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  • Question 1 - A 26-year-old male comes to the emergency department after sustaining a foot injury...

    Incorrect

    • A 26-year-old male comes to the emergency department after sustaining a foot injury from a sliding tackle while playing soccer. He is a healthy young man with no notable medical history and is a non-smoker.

      During the examination, it is observed that he has lost sensation in the posterolateral leg and lateral foot.

      Which nerve is most likely to have been damaged?

      Your Answer: Saphenous nerve

      Correct Answer: Sural nerve

      Explanation:

      The sural nerve provides sensory innervation to the posterolateral leg and lateral foot, while the saphenous nerve innervates the medial aspect of the leg and foot. The lateral femoral cutaneous nerve supplies the lateral thigh.

      Cutaneous Sensation in the Foot

      Cutaneous sensation in the foot is the ability to feel touch, pressure, temperature, and pain on the skin of the foot. Different regions of the foot are innervated by different nerves, which are responsible for transmitting sensory information to the brain. The lateral plantar region is innervated by the sural nerve, while the dorsum (excluding the 1st web space) is innervated by the superficial peroneal nerve. The 1st web space is innervated by the deep peroneal nerve, and the extremities of the toes are innervated by the medial and lateral plantar nerves. The proximal plantar region is innervated by the tibial nerve, while the medial plantar region is innervated by the medial plantar nerve and the lateral plantar region is innervated by the lateral plantar nerve. Understanding the innervation of the foot is important for diagnosing and treating conditions that affect cutaneous sensation in this area.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
      34
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  • Question 2 - A 16-year-old soccer player injures her ankle while playing a game. She reports...

    Incorrect

    • A 16-year-old soccer player injures her ankle while playing a game. She reports that her ankle turned inward, causing her foot to roll inward, and she experienced immediate pain and swelling.

      What ligament is the most probable to have been sprained in this scenario?

      Your Answer: LisFranc ligament

      Correct Answer: Anterior talofibular ligament

      Explanation:

      The most frequently sprained ligament in ankle inversion injuries is the anterior talofibular ligament, which runs from the talus to the fibula and restricts inversion in plantar flexion. The calcaneonavicular ligament, located between the calcaneus and navicular bones, stabilizes the medial longitudinal arch and is not involved in resisting inversion or eversion, making it unlikely to be injured. The deltoid ligament, found on the medial side of the ankle, resists eversion and is therefore not typically affected in inversion injuries. The interosseous ligament, located between the tibia and fibula above the ankle joint, is only impacted if there is trauma to the lower leg. The Lisfranc ligament, which connects the second metatarsal to the medial cuneiform, is more commonly disrupted by direct blows or axial loads on a plantarflexed foot with rotation, whereas a simple sprain to the anterior talofibular ligament is more common in inversion injuries.

      Ankle Sprains: Types, Presentation, Investigation, and Treatment

      Ankle sprains occur when ligaments in the ankle are stretched or torn. The ankle joint is composed of the distal tibia and fibula and the superior aspect of the talus, which form a mortise secured by ligamentous structures. Low ankle sprains involve the lateral collateral ligaments, with the anterior inferior tibiofibular ligament being the most commonly injured. Inversion injury is the most common mechanism, causing pain, swelling, tenderness, and sometimes bruising. Low ankle sprains are classified into three grades based on the extent of ligament disruption, bruising and swelling, and pain on weight-bearing. Radiographs should be done to rule out associated fractures, and MRI may be useful for evaluating perineal tendons. Treatment for low ankle sprains involves rest, ice, compression, and elevation, with occasional use of a removable orthosis, cast, or crutches. Surgical intervention is rare.

      High ankle sprains involve the syndesmosis, which is rare and severe. The mechanism of injury is usually external rotation of the foot, causing the talus to push the fibula laterally. Patients experience more pain when weight-bearing than with low ankle sprains. Radiographs may show widening of the tibiofibular joint or ankle mortise, and MRI may be necessary for high suspicion of syndesmotic injury. Treatment for high ankle sprains involves non-weight-bearing orthosis or cast until pain subsides, or operative fixation if there is diastasis or failed non-operative management.

      Isolated injuries to the deltoid ligament are rare and frequently associated with a fracture, such as Maisonneuve fracture of the proximal fibula. Treatment for deltoid ligament injuries is similar to that for low ankle sprains, provided the ankle mortise is anatomically reduced. If not, reduction and fixation may be necessary.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
      29.5
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  • Question 3 - Which of the following structures separates the posterior cruciate ligament from the popliteal...

    Incorrect

    • Which of the following structures separates the posterior cruciate ligament from the popliteal artery?

      Your Answer: Semitendinosus

      Correct Answer: Oblique popliteal ligament

      Explanation:

      The oblique popliteal ligament separates the origin of the posterior cruciate ligament from the popliteal vessels, while the transverse ligament is situated in front.

      The knee joint is the largest and most complex synovial joint in the body, consisting of two condylar joints between the femur and tibia and a sellar joint between the patella and femur. The degree of congruence between the tibiofemoral articular surfaces is improved by the presence of the menisci, which compensate for the incongruence of the femoral and tibial condyles. The knee joint is divided into two compartments: the tibiofemoral and patellofemoral compartments. The fibrous capsule of the knee joint is a composite structure with contributions from adjacent tendons, and it contains several bursae and ligaments that provide stability to the joint. The knee joint is supplied by the femoral, tibial, and common peroneal divisions of the sciatic nerve and by a branch from the obturator nerve, while its blood supply comes from the genicular branches of the femoral artery, popliteal, and anterior tibial arteries.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
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  • Question 4 - A 12-year-old boy presents to the orthopaedic clinic with complaints of right knee...

    Incorrect

    • A 12-year-old boy presents to the orthopaedic clinic with complaints of right knee pain. He has been experiencing pain for the past 4 months, which usually lasts for a few hours. During examination, he displays an antalgic gait and appears to have a shortened right leg. While the right knee appears normal, he experiences pain on internal and external rotation of the right hip. Imaging reveals flattening of the femoral head. What is the most probable underlying diagnosis?

      Your Answer: Child abuse

      Correct Answer: Perthes disease

      Explanation:

      Understanding Perthes’ Disease

      Perthes’ disease is a condition that affects the hip joints of children between the ages of 4-8 years. It is caused by a lack of blood supply to the femoral head, leading to bone infarction and degeneration. Boys are five times more likely to develop this condition, and around 10% of cases are bilateral. Symptoms include hip pain, limping, stiffness, and reduced range of hip movement. Early changes can be seen on x-rays, such as widening of the joint space, while later changes include decreased femoral head size and flattening.

      Diagnosis is typically made through a plain x-ray, but a technetium bone scan or magnetic resonance imaging may be necessary if symptoms persist despite a normal x-ray. Complications of Perthes’ disease can include osteoarthritis and premature fusion of the growth plates.

      The Catterall staging system is used to classify the severity of the disease, with Stage 1 being the mildest and Stage 4 being the most severe. Management options include casting or bracing to keep the femoral head within the acetabulum, observation for children under 6 years old, and surgical intervention for severe deformities in older children.

      Overall, most cases of Perthes’ disease will resolve with conservative management, and early diagnosis can improve outcomes. It is important for parents and healthcare providers to be aware of the symptoms and seek medical attention if they suspect a child may be affected by this condition.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
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  • Question 5 - A 35-year-old woman arrives at the emergency department complaining of worsening bone pain...

