Hip II Structured SBA Questions

The FRCS (Tr & Orth) exam comprises of two parts, and transition to the Part 2 clinical and viva voce exam is dependent upon candidates passing the Part 1 written component.

Pathology II Structured SBA Questions

• The liver is tethered by the following ligaments:

  • The falciform ligament attaches the liver anteriorly to the diaphragm and the anterior abdominal wall above the umbilicus.

  • The coronary ligaments extend laterally to attach the liver to the diaphragm. Beginning at the suprahepatic inferior vena cava (IVC), the lateral extensions of the coronary ligaments form the triangular ligaments (right and left), which are also attached to the diaphragm.

• The anatomical division of the liver into the eight classic Couinaud segments has no practical application in traumatic liver resection, where the resection planes are nonanatomical and are dictated by the extent of injury. However, the external anatomical landmarks may be useful in planning operative maneuvers.

  • The plane between the center of the gallbladder and IVC runs along the middle hepatic vein, and serves as the line of division between the right and left lobes.

  • The left lobe is divided by the falciform ligament into the medial and lateral segments.

  • Dissection along the falciform ligament should be performed carefully, so as to avoid injury to the portal venous supply to the medial segment of the left lobe inferiorly and the hepatic veins superiorly.

• The retrohepatic IVC is approximately 8–10 cm long and is partially embedded into the liver parenchyma. In some cases, the IVC is completely encircled by the liver, further complicating exposure and repair.

• There are three major hepatic veins (right, middle, and left), as well as multiple accessory veins. The first 1–2 cm of the major hepatic veins are extra-hepatic, with the remaining 8–10 cm intra-hepatic. In approximately 70% of patients, the middle hepatic vein joins the left hepatic vein before entering the IVC.

• The common hepatic artery originates from the celiac artery. It is responsible for approximately 30% of the hepatic blood flow, but supplies 50% of the hepatic oxygenation. It branches into the left and right hepatic arteries at the liver hilum in the majority of patients. In a common anatomical variant, the right hepatic artery may arise from the superior mesenteric artery. Less frequently, the entire arterial supply may arise from the superior mesenteric artery. Alternatively, the left hepatic artery may arise from the left gastric artery in 15–20% of patients.

• The portal vein provides approximately 70% of hepatic blood flow, and 50% of the hepatic oxygenation. It is formed by the confluence of the superior mesenteric vein and the splenic vein behind the head of the pancreas. The portal vein divides into right and left extrahepatic branches at the level of the liver parenchyma.

• The porta hepatis contains the hepatic artery (medial), common bile duct (lateral), and portal vein (posterior, between the common bile duct and the hepatic artery).

• The right hepatic duct is easier to expose after removal of the gallbladder.

• The left hepatic duct, the left hepatic artery, and the left portal vein branch enter the undersurface of the liver near the falciform ligament.

• The popliteal fossa is diamond-shaped and its borders are formed by the semimembranosus and semitendinosus muscles superiomedially, the biceps femoris muscle superiolaterally, the medial head of the gastrocnemius muscle inferiomedially, and the lateral head of the gastrocnemius muscle inferiolaterally. It contains the popliteal artery and vein, the tibial and common peroneal nerves, and is covered by subcutaneous tissue and skin.

• The popliteal artery is the continuation of the superficial femoral artery after it passes through the adductor canal, an opening in the adductor magnus muscle, in the lower thirds of the thigh. It courses downward and laterally to the midline of the knee between the two condyles of the femur, into the popliteal fossa.

• The popliteal artery has three segments: suprageniculate (above knee), midpopliteal (behind knee), and infrageniculate (below knee). Exposure to each segment of the popliteal artery is distinct.

• The popliteal artery has superior and inferior genicular branches, which provide blood supply to the tissues surrounding the knee joint and provide important collaterals when there are occlusions of the superficial femoral or popliteal artery.

• Below the knee, the popliteal artery branches into the anterior tibial artery, followed by the peroneal branch about 2–3 cm lower, which itself then branches into the peroneal and posterior tibial arteries.

