Physician Assistant Written Examination Question Pool - Lower Limb and Back

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Lecture 01: Introduction, Anatomical Position and Planes, Superficial Lower Limb, and Saphenous Opening. (M. Johnson)

Essay - Handwritten Prose. 10 Points Each.

1. A 55-year-old male has complaints of numbness, burning, and tingling of the superolateral thigh. The history and physical examination reports that the patient gained 40 pounds during the past year. A pendulous abdomen is observed. Meralgia paresthetica is diagnosed. Discuss the anatomy of the lateral femoral cutaneous nerve. Explain the difference between peripheral nerve entrapment and spinal nerve entrapment with regard to sensory deficits. How might the patient’s recent weight gain contribute to his condition?

True/False. 1 Point Each.

1. The falciform edge of the saphenous hiatus is immediately anterior to the femoral canal. (False. Anterior to the femoral artery.)
2. The superficial epigastric vein drains the anterior abdominal wall and may become enlarged during portal hypertension. (True. Anastomosis with paraumbilical veins contributing to caput medusae.)
3. The great saphenous vein passes anterior to the lateral malleolus and the lesser saphenous vein passes posterior to the medial malleolus. (False. GSV passes anterior to medial malleolus.)

Lecture 02: Anterior Compartment of Thigh: Femoral Triangle, Adductor Canal. (G. Kincheloe)

Essay - Handwritten Prose. 10 Points Each.

1. A 65 year old man is about to receive a total knee arthroplasty. Why would a nerve block in the adductor canal be favorable to a nerve block in the femoral triangle? Discuss the contents of the femoral triangle and adductor canal. What are the potential effects of administering anesthesia in each area.
2. A patient enters the ED with pain in their right inguinal region. They have adopted a flexed-hip position in an effort to alleviate the pain. Upon inspection, you notice a protrusion on the patient's thigh just inferior to the inguinal ligament. Discuss the anatomy of a femoral hernia? What are the anatomical relationships of the muscular and vascular lacuna as well as the femoral sheath and femoral canal.

True/False. 1 Point Each.

1. The the femoral ring defines the superior entrance into the femoral canal. (True. Medial compartment of femoral sheath.)
2. The femoral artery, within the adductor canal, is deep to the femoral vein. (False. Superficial.)
3. The lateral femoral cutaneous nerve passes through he vascular lacuna. (False. The muscular lacuna.)

Lecture 03: Medial Compartment of Thigh. (R. Saint-Fort)

Essay - Handwritten Prose. 10 Points Each.

1. A 29-year-old female athlete complains of medial knee pain and swelling. A radiograph reveals inflammation of a bursa lying deep to the pes anserinus. Discuss the anatomy of the pes anserinus, the musculature involved, innervation, and anatomical relationships.
2. Two pediatric patients, ages 3 and 15, present with a unilateral hip dislocations. Discuss the arterial distribution to the head of the femur and fovea capitis. Why might there be more concern for one child compared to the other.
3. An 18-year-old male presents to the ED with lower limb ischemia due to acute arterial occlusion of the femoral artery within the adductor canal. The patient was immediately received surgery for adductor canal syndrome. Discuss the adductor canal boundaries, contents, innervation, musculature, and relationships.

True/False. 1 Point Each.

1. Perforating arteries from the deep femoral artery pierce the adductor longus muscle at its insertion along the lateral lip on the linea aspera. (False. Adductor magnus at medial lip linea aspera)
2. The posterior division of the obturator nerve passes anterior to adductor magnus and posterior to adductor longus. (True. Know relationships to adductor brevis.)
3. Adductor magnus is a hybrid (dual innervation) muscle receiving innervation from the obturator nerve for the posterior part. (False. Anterior is obturator and posterior is tibial part of sciatic.)

Lecture 04: Gluteal Region. (M. Johnson)

Essay - Handwritten Prose. 10 Points Each.