    Correct

    • A 35-year-old woman arrives at the emergency department complaining of worsening bone pain in her left hip over the past few days. She mentions feeling ill and feverish, but attributes it to a recent cold. The patient is a known IV drug user and has not traveled recently.

      During the examination, the left hip appears red and tender, and multiple track marks are visible.

      Which organism is most likely responsible for her symptoms?

      Your Answer: Staphylococcus aureus

      Explanation:

      Osteomyelitis is most commonly caused by Staphylococcus aureus in both adults and children. IV drug use is a known risk factor for this condition as it can introduce microorganisms directly into the bloodstream. While Escherichia coli can also cause osteomyelitis, it is more prevalent in children than adults. Mycobacterium tuberculosis can also lead to osteomyelitis, but it is less common than Staphylococcus aureus. Bone introduction typically occurs via the circulatory system from pulmonary tuberculosis. However, antitubercular therapy has reduced the incidence of tuberculosis, making bone introduction less likely than with Staphylococcus aureus, which is part of the normal skin flora. Salmonella enterica is the most common cause of osteomyelitis in individuals with sickle cell disease. As the patient is not known to have sickle cell, Staphylococcus aureus remains the most probable cause.

      Understanding Osteomyelitis: Types, Causes, and Treatment

      Osteomyelitis is a bone infection that can be classified into two types: haematogenous and non-haematogenous. Haematogenous osteomyelitis is caused by bacteria in the bloodstream and is usually monomicrobial. It is more common in children and can be caused by risk factors such as sickle cell anaemia, intravenous drug use, immunosuppression, and infective endocarditis. On the other hand, non-haematogenous osteomyelitis is caused by the spread of infection from adjacent soft tissues or direct injury to the bone. It is often polymicrobial and more common in adults, with risk factors such as diabetic foot ulcers, pressure sores, diabetes mellitus, and peripheral arterial disease.

      Staphylococcus aureus is the most common cause of osteomyelitis, except in patients with sickle-cell anaemia where Salmonella species are more prevalent. To diagnose osteomyelitis, MRI is the imaging modality of choice, with a sensitivity of 90-100%.

      The treatment for osteomyelitis involves a course of antibiotics for six weeks. Flucloxacillin is the preferred antibiotic, but clindamycin can be used for patients who are allergic to penicillin. Understanding the types, causes, and treatment of osteomyelitis is crucial in managing this bone infection.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
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  • Question 6 - A 50-year-old obese female with twice-yearly flares of ulcerative colitis has presented to...

    Correct

    • A 50-year-old obese female with twice-yearly flares of ulcerative colitis has presented to the gastroenterology department with flare. She was previously being managed well with steroids. After doing the thiopurine methyltransferase (TPMT) test she is started on a medication. A complete blood count done after a month of starting treatment shows:

      Hb 112 g/L Male: (135-180)
      Female: (115 - 160)
      Platelets 68 * 109/L (150 - 400)
      WBC 25 * 109/L (4.0 - 11.0)

      What is the active compound that the drug being used in the treatment of this patient's condition is metabolized to?

      Your Answer: Mercaptopurine

      Explanation:

      Azathioprine is utilized for treating Crohn’s disease in this patient, and it is likely that the drug is metabolized into mercaptopurine, an active compound that acts as a purine analogue and inhibits purine synthesis.

      In the purine catabolism pathway, inosine is produced when AMP is deaminated by adenylate (AMP) deaminase to form IMP. Inosine is then formed by hydrolysis of IMP with nucleotidase.

      Hypoxanthine is also produced in the purine catabolism pathway through the phosphorylation of inosine. Xanthine is formed when hypoxanthine is oxidized by xanthine oxidase.

      The answer purine is incorrect because azathioprine does not convert into purines, but rather it inhibits their synthesis.

      Azathioprine is a medication that is converted into mercaptopurine, which is an active compound that inhibits the production of purine. To determine if someone is at risk for azathioprine toxicity, a test for thiopurine methyltransferase (TPMT) may be necessary. Adverse effects of this medication include bone marrow depression, nausea and vomiting, pancreatitis, and an increased risk of non-melanoma skin cancer. If infection or bleeding occurs, a full blood count should be considered. It is important to note that there may be a significant interaction between azathioprine and allopurinol, so lower doses of azathioprine should be used. However, azathioprine is generally considered safe to use during pregnancy.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
      36.3
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  • Question 7 - A 27-year-old man presents to the Emergency Department following a car accident. He...

    Correct

    • A 27-year-old man presents to the Emergency Department following a car accident. He has no visible wounds or head trauma, but he is experiencing left lower limb pain and is unable to walk. Upon examination, he displays a high stepping gait and there is swelling and deformity below the knee. An X-ray confirms a fractured neck of the fibula.

      Which function is most likely impacted in this patient?

      Your Answer: Dorsiflexion of foot

      Explanation:

      A fibular neck fracture can result in foot drop due to common peroneal nerve injury. The nerve is often injured because it winds around the neck of the fibula. The common peroneal nerve is responsible for dorsiflexion of the foot, and an injury to this nerve can cause foot drop, which is characterized by a high stepping gait. In foot drop, the foot appears floppy, and the toes point downward, scraping the ground while walking. The patient tends to lift their foot very high to avoid dragging it on the ground. Eversion of the foot is not the correct answer, as it is controlled by the superficial peroneal nerve. Flexion of toes is also an incorrect answer, as it is controlled by the medial plantar nerve.

      Lower limb anatomy is an important topic that often appears in examinations. One aspect of this topic is the nerves that control motor and sensory functions in the lower limb. The femoral nerve controls knee extension and thigh flexion, and provides sensation to the anterior and medial aspect of the thigh and lower leg. It is commonly injured in cases of hip and pelvic fractures, as well as stab or gunshot wounds. The obturator nerve controls thigh adduction and provides sensation to the medial thigh. It can be injured in cases of anterior hip dislocation. The lateral cutaneous nerve of the thigh provides sensory function to the lateral and posterior surfaces of the thigh, and can be compressed near the ASIS, resulting in a condition called meralgia paraesthetica. The tibial nerve controls foot plantarflexion and inversion, and provides sensation to the sole of the foot. It is not commonly injured as it is deep and well protected, but can be affected by popliteal lacerations or posterior knee dislocation. The common peroneal nerve controls foot dorsiflexion and eversion, and can be injured at the neck of the fibula, resulting in foot drop. The superior gluteal nerve controls hip abduction and can be injured in cases of misplaced intramuscular injection, hip surgery, pelvic fracture, or posterior hip dislocation. Injury to this nerve can result in a positive Trendelenburg sign. The inferior gluteal nerve controls hip extension and lateral rotation, and is generally injured in association with the sciatic nerve. Injury to this nerve can result in difficulty rising from a seated position, as well as difficulty jumping or climbing stairs.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
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  • Question 8 - A 73-year-old male slips on ice and falls, resulting in a right intertrochanteric...

    Incorrect

    • A 73-year-old male slips on ice and falls, resulting in a right intertrochanteric hip fracture. Due to his cardiac comorbidities, the anesthesiologist opts for a spinal anaesthetic over general anaesthesia. Can you list the anatomical order in which the needle passes to reach cerebrospinal fluid?