• The anterior tibial artery pierces the upper part of the interosseous membrane, courses in front of the membrane, under the extensor muscles of the anterior muscle compartment, and distally becomes the dorsalis pedis artery.

• The tibioperoneal trunk is the direct continuation of the popliteal artery and, after approximately 3 cm, branches to form the peroneal artery laterally and the posterior tibial artery medially. The peroneal and posterior tibial arteries lie in the deep posterior compartment of the leg posteriorly of the fibula and tibia, respectively.

• The posterior tibial artery continues directly to the ankle and lies superficially posterior to the medial malleolus, while the peroneal artery branches above the ankle to form collaterals to the dorsalis pedis and plantar branches of the posterior tibial artery in the foot.

• The popliteal vein lies posterior to the artery (more laterally superiorly to more medially inferiorly). The tibial nerve is lateral and posterior to the artery.

• Both kidneys have similar muscular surroundings. Posteriorly, the diaphragm covers the upper third of each kidney. Medially, the lower two-thirds of the kidney lie against the psoas muscle, and laterally, the quadratus lumborum.

• The right kidney borders the duodenum medially. Its lower pole lies behind the hepatic flexure of the colon.

• The left kidney is bordered superiorly by the tail of the pancreas, the spleen superolaterally, and the splenic flexure of the colon inferiorly.

• The Gerota’s fascia encloses the kidney and is an effective barrier for containing blood or a urine leak.

• The renal artery and vein travel from the aorta and IVC just below the SMA at the level of the second lumbar vertebra. The vein lies anterior to the artery. The renal pelvis and ureter are located posterior to the vessels.

• The right renal artery takes off from the aorta with a downward slope under the IVC into the right kidney. The left renal artery courses directly off the aorta into the left kidney. Each renal artery branches into five segmental arteries as it approaches the kidney.

• The right renal vein is typically 2–4 cm in length, does not receive any branches, and enters into the lateral edge of the IVC. Ligation of the vein causes hemorrhagic infarction of the kidney because of the lack of collaterals.

• The left renal vein is typically 6–10 cm in length, passes posterior to the SMA and anterior to the aorta. The left renal vein receives branches from the left adrenal vein superiorly, lumbar veins posteriorly, and the left gonadal vein inferiorly. This allows for ligation of the left renal vein close to the IVC.

• Strict antiseptic precautions and personal protective equipment should be used during the procedure. A single dose of prophylactic antibiotics with Cefazolin should be administered before the procedure. There is no need for further prophylaxis.

• Chest tubes can be inserted with an open or percutaneous dilational technique.

• The site of insertion is the same for open or percutaneous insertion and for hemothorax or pneumothorax, at the fourth or fifth intercostal space, at the level of the nipple in males.

• Autotransfusion should be considered in all cases with large hemothoraces.

• The upper arm has two muscle compartments: the anterior, which includes the biceps, and the posterior, which includes the triceps muscle.

• The forearm has two major compartments: the anterior containing the flexor muscles, and the posterior containing the extensor muscles. The mobile wad creates the third compartment.

• The upper extremity is perfused by branches from the deep and superficial brachial artery. The proximal brachial artery lies in the groove between the biceps and triceps muscles. Distally, it courses in front of the humerus. At the antecubital fossa, it runs deep to the bicipital aponeurosis and bifurcates into the radial and ulnar arteries, just below the elbow. The artery is surrounded by the two concomitant brachial veins, which run on either side of the artery.

• The profunda brachial artery is a large branch arising from the proximal brachial artery distal to the teres major muscle and follows the radial nerve closely. It provides collateral circulation to the lower arm.

• The basilic vein courses in the subcutaneous tissue in the medial aspect of the lower arm. At the midpoint, it penetrates the fascia to join one of the brachial veins.

• The cephalic vein is entirely in the subcutaneous tissues, courses in the deltopectoral groove, and empties into the junction of the brachial and axillary veins.

• In the upper arm, the median nerve lies in front of the brachial artery. It then crosses over the artery midway down the upper arm, where distally it lies posteromedial to the artery.

