GET

THROUGH
First FRCR:
Questions for the
Anatomy Module
This page intentionally left blank
 GET
THROUGH
First FRCR:
Questions for the
Anatomy Module
Dr Grant Mair – BSc (Hons), MB ChB, MRCS
Specialist Trainee in Radiology: The Royal Infirmary of Edinburgh, UK
Previously, Anatomy Demonstrator: Otago University, Dunedin, New Zealand

Dr Andrew J Baird – MB ChB, MRCS

Specialist Trainee in Radiology: The Royal Infirmary of Edinburgh, UK

Consultant editors
Dr Judith M Anderson – MB ChB, MRCP, MSc, FRCR
Consultant Radiologist: The Royal Infirmary of Edinburgh, UK

Dr Gordon S Findlater – BSc (Hons), PhD

Head of Anatomy: University of Edinburgh, UK
First published in Great Britain in 2011 by
Hodder Arnold, an imprint of Hodder Eduction, an Hachette UK company,
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 CONTENTS
Preface vii
Bibliography viii
Abbreviations ix

1 HEAD AND NECK Questions 1

Answers 41
2 THORAX Questions 64
Answers 94
3 UPPER LIMB Questions 116
Answers 136
4 ABDOMEN Questions 147
Answers 168
5 PELVIS Questions 183
Answers 202
6 LOWER LIMB Questions 212
Answers 232
7 MOCK EXAM Questions 246
Answers 266

Index 276

v
This book is dedicated to Suzanne and Mairi,
to thank them for their patience.
 PREFACE

Early in 2010 the Royal College of Radiologists re-introduced anatomy as a separate

module in the First FRCR examination to be completed in conjunction with the
revised physics module which was introduced the previous year. Anatomy is now
examined in an electronic image viewing session. Candidates are required to answer
a total of 100 questions based on the anatomy identifiable in a series of 20 different
radiological images (5 questions per image) sourced from a variety of modalities:
namely, radiography, fluoroscopy, ultrasound, CT and MRI (including multi-planar
sections). Notably, endoscopic/body cavity ultrasound and nuclear medical images
are excluded from this new anatomy syllabus. Further detailed information relating
to the examination can be viewed on the Royal College website at www.rcr.ac.uk.
We are both Specialty Trainees in Radiology on the South East Scotland training
scheme. When compiling this book we have endeavoured to recreate the question
format that candidates are likely to encounter in the anatomy module of the First
FRCR examination. Answers and explanations are provided for each question,
and while these are not exhaustive, it is hoped that they will clarify the salient
anatomical points and form a basis for further reading if required. Unless otherwise
stated, our explanations were written with reference to the anatomical textbooks
listed in the bibliography. While attempting to cover the curriculum we have also
concentrated on subject areas felt to be most important or relevant, in addition to
including what could be termed ‘exam favourites’. Chapters are divided according
to anatomical regions rather than body systems as this is more representative of the
imaging that is encountered in everyday practice. As a result, some of the systems
(e.g. vascular, neurological and spinal) are covered over two or more chapters.
Dr Judith Anderson is Consultant Radiologist at the Royal Infirmary of
Edinburgh and an Educational Supervisor for the South East Scotland radiology
training scheme.
Dr Gordon Findlater is Head of the Department of Anatomy at the University
of Edinburgh. Both have maintained great enthusiasm for this project in spite of
the frequent challenges, problems and deadlines presented to them by the authors.
Their guidance and assistance have been essential to the creation of this book and
we are indebted to them both.

Finally, we wish you every success in the exam!

Grant Mair
Andrew Baird
Edinburgh

vii
 BIBLIOGRAPHY

Abrahams PH, Hutchings RT and Marks SC. McMinn’s Color Atlas of Human
Anatomy, 4th Ed. London: Mosby, 1998

Alty J, Hoey E, Wolstenhulme S and Weston M. Practical Ultrasound: an Illustrated

Guide. London: RSM Press, 2006

Butler P, Mitchell A and Ellis H. Applied Radiological Anatomy. Cambridge:

Cambridge University Press, 2007

Hansen JT. Netter’s Anatomy Flash Cards, 2nd Ed. Philadelphia: Saunders Elsevier,
2007

Marieb EN and Hoehn KH. Human Anatomy & Physiology, 7th Ed. San Francisco:
Pearson Education, 2007

Moore KL and Agur AMR. Essential Clinical Anatomy. Baltimore: Williams &
Wilkins, 1996

Raby N, Berman L and de Lacey G. Accident and Emergency Radiology: A Survival

Guide. Philadelphia: Saunders Elsevier, 2003

Ryan S, McNicholas M and Eustace S. Anatomy for Diagnostic Imaging, 2nd Ed.
Philadelphia: Saunders Elsevier, 2004

Sinnatamby CS. Last’s Anatomy Regional and Applied, 10th Ed. Edinburgh:
Churchill Livingstone Harcourt, 2001

Standring S. Gray’s Anatomy, The Anatomical Basis of Clinical Practice, Expert

Consult – Online and Print, 40th Ed. Philadelphia: Churchill Livingstone Elsevier,
2008

Weir J, Abrahams PH, Spratt JD and Salkowski LR. Imaging Atlas of Human
Anatomy, 4th Ed. Philadelphia: Mosby Elsevier, 2010

Weissleder R, Wittenberg J, Harisinghani MG and Chen JW. Primer of Diagnostic

Imaging, 4th Ed. Philadelphia: Mosby Elsevier, 2007

viii
 ABBREVIATIONS

ACJ Acromioclavicular joint MLO Medio-lateral oblique

ACL Anterior cruciate ligament mm Millimetre
AIIS Anterior inferior iliac spine MRA Magnetic resonance
AP Antero-posterior angiography
ASIS Anterior superior iliac spine MRCP Magnetic resonance
AV Atrio-ventricular cholangiopancreatography
C1–8 Cervical spinal levels (C8 is MRI Magnetic resonance
neural level only) imaging
CBD Common bile duct N1–3 Cancer staging criteria for
CFV Common femoral vein lymph nodes
CISS Constructive interface in OM Occipito-mental
steady state (gradient echo OPG Orthopantomogram
MRI sequence) PA Postero-anterior or
cm Centimetre pulmonary artery
CN I–XII Cranial nerves 1–12 PB Peroneus brevis
CRL Crown-rump length PCL Posterior cruciate ligament
CSF Cerebrospinal fluid PDA Posterior descending artery
CT Computed tomography PL Peroneus longus
CTPA CT pulmonary angiogram PUJ Pelvi-ureteric junction
CXR Chest x-ray PV Pulmonary veins
DDH Developmental dysplasia of RAO Right anterior oblique
the hip RCA Right coronary artery
EDL Extensor digitorum longus S1–5 Sacral spinal levels
EHL Extensor hallucis longus SA Sino-atrial
FDL Flexor digitorum longus SCM Sternocleidomastoid
FDP Flexor digitorum profundus SI Sacro-iliac
FDS Flexor digitorum SMA Superior mesenteric artery
superficialis SMV Superior mesenteric vein
FHL Flexor hallucis longus SVC Superior vena cava
IAM Internal auditory meatus T1–12 Thoracic spinal levels
IMA Inferior mesenteric artery T1W/T2W T1/T2 weighted MRI
IV Intravenous TA Tibialis anterior
IVC Inferior vena cava TMJ Temporomandibular joint
IVU Intravenous urogram TP Tibialis posterior
L1–5 Lumbar spinal levels True FISP True fast imaging with
LAD Left anterior descending steady state precession
LAO Left anterior oblique (MRI sequence)
LCA Left coronary artery VUJ Vesico-ureteric junction
ix
This page intentionally left blank
 1 HEAD AND NECK

Q1
a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure which fills the space labelled E

1
 Q2
Chapter 1 HEAD AND NECK – Questions

a Name the structure labelled A

b Name the triangular space labelled B
c Name the structure labelled C
d Name the foramen labelled D
e Name the bony ridge labelled E

2
Q3

Chapter 1 HEAD AND NECK – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the suture labelled C
d Name the structure labelled D
e Name the structure labelled E

3
 Q4
Chapter 1 HEAD AND NECK – Questions

a Name the skull layer identified with label A

b Name the suture labelled B
c Name the structure that runs along the bony groove identified as C
d Name three structures that pass through D
e Name the structure labelled E

4
Q5

Chapter 1 HEAD AND NECK – Questions

a Name the structure labelled A
b Name the suture labelled B
c Name the H-shaped suture complex labelled C
d Name the structure labelled D
e Name the suture labelled E

5
 Q6
Chapter 1 HEAD AND NECK – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name all the left upper teeth lying lateral to B
d Name the structure labelled D
e Name the structure labelled E

6
Q7

Chapter 1 HEAD AND NECK – Questions

a Name the most radio-opaque part of the tooth labelled A
b Name the three constituent parts of a tooth as defined by B
c Name the structure labelled C
d Name the structure labelled D
e Name the radiolucent line seen around each tooth below the gumline

7
 Q8
Chapter 1 HEAD AND NECK – Questions

a Name the foramen labelled A

b Name the foramen labelled B
c Name the foramen labelled C
d Name the structure labelled D
e Name the structure labelled E

8
Q9

Chapter 1 HEAD AND NECK – Questions

a Name the structure labelled A
b Name the foramen labelled B
c Name the foramen labelled C
d Name the foramen labelled D
e Name the structure that passes through the foramen labelled E

9
 Q10
Chapter 1 HEAD AND NECK – Questions

a Name the bone labelled A

b Name the bony ridge labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the suture labelled E

10
Q11

Chapter 1 HEAD AND NECK – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structures labelled D
e Name the structure labelled E

11
 Q12
Chapter 1 HEAD AND NECK – Questions

a Name the artery which supplies the vascular territory indicated by A

b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E, which has been highlighted with a grey line

12
Q13

Chapter 1 HEAD AND NECK – Questions

a Name the fissure labelled A
b Name the CSF space labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the CSF space labelled E

13
 Q14
Chapter 1 HEAD AND NECK – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

14
Q15

Chapter 1 HEAD AND NECK – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the space which has been measured
e Describe how blood gets from A to C

15
 Q16
Chapter 1 HEAD AND NECK – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the structures labelled D
e Name the part of the brainstem demonstrated on this slice

16
Q17

Chapter 1 HEAD AND NECK – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the fissure labelled C
d Name the structure labelled D
e Name the structure labelled E

17
 Q18
Chapter 1 HEAD AND NECK – Questions

a Name the constituent parts of the structure labelled A

b Name the structure labelled B
c Name the structure situated between A and B
d Name the structure labelled D
e Name the structure labelled E

18
Q19

Chapter 1 HEAD AND NECK – Questions

a Name the structure labelled A
b Name the two structures situated between A and the insular cortex
c Name the CSF channel labelled C
d Name the structure labelled D
e Name the structure labelled E and its two constituent parts

19
 Q20
Chapter 1 HEAD AND NECK – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C and what it connects
d Name the structures labelled D
e Name the structure labelled E

20
Q21

Chapter 1 HEAD AND NECK – Questions

a Name the structures labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structures labelled E

21
 Q22
Chapter 1 HEAD AND NECK – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

22
Q23

Chapter 1 HEAD AND NECK – Questions

a Name the structure labelled A
b Name the structure labelled B
c Describe the movement provided by the muscle labelled C
d Name the structure labelled D
e Name the opening labelled E

23
 Q24
Chapter 1 HEAD AND NECK – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the CSF filled space containing C in this image
e Name the structure outlined and labelled E

24
Q25

Chapter 1 HEAD AND NECK – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structures labelled C
d Name the structure labelled D
e Name the structure labelled E

25
 Q26
Chapter 1 HEAD AND NECK – Questions

a Name the vertebral body labelled A

b Name the normal variant demonstrated and labelled as B
c Name the structure outlined by calcification and labelled C
d Name the structure labelled D
e Name the structure labelled E

26
Q27

Chapter 1 HEAD AND NECK – Questions

a Name the upper limit of normal size in adults for the space labelled A
b Name the structures labelled B
c Name the structures labelled C
d Name the structure labelled D
e Name the structure labelled E

27
 Q28
Chapter 1 HEAD AND NECK – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

28
Q29

Chapter 1 HEAD AND NECK – Questions

a Name the structure labelled A
b Name the line labelled B
c Name the inter vertebral space labelled C
d Name the structure labelled D
e Name the structure labelled E

29
 Q30
Chapter 1 HEAD AND NECK – Questions

a Name the structure labelled A

b Name the structures labelled B
c Name the structure labelled C
d Name the major structure that travels through the foramen labelled D
e Name the vertebral level demonstrated

30
Q31

Chapter 1 HEAD AND NECK – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure which holds C against A

31
 Q32
Chapter 1 HEAD AND NECK – Questions

a Name the structure labelled A

b Name the space labelled B
c Name the muscle labelled C
d Name the space labelled D
e Name the structure labelled E

32
Q33

Chapter 1 HEAD AND NECK – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structures labelled E

33
 Q34
Chapter 1 HEAD AND NECK – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the echogenic structure labelled D
e Name the constituent part of structure A that passes over structure D

34
Q35

Chapter 1 HEAD AND NECK – Questions

a Name the structure labelled A
b Name the structure labelled B
c What is the significance of the line drawn and labelled C
d Name the structure labelled D
e Name the structure labelled E

35
 Q36
Chapter 1 HEAD AND NECK – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the three major structures which pass through the gland labelled C
d Name the structure labelled D
e Name the structure labelled E

36
Q37

Chapter 1 HEAD AND NECK – Questions

a Name the cranial nerve that supplies motor function to the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

37
 Q38
Chapter 1 HEAD AND NECK – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the osseous structure labelled D
e Name the structure labelled E

38
Q39

Chapter 1 HEAD AND NECK – Questions

a Name the structure labelled A
b Name the structures labelled B
c Name the muscle group labelled C
d Name the distal structure to which B contribute
e Describe the relationship between structures B and C within the root of the neck

39
 Q40
Chapter 1 HEAD AND NECK – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name three of the commonly described branches of B
d Name the structure through which D passes at the segment labelled
e Name the vessel from which the left common carotid artery arises

40
 1 HEAD AND NECK
– ANSWERS

Q1 Answers
a Frontal sinus
b Maxillary sinus
c Sphenoid sinus
d Mastoid air cells
e Interspinous ligament

Radiograph of adult skull, lateral view

The paranasal sinuses should be radiolucent on plain radiography in adults; they

can be filled with fluid and/or soft tissue in cases of trauma or disease. In children,
the paranasal sinuses are much smaller (maxillary and ethmoidal) or even non-
existent (sphenoid and frontal) at birth and progressively pneumatize with age;
this is usually complete by the early teen years. The mastoid air cells are normally
pneumatized throughout life.
Several ligaments hold the vertebrae together. Most superficially, the
supraspinous ligament runs across the tips of the spinous processes and in this
region is continuous with the ligamentum nuchae. Deep to this and between
adjacent spinous processes lie the interspinous ligaments. Ligamentum flavum
covers the internal space between vertebral bodies posteriorly within the spinal
canal. The posterior longitudinal ligament runs along the posterior aspect of the
vertebral bodies while the anterior longitudinal ligament runs along their anterior
aspect.

Scuderi AJ, Harnsberger HR, Boyer RS. Pneumatization of the paranasal sinuses: Normal features
of importance to the accurate interpretation of CT scans and MRI images. Am J Roentgenol 1993;
160:1101–1104.

41
 Q2 Answers
Chapter 1 HEAD AND NECK – Answers

a Frontal sinus
b Superior orbital fissure
c Innominate line
d Foramen rotundum
e Petrous ridge

Occipito-frontal facial radiograph

This view demonstrates the frontal and ethmoid sinuses well.

Projected within the orbit it is possible to discern the greater and lesser (more
medial) wings of sphenoid and the triangular superior orbital fissure in between.
The innominate line represents the lateral edge of the greater wing of sphenoid. The
foramen rotundum lies beneath the superior orbital fissure.

Q3 Answers
a Maxillary sinus (or antrum)
b Lamina papyracea
c Fronto-zygomatic suture
d Zygomatic arch
e Coronoid process of mandible

Occipito-mental (OM) radiograph

The OM view is used to evaluate the facial bones; it provides excellent visualization
of the zygomatic arches and maxillary sinuses. The zygomatic arch is formed via
a union of the temporal and zygomatic bones and is said to have the appearance
of an elephant’s trunk on an OM radiograph. The zygoma forms the prominence
of the cheek and it also articulates with the frontal and maxillary bones via
appropriately named sutures.
The medial wall represents the thinnest bony part of the orbit and is aptly named
the lamina papyracea, meaning paper layer. The ethmoid bone forms most of the
medial orbital wall but there are also contributions from the lacrimal, sphenoid and
frontal bones.

Q4 Answers
a Diploic layer
b Sagittal suture
c Right transverse venous sinus
d The following all pass through the foramen magnum: junction of medulla and

42
 Chapter 1 HEAD AND NECK – Answers
cervical spinal cord, vertebral arteries, spinal arteries and veins, spinal root of the
accessory nerve (CN XI), meninges, menigeal branches of vertebral arteries.
e Petrous ridge

Towne’s view (antero-posterior (AP) fronto-occipital projection)

The Towne’s view is directed in parallel with the antero-medial skull base and
projects the frontal bones over the occipital bones. The facial bones are largely
obscured although a Towne’s view provides good visualisation of the mandibular
condyles.
Skull bones are formed as two parallel layers of cortex surrounding a spongy
cancellous layer known as the diploe. Numerous diploic veins connect the intra and
extra-cranial vascular spaces.

Q5 Answers
a Anterior fontanelle
b Coronal suture
c Pterion
d Anterior clinoid process
e Lambdoid suture

Skull radiograph in a child of 16 months, lateral view

The skull sutures are unfused in utero, allowing the cranial shape to change during
delivery. Antero-superiorly where the coronal suture meets the midline sagittal
suture there is initially a defect in bone formation known as the anterior fontanelle.
Closure of the anterior fontanelle is variable, but is usually complete by 24 months
of age. Where the sagittal suture meets the lamboidal suture posteriorly there is a
further defect known as the posterior fontanelle; this usually closes by two months
of age. In adulthood, the remnant fontanellae are known anteriorly as the bregma
and posteriorly as the lambda.
The weakest point in the adult skull is laterally at the junction of the frontal,
temporal, sphenoidal and parietal bones. This H-shaped suture configuration is
known as the pterion. Clinically this is important as blunt trauma to this region is
more likely to result in fracture and importantly, the middle meningeal artery lies
immediately beneath the pterion and can also be damaged.
The paired anterior clinoid processes are a posterior projection from the lesser
wing of sphenoid. There are also paired posterior clinoid processes; these arise
from the dorsum sellae of the sphenoid bone. The four clinoid processes provide
attachment for structures around the pituitary fossa including the diaphragma
sellae.

Aisenson MR. Closing of the anterior fontanelle. Pediatrics 1950; 6:223–226.

43
 Q6 Answers
Chapter 1 HEAD AND NECK – Answers

a Condylar process of the mandible

b Medial incision, left upper quadrant
c Lateral incisor, canine, 1st and 2nd premolars and 1st, 2nd and 3rd molars (3rd
is unerupted)
d Anterior arch of C1
e Mandibular canal

Orthopantomogram (OPG)

The OPG provides a single image of the entire dentition, lower maxilla and
mandible. This is achieved through a form of tomography where the image is taken
whilst moving round the patient. In addition to the structures described, an OPG
also usually shows the anterior aspect of the upper cervical spine, maxillary sinuses,
nasal septum and hyoid (all seen on this image).
Adult teeth number 32 (20 deciduous teeth in childhood) and are usually divided
into quadrants of eight for descriptive purposes (left and right upper and lower).
In each quadrant there is a medial and lateral incisor, a canine, two premolars and
three molars. The third molar may remain unerupted well into adulthood (wisdom
teeth).
The mandibular canal carries the inferior alveolar artery and nerve (a branch of
CN V3) which exit the mandible via the mental foramen (not shown here).

Q7 Answers
a Enamel
b Crown, neck and root
c Dentine
d Pulp cavity
e Periodontal membrane

Radiograph of upper and lower right teeth in an adult, zoomed up image

Each tooth is composed of a crown (above the gumline), a neck and a root. Teeth
are primarily formed from dentine which is similar to compact bone. The inner
core of a tooth is composed of soft tissues (and is therefore more radiolucent) and
is known as the pulp cavity. Beneath the gumline, the division between tooth and
surrounding bone is highlighted by the very dense bone of the lamina dura lying
immediately outside the radiolucent line of the periodontal membrane of the
tooth. The intra-oral part of each tooth (crown) is covered by dense radio-opaque
enamel which is the hardest part of the tooth. Defects to the enamel (usually as a
consequence of decay) are repaired with dental fillings; these are dense and appear
radio-opaque on radiography (as shown).

44
Q8 Answers

Chapter 1 HEAD AND NECK – Answers

a Foramen rotundum
b Foramen ovale
c Foramen spinosum
d Condylar process of the mandible
e Frontal process of the zygoma

CT with bone windows at level of skull base, axial section

The skull base is generally symmetrical across the midline sagittal plane and its
many foramina are clearly visible on CT. On each side, the foramen rotundum
(more rounded appearance than foramen ovale) transmits the second (maxillary)
branch of the trigeminal nerve (CN V). Postero-lateral to this, the foramen ovale
transmits the third (mandibular) division of the trigeminal nerve. Immediately
postero-lateral again sits the foramen spinosum; this allows passage of the middle
meningeal artery (a branch of the maxillary artery).

Q9 Answers
a Clivus
b Carotid canal
c Jugular foramen
d Foramen magnum
e Hypoglossal nerve

CT with bone windows at level of skull base, axial section

The clivus represents the posterior aspect of the sphenoid bone and forms part of
the anterior wall of the posterior cranial fossa. The pons sits immediately posterior
to the clivus.
The carotid artery takes a tortuous course through the skull base; it enters the
skull via the carotid canal traversing the foramen lacerum (seen on this image
just medial to the carotid canal as a ragged opening) to enter the cranial cavity.
Immediately thereafter, the carotid artery enters the venous cavernous sinus where
it makes several turns before entering the subarachnoid space to divide into its
terminal branches.
In addition to the jugular vein, the jugular foramen transmits cranial nerves
IX (glossopharyngeal), X (vagus) and XI (accessory). The hypoglossal canal lies
medial to and below the jugular foramen and transmits the hypoglossal nerve (CN
XII). The foramen magnum is the major and only unpaired opening in the cranial
floor and allows the medulla to continue caudally as the spinal cord. In addition,
the vertebral arteries enter the skull via this route along with the spinal root of
CN XI.

45
 Q10 Answers
Chapter 1 HEAD AND NECK – Answers

a Frontal bone
b Lesser wing of sphenoid
c Dorsum sellae
d Mastoid air cells
e Lambdoidal suture

CT with bone windows showing cranial fossae, axial section

The cranium is divided into three fossae which are arranged in a stepwise fashion
from front to back. The anterior cranial fossa, containing the frontal lobes of
the cerebral hemispheres, is at the highest level and lies between the frontal
bones anteriorly and the sphenoid ridge (formed by the lesser wing of sphenoid)
posteriorly. The base of the anterior cranial fossa is predominantly formed by the
orbital plates of the frontal bones separating the frontal lobes of the brain from the
orbits. In the midline the perforated cribriform plates of the ethmoid bone enable
olfactory nerve fibres to pass from the nasal cavity to the olfactory bulbs. The floor
of the middle cranial fossa is formed anteriorly by the greater wing of sphenoid
and posteriorly by the petrous part of the temporal bone; the petrous ridge defines
its posterior limit. The middle cranial fossa supports the anterior aspect of the
temporal lobes. The posterior cranial fossa is formed largely by the occipital bone
and contains the cerebellum.
The dorsum sellae is the posterior part of the bony cavity formed to house the
pituitary gland and arises from the body of the sphenoid bone.
It is important to recognize the various skull sutures and their normal locations
as fractures can have similar appearances.

Q11 Answers
a Superior sagittal sinus
b Confluence of sinuses
c Straight sinus
d Internal cerebral veins
e Inferior sagittal sinus

CT venogram, maximum intensity projection, midline sagittal view

The dural venous sinuses exist between the two layers of dura and allow drainage
of blood from the brain. Superficial cerebral veins coalesce into larger vessels (e.g.
the superior anastomotic vein of Trolard, and the inferior anastomotic vein of
Labbe) and then tend to drain via the superior sagittal or transverse sinuses. Deep
cerebral veins such as the internal cerebral veins coalesce to form the great cerebral
vein (of Galen) which combines with the inferior sagittal sinus to form the straight
sinus. The superior sagittal sinus combines with the straight sinus at the confluence
of sinuses. From here, venous blood drains via the transverse sinuses (one side is
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 Chapter 1 HEAD AND NECK – Answers
usually dominant and therefore larger), through the sigmoid sinuses and into the
internal jugular veins bilaterally. Anteriorly, venous blood from the ophthalmic and
superficial middle cerebral veins as well as from the sphenoparietal sinus collects
in the cavernous sinuses. The cavernous sinuses are situated on either side of the
body of sphenoid and each contains the first intracranial part of the internal carotid
artery and the abducent nerve (CN VI). The occulomotor (CN III), trochlear (CN
IV), plus ophthalmic and maxillary branches of the trigeminal nerve (CN V) course
through the lateral wall of the cavernous sinuses. Blood ultimately drains from the
cavernous sinuses through the superior and inferior petrosal sinuses. The superior
petrosal runs along the anterior margin of the tentorium cerebelli at the petrous
ridge to reach the distal transverse sinus where it continues as the sigmoid sinus.
The inferior petrosal drains more inferiorly joining the distal sigmoid sinus as it
becomes the internal jugular vein.

Q12 Answers
a Anterior cerebral artery
b Head of the caudate
c Third ventricle
d Ambient cistern
e Internal capsule

CT brain scan, axial section at the level of the third ventricle

Vascular territories of the brain are best demonstrated diagrammatically; an in-

depth description is beyond the scope of this text.
The caudate nucleus is a long thin structure with a head, body and tail. Its course
is compliant with that of the lateral ventricle. The caudate is composed of grey
matter and is considered one of the basal ganglia which as a group are concerned
with movement as part of the extra-pyramidal system.
Cerebrospinal fluid (CSF) is produced through ultrafiltration of blood plasma by
choroid plexus; most is produced in the lateral ventricles. CSF flows from the lateral
ventricles to the midline third ventricle through the interventricular foramina (of
Monro); from here it passes through the midbrain via the cerebral aqueduct to the
fourth ventricle posteriorly. Once in the fourth ventricle, CSF will pass either to
the sub-arachnoid space (predominantly) via the medial and lateral apertures of
Magendie and Luschka, respectively, or in a caudal direction through the central
canal of the spinal cord. The named ventricles and several subarachnoid cisterns are
visible on CT. The ambient cisterns extend around both sides of the midbrain and
communicate posteriorly with the quadrigeminal cistern. The posterior cerebral
arteries pass through the ambient cisterns.
The internal capsule represents white matter tracts connecting the cerebral
cortices with the brainstem and spinal cord. The anterior and posterior limbs meet
at the genu (meaning knee) and form a V shape which is visible on axial CT slices.
Both primary motor and sensory pathways for the entire body are concentrated
in the anterior two thirds of the posterior limb; the upper body is represented
anteriorly towards the genu while the lower body is represented more posteriorly.
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 Q13 Answers
Chapter 1 HEAD AND NECK – Answers

a Sylvian fissure
b Pontine/interpeduncular cistern
c Pons
d Middle cerebellar peduncle
e Fourth ventricle

Contrast enhanced CT head, axial section at the level of the fourth ventricle

The sylvian fissure (or lateral sulcus) separates the frontal and temporal lobes and
contains branches of the middle cerebral artery. The pontine cistern is continuous
with the interpeduncular cistern above and the foramen magnum below and
contains the basilar artery. Due to the angulation of this CT image (parallel
with skull base) the CSF space shown contains elements of both pontine and
interpeduncular cisterns.
The pons is recognizable by its anterior bulge (‘pot belly’ appearance when
seen in sagittal section) and by the largest of the cerebellar peduncles (middle)
connecting it posteriorly with the cerebellum (also forming the lateral walls of the
fourth ventricle).

Q14 Answers
a Interhemispheric fissure containing falx cerebri
b Cingulate gyrus
c Sylvian fissure
d Cavum septum pellucidum
e Insular cortex

Ultrasound of neonatal brain, coronal section

Prior to closure of the anterior fontanelle it is possible to visualize the neonatal

brain using ultrasound.
The two cerebral hemispheres meet in the midline and are separated by the
interhemispheric (great longitudinal) fissure. The falx cerebri is a double dural layer
running through this fissure connecting the superior and inferior sagittal venous
sinuses. The inferior border of the interhemispheric fissure is bounded by the
corpus callosum. The first major gyrus superior to and running parallel with the
corpus callosum (best seen on sagittal view) is the cingulate gyrus. Functionally the
cingulate gyri are part of the limbic system.
Cavum septum pellucidum is a normal variant where CSF is found between the
septi pellucidum in the midline. The insular cortex lies deep to the sylvian fissure
(or lateral sulcus).

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Q15 Answers

Chapter 1 HEAD AND NECK – Answers

a Cerebral hemisphere, frontal/parietal lobe
b Origin of falx cerebri
c Superior sagittal sinus
d Subarachnoid space
e Superficial cerebral veins drain to the superior sagittal sinus

Ultrasound of neonatal brain, coronal section with close up view of subarachnoid

space

As part of the assessment of the neonatal brain using ultrasound, the subarachnoid
spaces are measured. The subarachnoid space is filled with CSF and surrounds the
brain. Multiple bridging cerebral veins cross the subarachnoid space and drain
into the venous sinuses. The arachnoid layer is usually closely adherent to the
more superficial dura. Only a potential space exists between these layers; however
this potential space can become real if the bridging cerebral veins are damaged
leading to a subdural haemorrhage. The third meningeal layer is the pia and it is
closely adherent to the brain surface and separated from the arachnoid layer by the
aforementioned CSF filling the subarachnoid space.

