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GRAY"SAnatomyReview

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GRAY"SAnatomyReview

Marios Loukas, MD, PhD

Associate Professor

Department of Anatomical Sciences

St. Georges University School of Medicine

Grenada, West Indies

Gene L. Colborn, PhD

Professor Emeritus of Anatomy and Surgery

The Medical College of Georgia

Augusta, Georgia

Peter Abrahams, MBBS, FRCS(ED), FRCR, DO(Hon)

Professor of Clinical Anatomy

Medical Teaching Centre

Institute of Clinical Education

Warwick Medical School

University of Warwick

United Kingdom

Stephen W. Carmichael, PhD, DSc

Department of Anatomy

Mayo Clinic

Rochester, Minnesota

With illustrations from Abrahams P, Boon J, Spratt J:

McMinns Clinical Atlas of Human Anatomy,

6th edition. St. Louis: Elsevier, 2008

1600 John F. Kennedy Blvd.

Ste 1800

Philadelphia, PA 19103-2899

GRAY"S ANATOMY REVIEW ISBN: 978-0-443-06938-3

International ISBN: 978-0-8089-2403-6

Copyright

2010 by Churchill Livingstone, an imprint of Elsevier Inc.

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier"s Rights Department: phone: (1) 215 239 3804 (US) or (44) 1865 843830 (UK); fax: (

44) 1865 853333; e-mail: healthpermissions@elsevier.com . You may also complete your request

on-line via the Elsevier website at http://www.elsevier.com/permissions .

Notice

Knowledge and best practice in this eld are constantly changing. As new research and experience broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recom- mended dose or formula, the method and duration of administration, and contraindications. It is

the responsibility of the practitioner, relying on their own experience and knowledge of the patient,

to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the Author assumes any liability for any injury and/or damage to persons or property arising out of or related to any use of the material contained in this book.

The Publisher

Library of Congress Cataloging-in-Publication Data

Loukas, Marios.

Gray"s anatomy review / Marios Loukas, Stephen Carmichael, Gene L.

Colborn.

p. ; cm. Questions in this review are correlated with the textbook Gray"s anatomy for students and with Gray"s atlas of anatomy.

ISBN 978-0-443-06938-3

1. Human anatomy--Examinations, questions, etc. I. Carmichael,

Stephen W. II. Colborn, Gene L. III. Gray"s anatomy for students. IV.

Gray"s atlas of anatomy. V. Title.

[DNLM: 1. Anatomy--Examination Questions. QS 18.2 L888g 2009]

QM32.L68 2010

611.0076--dc22 2008046824

Acquisitions Editor: William Schmitt

Developmental Editor: Andrew Hall

Design Direction: Ellen Zanolle

Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1

To my daughter, Nicole, and my wife, Joanna, for their continuous support and love

Marios Loukas

To my wife and friend, Sarah

Gene Colborn

To “Lucy in the Sky with Diamonds," who puts up with my early mornings and late nights

Peter Abrahams

To Susan Stoddard and Allen Carmichael

Stephen Carmichael

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Rote memorization of anatomic facts has been the car- dinal feature of exhaustive, and exhausting, courses in human anatomy for many generations of students in medicine, dentistry, and other allied health science programs. Often, little distinction was made between the wheat and the chaff, and little attention was given to the practical, clinical application of the data. In the face of the modern explosion of information and tech- nical advances in the medical sciences, Gray"s Anatomy for Students was conceived and written as a clinically oriented, student-friendly textbook of human anatomy. The authors, Richard L. Drake, Wayne Vogl, and Adam W. M. Mitchell, have provided a sound base for student learning and understanding of both normal and altered human anatomy in the clinical setting.

This book, the Gray"s Anatomy Review , was de-

signed for use by students after they have read the textbook and is in keeping with course objectives. The questions, answers, and explanations in this book are intended to serve multiple purposes for students in various programs:

1. This review provides a thought-provoking source for

study by students in preparation for examinations in various programs of gross anatomy.

2. To avoid pointless memorization by the student, all

the questions are framed within clinical vignettes that guide the student toward practical applications of the textual material. 3. The multiple-choice, single-best-answer format of the questions is designed to facilitate student review in preparation for the USMLE and similar testing methods.

4. The explanations of the answers emphasize the crit-

ical importance of understanding normal and dys- functional human anatomy.

5. Student understanding is further enhanced by criti-

cal examination of alternative, incorrect answers that students might be tempted to choose.

6. Finally, the review provides a succinct distillation of

the plethora of facts in clinical anatomy, assisting the student"s learning and understanding of impor- tant concepts in the practice of medicine, irrespec- tive of the student"s career choice.

The questions in this review are correlated with

Gray"s Anatomy for Students and with Gray"s Atlas of Anatomy by Richard L. Drake, Wayne Vogl, Adam W. M. Mitchell, Richard M. Tibbitts, and Paul E. Richardson. Each answer is referenced to pages in the anatomy text (GAS) and in the atlas (GA) . We have incorporated or adapted many drawings, full-color illustrations, and ra- diologic images in an attempt to accelerate the learning process and to enhance understanding of both the anat- omy and the clinical applications. The primary sources upon which we have drawn for illustrative material are from the 6th edition of McMinn"s Clinical Atlas of Hu- man Anatomy by Peter H. Abrahams, Joahannes M.