• The ulnar nerve is behind the artery in the upper half of the arm. Midway down the arm, it pierces the intermuscular septum and courses more posteriorly, away from the artery, behind the medial epicondyle.

• On the right side, the subclavian artery originates from the innominate (brachiocephalic) artery, which branches into the right subclavian and right common carotid arteries. On the left side, it originates directly from the aortic arch. In some individuals, the left subclavian artery may have a common origin with the left common carotid artery.

• The subclavian artery courses laterally, passing between the anterior and middle scalene muscles. This is in contrast to the subclavian vein, which is located superficial to the anterior scalene muscle.

• The subclavian artery is divided into three parts on the basis of its relationship to the anterior scalene muscle. The first part extends from its origin to the medial border of the anterior scalene muscle, coursing deep to the sternocleidomastoid and the strap muscles. It gives rise to the vertebral, internal mammary (internal thoracic), and thyrocervical arteries. The second part lies deep to the anterior scalene muscle and superficial to the upper and middle trunks of the brachial plexus. Here, it gives rise to the costocervical artery (on the left side, costocervical artery comes off the first part of the subclavian artery). The third part is located lateral to the anterior scalene muscle, and courses over the lower trunk of the brachial plexus, usually giving rise to the dorsal scapular artery, although its branches are not constant.

• The subclavian artery continues as the axillary artery, as it passes over the first rib. The external landmark for this transition is the lower border of the middle of the clavicle. The external landmark for the axillary artery is a curved line from the middle of the clavicle to the deltopectoral groove.

• The subclavian vein is the continuation of the axillary vein and originates at the level of the outer border of the first rib. It crosses in front of the anterior scalene muscle, and at the medial border of the muscle, it joins the internal jugular vein to form the innominate (brachiocephalic) vein. The left thoracic duct drains into the left subclavian vein at its junction with the left internal jugular vein. The right thoracic duct drains into the junction of the right subclavian vein and right internal jugular vein.

• The vagus nerve is in close proximity to the first part of the subclavian artery and it lies medial to the internal mammary artery. On the right side, it crosses in front of the artery and immediately gives off the recurrent laryngeal nerve (RLN), which loops behind the subclavian artery and ascends behind the common carotid artery into the tracheoesophageal groove. On the left side, the vagus nerve travels between the common carotid and subclavian arteries and immediately gives rise to the RLN, which loops around the aortic arch and ascends into the tracheoesophageal groove.

• The abdominal aorta bifurcates into the two common iliac arteries at the level of the fourth to fifth lumbar vertebrae (surface landmark is the umbilicus). The common iliac arteries are about 5–7 cm in length.

• At the level of the sacroiliac joint, the common iliac arteries bifurcate to the external and the internal iliac arteries.

• The external iliac artery runs along the medial border of the psoas muscle and goes underneath the inguinal ligament to become the common femoral artery. It gives two major branches: the inferior epigastric artery, just above the inguinal ligament, and the deep iliac circumflex artery, which arises from the lateral aspect of the external iliac artery opposite the inferior epigastric artery.

• The internal iliac artery is a short and thick vessel, about 3–4 cm in length. It divides into the anterior and posterior branches at the sciatic foramen. These branches provide blood supply to the pelvic viscera, perineum, pelvic wall, and the buttocks.

• The ureter crosses over the bifurcation of the common iliac artery.

• The common iliac veins lie medially and posterior to the common iliac arteries. They join to form the inferior vena cava at the level of the fifth lumbar vertebra, posterior to the right common iliac artery.

• The common femoral artery is a continuation of the external iliac artery and is approximately 4 cm long. It begins directly behind the inguinal ligament, midway between the anterior superior iliac spine and the symphysis pubis.

• The profunda femoris artery arises from the lateral aspect of the common femoral artery, towards the femur, approximately 3–4 cm below the inguinal ligament. The common femoral artery continues obliquely down the anteromedial aspect of the thigh as the superficial femoral artery.

• The superficial femoral artery exits the femoral triangle to enter the subsartorial canal and ends by passing through an opening in the adductor magnus to become the popliteal artery.

• In the upper third of the thigh, the femoral vessels are contained within the femoral triangle (Scarpa’s triangle).