Q16 Answers
a Intra-conal fat
b Temporal (inferior) horn of the right lateral ventricle
c Basilar artery
d Posterior communicating arteries
e Midbrain

T2W MRI of head, axial section

The extra-ocular muscles are arranged as a cone; this configuration is used to define
intra and extra-conal compartments within the orbit.
The circle of Willis supplies arterial blood to the brain and is formed when
the basilar and the right and left internal carotid arteries divide at the base of the
brain. The basilar divides to form right and left posterior cerebral arteries, while
each internal carotid divides to form an anterior and a middle cerebral artery.
Posterior communicating arteries link the posterior and middle cerebral vessels
bilaterally while the anterior communicating artery completes the circle (of Willis)
by connecting the two anterior cerebral arteries. This configuration of anastomoses
between the anterior and posterior arterial blood supplies to the brain provides the
potential for collateral flow if part of the circulation is compromised.
The midbrain can be recognized in axial cross section by identification of the two
cerebral peduncles anteriorly which are separated by the interpeduncular cistern.
Posteriorly the midbrain has four rounded prominences, the superior and inferior
colliculi (also known as the corpora quadrigemini).
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 Q17 Answers
Chapter 1 HEAD AND NECK – Answers

a Hippocampus
b Basilar artery
c Sylvian fissure
d Insula
e Corpus callosum

T2W MRI of brain, coronal section at level of the hippocampi

The limbic system describes a number of structures including the hippocampus,

amygdala, cingulate gyrus, mammillary body and fornix (to name only a few)
which are grouped as two C-shaped arches located medially in the cerebral
hemispheres. They are functionally related, all being involved with emotion,
memory and instinctive behaviour. Many of these structures are recognizable on
MRI. The hippocampus is best seen in the coronal plane as a curved elevation in the
floor of the inferior horn of the lateral ventricle. The parahippocampal gyrus lies
inferior to the hippocampus and forms the infero-medial part of the temporal lobe.
The insular cortex forms the floor of the lateral sulcus (sylvian fissure); its function
is not clearly defined but is related to the limbic system.
The corpus callosum is the largest of the commissural white matter tracts
(commisures link corresponding parts of the two hemispheres) and is best
demonstrated on a midline sagittal view.

Q18 Answers
a Rostrum, genu, body and splenium of the corpus callosum
b Fornix
c Septum pellucidum
d Sphenoid sinus
e Soft palate

TW1 MRI, midline sagittal section

The corpus callosum is the largest of the commissural white matter tracts. The
genu (or knee) is the bend at its anterior end. Inferior to the genu is the rostrum,
posterior to the genu running horizontally is the body of the corpus callosum, while
the splenium is its bulbous posterior part.
The fornices are white matter tracts which run from the hippocampi postero-
laterally to converge on the thalamus anteriorly near the midline.
Between the corpus callosum and the fornices lies the septi pellucidum. These
paper thin structures form the medial wall of the lateral ventricles. Often the two
septi pellucidum are opposed anteriorly in the midline; if there is a CSF filled space
between them it is known as cavum septum pellucidum.

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 Chapter 1 HEAD AND NECK – Answers
Of the four paired paranasal sinuses, the sphenoid and frontal sinuses are visible
in the midline.
The roof of the oral cavity is known as the palate and is composed of hard and
soft parts. The hard palate is formed by the palatine processes of the maxillae
and the paired palatine bones and composes the anterior two thirds of the palate.
The soft palate is a mobile fibro-muscular continuation of the hard palate which
prevents food from passing up into the nasal cavity during swallowing.

Q19 Answers
a External capsule
b Claustrum and extreme capsule
c Foramen of Monro
d Thalamus
e Lentiform nucleus composed of globus pallidus and putamen

T2W MRI of brain at level of third ventricle, axial section

The internal capsule is a white matter tract and forms a V-shape on axial section
with the point directed towards the midline. Medial to the anterior limb of this V
is the head of the caudate nucleus while the thalamus lies medial to the posterior
limb and lateral to the third ventricle. Lateral to the internal capsule on this view
is the lentiform nucleus. Like the caudate nucleus, the lentiform nucleus is one of
the paired basal ganglia which as a group are functionally involved with movement.
The lentiform is lens-shaped when viewed on axial section, hence the name. The
constituent parts of the lentiform nucleus are (from medial to lateral) globus
pallidus and putamen. The external capsule is a further white matter tract lying
lateral to the lentiform nucleus. Lateral to the external capsule, in order, are the
claustrum (further paired basal ganglia), the extreme capsule and finally the insular
cortex.

Q20 Answers
a Massa intermedia of thalamus
b Mamillary body
c Cerebral aqueduct (of Sylvius) allows CSF to flow from 3rd to 4th ventricles
d Superior and inferior colliculi
e Median aperture (of Magendie)

T2W MRI of brain zoomed up image, midline sagittal section

The massa intermedia connects the left and right thalami in the midline. CSF
within the third ventricle flows around the massa intermedia within the third
ventricle.

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Chapter 1 HEAD AND NECK – Answers

The mamillary bodies are part of the limbic system and connect with the fornices
bilaterally. The mamillary bodies are in the roof of the interpeduncular cistern.
The colliculi are paired as two superior and two inferior. They form four masses
of tissue situated as the corners of a square on the posterior aspect of the tectal plate
of the midbrain. Functionally, the colliculi are concerned with reflexes by acting as
relay pathways; the superior relate to vision, the inferior to hearing.

Q21 Answers
a Superior and inferior colliculus
b Tentorium cerebelli
c Left superior cerebellar peduncle
d Vermis
e Folia

T1W MRI through cerebellum and 4th ventricle, coronal section

The cerebellum lies in the posterior fossa of the cranium and is separated from the
cerebral hemispheres by the tentorium cerebelli, an invagination of dura between
the cerebral and cerebellar hemispheres similar to the falx cerebri in the sagittal
midline. The cerebellum lies posterior to the brain stem and the two are connected
by three paired peduncles, named superior, middle and inferior. Between these
peduncles and between the cerebellum and brainstem is the 4th ventricle. The two
cerebellar hemispheres are joined in the midline by the vermis. Each hemisphere is
divided into anterior, posterior and flocculonodular (inferior) lobes; the nodule lies
at the end of the vermis near the floor of the 4th ventricle. The cerebellar surface is
highly convoluted, the gyri are known as folia (as in foliage or leaves).

Q22 Answers
a Interpeduncular cistern
b Crus cerebri
c Red nucleus
d Superior colliculus
e Substantia nigra

T1W MRI at level of midbrain, axial section

The crus cerebri are white matter tracts that run from the internal capsule to the
pons over the antero-lateral aspect of the midbrain. The cerebral peduncle is the
whole of the midbrain excluding the tectum (superior and inferior colliculi). A
CSF cleft is formed between the paired cerebral peduncles anteriorly known as
the interpeduncular cistern; occult subarachnoid haemorrhage can sometimes be
found here.

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 Chapter 1 HEAD AND NECK – Answers
The red nuclei and substantia nigra are both concerned with motor function; the
substantia nigra is considered one of the basal ganglia. The red nuclei are usually
found at the level of the superior colliculi.
The cerebral aqueduct (of Sylvius) may be seen on an axial section of midbrain
between the red nuclei and superior colliculus as an area of CSF signal intensity
(this is just visible on the image provided).

Q23 Answers
a Superior oblique muscle
b Posterior ethmoid sinus
c The inferior rectus muscle provides downward (and medial) rotation of the
eyeball
d Inferior nasal concha (or turbinate)
e Maxillary ostium (part of the ostiomeatal complex)

T1W MRI through posterior orbits and paranasal sinuses

The eye moves through the function of six muscles. These are named superior,
inferior, medial and lateral rectus and the superior and inferior oblique muscles.
The recti muscles pull the eye in the direction they are situated. The oblique
muscles are named counter intuitively as the superior depresses the eye while the
inferior raises it. Most of these muscles are supplied by the occulomotor nerve
(CN III), except the lateral rectus and superior oblique which are supplied by the
abducent (CN VI) and trochlear nerves (CN IV), respectively.
The three paired nasal conchae (superior, middle and inferior) are separated
by spaces known as meati. The paranasal sinuses are situated around the nasal
cavity and also drain into it. They are paired and include the frontal, ethmoid
(with anterior, middle and posterior parts), sphenoid and maxillary sinuses. The
maxillary sinus drains from its superior medial aspect via the maxillary ostium
into the ethmoid infundibulum which in turn drains into the middle meatus of the
nasal cavity. These structures are collectively known as the ostiomeatal complex.
The nasolacrimal duct running from the medial angle of the eye also drains into the
nasal cavity (inferior meatus).

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 Q24 Answers
Chapter 1 HEAD AND NECK – Answers

a Cochlea
b Lateral (or horizontal) semicircular canal
c Vestibular nerve (superior or inferior)
d Internal auditory meatus
e Cerebello-pontine angle

T2W MRI of middle ear structures, zoomed up high resolution axial section

Structures in the internal auditory meatus (IAM) can be well visualized on high
resolution T2W MRI scans (using IAM specific sequences, e.g. CISS (constructive
interface in steady state).
Four nerves run through the IAM and depending on the level of the axial
section are usually visualized as two superior and two inferior nerves running in
parallel. With a more superiorly orientated section, the facial nerve is seen anterior
to the superior division of the vestibular nerve (CN VII and one of the three
branches of CN VIII, respectively). With a slightly inferiorly orientated section
the cochlear nerve is seen anterior to the inferior division of the vestibular nerve
(both branches of CN VIII, the vestibulocochlear nerve). This orientation may be
difficult to appreciate on axial section as the superior and inferior nerves lie very
close together (the two anterior nerves seem to cross over on the image provided).
For identification purposes, remember that the vestibular nerves lie posterior to the
facial and cochlear nerves. To ease orientation and identification of the individual
nerves, images can be reformatted and viewed in an oblique sagittal section. In this
scenario the nerves are orientated as the four corners of a square.
The cochlea lie antero-medial to the semicircular canals within the petrous
portion of the temporal bone.
There are three semicircular canals; anterior, posterior and lateral. The lateral
(or horizontal) canal is orientated in-plane with an axial section; the other two
are orientated vertically with respect to the horizontal canal and at 90 degrees to
one another. The posterior canal runs in parallel with the petrous ridge, while the
anterior canal lies at 90 degrees to the petrous ridge.

Q25 Answers
a Meckel’s cave
b Trigeminal nerve
c Superior cerebellar peduncles
d Pons
e Anterior temporal lobe

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T2W MRI showing trigeminal nerve origin, oblique axial section

Chapter 1 HEAD AND NECK – Answers

The trigeminal nerve (CN V) arises from the pons and passes anteriorly into
Meckel’s cave where it forms the trigeminal ganglion. Meckel’s cave is a CSF filled
space lined by dura which lies postero-lateral to the cavernous sinus on the antero-
medial aspect of the petrous temporal bone.
The superior cerebellar peduncles arise from the midbrain but run infero-
posterioly and are therefore visualized on this oblique view through the upper pons.

Kamel HAM and Toland J. Trigeminal Nerve Anatomy: Illustrated Using Examples of Abnormalities. Am
J Roentgenol 2001; 176:247–251.

Q26 Answers
a C7 vertebra
b Bifid spinous process of C4 vertebra
c Thyroid cartilage
d Hyoid bone
e Angle of mandible

Radiograph of C-spine, AP view

Individual vertebrae can be distinguished on an AP cervical radiograph by

counting up from T1, which is the first to articulate with a rib (bear in mind C7 can
sometimes articulate with a normal variant cervical rib, but this is usually much
shorter than the typical upper thoracic ribs). Often, the dens of C2 is also visible
and enables vertebral identification from the top.
The laryngeal cartilages can calcify with age and this makes their identification
on plain radiography possible. The thyroid cartilage is the largest of the laryngeal
cartilages. Each lamina of the thyroid cartilage lies antero-lateral to the vocal cords
and their associated cartilages, providing protection and support. These laminae
slope outwards from below as shown and meet in the midline at the laryngeal
prominence (also known as Adam’s apple). The thyroid cartilage is connected to the
hyoid bone above via the thyrohyoid membrane and to the cricoid cartilage below
via the cricothyroid ligament. It is the top free edge of the cricothyroid membrane
that forms the vocal cord. In the mid-line running between the arch of the cricoid
and the inferior aspect of the thyroid cartilage is a thickening of the cricothyroid
membrane called the cricothyroid ligament.
The hyoid bone divides the neck into infra and supra-hyoid regions and provides
anchorage for a number of muscles in the anterior neck. The hyoid is active during
swallowing and speech.

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 Q27 Answers
Chapter 1 HEAD AND NECK – Answers

a 3mm
b Zygapophyseal (facet) joint spaces
c Calcification within laryngeal cartilages
d Prevertebral soft tissues
e Spinous process of C7 (vertebra prominens)

Radiograph of neck, lateral view

The distance between the anterior arch of C1 and the dens of C2 should be less
than 3mm in adults and can be up to 5mm in children. Disruption of the joint may
be indicated by widening of this space.
The cervical spine is more mobile than other parts of the vertebral column; the
obliquely orientated superior and inferior facets allow rotation, flexion/extension
and lateral bending. Facet joints are also known as zygapophyseal joints. On a true
lateral view, the facet joints should run in parallel with one another.
The prevertebral soft tissues of the neck usually measure only a few millimetres
anterior to the vertebral bodies of C1–4. Below this level the prevertebral layer
expands (primarily due to the oesophagus) and when measured is usually
equivalent in size to the corresponding vertebral body. Another way to remember
this is with the phrase ‘7 at 2 and 2 at 7’; this translates as 7mm of soft tissue at the
C2 level and 2cm of soft tissue at the C7 level. Trauma, infection and malignancy
can all enlarge the prevertebral soft tissue.
The spinous process of C7 is the largest of all cervical vertebrae and so is also
named vertebra prominens; this may be useful when trying to identify a particular
vertebra if the provided views are limited.

Q28 Answers
a Dens (odontoid peg) of C2
b Lateral mass of C1
c Superior articular facet of C2
d C2–3 interspace
e Reparative ‘filling’ in left lower molar tooth

Radiograph of odontoid peg, AP open mouth view

With an open mouth view, the dens of C2 is seen to lie centrally between the two
lateral masses of C1. The vertebral body and spinous process of C2 are also usually
seen. There is some overlap from the dentition and mandible on this view; these
features should be recognized.

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Q29 Answers

Chapter 1 HEAD AND NECK – Answers

a Body of C2 vertebra
b Anterior vertebral line
c C7/T1 joint (interspace)
d 1st rib
e Posterior border of the scapula

Radiograph of cervical and upper thoracic spine, lateral ‘swimmers’ view

On a lateral c-spine radiograph, overlap of the shoulders can restrict visualization

of the C7/T1 joint. The swimmers view places the patient with one arm up and the
other down (as if in mid stroke of front crawl or freestyle) to minimize this bony
overlap.
Several vertical lines can be used to assess spinal alignment including the anterior
vertebral line which joins the anterior aspects of the vertebral bodies.
It is important to recognize the other overlapping bony contours seen on this
view such as the humerus, scapula, clavicle and ribs.

Q30 Answers
a Body of hyoid bone
b Tubercles (anterior and posterior) of left transverse process
c Pedicle
d Vertebral artery
e C3

CT of neck with bone windows at level of hyoid and C3 vertebra, axial section

The hyoid bone has a body which curves in the midline and two greater horns
which articulate laterally with the body. The stylohyoid ligaments attach to the
lesser horns (not shown) of the hyoid. The hyoid lies at the C3 vertebral level.
A typical cervical vertebra is shown (C3). The major differences between cervical
and other vertebrae are the inclusion of formina in the transverse processes and
also the existence of anterior and posterior tubercles arising from the transverse
processes. The transverse foramina allow transmission of the vertebral arteries to
the skull; these are usually accompanied by veins and sympathetic nerves.

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 Q31 Answers
Chapter 1 HEAD AND NECK – Answers

a Anterior arch of C1
b Lateral mass of C1
c Dens
d Posterior arch of C1 (neural arch)
e Transverse ligament of C1

CT of neck with bone windows at level of C1 vertebra, axial section

The first cervical vertebra is also known as the atlas as it ‘holds up’ the skull. The
atlas is unusual by virtue of not having a vertebral body (the body has become
detached from C1 and has fused with the body of C2 to form the dens); it is
composed of two lateral masses and an anterior and a posterior arch. Note that the
posterior arch is not considered to be composed of right and left lamina as in other
vertebrae.
The dens is a superior projection of C2 which enables rotation of C1 on C2
(therefore termed the axis vertebra). The dens is held in place by a strong transverse
ligament known as the transverse ligament of the atlas. This ligament is continuous
with two vertical bands of connective tissue joining the occipital bone superiorly
and the body of C2 inferiorly. Collectively these three ligaments form a cross over
the posterior aspect of the dens known as the cruciform ligament.

Q32 Answers
a Anterior arch of C1 vertebra
b Nasopharynx
c Mylohyoid muscle
d Laryngopharynx
e Oesophagus

CT of neck with bone windows, midline sagittal section

The nasopharynx is the posterior extension of the nasal cavity and lies superior to
the soft palate; it begins at the nasal chaonae which are the posterior openings of
the nasal cavity. The oropharynx is continuous with the oral cavity and extends
to the epiglottis. Inferior to the epiglottis, in continuity with and extending to the
trachea is the laryngopharynx. The larynx contains the vocal cords.
The floor of the mouth is formed by the mylohyoid muscle which closes the
inferior opening of the mandible and functionally acts to elevate the tongue, floor
of mouth and hyoid when swallowing and speaking.

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Q33 Answers

Chapter 1 HEAD AND NECK – Answers

a Epiglottis
b Greater horn of hyoid bone
c Thyroid cartilage
d Cricothyroid membrane forming vocal cords
e Cartilaginous tracheal rings

CT scan through larynx shown with bone windows, coronal section

The larynx connects the pharynx with the trachea and contains the vocal cords.
Several cartilaginous structures compose the larynx. The thyroid cartilage provides
antero-lateral coverage of the vocal cords, while the epiglottic cartilage acts like a
lid to cover the larynx when swallowing. The arytenoid cartilages sit on either side
of the midline on the lamina of the cricoid cartilage. Attached to the anteriorly
projecting vocal processes of the arytenoid are the vocal cords; movement here
leads to changes in the length and tension of the vocal cords which is the means
for vocalizing. The corniculate and cuneiform cartilages are very small structures
attached to the arytenoid cartilage, these are not usually individually discernable
with CT. The cricoid cartilage lies between the thyroid cartilage above and the
trachea below and is the only complete ring of cartilage in the larynx or trachea.

Q34 Answers
a Right lobe of thyroid
b Sternocleidomastoid muscle
c Internal jugular vein
d Tracheal ring
e Isthmus of the thyroid

Ultrasound scan through right lobe of thyroid, axial section

The thyroid gland has two lobes which lie on either side of the trachea just inferior
to the thyroid cartilage at the level of C5 to T1. These lobes are joined in the
midline by an isthmus. The thyroid is enclosed within the pretracheal fascia and
hence moves with the trachea during swallowing. Strap muscles (sternohyoid and
sternothyroid) cover the thyroid and are visible in the image provided.
Immediately lateral to the thyroid lie the internal carotid arteries. Antero-
lateral to these are the internal jugular veins. These major blood vessels to the
head are protected throughout their superficial course within the neck by the
sternocleidomastoid muscle.
The trachea is supported anteriorly by C-shaped arches of hyaline cartilage.
These prevent the trachea from collapsing and are brightly echogenic on
ultrasound.

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 Q35 Answers
Chapter 1 HEAD AND NECK – Answers

a Pons
b Pituitary fossa containing the pituitary gland
c Skull base lines (McRae’s line defines the opening of the foramen magnum)
enable confirmation that cranial contents remain within the skull and also that
there is not invagination of the dens of C2 from below.
d Superior medullary velum
e Epiglottis

T2W MRI, midline sagittal section

The pons is recognizable on midline sagittal section by its large anterior bulge
(‘pot belly’); this is composed of the cerebellopontine fibres which extend postero-
laterally on either side to form the middle cerebellar peduncles.
The pituitary gland is a midline structure which rests within the bony sella
turcica on the superior aspect of the sphenoid. On T1W weighted MR imaging the
posterior lobe of the pituitary gland is normally high signal.
A thin layer of tissue extends between the superior cerebellar peduncles to form
the roof of the 4th ventricle; this is known as the superior medullary velum.

Q36 Answers
a Parapharyngeal space
b Medial pterygoid muscle
c The facial nerve, external carotid artery and retromandibular vein pass through
the parotid gland
d Internal carotid artery
e Masseter muscle

T1W MRI of neck at level of parotid glands, axial section

The parapharyngeal space is a triangular fatty filled area situated lateral to the
pharynx and anterior to the major blood vessels for the head. It is important to
recognize this area because it can be readily displaced and/or infiltrated by disease.
There are four muscles of mastication and these all attach to the mandible. Only
the masseter muscle lies lateral to the mandible. The medial and lateral pterygoid
muscles are so named because of their origin medial and lateral to the lateral
pterygoid plate (an inferior process of the sphenoid bone). The medial pterygoid
attaches distally to the medial aspect of the mandibular ramus, while the lateral
pterygoid attaches to the neck of the mandible. The fourth muscle of mastication is
the temporalis.
The parotid gland is the largest of the three paired salivary glands and sits
between the ramus of the mandible and the mastoid process and extends down to
the angle of the mandible with both a deep and a superficial lobe. The facial nerve

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 Chapter 1 HEAD AND NECK – Answers
(CN VII) divides into its terminal branches within the parotid gland, therefore
disease within the parotid can lead to ipsilateral facial palsy (lower motor neurone).
The other major structures which can be seen passing through the parotid gland are
the external carotid artery and the retromandibular vein (formed from the union of
superficial temporal and maxillary veins).

Q37 Answers
a Hypoglossal nerve (CN XII)
b Epiglottis within oropharynx
c Vertebral artery
d Upper cervical spinal cord
e Sternocleidomastoid muscle

T1W MRI through neck at level of C2/3, axial section

Immediately posterior to the tongue is the oropharynx. This channel provides

combined passage for both the foods we eat and the air we breathe. At rest the
oropharynx is open to both the oesophagus and the trachea simultaneously. As
a food bolus is propelled backwards by the muscular action of the tongue, the
swallowing reflex is instigated. The hyoid bone rises in the midline bringing the
epiglottis down over the laryngeal opening. Constriction of the pharyngeal muscles
forces the food inferiorly where it is directed into the oesophagus.

Q38 Answers
a Sternocleidomastoid muscle
b Splenius muscle
c Trapezius muscle
d Spine of scapula
e Supraspinatus muscle

T1W MRI of posterior neck and shoulder muscles, coronal view

Each splenius muscle is composed of two parts (capitis and cervicis) which act as
a single functional group. When both sides contract together they act to extend
the head and neck. Independently, the splenius will perform lateral flexion and
rotation of the neck to the same side. Lateral flexion also involves the ipsilateral
sternocleidomastoid as well as other neck muscles.
The trapezius muscle covers the superior aspect of the shoulder and
functionally is used to shrug the shoulders (upper fibres). The trapezius and
sternocleidomastoid are innervated by the accessory nerve (motor, CN XI) and
branches from the cervical plexus (sensory, C3/4).

61
 Q39 Answers
Chapter 1 HEAD AND NECK – Answers

a Sternocleidomastoid muscle
b Left lower anterior cervical nerve roots
c Scalene muscles
d Brachial plexus
e The brachial plexus nerve roots leave the root of the neck by passing between the
anterior and medial scalene muscles

T1W MRI of neck showing brachial plexus nerve roots, coronal view

The brachial plexus provides nerve supply to the upper limb. It is formed from the
anterior nerve roots of C5 to T1. These nerve roots pass between the anterior and
medial scalene muscles to exit the root of the neck. The subclavian artery follows
the same path between anterior and medial scalene muscles; the subclavian vein
passes anterior to the scalenus anterior muscle. The scalene muscles also include
scalenus posterior.

Q40 Answers
a Vertebral artery
b External carotid artery
c There are eight commonly described branches of the external carotid artery,
these are: superior thyroid, ascending pharyngeal, lingual, facial, occipital,
posterior auricular, superficial temporal and maxillary arteries
d Foramen lacerum within the petrous bone
e Aortic arch

Magnetic resonance angiography (MRA) of major head and neck arteries, anterior
view

The major vessels supplying the head and neck are the paired common carotid and
vertebral arteries.
The vertebral arteries arise from the subclavian arteries in the root of the neck.
They course through the transverse formina of C6 to C1 vertebrae before entering
the cranium via the foramen magnum to form the basilar artery in the midline. The
vertebral arteries give off no branches in the neck.
The left common carotid artery arises directly from the aortic arch, while the
right common carotid is one of the terminal branches of the brachiocephalic
artery; the other is the right subclavian artery. At the level of C3/C4, both common
carotid arteries bifurcate into their internal and external branches. The internal
carotid begins postero-lateral to the external carotid artery. The internal carotid
provides no branches within the neck, instead heading straight for the carotid
canal in the skull base. Once through the carotid canal, the internal carotid artery
turns 90 degrees antero-medially and passes through the foramen lacerum within

62
 Chapter 1 HEAD AND NECK – Answers
the petrous temporal bone. Turning superiorly once again, the internal carotid
enters the cavernous sinus within the cranial vault and undergoes two final turns
before terminating as the anterior and middle cerebral arteries. The external
carotid provides arterial blood to the upper neck, face (including scalp) and
nasopharynx. There are eight commonly described branches of the external carotid
artery (superior thyroid, ascending pharyngeal, lingual, facial, occipital, posterior
auricular, superficial temporal and maxillary arteries), but individual variation is
described.

63
 2 THORAX

Q1
a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

D C

B
A

64
Q2

Chapter 2 THORAX – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the angle outlined and labelled E

65
 Q3
Chapter 2 THORAX – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the motor nerve supply of the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

66
Q4

Chapter 2 THORAX – Questions

a Name the structure labelled A
b Name the structures located superior and inferior to the structure labelled A
c Name the airway labelled C
d Name the structure labelled D
e Name the anatomical variant demonstrated in this image

67
 Q5
Chapter 2 THORAX – Questions

a Name the lymph node station indicated by label A

b Name the lymph node station indicated by label B
c Name the lymph node station outlined and indicated by label C
d Name the lymph node station indicated by label D
e Name the anatomical variant demonstrated on this image

68
Q6

Chapter 2 THORAX – Questions

a Name the structure that lies in position A
b Name the structure that lies in position B
c Define the normal measurement of line C
d Name the structure labelled D
e Name the normal constituents of the structure outlined and labelled E

69
 Q7
Chapter 2 THORAX – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structures labelled C
d Name the structure labelled D
e Name the structure labelled E

70
Q8

Chapter 2 THORAX – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

71
 Q9
Chapter 2 THORAX – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the region outlined and labelled C
d Name the structure labelled D
e Name the structure labelled E

72
Q10

Chapter 2 THORAX – Questions

a Name the structure labelled A
b Name the joint space labelled B
c Name the joint positioned lateral to B
d Name the structure labelled D
e Name the structure labelled E

73
 Q11
Chapter 2 THORAX – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structures labelled C
d Name the tissue predominant in the area labelled D
e Name the type of structure labelled E

74
Q12

Chapter 2 THORAX – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

75
 Q13
Chapter 2 THORAX – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

76
Q14

Chapter 2 THORAX – Questions

a Name the structure that creates the impression labelled A
b Name the structure that creates the impression labelled B
c Name the structure crossing the midline (right to left) posteriorly to the
oesophagus at the level labelled C
d Name the linear structures labelled D
e Name the nodal group into which lymph from the oesophagus drains at
position E

77
 Q15
Chapter 2 THORAX – Questions

a Name the structure labelled A

b Name the parent artery whose branches supply the structure labelled A
c Name the vertebral level at the point labelled C
d Name the nerve(s) which crosses the diaphragm at the point labelled C
e Name the structure labelled E

78
Q16

Chapter 2 THORAX – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

79
 Q17
Chapter 2 THORAX – Questions

a Name the structure labelled A

b Define the upper limit of normal diameter of the structure labelled B
c Name the nerve located at the site labelled C
d Name the vertebral level of the corresponding diaphragmatic opening for the
structure labelled D
e Name the additional structure(s) that cross the diaphragm through the same
opening as structure D

80
Q18

Chapter 2 THORAX – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D (pointing at right carotid)
e Name the anatomical variant demonstrated in this image

81
 Q19
Chapter 2 THORAX – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

82
Q20

Chapter 2 THORAX – Questions

a Name the structure outlined and labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

83
 Q21
Chapter 2 THORAX – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

84
Q22

Chapter 2 THORAX – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

85
 Q23
Chapter 2 THORAX – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the structure that courses cranio-caudally anterior to the structure
labelled C
e Name the structure that courses cranio-caudally posterior to the structure
labelled C

86
Q24

Chapter 2 THORAX – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the muscle group labelled D
e Name the substance which is seen in greater abundance with increasing age at
the site labelled E

87
 Q25
Chapter 2 THORAX – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the anatomical variant shown in this image

88
Q26

Chapter 2 THORAX – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

89
 Q27
Chapter 2 THORAX – Questions

a Name the structure labelled A

b Name the motor nerve supplying the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

90
Q28

Chapter 2 THORAX – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

91
 Q29
Chapter 2 THORAX – Questions

a Name the structures labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the insertion point(s) of the structure labelled C
e Name the structure labelled E

92
Q30

Chapter 2 THORAX – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

93
 2 THORAX –
ANSWERS

Q1 Answers
a Right atrium
b Left ventricle
c Left pulmonary artery
d Superior vena cava (SVC)
e Left hemi-diaphragm

Chest radiograph, PA projection

Cardiac and mediastinal silhouettes seen on the chest radiograph depend on there
being contrast between the cardiac edge and adjacent aerated lung. Pathology
within the chest can alter the appearance of one or more of these edges in a way
that can enable accurate anatomical localization of the problem – the ‘silhouette
sign’.
The majority of the right cardiac border is made up of the right atrium with a
small section of IVC inferiorly and the right hilum of the lung and SVC superiorly.
From superior to inferior, the left mediastinal silhouette is formed by the left
subclavian artery, distal aortic arch (aortic knuckle), pulmonary trunk and the
hilum of the left lung. The left cardiac border is composed mostly of left ventricle,
with the auricle of the left atrium forming the uppermost part of this border.
The left pulmonary artery spirals over the top of the left bronchus such that its
branches come to lie posterior to the bronchi. The right pulmonary artery, longer
than the left, passes anterior to the carina and at the lung root lies anterior to the
bronchus. The right pulmonary artery gives off its branch to the upper lobe then
enters the hilum where its branches also spiral over the bronchi to come to lie
posterior to them.
Viewed from the front, the diaphragm curves up into the right and left domes.
The highest point of the right dome is at the 6th intercostal space anteriorly
(ranging from the 4th to the 7th). The left dome is usually 2cm lower than the
right, although this may not be the case in all subjects. The level of the dome of the
diaphragm can move about 4cm in deep respiration, but again there is a wide range
of normal.

