HAD Unit III Review
Tom Eck ecktw@umdnj.edu
Unit III Exam
• A ton of material, but questions tend to be a bit
more targeted—be sure to use the TBL as a guide
• Lab: review the prosections, especially the pelvis
ones
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Abdominal Wall
Perineum
Gastrointestinal Tract
Genitourinary
Lower Limb
Lymphatics
Embryology
Shelf
Abdominal Wall
•
•
•
•
•
•
Fascia Layers
Innervation – intercostals, iliohypogastric, ilioinguinal
Musculature – rectus abd., obliques, quad. lumborum
Vessels – inferior and superior epigastric
Hernias – inguinal, femoral, congenital
Abdominal folds
▫ Median = urachus
▫ Medial = umbilical arteries (deoxygenated)
▫ Lateral = inferior epigastric vessels
1. When surgeons cut through the anterior abdominal wall
below the arcuate line, which of the following do they
NOT encounter?
1. Camper’s fascia
2. Scarpa’s fascia
3. Anterior layer of
rectus sheath
4. Posterior layer of
rectus sheath
5. Transversalis fascia
0%
1
0%
0%
2
3
0%
0%
4
5
Layers of Anterior Abdominal Wall
1.
2.
3.
4.
Skin
Camper (fatty)
Scarpa (fibrous)
Muscles
5.
6.
7.
-
Transversalis Fascia (fibrous)
Extraperitoneal Fat
Parietal Peritoneum
Above the arcuate line, the aponeuroses of the
abdominal muscles ensheath the rectus
abdominus
Below the arcuate line, they pass in front of it
-
-External Oblique
-Internal Oblique
-Transversus Abdominus
2. What would likely result from a vertical incision
through the right semilunar line superior to the umbilicus?
1. Paralysis of the right
rectus abdominis
2. Ischemia of the right
rectus abdominis
3. Paralysis of the right
external oblique
4. Ischemia of the right
external oblique
0%
1
0%
2
0%
3
0%
4
Innervation and Blood Supply to Rectus
Blood Supply via Superior Epigastric
Abdominus
Semilunar Line
Innervation via
Intercostals
Blood Supply via Inferior Epigastric
3. You palpate a mass lateral to the inferior epigastric
artery and superior to the inguinal ligament. What is true
of this hernia?
25%
25%
25%
2
3
25%
1. It always passes
through the superficial
inguinal ring
2. It is encased in
spermatic fascia
3. It does not pass through
the deep inguinal ring
4. It passes medial to
femoral vein
1
4
Hernias of the Myopectineal Orifice
• Superior to Inguinal Ligament = Inguinal
▫ Direct: between medial and lateral umbilical folds
(in Hesselbach’s Triangle)
 medial fold = obliterated umbilical artery
 lateral fold = inferior epigastric vessels
▫ Indirect: lateral to lateral umbilical fold; may be
congenital, due to failure of processus vaginalis to
close
• Inferior to the Inguinal Ligament = Femoral
▫ Passes through the femoral canal medial to the
femoral veins
4. Which nerve supplies the efferent limb of the
cremasteric reflex?
1.
2.
3.
4.
Iliohypogastric nerve
anterior scrotal nerve
Ilioinguinal nerve
genital branch of
genitofemoral nerve
5. femoral branch of
genitofemoral nerve
0%
1
0%
0%
2
3
0%
0%
4
5
Cremasteric Reflex
• Afferent Limb: femoral branch of
genitofemoral nerve and ilioinguinal
nerve
• Efferent Limb: genital branch
of genitofemoral nerve
• Iliohypogastric Nerve (L1): skin
above inguinal ligament
• Ilioinguinal Nerve (L1): skin of
anterior scrotum and adjacent thigh
• Genitofemoral (L1, L2): skin below
inguinal ligament, motor to cremaster
• Note: both the ilioinguinal nerve and the genital branch of the
genitofemoral nerve pass through the inguinal canal
Perineum
• Fascia Layers
• Muscles – external urethral sphincter, external anal
sphincter, bulbospongiosus, ischiocavernosus
• Innervation – Pudendal Nerve, primarily
• Autonomics (i.e. point and shoot)
5. When fluid deep to Scarpa’s fascia in the abdominal
wall reaches the perineum, where does it accumulate?