      Your Answer: Skin -> supraspinous ligament -> ligamentum flavum -> interspinous ligament -> subdural space -> epidural space -> subarachnoid space

      Correct Answer: Skin -> supraspinous ligament -> interspinous ligament -> ligamentum flavum -> epidural space -> subdural space -> subarachnoid space

      Explanation:

      To reach the cerebrospinal fluid in the subarachnoid space during a mid-line approach to a spinal anaesthetic, the needle must pass through three ligaments and two meningeal layers. These include the supraspinatus ligament, interspinous ligament, ligamentum flavum, epidural space, subdural space, and subarachnoid space. Local anaesthetics, such as bupivacaine with or without opioids, are injected into the CSF to block Na+ channels and inhibit the action potential. This can reduce surgical stress and sympathetic stimulation in high-risk patients, but may also lead to vasodilation and hypotension. Spinal anaesthesia may be contraindicated in patients with coagulopathy, severe hypovolemia, increased intracranial pressure, severe aortic or mitral stenosis, or infection over the overlying skin.

      Anatomy of the Vertebral Column

      The vertebral column is composed of 33 vertebrae, which are divided into four regions: cervical, thoracic, lumbar, and sacral. The cervical region has seven vertebrae, the thoracic region has twelve, the lumbar region has five, and the sacral region has five. However, the spinal cord segmental levels do not always correspond to the vertebral segments. For example, the C8 cord is located at the C7 vertebrae, and the T12 cord is situated at the T8 vertebrae.

      The cervical vertebrae are located in the neck and are responsible for controlling the muscles of the upper extremities. The C3 cord contains the phrenic nucleus, which controls the diaphragm. The thoracic vertebrae are defined by those that have a rib and control the intercostal muscles and associated dermatomes. The lumbosacral vertebrae are located in the lower back and control the hip and leg muscles, as well as the buttocks and anal regions.

      The spinal cord ends at the L1-L2 vertebral level, and below this level is a spray of spinal roots called the cauda equina. Injuries below L2 represent injuries to spinal roots rather than the spinal cord proper. Understanding the anatomy of the vertebral column is essential for diagnosing and treating spinal cord injuries and other related conditions.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
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  • Question 9 - A 32-year-old male patient visits his GP with a complaint of progressive weakness...

    Incorrect

    • A 32-year-old male patient visits his GP with a complaint of progressive weakness in his right arm for the past 3 months. He reports that he suffered a humerus fracture after a fall and has since experienced difficulty in straightening his arm, especially against resistance. Upon examination, his sensation is normal, but he exhibits significantly reduced extension in his forearm, wrist, and fingers.

      Which nerve is the most probable cause of the injury?

      Your Answer: Median nerve

      Correct Answer: Radial nerve

      Explanation:

      The radial nerve supplies all the extensor muscles in the arm, and a recent humerus fracture in this patient may have caused damage to this nerve. Midshaft humeral fractures can put the radial nerve at risk as it travels down the arm in the radial groove on the surface of the humerus.

      In contrast, the axillary nerve is most commonly damaged in humeral head dislocations or fractures of the humeral neck, resulting in weakened shoulder abduction or reduced sensation in the inferior region of the deltoid muscle.

      The median nerve is typically affected at the wrist and is commonly injured in carpal tunnel syndrome. Symptoms of median nerve damage include weakened pronation (if injured at the elbow), paralysis of the thenar muscles (if injured at the wrist), or loss of sensation over the palmar aspect of the lateral 3½ fingers.

      Damage to the musculocutaneous nerve is rare and usually occurs as part of a larger injury to the brachial plexus. Symptoms of musculocutaneous nerve damage include weakened elbow flexion or loss of sensation to the lateral part of the forearm.

      Finally, a medial epicondyle fracture can damage the ulnar nerve, resulting in weakness of the majority of the intrinsic hand muscles or loss of sensation to the medial 1½ fingers.

      Upper limb anatomy is a common topic in examinations, and it is important to know certain facts about the nerves and muscles involved. The musculocutaneous nerve is responsible for elbow flexion and supination, and typically only injured as part of a brachial plexus injury. The axillary nerve controls shoulder abduction and can be damaged in cases of humeral neck fracture or dislocation, resulting in a flattened deltoid. The radial nerve is responsible for extension in the forearm, wrist, fingers, and thumb, and can be damaged in cases of humeral midshaft fracture, resulting in wrist drop. The median nerve controls the LOAF muscles and can be damaged in cases of carpal tunnel syndrome or elbow injury. The ulnar nerve controls wrist flexion and can be damaged in cases of medial epicondyle fracture, resulting in a claw hand. The long thoracic nerve controls the serratus anterior and can be damaged during sports or as a complication of mastectomy, resulting in a winged scapula. The brachial plexus can also be damaged, resulting in Erb-Duchenne palsy or Klumpke injury, which can cause the arm to hang by the side and be internally rotated or associated with Horner’s syndrome, respectively.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
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  • Question 10 - A 38-year-old woman has made the decision to have a thyroidectomy for her...

    Incorrect

    • A 38-year-old woman has made the decision to have a thyroidectomy for her Graves' disease. During the procedure, one of the blood vessels supplying the thyroid gland, the superior thyroid artery, will be ligated.

      What is the correct description of the superior thyroid artery?

      Your Answer: A branch of the thyrocervical trunk that supplies the anterior portions of the thyroid gland

      Correct Answer: A branch of the external carotid artery that supplies the superior portion of the thyroid gland

      Explanation:

      The superior thyroid artery is the initial branch of the external carotid artery and is responsible for supplying the upper pole of the thyroid gland. It descends towards the gland after arising and generally provides blood to the superior and anterior regions. On the other hand, the inferior thyroid artery originates from the thyrocervical trunk, which is a branch of the subclavian artery. It travels in a superomedial direction to reach the inferior pole of the thyroid and typically supplies the postero-inferior aspect.

      Anatomy of the Thyroid Gland

      The thyroid gland is a butterfly-shaped gland located in the neck, consisting of two lobes connected by an isthmus. It is surrounded by a sheath from the pretracheal layer of deep fascia and is situated between the base of the tongue and the fourth and fifth tracheal rings. The apex of the thyroid gland is located at the lamina of the thyroid cartilage, while the base is situated at the fourth and fifth tracheal rings. In some individuals, a pyramidal lobe may extend from the isthmus and attach to the foramen caecum at the base of the tongue.

      The thyroid gland is surrounded by various structures, including the sternothyroid, superior belly of omohyoid, sternohyoid, and anterior aspect of sternocleidomastoid muscles. It is also related to the carotid sheath, larynx, trachea, pharynx, oesophagus, cricothyroid muscle, and parathyroid glands. The superior and inferior thyroid arteries supply the thyroid gland with blood, while the superior and middle thyroid veins drain into the internal jugular vein, and the inferior thyroid vein drains into the brachiocephalic veins.

      In summary, the thyroid gland is a vital gland located in the neck, responsible for producing hormones that regulate metabolism. Its anatomy is complex, and it is surrounded by various structures that are essential for its function. Understanding the anatomy of the thyroid gland is crucial for the diagnosis and treatment of thyroid disorders.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
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  • Question 11 - A 78-year-old man presents with symptoms of claudication. It is decided to assess...