Felson B, Felson H. Localization of Intrathoracic Lesions by means of the Postero-anterior

Roentgenogram: The Silhouette Sign. Radiology 1950; 55:363–374.

94
Q2 Answers

Chapter 2 THORAX – Answers

a Right 1st rib
b Paratracheal stripe
c Medial border of the left breast
d Aortic arch
e Left cardiophrenic angle

Chest radiograph, PA projection

The structures which create the mediastinal contour on a frontal radiograph are in
part dependant on the age of the patient. The thymus is prominent in the superior
mediastinum in paediatric patients and usually atrophies during childhood. The
dense curved line on the right mediastinal border is formed by the ascending aorta,
which lies relatively anterior in the chest. The distal aortic arch usually lies in the
left posterior chest and is seen as the aortic knuckle.
The right paratracheal stripe is normally visible because the right upper
pulmonary lobe lies immediately adjacent to the lateral tracheal wall. The opaque
stripe is formed by the visceral and parietal pleura and some mediastinal fat.
Normally the width should not exceed 3mm.
Breast shadows can produce lines which are projected over the chest.

Q3 Answers
a Trachea
b Spinous process
c Left phrenic nerve
d Medial border of right scapula
e Spine of right scapula

Chest radiograph, PA projection

The upper margin of the trachea as seen on a chest radiograph is approximately at

the level of C6. It terminates at the carina, the position of which can vary depending
on whether the radiograph is taken in inspiration (T4) or expiration (T6). The arch
of the aorta and left-sided vessels lie along its left border and the pleura lies along
the right (which forms the paratracheal stripe).
Vertebral spinous processes are viewed en face in this image.
Hemi-diaphragms are mainly innervated by the left and right phrenic nerves,
which arise from spinal nerve roots C3–5 and supply all motor and most sensory
innervation (sensory innervation of the peripheral diaphragm is partly through
intercostal nerves). Phrenic neuropraxia or neuropathy results in the ipsilateral
hemidiaphragmatic dome lying in a more cranial position than usual due to muscle
relaxation. This can be idiopathic or as a result of mediastinal disease.
Scapular position in the frontal radiograph can vary. Asking the patient to put
their hands on hips or overhead causes supero-lateral rotation of the scapula and
therefore lessens the degree of overlay seen on the radiograph.

Naveed N. Good positioning is key to PA chest x-ray exams. 2001 www.auntminnies.com 95

 Q4 Answers
Chapter 2 THORAX – Answers

a Horizontal (minor) fissure

b Anterior segment of upper lobe (superior) and the middle lobe (inferior)
c Bronchus intermedius
d Anterior segmental pulmonary artery
e Azygos fissure

Chest radiograph, AP projection

On a frontal radiograph, the visible line of the minor fissure consists of two layers
of adjacent visceral pleura; the top layer from the anterior segment of the right
upper lobe with pleura from the right middle lobe as the lower layer. On a frontal
radiograph it runs transversely from the interlobar artery at the hilum, usually
within 1cm of the hilar point, to the lateral aspect of the 6th rib.
Accessory fissures are occasionally present and the most common of these is the
azygos fissure. As a result of incomplete migration of the embryological azygos
vein through the right upper lobe, there remains a fissure of invaginated parietal
and visceral pleura with the azygos vein lying at the base. This is seen on frontal
radiograph as a curvilinear line running from the mediastinum through the right
upper zone with a rounded opacity at its lower end. The section of right upper
lobe between the fissure and mediastinum is termed the azygos lobe, however it is
not an independent segment as it derives arterial and bronchial supply from the
apical or posterior segment of the right upper lobe. A triangular area that marks the
uppermost margin of the fissure is known as the trigone parietale. Stibbe (1919)
classified the azygos lobe into being one of three types depending on the position of
the trigone on the pulmonary apex. In type A, the trigone is located on the lateral
aspect of the pulmonary apex; in type B, the trigone is situated in the midpoint of
the cupula of the apex and in type C, the trigone is located on the medial aspect of
the apex. Opacification of the normal azygos lobe has been described, especially in
type B and C configurations.
On a frontal radiograph it is common to see one or both of the anterior
segmental bronchi and arteries as rounded structures which are viewed ‘end-on’.
They should measure approximately 4–5mm diameter with the bronchus usually
lying more laterally.

Stibbe EP. The Accessory Pulmonary Lobe of the Vena Azygos. Journal of Anatomy 1919; 53:305–314.
Caceres J. The Azygos Lobe: Normal Variants That May Simulate Disease. European Journal of Radiology
1998; 27:15–20.
Caceres J, Mata JM, Alegret X, Palmer J, Franquet T. Increased Density of the Azygos Lobe on Frontal
Chest Radiographs Simulating Disease: CT Findings in Seven Patients. Am J Roentgenol 1993; 160:245–
248.

96
Q5 Answers

Chapter 2 THORAX – Answers

a Left upper paratracheal nodes (2L)
b Right lower paratracheal nodes (4R)
c Sub-carinal nodes (7)
d Right tracheobronchial nodes (10R)
e Right cervical rib

Chest radiograph, PA projection, zoomed up view

Lymph nodes are located throughout the mediastinum and there is wide variation
amongst normal individuals in their number and distribution. The descriptive
nomenclature used does not correspond with the anatomical divisions of the
mediastinum but is based on lymph node maps which have been variously defined
by Naruke (1967) and Mountain (1996). A revised internationally standardized
mapping criteria compiled by Rusch (2009) has been adopted by the American
Joint Committee on Cancer (AJCC) and the Union Internationale Contre le Cancer
(UICC).
The location of nodes are divided into numbered ‘stations’ with the suffix ‘L’
or ‘R’ to define laterality where needed. The boundaries of the stations are not
symmetrical, reflecting differences in lymphatic drainage between the left and right
lungs. There are 14 numbered stations in total.
In practical terms, when describing lymph nodes in the context of lung cancer
staging there are three groups: ipsilateral hilar and/or tracheobronchial nodes
(stations 10–14); ipsilateral mediastinal or sub carinal nodes (stations 1–9); and
contralateral hilar or mediastinal, scalene or supraclavicular nodes. Involvement of
these nodes defines N1, N2 and N3 disease respectively.
A cervical rib is the product of excessive elongation of the costal element of the
seventh cervical vertebra. It may be an osseous or fibrous structure which extends
to the first rib. These can cause compression of the subclavian artery and T1 nerve
root at the thoracic outlet.

Naruke T. The spread of lung cancer and its relevance to surgery. Nippon Kyobu Geka Gakkai Zasshi
1967; 68:1607–1621.
Mountain CF, Dresler CM. Regional lymph node classification for lung cancer staging. Chest 1997;
111:1718–1723.
Rusch VW, Asamura H, Watanabe H et al. The IASLC Lung Cancer Staging Project: A Proposal for a New
International Lymph Node Map in the Forthcoming Seventh Edition of the TNM Classification for Lung
Cancer. Journal of Thoracic Oncology 2009; 4:568–577.
Sobin LH, Gospodarowicz MK, Wittekind C. TNM Classification of Malignant Tumours, Wiley-Blackwell,
Chichester, 2009.
Edge SB, Byrd DR, Compton CC, Fritz AG. AJCC Cancer Staging Manual, 7th Ed, Springer, New York,
2010.

97
 Q6 Answers
Chapter 2 THORAX – Answers

a Mitral valve
b Aortic valve
c >2.5cm
d Azygo-oesophageal stripe
e Superior pulmonary vein and lower lobe pulmonary artery (Hilar point)

Chest radiograph, PA projection

The cardiac valves are not usually visible on plain radiographs; however associated
calcification or prosthetic implants can be seen. All four valves lie along a line
from 3rd left to 6th right costal cartilages (or from the mid left atrium to the
right cardiophrenic angle on chest x-ray (CXR)). In the frontal projection the
mitral and aortic valves are positioned centrally. The mitral annulus is larger and
usually orientated in a more vertical direction. The aortic valve is smaller and lies
orientated at around 45 degrees to vertical. The lowest point of the aortic valve lies
very close to the anterior annulus of the mitral valve and this is where the two are in
fibrous anatomical continuity.
The diaphragmatic height can be calculated by drawing a line from the
costophrenic angle to the cardiophrenic angle. Perpendicular measurement
to the diaphragmatic dome should be >2.5cm, a height less than this suggests
diaphragmatic flattening, possibly as a result of pulmonary hyperexpansion.
For descriptive purposes, when referring to pleural reflections around the
mediastinum a ‘line’ typically measures <1mm in width, an example being the
opposed layers of pleura of the fissures. A ‘stripe’ is typically >1mm wide and
occurs when a mediastinal structure has gas on both sides (as in this case). An ‘edge’
is used to describe when structures of two different densities come into contact
with each other.
The azygo-oesophageal stripe is formed where the azygos vein runs in close
approximation to the right postero-lateral oesophageal margin. Following the
course of the azygos vein, it is seen superiorly to veer towards the right. The right
lung abuts the two structures at the azygo-oesophageal recess and, together with gas
in the oesophageal lumen, forms this visible stripe.
The hilar point is formed where the superior pulmonary vein crosses the
descending pulmonary artery. They should form an angle of approximately
120 degrees with the right hilar point projected over the 6th intercostal space and
lying 1cm lower than the left.

Sussmann AR, Ko JP. Understanding chest radiographic anatomy with MDCT reformations. Clinical
Radiology 2010; 65:155–166.

98
Q7 Answers

Chapter 2 THORAX – Answers

a Right lobe of thymus
b Secondary ossification centre of the coracoid process
c Pedicles of the vertebrae
d Lateral border of the scapula
e Left lobe of thymus

Chest radiograph in a neonate, AP projection

The major intra-thoracic anatomy of the newborn is largely similar to that of an

adult with the notable exception of the thymus gland. The thymus is a lymphoid
organ which is located within the anterior mediastinum; its relative volume is far
greater in infants than in adults. On a frontal radiograph the thymus commonly
creates an opacity extending from the mediastinum into one or both lung fields;
however the classic description of a triangular ‘sail’ sign is not always seen. The
normal thymus is not usually visible on a frontal radiograph beyond the age of five
years.

Q8 Answers
a Left hemi-diaphragm
b Gas bubble in gastric fundus
c IVC
d Scapular spine
e Descending aorta

Right lateral chest radiograph

The dome of the left hemi-diaphragm is typically at a level inferior to that of the
right and does not extend to the anterior chest wall due to the position of the heart.
Along with the presence or absence of the gastric air bubble, these are features
that can allow differentiation between the two hemi-diaphragms on a lateral chest
radiograph.
The aortic arch can be seen in profile as it courses towards the back of the chest,
becoming the descending aorta at around the level of the fourth thoracic vertebra.
The superior and inferior vena cava both terminate at the right atrium and
therefore lie towards the front of the chest (within the ‘middle’ mediastinum), with
the IVC penetrating the right hemi-diaphragm at the level of T8 vertebral body.
To minimize composite bone overlap from the humerus, patients are asked to lift
their arms out of the line of projection. This usually results in the scapula rotating
externally and therefore entering into the field of view.

Padley S, MacDonald LS. Grainger & Allison’s Diagnostic Radiology, Ch 12 – The Normal Chest, 5th Ed,
Churchill Livingstone Elsevier, Edinburgh, 2008.
Ahmad N. Mastering AP and lateral positioning for chest x-ray. 2001 www.auntminnie.com

99
 Q9 Answers
Chapter 2 THORAX – Answers

a Cardiac incisura (cardiac fat pad)

b Trachea
c Costophrenic recess (or sulcus)
d Left subclavian artery
e Oblique (major) fissure of left lung

Left lateral chest radiograph

The anterior aspect of the left lung base may come to lie in contact with the apex
of the heart or more commonly with the epicardial fat pad. The latter of these will
displace the lung from the antero-medial chest wall and can be mistaken for a mass
lesion. The size and morphology of this fat pad can be variable, with rounded,
angular and straight configurations described.
The costophrenic recess (or costophrenic sulcus) forms the inferior margin of
the pleural cavity on both sides. Depth and location of the recess is dependant on,
among other things, patient size, age and respiratory health. The lateral recess is
seen readily on frontal radiographs, whereas the posterior aspect is best visualized
using a lateral projection. On the right side, the posterior recess has been shown
to be, on average, 3cm lower than the lateral costophrenic recess with its inferior
aspect at the level of the L1 vertebral body.
Both the left subclavian and right brachiocephalic arteries travel postero-
superiorly in the upper thorax and can be seen as they cross the air-filled trachea.
The margin of the left subclavian artery can be seen to follow a gentle curve across
the posterior aspect of the trachea. In contrast, the brachiocephalic artery has a
slightly convex appearance in most people. The silhouette of both vessels should
have only slightly curved margins and any striking linear convexity within this
region could be the result of an underlying mass lesion.

Oh JK, Ahm MJ, Kim HL, Park SH, Shin E. Retrodiaphragmatic portion of the lung: how deep is the
posterior costophrenic sulcus on posteroanterior chest radiography? Clinical Radiology 2009; 64:786–
791.
Sussmann AR, Ko JP. Understanding chest radiographic anatomy with MDCT reformations. Clinical
Radiology 2010; 65:155–166.

Q10 Answers
a Clavicle
b Manubriosternal joint
c 2nd sternocostal joint
d Manubrium
e Body of the sternum

100
 Chapter 2 THORAX – Answers
Radiograph of the sternum, lateral view

The sternum is an anterior midline structure which gives structural support to

the anterior thoracic wall. The upper bone is the manubrium. This has lateral
articulations with the first costal cartilage by means of a primary cartilaginous
joint. The manubriosternal joint is a symphysis where the manubrium articulates
with the body of the sternum. This joint is slightly angulated (angle of Louis) and
indicates the level of the 2nd sternocostal joint. Posteriorly the manubriosternal
joint is at the level of the disc between vertebrae T4 and T5. Above this level is
the superior mediastinum and below it the inferior mediastinum. The body of
the sternum articulates with the costal cartilages of the 3rd–7th ribs by means of
single synovial joints. At the inferior aspect of the sternum is the xiphisternal joint
which is a symphysis between the body of the sternum and xiphoid process. The
manubriosternal and xiphisternal joints frequently calcify in later life.

Q11 Answers
a Areola
b Retro-areolar duct
c Fibrous septae/suspensory ligaments of Cooper
d Fibro-glandular breast tissue
e Blood vessel

Mammogram left breast, cranio-caudal projection

The cranio-caudal projection is one of two views commonly used in breast

radiography. Mammographic appearance of normal breast tissue depends on
the proportion of fibro-glandular tissue to fat. It is usual for breasts to contain
proportionally more fat with advancing age.
The skin of the areola is normally focally thickened. Retro-areolar ducts are seen
as tubular densities which fan out into the breast from the nipple. Blood vessels
within the breast can be very difficult to see and are only visible if surrounded by
fatty tissue. Determining the type and location of a vessel is not always possible.
Fine fibrous bands which run in a radial direction are another of the linear
structures which are seen within the breast. These are the suspensory ligaments of
Cooper which serve to support the structure of the breast.
Lymph nodes exist within the normal breast, especially within the upper outer
quadrant. Normal nodes should be round or ovoid in shape, demonstrate a low soft
tissue density and contain a fatty hilum.

101
 Q12 Answers
Chapter 2 THORAX – Answers

a Pectoralis major muscle

b Infra-mammary skin fold
c Axillary lymph node
d Nipple
e Retro-areolar duct

Mammogram right breast, mediolateral oblique (MLO) projection

The MLO view of the breast demonstrates the pectoralis muscle, axilla and
infra-mammary fold as well as the breast. The distribution and proportion of
fibro-glandular breast tissue varies between patients and there is a wide range of
‘normal’ appearances. Wolfe (1976) described four categories of breast parenchymal
distribution: N1, primarily fatty; P1, £25% prominent ducts; P2, >25% prominent
ducts; and DY, dense fibroglandular tissue. Although not used in everyday clinical
use, these categories can be used to ensure standardization when conducting
research or audit.
Axillary lymph nodes are frequently seen on MLO mammograms. Although
usually larger than those seen within the breast, the presence of fatty hilum remains
useful in confirming their identity.

Wolfe JN. Breast patterns as an index of risk for developing breast cancer. Am J Roentgenol 1976;
126:1130–1137.

Q13 Answers
a Right coronary artery (RCA)
b Conus branch artery
c Sino-atrial node artery
d Posterior descending artery (PDA)
e Acute marginal branch artery

Right coronary angiogram, left anterior oblique (LAO)/cranial projection

Several angled projections are usually obtained to demonstrate all the parts of the
tortuous coronary arteries. This example is a predominantly LAO projection with
cranial angulation.
The conus branch supplies the right ventricular outflow tract. It arises as the first
branch from the RCA (or occasionally from a separate small ostium in the right
coronary sinus) in 60%. This artery arises from the circumflex in 40%.
The sino-atrial node artery is supplied in 60% from the RCA (the second
branch). This heads posteriorly to supply the sino-atrial node, which is located in
the superior aspect of the crista terminalis in the right atrium. In 40% this artery
arises from the circumflex artery.

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Branches given off by the mid-RCA supply the atria and ventricles including
one or more acute marginal branches. In 85% the RCA terminates by becoming
the PDA and one or more postero-lateral branches. At this point, there is usually a
branch given off to the atrio-ventricular node.
‘Dominance’ in the coronary circulation is determined by the arterial system
which supplies the PDA. In the example provided, the RCA gives rise to the PDA
(right-dominant, the typical configuration). In 15% of individuals, either the
circumflex artery supplies the PDA (left dominant) or there is combined supply of
the PDA and postero-lateral arteries by the RCA and circumflex arteries respectively
(co-dominant).

Libby P, Bonow RO, Zipes DP, Mann DL. Braunwald’s Heart Disease: A Textbook of Cardiovascular
Medicine, 8th Ed, Saunders, Philadelphia, 2007.
Lin EC et al . Coronary CT Angiography. 2010; eMedicine: www.emedicine.medscape.com

Q14 Answers
a Arch of the aorta
b Left main bronchus
c Thoracic duct
d Longitudinal mucosal folds of the oesophagus
e Posterior mediastinal nodes

Barium swallow examination, frontal view

Within the chest, normal impressions seen in the left wall of the oesophagus are
(from superior to inferior) the aortic arch, left main bronchus and left atrium.
A circumferential impression can often be seen at the level of the diaphragmatic
hiatus. Aberrant vessels are a recognized cause of posterior impression (aberrant
right subclavian artery) and anterior impression (aberrant left pulmonary artery).
The thoracic duct lies right and posterior to the lower thoracic oesophagus. It
crosses the midline at the level of T5/6 then ascends along the left lateral aspect
of the oesophagus behind the aorta and left subclavian artery. Drainage into
the venous circulation occurs near the junction of the left internal jugular and
subclavian veins.
Fine longitudinal folds are the typical mucosal appearance of the thoracic
oesophagus.
Lymph from the upper oesophagus drains to the deep cervical nodes, the middle
oesophagus drains to the posterior mediastinal nodes and the lower oesophagus to
the para-aortic group of the coeliac nodes.

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 Q15 Answers
Chapter 2 THORAX – Answers

a Gastro-oesophageal junction
b Left gastric artery
c T10
d Left and right vagus nerves/vagal trunks (CN X)
e Air bubble in the gastric fundus

Double-contrast barium swallow, right anterior oblique (RAO) projection

The oesophagus courses forward and left in the lower chest where it passes in
front of the aorta before crossing through the diaphragm hiatus at the level of
T10. The hiatus is approximately 3cm left of the midline and the oesophageal wall
often shows an indentation at this level. Crossing with the oesophagus through
the diaphragm are the vagus nerves (CN X), branches of the left gastric vessels and
lymphatics.
The oesophageal mucosa contains fine longitudinal folds measuring
approximately 3mm thick whilst the gastric mucosal folds are seen to be thicker.
The site of transition marks the gastro-oesophageal junction.
Arterial supply of the oesophagus can be divided into upper, middle and lower
thirds. Branches of the inferior thyroid artery supply the upper; branches of the
descending thoracic aorta supply the middle; and branches of the left gastric artery
supply the lower third.

Q16 Answers
a Left superior pulmonary vein
b Right superior apical pulmonary artery
c Left subclavian artery (first part)
d Serratus anterior muscle
e Ligamentum arteriosum

CT pulmonary angiogram (CTPA), oblique coronal section

The pulmonary artery (PA) bifurcates soon after exiting the fibrous pericardium.
The right PA is the longer branch and crosses the midline below the carina ending
anterior to the right main bronchus at the hilum. Here it bifurcates into the right
upper lobe branch and the interlobar branch, which supplies the middle and lower
lobes. Thereafter pulmonary arteries are named in accordance with the segments
supplied. Internationally standardized nomenclature of bronchopulmonary
segmental anatomy was published by the British Thoracic Society in 1950 and
can be seen below. Variations are common and there remains debate over what
comprises a ‘normal’ configuration of segmental bronchopulmonary anatomy, as is
described in the footnote.

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Bronchopulmonary Segments:

Chapter 2 THORAX – Answers

RIGHT LUNG LEFT LUNG
UPPER LOBE: apical, posterior,
UPPER LOBE: apical, posterior,
anterior, superior lingular, inferior
anterior
lingular
MIDDLE LOBE: medial, lateral
LOWER LOBE: apical (superior), LOWER LOBE: apical (superior),
anterior basal, lateral basal, posterior anterior basal, lateral basal, posterior
basal, medial basal basal
TOTAL = 10 TOTAL = 9*

*Gray’s Anatomy (40th Ed, 2008) and Applied Radiological Anatomy (2006) describe a combined apico-
posterior segment of the left upper lobe. The latter text also does not list the medial basal segment of the
left lower lobe as being a separate segment.

The shorter left pulmonary artery passes superior to the left main bronchus and
runs within the concavity of the aortic arch. Here, the left PA and aorta are attached
via the ligamentum arteriosum, the fibrous remnant of the foetal ductus arteriosus.
The subclavian artery arises on the left from the aortic arch, and on the right
from the brachiocephalic artery (trunk). It is anatomically divided into three parts
by the scalenus anterior muscle, to which the first part lies medially, second part lies
posteriorly and third part lies laterally.
Pulmonary veins do not follow a segmental distribution, but travel in the
intersegmental septae alongside lymphatic vessels. Usually two veins drain into each
side of the left atrium, carrying blood from above and below the oblique fissures
on both sides and entering the hilum slightly anterior to the PA. There are normal
variations seen in the number of pulmonary veins (PV) draining into the atrium,
for example three PV on the right or a single PV on the left.

Brock RC. The Nomenclature of Broncho-pulmonary Anatomy – An International Nomenclature

Accepted by the Thoracic Society. Thorax 1950; 5:222–228.
Lee KS, Bae WK, Lee BH, Kim IY, Choi EW, Lee BH. Bronchovascular anatomy of the upper lobes:
evaluation with thin section CT. Radiology 1991; 181:765–772.
Jardin M, Remy J. Segmental bronchovascular anatomy of the lower lobes: CT analysis. Am J Roentgenol
1986; 147:457–468.

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 Q17 Answers
Chapter 2 THORAX – Answers

a Left atrial appendage

b 2cm
c Left recurrent laryngeal nerve (branch of CN X)
d T8 (caval opening)
e Right phrenic nerve

CT pulmonary angiogram, coronal section

The left atrial appendage is a blind-ending recess positioned in the upper postero-
lateral left atrium. This can be a site of mural thrombus formation, especially in
patients with atrial fibrillation secondary to mitral valve disease.
The right interlobar artery can be seen on the PA chest radiograph running
out lateral to the right cardiac border with bronchus intermedius in between. The
diameter of the artery should not exceed 2cm (mean 1.4cm).
The recurrent laryngeal nerves supply the cervical trachea and oesophagus and
the larynx. They are branches of the vagus (CN X) nerves which arise at the base of
the neck on the right and down in the thorax on the left. On the right, the recurrent
laryngeal nerve loops around the subclavian artery before heading cranially; on the
left it passes under the arch of the aorta posterior to the ligamentum arteriosum,
which runs between the aorta and left PA.
The caval opening in the diaphragm is at the level of the T8 vertebral body; the
right phrenic nerve also crosses the diaphragm through this opening.

Bush A. Diagnosis of pulmonary hypertension from radiographic estimates of pulmonary arterial size.
Thorax 1988; 43:127–131.

Q18 Answers
a Right internal mammary (internal thoracic) artery
b Posterior descending (interventricular) artery
c First part of the left axillary artery
d Right carotid artery
e ‘Bovine arch’

CT aortic angiogram, maximum intensity projection, coronal section

The Bovine arch configuration of vessels shown in this image is the most common
arch anomaly and is said to be present in 13% of the population. It is when the left
common carotid artery arises from the right brachiocephalic trunk rather than
the arch and results in there being only two arch branches. Despite its name, this
arch vessel configuration is not the same as is found in cows and other ruminant
animals. The actual ‘bovine’ aortic arch has a single large branch from which
bilateral carotid and subclavian arteries arise. Despite this discrepancy, the term is
widely used and understood in human medicine.
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The first part of the subclavian artery is the section lying medial to scalenus
anterior and gives rise to three branches. From proximal to distal these are the
vertebral artery, thyrocervical trunk and internal mammary (or internal thoracic)
artery. The last of these travels inferiorly in the chest wall alongside the lateral
sternal edge.
Lateral to the first rib, the subclavian becomes the axillary artery. This is
anatomically divided into three parts depending on the position relative to
pectoralis minor, to which the first part is medial, the second part posterior and
third part lateral.

Layton KF, Kallmes DF, Cloft HJ, Lindell IP, Cox CV. Bovine Aortic Arch Variant in Humans:
Clarification of a Common Misnomer. Am J Neuroradiol 2006; 27:1541–1542.

Q19 Answers
a Right coronary artery (RCA)
b Left anterior descending (LAD) artery
c Left atrial appendage
d Non-coronary (or posterior coronary) sinus
e Interatrial septum

CT chest with intravenous contrast, maximum intensity projection, axial section

The right and left main coronary arteries originate from their respective coronary
sinuses. The third sinus of Valsalva lies right posterior and is called the non-
coronary sinus.
The RCA originates anteriorly and travels between the right auricle and
infundibulum of the right ventricle. It then follows the atrio-ventricular groove
down to the inferior cardiac margin giving off the sino-atrial (SA) nodal and conus
branches. The nodal branch is variable in its origin arising from the RCA in 60%
of individuals and from the left coronary artery (LCA), circumflex branch, in the
remaining 40%. The posterior descending artery (PDA) travels along the base of the
heart. In 85% of people, the RCA supplies the PDA in a ‘right dominant system’.
The left main stem originates postero-laterally and travels between the left auricle
and the pulmonary trunk. The circumflex continues on this same course, travelling
over the left side of the heart along the atrio-ventricular groove. It gives off the
obtuse marginal branches and in approximately 40% of people the sino-atrial (SA)
nodal branch. The LAD courses along the interventricular groove on the anterior
surface of the heart. It supplies diagonal branches to the left and right ventricles and
also perforating branches to the interventricular septum.
The left atrial cavity is smooth-walled, indicating that it developed from the
incorporation of the pulmonary veins into the wall of the developing heart. The
roughened wall of the left auricle indicates that it is the remnant of what was once
an embryological cardiac chamber. The atrio-ventricular (AV) node cannot be seen
on diagnostic imaging; however its position is reasonably constant within the right
atrium. It lies in the interatrial septum, above the insertion of the septal tricuspid
valve leaflet and left of the opening to the coronary sinus.
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 Q20 Answers
Chapter 2 THORAX – Answers

a Sino-tubular junction
b Papillary muscle in the left ventricle
c Left main stem coronary artery
d Non-coronary (right posterior) aortic valve cusp
e Right atrial appendage (auricle)

CT coronary angiogram, coronal section

Distal to the aortic orifice the wall of the ascending aorta bulges into the three
sinuses of Valsalva. The RCA originates from anterior (right coronary) sinus
and the LCA from the left posterior (left coronary) sinus. They are positioned in
accordance with the three cusps of the valve which allows for a wider opening and
therefore reduction in the resistance of flow. Its transition to the ascending aorta is
called the sino-tubular junction.
The atrioventricular valve cusps of both the tricuspid and bicuspid (mitral)
valves are attached by means of chordae tendinae to papillary muscles. These arise
from the wall of each ventricle and contract in systole pulling tightly on the valve
leaflets and hence preventing retrograde flow. Rupture of a papillary muscle, a rare
complication of myocardial infarction, results in an acute regurgitation through
the mitral valve often leading to heart failure. In these cases, the postero-medial
papillary muscle is twice as likely to be affected as the antero-medial papillary
muscle. This is thought to be due to the postero-medial muscle being supplied by
the LAD system alone while the antero-medial usually receiving blood supply from
both the circumflex and LAD systems.
Above and to the left of the SVC opening is the right auricle, a large triangular
muscular out-pouch of the right atrium. It sits adjacent to the aorta and the AV
groove.

Minami H. Papillary muscle rupture following acute myocardial infarction. Jpn J Thorac Cardiovasc Surg
2004; 52(8):367–371.

Q21 Answers
a Left internal mammary (thoracic) artery
b Left anterior descending (LAD) artery
c Epicardial fat
d Right main pulmonary artery
e Right inferior pulmonary vein

Cardiac CT, maximum intensity projection, oblique section

This image demonstrates the close proximity of the LAD and left internal
mammary artery. This is an oblique section taken approximately along the line of
the interventricular septum/long cardiac axis.
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 Chapter 2 THORAX – Answers
The serous pericardium consists of two layers, the parietal and visceral
pericardium. The visceral pericardium is attached to the surface of the heart
whereas the parietal pericardium is attached to the inner aspect of the fibrous
pericardium. The space between the visceral and parietal pericardia is the
pericardial space or cavity which in health is little more than a potential space
containing a few millilitres of lubricating pericardial fluid. These layers cannot
normally be differentiated on CT. It is common to see a layer of epicardial fat in
between the myocardium and the visceral pericardium.