1. A penetrating injury to the upper left quadrant of the gluteal region may cause permanent disruption of the gate cycle (Trendelenburg Gait). Describe the anatomical pathways of the superior gluteal nerve and the functional deficits and compensation(s) resulting from injury to this nerve.
2. The piriformis muscle is referred to as the “gateway” to the gluteal region. Indicate your understanding of the piriformis muscle and the short external (lateral) rotator muscles of the hip. Include structure, orientation, relationships, ligamentous support, innervation, vasculature, and lymphatic drainage.

True/False. 1 Point Each.

1. The pudendal nerve, as it travels from proximal to distal, enters the gluteal region by passing through the lesser sciatic foramen and enters the ischiorectal fossa by passing through the greater sciatic foramen. (False. Enters gluteal region by passing through the greater sciatic foramen.)
2. The superior and inferior gemellus muscles converge onto the tendon of obturator internus and all three muscles act to medially rotate the hip. (False. Laterally rotate the hip.)
3. The inferior cluneal nerves are derived from ventral rami and the superior cluneal nerves are derived from dorsal rami. (True. Tough one.)

Lecture 05: Posterior Compartment of the Thigh and Popliteal Fossa. (L. Urbanik)

Essay - Handwritten Prose. 10 Points Each.

1. An 84-year-old woman fell and fractured her left ischial tuberosity. Discuss the anatomy of the posterior compartment of the thigh, including bony landmarks, muscle attachments, actions, innervation, vasculature, relationships and provide an account of symptoms the woman may experience as a result of her injury.
2. A 32-year-old man suffers a laceration posterior to his right knee. He has extreme difficulty flexing his right knee and a loss of sensation on the posterior aspect of his right leg. Discuss the anatomy of the popliteal fossa, including boundaries, contents, musculature, vascular supply, innervation, lymphatics and relationships. Account for the symptoms he is reporting.

True/False. 1 Point Each.

1. The superior medial genicular artery passes through the adductor hiatus. (True. Tough one.)
2. Holding the thigh in extension while testing the strength of knee flexion provides an assessment of the peroneal (fibular) portion of the sciatic nerve. (True. Short head of the biceps is monoarticulate and, thus, not weakened by hip extension.)
3. The hamstring part of the adductor magnus qualifies as a hamstring muscle. (False. Not biarticulate. Tricky.)

Lecture 06: Posterior Compartment of the Leg. (M. Olsen)

Essay - Handwritten Prose. 10 Points Each.

1. Dr. Bollard presented a clinical case illustrating compartment syndrome of the posterior compartment of the leg. Discuss the anatomy of the posterior compartment of the leg. Include musculature, vasculature, innervation, and relationships. What symptoms indicate that the neurovasculature is compromised due to compression of the posterior compartment?

True/False. 1 Point Each.

1. The tendon of flexor hallucis longus passes through the most posterior/inferior tunnel of the flexor retinaculum. (True. Tom, Dick, and a very nervous Harry.)
2. The soleus muscle has two heads of origin and a superior free edge that provides passageway for the tibial nerve into the deep compartment of the posterior leg. (True. Possible site of entrapment. There is something fishy about this question.)
3. The heads of the gastrocnemius muscle receive blood supply from the sural arteries and nerve supply from the sural nerves. (False. Sural arteries is correct. Diabolical.)

Lecture 07: Lateral and Anterior Compartments of the Leg, Dorsum of the Foot. (G. Francis)

Essay - Handwritten Prose. 10 Points Each.

1. A 22-year-old basketball player landed on another player’s foot, causing rapid dorsiflexion of the ankle while in an inverted state. The patient’s has pain on the plantar surface and point tenderness of fibular tendons. Radiography reveals a displacement of an os peroneum 13mm proximal to the region of the peroneal tubercle. Rupture of the fibularis longus tendon is suspected. Discuss the lateral compartment of the leg, including boundaries, muscles, nerves, and vascular supply for this compartment. Include the actions of the muscles of this compartment and the terminal cutaneous branches of the superficial fibular nerve.
2. A 32-year-old male presents with swelling in the anterior leg and ache. The patient has loss of sensation between the 1st and 2nd toe. Dorsalis pedis pulse is absent. The patient is diagnosed with anterior compartment syndrome. Discuss the anatomy of the anterior compartment of the leg. Why is there loss of sensation in the region between the first two toes. Why is the dorsalis pedis pulse absent.