Boon, and Jonathan D. Spratt.

PREFACE

vii

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A clinical review book is the work not only of the au- thors but also of numerous scientiÞ c and clinical friends and colleagues who have been so generous with their knowledge and given signiÞ cant feedback and help. This book would not have been possible were it not for the contributions of the colleagues and friends listed below.

A very special group of medical students, members

of the Student Clinical Research Society at the Depart- ment of Anatomical Sciences at St. GeorgesÕ University, helped enormously with the completion of this project through their comments and criticism.

Steven Andrade

Esther Bilinsky

Samuel Bilinsky

Julie Ferrauiola

Chris Groat

Michael Hill

Rajkamal Khangura

Alexis Lanteri The authors thank the following individuals and their institutions for kindly supplying various clinical, operative, endoscopic, and imaging photographs: Dr. Ray Armstrong, Rheumatologist, Southampton Gen- eral Hospital, Southampton, and Arthritis Research

Campaign

Professor Paul Boulos, Surgeon, Institute of Surgical Studies, University College London Medical School,

London

Professor Norman Browse, Emeritus Professor of Sur- gery, and Hodder Arnold Publishers, for permission to use illustrations from Symptoms and Signs of Sur- gical Disease, 4th edition, 2005 Mr. John Craven, formerly Consultant Surgeon, York

District Hospital, York

Professor Michael Hobsley, formerly Head of the De- partment of Surgical Studies, The Middlesex Hospi- tal Medical School, London

Mr. Ralph Hutchings, photographer for Imagingbody

.com Mr. Umraz Khan, Plastic Surgeon, Charing Cross Hos- pital, London Professor John Lumley, Director, Vascular Surgery Unit, St. BartholomewÕs and Great Ormond Street Hospi- tals, London Dr. J. Spratt, Consultant Radiologist, University Hospi- tal of North Durham Dr. William Torreggiani, Radiologist, The Adelaide and

Meath Hospital, Tallaght, Dublin

Miss Gilli VaÞ dis, Ophthalmologist, Central Middlesex

Hospital, London

Mr. Theo Welch, Surgeon, Fellow Commoner QueensÕ

College, Cambridge

Professor Jamie Weir, Department of Clinical Radiol- ogy, Grampian University Hospitals Trust, Aberdeen,

Scotland, and editor of Imaging Atlas of Human

Anatomy, 3rd edition, Elsevier 2003.

ACKNOWLEDGMENTS

Elizabeth Lax

Gopi Maharaja

Nadine Mirzayan

Michelle Shirak

Ashley Steinberg

Darius Strike

Ashley Sullivan

The following Professors from the Department of

Anatomical Sciences at St. GeorgesÕ University have also been very helpful with their comments and criticism.

Feisal Brahim, Ph.D.

Danny Burns, MD., Ph.D.

Brian Curry, Ph.D.

Robert Hage, MD., Ph.D.

Robert Jordan, Ph.D.

Vid Persaud, MD., Ph.D.

Vish Rao, Ph.D.

Dr. R. Shane Tubbs, Ph.D., Associate Professor at

the University of Alabama, Birmingham, has always been a great friend and colleague. His continuous sup- port, comments, criticism, and enthusiasm have con- tributed enormously to the completion of this project. ix

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1 BACK. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . 1

2 THORAX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . .19

3 ABDOMEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . .57

4 PELVIS AND PERINEUM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111

5 LOWER LIMB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . .133

6 UPPER LIMB. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . .169

7 HEAD AND NECK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.211

CONTENTS

xi

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1

1 A 55-year-old man with severe coughing is ad-

mitted to the hospital. Radiographic examination re- veals tuberculosis of the right lung, with extension to the thoracic vertebral bodies of T6 and T7, producing a ìgibbus deformity.î Which of the following condi- tions is most likely also to be con rmed by radio- graphic examination?

A. Lordosis

B. Kyphosis

C. Scoliosis

D. Spina bi da

E. Osteoarthritis

2 A 68-year-old man is admitted to the hospital due

to severe back pain. Radiographic examination reveals severe osteoporosis of the vertebral column, with crush fractures of vertebrae L4 and L5. Which of the follow- ing parts of the vertebrae are most likely to be fractured in this patient?

A. Spinal process

B. Vertebral bodies

C. Transverse process

D. Superior articular process

E. Intervertebral disk

3 A 45-year-old man is admitted to the hospital

because of severe pain in the back and lower limb. Radiographic examination reveals spinal stenosis syn- drome. Which of the following conditions is most likely to be con rmed by MRI examination?

A. Hypertrophy of supraspinous ligament

B. Hypertrophy of interspinous ligament

C. Hypertrophy of ligamentum avum

D. Hypertrophy of anterior longitudinal ligament

E. Hypertrophy of nuchal ligament

4 A 35-year-old man is admitted to the hospital af-

ter a severe car crash. Radiographic examination re- veals an injury to the dorsal surface of the neck and a fracture in the medial border of the right scapula. Dur- ing physical examination the patient presents with the scapula retracted laterally on the affected side. Which of the following nerves has most likely been injured on that side?