Q22 Answers
a Right oblique fissure
b Anterior pleural junction
c Left main bronchus
d Superior lingular segmental bronchus
e Azygos vein

High resolution CT chest, axial section

The oblique or major fissure separates the lower lobe from the remainder of the
lung on both sides. The degree to which the fissures are developed is variable, with
the transverse (horizontal) fissure being fully developed in only a third of people
and absent in 10%. Underdevelopment can be difficult to determine radiologically.
The line seen on plain radiographs is due to the composite layering of visceral
pleura from both lobes surrounded by air and is only seen when viewing the fissure
in profile (i.e. oblique fissure seen on lateral chest x-ray (CXR), transverse fissure
seen on PA CXR). CT imaging normally displays the fissures as a clear line, but with
underdevelopment of the fissure the position is indicated by a thin, dark linear strip
which is devoid of traversing lung markings or vessels. The anterior junction of the
pleura is responsible for the anterior junctional line that is seen on CXR and is the
location of the sternopericardial ligaments.
Azygos means ‘unpaired’ and the azygos vein travels up the right paraspinal
region, draining the posterior intercostal veins from the right side of the chest. It
drains into the posterior aspect of the SVC, after having passed over the top of the
right main bronchus. On the left are the hemiazygos (inferiorly) and accessory
hemi-azygos (superiorly) veins. They provide drainage of the left inferior and
superior posterior intercostal veins respectively and the two veins are occasionally
in continuity. The hemiazygos veins usually cross the midline from left to right at
the level of T9 to drain into the azygos vein.
Bronchi are named according to the lung segments which they supply. Juxta-
cardiac lung is predominantly middle lobe on the right and lingula on the left. Both
are divided into two segments with medial/lateral segments of the right middle lobe
and superior/inferior segments of the lingula on the left.

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 Q23 Answers
Chapter 2 THORAX – Answers

a Inferior right pulmonary vein

b Right upper lobe bronchus
c Right pulmonary artery
d Right phrenic nerve
e Right vagus nerve

CT chest with intravenous (IV) contrast and lung windowing, sagittal section

The position of the pulmonary artery in relation to the bronchus can allow
determination of whether it is right or left in the absence of other indicators. The
right main bronchus is ‘epi-arterial’ (at the same level as the right pulmonary
artery). The left main bronchus is ‘hypo-arterial’ (below the left pulmonary artery).
The superior pulmonary vein travels down through the hilum to reach the left
atrium whilst the inferior vein approaches on a straighter course from the back.
The right main bronchus gives rise to the upper lobe branch soon after the carina
and then continues as bronchus intermedius.
The vagus nerves pass posterior to the lung roots and cross the diaphragm
alongside the oesophagus (vagal trunks). The phrenic nerves travel anterior to the
lung root and down the antero-lateral surface of the pericardium to supply motor
innervation to the diaphragm.

Q24 Answers
a Lamina
b Costovertebral joint
c Pedicle
d Erector spinae muscles
e Fat (yellow marrow)

CT thoracic spine, bone windows, axial section

The thoracic vertebrae are recognized in the axial plane by the presence of
articulation with ribs. A synovial articulation occurs between the vertebral body
and the head of the rib. Another articulation occurs between the tubercles of the
rib and the anterior surface of the transverse process, known as the costotransverse
joint. The vertebral bodies are slightly wedge-shaped in sagittal plane, which
contributes to the kyphotic shape of the thoracic vertebral column. The pedicles
pass back from the superior half of each vertebral body.
Extensor paraspinal muscles run the length of the spine lying in the vertebral
grooves on either side of the spinous processes. The largest and most powerful of
these is erector spinae, the component parts of which form the intermediate layer of
the intrinsic back muscles.
In childhood the cancellous bone of the vertebral bodies contains red

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(haematopoetic) marrow, but this usually converts to yellow (fatty) marrow
throughout adult life. At age 30 years, there will have been approximately 30%
conversion and this continues over time. The appearance of vertebral bodies on
MRI varies depending on the constituency of marrow. Red marrow shows greater
contrast enhancement where as yellow marrow shows as higher signal on non-
contrast T1W.

Q25 Answers
a Pectoralis minor
b Subscapularis
c Intercostal muscles
d Infraspinatus
e Aberrant right subclavian artery

CT upper chest with contrast, in arterial phase, axial section

The superficial muscles of the chest wall consist of pectoralis major and minor
anteriorly; serratus anterior laterally; muscles of the shoulder girdle postero-
laterally; trapezius and erector spinae posteriorly. The muscles which lie between
the ribs (intercostals) are found in three layers: external, internal and innermost.
The fibres of these muscles are orientated perpendicular to each other in a similar
(though unrelated) fashion to the three muscles of the anterior abdominal wall.
The intercostal neurovascular bundles run in the subcostal groove and are located
between the internal and innermost muscle layers.
The four muscles that are principally responsible for stability and movement of
the shoulder girdle are subscapularis, supraspinatus, infraspinatus and teres minor.
Collectively they are known as the rotator cuff muscles.
An aberrant right subclavian artery takes its origin as the last branch from a left-
sided aortic arch. It then crosses from left to right, passing behind the oesophagus
in doing so. This can be a cause of posterior indentation seen in the oesophageal
contour during barium swallow examinations and can occasionally be symptomatic
(dysphagia lusoria).

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 Q26 Answers
Chapter 2 THORAX – Answers

a Mitral valve anterior leaflet

b Muscular interventricular septum
c Moderator band of the right ventricle
d Tricuspid valve anterior leaflet
e Right middle lobe of lung

Cardiac MRI, axial section

The atrioventricular valve cusps are tethered to the papillary muscles of the
ventricular wall by chordae tendinae and act to prevent reflux of blood from the
ventricle into the atrium. The bi-leaflet mitral valve is in the left heart; the anterior
leaflet is the larger of the two and forms a division between the left ventricular
inflow and outflow tracts. On the right side is the tricuspid valve, with leaflets sited
in the anterior, posterior and septal positions.
The moderator band is a muscular bundle that crosses the right ventricular
cavity, running from the lower interventricular septum to the anterior wall. It
attaches at the level of the anterior papillary muscle and carries the right bundle
branch fibres of the conducting system.
The interventricular septum is supplied via the septal branches of the left
anterior descending (anterior interventricular) artery which runs the length of the
anterior interventricular groove.

Q27 Answers
a Scalenus anterior muscle
b Right spinal accessory nerve (CN XI)
c Dorsal scapular artery
d Right recurrent laryngeal nerve
e Inferior cerebellar peduncle

T1W MRI base of neck, oblique coronal section

The scalenus anterior muscle and its relations are central to the anatomy of the
root of the neck. It arises from the anterior tubercles of C3–6 in the form of four
tendinous origins, passing infero-laterally and attaching to the upper surface of the
first rib:

Anterior relations: Phrenic and vagus nerves (the right recurrent laryngeal branch
loops beneath the 1st part of the right subclavian artery)
Ascending cervical, transverse cervical and suprascapular
arteries
Internal jugular vein
Deep cervical lymph nodes

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 Chapter 2 THORAX – Answers
Medial relations: Inferior thyroid, vertebral, thyrocervical, internal mammary
and subclavian (1st part) arteries
Vertebral veins
Ansa subclavia
Thoracic duct
Posterior relations: Costocervical, superior intercostal, deep cervical and subclavian
(2nd part) arteries
Lateral relations: Dorsal scapular and subclavian (3rd part) arteries
Trunks of brachial plexus

The trapezius muscle is a large flat muscle which is the most superficial major
muscle on the upper back. It arises posteriorly in the midline, from the skull to
lower thorax, and converges to insert onto the inner aspect of the pectoral girdle
at the clavicle, acromion and scapular spine. Motor nerve supply is from the spinal
part of the accessory nerve which is the eleventh cranial nerve.

Q28 Answers
a Oesophagus
b Zygapophyseal (facet) joint
c Dorsal root ganglia within the intervertebral canal
d Intervertebral disc
e Ligamentum nuchae

T1W MRI cervical and thoracic spine, sagittal section

The distal oesophagus courses left and anterior, passing in front of the aorta before
traversing the diaphragm at the T10 level.
Thoracic vertebral bodies articulate together through zygapophyseal (facet)
joints. Positioned either side of the midline they are small synovial joints between
the inferior articular processes of the vertebra above and the superior articular
processes of the vertebra below. On the side of the vertebral bodies are costal demi-
facets for articulation with the ribs. The first rib and lower two ribs have a slightly
different configuration. T1 has a complete facet superiorly for articulation with the
first rib, and a demi-facet inferiorly for articulation with the 2nd rib. Both T11 and
T12 have only a single complete facet for articulation with their corresponding ribs.
Additional support to the vertebral column is given by the anterior and posterior
longitudinal ligaments running anterior and posterior to the vertebral bodies
and associated discs; the ligamentum flavum running between adjacent laminae;
interspinous ligaments running between adjacent vertebral spinous processes and
the supraspinous ligament (known as the ligamentum nuchae above C7) running
along the tips of the spinous processes.
Intervertebral discs consist of a cartilaginous endplate, the annulus fibrosis
and the nucleus pulposis. As a result of being firmly attached to the anterior

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Chapter 2 THORAX – Answers

longitudinal ligament the annulus has greater strength anteriorly. Degeneration

of the nucleus pulposis results in dehydration which changes the MRI signal
characteristics (darker on T2W images).
The intervertebral foramina lie between adjacent vertebrae with the pedicle
of the vertebra above forming the roof and the pedicle of the vertebra below
forming the floor. In the thoracic, lumbar and sacral regions they transmit the
corresponding spinal nerve and its respective dorsal root ganglion as well as the
smaller spinal artery and vein. (In the cervical region spinal nerves emerge above
their corresponding vertebra with the 8th cervical spinal nerve emerging below the
7th cervical vertebra).

Q29 Answers
a The three trunks of the brachial plexus
b Scalenus anterior
c Sternocleidomastoid
d Manubrium and clavicle
e Pectoralis major

T1W MRI root of neck, sagittal section

The attachment of the scalenus anterior is onto the upper surface of the first rib.
It passes between the subclavian artery and subclavian vein, with the artery lying
deep to the muscle and running alongside the three cords of the brachial plexus.
The anatomy of the brachial plexus is complex, and a full description is beyond the
scope of this text. For simplicity it can be divided into sections which are (proximal
to distal) the roots, trunks, divisions, cords and terminal branches. The roots refer
to the anterior rami of the C5–T1 spinal nerve roots which come together to form
three trunks in the neck. These divide into six divisions posterior to the clavicle
(three anterior and three posterior) before reorganizing themselves again into three
cords posterior to pectoralis minor. The cords surround the axillary artery and are
named medial, lateral and posterior according to their position in relation to the
artery as they enter the axilla before finally dividing into the terminal branches.
Sternocleidomastoid muscle arises from the mastoid process and occipital
bone and passes obliquely downwards and forwards to insert medially into the
manubrium (‘sternal head’) and clavicle (‘clavicular head’). As an anatomical
landmark, it forms the division of the anterior and posterior triangles of the lateral
neck.

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Q30 Answers

Chapter 2 THORAX – Answers

a Second part of Axillary artery
b Pectoralis major
c Tendon of subscapularis
d Trapezius
e Pectoralis minor

T1W MRI of upper chest and shoulder, axial section

The axillary artery is divided into three parts. The first part lies medial, the second
part posterior and the third part lateral to pectoralis minor muscle. The axillary
artery lies postero-lateral to the axillary vein.
As well as descriptively dividing the axillary artery into its three parts, pectoralis
minor is the landmark used in delineating the three levels of axillary lymph nodes
– level I are lateral to pectoralis minor, level II are posterior to pectoralis minor
and level III are medial to pectoralis minor. The levels are utilized in the staging
of breast cancer, for which nodal involvement is the single most important factor
in determining prognosis. Involvement of level III nodes (N3a) carries a poorer
prognosis than involvement of level I or II.

Singletary SE. Revision of the American Joint Committee on Cancer Staging System for Breast Cancer.
Journal of Clinical Oncology 2002; 20:3628–3636.

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 3 n UPPER LIMB

Q1 tonghenbrahii
a Name the structure labelled A tender
b
c
Name the structure labelled B A
Name the structure that runs immediately lateral to the structure labelled B
d Name the structure labelled D
e Name the structures that connect the underside of the clavicle to the coracoid
process
Traproidignet
coronoid lignet
retawnisuss

surgical
recent
harem

116
 Q2

Chapter 3 UPPER LIMB – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure that lies at the centre of the ‘Y’ labelled as E

donde Quangwit

compete

seepule
spine
Humint
heed

117
 as
deltoid
Q3 scepter
Chapter 3 UPPER LIMB – Questions

a Name the structure labelled A y siinftaespineton

b Name the structure labelled B
att
c
d
Name the structure labelled C
Name the structure labelled D any
e Name the structure that runs through the groove labelled E

Longheed of bicep bruh i tend n

118
 Q4

Chapter 3 UPPER LIMB – Questions

a Name the structure labelled A
b Name the high signalled structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

it
await
d
trek
EP

short
glenoid
pigfer saw

119
 m
dit fade
Q5 sup
sub prosof
Chapter 3 UPPER LIMB – Questions

coracoid
a
b
Name the structure labelled A
Name the structure labelled B
Landed
c Name the structure labelled C
d
e
Name the structure labelled D
bicep
Name the group of structures labelled E
hardi

120
Q6

Chapter 3 UPPER LIMB – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

121
 Q7
Chapter 3 UPPER LIMB – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

122
Q8

Chapter 3 UPPER LIMB – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the three major neurovascular structures found in the area labelled E

123
 Q9
Chapter 3 UPPER LIMB – Questions

a Name the structure labelled A

b Name the vessels labelled B
c Name the vessel labelled C
d Name the structure labelled D
e Name the vessel labelled E

124
Q10

Chapter 3 UPPER LIMB – Questions

a Name the structure labelled A
b Name the soft tissue structure represented here in black and labelled B which
allows rotation of the proximal radius on the neighbouring ulna
c Name the structure labelled C
d Name the flared part of the humerus labelled D
e Name the function of the major muscle group that attaches to E

125
 Q11
Chapter 3 UPPER LIMB – Questions

a Name the soft tissue structure labelled A

b Name the bony recess labelled B
c Name the line indicated by C
d Name the structure labelled D
e Name the structure labelled E

126
Q12

Chapter 3 UPPER LIMB – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

127
 Q13
Chapter 3 UPPER LIMB – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the structures labelled D
e Name the structures that B and C terminate as in the hand

128
Q14

Chapter 3 UPPER LIMB – Questions

a Name the group of structures outlined and labelled A
b Name the structure labelled B
c Name the major function of the group of muscles labelled C
d Name the structure labelled D
e Name the structure labelled E

129
 Q15
Chapter 3 UPPER LIMB – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

130
Q16

Chapter 3 UPPER LIMB – Questions

a Name the structure labelled A
b Name the soft tissue structure which articulates the distal ulna with the carpus
and is located in the position labelled B
c Name the carpal bone labelled C
d Name the space indicated by D
e Name the carpal bone labelled E

131
 Q17
Chapter 3 UPPER LIMB – Questions

a Name the carpal bone labelled A

b Name the carpal bone labelled B
c Name the carpal bone labelled C
d Name the carpal bone labelled D
e Name the bone labelled E

132
Q18

Chapter 3 UPPER LIMB – Questions

a Name the structure labelled A
b Name the three major structures outlined and labelled B
c Name the structure labelled C
d Name the major contents of the area labelled D
e Name the five carpal bones demonstrated

133
 Q19
Chapter 3 UPPER LIMB – Questions

a Name the structure labelled A

b Name the structure labelled B
c Define the age by which ossification has begun in all eight of the carpal bones
d Name the structure labelled D
e Name the structure labelled E

134
Q20

Chapter 3 UPPER LIMB – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structures labelled D
e Name the structure labelled E

135
 3 UPPER LIMB –
ANSWERS

Q1 Answers
a Surgical neck of humerus
b Lesser tubercle of humerus
c Tendon of long head of biceps brachii
d Acromion process of scapula
e Trapezoid and conoid components of the coracoclavicular ligament

Radiograph of shoulder, AP view

The humerus has both anatomical and surgical necks. The anatomical neck defines
the border of the articular surface which covers approximately half of the humeral
head. The surgical neck is where the humeral head meets the shaft; fractures
commonly occur at the surgical neck, hence the name.
Laterally, the humeral head has a greater and lesser tubercle. The tubercles are
raised areas which allow for muscular attachment; the rotator cuff muscles attach
to the tubercles of the humerus. Between the greater and lesser tubercles runs the
inter-tubercular groove. The tendon of the long head of biceps runs through this
groove before attaching to the superior lip of the glenoid within the joint capsule of
the shoulder.
As well as the acromioclavicular joint (ACJ), the clavicle and scapula are linked
via the coracoclavicular ligament which is made up of a laterally situated trapezoid
ligament and the more medial conoid ligament. In cases of ACJ rupture the union
between these two bones remains stable if the coracoclavicular ligaments are intact.

136
Q2 Answers

Chapter 3 UPPER LIMB – Answers

a Clavicle
b Acromio-clavicular joint space
c Coracoid process
d Spine of the scapula
e Glenoid cavity

Trans-scapular radiograph of the shoulder

The trans-scapular view of the shoulder is predominantly used to determine

whether the humeral head articulates normally with the glenoid. The glenoid is
identified as the point where the coracoid process, body and spine of the scapula
meet; the humeral head should be projected centrally over this area. For further
orientation, the coracoid process faces anteriorly (to the left of the image provided
here).

Q3 Answers
a Deltoid muscle
b Infraspinatus muscle
c Subscapularis muscle
d Axillary vein
e The long head of biceps tendon runs through the inter-tubercular groove

T1W MRI of shoulder at level of gleno-humeral joint, axial view

The rotator cuff muscles of the shoulder comprise supraspinatus, infraspinatus,

subscapularis and teres minor. The tendons of these muscles coalesce with the
articular capsule of the shoulder joint and provide stability by holding the humeral
head in place. Distally the rotator cuff muscles attach to the greater and lesser
tubercles of the humerus, although only the subscapularis attaches to the lesser
tubercle. All but the supraspinatus are rotators of the humerus (supraspinatus is
active at the initiation of arm abduction).
The deltoid muscle forms the contour of the shoulder. Running from the outer
aspect of the lateral third of clavicle, over the acromion and along the outer aspect
of the spine of the scapula, it lies more superficially than the rotator musculature.
The deltoid is the major abductor of the arm.
Proximally, biceps brachii has two attachments. The long head tendon runs
through the intertubercular groove of the humerus to reach the supraglenoid
tubercle of the scapula. The short head of biceps attaches to the coracoid process of
the scapula.

137
 Q4 Answers
Chapter 3 UPPER LIMB – Answers

a Deltoid muscle
b Trace of synovial fluid within gleno-humeral joint
c Superior glenoid labrum
d Acromio-clavicular joint
e Epiphyseal line (fused)

T2W MRI of shoulder, coronal view

The gleno-humeral articulation of the shoulder is a synovial ball and socket

joint. It is normal to see a trace of synovial fluid with T2W MRI; in cases of joint
disease or trauma this fluid volume may be significantly increased. The glenoid
is naturally shallow providing only limited support for the humeral head. This
support is enhanced by a circumferential fibro-cartilaginous ring known as the
glenoid labrum. MRI provides a means of identifying and assessing the glenoid
labrum which appears as a low signal triangular structure arising from the
periphery of the osseous glenoid. Administration of contrast into the synovial joint
space enhances visualisation of this area and will more reliably demonstrate a tear
of the labrum.

Q5 Answers
a Subscapularis muscle
b Coracoid process of the scapula
c Distal end of clavicle
d Biceps brachii muscle
e Axillary neurovascular bundle

T1W MRI of shoulder, coronal section

It can be difficult with a single cross sectional image to orientate oneself with the
anatomy. Coronal sections of the shoulder are usually aligned with the scapula
which lies at an oblique angle (approximately 30 degrees antero-medially to
postero-laterally) to the shoulder in the true coronal plane. The pectoralis major
can be confused with the subscapularis in this scenario. Note however the region of
muscle attachment; the subscapularis attaches to the lesser tubercle of the humerus
which is part of the humeral head. Conversely, the pectoralis major attaches along
the lateral edge of the intertubercular groove more distally on the humerus near
the surgical neck. The MRI section provided here is anterior to the humerus but
posterior to the thorax on the anterior border of the scapula. It is worth looking
at an axial view of the shoulder on MRI to appreciate the orientation of this view.
Note also the trapezius and deltoid muscles in this image.
The axillary neurovascular bundle runs anterior to the subscapularis muscle as it
enters the arm.

138
Q6 Answers

Chapter 3 UPPER LIMB – Answers

a Acromion process of the scapula
b Supraspinatus muscle
c Spine of scapula
d Teres minor muscle
e Teres major muscle

T1W MRI of shoulder, coronal section

The four rotator cuff muscles of the shoulder are the supraspinatus, infraspinatus,
teres minor and subscapularis. The supraspinatus tendon runs through the
subacromial space (as shown) where it is prone to ‘wear and tear’, especially if there
is bony stenosis of the space.
The teres major muscle lies nearly parallel with the teres minor and also
originates from the lower border of the scapula. The teres major is different in its
distal attachment; it is not part of the rotator cuff, instead it attaches to the medial
lip of the intertubercular groove more distally on the humerus.
The axillary nerve (a posterior branch of the brachial plexus supplying deltoid and
skin over deltoid) and circumflex humeral vessels pass through the space between
teres major and minor (as shown). This is known as the quadrangular space; its
medial and lateral borders are the long head of triceps and the humerus, respectively.

Q7 Answers
a Axillary artery
b Circumflex humeral artery
c Brachial artery
d Deep brachial artery (profunda brachii)
e Superior ulnar collateral artery

Fluoroscopic angiogram of the arm, AP view

Arterial blood to the upper limb is predominantly supplied by the axillary artery;
numerous anastomoses exist around the scapula which can provide collateral
supply in the event of axillary artery obstruction. At the lower border of the axilla
(inferior border of teres major) the axillary artery becomes the brachial artery.
The final branches of the axillary artery are the posterior and anterior circumflex
humeral vessels; these arteries anastomose in a circle around the surgical neck of
humerus. The brachial artery runs down the medial aspect of the arm and ends
in the antecubital fossa where it bifurcates to form the radial and ulnar arteries.
In addition to supplying the arm with arterial blood, several collateral vessels
are derived from the brachial artery from different points along its course. These
collaterals regroup around the elbow providing alternative blood supply to the
forearm. The most notable include the deep brachial artery which follows the
course of the radial nerve posteriorly behind the humerus and also the superior and
inferior ulnar collateral arteries.
139
 Q8 Answers
Chapter 3 UPPER LIMB – Answers

a Cephalic vein
b Biceps brachii muscle
c Brachialis muscle
d Medullary cavity of the humerus
e Radial nerve, deep brachial artery(s), deep brachial vein(s)

T1W MRI arm, axial section proximal to the midpoint of humerus

Venous drainage of the arm has superficial and deep components. The major
superficial veins are the basilic and cephalic; the cephalic runs anteriorly over the
arm while the basilic follows a more medial path. The deeps veins are named after
their accompanying arteries.
The biceps brachii and brachialis muscles are the forearm flexors; the biceps
brachii also acts to supinate the forearm. The arm is divided into anterior and
posterior muscle compartments; collectively, biceps brachii and brachialis compose
the anterior compartment of the arm. The three heads of the triceps brachii muscle
form the posterior muscular compartment. These compartments are separated by
medial and lateral intermuscular septi.
The radial nerve runs laterally through the arm posterior to the humerus in the
plane between anterior and posterior muscular compartments. The deep brachial
artery and vein follow the same course as the radial nerve through the arm at this level.

Q9 Answers
a Confluence of the radial and ulnar veins/origin of the brachial vein
b Deep brachial veins
c Brachial vein
d Venous valve
e Cephalic vein

Fluoroscopic venogram right arm, AP view

Venous drainage of the upper limb is divided into deep and superficial components.
The superficial veins are numerous and for the most part variable in their
position. The cephalic and basilic veins are the major superficial veins of the arm
and are more consistent in their path; they originate from a venous plexus on the
dorsum of the hand and then travel up the medial (basilic) and lateral (cephalic)
aspects of the arm. The superficial veins drain into the deep system via numerous
perforating veins. Ultimately the basilic vein drains into the brachial vein in the
upper arm while the cephalic vein drains more proximally into the axillary vein.
The deep veins of the arm are paired with the arteries both in name and with
respect to the course they take.
Veins are recognizable on fluoroscopy by the existence of valves. These are
periodically situated along the vessels and can be recognized as a short dilated
segment; often the valve leaflets are seen within this segment (see image, labelled D).
140
Q10 Answers

Chapter 3 UPPER LIMB – Answers

a Radial tuberosity
b Annular ligament
c Capitulum
d Metaphysis
e Flexor muscles of the forearm

Radiograph of a skeletally mature elbow, AP view

The tendon for biceps brachii attaches to the radial tuberosity. There is also a
bicipital aponeurosis which attaches more medially to the fascia of the forearm.
The annular ligament forms a collar around the head of the radius allowing
radial rotation, a movement performed during pronation and supination of the
forearm. Knowledge of the annular ligament is important as the radial head can be
subluxed from this attachment in cases of ‘pulled elbow’ in children.
The capitulum of the humerus articulates with the radial head (the prefix capit
indicates head).
The flared part of any long bone adjacent to the epiphyseal plate is known as the
metaphysis.
Forearm flexors attach to the medial epicondyle (the common flexor origin
– the site of pain in ‘golfers elbow’) while forearm extensors attach to the lateral
epicondyle (the common extensor origin – the site of pain in ‘tennis elbow’).

Q11 Answers
a Anterior fat pad
b Olecranon fossa
c Anterior humeral line
d Olecranon process
e Coronoid process of ulna

Radiograph of a skeletally mature elbow, lateral view

The anterior fat pad (intracapsular, extrasynovial) is normally visible on a true

lateral radiograph of the elbow. There is also a posterior elbow fat pad which
normally resides in the olecranon fossa and is therefore not usually visible. An
elbow effusion of any cause can raise the posterior fat pad out of the olecranon
fossa making it visible on a lateral radiograph, i.e. the posterior fat pad sign.
The olecranon fossa is a recess on the posterior aspect of the distal humerus
which allows space for the olecranon process of the ulna when the elbow is fully
extended.
If a line is drawn down the anterior aspect of the humerus on a lateral elbow
view, this line should bisect the anterior third of the trochlea. Supracondylar
fractures of the humerus can disrupt this normal alignment.

141
 Q12 Answers
Chapter 3 UPPER LIMB – Answers

a Epiphysis of radial head

b Epiphysis of capitulum
c Epiphysis of lateral epicondyle
d Epiphysis of medial epicondyle
e Epiphysis of trochlea

Radiograph of elbow in a 12 year-old child, AP view

Skeletal development at the elbow involves six epiphyses. These growth centres
ossify in a consistent order although the age for the appearance of each centre can
vary between individuals. It is important to remember the order in which these
growth centres appear on plain radiography so that all bony fragments can be
accounted for and none are missed. The medial and lateral epicondylar epiphyses
in particular, are prone to injury and can appear in abnormal positions following
trauma. The order in which these bony growth centres appear is remembered by
the acronym CRITOE: The capitulum (C) appears first, usually around one year
of age. Next is the radial head (R), and then the medial or internal (I) epicondyle;
these are seen around five years of age. The trochlea (T) is seen around 11 years,
closely followed by the olecranon (O) at 12 years. Finally, the lateral or external (E)
epicondyle is usually apparent by 13 years of age.

Q13 Answers
a Brachial artery
b Ulnar artery
c Radial artery
d Anterior and posterior interosseous arteries
e Superficial and deep palmar arches

Fluoroscopic angiogram of forearm, AP view

The brachial artery traverses the antecubital fossa to reach the upper forearm before
dividing into its two terminal branches at the level of the radial neck. The radial
artery runs laterally while the ulnar artery runs medially through the forearm. Just
distal to its origin, the ulnar artery gives off the common interosseous artery which
quickly divides into the anterior and posterior interosseous arteries. These arteries
are so named because they travel along either side of the interosseous membrane
which connects the adjacent internal surfaces of the bony radius and ulna. In the
hand, the radial and ulnar arteries both contribute to anastomotic connections in
the form of the superficial and deep palmar arches. By this means, the entire hand
can potentially be supplied by either of these two major arteries.

142
Q14 Answers

Chapter 3 UPPER LIMB – Answers

a Radial neurovascular bundle (radial artery, nerve and vein)
b Cephalic vein
c Flexion and of the wrist and fingers
d Ulna
e Interosseous membrane

T1W MRI of mid forearm, axial section

There are three major neurovascular bundles in the forearm; radial, median and
ulnar. In addition there are anterior and posterior interosseous bundles; these lie
on either side of the interosseous membrane. The radius appears more rounded in
cross section when compared with the ulna.
The superficial veins are numerous in the forearm and are found in the
subcutaneous fat which is superficial to the deep fascia (the deep fascia covers
the muscular compartments). The cephalic and basilic veins are two of the most
recognizable superficial veins; the cephalic runs on the lateral side of the arm, while
the basilic runs medially. These vessels are continuous throughout most of the arm;
they arise from a common plexus of superficial veins on the dorsum of the hand
and are joined within the antecubital fossa by the median cubital vein.
Two major muscle groups are functional in the forearm. The flexors lie anterior
and as a group are bulkier than the posteriorly situated extensor compartment of
muscles.

Q15 Answers
a Scaphoid
b Lunate
c Radial styloid process
d Distal radioulnar joint
e Sesamoid bone on the thumb

Radiograph of the distal forearm and wrist, AP view

The eight carpal bones lie in two rows of four. The proximal row contains, from
lateral to medial, the scaphoid, lunate, triquetrum and pisiform. With the exception
of the pisiform these bones form a semicircle, the convexity of which is proximal
and articulates with the corresponding concave surface of the radius. The distal row
is formed, again from lateral to medial, by the trapezium, trapezoid, capitate and
hamate; these bones articulate with the proximal row at the mid-carpal joint. The
bones within each row articulate at intercarpal joints.
The ulnar surface of the distal radius has a notch for articulation with the ulna
– the distal radioulnar joint. Holding the radius and ulna together at the distal
radioulnar joint is the triangular cartilage running from the medial surface of the

143
Chapter 3 UPPER LIMB – Answers

radius to the styloid process of the ulna. Situated laterally is the pyramidal radial
styloid process.
In the thumb, a pair of sesamoid bones articulate with the flexor surface of the
metacarpal head. They are contained within the tendons of flexor pollicis brevis
and adductor pollicis.

Q16 Answers
a Ulna styloid
b Triangular fibrocartilage
c Pisiform
d Scapho-lunate joint space
e Trapezoid

Radiograph of right carpus, oblique view

The distal ulna appears shorter than the adjacent radius at the wrist on plain
radiographs. What is not apparent on these images is the existence of the triangular
fibrocartilage; this intracapsular structure articulates with the distal ulna and
with the triquetral and lunate carpal bones. The triangular fibrocartilage can
be visualized on MRI and arthrography can better demonstrate its integrity; if
disrupted, intracapsular contrast can spill into the distal radio-ulnar joint.
With an AP view of the wrist, the scaphoid and lunate normally overlap slightly.
On this oblique view the joint space is however, visible.

