The superficial layer of flexor muscles of the forearm all originate from the medial epicondyle of the humerus. Thus, this condition is also called medial epicondylitis and the most common finding is tenderness with palpation over the anterior aspect of the medial epicondyle. The muscles involved are most often the Pronator Teres, Flexor Carpi Radialis, and Palmaris Longus. The Flexor Digitorum Superficialis and Flexor Carpi Ulnaris may also be affected. There is no muscle attachment to the head of the radius (choice A). The lateral epicondyle of the humerus (choice B) is the attachment point of the common extensor tendon. The olecranon process of the ulna (choice D) is the attachment point for the Triceps Brachii, Flexor Carpi Ulnaris, and Anconeus. The tuberosity of the radius (choice E) receives the distal tendon of the biceps brachii.

58) A professional football player was diving for a touchdown when his face mask was grabbed and wrenched, causing neck hyperextension and rotation to the right. When brought to the sideline, the player complained of a burning sensation radiating down the right upper extremity and neurological examination revealed right lateral weakness of this limb. Movements affected were arm rotation and flexion, elbow flexion, forearm supination, and thumb flexion. The patient is diagnosed with a brachial plexus injury at the level of C6.
Which of the following muscles can perform arm and elbow flexion along with forearm supination?

The biceps brachii muscle attaches proximally by its short head to the coracoid process of the scapula and by its long head to the supraglenoid tubercle. Distally it attaches by a strong tendon to the tuberosity of the radius and by an aponeurosis to the ulna. It thus can perform arm and elbow flexion along with forearm supination. The brachialis (choice B) attaches proximally to the anterior aspect of the lower half of the humerus and distally to the coronoid process of the ulna. It can only perform elbow flexion. The brachioradialis (choice C) attaches from the lateral supracondylar ridge of the humerus to the base of the styloid process of the radius. Although innervated by the nerve to the extensor compartment, the radial nerve, it performs elbow flexion and forearm pronation. The coracobrachialis (choice D) attaches from the coracoid process of the scapula to the anterior aspect of the upper half of the humerus. It performs arm flexion and weak adduction. The supinator (choice E) attaches proximally to the lateral epicondyle of the humerus and the annular ligament of the radius. Distally, it covers nearly the upper third of the radius and attaches to its lateral anterior aspect. It supinates the forearm, but is a weaker supinator than the biceps brachii.

59) In cleaning the teeth in a patient, a dental hygienist accidentally cuts the gums of the posterior two molar teeth in the lower jaw on the lateral side. The pain of this injury is registered by which of the following nerves?

The gums on the lateral side of the mandibular molar teeth are innervated by the buccal nerve (long buccal nerve). All three superior alveolar nerves (choice A) supply the gums lateral to all maxillary teeth. The greater palatine nerve (choice C) innervates the gums medial to the maxillary premolar and molar teeth. The lingual nerve (choice D) supplies the gums medial to all mandibular teeth. The nasopalatine nerve (choice E) innervates the gums posterior to the maxillary incisors.

60) Recanalization of the bile duct after the 13th week after fertilization allows for bile produced in the liver to reach the duodenum. However, if recanalization fails to occur and this cannot be corrected surgically, the affected infant will need a liver transplant. During development, the liver arises from which of the following?

The liver arises as a ventral outgrowth from the caudal portion of the foregut. The midgut (choice C) arises past the junction point between the bile duct and the duodenum, distal to the formative outgrowth of the liver. The midgut gives rise to the small intestine and part of the large intestine. The hindgut (choice B) arises further distally and gives rise to the rest of the large intestine, the superior part of the anal canal, the epithelium of the urinary bladder, and most of the urethra. The pleuroperitoneal membrane (choice D) and the septum transversum (choice E) are developmental components of the diaphragm.

62) A 48-year-old female patient is brought to the emergency room by her husband. He reports that his wife suffers from hypertension but, as a high-level executive with a lot of pressure at work, she has been neglecting to take her medication. This morning, as he entered the garage to leave for work, he found his wife lying on the ground next to her own car. She was experiencing uncontrolled flailing of the left arm and leg. What is the most likely site of brain lesion in this patient?

Hemiballismus is a movement disorder characterized by involuntary large amplitude movements of one or both limbs on one side of the body. It results from infarct damage to the contralateral subthalamic nucleus of Luys, in this case the right one. The left subthalamic nucleus (choice D) controls the limbs on the right side of the body, which are not affected in this case. The anterior limbs of the internal capsule (choices A and B) contain mainly thalamocortical and corticothalamic fibers and lesions in these areas do not result in hemiballismus. Lesions in the cerebellum (choice C) also do not result in hemiballismus.

63) During a direct inguinal hernia repair operation, the attending surgeon reminds the firstyear surgical resident that an anatomical variation for the origin of the obturator artery exists. This artery normally arises from the internal iliac artery but it may also originate directly from which of the following vessels?

The obturator artery can originate from the inferior epigastric artery, a location which renders it vulnerable during inguinal hernia surgical repair. The common iliac artery (choice A) only has two branches, the external and internal iliac arteries. Within the pelvis, the external iliac artery (choice B) gives out two branches, the deep circumflex iliac and inferior epigastric arteries. The superior (choice E) and inferior (choice D) vesical arteries are branches of the internal iliac arteries, supplying the bladder.

64) A 37-year-old rural female patient developed pain in the lower abdomen and pelvic regions. Her physician suspects a ruptured ectopic pregnancy. However, because of the isolation of the rural community, no medical imaging or laboratory procedure is available and the physician decides to perform a culdocentesis. In the latter procedure, the needle will aspirate from which of the following spaces?

In culdocentesis, the needle is inserted through the posterior fornix of the vagina and fluid is aspirated from the rectouterine pouch. If nonclotting blood is collected then the likelihood of a ruptured ectopic pregnancy is high. This procedure is rapid and inexpensive, however, serum progesterone level assay or ultrasonography are preferred methods. The ovarian fossa (choice A) or vesicouterine pouch (choice E) are not used in culdocentesis. The uterine body (choice C) and cervix (choice D) would not reveal blood from a ruptured ectopic pregnancy and thus are also not used in culdocentesis.

65) An elderly resident of a nursing home fell down the front steps and subsequently became disoriented and lethargic. He is brought to the emergency room where an emergency MRI reveals that he has developed hydrocephalus due to a small hemorrhage obstructing the foramina of Monro. The foramina of Monro allow for communication between which of the following?