vein distribution at the level of the perforating veins bilaterally.What is the diagnostic investigation of choice for this lady?Ankle Brachial Pressure Index (ABPI)Lower limb arteriogramLower limb Contrast CT angiogramLower limb duplex venous ultrasound?? YOUR ANSWERLower limb MRI angiogramYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The AnswerVaricose veins are usually acquired and due to incompetent venous valves. Incompetence at the sapheno femoral junction is much more common than sapheno popliteal incompetence (85% versus15%). There is a higher incidence in pregnant women. Duplex ultrasonography is the pre-operative investigation of choice. Venous ulcers are due to high venous pressure, commonly due to failure of the calf muscle pump. The other investigations relate to arterial disease and are more invasive. Duplex ultrasound venography is safe in a pregnant patient, can exclude DVT, which is a risk factor due to the hypercoaguable state in pregnancy.98A 56-year-old female presents with pain and paraesthesia of the left buttock.Which nerve accompanies the piriformis muscle as it exits the pelvis, and is involved in 'piriformis syndrome'?Single best answer - select one answer onlyFemoral nerveInferior gluteal nervePudendal nerveSciatic nerve?? CORRECT ANSWERSuperior gluteal nerve?? YOUR ANSWERYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The AnswerPiriformis leaves the pelvis via the greater sciatic foramen, accompanied by the sciatic nerve. Piriformis syndrome occurs when the sciatic nerve is compressed or impeded by the piriformis muscle. It should be considered if no spinal cause can be determined for symptoms of sciatica.99A fractured neck of femur in the right leg of a 75-year-old female patient which is described as a “complete fracture through the femoral neck with partial displacement” should be classified as a Garden Stage what?I fractureII fractureIII fracture?? YOUR ANSWERIV fractureCannot be classified by Garden StageYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionFemoral neck fractures involve the narrow neck between the round head of the femur and the shaft. This fracture often disrupts the blood supply to the head of the femur. British orthopaedic surgeon Robert Symon Garden described a classification system for this type of fracture, referred to as the Garden classification and consisting of four grades:Type I is a stable fracture with impaction in valgus.?Type II is complete but non-displaced.?Type III is partially displaced (often externally rotated and angulated) with varus displacement but still has some contact between the two fragments.?Type IV is completely displaced and there is no contact between the fracture fragments.The blood supply of the femoral head is much more likely to be disrupted in Garden types 3 or 4 fractures. The treatment is to reduce the fracture (manipulate the fragments back into a good position) and fix them in place with metal screws where possible for physiologically younger patients. Common practice is to repair Garden I and II fractures with screws, and to replace Garden III and IV fractures with arthroplasty.100A 25-year-old football player sustains an ACL tear and requires surgery to reconstruct it.Which muscle tendon is used to achieve an ACL reconstruction?The biceps femorisThe politeus as it is easy to accessThe rectus femoris as it has a big tendonThe sartorius as it could be easily identified at the insertion near the tibial tuberosityThe semitendinosus because it has a high load to failure of 4000 Newton?? YOUR ANSWERYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The AnswerRectus femoris, vastus medialis, vastus intermedius and vastus lateralis form the quadriceps tendon. This tendon inserts on the patellar. Biceps femoris, semitendinosus, semimembranosus and the hamstring portion of adductor magnus are all in the posterior fascial compartment of the thigh. Biceps femoris inserts on the head of the fibula. Semimembranosus inserts on the medial condyle of the tibia.101Following a stab injury a patient has his sciatic nerve cut as it exits the pelvis.Which one of the following statements is CORRECT regarding this patient?Single best answer question – choose ONE true option onlyExtension of the knee would be eliminatedThe long head of the biceps femoris muscle would be affected but not the short headThere would still be cutaneous sensation over the anteromedial surface of the thigh?? YOUR ANSWERThe muscles in the anterior compartment of the leg would still be functionalThe sartorius and gracilis muscles would