1. just under the skin
2. the superficial perineal
pouch
3. the deep perineal
pouch
4. the ischioanal fossa
0%
1
0%
2
0%
3
0%
4
Superficial
Perineal Spaces (of Urogenital Triangle)
Skin
Subcutaneous Fat  Camper Fascia on Abdomen
Colles Fascia*  Scarpa’s Fascia of Abdomen  Dartos Fascia of Scrotum
Superficial Perineal Compartment (Ischiocavernosus, Bulbospongiosus, etc.)
Perineal Membrane
Deep
Deep Perineal Compartment (External Sphincter, etc.)
Levator Ani (Encased in Fascia)
*Note: also continuous with the fascia lata of the thigh, though fluid will
not pass laterally
6. When anesthetic is injected near the ischial spine,
which of the following areas retains sensation?
1. anal region
2. anterior labium majora
3. posterior labium
majora
4. anterior labium minora
5. posterior labium minora
0%
1
0%
0%
2
3
0%
0%
4
5
Pudendal Nerve
• S2, S3, S4
• the pudendal nerve supplies
ALL of the perineal muscles
and ALL of the overlying skin…
• EXCEPT for the anterior
scrotum/labium majora, which
are supplied by the iliofemoral
nerve
• Path: exits greater sciatic
foramen and wraps around the
ischial spine to enter the lesser
sciatic foramen, extending
anteriorly to the perineum
Pudendal Nerve Block
• anesthetized it as it wraps
around the ischial spine
• Pudendal Nerve Branches
▫ Inferior Anal Nerves: external
anal sphincter, perianal skin
▫ Perineal Nerve: perineal
muscles, perineal skin
▫ Dorsal Nerve of the
Penis/Clitoris: external
urethral sphincter
Block here
GI Tract
• Arterial Supply
▫ Foregut = Celiac Truck
▫ Midgut = Superior Mesenteric Artery
▫ Hindgut = Inferior Mesenteric Artery
• Portal Circulation
• Biliary Flow
• Innervation (Sympathetic and Parasympathetic)
• major relationships (i.e. superior mesenteric artery
passes over the third part of the duodenum)
7. Which artery is in direct danger from an ulcer eroding
the posterior wall of the stomach’s body?
1.
2.
3.
4.
5.
common hepatic
left gastric
right gastric
gastroduodenal
splenic
0%
1
0%
0%
2
3
0%
0%
4
5
The Celiac Trunk
Splenic Artery
• artery of the foregut
• Three branches:
▫ Splenic
▫ Common hepatic
▫ Left gastric
• Artery endangered by
ulcer in posterior wall
of first part of the
duodenum?
▫ Gastroduodenal artery
Celiac Trunk
8. Which vessel(s) have reversed flow to permit a
collateral circulation in this patient with chronic hepatitis?
1.
2.
3.
4.
5.
periumbilical veins
left umbilical vein
gastric veins
middle rectal veins
Inferior rectal veins
0%
1
0%
0%
2
3
0%
0%
4
5
Porto-Caval Anastamoses
1. Paraumbilical veins 
superficial veins of
abdominal wall
Caput medusae
2. Superior rectal veins 
Middle and Inferior
Rectal Veins (Inferior
Iliac Vein) Internal
hemorrhoids
3. Gastric veins  Veins of
Lower Esophagus (
Azygous System)
Esophageal varices
1,2,3
9. If the left renal vein becomes occluded near its
termination, which of the following will result?
20%
1.
2.
3.
4.
5.