Q17 Answers
a Capitate
b Lunate
c Scaphoid
d Trapezium
e Ulna

Radiograph of wrist, lateral view

When viewed laterally, the lunate normally rests within the cup-shaped distal end of
the radius. Similarly, the capitate sits within the distal hollow formed by the curve
of the lunate; i.e. capitate sits within lunate sits within radius. This configuration
is disrupted in lunate and perilunate dislocations which are best demonstrated
with the lateral view. The other carpal bones are more difficult to recognize when
viewed laterally as there is too much overlap, however by remembering that the
trapezium sits under the thumb, this bone can also be identified. Due to differences
in the appearance of their styloid processes, the radius and ulna can also usually be
differentiated.

144
Q18 Answers

Chapter 3 UPPER LIMB – Answers

a Hypothenar eminence
b Ulnar nerve, ulnar artery and vein
c Flexor retinaculum
d Median nerve, four flexor digitorum superficialis tendons, four flexor digitorum
profundus tendons and the tendon for flexor pollicus longus
e Trapezium, trapezoid, capitate, hamate, pisiform (as seen left to right of the
image)

T1W MRI of wrist at level of carpal tunnel, axial section

The flexor retinaculum forms the roof of the carpal tunnel and extends from
the hook of hamate and pisiform medially to the tubercles of the trapezium
and scaphoid laterally. The major contents of the carpal tunnel are the median
nerve, the four flexor digitorum superficialis tendons, the four flexor digitorum
profundus tendons and the tendon of flexor pollicus longus. The flexor retinaculum
can be surgically divided as treatment for carpal tunnel syndrome where there is
compressive median nerve neuropathy. Note that the ulnar nerve does not travel
through the carpal tunnel and is spared in cases of carpal tunnel syndrome.
There are two muscular prominences on the palmar surface of the hand; the
thenar and hypothenar eminences. These muscle groups are responsible for flexion,
abduction and opposition of the thumb and little finger (5th digit), respectively.

Q19 Answers
a Triquetral
b Scaphoid
c 12 years
d Epiphysis for the middle phalynx of the index finger
e Physis for the 5th metacarpal

Radiograph of the hand and wrist in a 7 year-old child, AP view

There are multiple ossification centres in the developing hand and wrist. The carpal
bones ossify in a predictable fashion; the capitate and hamate are visible by one year
of age, the triquetral by two years, the lunate by three years, the scaphoid, trapezoid
and trapezium appear by six years of age while the pisiform is expected by the age
of 12 years. A child’s physiological age can be estimated by comparing the extent
of bony development against published radiographic standards of normal. In such
calculations, the epiphyses of the metacarpals and digits are often assessed, it is
therefore important to know where each epiphysis belongs in relation to its parent
bone. The metacarpal epiphyses lie distal to the bone (this can be confused with or
mask a common injury to the 5th metacarpal), while the phalangeal epiphyses lie
proximally.

145
 Q20 Answers
Chapter 3 UPPER LIMB – Answers

a Palmar aponeurosis
b Tendon of flexor digitorum superficialis for the middle finger
c Thenar eminence
d Palmar digital arteries
e Lumbrical muscle to ring finger

T1W MRI of hand, axial section through midpoint of metacarpals

The palmar aponeurosis is a thickening of the deep fascia within the palm; it
supports and protects structures in the palm.
The median and ulnar nerves terminate in the palm with branches supplying
both muscles and skin of the hand. Similarly, the deep and superficial arterial
palmar arches give off branches to the hand and fingers; each finger receives blood
from a single common palmar digital artery that further divides into medial and
lateral proper digital branches. These digital branches run the length of the finger.
Finger flexion is achieved through the action of several muscles. The long flexors
of the fingers are the flexors digitorum superficialis (FDS) and profundus (FDP).
There are four tendons for each (one to each finger) with the profundi lying deep
to the supericialis throughout their course. For each of the four digits, the tendon
of FDS splits and is attached to the sides of the middle phalynx. Through this split
passes the tendon of FDP on its way to the base of the distal phalynx. The long
flexors act upon the interphalangeal joints. Arising in the palm from the tendons of
FDP are four palmar muscles known as the lumbricals which provide flexion at the
metacarpal-phalyngeal joints. The lumbrical muscles are situated superficially to
the interosseous muscles which fill the spaces between the metacarpals.

146
 4 ABDOMEN

Q1
a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

147
 Q2
Chapter 4 ABDOMEN – Questions

a Name the structures labelled A

b Name the structures labelled B
c Name the structure that partially arises from the antero-medial aspect of the
structures labelled B
d Name the structure labelled D
e Name the skeletal anatomical variant demonstrated in this image

148
Q3

Chapter 4 ABDOMEN – Questions

a Name the superficial blood vessel into which catheter A has been inserted
b Name the superficial blood vessel into which catheter B has been inserted
c Name the vessels/structures through which the tip of catheter A has travelled
d Name the vessels/structures through which the tip of catheter B has travelled
e Name the structure labelled E

149
 Q4
Chapter 4 ABDOMEN – Questions

a Name the structure labelled A

b Name the vertebral column in which structure A lies
c Name the opening labelled C
d Name the structure labelled D
e Describe why structure D is atypical at the vertebral level indicated

150
Q5

Chapter 4 ABDOMEN – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

151
 Q6
Chapter 4 ABDOMEN – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

152
Q7

Chapter 4 ABDOMEN – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

153
 Q8
Chapter 4 ABDOMEN – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

154
Q9

Chapter 4 ABDOMEN – Questions

a Name the segment of the structure labelled A
b Name the segment of the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

155
 Q10
Chapter 4 ABDOMEN – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

156
Q11

Chapter 4 ABDOMEN – Questions

a Name the peritoneal ligament arising from structure A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the peritoneal ligament arising from structure E

157
 Q12
Chapter 4 ABDOMEN – Questions

a Name the opening outlined and labelled A

b Name the cavity into which A opens
c Name the structure labelled C
d Name the peritoneal structure indicated by the lines labelled D
e Name the peritoneal structure indicated by the line labelled E

158
Q13

Chapter 4 ABDOMEN – Questions

a Name the gas filled structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the embryological vascular remnant located at site E

159
 Q14
Chapter 4 ABDOMEN – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the space labelled C
d Name the structure labelled D
e Name the anatomical variant demonstrated in this image

160
Q15

Chapter 4 ABDOMEN – Questions

a Name the structure labelled A
b Name the region outlined and labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure responsible for the indentation at position E

161
 Q16
Chapter 4 ABDOMEN – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

162
Q17

Chapter 4 ABDOMEN – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

163
 Q18
Chapter 4 ABDOMEN – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the part of the structure labelled C
d Name the structure labelled D
e Name the part of the structure labelled E

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Q19

Chapter 4 ABDOMEN – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

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 Q20
Chapter 4 ABDOMEN – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the major biliary structure not seen in this image
e Name the pancreatic anatomical variant demonstrated in this image

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Q21

Chapter 4 ABDOMEN – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the artery that supplies most of the spinal cord visible in this image
(inferior to T9)

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 4 ABDOMEN –
ANSWERS

Q1 Answers
a Left kidney
b Liver
c Right psoas muscle
d Descending colon
e Stomach

Abdominal radiograph

On plain radiography, the presence of an interface between tissues of differing

contrast is required to enable visualization of structures. In the case of the liver,
kidney and psoas muscles there is para-renal, peri-renal and retroperitoneal fat
to provide this contrast. The descending colon is surrounded on three sides by
peritoneum but there is adjacent preperitoneal fat which can give contrast, as in this
case. There is often gas within the lumen of the bowel to provide negative contrast
as is commonly seen in the stomach and colon.

Q2 Answers
a Haustra
b Transverse processes of lumbar spine
c Psoas major muscle
d Right pedicle of L2
e Six lumbar vertebrae (or one pre-sacral vertebra)

Abdominal radiograph

The teniae coli run the length of the colon, from the caecum to the sigmoid. They
are focal areas of thickening in the longitudinal muscular layer which run along
the anterior, postero-medial and postero-lateral aspects of the colon. As they are
shorter than the colon, the bowel is pulled into folds, or haustra, which can be seen
on radiographs. The taeniae coli converge at the appendix base proximally and the
rectum distally.

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 Chapter 4 ABDOMEN – Answers
The psoas major muscle arises from the antero-medial aspect of the lumbar
transverse processes and the lower borders of the T12–L5 vertebral bodies.
Aberrations at the lumbar-sacral junction are occasionally seen. An example is
the presence of six lumbar vertebrae, the sixth vertebra being called the first pre-
sacral vertebra. ‘Sacralization’ of L5 occurs when it is fused to S1. ‘Lumbarization’ of
S1, which is less common, occurs when S1 is significantly separated from S2.

Q3 Answers
a Left umbilical artery
b Umbilical vein
c Umbilical, left internal iliac and left common iliac arteries, aorta
d Umbilical vein, left portal vein, ductus venosus, IVC
e Liver

Abdominal radiograph of a neonate

Umbilical vascular catheters can be used for vascular sampling and monitoring in
the neonatal period.
There are paired umbilical arteries which are branches of the internal iliac
arteries on both sides. The distal artery will normally occlude shortly after
transection of the cord at birth, going on to form the medial umbilical ligament.
The proximal artery will remain patent however and provides branches to the
bladder and ductus deferens. Early in-utero there is a pair of umbilical veins but
only one usually persists to birth. This umbilical vein carries oxygenated blood
towards the foetal heart and initially drains into the left portal vein, where it then
bypasses the hepatic circulation to enter the inferior vena cava (IVC) through the
ductus venosum. Both the ductus venosum and umbilical vein occlude and become
fibrotic following birth, becoming the ligamentum venosum and ligamentum teres
respectively.
The relative size of the normal liver is large in neonates. Proportional to total
body height, the longitudinal length of the right lobe in neonates is almost twice
that at aged 16 years.

Konuş OL, Ozdemir A, Akkaya A et al. Normal liver, spleen, and kidney dimensions in neonates, infants,
and children: evaluation with sonography. Am J Roentgenol 1998; 171:1693–1698.

Q4 Answers
a Pars interarticularis
b Posterior column
c Neural foramen/intervertebral foramen
d Facet (zygapophyseal) joint
e The inferior articular facet faces forward

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 Radiograph of lumbar spine, lateral view
Chapter 4 ABDOMEN – Answers

The anatomy of the five lumbar vertebrae differs from the thoracic vertebrae in a
number of areas, enabling them to withstand greater degrees of axial stress. The
vertebral bodies are larger in transverse diameter than in antero-posterior diameter.
The adjacent articular facets directly face each other (in the sagittal plane) and the
laminae are shorter and do not overlap. The pars interarticularis is the laminar
region between the facet joints and is the area fractured in spodylolysis. The
pedicles enclose the intervertebral or neural foramina, as happens in the thoracic
spine.
The fifth lumbar vertebra is atypical of others, and has differences in structure to
facilitate articulation with the sacrum. The vertebral body is wedge-shaped and is
taller anteriorly to accommodate the downward sloping S1. The inferior facet faces
forward which allows a stronger articulation with S1 and also prevents anterior
subluxation. The transverse process is very large and triangular and attaches to the
pedicle and vertebral body of L5.
The ‘three column’ principle can be used as a means of predicting mechanical
integrity (and therefore the degree of stability) of the spine following injury or
disruption.
The anterior column is formed by the anterior longitudinal ligament, anterior
part of the vertebral body and the anterior annulus fibrosis.
The middle column consists of the posterior longitudinal ligament, posterior
wall of the vertebral body and posterior annulus fibrosis.
The posterior column consists of the neural arch (or posterior elements)
and the posterior ligamentous complex of ligamentum flavum, interspinous
ligaments, supraspinous ligaments and intertransverse ligaments.

Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal
fractures. Spine 1983; 8:817–831.

Q5 Answers
a Ileum
b Jejunum
c Descending/second part of duodenum
d Gastric (pyloric) antrum
e Duodenal cap

Barium small bowel follow-through examination

The antrum of the stomach is the area distal to the incisura on the lesser curve and
narrows to form the pyloric canal. The duodenum, which is mainly retroperitoneal,
is roughly ‘C’-shaped with the concavity to the left and is described in four parts.
The first part of the duodenum travels posteriorly and superiorly to vertebral
level L1, making it appear shortened in a frontal projection. Mucosal folds are

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 Chapter 4 ABDOMEN – Answers
thin and lie in a parallel or spiral configuration. The duodenal cap is the proximal
2.5cm of duodenum, which lies between the peritoneal folds of the greater and
lesser omenta and forms the inferior boundary of the opening into the lesser
sac (epiploic foramen). The second part of the duodenum runs inferiorly to
vertebral level L3, and is where circular valvulae conniventes of small bowel begin
properly. A longitudinal duodenal fold may be seen which marks the position
of the ampulla (of Vater). The third part travels horizontally and the fourth part
ascends to vertebral level L2 where it passes out from behind the peritoneum to
become the jejunum at the duodenal-jejunal flexure. The ligament of Treitz is a thin
musculofibrous suspensory band that connects the fourth part of the duodenum
with the right diaphragmatic crus.
The proximal two-fifths of the small bowel is called the jejunum, the distal
three-fifths the ileum. When compared to the ileum, the jejunum is usually of wider
caliber, with a thicker wall and thicker, more numerous valvulae conniventes. The
jejunum is usually positioned in the upper left abdomen, while the ileum lies in
the lower right abdomen. In barium studies, the jejunum often shows a ‘feathery’
mucosal pattern, compared to a more solid and featureless appearance of the ileum.

Q6 Answers
a Splenic artery
b Gastroduodenal artery
c Common hepatic artery
d Left hepatic artery
e Right renal pelvis

Digital subtraction angiogram of the coeliac axis, AP view

The coeliac artery is the uppermost of three un-paired aortic branches which
provide blood supply to the abdominal viscera. It arises from the anterior aspect
of the abdominal aorta at the level of T12–L1 as a single trunk which typically
branches into three divisions: the common hepatic, left gastric and splenic arteries
which course right, superiorly and left respectively (the left gastric artery is not well
opacified on this image). This usual configuration of vessels is present in around
55% of the population.
The coeliac trunk is primarily responsible for supplying the foregut structures,
the superior mesenteric artery supplying the mid-gut and the inferior mesenteric
artery the hindgut. In reality there are often rich vascular connections between
these circulations and overlap of the territories they supply. There is a lot of variety
in coeliac arterial anatomy amongst individuals. Michel’s classification of hepatic
arterial supply alone lists ten different normal variations.
Intra-arterial contrast is readily filtered from the blood by the kidneys once it
enters the systemic circulation. Opacification of the renal collecting systems is
commonly seen during angiographic studies.

Michel NA. Blood supply and anatomy of the upper abdominal organs with a descriptive atlas, Lippincott,
Philadelphia, 1955, pp. 64–69.
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 Q7 Answers
Chapter 4 ABDOMEN – Answers

a Rectum
b Appendix
c Ascending colon
d Transverse colon
e Sigmoid colon

Full length radiograph from a barium enema examination, frontal view

The large intestine consists of eight parts which, from proximal to distal, are:
caecum, vermiform appendix, ascending colon, transverse colon, descending colon,
sigmoid colon, rectum and anal canal.
The caecum is the blind-ended pouch of the colon just distal to the ileocaecal
valve. It is covered with peritoneum which is reflected downwards to the floor of
the right iliac fossa and determines both the mobility of the caecum and size of the
retrocaecal space. The ascending and descending colon are invested in peritoneum
and are relatively immobile. The transverse and sigmoid colon are invested in their
own mesentery (or mesocolon), as is the appendix which arises from the posterior
aspect of the caecum. These three are therefore the most mobile parts of the large
intestine. The rectum is covered on its upper third by peritoneum. Deep to the
peritoneal reflection, the rectum is surrounded by pelvic visceral fat and fascia
(mesorectum).

Q8 Answers
a Coeliac trunk
b Superior mesenteric artery (SMA)
c Inferior mesenteric artery
d Third part of duodenum
e Left renal vein

Contrast enhanced abdomino-pelvic CT, midline sagittal section

This image demonstrates the relative positions of the three un-paired ventral aortic
branches.
The coeliac trunk arises at the T12–L1 level and often takes a caudal course from
the anterior aorta. It runs above the pancreas and the splenic vein and lies posterior
to the left lobe of liver.
The SMA arises from the anterior aorta at around the level of L1. In approximately
0.5% of people the coeliac artery and SMA arise from a single (coeliacomesenteric)
trunk. Running in a transverse direction deep to the SMA are the left renal vein and
third part of duodenum. The pancreas and portal vein lie anteriorly. The SMA runs
within the mesenteric root lying to the left of the superior mesenteric vein (SMV).
The inferior mesenteric artery (IMA) arises from the left anterior aspect of the

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 Chapter 4 ABDOMEN – Answers
aortic wall at the level of L3 and branches into the left colic and superior rectal
arteries.

Q9 Answers
a Right lateral superior (VII)
b Left medial inferior (III)
c Superior mesenteric vein
d Jejunal branch of the superior mesenteric artery
e Gallbladder

CT of abdomen and pelvis at the level of the superior mesenteric vessels, coronal
section

The superior mesenteric artery arises just proximal to the origins of the renal
arteries. The artery courses anteriorly and then inferiorly, running alongside and to
the left of the superior mesenteric vein. From the left lateral aspect of the SMA, a
total of 4–6 jejunal branches arise, with each artery dividing into two and joining to
form an arcade of vessels which parallels the orientation of the intestine. A branch
of the dorsal pancreatic artery may arise from the SMA just proximal to the first
jejunal branch. The middle colic branch and right colic branch arise from the right
side of the SMA, and supply the transverse colon and ascending colon respectively.
Occasionally a second artery accompanies the middle colic artery in the transverse
mesocolon before coursing inferiorly to connect with the left colic artery. This is
known as an artery of Riolan and, if present, forms a communication between the
superior mesenteric and inferior mesenteric arterial systems. The ileocolic artery
arises from the distal SMA and supplies branches to the caecum, terminal ileum
and appendix. A total of 9–13 ileal branches arise from the terminal SMA and form
into arcades (in a similar fashion to the jejunal branches) to supply the ileum. The
distal ileal branch forms an anastomosis with the ileocolic artery.
Hepatic segments are regions of the liver that share a common blood supply (both
hepatic arterial and portal venous) and biliary drainage. There are eight segments
in total and they were first described by Couinaud, a French hepatobiliary surgeon,
in 1957. The liver is divided by the principal plane into two anatomical halves and
these are further sub-divided into four segments. The planes of segmental division
are marked by the hepatic veins in the longitudinal axis and the portal vein in the
transverse axis. Segment IV is different in that it extends either side of the portal
vein and can be given the suffix (a) for the superior part and (b) for the inferior
part. When the liver is viewed from the front the segments are numbered in an
approximately clockwise fashion beginning at the caudate lobe which is segment
I. Segments VII, VIII, IV(a) and II run right-to-left superior to the portal vein and
segments VI, V, IV(b) and III run in a similar manner inferior to the portal vein.

Claude Couinaud. Le Foie: Études anatomiques et chirurgicales (The Liver: Anatomical and Surgical
Studies), Masson, Paris, 1957.

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 Q10 Answers
Chapter 4 ABDOMEN – Answers

a Crus of right hemi-diaphragm

b Left adrenal gland
c Right adrenal gland
d Body of the stomach
e T12 vertebral body

CT of the upper abdomen with oral and intravenous contrast, in the portal venous
phase, axial section

The adrenal glands lie retroperitoneally and above the kidneys with the position of
the gland on the right being more consistent. It lies posterior to the inferior vena
cava, medial to the right lobe of the liver and lateral to the right diaphragmatic crus.
It is lower and more medial in relation to the spine than the left adrenal.
The stomach is J-shaped and shows much variation in size and shape between
individuals. It has two curvatures – the greater and lesser curves. The incisura is an
angulation towards the pyloric end of the lesser curve. There are two orifices, the
cardia (upper) and pylorus (lower). The part above the cardia is called the fundus.
Between the cardia and the incisura is the body of the stomach and distal to the
incisura is the gastric (pyloric) antrum. The stomach is lined by mucosa which
forms into temporary folds called rugae. These can be seen in this image as lines
running the length of the gastric body.

Q11 Answers
a Phrenicocolic ligament
b Left renal vein
c Head of pancreas
d Second part of duodenum
e Duodenocolic ligament

Porto-venous CT at the level of the L2 vertebra, axial section

The ascending and descending colon are both retroperitoneal structures which
are fixed anteriorly and on both sides by peritoneum. At the hepatic flexure, the
peritoneum extends to form the duodenocolic ligament which is continuous with
the transverse mesocolon and contains the lymphatic vessels draining the right
colon. The phrenicocolic ligament is a similar structure on the left side which
extends from the splenic flexure to the diaphragm at the level of the 11th rib. This
is continuous with both the transverse mesocolon and splenorenal ligament and
provides additional support to the spleen as well as forming a barrier between the
infracolic and supracolic compartments.
The left renal vein is five times longer than the right and passes anterior to the
aorta from the renal hilum to drain into the IVC. It receives the inferior phrenic,
gonadal and suprarenal veins on the left. The right renal vein receives no extrarenal
tributaries.
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Q12 Answers

Chapter 4 ABDOMEN – Answers

a Foramen of Winslow/epiploic foramen
b Lesser sac
c Left lobe of the liver
d Splenorenal ligament
e Gastrosplenic ligament

CT abdomen at the level of L1, axial section

The lesser sac of the peritoneum lies between the pancreas and the posterior wall of
the stomach, duodenum, lesser omentum and hepatoduodenal ligament. It extends
for a variable extent superiorly to the diaphragmatic crus and inferiorly to the root
of the transverse mesocolon. A fold of peritoneum surrounding the left gastric
artery forms a division between two recesses in the lesser sac. The sac is formed
from the embryological liver migrating from a central position into the right upper
abdomen. This causes stretching of the visceral peritoneal covering and the creation
of a space along its path.
The foramen of Winslow, or epiploic foramen, is a communication under the
free bottom edge of the lesser omentum between the greater sac and lesser sac. It
measures 25mm and is located between the IVC and free margin of the ligament
containing the portal triad of vessels – the hepatoduodenal ligament.
The splenorenal, or lienorenal, ligament connects the posterior aspect of the
spleen to the anterior para-renal space and contains the splenic vessels, tail of the
pancreas and surrounding fat. The gastrosplenic ligament connects the greater
curve of the stomach with the splenic hilum and contains left gastroepiploic and
short gastric vessels. Together these two ligaments comprise the lateral boundary of
the lesser sac.

DeMeo JH, Fulcher AS, Austin RF Jr et al. Anatomic CT demonstration of the peritoneal spaces,
ligaments, and mesenteries: normal and pathologic processes. Radiographics 1995; 15:755–770.

Q13 Answers
a Transverse colon
b Splenic vein
c Right portal vein
d Left portal vein
e Umbilical vein

Upper abdominal CT with contrast (portal venous phase), axial section

The portal venous system serves to channel the blood drained from the gut and
spleen into the liver prior to it entering the systemic circulation. The main portal
vein is approximately 7cm long and is a direct continuation of the SMV, coursing

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Chapter 4 ABDOMEN – Answers

anterior to the IVC towards the porta hepatis. Portal venous tributaries are the
splenic (into which drains the inferior mesenteric vein), cystic, gastric and superior
pancreatoduodenal veins. The portal vein divides into right and left limbs which
in turn supply branches to the various hepatic segments. The portal vein supplies
approximately 75% of the blood to the liver with the remainder being supplied via
the hepatic arterial system.
Flow in the umbilical vein usually ceases following birth, but it remains a
potential site of porto-systemic anastomoses. Other sites of porto-systemic
anastomoses are at the lower oesophagus, upper anal canal, bare area of liver and
retroperitoneal areas.

Q14 Answers
a Abdominal aorta
b Psoas muscle
c Hepato-renal (Morison’s) pouch
d Posterior renal fascia (fascia of Zuckerlandl)
e Double IVC

Abdominal CT with oral and IV contrast, axial section

The IVC is normally formed from the confluence of the common iliac veins at
the L5 level, behind the right common iliac artery and it travels up the posterior
abdominal wall on the right of the midline. Developmental anomalies of one
or more of the caval segments (hepatic, supra-renal, renal and infra-renal) are
occasionally present. Duplication of the infra-renal IVC (‘Double-IVC’) is a
developmental anomaly of the infra-renal segment resulting in persistence of both
embryological supracardinal veins and is seen in 0.2–3% of the population. In these
cases the left IVC typically drains into the left renal vein, which in turn joins the
right-sided IVC as normal. Variations in the configuration of the renal segment
(right suprasubcardinal and postsubcardinal anastomoses) are most common
anomalies encountered, with retro-aortic and circum-aortic left renal veins present
in approximately 8% and 2% of the population, respectively.
The kidneys are surrounded by perirenal fat which in turn is surrounded by the
anterior and posterior leaves of renal fascia. The anterior leaf is Gerota’s fascia and
the posterior leaf is the fascia of Zuckerlandl. These divide the retroperitoneal space
into three compartments: the peri-renal, anterior para-renal and posterior-para-
renal spaces.
Morison’s pouch lies at the posterior aspect of the right sub-hepatic space
anterior to the right kidney and is the most dependant position of the peritoneal
cavity in a supine patient. Its importance as a potential site of fluid accumulation
within the abdomen was described by Morison in 1894.

Bass JE, Redwine MD, Kramer LA et al. Spectrum of Congenital Anomalies of the Inferior Vena Cava:
Cross-sectional Imaging Findings. RadioGraphics 2000; 20:639–652.

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Cheesbrough RM. Gerota versus Zuckerkandl: the renal fascia revisited. Radiology 1989; 173:845–846.

Chapter 4 ABDOMEN – Answers

Morison JR. The Anatomy of the Right Hypochondrium Relating Especially to Operations for Gall
Stones. 1894; 1766:968–971.

Q15 Answers
a Major calyx
b Pelvi-ureteric junction
c Renal artery
d External iliac artery
e Gonadal artery

CT urogram of the right kidney, maximum intensity projection, coronal section

The renal collecting system consists of several minor calyces which form two
or three major calyces. These then drain into the renal pelvis, which is a conical
structure located at the hilum of the kidney. It is usually the most posterior of the
hilar structures. The right renal artery is longer than the left and the opposite is true
with the renal veins. The kidney consists of five segments (apical, posterior, lower,
upper and middle) which are each supplied by a segmental artery and vein.
The transition between renal pelvis and ureter is the pelvi-ureteric junction,
which along with the vesico-ureteric junction are the narrowest segments of the
upper renal tract.
The ureter passes inferiorly along the anterior border of psoas major muscle. It
is crossed by the gonadal artery which arises from the anterior aorta (L2 vertebral
level) and travels obliquely down towards the testis or ovaries. Inferiorly the right
ureter is crossed by the ileo-colic and right colic vessels as well as the root of the
mesentery. It deviates medially from the psoas muscle and crosses anterior to the
bifurcation of the common iliac artery (where the iliac artery is positioned anterior
to the iliac vein) prior to passing into the pelvis.

Q16 Answers
a Transversus abdominis
b Internal oblique
c Aponeurosis of external oblique
d Rectus abdominis
e Linea alba

CT at the level of the iliac crest, axial section

The musculature of the anterior and lateral abdominal wall consists of four main
muscles; rectus abdominis, external oblique, internal oblique and transversus
abdominis.

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Chapter 4 ABDOMEN – Answers

The two recti lie either side of the midline and extend from the 5th, 6th and 7th
costal cartilages to the pubis. They are interconnected by the linea alba and invested
within a thick fascial covering known as the rectus sheath which is formed by the
aponeuroses of the external oblique, internal oblique and transversus abdominis
muscles.
The external oblique is the largest and most superficial of the three antero-
lateral muscles. It arises from ribs 4–12 and interdigitates with slips of muscle
from serratus anterior and latissimus dorsi. As it passes anteriorly it becomes an
aponeurosis which forms part of the anterior rectus sheath, anterior to rectus
abdominis. The free lower edge of the external oblique is attached between
the anterior superior iliac spine and the pubic tubercle and forms the inguinal
ligament.
The internal oblique lies deep to and is smaller than the external oblique. It arises
from the costal margin and thoracolumbar fascia and is inserted into the inguinal
ligament below. As it passes anteriorly it becomes an aponeurosis which, above the
umbilicus, splits around the rectus abdominis and contributes to both the anterior
and posterior layers of the rectus sheath.
The transversus abdominis is the deepest of the three muscles, arising from
the costal margin, thoracolumbar fascia, iliac crest and inguinal ligament. It also
becomes an aponeurosis which, above the umbilicus contributes to the posterior
layer of the rectus sheath.
Below the umbilicus, all three aponeuroses pass anterior to the rectus abdominis.
This produces a whitening of the anterior wall where the rectus passes deep to all
three layers and is known as the arcuate line.

Q17 Answers
a Portal vein
b Hepatic artery
c Common bile duct
d Gallbladder
e Hepatic vein

Ultrasound of the liver at the porta-hepatis, transverse section

The common bile duct lies anterior to the portal vein at the porta-hepatis. To the
left of the common bile duct and running in an oblique course, is the hepatic artery.
The diameter of the common bile duct is measured at the level of the hepatic artery
and should not exceed 4mm in young adults. The calibre of the common bile duct
usually increases with age.
The portal veins characteristically have hyperechoic walls which can enable
differentiation on ultrasound from dilated biliary ducts or hepatic veins, which
typically do not. The venous drainage of the liver occurs directly into the IVC
through the middle, left and right hepatic veins. They form a confluence with the
intra-hepatic IVC at the level of T9, just below the caval diaphragmatic hiatus.

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 Chapter 4 ABDOMEN – Answers
Wu CC, Ho YH, Chen CY. Effect of aging on common bile duct diameter: a real time ultrasonographic
study. J Clin Ultrasound 1984; 12:473–478.
Laing FC. The gallbladder and bile ducts. In Diagnostic ultrasound (eds Rumack C, Wilson S, Carboneau
JW), Mosby, St Louis, MO, 1998, p. 207.