not be able to contractYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The AnswerThe sciatic nerve is a large nerve that runs down the lower limb. It is the longest single nerve in the body. The sciatic nerve supplies nearly the whole of the skin of the leg, the muscles of the back of the thigh and those of the leg and foot. A transection of the sciatic nerve at its exit from the pelvis will affect all the above-mentioned functions except cutaneous sensation over the anteromedial surface of the thigh, which comes from the femoral nerve.102A 21-year-old basketball player complains of ankle pain following a twisting injury, his ankle is swollen and tender medially.The most likely injured ligament is:Anterior talofibular ligamentCalcaneofibular ligamentCalcaneonavicular ligamentDeltoid ligament?? YOUR ANSWERSyndesmosisYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe medial ligament of the ankle, otherwise known as the ‘deltoid ligament’, has two layers. The deep part is narrow and much shorter than the superficial part, which is triangular in shape. The superficial part of the medial ligament is attached to the borders of the tibial malleolus, and has a continuous attachment from the medial tubercule of the talus along the edge of the sustentaculum tali and spring ligament to the tuberosity of the navicular bone. The lateral ligament consists of three separate bands, and it is this ligament which is usually damaged in inversion injuries (a sprain) of the ankle. The ligaments themselves cannot be seen on X-ray, although avulsion fractures may be detectable on X-ray.103Regarding the cutaneous nerve supply of lower limb.Which nerve supplies the medial aspect of the lower leg and foot?The deep peroneal nerve of the common femoral nerveThe intermediate cutaneous of the femoral nerveThe medial cutaneous nerve of the femoral nerveThe saphenous nerve of the femoral nerve?? YOUR ANSWERThe sural nerve of the tibial nerveYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe lateral, intermediate and cutaneous nerves are all branches of the femoral nerve. On the anterior thigh, medial to the line of the sartorius and below the inguinal ligament, skin is supplied by the ilioinguinal nerve and the femoral branch of the genitofemoral nerve. The saphenous nerve is a branch of the femoral nerve and supplies skin on the medial side of the lower leg. The sural nerve is a branch of the tibial nerve but it receives a communicating branch from the common peroneal nerve. The dorsum of the foot is innervated by the superficial peroneal nerve except the first dorsal space, which is innervated by the deep peroneal nerve.104An 18-year-old female basket player presents 2 weeks after sustaining a knee injury while landing from a jump. There was an audible popping sound at the time of injury and she developed swelling later that evening. On physical examination, she has a positive Lachman test.What is the origin and insertion of the damaged ligament?From intercondylar notch on lateral femoral condyle to tibia?? CORRECT ANSWERFrom intercondylar notch on medial femoral condyle to tibia?? YOUR ANSWERFrom lateral femoral condyle to fibulaFrom medial femoral epicondyle to medial meniscusFrom medial femoral epicondyle to proximal tibiaYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The AnswerThe Lachman test is used for examination of the Anterior Cruciate Ligament (ACL) where there is suspicion of a torn ACL. The ACL is attached to the anterior intercondylar area of the tibia and passes upwards, backwards and laterally to the medial surface of the lateral femoral condyle. The posterior cruciate ligament is attached to the posterior intercondylar area of the tibia and passes upwards, forwards and medially to the lateral surface of the medial femoral condyle. Both cruciate ligaments are intracapsular but extrasynovial. The medial meniscus is attached to the medial collateral ligament but the lateral collateral ligament is not attached to the lateral meniscus as the popliteus muscle runs between them.105A 1-day-old boy is referred to the paediatricians with omphalocoele, microcephaly, difficulty feeding and crytptorchidism. He is diagnosed with Trisomy 18 after further investigation.Which lower limb abnormality is associated with this condition?AmeliaCongenital talipesequinovarus?? CORRECT ANSWERGenuvalgusGenuvarus?? YOUR ANSWERMeromeliaYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The AnswerTrisomy 18 is also known as Edward syndrome, and presents with a variety of developmental defects. It is associated