True/False. 1 Point Each.

1. The superficial fibular nerve provides cutaneous sensation to the space between the first and second toes. (False. Deep peroneal nerve does this.)
2. Branches of the superficial fibular nerve and of the deep fibular nerve provide cutaneous sensation to the entirety of the dorsum of the foot. (False. Sural nerve supplies the lateral dorsum.)
3. The anterior intermuscular septum of the leg is the lateral boundary of the anterior leg compartment. (True. And the anterior boundary of the lateral compartment.)

Lecture 08: Sole of Foot. (L. Urbanik)

Essay - Handwritten Prose. 10 Points Each.

1. A 31-year-old male stepped on a nail. The nail entered distal to the calcaneus and proximal to the base of the 1st metatarsal. Discuss structures related to the medial longitudinal arch including bones, ligaments, muscles, and neurovasculature. Which structures could be compromised?

True/False. 1 Point Each.

1. The sustentaculum tali provides a pulley for the tendon of flexor hallucis longus. (True.)
2. The spring ligament (plantar calcaneonavicular ligament) is superior to the tendon for flexor hallucis longus and inferior to the head of the talus. (True. The spring ligament is the staple for the keystone.)
3. The lateral plantar nerve and artery travel superior to flexor digitorum brevis and inferior to quadratus plantae. (True. Vulnerable to pes planus.)

Lecture 09: Joints of the Lower Limb. (J. Radler)

Essay - Handwritten Prose. 10 Points Each.

1. An 18-year-old football player is struck on the posterior lateral aspect of the knee. He has a positive anterior drawer sign (forward displacement of the tibia). There is tenderness and laxity of the medial knee to valgus stress. Discuss the anatomy of the knee joint. Include bones, cartilage, and ligaments. What injury is indicated by the positive anterior drawer sign. Why is there medial laxity during a valgus stress test to the knee. What structures are likely damaged by this injury?
2. The passenger of a sports car was thrown forward during an acute deceleration. A posterior dislocation of the hip joint was confirmed. Discuss the anatomy of the hip joint. Include bones, cartilage, and ligaments. What structures are likely injured?

True/False. 1 Point Each.

1. Standing upright at rest is metabolically efficient because ligaments, not muscles, counteract the force of gravity at the hip and knee joints. (True. Triceps surae are active at ankle.)
2. The anterior cruciate ligament prevents posterior displacement of the tibia relative to the femur. (False. Anterior displacement.)
3. When the knee is fully extended and weight bearing (locked knee joint), contraction of the popliteus muscle causes medial rotation of the femur to unlock the knee joint. (False. Lateral rotation of the femur unlocks the knee.)

Lecture 10: Back: Surface Anatomy, Vertebral Column. Vertebral Canal and Meninges. (N. Yoshioka)

Essay - Handwritten Prose. 10 Points Each.

1. A 67-year-old male has bilateral lower extremity weakness, numbness, and tingling. Lumbar spinal stenosis is confirmed. Describe the anatomical structures of the vertebral column that would be cut during a laminectomy. Include bony landmarks, ligaments, vasculature, and innervation. Relate the anatomical differences between spinal and neuroforaminal stenosis to the patient’s symptoms.
2. A 12-year-old female has severe headache, fever, and neck stiffness. A lumbar puncture is performed. Describe the anatomy of the vertebral column and spinal canal at vertebral level L4. Include bony landmarks, ligaments, vasculature, and innervation. Describe the fascial layers penetrated during lumbar puncture.

True/False. 1 Point Each.

1. Rotation of the trunk occurs through gliding movement of the facet joints of the lumbar vertebral column. (False. Lumbar vertebrae primarily allow for flexion and extension.)
2. The artery of Adamkiewicz is critical for augmenting blood supply to the posterior spinal cord and can result in paraplegia (paralysis of lower extremities) if ligated. (False. Affects anterior spinal cord (motor). Anterior segmental artery.)
3. The pars interarticularis can be located at the intersection of the pedicle, lamina, and superior and inferior articular processes of a vertebra. (True. Neck of Scotty dog.)