Q18 Answers
a Right adrenal/supra-renal gland
b Common bile duct
c Body of the pancreas
d Inferior vena cava
e Caudate lobe (segment I) of the liver

Ultrasound of upper abdomen, transverse section

The right adrenal (supra-renal) gland lies antero-medial to the right upper pole of
the kidney and it is adherent to the posterior wall of the inferior cava. The blood
supply is principally provided by the suprarenal artery, however collateral supply
comes from the renal and inferior phrenic arteries. Venous drainage is through the
suprarenal vein, which drains into the IVC on the right and the left renal vein on
the left. The adrenals are a similar size on both sides, with the average widths of
the anterior, posteromedial and posterolateral limbs being 6.5mm, 3mm and 3mm
respectively. The anterior limb of the right adrenal is usually less prominent than
the left because of its proximity to the IVC.
The pancreas is divided into four parts – head, neck, body and tail. The head
lies to the right of the midline and within the concavity of the duodenal curve and
extends inferiorly as the hook-shaped uncinate process. The neck is the part of the
pancreas which is immediately anterior to the proximal portal vein. The body begins
in line with the left border of the vertebral column and the distal pancreatic tail is
the part contained within the lienorenal ligament alongside the splenic vessels.
The caudate lobe (segment I) of the liver is situated posterior and to the right of
the hepatic IVC. It is unusual in that it receives a blood supply from both right and
left hepatic arteries and portal veins and drains directly into the IVC through small
perforating veins.

Q19 Answers
a Right hemi-diaphragm
b Renal pyramid
c Column of Bertin
d Renal sinus fat
e Right psoas major

179
 Ultrasound of right kidney, longitudinal section
Chapter 4 ABDOMEN – Answers

The kidney parenchyma comprises of an outer cortex and inner medulla. Columns
of Bertin are regions of cortical tissue which pass towards the renal hilum dividing
the medulla into several pyramids. At the top of the pyramids, the papillae drain
into the calyces which in turn drain into the renal pelvis. The renal sinus partially
encloses the renal pelvis and contains fat and lymphatics.
The hemi-diaphragm is located above the kidney and has an echogenic
appearance on ultrasound. Psoas major lies postero-medially and can be seen in
longitudinal section below the kidney.

Q20 Answers
a Dorsal pancreatic duct (of Santorini)
b Common bile duct
c Left hepatic bile duct
d Gallbladder
e Pancreas divisum

MRCP

Bile drained from the hepatocytes runs in bile duct tributaries which pass alongside
portal venous and hepatic arterial vessels in ‘portal triads’. All three systems
conform to the segmental divisions of the liver. The segmental and sectoral ducts
typically unite to form the right and left hepatic ducts which then converge at
the porta hepatis to become the common hepatic duct. The cystic duct from the
gallbladder usually drains into the common hepatic duct, after which it becomes
the common bile duct (CBD). The location of cystic duct insertion and therefore
the length of the common bile duct can vary, however an average length is
approximately 8cm.
There are numerous variations in the configuration and course of the intra-
hepatic biliary ducts and in approximately 50% the anatomy is not ‘typical’ (as
in this image). In this case the main confluence at the porta hepatis is formed by
a right sectoral duct and the left hepatic duct, with the remaining right sectoral
duct inserting more distally into the CBD. This is one of the convergence étagée or
shelved confluence variations seen in approximately 20% of the population. This
variation is of interest to surgeons as an aberrant posterior sectoral duct can be
mistaken for the cystic duct during gallbladder surgery.
The gallbladder is not visible on this image. There can be a number of reasons
for this which include: previous cholecystectomy (common), chronic cholecystitis,
cholelithiasis and agenesis (rare).
Normally the pancreatic duct combines with the common bile duct to form the
ampulla of Vater. This then drains into the second part of the duodenum, with the
flow being controlled by a muscular sphincter (of Oddi). The main pancreatic duct
is formed in-utero from fusion of the embryological dorsal and ventral ducts. It is

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 Chapter 4 ABDOMEN – Answers
common for some communication to persist between the pancreatic ductal systems
but in approximately 6% of individuals these ducts remain entirely separate in what
is termed pancreas divisum. In this anatomical variant the main dorsal duct (of
Santorini) drains the tail and body of the pancreas and empties into the duodenum
proximally via a separate opening – the minor papilla. The smaller ventral duct (of
Wirsung), which serves the pancreatic head, then joins the distal CBD to drain into
the duodenum via the major papilla. The ventral duct is seen on this image running
inferior and parallel to the distal CBD.

Healy JE, Schroy PC. Anatomy of the Biliary Ducts Within the Human Liver: Analysis of the Prevailing
Pattern of Branchings and the Major Variations of the Biliary Ducts. AMA Arch Surg 1953; 66:599–616.
Bismuth H, Vibert E. Chapter 90: Surgical Anatomy of the Liver and Biliary Ducts. In Master Volume of
Surgery, Volume 1 (eds Fischer JE, Bland KI), Lippincott Williams & Wilkins 2007.
Khan MA, Aktar A. Pancreas Divisum. Radiology 2010; eMedicine: www.emedicine.medscape.com

Q21 Answers
a Conus medullaris
b Posterior longitudinal ligament
c Epidural fat
d Basivertebral vein
e Artery of Adamkiewicz

T2W MRI of lower spine, midline sagittal section

The spinal cord terminates at the conus medullaris which is located opposite L1
or L2 in adults, but is positioned lower (L3) in children. This occurs because the
relative growth of the spinal canal and meninges is greater than that of the spinal
cord. The conus medullaris marks the termination of the cord only, as the lumbar
and sacral nerve roots continue their descent within the thecal sac forming the
cauda equina. There is a bulge in the spinal cord proximal to its termination, at
around the level of T9–L1 vertebral bodies. This is the lumbar enlargement and is
the location of the lower limb plexus (L2–S3) of nerve roots. A similar, but smaller,
cervical enlargement occurs in the cord at the C3–T1 vertebral levels due to the
upper limb plexus of nerve roots (C5–T1). Both of these enlargements occur as a
result of a greatly increased mass of motor cells within the anterior horns of the
grey matter.
The posterior longitudinal ligament provides stability to the posterior border of
the vertebral bodies and intervertebral discs extending from the body of the axis
(C2) to the sacrum. It is attached to the intervertebral discs but separated from the
posterior wall of the vertebral bodies by the basivertebral veins and the associated
venous plexus. The epidural space lies between the posterior longitudinal ligament
and spinal dura. This space is more capacious in the lumbar region than elsewhere
and is filled with epidural fat.
Blood supply to the spinal cord is through one anterior and two posterolateral

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Chapter 4 ABDOMEN – Answers

spinal arteries. The proximal arteries supplying them vary throughout the length of
the cord. Several radiculomedullary and intercostal arteries supply the upper (C1–
T2) and middle (T3–T8) territories respectively, however the blood supply to the
lower segment is mainly provided from a single source, the artery of Adamkiewicz.
It usually arises from a radicular artery somewhere between the 9th thoracic and
1st lumbar segment and on the left side 80% of the time. The inconsistency in its
location makes it susceptible to inadvertent iatrogenic damage during endovascular
intervention. Two pairs of basivertebral veins drain each of the thoracic and lumbar
vertebra and empty into the epidural plexus.

182
 5 PELVIS

Q1
a Name the space labelled A
b Name the bony contour labelled B
c Name the muscle that attaches to C
d Name the bony structure labelled D
e Name the bony structure indicated as E

183
 Q2
Chapter 5 PELVIS – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structures labelled E

184
Q3

Chapter 5 PELVIS – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the vessels over which the ureter crosses at the level labelled C
d Name the structure labelled D which is seen projected through the bladder
e Define the gender of this patient

185
 Q4
Chapter 5 PELVIS – Questions

a Name the space indicated by A

b Name the structure labelled B
c Name the structure labelled C
d Name the structures labelled D
e Name the arteries supplying the rectum

186
Q5

Chapter 5 PELVIS – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure filled with gas and outlined by C
d Name the structure labelled D
e Name the structure labelled E

187
 Q6
Chapter 5 PELVIS – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

188
Q7

Chapter 5 PELVIS – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the muscle group labelled E

189
 Q8
Chapter 5 PELVIS – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the layer labelled C
d Name the layer labelled D
e Name the structure labelled E

190
Q9

Chapter 5 PELVIS – Questions

a Name the structure labelled A
b Name the structure labelled B
c Define CRL as labelled C
d Name the structure labelled D
e Name the structure labelled E

191
 Q10
Chapter 5 PELVIS – Questions

a Name the structure labelled A

b Name the structures labelled B
c Name the artery and vein normally found in the position labelled C
d Name the blood vessel from which arterial supply for A arises
e Name the three ligamentous attachments of A

192
Q11

Chapter 5 PELVIS – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

193
 Q12
Chapter 5 PELVIS – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the functional muscle group to which E belongs

194
Q13

Chapter 5 PELVIS – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

195
 Q14
Chapter 5 PELVIS – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

196
Q15

Chapter 5 PELVIS – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

197
 Q16
Chapter 5 PELVIS – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the fatty spaces either side of structure B
d Name the structure labelled D
e Name the structure labelled E

198
Q17

Chapter 5 PELVIS – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

199
 Q18
Chapter 5 PELVIS – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

200
Q19

Chapter 5 PELVIS – Questions

a Name the vertebral level at which the aorta bifurcates, as labelled A
b Name the artery labelled B
c Name the major divisions of the internal iliac artery
d Name one of the branches of the external iliac artery
e Name the vessel from which the gonadal arteries arise

201
 5 PELVIS – ANSWERS

Q1 Answers
a Obturator foramen
b Pectineal line
c The straight head of rectus femoris attaches to the anterior inferior iliac spine
d Coccyx
e Posterior rim of right acetabulum

Radiograph of female pelvis, close up frontal view

The bony pelvis forms a complete ring and is composed of the paired innominate
bones (themselves a fusion of three bones; ilium, ischium and pubis), the sacrum
and coccyx. The paired sacro-iliac joints and pubic symphysis complete the ring.
The obturator foramina are almost completely closed over by the obturator
membrane but do transmit the obturator nerves and vessels which supply the inner
thigh.

Q2 Answers
a Ischial spine
b Pubic symphysis
c Sacro-iliac (SI) joint
d Soft tissue penile shadow
e Anterior sacral formina

Radiograph of male pelvis, close up frontal view

The morphology of the male and female pelvis differs in a number of ways. The
male pelvis is more narrow and deep and it is said to be heart-shaped compared
with the more round or oval, wide and shallow female pelvis. The sub-pubic angle
formed by the pubic rami is more acute in the male pelvis and the ischial spines
are usually more prominent. Soft tissue shadowing from genitalia or implantable
contraceptive devices may give further clues as to the gender of the patient.
The sacral foramina allow passage of the sacral nerves and accompanying vessels.

202
Q3 Answers

Chapter 5 PELVIS – Answers

a Upper pole major calyx
b Pelvi-ureteric junction (PUJ)
c Common iliac vessels
d Vesico-ureteric junction (VUJ)
e Female patient. Note an intra uterine contraceptive device is in situ. In addition,
the bony pelvis has a classical female configuration

Intravenous Urogram (IVU), full length AP view

At the apex of the renal pyramids (renal papillae) formed urine drains into the
cup-shaped minor renal calyces. These coalesce into two or sometimes three major
calyces which further join to form the renal pelvis. The ureters are fibromuscular
tubes which run from the renal pelvis (pelvi-ureteric junction, PUJ) to the postero-
lateral aspect of the bladder (vesico-ureteric junction, VUJ). The ureters run along
the posterior abdominal wall over the psoas muscle. At the pelvic brim they run
anterior to the common iliac vessels; this causes a narrowing of the ureter seen on
IVU which is projected at the level of the sacroiliac joints.

Q4 Answers
a Presacral space
b L5/S1 or lumbosacral joint
c Pubic tubercle
d Rectal folds or rectal valves
e Superior, middle and inferior rectal arteries

Lateral rectal view from barium enema series

The rectum is the terminal part of the colon. Anatomically the rectum follows
the curves of the lower sacrum and coccyx when viewed laterally (as shown) and
is S-shaped (when viewed in an AP projection). The three curves of this ‘S’ are
represented internally as transverse folds known as the rectal valves (of Houston).
The presacral space contains fat, blood vessels, lymph nodes and lymphatics and
also nerves.
The superior rectal artery represents the continuation of the inferior mesenteric
artery and supplies the proximal rectum. The paired middle rectal arteries are
branches of the anterior division of the internal iliac artery. The paired inferior
rectal arteries are branches of the internal pudendal artery, which is also a branch of
the anterior division of the internal iliac.

203
 Q5 Answers
Chapter 5 PELVIS – Answers

a Internal cervical ostium (internal os)

b Cervical canal
c Gas-filled vagina
d Isthmus of the fallopian tube
e Infundibulum of the fallopian tube

Normal hysterosalpingogram

When investigating female subfertility, uterine tubal patency can be assessed with a
fluoroscopic hysterosalpingogram where contrast is passed into the uterine cavity.
A normal result demonstrates unobstructed tubal flow and free spillage of contrast
into the peritoneal cavity bilaterally. Identifiable features include the cervical canal
between the external and internal ostia, a normally triangular-shaped uterine
cavity, and the isthmus (narrowest part), ampulla (longest and widest mid portion)
and infundibulum (funnel-shaped distal end sited in relation to the ovary) of the
uterine (fallopian) tubes.

Sieglar AM. Hysterosalpingography. Fertil Steril 1983; 40:139–158.

Q6 Answers
a Urinary bladder filled with radio opaque contrast
b Prostatic urethra
c Membranous urethra
d Bulbous urethra
e Penile urethra

Micturating cystourethrogram in an adult male, oblique view

The male urethra is much longer than the female urethra. In general terms, the
male urethra is divided into anterior and posterior segments. The posterior urethra
runs from the internal (involuntary) sphincter at the bladder neck to the urogenital
diaphragm (true pelvic floor) and includes prostatic and membranous parts. The
membranous urethra is the narrowest part and represents the external (voluntary)
sphincter where the urethra crosses the urogenital diaphragm. Distal to this, the
anterior urethra (also known as the spongy urethra due to its course through
corpus spongiosum) is composed of bulbous (within bulb of penis) and penile
segments.
The ejaculatory ducts empty into the prostatic urethra.

204
Q7 Answers

Chapter 5 PELVIS – Answers

a Sacro-iliac (SI) joint
b Sacral canal
c Median sacral crest
d Unfused S1–S2 joint
e Iliopsoas (hip flexors)

Oblique view of paediatric sacrum from CT study presented in bone windows

The sacrum forms from fusion of the five sacral vertebrae; this process is not
complete until adulthood. Fusion of the spinous processes of the sacral vertebrae
creates the median sacral crest. The sacral canal is a continuation of the vertebral
canal and transmits the sacral nerve roots (cauda equina) which subsequently exit
the sacrum via the anterior or posterior sacral foramina.

Q8 Answers
a Vaginal stripe (collapsed vaginal cavity)
b Bladder wall
c Myometrium
d Endometrium
e Cervix

Trans-abdominal ultrasound of the female pelvis, midline sagittal view

With trans-abdominal ultrasound of the female reproductive tract, the inferiorly

placed vagina lies at an acute angle to the uterus (the latter is anteflexed over
the bladder) and its cavity is usually collapsed appearing as an echogenic stripe.
The thick muscular (myometrial) layer of the uterus appears less bright and is
homogenous. Internal to this, the central endometrial stripe is also echogenic on
ultrasound. The thickness of the endometrium changes according to the stage
of the menstrual cycle; post menopause, endometrial thickening can indicate
disease. The cervix forms the cylindrical inferior part of the uterus and provides
communication between the vaginal and uterine cavities.

205
 Q9 Answers
Chapter 5 PELVIS – Answers

a Gestational sac
b Foetus
c Crown Rump Length
d Chorion
e Myometrium

Zoomed image from trans-abdominal ultrasound displaying early pregnancy

Ultrasound performed in early pregnancy can enable assessment of gestational age;

this can be calculated using several means, but measurement of foetal crown-rump
length (CRL) or biparietal diameter is common. The echobright layer surrounding
the gestational sac is the chorion.

Campbell S, Warsof SL, Little D, Cooper DJ. Routine ultrasound screening for the prediction of
gestational age. Obstetrics & Gynaecology 1985; 65:613–620.

Q10 Answers
a Ovary
b Developing ovarian follicles
c Internal iliac artery and vein
d Aorta
e Ligament of ovary, suspensory ligament of ovary, broad ligament

Trans-abdominal ultrasound of ovary, longitudinal view

Developing ovarian follicles may be demonstrated with ultrasound as well defined

anechoic areas usually in the periphery of the ovary; the appearances of which
vary significantly throughout the menstrual cycle. The ovaries lie posteriorly in the
pelvis, on either side of the uterus although their position can vary. Postero-lateral
to the ovaries run the internal iliac vessels.
The gonadal arteries arise directly from the aorta in both males and females.
The ovary has three ligamentous attachments; the ovarian ligament connects the
ovary to the uterus in the midline, the suspensory ligament of the ovary elevates the
ovary towards the lateral pelvic wall and contains the ovarian vessels, lymphatics
and nerves, while the broad ligament envelopes the ovaries, uterus and uterine
(fallopian) tubes.

Q11 Answers
a Head of epididymis
b Rete testis
c Mediastinum testis
206
 Chapter 5 PELVIS – Answers
d Trace of fluid within tunica vaginalis/physiological hydrocele
e Vas deferens

Ultrasound of right testis, longitudinal view

The testis has a homogenous appearance on ultrasound. Several distinct structures

are however identifiable.
An echogenic line running through the middle of the testis is known as the
mediastinum testis and represents fibrous septae which divide the gland into
lobules.
Within the superior end of the testis there is an area of increased echogenicity
known as the rete testis. The rete testis is the confluence of the seminiferous
tubules which convey sperm from the testis to the epididymis for storage and
concentration.
A triangular-shaped area of similar echogenicity to the testis and lying
immediately adjacent to its superior pole represents the head of the epididymis. The
epididymis runs the length of the testis; at its distal end, the tail of the epididymis
is continuous with the origin of the vas deferens. The vas deferens is the tube which
delivers sperm from the testis to the ejaculatory duct in the prostatic urethra. From
the distal end of the epididymis, the vas deferens turns 180 degrees and travels up
the posterior wall of the scrotum. The vas deferens is often visible on ultrasound as
a deeply situated tube running parallel to the testis and it becomes more prominent
following vasectomy.

Q12 Answers
a Ischiocavernosus muscle
b Bulbospongiosus muscle
c Spermatic cord
d External anal sphincter
e The obturator externus is one of the external rotators of the hip

T1W MRI of male pelvic floor, axial slice

The penis is composed of three cylindrical bodies of erectile tissue, namely the
corpus spongiosum (contains the urethra) and two paired corpora cavernosa (lie
dorsally in the penis). In the pelvic floor the cavernosa divide to form the penile
crura which lie along the ischiopubic rami, while the spongiosum forms the penile
bulb in the midline. Muscular compression of these tissues by the ischiocavernosus
and bulbospongiosus muscles at the root of the penis leads to erection.
The spermatic cord contains the structures running to and from the testis; the
major structures include the vas deferens, testicular artery, pampiniform venous
plexus and nerves.
The external anal sphincter is a ring of voluntary muscle surrounding the anal
canal and is part of the levator ani muscle group.

207
 Q13 Answers
Chapter 5 PELVIS – Answers

a Iliacus muscle
b External iliac artery
c Opening of the prostatic urethra (internal urethral orifice)
d Obturator internus muscle
e Ligamentum teres of the hip

T2W MRI of male pelvis, coronal section through prostate

The prostate sits on the urogenital diaphragm in the lower pelvis immediately
beneath the urinary bladder. The prostatic urethra can be visualised with MRI.
Iliacus is a hip flexor which arises from the iliac fossa (hence the name) and joins
with the psoas major muscle in its attachment to the lesser trochanter of the femur.
The obturator internus muscle is attached to the lateral wall of the pelvic cavity and
leaves the pelvis posteriorly by passing through the lesser sciatic foramen to attach
to the greater trochanter of the femur.
The external iliac artery runs along the medial border of psoas major before
exiting the pelvis.

Q14 Answers
a Rectus abdominis muscle
b Urinary bladder
c Urethra surrounded by external urethral sphincter
d Vagina
e Levator ani muscle

T2W MRI of female pelvic floor, axial section

The female pelvic floor has many of the same constituents as the male equivalent.
The urogenital diaphragm stretches between the two sides of the pubic arch and
provides support for the vagina. In both sexes, the urethra passes through the
urogenital diaphragm which forms the external urethral sphincter at this level.
The ischiocavernosus and bulbospongiosus muscles have a very similar location
in both sexes (not shown here) but in females the bulbospongiosus surrounds the
vagina and these muscles provide erectile function to the clitoris.
The levator ani are a group of muscles which close the pelvic outlet (pelvic
diaphragm) and form a loop around the anus providing support at the level of the
pelvic floor. Lateral to the levator ani muscles lie the ischioanal fossae. These are
fat filled triangular spaces which normally accommodate rectal expansion when
required. Occasionally the ischioanal fossae can become infected leading to an
ischioanal abscess. An ischioanal abscess can spontaneously open into both the anal
canal and perineal skin leading to the formation of a perianal fistula.

208
Q15 Answers

Chapter 5 PELVIS – Answers

a Endometrium
b Junctional zone of myometrium
c Trace of fluid in the recto-uterine pouch (of Douglas)
d Endocervical canal
e Myometrium of uterus

T2W MRI of female pelvis, midline sagittal section

T2W MRI is often used to evaluate the uterus as its zonal anatomy can be
appreciated. The endometrium, endocervical canal and vaginal canal all appear
with high signal intensity. The myometrium is divided into the low signal, inner
junctional zone and the intermediate signal of uterine bulk. Both the internal and
external cervical os can usually be seen at either end of the endocervical canal. The
cervix normally protrudes into the upper vagina creating anterior and posterior
recesses, known as the fornices. The position of the uterus is readily appreciated
relative to the bladder; the normal position is anteverted (angle between vagina and
uterus) and anteflexed (angle between cervix and uterus) meaning it lies anterior to
the cervix and curves anteriorly over the bladder (as shown).
The deepest intraperitoneal part of the female pelvis is the space between the
posterior uterus and anterior rectum. This is known as the recto-uterine pouch
(of Douglas) and will often be seen to contain a trace of free peritoneal fluid (as a
consequence of ovulation). In pathological states, this area is also where free fluid
may collect first.

Q16 Answers
a Seminal vesicle
b Perirectal/mesorectal fascia
c Perirectal and pararectal fat
d Natal cleft
e Coccygeus muscle

T1W MRI of male pelvis at level of seminal vesicles, axial section

The seminal vesicles produce the medium in which sperms are transmitted from
the body. The seminal vesicles lie on either side of the midline posterior to the
prostate and bladder and anterior to the rectum in males. T2W MRI shows the
seminal vesicles to be fluid filled.
The rectum is surrounded by fat within which is a layer known as the perirectal
(or mesorectal) fascia. The perirectal fascia is an important plane to identify when
staging rectal cancer using MRI.
The coccygeus muscle extends from the inferior sacrum and coccyx to the ischial
spine and is one of the muscles of the pelvic diaphragm along with the levator ani
group. The pelvic diaphragm separates the pelvic cavity from the perineum.
209
 Q17 Answers
Chapter 5 PELVIS – Answers

a Sacroiliac joint
b Sacral nerve root in sacral foramina
c Obturator internus muscle
d Rectum
e Levator ani muscle

T1W MRI showing rectum and posterior pelvis, coronal section

The sacroiliac joints are synovial joints but have very little mobility. They are strong
weight bearing joints which link the spine to the pelvis. On MRI, the sacroiliac
joints should show the interlocking corticated edges of both the sacrum and ileum.
The sacral nerves enter the pelvic cavity through the anterior sacral foramina as
is demonstrated on this image. Sacral nerves supply the pelvis and lower limb.
The obturator internus muscle is an external rotator of the hip and covers most
of the lateral wall of the pelvic cavity.

Q18 Answers
a Urinary bladder
b Right seminal vesicle
c Central zone of the prostate
d Prostatic urethra
e Peripheral zone of prostate

T2W MRI of prostate, coronal section

The prostate usually measures 3–5cm in length and sits inferior to the urinary
bladder. The first part of the urethra passes through the prostate and is therefore
named the prostatic urethra. Both transrectal ultrasound and T2W MRI can
demonstrate the peripheral, central and transitional zones of the prostate. Most of
the glandular tissue of the prostate can be found in the peripheral zone. On coronal
T2W MRI the peripheral zone is seen as a high signal ‘U’ shaped area surrounding
the lower signal superiorly placed central zone. The transitional zone surrounds
the midportion of the urethra (not well seen here) and is not always differentiated
from the central zone. The ‘central gland’ is a term used to describe the central and
transitional zones collectively. With increasing age the transitional zone tends to
hypertrophy; this can lead to an increase in size of the central gland which may
reduce the diameter of the prostatic urethra leading to urinary outflow problems.
The seminal vesicles sit on either side of the midline postero-superiorly to the
prostate and are fluid filled.

210
Q19 Answers

Chapter 5 PELVIS – Answers

a The aorta bifurcates into the right and left common iliac arteries at the level of
L4
b Inferior mesenteric artery
c The internal iliac artery has anterior and posterior divisions
d Inferior epigastric artery or deep circumflex iliac artery
e The gonadal arteries (testicular or ovarian) arise directly from the abdominal
aorta at the level of L2

Abdomino-pelvic MRA

The abdominal aorta is a direct continuation of the thoracic aorta and runs from
the aortic opening in the diaphragm at T12 to its bifurcation into the two common
iliac vessels at the level of L4. In the infra renal portion, the major branches are the
right and left gonadal arteries, the inferior mesenteric artery and usually four paired
lumbar arteries. The gonadal vascular and lymphatic vessels are in similar locations
meaning lymph of testicular or ovarian origin will drain to para-aortic nodes.
The internal iliac artery supplies the pelvis; the posterior division has branches
to the posterior pelvic wall and musculature while the anterior division supplies the
pelvic viscera and perineum. The external iliac artery predominantly supplies the
lower limb becoming the common femoral artery as it passes under the inguinal
ligament. Just before leaving the pelvis however, the external iliac artery has two
branches which supply the anterior abdominal wall, namely the inferior epigastric
and the deep circumflex iliac arteries.

211
 6 LOWER LIMB

restus femoris
Q1 Right
a Name the muscle that attaches to the structure labelled A
b Name the ligament that attaches to the structure labelled A
liefemont
c Name the line labelled C Shenton line
d left
Name the structure labelled D acetabula roof
e Name the structure labelled E Left
Left sacral alar bone

G
A
I

212
Q2

Chapter 6 LOWER LIMB – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the angle labelled D
e Name the structure labelled E

213
 Q3
Chapter 6 LOWER LIMB – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

214
Q4

Chapter 6 LOWER LIMB – Questions

a Name the structure labelled A
b Name the angle labelled B
c Name the angle labelled C
d Name the structure labelled D
e Name the structure labelled E

215
 Q5
Chapter 6 LOWER LIMB – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure positioned lateral to structure A
d Name the space immediately medial to structure A
e Name the major superficial vein which drains into structure A

216
Q6

Chapter 6 LOWER LIMB – Questions

a Name the nerve labelled A
b Name the nerve labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

217
 Q7
Chapter 6 LOWER LIMB – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

218
Q8

Chapter 6 LOWER LIMB – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure that runs through the groove labelled C
d Name the structure labelled D
e Name the structure labelled E

219
 Q9
Chapter 6 LOWER LIMB – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Define the age at which ossification of the patella normally begins

220
Q10

Chapter 6 LOWER LIMB – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

221
 Q11
Chapter 6 LOWER LIMB – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

222
Q12

Chapter 6 LOWER LIMB – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

223
 Q13
Chapter 6 LOWER LIMB – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

224
Q14

Chapter 6 LOWER LIMB – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structures labelled E

225
 Q15
Chapter 6 LOWER LIMB – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the joint space labelled C
d Name the structure labelled D
e Define the normal angle at the position labelled E

226
Q16

Chapter 6 LOWER LIMB – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

227
 Q17
Chapter 6 LOWER LIMB – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

228
Q18

Chapter 6 LOWER LIMB – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

229
 Q19
Chapter 6 LOWER LIMB – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the level of the spinal nerve root supplying structure D
e Name the structure labelled E

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Q20

Chapter 6 LOWER LIMB – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the sensory dermatome at the site labelled D
e Name the structure labelled E

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ANSWERS

Q1 Answers
a Straight head of rectus femoris muscle
b Iliofemoral ligament (of Bigelow)

E
c Shenton’s line
d Acetabular roof
e Sacral ala

Radiograph of pelvis, AP view

A number of lower limb muscles originate from the bony pelvis. Of the anterior
femoral muscles, sartorius and tensor fascia lata originate from the anterior
superior iliac spine (ASIS) while the straight head of rectus femoris arises from
the anterior inferior iliac spine (AIIS). The adductor muscles including gracillis
and pectineus arise from the pubic bone. The largest of these, adductor magnus,
also takes origin from the ischiopubic ramus and the ischial tuberosity. The three
hamstrings also arise from the ischial tuberosity. The ASIS and AIIS both have
accessory ossification centres which appear at puberty and fuse at around 25 years.
The hip joint is stabilized by three ligaments and the joint capsule. The
capsule encloses the femoral head and neck and is strongest in the anterior and
superior portions. The iliofemoral ligament (of Bigelow) attaches the ASIS to the
intertrochanteric line. Posterior support is provided by the ischiofemoral ligament
and inferior support by the pubofemoral ligament.
Shenton’s line should course a smooth, unbroken curve along the underside
of the femoral neck, acetabulum and superior pubic ramus on an AP pelvic
radiograph. This was originally described specifically in relation to tuberculosis of
the hip, however a variety of hip conditions can cause interruption or angulation
of this line. When assessing the posterior (ilioischial) and anterior (iliopubic)
columns of the acetabulum with a radiograph, oblique projections (Judet views) are
commonly used.
The sacral ala is the wing-like portion positioned lateral to the sacral body
which is the product of fused costal elements and transverse processes of the sacral
vertebrae.

Shenton EWH. Disease in bone and its detection by the X-Rays. 1911; Macmillan:42–43.