with talipesequinovarus (or ‘club foot’) and polydactyly. Amelia and meromelia are total and partial absence of a limb, respectively.106The modified synovial joint allows flexion and extension in one plane.Which of the lower limb joints is a modified synovial joint?The calcaneocuboid joint?? YOUR ANSWERThe hip jointThe inferior tibiofibular jointThe intermetatarsal jointsThe knee?? CORRECT ANSWERYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe knee is a modified synovial hinge joint.The tibiotalar joint is a synovial hinge joint. The inferior tibiofibular joint is fibrous.107A patient presents with numbness in the first, second and third toes and dorsum of foot.The nerves contributing to the numbness include:The deep peroneal nerveThe lateral plantar nerveThe superficial peroneal nerve?? YOUR ANSWERThe sural nerveThe tibial nerveYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe common peroneal nerve branches to form the superficial and deep peroneal nerves. The cutaneous sensory innervation of the superficial peroneal nerve includes the anterolateral lower leg and the dorsum of the foot (except the 1st webspace, which is innervated by the deep peroneal nerve).108In mid-shaft fractures of the femur, the proximal fragment becomes abducted and externally rotated due to the action of which muscle inserting at the greater trochanter?Gluteus medius?? YOUR ANSWERObturator externisObturator internisPiriformisQuadratus femorisYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe unopposed action of the hip flexors causes proximal fragment flexion. The action of the gluteal muscles, which are inserted into the greater trochanter causes the proximal fragment to become abducted and externally rotated. All the muscles listed insert at the greater trochanter, however only Gluteus medius is classed as an abductor.109The obturator nerve enters the thigh through the obturator canal and supplies sensation to medial side of the thigh.Which of these muscles are commonly innervated by the obturator nerve??Gracilis?? CORRECT ANSWERObturator internus?? YOUR ANSWERPectineusSemimembranosusVastus medialisYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The AnswerThe obturator nerve (L2, L3, L4) exits the obturator foramen and divides into anterior and posterior branches. The anterior branch innervates adductor brevis, adductor longus, gracilis. The posterior branch innervates obturator externus and part of adductor magnus. Semimembranosus is one of the hamstring muscles and is innervated by the tibial portion of the sciatic nerve. Obturator internus is innervated by the nerve to obturator internus, which, also supplies the superior gemellus.110A 53-year-old male presents with intermittent shooting pain along the posterior aspect of the lower limb. On examination, the pain is exacerbated by flexing the hip, and relieved by subsequent knee flexion.Which muscle passes through the greater sciatic foramen alongside the sciatic nerve?Gluteus mediusGluteus minimusObturatorexternusPiriformis?? YOUR ANSWERSuperior gemellusYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe piriformis originates from the anterior sacrum, and then passes through the greater sciatic foramen to insert on the greater trochanter of the femur. It acts to rotate the thigh laterally.111A 28-year-old man with a long standing history of back pain presents acutely with shooting pains to the outer aspect of his right foot, reduced sensation to the sole of the right foot, weakness of plantar flexion of the right ankle and an absent ankle jerk reflex on the right side. There is no bladder or bowel incontinence.Which nerve root is most likely to be compressed?Cauda EquinaLeft S1 nerve rootRight L1 nerve rootRight L5 nerve rootRight S1 nerve root?? YOUR ANSWERYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionSigns of S1 nerve root compression include: reduced sensation in the S1 dermatome (sole of the foot); weakness of plantar flexion of the ankle; and absent or reduced ankle jerk. As this is a unilateral problem and there is no evidence of bowel or bladder incontinence then there is no evidence of cauda equina.112A patient presents with varicosities around the lateral malleolus and further varicosities on the postero-lateral aspect of the leg up to the level of the knee joint.?Which of the following is correct?Single best answer question – choose ONE true option onlyThe patient has varicosities of the long saphenous veinThere is an incompetence at the sapheno-femoral junctionThe incompetent valve is unlikely to be in the popliteal