A. Axillary

B. Long thoracic

C. Dorsal scapular

D. Greater occipital

E. Suprascapular

1 BACK BACK 2

5 A 64-year-old man arrived at the clinic with a

severely painful rash and skin eruptions that are local- ized entirely on one side of his body, closely following the dermatome level of spinal nerve C7. The patient was diagnosed with herpes zoster virus. In what struc- ture has the virus most likely proliferated to cause the patient's current condition?

A. The sympathetic chain

B. The dorsal root ganglion of the C7 spinal

nerve

C. The lateral horn of the C7 spinal cord

segment

D. The posterior cutaneous branch of the dorsal

primary ramus of C7

E. The ventral horn of the C7 spinal cord

segment

6 A 45-year-old woman states that she has experi-

enced moderate pain for 2 years over her left lower back, pain that radiates to her left lower limb. She states that after lifting a case of soft drinks, the pain became intense. She was admitted to the emergency department. Radiographic examination revealed disk herniation between vertebral levels L4 and L5. Which of the following nerves was most likely affected by the disk herniation?

A. L1

B. L2

C. L3

D. L4

E. L5

7 A 3-year-old child is admitted to the emergency

department with severe headache, high fever, mal- aise, and confusion. Radiographic and physical ex- aminations reveal that the patient suffers from men- ingitis. A lumbar puncture is ordered. Which vertebral level is the most appropriate location for the lumbar puncture?

A. T12-L1

B. L1-2

C. L2-3

D. L4-5

E. L5-S1

8 When a lumbar puncture is performed to sample

cerebrospinal uid, which of the following external landmarks is the most reliable to determine the posi- tion of the L4 vertebral spine?

A. The inferior angles of the scapulae

B. The iliac crests

C. The lowest pair of ribs bilaterally

D. The posterior superior iliac spines

E. The posterior inferior iliac spines

9 A 39-year-old male presents with severe neck

pain after a whiplash injury, sustained when his car was struck from behind. Radiographic studies reveal trauma to the ligament lying on the anterior surface of the cervical vertebral bodies. Which ligament is this?

A. Anterior longitudinal ligament

B. Ligamentum avum

C. Nuchal ligament

D. Posterior longitudinal ligament

E. Transverse cervical ligament

10 A 65-year-old male complains of severe back pain

and inability to move his left lower limb. Radiographic studies demonstrate the compression of nerve elements at the intervertebral foramen between vertebrae L5 and S1. Which structure is most likely responsible for this space-occupying lesion?

A. Anulus brosus

B. Nucleus pulposus

C. Posterior longitudinal ligament

D. Anterior longitudinal ligament

E. Ligamentum avum

11 A 27-year-old man is admitted to the emergency

department after a car crash. Physical examination re- veals weakness in medial rotation and adduction of the humerus. Which of the following nerves was most probably injured?

A. Thoracodorsal

B. Axillary

C. Dorsal scapular

D. Spinal accessory

E. Radial

12 A 39-year-old woman complains of an inability to

reach the top of her head to brush her hair. History reveals that she had undergone a bilateral mastectomy procedure 2 months earlier. Physical examination dem- onstrates winging of both of her scapulae. Which nerves were most likely damaged during surgery?

A. Axillary

B. Spinal accessory

C. Long thoracic

D. Dorsal scapular

E. Thoracodorsal

BACK 3

13 A 19-year-old man is brought to the emergency

department after dislocating his shoulder while playing football. Following treatment of the dislocation, he can- not initiate abduction of his arm. An MRI of the shoul- der shows a torn muscle. Which muscle was most likely damaged by the injury?

A. Coracobrachialis

B. Long head of the triceps

C. Pectoralis minor

D. Supraspinatus

E. Teres major

14 A 1-year-old girl is brought to the clinic for a rou-

tine checkup. The child appears normal except for a dimpling of the skin in the lumbar region with a tuft of hair growing over the dimple. You reassure the mother that this condition is seen in 10% to 25% of births and normally has no ill effects. What is this relatively com- mon condition that results from incomplete embryo- logic development?

A. Meningomyelocele

B. Meningocele

C. Spina bi da occulta

D. Spina bi da cystica

E. Rachischisis

15 Which nerve bers carry the sensation of a mos-

quito bite on the back, just lateral to the spinous pro- cess of the T4 vertebra?

A. Somatic afferent

B. Somatic efferent

C. Visceral afferent

D. Visceral efferent

E. Somatic efferent and visceral afferent

16 A 15-year-old female was suspected to have men-

ingitis. To obtain a sample of cerebrospinal uid by spinal tap in the lumbar region (lumbar puncture), the tip of the needle must be placed in which of the follow- ing locations?

A. In the epidural space

B. Between anterior and posterior longitudinal

ligaments

C. Super cial to the ligamentum avum

D. Between arachnoid mater and dura mater

E. In the subarachnoid space

17 In the event of intervertebral disk herniation in

the cervical region, which of the following ligaments is in an anatomic position to protect the spinal cord from direct compression?

A. Supraspinous

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