    Incorrect

    • A 78-year-old man presents with symptoms of claudication. It is decided to assess his ankle brachial pressure index. Using a handheld doppler device, the signal from the dorsalis pedis artery is detected. Which vessel does this artery continue from?

      Your Answer: Popliteal artery

      Correct Answer: Anterior tibial artery

      Explanation:

      The anterior tibial artery continues as the dorsalis pedis.

      The foot has two arches: the longitudinal arch and the transverse arch. The longitudinal arch is higher on the medial side and is supported by the posterior pillar of the calcaneum and the anterior pillar composed of the navicular bone, three cuneiforms, and the medial three metatarsal bones. The transverse arch is located on the anterior part of the tarsus and the posterior part of the metatarsus. The foot has several intertarsal joints, including the sub talar joint, talocalcaneonavicular joint, calcaneocuboid joint, transverse tarsal joint, cuneonavicular joint, intercuneiform joints, and cuneocuboid joint. The foot also has various ligaments, including those of the ankle joint and foot. The foot is innervated by the lateral plantar nerve and medial plantar nerve, and it receives blood supply from the plantar arteries and dorsalis pedis artery. The foot has several muscles, including the abductor hallucis, flexor digitorum brevis, abductor digit minimi, flexor hallucis brevis, adductor hallucis, and extensor digitorum brevis.

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      • Musculoskeletal System And Skin
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  • Question 12 - Which of the following poses the lowest risk of developing osteoporosis for individuals...

    Incorrect

    • Which of the following poses the lowest risk of developing osteoporosis for individuals in their 20s?

      Your Answer: Long term unfractionated heparin therapy

      Correct Answer: Obesity

      Explanation:

      Osteoporosis is more likely to occur in individuals with low body weight.

      Osteoporosis is a condition that is more prevalent in women and increases with age. However, there are many other risk factors and secondary causes of osteoporosis. Some of the most significant risk factors include a history of glucocorticoid use, rheumatoid arthritis, alcohol excess, parental hip fracture history, low body mass index, and current smoking. Other risk factors include a sedentary lifestyle, premature menopause, certain ethnicities, endocrine disorders, gastrointestinal disorders, chronic kidney disease, and certain genetic disorders. Additionally, certain medications such as SSRIs, antiepileptics, and proton pump inhibitors may worsen osteoporosis.

      If a patient is diagnosed with osteoporosis or has a fragility fracture, further investigations may be necessary to identify the cause of osteoporosis and assess the risk of subsequent fractures. Recommended investigations include a history and physical examination, blood tests such as a full blood count, urea and electrolytes, liver function tests, bone profile, CRP, and thyroid function tests. Other procedures may include bone densitometry, lateral radiographs, protein immunoelectrophoresis, and urinary Bence-Jones proteins. Additionally, markers of bone turnover and urinary calcium excretion may be assessed. By identifying the cause of osteoporosis and contributory factors, healthcare providers can select the most appropriate form of treatment.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
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  • Question 13 - A 12-year-old boy with sickle cell anaemia arrives at the emergency department with...

    Incorrect

    • A 12-year-old boy with sickle cell anaemia arrives at the emergency department with a hot, swollen, erythematous and painful knee. The symptoms developed over a few hours and he is unable to bear weight on the affected leg. Upon joint aspiration, cloudy synovial fluid with neutrophilia is observed. What is the primary mode of transmission for this condition?

      Your Answer: Respiratory droplets

      Correct Answer: Hematogenous spread

      Explanation:

      Septic arthritis is often characterized by sudden joint pain, swelling, and warmth, and is typically caused by hematogenous spread of bacteria. Staphylococcus aureus is the most common causative organism, except in individuals with sickle cell anemia, where Salmonella is more common. While direct introduction or extension from a nearby infection can also cause septic arthritis, hematogenous spread is the most frequent cause. Unlike respiratory diseases, septic arthritis is not spread through respiratory droplets. In sexually active patients, gonococcal arthritis caused by Neisseria gonorrhoeae should be considered as a potential cause.

      Septic Arthritis in Adults: Causes, Symptoms, and Treatment

      Septic arthritis is a condition that occurs when bacteria infect a joint, leading to inflammation and swelling. The most common organism that causes septic arthritis in adults is Staphylococcus aureus, while Neisseria gonorrhoeae is the most common organism in sexually active young adults. The infection is usually spread through the bloodstream, often from distant bacterial infections such as abscesses. The knee is the most commonly affected joint in adults.

      Symptoms of septic arthritis include acute joint swelling, restricted movement, warmth to the touch, and fever. To diagnose the condition, synovial fluid sampling is necessary and should be done before administering antibiotics if needed. Blood cultures and joint imaging may also be necessary.

      Treatment for septic arthritis involves intravenous antibiotics that cover Gram-positive cocci, such as flucloxacillin or clindamycin if the patient is allergic to penicillin. Antibiotics are typically given for several weeks, and patients may be switched to oral antibiotics after two weeks. Needle aspiration is used to decompress the joint, and arthroscopic lavage may be required. Overall, prompt diagnosis and treatment are essential to prevent joint damage and other complications.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
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  • Question 14 - A 33-year-old female visits her doctor complaining of a red rash on her...

    Incorrect

    • A 33-year-old female visits her doctor complaining of a red rash on her hands. She first noticed the rash a few weeks ago after moving into her new apartment with her partner. However, in the past few days, the rash has become extremely itchy and is keeping her up at night. Despite using her regular moisturizer cream, the rash has not improved. Upon examination, the doctor observes a bilateral erythematous rash on both hands that extends into the interdigital spaces, with multiple excoriation marks. The rash is not present anywhere else, and there are no other significant findings.

      What is the likely diagnosis, and what is the underlying mechanism behind this patient's presentation?

      Your Answer: Allergic reaction to moisturiser

      Correct Answer: Delayed-type IV hypersensitivity reaction

      Explanation:

      The severe itching caused by scabies is a result of a delayed-type IV hypersensitivity reaction to the mites and their eggs, which occurs around 30 days after infestation. This type of reaction involves T-cells and antigen-presenting cells, leading to an inflammatory response. Scabies is typically spread through close skin-to-skin contact with an infected person. An allergic reaction to the patient’s regular moisturizer would be a type I hypersensitivity reaction, which causes acute itching. Antigen-antibody complex deposition in the epidermis would be a type III hypersensitivity reaction, while psoriasis is caused by hyperproliferation of epidermal keratinocytes and presents with red, scaly patches on extensor surfaces. Bacterial skin infections like cellulitis cause warm, swollen, and red skin with systemic symptoms like fever.

      Scabies: Causes, Symptoms, and Treatment

      Scabies is a skin condition caused by the mite Sarcoptes scabiei, which is spread through prolonged skin contact. It is most commonly seen in children and young adults. The mite burrows into the skin, laying its eggs in the outermost layer. The resulting intense itching is due to a delayed hypersensitivity reaction to the mites and eggs, which occurs about a month after infection. Symptoms include widespread itching, linear burrows on the fingers and wrists, and secondary features such as excoriation and infection.

      The first-line treatment for scabies is permethrin 5%, followed by malathion 0.5% if necessary. Patients should be advised to avoid close physical contact until treatment is complete and to treat all household and close contacts, even if asymptomatic. Clothing, bedding, and towels should be laundered, ironed, or tumble-dried on the first day of treatment to kill off mites. The insecticide should be applied to all areas, including the face and scalp, and left on for 8-12 hours for permethrin or 24 hours for malathion before washing off. Treatment should be repeated after 7 days.