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Q2 Answers

Chapter 6 LOWER LIMB – Answers

a Ischiopubic synchondrosis
b Sacroiliac joint
c Symphysis pubis
d Acetabular angle
e Triradiate cartilage of the acetabulum

Pelvic radiograph in a 12 month-old infant, AP view

The inonimate bones of the pelvis are made up of the ilium, ischium and pubis. In
infants and children these bones are each separated by a radiolucent physis. The
three bones converge at the triradiate cartilage of the acetabulum.
Assessment of the acetabulum and femoral head on paediatric radiographs can
be complemented using two principal measurements. Both of these utilize a line
drawn connecting the tri-radiate cartilages on both sides (known as the ‘Y–Y’ or
Hilgenreiner line).
The acetabular angle is measured between the Y–Y line and a line along the
ossified acetabular concavity and pubic ramus. This angle is approximately
28 degrees at birth and decreases gradually with age, reflecting normal bony
maturation of the acetabulum. Developmental dysplasia of the hip (DDH) often
results in an increased acetabular angle.
Positioning of the femoral head can be assessed by adding a line which is drawn
perpendicular to the Hilgenreiner line at the outer acetabular margin (known as the
Perkins line). These will serve to divide the hip into quadrants. The normal location
of the ossified femoral head is in the infero-medial quadrant.
The sacro-iliac joints are synovial joints but despite this have very little
movement. They are extensively reinforced by means of the anterior, posterior and
interosseous sacroiliac ligaments. The pubic symphisis is a secondary cartilaginous
joint which is normally immobile.

Norton KI, Polin SAM. Developmental Dysplasia of the Hip. Radiology 2009; eMedicine: www.
emedicine.medscape.com

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 Q3 Answers
Chapter 6 LOWER LIMB – Answers

a Superficial femoral artery

b Profunda femoris artery
c Lateral circumflex femoral artery
d Common femoral artery
e Superficial circumflex iliac artery

Digital subtraction angiogram right groin

The external iliac artery becomes the common femoral artery after passing
beneath the inguinal ligament, midway between the ASIS and pubic tubercle.
Four arteries take their origin from the proximal common femoral artery. The
superficial circumflex iliac arteries course laterally towards the femoral neck and
ASIS. Running in a medial direction are the superficial epigastric artery and the
superficial and deep (external) pudendal arteries.
The circumflex arteries contribute to an anastomosis with the inferior gluteal
artery which encircles the proximal femur, providing most of its blood supply.
Branches from this anastomosis enter the outer hip capsule to supply the femoral
neck. An additional blood supply comes through the ligamentum teres, though
this is minimal in the fully developed hip making the femoral head susceptible
to avascular necrosis following intracapsular proximal femoral fractures.
The descending branch of the lateral femoral circumflex artery also forms an
anastomosis with the geniculate arteries around the knee and this can provide a
path of collateralization to the leg in cases of superficial femoral artery occlusion.
The common femoral artery divides into the superficial femoral artery and
profunda femoris artery, the latter of which principally supplies the thigh.

Q4 Answers
a Femoral head
b Alpha angle
c Beta angle
d Cartilaginous acetabular roof
e Osseus acetabular concavity

Hip ultrasound in a 6 month-old child, coronal view

Normal development of the hip joint is reliant on there being adequate contact
between the femoral head and acetabulum. Abnormalities of subluxation and
dislocation need to be recognized in order to prevent dysplastic development.
In infants there is a discrepancy in size between the large femoral head and the
relatively under developed acetabulum and since the hip joint is predominantly
cartilaginous, the preferred modality for assessment is ultrasound.
The ilium, ossified acetabulum and cartilaginous acetabulum are all seen on

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coronal imaging. The non-ossified femoral head has a ‘speckled’ echotexture. There
are three lines which enable assessment of the hip joint: the ‘baseline’ runs parallel
to the ilium; the ‘acetabular roofline’ runs along the plane of the bony acetabular
concavity and the ‘inclination’ line runs from the lateral bony acetabulum along the
underside of the cartilaginous roof.
The alpha angle is a measurement of acetabular depth (and therefore
maturity) and lies between the baseline and acetabular roofline. The beta angle
is a measurement of acetabular cartilaginous roof coverage and lies between the
baseline and the inclination line. Dysplastic hips have a low alpha angle and high
beta angle (i.e. immature bony acetabulum and predominantly cartilaginous
coverage of the femoral head). An alpha angle >60 degrees and beta angle
<55 degrees is normal.
An alternative assessment of acetabular maturity is to define the distance
from the medial aspect of the femoral head to the baseline as a percentage of
total femoral head diameter. This is known as the d/D ratio and a value >58% is
considered normal.

Norton KI, Polin SAM. Developmental Dysplasia of the Hip. Radiology 2009; eMedicine: www.
emedicine.medscape.com

Q5 Answers
a Common femoral vein (CFV)
b Femoral head
c Femoral artery
d Femoral canal
e Long saphenous vein

Colour flow Doppler of the common femoral vein, longitudinal view

The walls of veins, like arteries, comprise of three layers; the endothelium-lined
tunica intima, muscular tunica media and the connective tissue covering of
tunica adventitia. Where the wall architecture of arteries and veins differ is in the
thickness of these three layers and of the muscular medial layer in particular. This
is relatively thin in the walls of veins which results in them being unable to oppose
radial compression – a feature that can help distinguish between artery and vein
on ultrasound examination. Lateral to the femoral vein lies the femoral artery. The
femoral canal lies medial to the femoral vein and usually contains a lymph node (of
Cloquet).
The hip joint lies deep to the common femoral vessels. As the femoral vein passes
beyond the superior margin of the femoral head it adopts a deeper course before
passing beneath the inguinal ligament and becoming the external iliac vein. The
femoral head is used as a radiological landmark in percutaneous femoral arterial
punctures to ensure that the arteriotomy is inferior to the inguinal ligament and
therefore controllable with manual compression on the groin.

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 Q6 Answers
Chapter 6 LOWER LIMB – Answers

a Sciatic nerve
b Obturator nerve
c Iliopsoas muscle
d Spermatic cord
e Greater trochanter of the femur

T1W MRI hip and pelvis, axial section

The sciatic nerve (spinal nerves L4, 5, S1, 2, 3) is the largest nerve to emerge from
the sacral plexus and exits the pelvis through the greater sciatic foramen to lie
within the buttock. As it travels inferiorly in the posterior compartment of the
thigh, branches emerge to supply the hamstring muscles. At the level of the upper
popliteal fossa, it divides into the tibial and common peroneal nerves. The tibial
nerve remains in the posterior compartment of the leg and supplies the flexor
muscles of the calf. The common peroneal nerve swings laterally around the
neck of the fibula where it divides into a superficial branch supplying the lateral
compartment (evertors) and a deep branch supplying the anterior compartment
(extensors) in the leg. Damage to the sciatic nerve can therefore have a devastating
effect on lower limb function.
The obturator and femoral nerves are branches from the lumbar plexus (L2, 3,
4) and supply the obturator/adductor and the anterior thigh muscles respectively.
Both nerves also supply sensory branches to the skin as well as the hip and knee
joints. The femoral nerve exits the pelvis lateral to the artery in the femoral triangle.
Medial to the femoral artery is the femoral vein, medial to which is the fat filled
femoral canal. The obturator nerve exits through the obturator foramen which is
located in the lateral wall of the pelvis adjacent to the common iliac bifurcation.
The spermatic cord passes through the inguinal canal which is superficial and
superior to the femoral canal and runs in a medial direction. All three of these
channels – the femoral canal, the obturator foramen and the inguinal canal – are
common sites of intestinal herniation.
Iliopsoas is the joining of the psoas major and iliacus muscles which forms at the
inner aspect of the ilium. It runs anteriorly to pass beneath the inguinal ligament
before inserting into the lesser trochanter of the femur.

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Q7 Answers

Chapter 6 LOWER LIMB – Answers

a Common tendinous origin of the hamstrings
b Vastus lateralis
c Adductor magnus
d Ischio-anal fossa
e Tensor fascia lata

T1W MRI at greater trochanter level, axial section

The anterior femoral muscles comprise of the iliopsoas, tensor fascia lata, sartorius
and quadriceps muscles. Tensor fascia lata arises from the ASIS and inserts into
the iliotibial tract which is a strong band of fascia on the lateral aspect of the thigh
(fascia lata). This inserts into the fibular head. Sartorius is a narrow muscle which
also originates from the ASIS and courses superficially across the thigh to insert into
the medial tibial condyle. The quadriceps is made up of the three vastus muscles
(lateralis, medialis and intermedius) and rectus femoris. These all share a common
tendinous insertion into the tibial tuberosity via the patellar tendon and serve to
extend the knee joint. Rectus femoris arises from the AIIS and the acetabulum,
vastus lateralis and medialis from the greater trochanter and the linea aspera and
vastus intermedius from the anterior femoral shaft. All four quadriceps muscles are
supplied by the femoral nerve (L3, 4).
The hamstrings (semimembranosus, semitendinosus and biceps femoris) share a
common tendinous origin from the ischial tuberosity. Biceps femoris attaches to the
fibular head while semimembranosus and semitendinosus insert into the medial
tibia. All are supplied by the profunda femoris artery and the sciatic nerve.
The adductor muscles are separated from the anterior thigh muscles by the
medial intermuscular septum, which attaches to the fascia lata. There is no septum
dividing them from the posterior compartment. They consist of gracilis and
the three adductors: longus, brevis and magnus. All take origin from the pubis,
with magnus having a second origin alongside the hamstrings from the ischial
tuberosity. Gracilis crosses the inner aspect of the thigh superficially to insert into
the superior medial tibia behind sartorius. The adductors insert into the linea
aspera of the femur and in the case of adductor magnus, also into the adductor
tubercle. These muscles are supplied by the obturator nerve and by the profunda
femoris and obturator arteries.
The ischio-anal (also known as ischio-rectal) fossae lie below and lateral to
the levator ani muscles and are enclosed by the sacrotuberous ligaments and
gluteus maximus posteriorly, obturator internus fascia laterally and the urogenital
perineum inferiorly. Within these fatty spaces run the pudendal vessels and nerves.
They are significant as a potential site of abscess formation, which can complicate
sepsis of the rectum or anal canal.

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 Q8 Answers
Chapter 6 LOWER LIMB – Answers

a Lateral femoral epicondyle

b Medial tibial plateau
c Popliteus tendon
d Medial tibial spine or tubercle of intercondylar eminence
e Patella

AP radiograph of knee

The tibiofemoral space should normally measure 3–8mm. The tibial plateaus match
the shape of the respective femoral condyles with the medial side being smaller and
more rounded. The tibial spines, or tubercles of the intercondylar eminence, are the
distal attachment of both anterior and posterior cruciate ligaments (ACL and PCL,
respectively).
Popliteus is the only muscle that enters the knee joint.

Q9 Answers
a Distal femoral epiphyseal (growth) plate
b Proximal tibial epiphysis
c Proximal tibial metaphysis
d Femoral diaphysis
e 3–6 years

AP knee radiograph in a 2 year-old child

Long bone formation and growth occur as a result of cartilaginous ossification.

All long bones have a cartilaginous growth plate or epiphyseal plate. The ossified
bone on either side of this is known as the epiphysis (distal) and metaphysis
(proximal). The shaft of a long bone is the diaphysis and the junction between it
and the metaphysis is termed the diametaphysis. An apophysis is an ossified area
which is located on one side of the bone. Apophyses do not normally contribute to
increasing the length of a bone and are usually situated at the site of a tendinous
insertion, for example at the 5th metatarsal base.
Ossification of the patella begins sometime between the ages of three and six
and is usually completed by the onset of puberty. Ossification originates in several
different locations that normally coalesce to form a single bone. Occasionally one
centre (typically the upper lateral quadrant) will not fuse with the others which
results in a bipartate patella.

Q10 Answers
a Popliteal artery
b Posterior tibial artery
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 Chapter 6 LOWER LIMB – Answers
c Medial genicular artery
d Anterior tibial artery
e Fibular head

Digital subtraction angiogram of leg, AP view

The popliteal artery is a continuation of the superficial femoral artery. It gives off
seven branches within the popliteal fossa which supply the knee joint and adjacent
muscles: superior/inferior muscular branches; medial superior/inferior geniculatar
branches; lateral superior/inferior geniculatar branches and the middle genicular
branch.
The popliteal artery divides into the anterior tibial artery and posterior tibial
artery below the knee. Just distal to this division, the peroneal artery branches from
the posterior tibial artery (as seen on this image). As these three branches diverge
within a short distance, this area is often referred to as the popliteal trifurcation.

Q11 Answers
a Popliteus tendon
b Lateral head of gastrocnemius
c Infrapatellar (Hoffa’s) fat pad
d Fabella
e Tibial tuberosity

T1W MRI knee, lateral sagittal section

A spherical osseous or cartilaginous fabella (Latin for ‘little bean’), is occasionally

seen in the vicinity of the knee. The location can be variable though it is usually
within the lateral head of gastrocnemius muscle, in the postero-lateral aspect of the
knee.
The popliteus muscle has its inferior origin above the soleal line of the posterior
tibia. It runs in a supero-lateral course to its tendinous insertion into the groove
on the lateral femoral condyle. Further insertion sites are at the posterior fibular
head and the posterior lateral meniscus and these act to buttress the postero-lateral
aspect of the knee joint. The action of popliteus is as the primary internal rotator
of the tibia on the femur and it is the only muscle to enter the knee joint capsule.
It also acts to laterally rotate the femur on the fixed tibia effectively unlocking the
knee to allow flexion of the extended knee.
The joint capsule contains a triangular, anterior fat-pad sitting deep to the
patellar tendon and surrounded by synovium. This is the infrapatellar (Hoffa’s) fat
pad which contains the deep infra-patellar bursa within its inferior aspect.
The tibial tuberosity is the bony ridge on the anterior tibial border into which the
quadriceps tendon inserts.

Seebacher JR, Inglis AE, Marshall JL, Warren RF. The Structure of the Posterolateral Aspect of the Knee.
J Bone Joint Surg [Am] 1982; 64:536–541.

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 Q12 Answers
Chapter 6 LOWER LIMB – Answers

a Posterior knee joint capsule

b Posterior cruciate ligament
c Anterior horn of lateral meniscus
d Anterior meniscofemoral ligament (of Humphrey)
e Transverse ligament

T1W MRI of knee, oblique sagittal section

The cruciate ligaments lie entirely within the knee joint capsule and are principally
involved in the provision of antero-posterior joint stability. They both achieve this
by adjoining the side of the tibial intercondylar process to its contralateral femoral
condyle and are named according to the location of their tibial insertions. The
PCL passes upwards, forwards and medially from the lateral aspect of the posterior
tibial spine to the lateral aspect of the medial condyle. The ACL passes upwards,
backwards and laterally from the anterior aspect of the tibial spine to the medial
aspect of the lateral condyle.
The menisci consist of two semi-lunar fibrocartilages which serve to deepen the
tibial articular surface. The medial meniscus is the larger of the two and, unlike the
lateral meniscus, is attached firmly to its respective collateral ligament.
The appearance of meniscal ligaments can mimic meniscal pathology if
incorrectly identified. The posterior horn of the lateral meniscus is attached to the
medial femoral condyle by means of a meniscofemoral ligament which frequently
splits into two parts to pass around the PCL. If the dominant part passes anterior
to the PCL then it is known as the ligament of Humphrey, and if it passes posterior
it is the ligament of Wrisberg. Anterior meniscal horns are interconnected by the
transverse ligament.

Q13 Answers
a Medial collateral ligament
b Tendon of biceps femoris
c Lateral collateral ligament
d Posterior cruciate ligament
e Long saphenous vein

T1W MRI of knee, coronal section

The medial collateral ligament is a band-like structure which connects the medial
femoral epicondyle to the tibial condyle. The lateral collateral ligament, which is
more cord like, connects the lateral femoral epicondyle to the head of the fibula
and is separated from the lateral joint capsule by the tendon of popliteus muscle.
Additional lateral stability is provided via the ilio-tibial tract and biceps femoris,
which share a common (conjoint) tendinous insertion into the postero-lateral

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fibular head. The other name for this insertion is the arcuate ligament. The tendon
of popliteus passes under this on its way to its attachment to the lateral aspect of the
lateral condyle of the femur.
The long saphenous vein (also known as the great saphenous vein) runs up the
medial aspect of the leg and thigh to drain into the femoral vein at the sapheno-
femoral junction. The short saphenous vein arises from the lateral aspect of the
dorsal venous arch and passes posterior to the lateral malleolus. It runs up the back
of the calf to drain into the popliteal vein at the sapheno-popliteal junction. The
short and long saphenous veins are the two main superficial venous channels in the
leg.

Q14 Answers
a Interosseous membrane
b Peroneus longus
c Tibialis posterior
d Medial head of gastrocnemius
e Posterior tibial neurovascular bundle

T1W MRI mid leg, axial section

Muscles of the leg are contained within three compartments: anterior (extensor);
lateral (peroneal/evertor); and posterior (calf/flexor).
The anterior compartment contains the extensor muscles (tibialis anterior – TA,
extensor hallucis longus – EHL, extensor digitorum longus – EDL and peroneus
tertius) as well as the deep peroneal nerve and anterior tibial artery. It is bounded
by the deep fascia and interosseous membrane and is a rigid compartment with
limited scope for expansion.
The lateral compartment contains peroneus longus (PL) and peroneus brevis
(PB) muscles plus the superficial peroneal nerve.
The posterior compartment is the largest and consists of superficial and deep
groups which are divided by the deep transverse fascia. Soleus, the two heads of
gastrocnemius and plantaris make up the superficial group whilst flexor digitorum
longus (FDL), flexor hallucis longus (FHL) and tibialis posterior (TP) are the deep
group. Also passing through this compartment are the posterior tibial and peroneal
arteries and the tibial nerve.

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 Q15 Answers
Chapter 6 LOWER LIMB – Answers

a Talus
b Achilles tendon
c Posterior subtalar joint (talocalcaneal joint)
d Cuboid
e 30 degrees

Radiograph of ankle, lateral view

The talus consists of a head, neck and body and is a bone with no muscular
attachments. As the name suggests, the neck is the slightly narrowed part of the
talus which joins the body (posterior) and head (anterior). In adults it is angled
such that it points roughly along the line of the first metatarsal.
The subtalar joint is functionally a single joint between the talus and calcaneum
however it is made up of two components. The talocalcaneal (posterior) joint is
between the posterior facet on the underside of the talus and the adjacent facet that
is located on the upper calcaneum. The talocalcaneonavicular joint adjoins the talar
head, the antero-superior surface of the calcaneum and the posterior surface of the
navicular together with the spring ligament.
Bohler’s angle is a means of assessing the calcaneal profile height. The lines
converge on the anterior end of the superior articular facet, with one line beginning
at the posterior end of the same articular facet and the other beginning at the
postero-superior calcaneal margin: 30 degrees is normal. Calcaneal fractures are
usually due to excessive axial loading (often resulting from a fall or a road traffic
accident) which can cause impaction and flattening of the posterior facet and a
reduction in Bohler’s angle. In the context of trauma, an angle <23 degrees is highly
suggestive of a calcaneal fracture.

Isaacs J, Baba M, Szomer ZS. FA5: The Diagnostic Accuracy of Böhler’s Angle in Fractures of the
Calcaneus. J Bone Joint Surg [Br] Proceedings 2010; 92: 178.

Q16 Answers
a Flexor hallucis longus tendon
b Tibialis posterior tendon
c Long saphenous vein
d Peroneus longus tendon
e Medial malleolus

T1W MRI of ankle, axial section

Tibialis posterior, flexor digitorum longus and flexor hallucis longus are three of
the seven muscles of the posterior compartment of the leg (the remainder being
gastrocnemius, soleus, popliteus and plantaris). All three take their origin from

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the middle third of the posterior tibia and/or fibula and insert onto the plantar
aspect of the foot via long slender tendons that converge to pass behind the medial
malleolus. Identifying which tendon is which is helped with the mnemonic ‘Tom,
Dick and Harry’ (from medial to lateral the order in which they lie is TP, FDL and
then FHL.)
The lateral (or peroneal) compartment contains the two peroneal muscles –
longus and brevis. Peroneus longus tendon is the more superficial of the two above
the ankle. Both muscles originate from the lateral aspect of the fibula and pass
posterior to the lateral malleolus and beneath the peroneal retinaculum before
inserting onto the 5th metacarpal (brevis) and medial cuneiform/1st metatarsal
(longus). Insertion of the peroneus brevis tendon into the base of the 5th metatarsal
renders this site susceptible to fracture in the context of ankle trauma. Despite its
name, peroneus tertius is within the anterior compartment.

Q17 Answers
a Extensor digitorum tendon
b Tibialis anterior tendon
c Peroneal retinaculum
d Anterior inferior talofibular ligament
e Talotibial joint

T1W MRI of ankle, axial section

Tibialis anterior, extensor hallucis longus and extensor digitorum longus are three
of the four anterior compartment muscles (the other being peroneus tertius) and
originate from the anterior surface of the tibia and fibula. They form tendons above
the ankle joint which pass anteriorly beneath the extensor retinaculum. Similar
to their flexor counterparts their relative positions are constant in relation to each
other at the ankle. Their configuration is slightly different however but this can be
remembered using a variation on the mnemonic, which on this occasion is ‘Tom,
Harry and Dick’ (from medial to lateral the order in which they lie is TA, EHL and
then EDL).
Ligaments of the ankle joint are numerous and fall broadly into three groups:
1 The distal tibiofibular joint is classed as a syndesmosis and consists of anterior
and posterior tibiofibular ligaments and the interosseous ligament which is a
continuation of the interosseous membrane.
2 The medial (deltoid) ligament complex consists of (from anterior to
posterior) the tibionavicular, tibiocalcaneal and posterior tibiotalar ligaments.
The anterior portion of the deltoid ligament blends into the calcaneonavicular
(or spring) ligament.
3 Three structures make up the lateral ligament complex and they are (from
anterior to posterior) the anterior talofibular, calcaneofibular and posterior
talofibular ligaments.

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 Q18 Answers
Chapter 6 LOWER LIMB – Answers

a Deep part of deltoid ligament

b Interosseous talocalcaneal ligament
c Talofibular joint
d Abductor hallucis muscle
e Peroneus longus tendon

T2W MRI of ankle, coronal section

This image demonstrates the anatomy of the lateral and medial (deltoid)
collateral ligaments of the ankle and the subtalar (hindfoot) joint. The ankle
joint permits dorsiflexion and plantarflexion of the foot. Mobility of the subtalar
joint supplements this by enabling inversion (in plantarflexion) and eversion (in
dorsiflexion) of the forefoot.
Three superficial first-layer plantar muscles arise from the calcaneus. Medial to
lateral they are: abductor hallucis, flexor digitorum brevis (similar in function to its
upper limb counterpart flexor digitorum superficialis), and abductor digiti minimi.
All of these muscles are supplied via the S2 nerve root.

Q19 Answers
a Sesamoid bone
b Tendon of flexor hallucis longus
c Interosseous muscle
d L5
e Plantar aponeurosis

MRI of foot at distal metatarsal level, coronal section

Two sesamoid bones are normally seen on the plantar aspect of the foot where
flexor hallucis brevis inserts to the 1st metatarsal head. Between them runs the
tendon of flexor hallucis longus.
The muscles of the plantar aspect of the foot are divided in four layers, all of
which lie deep to the plantar aponeurosis. They include the short flexors and
abductors as well as the tendons of flexor digitorum longus and flexor hallucis
longus. Interosseous muscles are arranged in a similar fashion as in the hands,
comprising of plantar and dorsal layers which adduct and abduct the toes
respectively (remember ‘PAd’ and ‘DAb’).
Extensor hallucis longus is supplied by the deep peroneal nerve and testing its
function against resistance (e.g. standing on tip-toes) assesses the integrity of the
anterior ramus of the L5 spinal nerve.
The plantar aponeurosis is a dense layer of collagen which extends across the
sole of the foot. It arises from the medial side of the calcaneus to insert into the five
metatarsophalyngeal joints and adds strength to the subcutaneous tissues of the sole.

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Q20 Answers

Chapter 6 LOWER LIMB – Answers

a Achilles tendon
b Tendon of tibialis anterior muscle
c Navicular
d L4
e Intermediate cuneiform

T1W MRI of medial foot, axial section

The seven tarsal bones are arranged in three rows. The proximal row consists of
the talus and calcaneus. Distally there are the three cuneiform bones (medial,
intermediate and lateral) which are positioned medially and the cuboid which
is positioned laterally. The middle row consists of the navicular which is on the
medial side and lies between the talus and cuneiforms. On the lateral aspect of the
foot the calcaneum articulates directly with the cuboid.
Several of the calf muscles insert onto the tarsal bones. Gastrocnemius and
soleus, the large superficial muscles of the posterior calf, coalesce to form the
Achilles tendon which attaches to the posterior surface of the calcaneum (plantaris
is a small, slender vestigial calf muscle which sometimes contributes to this, but
is absent in a number of people). Tibialis anterior has tendinous attachments to
both the medial cuneiform and the base of the first metatarsal. Peroneus longus
attaches to the same bones but on the inferior aspect. Tibialis posterior has many
attachments: to the medial condyle of the navicular; to all of the tarsal bones
(except the talus); and to the bases of the 2nd, 3rd and 4th metatarsals.
The dermatomes of the foot divide it into three regions positioned medial to
lateral. The L4 dermatome includes the great toe. The L5 dermatome incorporates
the central foot and 2nd to 4th toes, while the S1 dermatome includes the little toe
and lateral foot.

245
 7 MOCK EXAM

Q1
a Name the structures labelled A
b Name the structure labelled B
c Name the structures labelled C
d Name the structure labelled D
e Name the structure labelled E

246
Q2

Chapter 7 MOCK EXAM – Questions

a Name the structure that attaches to A
b Name the structure labelled B
c Name the muscles contained within the anterior humeral compartment at the
level indicated
d Name the structure labelled D
e Name the major ligaments that join the humerus to forearm bones

247
 Q3
Chapter 7 MOCK EXAM – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

248
Q4

Chapter 7 MOCK EXAM – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the area labelled C
d Name the structure labelled D
e Name the anatomical variant demonstrated in this image

249
 Q5
Chapter 7 MOCK EXAM – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure which separates the two lateral ventricles

250
Q6

Chapter 7 MOCK EXAM – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the two lower limb muscles that attach to C
d Name the structure labelled D
e Name the structure labelled E

251
 Q7
Chapter 7 MOCK EXAM – Questions

a Name the structure labelled A

b Name the space labelled B
c Name the part of the structure labelled C
d Name the structure labelled D
e Name the muscle that arises from both of the areas labelled E

252
Q8

Chapter 7 MOCK EXAM – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

253
 Q9
Chapter 7 MOCK EXAM – Questions

a Name the structure labelled A

b Name the structure that connects the two structures labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

254
Q10

Chapter 7 MOCK EXAM – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

255
 Q11
Chapter 7 MOCK EXAM – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the area outlined and labelled D
e Name the osseous ridge labelled E

256
Q12

Chapter 7 MOCK EXAM – Questions

a Name the structure labelled A
b Name the structure outlined and labelled B
c Name the four rotator cuff muscles
d Name the anatomical landmark that defines the upper border of the brachial
vessels
e Name the five terminal branches of the brachial plexus

257
 Q13
Chapter 7 MOCK EXAM – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the artery supplying the structure labelled D
e Name the space labelled E

258
Q14

Chapter 7 MOCK EXAM – Questions

a Name the structure that links the radius and ulna in the space labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structures that the radial and ulnar arteries terminate as

259
 Q15
Chapter 7 MOCK EXAM – Questions

a Name the structures labelled A

b Name the structures labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structures labelled E

260
Q16

Chapter 7 MOCK EXAM – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

261
 Q17
Chapter 7 MOCK EXAM – Questions

a Name the structure labelled A

b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

262
Q18

Chapter 7 MOCK EXAM – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the vertebral level at which the C5 spinal nerve exits the vertebral canal

263
 Q19
Chapter 7 MOCK EXAM – Questions

a Name the structure labelled A

b Name the group of neurovascular structures outlined and labelled B
c Name the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

264
Q20

Chapter 7 MOCK EXAM – Questions

a Name the structure labelled A
b Name the structure labelled B
c Name the motor nerve supplying the structure labelled C
d Name the structure labelled D
e Name the structure labelled E

265
 7 MOCK EXAM –
ANSWERS

Q1 Answers
a Sacral nerve roots in sacral canal (cauda equina)
b Fat in the presacral space
c Rectal folds (valves)
d Posterior fornix of vagina
e Junctional zone of the myometrium

T2W MRI of female pelvis, midline sagittal section

The spinal cord terminates at the conus which is normally sited at the L1/2 level.
The distal lumbar and sacral nerve roots leave the cord at the conus and collectively
form the cauda equina (due to their somewhat similar appearance to a horse’s tail)
within the vertebral canal.
Physiological fluid and the mucosal surfaces of the uterus, cervix and vagina
produce high signal on T2 which makes these collapsed cavities visible.

Q2 Answers
a Tendon of biceps brachii muscle
b Coronoid process of ulna
c Biceps brachii and brachialis
d Olecranon fossa
e Medial and lateral (ulnar and radial) collateral ligaments

Radiographs of elbow, AP and lateral views

The major flexors of the elbow are the biceps brachii and brachialis muscles
which lie within the anterior humeral compartment. Their action is aided by
the brachioradialis muscle (particularly when the forearm is in the mid-prone
position), the belly of which is contained within the forearm.
The elbow joint is stabilized medially and laterally by strong collateral ligaments
which originate from the epicondyles of the humerus. These are also known as the
radial and ulnar collateral ligaments. The radial collateral ligament is continuous
with the annular ligament of the radius. The ulnar collateral ligament has three
266
 Chapter 7 MOCK EXAM – Answers
discrete bands; anterior, posterior and oblique joining it to the coronoid process
and olecranon of the ulna.

Q3 Answers
a Gastro-oesophageal junction
b Crus of right hemi-diaphragm
c Right colic flexure (hepatic flexure)
d Tail of the pancreas
e Left ureter

CT of upper abdomen with contrast, oblique coronal section

The two diaphragmatic crura arise from the upper lumbar vertebrae (L1/2/3 on
the right and L1/2 on the left) and arch superiorly and anteriorly to form the
margins of the aortic and oesophageal hiatuses. They are connected anteriorly by
the median arcuate ligament which forms the anterior border of the aortic hiatus
(T12). Anterior to this is the oesophageal hiatus (T10). The third and most anterior
diaphragmatic hiatus is for the IVC (T8) which is situated immediately inferior to
the right atrium within the large central tendon of the diaphragm.