20%
20%
2
3
20%
20%
caput medusae
esophageal varices
internal hemorrhoids
left varicocele
right varicocele
1
4
5
Memorize major branches/tributaries of the abdominal aorta and IVC as well as
how they relate to each other. Be able to draw this out.
10. When the pain of acute appendicitis moves into the
right lower quadrant from the periumbilical region, which
nerves carry this sensation?
1. visceral afferents from
the foregut
2. visceral afferents from
the midgut
3. visceral afferents from
the hindgut
4. intercostal nerves
0%
1
0%
2
0%
3
0%
4
Referred Pain in Appendicitis
• Initial pain = periumbilical; visceral afferents
from inflamed appendix refer to the T10
dermatome
• Later pain = LRQ; as the parietal peritoneum is
irritated, somatic afferents from intercostal
nerves (subcostal, iliohypogastric, etc.)
transmit well-localized pain
Genitourinary
•
•
•
•
Arterial Supply
Follow the Urinary Tract
Female Reproductive Tract
Male Reproductive Tract
▫ SEVEN UP (Seminiferous Tubules, Epididymus, Vas
Deferens, Ejaculatory Duct, (Nothing), Urethra
and Penis)
• Innervation (Sympathetic and Parasympathetic)
11. If a surgeon were to accidentally lacerate one of the
following, which would involve the least risk of
hemorrhage?
1.
2.
3.
4.
5.
6.
suspensory ligament
mesovarium
mesosalpinx
mesometrium
round ligament
cardinal ligament
0%
0%
1
2
0%
0%
0%
0%
3
4
5
6
Ligaments of the Female Reproductive Tract
• Broad ligament
▫ Mesovarium
▫ Mesosalpinx
▫ Mesometrium
• Suspensory Ligament:
carries ovarian
neurovascular bundle
• Cardinal Ligament:
carries the uterine
artery, situated below
the broad ligament
• Round Ligament (and
Ovarian ligament):
remnant of
gubernaculum
12. What does this hysterosalpingogram demonstrate?
0%
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0%
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0%
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ut
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fis
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0%
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1. uterine fistula
2. endometriosus
3. fallopian tube
obstruction
4. congenital ovarian
agenesis
5. normal anatomy
• the female
reproductive tract
communicates with the
peritoneal cavity via
the fallopian tubes
• a major route for
spread of infection
• basis for abdominal
pregnancy
13. Which of the following is at greatest risk in a
hysterectomy?
uterine artery
ureter
urinary bladder
urethra
rectum
la
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um
0%
re
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...
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e
0%
ur
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hr
a
0%
r
0%
ur
in
ar
e
ar
te
ry
0%
ut
er
in
1.
2.
3.
4.
5.
The Ureter
• Know the path of the ureter
• At risk for damage when the
uterine artery is ligated
• Passes along the posterior
abdominal cavity
• Crosses the external iliac
artery lateral to the internal
iliac artery below the pelvic
brim
• “water under the bridge” passes under the uterine
artery, lateral to the lateral
fornix of the vagina before
entering the urinary bladder
14. Along which nerve(s) do fibers carrying pain from the
prostate travel?
25% 25% 25% 25%
in
. ..
...
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..
1. hypogastric nerve
2. sacral splanchnic
nerves
3. pelvic splanchnic
nerves
4. thoracoabdominal
splanchnic nerves
Visceral Pain
• pain line = lower limit of peritoneum
• above the pelvic pain line, visceral afferents follow
sympathetic fibers
• below the pain line, visceral afferents follow
parasympathetic fibers
• Pelvic splanchnic nerves carry Parasympathetic
fibers
• Sacral splanchnic nerves carry Sympathetic fibers
(as do all other splanchnic nerves)
• Don’t get hung up on pathways for autonomics (i.e.
greater splanchnic  celiac ganglion, etc.; straight
from Dr. Vasan); symptoms are more important
15. Which branch of the internal iliac artery supplies the
superior portion of the bladder?
obturator
umbilical
uterine
vaginal
superior vesicle
0%
su
pe
r
io
rv
es
ic.