fossaBoth short and long saphenous veins are affectedThe patient has varicosities of the short saphenous system?? YOUR ANSWERYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The AnswerThe short saphenous system passes posterior to the lateral malleolus and ascends the leg lateral to the Achilles tendon. It usually perforates the popliteal fossa and terminates in the popliteal vein. The incompetent valve is likely to be at this junction.The great saphenous passes above the medial malleolus, ascending obliquely across the inferior third of the patella and passes a hands breadth posterior to the patella on the medial side of the knee. It passes through the superficial fascia and the saphenous opening in the fascia lata, ending at the sapheno-femoral junction.113The short head of the biceps femoris muscle is innervated by:Single best answer question – choose ONE true option onlyThe common peroneal part of the sciatic nerve?? YOUR ANSWERThe same nerve as the pectineus muscleThe same nerve as the piriformis muscleThe tibial part of the sciatic nerveThe same portion of the sciatic nerve as innervates the semitendinosus muscleYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe short head of biceps femoris arises from the lateral lip of the linea aspera, between the adductor magnus and vastus lateralis, extending up almost as high as the insertion of the gluteus maximus; from the lateral prolongation of the linea aspera to within 5 cm of the lateral condyle; and from the lateral intermuscular septum. The fibres of the short head merge into the aponeurosis formed by the long head; this aponeurosis becomes gradually contracted into a tendon, which is inserted into the lateral side of the head of the fibula and by a small slip into the lateral condyle of the tibia. At its insertion, the tendon of biceps femoris divides into two portions, which embrace the fibular collateral ligament of the knee joint. From the posterior border of the tendon, a thin expansion is given off to the fascia of the leg. The tendon of insertion of this biceps forms the lateral hamstring; the common peroneal nerve descends along its medial border. The nerve to the short head of the biceps femoris is derived from the common peroneal part of the sciatic nerve.114A 17-year-old male is brought to the emergency room following a road traffic accident, and is quickly diagnosed with hypovolaemic shock. Several attempts at intravenous cannulation are unsuccessful, and so an incision is made anterior to the medial malleolus.Which vessel should be cannulated?Anterior tibial veinDorsal venous archLong saphenous vein?? YOUR ANSWERMedial marginal veinShort saphenous veinYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe long (or ‘great’) saphenous vein passes anterior to the medial malleolus of the tibia before ascending up the medial aspect of the leg. It traverses the posterior aspect of the femoral medial epicondyle before ascending to penetrate the fascia lata and confluence with the femoral vein at the saphenofemoral junction. It can be accessed via an incision anterior to the medial malleolus when emergency venous access is required.115A 50-year-old carpenter presented with swelling and pain anterior to his knee.Which knee bursa is likely to be involved?The deep infrapatellar bursa behind the infrapatellar bursaThe popliteal bursa protecting the patellar tendonThe prepatellar bursa protecting the patella?? YOUR ANSWERThe superficial infrapatellar bursa which lies between the ligamentum patellae and skinThe suprapatellar bursa which communicates with the knee jointYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThere are four anterior bursae: suprapatellar, prepatellar, superficial infrapatellar and deep infrapatellar. There are two posterior bursae: popliteal and semimembranosus. The deep infrapatellar bursa lies between the ligamentum patellae and the tibia. The superficial infrapatellar bursa lies between the skin and the lower half of the ligamentum patellae. The prepatellar bursa lies in the subcutaneous tissue over the lower half of the patella and upper part of the ligamentum patellae.116A patient complains of deficit in the cutaneous field halfway down the anterior surface of the thigh. This:Single best answer question – choose ONE true option onlyIs due to damage to the sciatic nerveWould result from compression of the ventral roots of L5 to S2Would result from damage to a nerve accompanying the artery in the adductor canalCould be the result of nerve damage during surgical procedures in the femoral sheathWould result