  • The femoral triangle is formed laterally by the medial border of the sartorius muscle, medially by the adductor longus, and superiorly by the inguinal ligament.

  • In the femoral triangle, the femoral vein lies medial to the femoral artery. The greater saphenous vein drains into the femoral vein about 3–4 cm below the inguinal ligament; further distally, the femoral vein lies posterior to the artery and maintains this relationship in the popliteal fossa. The femoral nerve and its branches are found lateral to the common femoral artery.

• In the middle third of the thigh, the femoral artery lies within the adductor canal (Hunter’s canal), an aponeurotic tunnel in the middle third of the thigh that extends from the apex of the femoral triangle to the opening in the adductor magnus.

  • The adductor canal is bounded by the sartorius muscle anteriorly, the vastus medialis laterally, and the adductor longus and magnus posteromedially. A fascial plane between the vastus medialis and adductor longus and magnus covers the canal.

  • The canal contains the femoral artery and vein, the saphenous nerve which crosses from lateral to medial, and branches of the femoral nerve.

  • The femoral vein courses from a medial position in the groin to a posterior and then lateral position with respect to the artery as it moves distally towards the knee.

  • The greater saphenous vein courses medially to lie on the anterior surface of the thigh, before entering the fascia lata and joining the common femoral vein at the sapheno-femoral junction near the femoral triangle.

• The lower extremity fascial compartments include three gluteal, three thigh, four calf, and nine of the foot. These compartments contain muscles, nerves, and blood vessels.

• The compartments of the buttock include the gluteus maximus, the gluteus medius/minimus, and the extension of the fascia lata of the thigh into the gluteal region. The sciatic nerve is the only major neurovascular structure in the compartments of the buttock.

• The thigh has three compartments:

  • The anterior compartment contains the quadriceps femoris and sartorius muscles, as well as the femoral vessels and femoral nerve.

  • The posterior compartment contains the biceps femoris, semitendinosus, and semimembranosus muscles and the sciatic nerve.

  • The medial compartment contains the adductor muscle group and the gracilis muscle.

• The lower leg has four leg compartments:

  • The anterior compartment: Contains the tibialis anterior muscle, extensor halluces muscle, extensor digitorum longus muscle, the anterior tibial artery, and the deep peroneal nerve.

  • The lateral compartment: Contains the peroneus longus and brevis muscles, and the superficial peroneal nerve.

  • The superficial posterior compartment: Contains the gastrocnemius muscle, soleus muscles, plantaris muscle, and the sural nerve.

  • The deep posterior compartment: Contains the flexor hallucis longus muscle, flexor digitorum longus muscle, tibialis posterior muscles, popliteus muscle, the posterior tibial artery, and the tibial nerve.

• The foot contains a total of nine compartments, including four interosseous (medial, lateral, deep, and superficial central) and the adductor hallucis compartments that may require decompression in crush injuries to the foot. The medial, lateral, and superficial compartments pass through the entire length of the foot, while the interosseous compartments and the calcaneal compartments are confined to the forefoot and the hind foot, respectively.

• There are three meninges covering the brain: the dura mater, the arachnoid mater, and the pia mater.

  • The dura mater is the thickest and strongest membrane, and is firmly attached to the inner surface of the cranial bone, especially along the sutures. It contains the meningeal arteries.

  • The arachnoid mater is a thin membrane under the dura mater. Its inner surface has numerous thin trabeculae extending downward, into the subarachnoid space.

  • The pia mater is a thin membrane that covers the surface of the brain, entering the grooves and fissures.

• Due to the tight adhesion of the dura mater to the inner skull, significant force is required to separate them. In contrast, separation of the dura from the subarachnoid mater can occur with relatively little force.

• The middle meningeal artery arises from the external carotid artery. It enters the foramen spinosum and branches into the anterior, middle, and posterior branches with various patterns. It is a common source of bleeding in acute epidural hematomas (EDHs).

• The bridging veins connect the cortical superficial veins to the sagittal sinus in the dura. They are a common source of bleeding in acute subdural hematomas (SDHs).