..
in
al
0%
va
g
rin
e
0%
ut
e
bi
lic
al
0%
um
at
or
0%
ob
tu
r
1.
2.
3.
4.
5.
The Internal Iliac Artery
• posterior division: superior gluteal,
iliolumbar, lateral sacral
• anterior division: supplies the viscera of the
pelvis from anterosuperior to posteroinferior
The Anterior Division
Obturator Foramen
Obturator
Umbilical ( S. vesicle)
Uterine
Greater Sciatic
Foramen
Vaginal
Middle Rectal
Inferior
Gluteal
Internal
Pudendal
Inferior Vesicle
(in males)
Lower Limb
• Muscles, Actions, and Innervations
• Same kinds of things as upper limb, except…
▫ ligaments are stressed a bit more
▫ the foot matters <<< the hand
▫ In general, somewhat less detail required—
knowing muscle compartment often enough to
define action and innervation
▫ know all major nerve deficits, how to recognize
them, and what structures are involved
16. What action at the hip might be lost if the nerve that
passes through the obturator foramen were damaged?
1.
2.
3.
4.
5.
6.
flexion
extension
adduction
abduction
medial rotation
lateral rotation
0%
0%
1
2
0%
0%
0%
0%
3
4
5
6
Medial Compartment of Thigh
• Innervation: obturator nerve
• Receives blood supply, in part, from the obturator
artery
• Muscles: adductors longus, brevis, and magnus;
gracilis, obturator externis*
• For most muscles, simply knowing the
compartment will tell you its primary action
*The pectineus is the only muscle that contributes to adduction, but is not
innervated by the obturator nerve.
17. If a tumor were to compress the structures that exit
the greater sciatic foramen superior to the piriformis,
which of the following might be lost?
1.
2.
3.
4.
thigh extension
hip abduction
foot eversion
posterior thigh
sensation
5. urinary continence
0%
1
0%
0%
2
3
0%
0%
4
5
Greater Sciatic Foramen
• formed from greater sciatic
notch, closed off inferiorly
by the sacrospinous ligament
and posteromedially by the
sacrotuberous ligament
• the superior gluteal nerve
innervates the gluteus
medius, gluteus minimus,
and tensor of the fascia lata
 all three provide hip
abduction (and medial
rotation); loss = “hip drop”
•
•
•
•
thigh extension = tibial, inferior gluteal;
foot eversion = peroneal (superficial);
posterior thigh sensation = post. femoral cutaneous
urinary continence = pudendal (external urethral sphincter)
18. What action at the hip would be most weakened by
avulsion of the lesser trochanter of the femur?
1.
2.
3.
4.
5.
extension
flexion
abduction
adduction
elevation
0%
1
0%
0%
2
3
0%
0%
4
5
Iliopsoas
• The most powerful flexor of
the hip
Iliacus
• Three muscles: psoas major,
psoas minor, iliacus
• Psoas major and iliacus are
the only muscles that insert Greater
Trochanter
at the lesser trochanter
• Psoas major significant for
signaling apendicitis, route
for spread of infection
to/from thigh
• Greater trochanter: most of
the gluteal muscles; gluteus
medius, minimus, gemelli,
obturator internis, piriformis
Psoas
Major
Lesser
Trochanter
Important Attachment Sites
Greater trochanter
Lesser trochanter
Tibial tuberosity = quadriceps femoris
Ischial tuberosity = hamstrings (except short head of
biceps femoris)
• Base of 5th metatarsal = fibularis brevis
• Base of 1st metatarsal = fibularis longus
•
•
•
•
• For most of the rest, simply knowing the bone (or
general region) should suffice
19. Following injury, if you note ease in abducting the
tibia, causing visual deformity (genu valgum), which
ligament may have been damaged?
1.
2.
3.
4.