Lecture 11: Muscles of the Back: Superficial, Intermediate, and Deep. (M. Pearce-Clawson)

Essay - Handwritten Prose. 10 Points Each.

1. A 26-year-old bodybuilder presents with muscular adhesions near the superior angle and medial border of the scapula. Manual therapy is prescribed to release adjacent neurovascular structures entrapped by scar tissue. Discuss the anatomy of the superficial back muscles. Include origin, insertion, relationships, innervation, and movements.

True/False. 1 Point Each.

1. Contraction of the superior fibers of trapezius paired with contraction of the inferior fibers of trapezius causes downward rotation (depression of glenoid fossa) of the scapula. (False. Upward rotation.)
2. Iliocostalis, a deep muscle of the back, is innervated by the dorsal rami of spinal nerves. (True. Original dorsal musculature.)
3. Levator scapulae is crossed by the spinal accessory nerve (cranial nerve eleven) on its medial side and by dorsal scapular nerve on its lateral side. (False. The reverse.)

Lecture 12: Suboccipital Region. (N. Morales)

Essay - Handwritten Prose. 10 Points Each.

1. Discuss the contents, structure, relationships, innervation (sensory and motor), vasculature, lymphatics, and clinical significance of the suboccipital triangle.

True/False. 1 Point Each.

1. The greater occipital nerve enters the back along the inferior margin of the obliquus capitis inferior muscle. (True. Suboccipital nerve enters within triangle.)
2. The vertebral artery leaves the suboccipital triangle as it passes through the anterior atlantooccipital membrane. False. Posterior atlantooccipital membrane.)
3. The greater occipital nerve is reliably located lateral to the occipital artery superior to the level of the superior nuchal line. (False. The greater occipital nerve and occipital artery intermingle superior to the superior nuchal line.)

Lecture 13: Introduction to Embryology. (N. Yoshioka)

Essay - Handwritten Prose. 10 Points Each.

1. None. You are, however, welcome to include embryology into your essay answers for credit. Doing so is optional

True/False. 1 Point Each.

1. None.

Lecture 14-15: Spinal Cord Clinical Anatomy and Function Part 1-2. (M. Johnson)

Essay - Handwritten Prose. 10 Points Each.

1. A 57-year-old patient presents with sudden onset of low back pain after lifting a heavy object, followed by motor and sensory deficits in the lower limb, saddle anesthesia, and incontinence. An MRI indicates a herniated intervertebral disc between L4 and L5 vertebrae. Cauda equina syndrome is diagnosed. Discuss the anatomy of the conus medullaris and cauda equina. Briefly account for each of the patient’s symptoms.
2. A 60-year-old patient has low back pain and sensory deficits in the lower limbs. Magnetic Resonate Imaging (MRI) indicates a tumor within the vertebral canal in the lower thoracic region causing compression of the posterior column of the spinal cord. Discuss the posterior column of the spinal cord at the lower thoracic level. Include the name of the tract, the sensory system it carries, the regions of the spinal cord in which it is present, and if the fibers travel in the ipsilateral or contralateral tract of the spinal cord.
3. A 75-year-old patient experiences hypoperfusion during thoracic surgery due to prolonged cross-clamping of the aorta. The patient begins to experience motor dysfunction in the lower limbs a couple of weeks after surgery. An MRI scan revealed a hyperintensity of the ventral horns of the spinal cord and was diagnosed with Anterior Spinal Artery Syndrome. What portions of the spinal cord are supplied by the anterior spinal artery? Describe the pathway and function of the lateral corticospinal tract.

True/False. 1 Point Each.

1. The artery of Adamkiewicz is critical for augmenting blood supply to the posterior spinal cord in the cervical region. (False. Affects anterior spinal cord (motor). Lower thoracic and lumbar region. Anterior segmental artery.)
2. A lesion of the corticospinal tract causes an upper motor neuron lesion and is characterized by disinhibition of spinal reflexes. (True. For example; Babinski Reflex. Hyperreflexia post spinal shock.)
3. Lower motor lesions affecting anterior horn motor cells and/or their processes is characterized by hyporeflexia. (True. Disrupts spinal reflexes.)