from damage to the nerve that innervates the pectineus muscle?? YOUR ANSWERYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The AnswerThe pectineus is supplied by the second, third and fourth lumbar nerves through the femoral nerve and by the third lumbar through the accessory obturator when this exists. Occasionally it receives a branch from the obturator nerve. The anterior surface of the thigh receives its innervation from, the femoral nerve as well so that is the nerve most likely to be injured. In the thigh, the anterior division of the femoral nerve gives off anterior cutaneous branches. The anterior cutaneous branches comprise the intermediate and medial cutaneous nerves. The intermediate cutaneous nerve pierces the fascia lata (and generally the sartorius) about 7.5 cm below the inguinal ligament and divides into two branches that descend in immediate proximity along the forepart of the thigh to supply the skin as low as the front of the knee. Here they communicate with the medial cutaneous nerve and the infrapatellar branch of the saphenous, to form the patellar plexus. In the upper part of the thigh, the lateral branch of the intermediate cutaneous communicates with the lumboinguinal branch of the genitofemoral nerve.117The ilioinguinal approach is indicated to internally fix acetabular fractures. This approach risks injury to the femoral sheath.What is the most medial structure of the femoral sheath?Femoral arteryFemoral canal?? CORRECT ANSWERFemoral nerveFemoral vein?? YOUR ANSWERLacunar ligamentYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe femoral sheath is a thickening derived from the transversalis and iliac fasciae. It encloses the femoral artery, femoral vein and femoral canal. Lymphatic vessels run in the femoral canal. The femoral nerve lies laterally to the sheath.118The patellar reflex is a monosynaptic deep tendon reflex arc that helps maintain posture and balance.Absent knee reflex is most likely to be due to which one of the following?Dorsal column demyelinationFemoral nerve transection?? YOUR ANSWERL1–L2 disc prolapseS2–S4 dorsal nerve root avulsionsT12 level cord transectionYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe patellar reflex is mediated by the femoral nerve formed from the posterior divisions of the L2–L4 anterior spinal rami, and is therefore lost after femoral nerve and L2–L4 dorsal root damage. T12 cord lesions result in an upper motor neurone lesion with exaggerated reflexes. Dorsal column lesions only affect central sensory processing since collaterals subserving spinal reflexes are preserved.119Which one of the following muscles is attached to the tibial tuberosity?Single best answer question – choose ONE true option onlyPectineusVastus intermedius?? CORRECT ANSWERTensor fascia lata?? YOUR ANSWERShort head of the biceps femorisAdductor brevisYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe tuberosity of the tibia gives attachment to the ligamentum patellae (which is the single strong tendon of the quadriceps femoris, including rectus femoris, vasti medialis, intermedius and lateralis). A bursa intervenes between the deep surface of the ligament and the part of the bone immediately above the tuberosity.120The posterior approach provides exposure to the acetabulum and hip.Which structure exits the greater sciatic foramen below the piriformis muscle?Anterior cutaneous nerve of the thigh superiorFemoral cutaneous nerveGluteal nerve and arterySuperior gluteal nerveNerve to obturator internus?? YOUR ANSWERYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe piriformis muscle lies partly within the pelvis and emerges through the greater sciatic foramen to enter the gluteal region. The structures passing or emerging from the upper border of the piriformis muscle include the superior gluteal nerve and vessels. Below the lower border of the piriformis emerge the inferior gluteal nerve and muscles, pudendal nerve and vessels, the nerve to obturator internus and the sciatic nerve.121The posterior tibial artery is a branch of the popliteal artery and supplies the posterior compartment of the leg.What is the main branch of the posterior tibial artery?Dorsalis pedis arteryGives rise to the anterior tibial artery?? YOUR ANSWERGives rise to the peroneal artery?? CORRECT ANSWERLateral calcaneal branchMedial and lateral genicular arteriesYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe popliteal artery divides into the anterior and posterior tibial arteries at the lower border of the popliteus muscle, anterior to the fibrous arch of