      Crusted scabies, also known as Norwegian scabies, is a severe form of the condition seen in patients with suppressed immunity, particularly those with HIV. The skin is covered in hundreds of thousands of mites, and isolation is essential. Ivermectin is the treatment of choice.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
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  • Question 15 - A 23-year-old individual presents to the emergency department with a gym-related injury. While...

    Incorrect

    • A 23-year-old individual presents to the emergency department with a gym-related injury. While lifting a heavy barbell off the floor, they experienced a hamstring pull. Upon examination, the doctor notes weak knee flexion facilitated by the biceps femoris muscle. The doctor suspects nerve damage to the nerves innervating the short and long head of biceps femoris. Which nerve specifically provides innervation to the short head of biceps femoris?

      Your Answer: Superior gluteal nerve

      Correct Answer: Common peroneal branch of sciatic nerve

      Explanation:

      The short head of biceps femoris receives innervation from the common peroneal division of the sciatic nerve. The superior gluteal nerve supplies the gluteus medius and minimus, while the inferior gluteal nerve supplies the gluteus maximus. The perineum is primarily supplied by the pudendal nerve.

      The Biceps Femoris Muscle

      The biceps femoris is a muscle located in the posterior upper thigh and is part of the hamstring group of muscles. It consists of two heads: the long head and the short head. The long head originates from the ischial tuberosity and inserts into the fibular head. Its actions include knee flexion, lateral rotation of the tibia, and extension of the hip. It is innervated by the tibial division of the sciatic nerve and supplied by the profunda femoris artery, inferior gluteal artery, and the superior muscular branches of the popliteal artery.

      On the other hand, the short head originates from the lateral lip of the linea aspera and the lateral supracondylar ridge of the femur. It also inserts into the fibular head and is responsible for knee flexion and lateral rotation of the tibia. It is innervated by the common peroneal division of the sciatic nerve and supplied by the same arteries as the long head.

      Understanding the anatomy and function of the biceps femoris muscle is important in the diagnosis and treatment of injuries and conditions affecting the posterior thigh.

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      • Musculoskeletal System And Skin
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  • Question 16 - A 30-year-old rower comes to your clinic complaining of a painful shoulder that...

    Incorrect

    • A 30-year-old rower comes to your clinic complaining of a painful shoulder that has been bothering him for the past two weeks. The pain is dull and comes and goes, mainly affecting the posterior and lateral parts of his shoulder. Heavy exercises such as weightlifting and rowing exacerbate the pain, so he has been avoiding these activities. During the examination, you notice tenderness on the posterior aspect of the shoulder, and there is some weakness on shoulder abduction. Quadrangular space syndrome is a rare possibility for this presentation. Which of the following is not a border of the quadrangular space?

      Your Answer: Teres major

      Correct Answer: Infraspinatus

      Explanation:

      The correct answer is infraspinatus, which is located superior to the quadrangular space. The quadrangular space is a passage for nerves and vessels between the anterior and posterior regions of the shoulder, bordered by the inferior border of teres major, the lateral border of the surgical neck of the humerus, the medial border of the lateral margin of the long head of triceps brachii, and the superior border of the inferior margin of teres minor. The axillary nerve and posterior circumflex artery pass through this space. Quadrangular space syndrome is a rare condition that involves compression of these structures, typically in young adults without trauma. Symptoms may include shoulder pain during resisted abduction and external rotation, as well as wasting of the deltoid muscle.

      The shoulder joint is a shallow synovial ball and socket joint that is inherently unstable but capable of a wide range of movement. Stability is provided by the muscles of the rotator cuff. The glenoid labrum is a fibrocartilaginous rim attached to the free edge of the glenoid cavity. The fibrous capsule attaches to the scapula, humerus, and tendons of various muscles. Movements of the shoulder joint are controlled by different muscles. The joint is closely related to important anatomical structures such as the brachial plexus, axillary artery and vein, and various nerves and vessels.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
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  • Question 17 - A 75-year-old man falls and injures his left hip. He is given paracetamol...

    Incorrect

    • A 75-year-old man falls and injures his left hip. He is given paracetamol by a junior doctor and sent home. After a few months, he returns with persistent pain and discomfort in the hip. The doctors suspect avascular necrosis of the femoral head. Which of the following features is least likely to be present?

      Your Answer:

      Correct Answer: Apoptosis of osteoblasts

      Explanation:

      Necrotic cell death does not involve apoptosis. Instead, the body typically attempts to repair the damage by promoting angiogenesis and the proliferation of fibroblasts. These cells may even differentiate into osteoblasts, which can then lay down new matrix.

      Avascular necrosis (AVN) is a condition where bone tissue dies due to a loss of blood supply, resulting in bone destruction and joint dysfunction. This commonly affects the femur’s epiphysis, which is a long bone. The causes of AVN include long-term steroid use, chemotherapy, alcohol excess, and trauma. Initially, AVN may not show any symptoms, but pain in the affected joint may develop over time. Plain x-rays may not show any abnormalities at first, but osteopenia and microfractures may be visible early on. The crescent sign may appear due to the collapse of the articular surface. MRI is the preferred diagnostic tool as it is more sensitive than radionuclide bone scanning. Joint replacement may be necessary for management.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
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  • Question 18 - Which of the following is not found in the deep posterior compartment of...

    Incorrect

    • Which of the following is not found in the deep posterior compartment of the lower leg?

      Your Answer:

      Correct Answer: Sural nerve

      Explanation:

      The deep posterior compartment is located in front of the soleus muscle, and the sural nerve is not enclosed within it due to its superficial position.

      Muscular Compartments of the Lower Limb

      The lower limb is composed of different muscular compartments that perform various actions. The anterior compartment includes the tibialis anterior, extensor digitorum longus, peroneus tertius, and extensor hallucis longus muscles. These muscles are innervated by the deep peroneal nerve and are responsible for dorsiflexing the ankle joint, inverting and evert the foot, and extending the toes.

      The peroneal compartment, on the other hand, consists of the peroneus longus and peroneus brevis muscles, which are innervated by the superficial peroneal nerve. These muscles are responsible for eversion of the foot and plantar flexion of the ankle joint.

      The superficial posterior compartment includes the gastrocnemius and soleus muscles, which are innervated by the tibial nerve. These muscles are responsible for plantar flexion of the foot and may also flex the knee.

      Lastly, the deep posterior compartment includes the flexor digitorum longus, flexor hallucis longus, and tibialis posterior muscles, which are innervated by the tibial nerve. These muscles are responsible for flexing the toes, flexing the great toe, and plantar flexion and inversion of the foot, respectively.

      Understanding the muscular compartments of the lower limb is important in diagnosing and treating injuries and conditions that affect these muscles. Proper identification and management of these conditions can help improve mobility and function of the lower limb.

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  • Question 19 - A 28-year-old male presents to the emergency department with a complaint of right...

    Incorrect

    • A 28-year-old male presents to the emergency department with a complaint of right arm pain. He reports that the pain started abruptly while lifting weights at the gym and that his arm feels weaker than usual.

      Upon performing an ultrasound of the upper arm, a distal biceps tendon tear is identified.

      Which specific movement is expected to be impacted by this injury?