5.
anterior cruciate
posterior cruciate
fibular collateral
tibial collateral
patellar
0%
1
0%
0%
2
3
0%
0%
4
5
Ligaments of the Knee
• The knee is the largest and least stable joint of the body;
know the deficits
• ACL = laxity in anterior displacement of tibia; connects
lateral femoral condyle to anterior tibia
• PCL = laxity in posterior displacement of tibia; connects
medial femoral condyle to posterior tibia
• FCL (lateral) = genu varum
• TCL (medial) = genu valgum
• vaLgum = Lateral displacement of distal component
• varum = medial displacement of distal component
• Coxa = hip; genu = knee; hallux = big toe
20. ID this ligament:
1.
2.
3.
4.
5.
anterior cruciate
posterior cruciate
fibular collateral
tibial collateral
patellar
0%
1
0%
0%
2
3
0%
0%
4
5
The ACL and PCL
• The attachments of the ACL and PCL are important to
know; they also explain why lateral rotation of the tibia—
when the knee is bent—is greater than medial rotation
MEDIAL
FEMORAL
CONDYLE
RIGHT KNEE
JOINT FROM
ABOVE
LATERAL
FEMORAL
CONDYLE
TIBIAL
PLATEAU
LATERAL ROTATION
The ligaments become lax
upon lateral rotation and
taut on medial rotation
The ACL and PCL
MEDIAL
FEMORAL
CONDYLE
RIGHT KNEE
JOINT FROM
ABOVE
LATERAL
FEMORAL
CONDYLE
TIBIAL
PLATEAU
ANTERIOR DISPLACEMENT
Only the ACL resists
anterior displacement.
Likewise, only the PCL
resists posterior
displacement.
21. In an individual complaining of “foot drop,” foot
inversion is also weakened, but not abolished. Which
muscle permits continued functionality?
1.
2.
3.
4.
5.
flexor digitorum longus
flexor hallucis longus
tibialis posterior
soleus
gastrocnemius
0%
1
0%
0%
2
3
0%
0%
4
5
Ankle Joint Movements
• “foot drop”: loss of deep fibular
nerve, specifically, but most
common injury occurs to the
common fibular nerve as it winds
around the neck of the fibula
•
•
•
•
Inversion: tibialis anterior and posterior
Eversion: lateral compartment muscles
Plantar flexion: posterior compartment muscles
Dorsiflexion: anterior compartment muscles
22. Which nerve, when damaged, leads to anesthesia over
the plantar surface of the foot?
1.
2.
3.
4.
5.
tibial
deep fibular
superficial fibular
femoral
obturator
0%
1
0%
0%
2
3
0%
0%
4
5
Cutaneous Nerves of the Lower Limbs
• Fairly important to know
• Generally, knowing the
name of the cutaneous
nerve is less important than
knowing the major nerve it
is derived from
• Tibial  medial/lateral
plantar
• Femoral  saphenous
• Know cutaneous distribution
of obturator, superficial
peroneal, deep peroneal
Lymphatics
• Memorize the lymph chart!!
• Also study lower limb drainage
• When in doubt—which there shouldn’t be any—
guess superficial inguinal!
23. To which group of nodes does lymph from the 5th toe
reach first?
1.
2.
3.
4.
5.
popliteal
superficial inguinal
deep inguinal
external iliac
internal iliac
0%
1
0%
0%
2
3
0%
0%
4
5
Lymphatics of the Lower Limbs
• Lymph following the
drainage of the small
saphenous vein  popliteal
( deep inguinal)
• Lymph following the
drainage of the great
saphenous vein 
superficial inguinal
• Lymph following the deep
veins of the legs  deep
inguinal
Embryology
• Gastrointestinal – know foregut, midgut,
hindgut derivatives; rotation
• Urinary – three stages of kidney development
• Reproductive – know the precursors to each
adult structure; know the male/female
homologs
• congenital abnormalities
24. Which of the following is derived from the ventral
mesentery of the stomach?
1.
2.
3.
4.
5.