the soleus muscle. The peroneal artery is the first branch of the posterior tibial artery. At the ankle joint, the posterior tibial artery passes deep to the flexor retinaculum.122A patient has paralysis of the quadriceps femoris muscle. Which one of the following movements will be most likely to be affected in this patient?Single best answer question – choose ONE true option onlyExtension of the leg?? YOUR ANSWERFlexion of the legFlexion of the thighAdduction of the thighAbduction of the thighYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe quadriceps femoris is the great extensor muscle of the leg, forming a large fleshy mass that covers the front and sides of the femur. It is subdivided into separate portions, which have received distinctive names. One, occupying the middle of the thigh and connected above with the ilium, is called from its straight course the rectus femoris. The other three lie in immediate connection with the body of the femur, which they cover from the trochanters to the condyles. The portion on the lateral side of the femur is the vastus lateralis; that covering the medial side, the vastus medialis; and that in front, the vastus intermedius.123A 21-year-old football player is brought to A&E following a tackle resulting in a valgus force being applied to the right knee as he was passing the ball. He is unable to weight bear and his knee is tense and swollen with a grade 3 effusion which developed over the first 12 hours. The knee is locked. On examination he has medial joint line tenderness but no lateral tenderness, there is good integrity on varus stress testing, but significant opening of the joint on valgus stress test. Lachman and posterior draw tests are normal.Which structure is most likely to have been injured?ACLLateral collateral ligamentLateral MeniscusMedial collateral ligament?? YOUR ANSWERPCLYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The AnswerA valgus stress applied to a fixed knee is most likely to damage 3 structures, the ACL, MCL and medial meniscus, with a non-fixed knee, e.g when the foot is kicking the ball to pass, the ACL is less likely to be injured. In the scenario in the question the medial meniscus is likely to have torn with a bucket handle tear giving the painful locked knee, the MCL is attached to the medial meniscus and is stressed on valgus stretch test which was the only abnormal finding, therefore the medial collateral ligament is most likely to be injured. The varus stress test tests the LCL. Lachmans test and the anterior drawer test test the ACL. The posterior drawer test tests the PCL.124A 35-year-old man was referred with left foot pain after falling from his bike; he has since developed flat foot deformity.Which ligament is likely to have been disrupted in his injury?The anterior talofibular ligamentThe calcaneonavicular (spring) ligament?? YOUR ANSWERThe capsular ligaments in front of and behind the ankle joint, which are weakThe deltoid ligament which is attached to the medial malleolusThe syndesmotic ligaments complexYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe ability of the medial longitudinal arch to prevent flatfoot deformity depends on the dynamic support of the posterior tibial tendon, the static support of ligaments and capsule (including the Spring ligament), and the manner in which the tarsal bones interlock. The ankle (tibiotalar) joint is a hinge joint. As with most hinge joints there is strong support at the sides but not in front and behind. The deltoid ligament is attached above to the medial malleolus and fans out to attach below, mainly on the talus, but also on the calcaneus. On the lateral side there are three smaller ligaments (anterior and posterior talofibular ligaments and calcaneofibular ligament). The ankle joint is most stable in dorsiflexion. The intermalleolar distance increases in dorsiflexion due to the increased width of the anterior part of the talus bone.125A young patient is tilting her pelvis while walking.Which clinical test is used to assess the hip abductors?Barlow’s testOber testOrtolani testThomas testTrendelenburg test?? YOUR ANSWERYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionTrendelenburg test: This test is performed with the patient standing. The patient is asked to raise one leg; the test is positive if the hip on the raised side drops. A positive test suggests weakness of the abductors of the other hip. Ober's tests for tight iliotibial band. The Thomas test, is for tight hip flexors. Barlow and Ortolani tests can be used in combination at birth and