      Your Answer:

      Correct Answer: Supination and elbow flexion

      Explanation:

      The biceps brachii is mainly responsible for supination and elbow flexion. If the tendon associated with this muscle is torn, it can affect these movements.

      External rotation is primarily performed by the infraspinatus and teres minor muscles, not the biceps brachii.

      The teres major muscle, not the biceps brachii, is responsible for internal rotation.

      Pronation is performed by the pronator quadratus and pronator teres muscles, while elbow flexion is performed by the triceps muscle. Therefore, these actions are not associated with the biceps brachii.

      Shoulder abduction involves muscles such as the supraspinatus and deltoid, but it does not involve the biceps brachii.

      Upper limb anatomy is a common topic in examinations, and it is important to know certain facts about the nerves and muscles involved. The musculocutaneous nerve is responsible for elbow flexion and supination, and typically only injured as part of a brachial plexus injury. The axillary nerve controls shoulder abduction and can be damaged in cases of humeral neck fracture or dislocation, resulting in a flattened deltoid. The radial nerve is responsible for extension in the forearm, wrist, fingers, and thumb, and can be damaged in cases of humeral midshaft fracture, resulting in wrist drop. The median nerve controls the LOAF muscles and can be damaged in cases of carpal tunnel syndrome or elbow injury. The ulnar nerve controls wrist flexion and can be damaged in cases of medial epicondyle fracture, resulting in a claw hand. The long thoracic nerve controls the serratus anterior and can be damaged during sports or as a complication of mastectomy, resulting in a winged scapula. The brachial plexus can also be damaged, resulting in Erb-Duchenne palsy or Klumpke injury, which can cause the arm to hang by the side and be internally rotated or associated with Horner’s syndrome, respectively.

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      • Musculoskeletal System And Skin
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  • Question 20 - Sarah, a 67-year-old female, fell down some stairs and fractured her left calcaneus....

    Incorrect

    • Sarah, a 67-year-old female, fell down some stairs and fractured her left calcaneus. Before starting the management, the doctors conducted a neurovascular examination of Sarah's lower limb and foot. They found that Sarah has palpable pulses, but she has reduced sensation in her lateral left foot. The doctor suspects that the fracture may have caused nerve damage, leading to the reduced sensation.

      What nerve could be affected by the fracture, resulting in the reduced sensation in Sarah's lateral left foot?

      Your Answer:

      Correct Answer: Sural nerve

      Explanation:

      The lateral foot is innervated by the sural nerve, which is a branch of both the common fibular and tibial nerves. The medial aspect of the leg is innervated by the saphenous nerve, which arises from the femoral nerve. The sole of the foot is mainly innervated by branches of the tibial nerve, including the medial calcaneal, lateral, and medial plantar nerves. The dorsum of the foot is mainly innervated by the superficial fibular nerve, while the web space between the first and second toes is innervated by the deep fibular nerve.

      Anatomy of the Lateral Malleolus

      The lateral malleolus is a bony prominence on the outer side of the ankle joint. Posterior to the lateral malleolus and superficial to the superior peroneal retinaculum are the sural nerve and short saphenous vein. These structures are important for sensation and blood flow to the lower leg and foot.

      On the other hand, posterior to the lateral malleolus and deep to the superior peroneal retinaculum are the peroneus longus and peroneus brevis tendons. These tendons are responsible for ankle stability and movement.

      Additionally, the calcaneofibular ligament is attached at the lateral malleolus. This ligament is important for maintaining the stability of the ankle joint and preventing excessive lateral movement.

      Understanding the anatomy of the lateral malleolus is crucial for diagnosing and treating ankle injuries and conditions. Proper care and management of these structures can help prevent long-term complications and improve overall ankle function.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
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  • Question 21 - In a confrontation, a 35-year-old woman was stabbed in the medial aspect of...

    Incorrect

    • In a confrontation, a 35-year-old woman was stabbed in the medial aspect of her left thigh. Upon examination, there is a noticeable decrease in knee extension. Additionally, there is a reduction in sensation over the anterior thigh.

      Which anatomical structure has been affected by the stabbing?

      Your Answer:

      Correct Answer: Femoral nerve

      Explanation:

      The femoral nerve is responsible for loss of knee extension and sensory loss to the anterior and medial aspect of the thigh following a stab injury. The muscles innervated by the femoral nerve are responsible for hip flexion and knee extension, while the nerve is responsible for sensation over the anterior thigh. Injury to the inferior gluteal nerve would result in loss of hip extension, while injury to the obturator nerve would result in a loss of sensation to the medial thigh and impaired hip adduction. Although the quadriceps tendon is vital to knee extension, it would not explain the sensory deficit and the location of the injury.

      Lower limb anatomy is an important topic that often appears in examinations. One aspect of this topic is the nerves that control motor and sensory functions in the lower limb. The femoral nerve controls knee extension and thigh flexion, and provides sensation to the anterior and medial aspect of the thigh and lower leg. It is commonly injured in cases of hip and pelvic fractures, as well as stab or gunshot wounds. The obturator nerve controls thigh adduction and provides sensation to the medial thigh. It can be injured in cases of anterior hip dislocation. The lateral cutaneous nerve of the thigh provides sensory function to the lateral and posterior surfaces of the thigh, and can be compressed near the ASIS, resulting in a condition called meralgia paraesthetica. The tibial nerve controls foot plantarflexion and inversion, and provides sensation to the sole of the foot. It is not commonly injured as it is deep and well protected, but can be affected by popliteral lacerations or posterior knee dislocation. The common peroneal nerve controls foot dorsiflexion and eversion, and can be injured at the neck of the fibula, resulting in foot drop. The superior gluteal nerve controls hip abduction and can be injured in cases of misplaced intramuscular injection, hip surgery, pelvic fracture, or posterior hip dislocation. Injury to this nerve can result in a positive Trendelenburg sign. The inferior gluteal nerve controls hip extension and lateral rotation, and is generally injured in association with the sciatic nerve. Injury to this nerve can result in difficulty rising from a seated position, as well as difficulty jumping or climbing stairs.

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  • Question 22 - A 60-year-old man comes to the dermatology clinic complaining of a rash. During...

    Incorrect

    • A 60-year-old man comes to the dermatology clinic complaining of a rash. During the examination, the doctor observes a linear rash on the lateral thigh of the left leg. The patient reports having undergone a left hip replacement surgery recently, and the rash has developed over the surgical scar.

      What skin condition is most likely responsible for this presentation?

      Your Answer:

      Correct Answer: Psoriasis

      Explanation:

      The Koebner Phenomenon: Skin Lesions at the Site of Injury

      The Koebner phenomenon refers to the occurrence of skin lesions at the site of injury. This phenomenon is commonly observed in various skin conditions such as psoriasis, vitiligo, warts, lichen planus, lichen sclerosus, and molluscum contagiosum. In other words, if a person with any of these skin conditions experiences trauma or injury to their skin, they may develop new lesions in the affected area.

      This phenomenon is named after Heinrich Koebner, a German dermatologist who first described it in 1876. The exact mechanism behind the Koebner phenomenon is not fully understood, but it is believed to be related to the immune system’s response to injury. In some cases, the injury may trigger an autoimmune response, leading to the development of new lesions.

      The Koebner phenomenon can be a frustrating and challenging aspect of managing skin conditions. It is important for individuals with these conditions to take precautions to avoid injury to their skin, such as wearing protective clothing or avoiding activities that may cause trauma. Additionally, prompt treatment of any new lesions that develop can help prevent further spread of the condition.