Greater omentum
Lesser omentum
Splenorenal ligament
Gastrosplenic ligament
Gastrocolic ligament
0%
1
0%
0%
2
3
0%
0%
4
5
Stomach Rotation
• The stomach rotates
clockwise 90° during
development
• Ventral mesentery  lesser
omentum
• Dorsal mesentery  greater
omentum
• The greater omentum can
be divided into gastrocolic,
gastrosplenic,
gastrophrenic, and
occasionally, splenorenal
ligaments
25. Which of the following is derived from an embryo
kidney structure?
1.
2.
3.
4.
5.
uterine tube
prostatic utricle
suspensory ligament
ductus deferens
round ligament
0%
1
0%
0%
2
3
0%
0%
4
5
Urogenital Development
• The urinary tract and
reproductive tract develop in
close association with each
other
• Much of the male reproductive
tract is derived from the
mesonephric duct of the second
set of kidneys (mesonephros),
including the ductus deferens
• Remember: Male = Mesonephric
duct = Medulla-Derived Testis
• Female = Paramesonephric duct
= Cortex-Derived Ovary
26. What restricts the normal ascent of a horseshoe
kidney?
1. inferior mesenteric vein
2. inferior mesenteric
artery
3. fused bladder
4. shortened ureters
0%
1
0%
2
0%
3
0%
4
Horseshoe Kidney
• Because the IMA is the
inferiormost vessel that
branches off the aorta
anteriorly, it will block the
ascent of a horseshoe kidney
• This condition is asymptomatic
Shelf Exam
• The Bad News: cumulative final; limited study
time
• The Good News: you’ve been preparing all
along! The clinical approach the course
directors employ is a good representation of
what you’ll see. Also, questions tend to be less
detail-oriented on the Shelf.
27. A 45-year-old woman has a uterine leiomyoma that is 5 cm in
diameter and is pressing on the urinary bladder, causing urinary
frequency. Which of the following is the most likely location of the
leiomyoma?
20%
20%
20%
2
3
20%
20%
1. cervical canal
2. lateral margin of uterine
cavity
3. subendrometrially in the
uterine cavity
4. subperitoneally on the
anterior surface of the
uterine corpus
5. subperitoneally on the
posterior surface of the
uterine fundus
1
4
5
• First, don’t let the details of the clinical scenario
intimidate you
• Who knows what a leiomyoma is?! Who cares!
• All we need to know is that its pushing on the
bladder and causing increased urinary frequency
• You are well equipped to handle most questions;
don’t assume anything is over your head
• The question is really just a convoluted way to test
our understanding of how the uterus relates to the
bladder
• Process of elimination 
• Cervical canal and
subendometrial are both
inside the uterus
• Lateral margin – too far away
• Subperitoneally – good – on
surface of uterus; anterior or
posterior? anterior – uterus
lies behind the bladder (this is
what they were testing!)
What’s on the Test?
• Go to nbme.org and look for “Basic Science Subject
Examinations” “Content Outline”
• You will find a breakdown of the topics and their
representation; 20 sample questions – do them
• Last year’s exam
• A ton of GI questions
• Very little head and neck – if you dissect the content
outline, this is plausible
• From asking around about previous years, I found this to
be a common observation
Study Suggestions
• My number one suggestion: make learning this unit your
number one priority, since GI and pelvis tend to be strongly
represented
• If you do that, you will leave yourself a day and a half to go
over the first two units (especially unit I)
• Review Books:
• BRS Gross Anatomy: detail can be a bit overwhelming;
focus on the pink boxes; comprehensive exam at end is
fairly representative; chapter exams are somewhat detailoriented
• High-Yield Embryology: embryo is 25 of 150 questions;
high-yield has a reasonable level of detail, no questions
Study Suggestions
• Another good approach: review your TBL’s; the questions tend
to cover the most clinically relevant material
• If you’re really ambitious, you might even consider reading
through the Big Moore Blue Boxes (depending on how
comfortable you are with the basic anatomy)
You’re almost there! Good luck!