can elicit a dislocated hip, assess its reducibility and diagnose an unstable hip which is dislocatable.126A 46-year-old female presents with lipodermatosclerosis, haemosiderosis and an ulcer on the medial aspect of the left calf. She is diagnosed with venous insufficiency and undergoes surgery.What is the surface anatomical location of the saphenofemoral junction?1cm medial to the femoral pulse2cm inferior to mid-inguinal point?? YOUR ANSWER2cm inferior to the mid point of the inguinal ligament2cm lateral and inferior to the pubic tubercle4cm lateral and inferior to the pubic tubercle?? CORRECT ANSWERYOUR ANSWER WAS INCORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe saphenofemoral junction occurs 4cm lateral and inferior to the pubic tubercle. The long saphenous vein passes through the fascia lata to confluence with the femoral vein.127What is the commonest pathological cause of the limping child aged 4 – 8 years?Congenital dislocation of the hip (CDH)Juvenile Idiopathic Arthritis (JIA)LeukaemiaPerthes disease?? YOUR ANSWERSlipped upper femoral epiphysis (SUFE)YOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionLimp is defined by a deviation from the normal gait pattern expected for a child's age.Hip disorders that cause limping in the child are often seen in well-defined age groups, and age can be used as a starting point in differential diagnosis:?birth – congenital dislocation of the hip (CDH);?4–8 years – Perthes disease;?10–20 years slipped upper femoral epiphysis (SUFE).Perthes disease is a condition in which avascular necrosis of the femoral head occurs. The incidence is approximately 1:10 000, the male to female ratio is 4:1. It presents between the ages of 4 and 8 years with a limp. The characteristic X-ray appearances may not become evident for up to three months after initial presentation.?Congenital dislocation of the hip has an incidence of approximately 5–20 in 1000 live births, falling to roughly 1–2 per 1000 infants 3 weeks later due to spontaneous stabilisation. It is more common in girls. It usually presents in the first three years of life, although most cases are now diagnosed on antenatal screening.?Slipped upper femoral epiphysis presents between the ages of 10 and 16 years and is more common in boys than girls.JIA is the classification for autoimmune arthritis in childhood replacing juvenile chronic/rheumatoid arthritis' and Still disease. Those affected are usually very young children, or older boys (aged 9 years upwards).128Of the spectrum of deformities associated with Pes Cavus, which of these is caused by compensatory use of the extensor digitorum to dorsiflex the ankle?CallusesClawing of the Toes?? YOUR ANSWERContracture of the Plantar FasciaIncreased Calcaneal AngleMetatarsalgiaYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionPes cavus is a high arch of the foot that does not flatten with weight bearing.The etiology of pes cavus can be identified approximately 80% of the time. The causes include malunion of calcaneal or talar fractures, burns, sequelae resulting from compartment syndrome, residual clubfoot, and neuromuscular disease. The remaining 20% of cases are idiopathic and nonprogressive. Identifying the etiology is essential to determine if the deformity is progressive, which assists in operative planning. All of these deformities above occur in Pes Cavus, however clawing of the toes occurs when the intrinsic muscles develop contractures and the long extensor to the toes (extensor digitorum), recruited to assist in ankle dorsiflexion, causes claw toe deformity due to a change in its axis of pull.129A 24-year-old footballer presents with a swollen painful knee. On examination he is noted to have significant joint effusion and a positive Lachman test.Which component of the knee joint has been injured?Anterior cruciate ligament?? YOUR ANSWERLateral collateral ligamentMedial collateral ligamentPatellar tendonPosterior cruciate ligamentYOUR ANSWER WAS CORRECT HYPERLINK "; \l "1" The Answer HYPERLINK "; \l "3" Comment on this QuestionThe anterior cruciate ligament provides stability to the knee joint. High impact sports that involve rapid changes of direction or direct lower limb trauma are often associated with injuries to the ligament. It originates from the lateral femoral condyle to insert into the intercondyloidtibial eminence. Lachman’s test requires the knee to be slightly flexed, and is positive when the tibia can be pulled abnormally anteriorly from a fixed femur. ................
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