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  • Question 23 - A 25-year-old man gets into a brawl and receives a cut on the...

    Incorrect

    • A 25-year-old man gets into a brawl and receives a cut on the back of his right arm, about 2 cm above the olecranon process. Upon examination at the ER, he is unable to straighten his elbow. Which tendon is the most probable one to have been severed?

      Your Answer:

      Correct Answer: Triceps

      Explanation:

      The elbow joint is extended by the triceps muscle, while the remaining muscles listed are responsible for flexion of the elbow joint.

      Anatomy of the Triceps Muscle

      The triceps muscle is a large muscle located on the back of the upper arm. It is composed of three heads: the long head, lateral head, and medial head. The long head originates from the infraglenoid tubercle of the scapula, while the lateral head originates from the dorsal surface of the humerus, lateral and proximal to the groove of the radial nerve. The medial head originates from the posterior surface of the humerus on the inferomedial side of the radial groove and both of the intermuscular septae.

      All three heads of the triceps muscle insert into the olecranon process of the ulna, with some fibers inserting into the deep fascia of the forearm and the posterior capsule of the elbow. The triceps muscle is innervated by the radial nerve and supplied with blood by the profunda brachii artery.

      The primary action of the triceps muscle is elbow extension. The long head can also adduct the humerus and extend it from a flexed position. The radial nerve and profunda brachii vessels lie between the lateral and medial heads of the triceps muscle. Understanding the anatomy of the triceps muscle is important for proper diagnosis and treatment of injuries or conditions affecting this muscle.

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  • Question 24 - A 28-year-old presents to the hospital with severe wrist pain. He was playing...

    Incorrect

    • A 28-year-old presents to the hospital with severe wrist pain. He was playing basketball with his friends when he fell with his hand outstretched. On examination, there is significant tenderness at the anatomical snuffbox. Pain is elicited as the thumb is longitudinally compressed. His grip strength is also diminished.

      A posteroanterior and lateral x-ray of the wrist joint is performed which gives inconclusive results. The patient's wrist is immobilized with a splint and he is advised an MRI in a week’s time for further evaluation.

      The patient inquires about possible complications and the doctor expresses concern that if the blood supply is interrupted, the bone tissue may be compromised.

      Which of the following structures is most likely to be responsible for this complication?

      Your Answer:

      Correct Answer: Dorsal carpal branch of radial artery

      Explanation:

      The primary neurovascular structure that can be affected by a scaphoid fracture is the dorsal carpal branch of the radial artery. This artery is responsible for supplying blood to the scaphoid bone, and a fracture can lead to a high risk of avascular necrosis in the proximal pole of the bone. Symptoms of a scaphoid fracture include tenderness in the anatomical snuffbox, pain when compressing the thumb longitudinally, and a loss of grip strength. While an X-ray may not provide a conclusive diagnosis, further imaging studies can confirm the presence of an occult fracture.

      The other answer choices are incorrect. The common digital arteries originate from the superficial palmar arch and supply the fingers. The deep palmar arch primarily supplies the thumb and index finger. The proper digital arteries arise from the common digital arteries and supply the fingers.

      A scaphoid fracture is a type of wrist fracture that usually occurs when a person falls onto an outstretched hand or during contact sports. It is important to identify scaphoid fractures as they can lead to avascular necrosis due to the unusual blood supply of the scaphoid bone. Patients with scaphoid fractures typically experience pain along the radial aspect of the wrist and loss of grip or pinch strength. Clinical examination involves checking for tenderness over the anatomical snuffbox, wrist joint effusion, pain on telescoping of the thumb, tenderness of the scaphoid tubercle, and pain on ulnar deviation of the wrist. Plain film radiographs and scaphoid views are used to diagnose scaphoid fractures, but MRI is considered the definitive investigation. Initial management involves immobilization with a splint or backslab and referral to orthopaedics. Orthopaedic management depends on the type of fracture, with undisplaced fractures typically treated with a cast and displaced fractures requiring surgical fixation. Complications of scaphoid fractures include non-union and avascular necrosis.

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  • Question 25 - A 55-year-old male visited his doctor complaining of pain and paresthesia in his...

    Incorrect

    • A 55-year-old male visited his doctor complaining of pain and paresthesia in his right hand, especially upon waking up. During the examination, the doctor observed weakness in the affected hand and a sensory disturbance in the front of his thumb and index finger. The patient was subsequently referred to an orthopaedic specialist who identified the ailment as carpal tunnel syndrome. What anatomical structure passes through the carpal tunnel?

      Your Answer:

      Correct Answer: Flexor pollicis longus

      Explanation:

      The median nerve innervates the abductor pollicis brevis and flexor pollicis brevis muscles. To remember other muscles innervated by the median nerve, use the acronym LOAF for lumbricals (first and second), opponens pollicis, abductor pollicis brevis, and flexor pollicis brevis. De Quervain Syndrome affects the extensor pollicis brevis and abductor pollicis longus muscles. Structures within the carpal tunnel include the flexor digitorum profundus (four tendons), flexor digitorum superficialis (four tendons), flexor pollicis longus, and median nerve.

      Carpal tunnel syndrome is a condition that occurs when the median nerve in the carpal tunnel is compressed. This can cause pain and pins and needles sensations in the thumb, index, and middle fingers. In some cases, the symptoms may even travel up the arm. Patients may shake their hand to alleviate the discomfort, especially at night. During an examination, weakness in thumb abduction and wasting of the thenar eminence may be observed. Tapping on the affected area may also cause paraesthesia, and flexing the wrist can trigger symptoms.

      There are several potential causes of carpal tunnel syndrome, including idiopathic factors, pregnancy, oedema, lunate fractures, and rheumatoid arthritis. Electrophysiology tests may reveal prolongation of the action potential in both motor and sensory nerves. Treatment options may include a six-week trial of conservative measures such as wrist splints at night or corticosteroid injections. If symptoms persist or are severe, surgical decompression may be necessary, which involves dividing the flexor retinaculum.

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  • Question 26 - A 75-year-old woman experiences a fracture at the surgical neck of her humerus...

    Incorrect

    • A 75-year-old woman experiences a fracture at the surgical neck of her humerus and requires surgery. During the operation, there are challenges in realigning the fracture, and a blood vessel located behind the surgical neck is damaged. What is the most probable vessel that was injured?

      Your Answer:

      Correct Answer: Posterior circumflex humeral artery

      Explanation:

      The surgical neck is where the circumflex humeral arteries are located, with the posterior circumflex humeral artery being the most susceptible to injury in this situation. The thoracoacromial and transverse scapular arteries are situated in a more superomedial position. It is worth noting that the axillary artery gives rise to the posterior circumflex humeral artery.

      The shoulder joint is a shallow synovial ball and socket joint that is inherently unstable but capable of a wide range of movement. Stability is provided by the muscles of the rotator cuff. The glenoid labrum is a fibrocartilaginous rim attached to the free edge of the glenoid cavity. The fibrous capsule attaches to the scapula, humerus, and tendons of various muscles. Movements of the shoulder joint are controlled by different muscles. The joint is closely related to important anatomical structures such as the brachial plexus, axillary artery and vein, and various nerves and vessels.

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  • Question 27 - A 25-year-old man is stabbed in the neck, in the area between the...

    Incorrect

    • A 25-year-old man is stabbed in the neck, in the area between the omohyoid and digastric muscles. During surgery to explore the injury, a nerve injury is discovered just above the lingual artery where it branches off from the external carotid artery. What is the most probable outcome of this injury?

      Your Answer:

      Correct Answer: Paralysis of the ipsilateral side of the tongue

      Explanation:

      The external carotid artery is located posterior to the hypoglossal nerve, while the lingual arterial branch is situated below it. In case of damage to the nerve, the genioglossus, hyoglossus, and styloglossus muscles on the same side will become paralyzed. When the patient is instructed to stick out their tongue, it will deviate towards the affected side.

      The Anterior Triangle of the Neck: Boundaries and Contents

      The anterior triangle of the neck is a region that is bounded by the anterior border of the sternocleidomastoid muscle, the lower border of the mandible, and the anterior midline. It is further divided into three sub-triangles by the digastric muscle and the omohyoid muscle. The muscular triangle contains the neck strap muscles, while the carotid triangle contains the carotid sheath, which houses the common carotid artery, the vagus nerve, and the internal jugular vein. The submandibular triangle, located below the digastric muscle, contains the submandibular gland, submandibular nodes, facial vessels, hypoglossal nerve, and other structures.

      The digastric muscle, which separates the submandibular triangle from the muscular triangle, is innervated by two different nerves. The anterior belly of the digastric muscle is supplied by the mylohyoid nerve, while the posterior belly is supplied by the facial nerve.

      Overall, the anterior triangle of the neck is an important anatomical region that contains many vital structures, including blood vessels, nerves, and glands. Understanding the boundaries and contents of this region is essential for medical professionals who work in this area.

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  • Question 28 - A 68-year-old man presents to an orthopedic surgeon with a two-month history of...

    Incorrect

    • A 68-year-old man presents to an orthopedic surgeon with a two-month history of dull pain in his left knee that is worse at night and unresponsive to over-the-counter pain relievers. Both knees appear normal with no swelling, tendon or ligament abnormalities, and no limited range of motion. The patient has a history of Paget disease of the bone and takes alendronic acid. The orthopedic surgeon notes a Codman triangle on knee X-ray due to periosteum elevation. What is the most likely condition affecting this patient?

      Your Answer:

      Correct Answer: Osteosarcoma

      Explanation:

      The presence of a Codman triangle on an X-ray is a strong indication of osteosarcoma, a bone tumor that can cause night pain and is unresponsive to analgesics. This condition is often associated with Paget disease of the bone, which increases the risk of developing osteosarcoma. Giant cell tumor is another bone tumor that can occur in young adults and has a characteristic ‘soap bubble’ appearance on X-ray. Osteochondroma is a common benign bone tumor that can rarely transform into a malignant chondrosarcoma. Osteoarthritis is a painful joint condition caused by mechanical destruction of the cartilage, often worsened by factors such as obesity and age. Treatment options for osteoarthritis include pain relief medication and joint replacement surgery.

      Types of Bone Tumours

      Benign and malignant bone tumours are two types of bone tumours. Benign bone tumours are non-cancerous and do not spread to other parts of the body. Osteoma is a benign overgrowth of bone that usually occurs on the skull and is associated with Gardner’s syndrome. Osteochondroma, the most common benign bone tumour, is a cartilage-capped bony projection on the external surface of a bone. Giant cell tumour is a tumour of multinucleated giant cells within a fibrous stroma that occurs most frequently in the epiphyses of long bones.

      Malignant bone tumours are cancerous and can spread to other parts of the body. Osteosarcoma is the most common primary malignant bone tumour that mainly affects children and adolescents. It occurs most frequently in the metaphyseal region of long bones prior to epiphyseal closure. Ewing’s sarcoma is a small round blue cell tumour that mainly affects children and adolescents. It occurs most frequently in the pelvis and long bones and is associated with t(11;22) translocation. Chondrosarcoma is a malignant tumour of cartilage that most commonly affects the axial skeleton and is more common in middle-age.

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  • Question 29 - A 65-year-old man with critical limb ischaemia is having a femoro-distal bypass graft....

    Incorrect

    • A 65-year-old man with critical limb ischaemia is having a femoro-distal bypass graft. When mobilizing the proximal part of the posterior tibial artery, what is the most vulnerable structure to injury?

      Your Answer:

      Correct Answer: Tibial nerve

      Explanation:

      The posterior tibial artery and tibial nerve are in close proximity to each other. The nerve passes behind the vessel about 2.5cm below where it begins. Initially, the nerve is positioned on the medial side of the artery, but it shifts to the lateral side after crossing it.

      Anatomy of the Posterior Tibial Artery

      The posterior tibial artery is a major branch of the popliteal artery that terminates by dividing into the medial and lateral plantar arteries. It is accompanied by two veins throughout its length and its position corresponds to a line drawn from the lower angle of the popliteal fossa to a point midway between the medial malleolus and the most prominent part of the heel.

      The artery is located anteriorly to the tibialis posterior and flexor digitorum longus muscles, and posteriorly to the surface of the tibia and ankle joint. The posterior tibial nerve is located 2.5 cm distal to its origin. The proximal part of the artery is covered by the gastrocnemius and soleus muscles, while the distal part is covered by skin and fascia. The artery is also covered by the fascia overlying the deep muscular layer.

      Understanding the anatomy of the posterior tibial artery is important for medical professionals, as it plays a crucial role in the blood supply to the foot and ankle. Any damage or blockage to this artery can lead to serious complications, such as peripheral artery disease or even amputation.

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  • Question 30 - An emergency medicine doctor has been called to verify the death of an...

    Incorrect

    • An emergency medicine doctor has been called to verify the death of an 86-year-old male patient. After washing his hands, he carefully observes the patient for signs of pallor, rigour mortis, and lividity. He proceeds to palpate the carotid arteries and applies painful stimulus to the sternum around the sternal angle. The doctor completes his examination by auscultating the chest for 1 minute and notes the vertebral landmark that corresponds to the sternal angle as the site of painful stimulus application.

      Can you correctly identify the location of the sternal angle based on the doctor's examination findings?

      Your Answer:

      Correct Answer: Lower border of the T4 vertebrae

      Explanation:

      The correct location of the sternal angle, also known as the angle of Louis, is at the lower border of the T4 vertebrae. While some sources may state that it lies between the 4th and 5th intercostal space, this still does not make the third answer correct as the sternal angle would then be located between the lower border of the 4th vertebrae and the upper border of the 5th vertebrae, which are the boundaries of the intercostal space between the two vertebral planes.

      The sternal angle is a significant anatomical landmark located at the level of the upper sternum and manubrium. It is characterized by several structures, including the upper part of the manubrium, left brachiocephalic vein, brachiocephalic artery, left common carotid, left subclavian artery, lower part of the manubrium, and costal cartilages of the 2nd ribs. Additionally, the sternal angle marks the transition point between the superior and inferior mediastinum, and is also associated with the arch of the aorta, tracheal bifurcation, union of the azygos vein and superior vena cava, and the crossing of the thoracic duct to the midline. Overall, the sternal angle is a crucial anatomical structure that serves as a reference point for various medical procedures and diagnoses.

    • This question is part of the following fields:

      • Musculoskeletal System And Skin
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