Q4 Answers
a Left gastric artery
b Latissimus dorsi
c Aorto-pulmonary window
d Trachea
e Double SVC

CT thorax with contrast, maximum intensity projection, coronal section

In the developing venous system, paired superior cardinal veins drain into the
two horns of the sinus venosus. The left horn develops into the coronary sinus
and the right horn is incorporated into the right atrium. The upper cardinal veins
interconnect via an oblique vein which becomes the left brachiocephalic vein. The
inferior aspect of the left-sided cardinal vein usually involutes leaving a single,
right-sided superior vena cava draining into the heart.
Failure to form an oblique vein results in a double SVC without communication.
Involution of the right cardinal vein rather than the left results in a left SVC, and
formation of an oblique vein but with no involution results in a double SVC
with communication (as in this case). In most cases, a left SVC will drain into the
coronary sinus.

Davies M, Guest PJ. Developmental abnormalities of the great vessels of the thorax and their
embryological basis. British Journal of Radiology 2003; 76:491–502.

267
 Q5 Answers
Chapter 7 MOCK EXAM – Answers

a Corpus callosum
b Right head of caudate
c Anterior limb left internal capsule
d Right internal carotid artery within cavernous sinus
e Septum pellucidum

T2W MRI of brain, coronal section at level of cavernous sinus

In coronal section the corpus callosum is clearly seen connecting the white matter
of the two cerebral hemispheres. Similarly, the limbs of the internal capsule are
seen to radiate from central to peripheral; the anterior limb lies anterior to the
midline of the brains long axis which roughly corresponds with the position of the
midbrain (the image provided is anterior to the brainstem).
The carotid artery turns through 180 degrees within the cavernous sinus before
exiting superiorly and dividing into its terminal branches.

Q6 Answers
a Natal cleft
b Ischiopubic ramus
c Sartorius and tensor fascia latae
d Sacral ala (or wing)
e L5/S1 joint (or interspace)

Radiograph of male pelvis, AP view

Many soft tissue shadows are seen overlying the bony structures on plain
radiography. These need to be recognised to exclude them from bony lucencies;
soft tissue shadows will generally extend beyond the boundaries of the bone they
overlie.
The pubis joins the ilium and ischium through superior (iliopubic) and inferior
(ischiopubic) rami.
The sacral alae (or wings) are the lateral expansions of the sacrum which
articulate with the ilium bilaterally.

268
Q7 Answers

Chapter 7 MOCK EXAM – Answers

a Medial tibial condyle
b Intercondylar fossa
c Base of the patella
d Adductor tubercle
e Soleus

Radiograph of knee, AP view

Parts of the patella are named in accordance with their shape, rather than the
positions in which they are found in vivo. The base forms the flatter superior aspect
and the apex lies inferiorly.
Soleus muscle is one of the three superficial calf muscles, and the only muscle to
arise from both the proximal fibula and tibia. It takes origin from the upper fibula,
including the head, as well as from the soleal line which is a thick oblique ridge
on the posterior aspect of the upper tibia. The origins are connected by a fibrous
band that passes over the popliteal vessels in the posterior calf. Soleus contains a
large number of small perforating veins to the great saphenous vein. It plays an
important role in maintaining venous flow by forcing blood from deep veins within
the calf through these perforators to superficial veins every time the muscle belly
contracts and therefore acts as a ‘venous pump’ in the lower limb.

Meissner MH, Moneta G, Burnand K et al. The hemodynamics and diagnosis of venous disease. Journal
of Vascular Surgery 2007; 46: S4–S24.

Q8 Answers
a Right pedicle of T1 vertebra
b Coronoid process of mandible
c Inferior nasal concha (or turbinate)
d Ethmoid sinus
e Mastoid air cells

Radiograph of mandible, AP view

The midline part of the mandible is known as the body and has the mandibular
protuberance anteriorly (the point of the chin). The mandibular rami are the more
vertical lateral components of the mandible; the angle of the mandible is where
the ramus meets the body, there are two of these. Both the condylar and coronoid
processes of the mandible arise from the ramus. The condylar process articulates
within the mandibular fossa of the temporal bone to form the temporomandibular
joint (TMJ). The coronoid process arises more anteriorly and provides attachment
for the temporalis, one of the four muscles of mastication.

269
 Q9 Answers
Chapter 7 MOCK EXAM – Answers

a Aortic valve
b Lesser omentum
c Left brachiocephalic vein
d Spleen
e Left atrium/auricle

MRI of the aortic root, oblique coronal section

The lesser omentum consists of two layers of peritoneum which extends between
the posterior aspect of the liver and the lesser curvature of the stomach. The hepatic
connection is ‘L’-shaped as it joins into the fissure for the ligamentum venosum
and porta hepatis. The lesser omentum runs from the right side of the intrathoracic
oesophagus, along the lesser curvature of the stomach and includes the first two
centimetres of duodenum. The free edge at this point forms the anterior margin of
the foramen of Winslow (epiploic foramen) and the lesser omentum is the anterior
boundary of the lesser sac.
The thyroid is supplied by paired inferior thyroid arteries (from the thyrocervical
trunk) and paired superior thyroid arteries (from the external carotid artery).
In a small percentage of people there is a further artery supplying the thyroid –
thyroidea ima – which arises directly either from the brachiocephalic trunk or the
arch of the aorta.

Summers JE. Surgical anatomy of the thyroid gland. Am Joint Surg 1950; 80:35–43.

Q10 Answers
a Intermediate (middle) cuneiform
b Calcaneus
c Cuboid
d Epiphysis of 1st metatarsal
e Medial malleolus of the tibia

Radiographs of the foot in a 7 year-old child, AP and oblique views

The bones of the foot consist of the tarsus, metatarsus and phalanges. Tarsal bones
of the foot are arranged in two rows. The proximal row consists of the calcaneus
and talus. The distal row includes the medial, intermediate and lateral cuneiform
bones medially and the cuboid laterally. On the medial side the navicular is
positioned between the talus proximally and the cuneiforms distally.

270
Q11 Answers

Chapter 7 MOCK EXAM – Answers

a Vastus medialis
b Biceps femoris
c Sartorius
d Adductor canal (Hunter’s canal, subsartorial canal)
e Linea aspera

T1W MRI of lower thigh, axial section

The adductor canal is a continuation from the apex of the femoral triangle. It is a
channel that runs down the medial and lower thigh located between vastus medialis
anteriorly, the adductors posteriorly and the sartorius medially. It serves to transmit
the superficial femoral artery (and descending genicular branch) and femoral vein
between the thigh and the popliteal fossa. To enter the popliteal fossa, the femoral
artery turns medially and passes posteriorly through an opening in the aponeurosis
of adductor magnus (adductor hiatus). The femoral vein lies deep to the artery
throughout the thigh, but superficial to it in the popliteal fossa. The saphenous
nerve enters the canal superiorly before exiting medially between sartorius and
gracilis.
The linea aspera is a roughened ridge on the posterior aspect of the femoral shaft
which receives the attachments of the biceps femoris (short head) and the abductor
muscles.

Q12 Answers
a Trapezius muscle
b Anatomical neck of humerus
c Supraspinatus, infraspinatus, teres minor and subscapularis
d Lower border of teres major
e Axillary, radial, ulnar, median and musculocutaneous nerves

T1W MRI of shoulder, coronal section

The trapezius muscle (upper fibres) is used to shrug the shoulders by raising and
rotating the scapula and raising the distal clavicle. It attaches distally to the lateral
third of clavicle, acromion and spine of scapula.
The brachial vessels of the arm are continuous with the axillary vessels; they leave
the axilla by passing distal to the lower border of teres major.
Most nerve supply to the upper limb derives from the brachial plexus. The nerve
roots of C5 to T1 combine and cross before the five terminal nerves are formed.
These nerves enter the arm surrounding the brachial artery.

271
 Q13 Answers
Chapter 7 MOCK EXAM – Answers

a Left gonadal (testicular) vein

b Jejunum
c Iliacus
d Ileo-colic artery
e Left sub-phrenic space

CT abdomen with contrast, coronal section

In males, the testicular veins enter the abdominal cavity through the inguinal canal
and run along the anterior aspect of the psoas muscle, usually in a pair either side
of the testicular artery. The vein on the right empties into the IVC but on the left it
usually inserts at a right angle into the left renal vein.
The superior mesenteric artery supplies the mid-gut structures, which includes
bowel from half way along the 2nd part of duodenum to the distal two thirds of the
transverse colon. Three branches of the SMA provide the colonic supply – the ileo-
colic, right colic and middle colic arteries.
The left sub-phrenic space is separated from the right sub-phrenic space by the
falciform ligament of the liver.

Q14 Answers
a Interosseous membrane
b Ulnar styloid
c Hook of hamate
d Epiphysis of thumb metacarpal
e Superficial and deep palmar arches

Radiograph of the wrist in a 13 year-old child, AP view

All carpal bones are visible in this image of an adolescent child and are almost
fully ossified. The long bone epiphyses are similarly nearing their final size prior to
fusion of the physes.

272
Q15 Answers

Chapter 7 MOCK EXAM – Answers

a Sternal and clavicular heads of sternocleidomastoid muscle
b Sternothryoid and sternohyoid muscles (strap muscles)
c Oesophagus
d Lamina
e Dorsal roots/ dorsal root ganglia of cervical cord

T2W MRI at root of neck, axial section

The sternocleidomastoid (SCM) muscle has, as the name suggests, a sternal and
clavicular head. Medial to the SCM lie the strap muscles. These are named by their
attachments; the sternothyroid lies deep to the sternohyoid. The strap muscles
depress the hyoid and larynx.
Each spinal nerve is formed from dorsal and ventral nerve roots which combine
as they leave the vertebral canal. The dorsal nerve root is sensory and its nerve cell
bodies are contained within the dorsal root ganglion. The ventral nerve roots are
motor and have their ganglia within the spinal cord. After leaving the vertebral
canal, a spinal nerve almost immediately divides into dorsal and ventral rami which
supply the posterior and anterior parts of the body, respectively.

Q16 Answers
a Anterior leaflet (cusp) of the mitral valve
b Papillary muscle
c Left breast
d Left coronary artery
e Left atrium

Cardiac MRI (Gradient Echo/True fast imaging with steady state precession (True
FISP)), long-axis vertical plane

This long axis vertical plane view demonstrates the left atrium and ventricle.
Horizontal long axis (or 4-chamber view) and short-axis plane can also be used
specifically for cardiac MRI.
The orientation of the heart means that there is significant obliquity in
the projection of the extra-cardiac structures. The lower part of the image is
significantly further left than the upper part.
This image is taken in early systole, shortly after closure of the mitral valve.

Lee VS. Cardiac MRI: Technical Aspects and Primer. Radiology 2002; eMedicine: www.emedicine.
medscape.com

273
 Q17 Answers
Chapter 7 MOCK EXAM – Answers

a Interosseous sacroiliac ligament

b Dorsal nerve root
c Nerve roots of the cauda equina
d Dorsal sacroiliac ligament
e Gluteus medius

T2W MRI of lower lumbar spine, axial section

Each sacro-iliac joint has to withstand significant forces as they support the axial
load of the trunk through their connection to the pelvis and lower limb. The
adjacent joint surfaces are irregular but reciprocal in outline which adds to this
strength. Additional support is provided by dorsal and ventral sacroiliac ligaments
and a deeper interosseous sacroiliac ligament. A small amount of movement is
permitted in the joint, predominantly in a rotatory axis.
Nerve roots exit the dura mater to pass obliquely and inferiorly through the
intervertebral foramina.

Q18 Answers
a Anterior lobe of the cerebellum
b Clivus
c Uvula
d Posterior arch of C1
e C4/5 level

T2W MRI of neck, midline sagittal section

On this view the anterior lobe of the cerebellum is visible divided from the
posterior lobe by the CSF filled primary fissure. The third major lobe of the
cerebellum is the flocculonodular lobe which lies antero-inferiorly.
There are thirty-one pairs of spinal nerves. These exit the spinal canal through
the intervertebral foramen which are formed from notches in the superior and
inferior pedicles of adjacent vertebrae. The individual nerves are named relative to
these adjacent vertebrae; cervical nerves are named relative to the inferior pedicle of
their foramen, however since there are eight cervical nerves but only seven cervical
vertebrae, the eighth cervical spinal nerve exits below the seventh cervical vertebra.
The remaining spinal nerves (thoracic, lumbar and sacral) are named relative to the
superior pedicle of their foramen, i.e. T7 exits at the T7/8 level.

274
Q19 Answers

Chapter 7 MOCK EXAM – Answers

a Common femoral artery
b Obturator artery, vein and nerve
c Seminal vesicle
d Peripheral zone of prostate
e Obturator internus muscle

T2W MRI of male pelvis with fat saturation, axial section

On this image, the urinary bladder is seen in the midline with the prostate beneath.
Prostatic zonal anatomy is well seen with the higher signal peripheral zone
surrounding the lower signal central gland. Superior and lateral to the prostate on
either side of the midline lie the seminal vesicles.
The iliac vessels are continuous distally with the common femoral vessels; the
name changes as they pass under the inguinal ligament and leave the pelvis. The
obturator vessels are branches of the anterior division of the internal iliac vessels.
The obturator vessels run along the lateral wall of the pelvis. Initially they lie medial
to the obturator internus muscle but distally they perforate this layer to reach the
obturator foramen.

Q20 Answers
a Azygous vein
b Axillary artery/brachial artery
c Long thoracic nerve
d Internal mammary artery
e Teres major

T1W MRI of the thorax at the level of the left axilla, axial section

The axillary artery passes through the axilla alongside the axillary vein, which lies
medial to the cords of the brachial plexus; these surround the artery and are named
according to their position relative to it.
As the axillary artery crosses the inferior border of teres major it is renamed the
brachial artery.
The long thoracic nerve is a branch of the upper roots of the brachial plexus,
arising from the posterior aspects of C5/6/7. It travels inferiorly along the
superficial fascia of serratus anterior. The action of serratus anterior is that of a
powerful lateral rotator (lower half) and protractor of the scapula.
The internal mammary artery, which is a branch of the subclavian artery, passes
down behind the first six costal cartilages on the inner anterior thoracic wall. The
artery is located lateral to the vein.

275
 INDEX

Note: page numbers in parentheses refer to questions. Other anterior descending coronary artery (82) 107, (84) 108
page numbers refer to answers. anterior fontanelle (5) 43
anterior humeral line (126) 141
abdominal wall muscles (162) 178 anterior inferior iliac spine (183) 202, 232
abductor digiti mimimi muscle 244 anterior inferior talofibular ligament (228) 243
abductor hallucis muscle (229) 244 anterior meniscofemoral ligament (223) 240
aberrant pulmonary arteries 103 anterior sacral foramina (184) 202
aberrant right subclavian artery (88) 111 anterior superior iliac spine 232
abscesses, ischioanal 208 anterior temporal lobe (25) 54
accessory fissures (pleura) 96 anterior tibial artery (221) 239
accessory hemiazygos vein 109 anterior vertebral line (29) 57
accessory nerve, spinal (90) 112 antrum, stomach (151) 170, 174
acetabular angle (213) 233 anus, external sphincter (194) 207
acetabulum (183) 202, (212) 232 aorta
child (215) 234–5 abdominal (149) 169, (160) 176, (192) 206, (201)
triradiate cartilage (213) 233 211
Achilles tendon (226) 242, (231) 245 arch (39) 62, (65) 95, (77) 103, (81) 106
acromio-clavicular joint (117) 137, (119) 138 descending (71) 99
acromion process, scapula (116) 136, (121) 139 root (254) 270
acute marginal branch artery (76) 102 aortic hiatus 267
Adam’s apple 55 aortic valve (69) 98, (83) 108, (254) 270
adductor brevis muscle 237 aorto-pulmonary window (249) 267
adductor canal (256) 271 aponeuroses
adductor hiatus 271 bicipital 141
adductor longus muscle 237 external oblique muscle (162) 178
adductor magnus muscle 237, (218) 237 palmar (135) 146
adductor tubercle (252) 269 plantar (230) 244
adolescents, carpal bones (259) 272 appendix (153) 172
adrenal gland (156) 174, (164) 179 aqueduct of Sylvius (20) 51, (22) 53
age arachnoid layer, meninges 49
gestational 206 arcuate ligament 241
physiological 145 median 267
alpha angle, paediatric hip (215) 234, 235 arcuate line 178
ambient cistern (12) 47 areola (74) 101
ampulla of Vater (151) 171, 181 arteries
ampulla, fallopian tube 204 brain 49
anastomoses end-on (lung) 96
axillary artery (122) 139 see also named arteries
brain arteries 49 arteries of Riolan 173
lower limb arteries 234 artery of Adamkiewicz (167) 181, 182
porto-systemic 176 arthrography, wrist 144
anatomical neck, humerus 136, (257) 271 arytenoid cartilages 59
angle of Louis 101 ascending colon (153) 172
angle of mandible (26) 55 atlanto-axial joint (28) 56
ankle joint (226 & 227) 242–3, (229) 244 atlas (C1) (6) 44, (27 & 28) 56, (31 & 32) 58
annular ligament (125) 141 posterior arch (263) 274
annulus fibrosus 113–14 atria (64) 94, (80) 106, (82) 107, (83) 108, (254) 270, (261)
anterior cerebral artery (12) 47 273
anterior clinoid process (5) 43 atrio-ventricular node 107

276
avascular necrosis, femoral head 234 cardiophrenic angles (65) 95

Index
axillary artery (81) 106, 107, (93) 115, (120) 138, (122) 139, carina 95
(265) 275 carotid arteries (81) 106, (250) 268
axillary lymph nodes (75) 102, 115 common carotid artery 62
axillary nerve (120) 138, 139, (257) 271 external carotid artery (36) 60, (40) 62, 63
axillary vein (118) 137, (120) 138, 275 internal carotid artery 59, (36) 60, 62–3, (250) 268
axis (C2) (28) 56, (29) 57, 58 carotid canal (9) 45
azygo-oesophageal line (69) 98 carpal bones 143, 144, (133) 145, (259) 272
azygos fissure (67) 96 carpal tunnel 145
azygos lobe 96 cauda equina 205, (246) 266, (262) 274
azygos vein (85) 109, (265) 275 caudate lobe, liver (164) 179
caudate nucleus (12) 47, (250) 268
barium small-bowel follow-through (151) 170–1 caval opening, diaphragm (80) 106
barium swallow (77) 103, (78) 104 cavernous sinuses 47, (250) 268
basal ganglia (19) 51 cavum septum pellucidum (14) 48, 50
basilar artery (16) 49, (17) 50 cephalic vein (123) 140, (124) 140, (129) 143
basilic vein 140, 143 cerebellar peduncles (13) 48, (21) 52, (25) 54–5, (90)
basivertebral veins (167) 181, 182 112
beta angle, paediatric hip (215) 234, 235 cerebello-pontine angle (24) 54
biceps brachii muscle (120) 138, (123) 140, (247) 266 cerebellum (21) 52, (263) 274
long head tendon (116) 136, (118) 137 cerebral aqueduct (20) 51, (22) 53
biceps femoris muscle 237, (256) 271 cerebral hemispheres (15) 49
tendon (224) 240–1 cerebral peduncles 49
bicipital aponeurosis 141 cerebrospinal fluid 47
Bigelow’s ligament (212) 232 cervical rib 55, (68) 97
biliary system (166) 180–1 cervical spine (1) 41, (26) 55, (27 & 28) 56, (29) 57, (31)
bipartite patella 238 58
bladder (188) 204, (190) 205, (196) 208, (200) 210 cervix uteri (187) 204, (190) 205, (197) 209
Bohler’s angle (226) 242 chest wall muscles (88) 111
bone marrow (87) 110–11 children
bovine arch (81) 106 carpal bones (259) 272
brachial artery (122) 139, (128) 142, (265) 275 elbow (127) 142
brachial plexus (39) 62, (92) 114, (257) 271 hip joint (215) 234–5
brachial vein (124) 140 knee joint (220) 238
brachialis muscle (123) 140, (247) 266 paranasal sinuses (1) 41
brachiocephalic artery 100 pelvis (213) 233
brachiocephalic vein, left 267, (254) 270 physiological age 145
brachioradialis muscle 266 skull (5) 43
brain (12) 47, (16) 49, (250) 268 choanae 58
neonate (14) 48, (15) 49 chorion (191) 206
vascular system 49 cingulate gyrus (14) 48
breast (65) 95, (74) 101, (75) 102, (261) 273 circle of Willis 49
carcinoma, axillary lymph nodes 115 circumflex coronary artery 107
bregma 43 circumflex humeral vessels 139, (122) 139
broad ligament (192) 206 cisterns (brain)
bronchi (77) 103, (85) 109, (86) 110 ambient cistern (12) 47
end-on 96 pontine cistern (13) 48
bronchopulmonary segments 104–5, 109 claustrum (19) 51
bronchus intermedius (67) 96, 110 clavicle (73) 100, (92) 114, (117) 137, (120) 138
bulbospongiosus muscle (194) 207, 208 clinoid processes (5) 43
bulbous urethra 204, (188) 204 clivus (9) 45, (263) 274
coccygeus muscle (198) 209
caecum 172 coccyx (183) 202
calcaneum 245, (255) 270 cochlea (24) 54
fractures 242 cochlear nerve (24) 54
calyces, kidney (161) 177, (185) 203 coeliac artery 171, (154) 172
capitate (132) 144, (133) 145 collateral arteries, arm 139
capitulum, humerus (125) 141, (127) 142 collateral ligaments
capsule, knee joint (223) 240 elbow joint (247) 266–7
cardia, stomach 174 knee joint (224) 240
cardiac fat pad (72) 100 collecting system, renal (161) 177
cardinal veins, superior 267 colliculi (superior & inferior) 49, (20) 51, (20 & 21) 52

277
 colon (153) 172, (159) 176 d/D ratio, paediatric hip 235
Index

blood supply 173 deep brachial artery (122) 139, (123) 140
descending (147) 168 deep brachial vein (123) 140, (124) 140
haustra (148) 168 deep circumflex iliac artery (201) 211
hepatic flexure (248) 267 deep palmar arch (128) 142, (259) 272
columns see three column principle deltoid ligament 243, (229) 244
columns of Bertin (165) 180 deltoid muscle (118) 137, (119) 138
common bile duct (163) 178, (164) 179, (166) 180 dens 55, (27 & 28) 56, (31) 58
common carotid artery 62 dentine (7) 44
common femoral artery (214) 234, (264) 275 dermatomes, foot (231) 245
common femoral vein (216) 235 descending aorta (71) 99
common hepatic artery (152) 171 descending colon (147) 168
common iliac artery (149) 169, 177, (185) 203, (201) 211 developmental dysplasia of hip 233, 235
common iliac vein (185) 203 diaphragm (64 & 65) 94, 95, (69) 98, (71) 99, (156) 174,
common peroneal nerve 236 (165) 180, (248) 267
compartments, leg (225) 241, 242, 243 caval opening (80) 106
conchae (inferior nasal) (23) 53, (253) 269 diaphragma sellae 43
condylar process, mandible (6) 44, (8) 45, (254) 269 diaphyses, femur (220) 238
condyles, tibia (252) 269 digital arteries, palmar (135) 146
confluence of sinuses (11) 46–7 diploe (4) 42, (4) 43
conoid component, coracoclavicular ligament (116) 136 discs (intervertebral) (91) 113–14
conus branch, coronary arteries (76) 102 distal radioulnar joint (130) 143
conus medullaris (167) 181 distal tibiofibular joint 243
Cooper’s ligaments (74) 101 dorsal pancreatic duct (166) 180, 181
coracoclavicular ligament (116) 136 dorsal root ganglia (91) 113
coracoid process, scapula (70) 99, (117) 137, (120) 138 dorsal sacroiliac ligament (262) 274
corniculate cartilages 59 dorsal scapular artery (90) 112
coronal sections, shoulder (120) 138 dorsal spinal nerve roots
coronal suture (5) 43 cervical (260) 273
coronary arteries (76) 102–3, (82) 107, (83) 108, (261) lumbar (262) 274
273 dorsum sellae (10) 46
anterior descending coronary artery (82) 107, (84) double inferior vena cava (160) 176–7
108 double superior vena cava (249) 267
posterior descending coronary artery (76) 102, 103, duct of Santorini (166) 180, 181
(81) 106, 107 duct of Wirsung 181
coronoid process ductus venosus (149) 169
mandible (3) 42, (253) 269 duodenocolic ligament (157) 174
ulna (126) 141, (247) 266 duodenum (151) 170–1, (154) 172, (157) 174
corpora cavernosa 207 duplication, inferior vena cava (160) 176–7
corpora quadrigemina 49, (20) 51, (22) 52, (20 & 21) 52 dura mater 49
corpus callosum (17 & 18) 50, (250) 268 dysphagia lusoria 111
corpus spongiosum 207
cortex, skull 43 edges, lines vs, pleural reflections 98
costophrenic recess (72) 100 ejaculatory ducts 204
costotransverse joints 110 elbow (125 & 126) 141, (127) 142
costovertebral joints (87) 110 elbow joint (247) 266
Couinaud, C., hepatic segments 173 collateral ligaments (247) 266–7
cranial fossae 46 enamel (7) 44
cranial nerves, in cavernous sinuses 47 endocervical canal (197) 209
cribriform plates 46 endometrium (190) 205, (197) 209
cricoid cartilage 59 epicardial fat (84) 108, 109
cricothyroid ligament 55 epicondyles
cricothyroid membrane 55, (33) 59 femur (219) 238
CRITOE (mnemonic) 142 humerus 141, (127) 142
crown rump length (191) 206 epididymis (193) 206, 207
crowns, teeth (7) 44 epidural fat (167) 181
cruciate ligaments, posterior (223) 240, (224) 240 epiglottis (33) 59, (35) 60, (37) 61
crus cerebri (22) 52 epiphyseal lines (119) 138
cuboid (226) 242, (255) 270 epiphyses
cuneiform bones (231) 245, (255) 270 elbow (127) 142
cuneiform cartilages 59 femur (220) 238
cystic duct 180 fingers (134) 145

278
 first metacarpal (259) 272 follicles, ovary (192) 206

Index
tibia (220) 238 fontanelles (5) 43
epiploic foramen (158) 175 foot
erectile tissue, penis (194) 207 dermatomes (231) 245
erector spinae muscles (87) 110 tarsal bones (231) 245, (255) 270
ethmoid sinuses (253) 269 foramen lacerum (40) 62
posterior (23) 53 foramen magnum (4) 42–3, (9) 45, (35) 60
extensor digitorum muscle (228) 243 foramen of Monro (19) 51
extensor hallucis longus muscle 243, (230) 244 foramen of Winslow (158) 175
extensor paraspinal muscles 110 foramen ovale (8) 45
extensors, leg (225) 241 foramen rotundum (2) 42, (8) 45
external capsule (19) 51 foramen spinosum (8) 45
external carotid artery (36) 60, (40) 62, 63 fornices (white matter) (18) 50
external iliac artery (161) 177, (195) 208 fornices, vagina 209, (246) 266
external oblique muscle 178 fourth ventricle (13) 48, 52
aponeurosis (162) 178 superior medullary velum (35) 60
external sphincter, anus (194) 207 frontal bone (10) 46
extra-ocular muscles (23) 53 frontal process, zygoma (8) 45
extreme capsule (19) 51 frontal sinus (1) 41, (2) 42, (18) 51
eye muscles (extra-ocular muscles) (23) 53 fronto-zygomatic suture (3) 42
fundus, stomach (71) 99, (78) 104, 174
fabella (222) 239
facet joints (zygoapophyseal joints) (27) 56, (91) 113, (150) gallbladder (155) 173, (163) 178, (166) 180
169 non-opacification 181
facial bones, occipito-mental view (3) 42 ganglia, dorsal spinal nerve roots (91) 113, (260) 273
facial nerve (24) 54, (36) 60–1 gastro-oesophageal junction (78) 104, (248) 267
falciform ligament, liver 272 gastrocnemius muscle (222) 239, (225) 241, 245
fallopian tube (187) 204 gastroduodenal artery (152) 171
falx cerebri (14) 48, (15) 49 gastrosplenic ligament (158) 175
fascia lata 237 genu of corpus callosum (18) 50
fascia of Zuckerkandl (160) 176, 177 genu of internal capsule (12) 47
fat pads Gerota’s fascia 177
cardiac (72) 100 gestational age 206
elbow (126) 141 gestational sac (191) 206
infrapatellar (222) 239 gleno-humeral joint (119) 138
female pelvis 202, (185) 203, (196) 208 glenoid cavity (117) 137
female reproductive tract, ultrasound (190) 205, (191) 206 glenoid labrum (119) 138
femoral artery (216) 235, 271 globus pallidus (19) 51
femoral canal (216) 235 gluteus medius muscle (262) 274
femoral head (215) 234, (216) 235 golfer’s elbow 141
femoral nerve 236 gonadal artery (161) 177, 206, (201) 211
femoral vein 235, 236, 271 see also ovarian artery; testicular artery
femur gonadal vein (258) 272
epicondyles (219) 238 gracilis muscle 237
greater trochanter (217) 236 great longitudinal fissure (14) 48
linea aspera (256) 271 great saphenous vein (216) 235, (224) 240, 241, (227)
ossification 235, (220) 238 242
fillings, dental (7) 44, (28) 56 greater trochanter (217) 236
fistula, perianal 208
flexor digitorum brevis 244 hamate (133) 145, (259) 272
flexor digitorum longus 242–3 hamstrings, origin (218) 237
flexor digitorum profundus, tendons (133) 145, 146 hand
flexor digitorum superficialis, tendons (133) 145, (135) blood supply (128) 142
146 bone development (134) 145
flexor hallucis longus muscle (227) 242–3, (230) 244 hard palate 51
flexor pollicis longus (133) 145 haustra, colon (148) 168
flexor retinaculum (133) 145 heart (64) 94, (84) 108–9
flexors, forearm (125) 141, (129) 143, 146 MRI (261) 273
flocculonodular lobe, cerebellum 274 valves see valves (cardiac)
foetal circulation 169 see also coronary arteries; ventricles
foetus (191) 206 hemiazygos vein 109
folia, cerebellum (21) 52 hepatic artery (163) 178, 179

279
 hepatic bile ducts (166) 180 interatrial septum (82) 107
Index

hepatic flexure of colon (248) 267 intercondylar eminence, tubercle of (219) 238
hepatic segments (155) 173 intercondylar fossa (252) 269
hepatic veins (163) 178, 179 intercostal arteries 182
hepato-renal pouch (160) 176, 177 intercostal muscles (88) 111
hepatoduodenal ligament 175 interhemispheric fissure (14) 48
hilar point (69) 98 interlobar arteries (80) 106
Hilgenreiner line (213) 233 intermediate cuneiform (231) 245
hip joint 232, (213) 233 internal auditory meatus (24) 54
blood supply 234 internal capsule (12) 47, 51, (250) 268
child (215) 234–5 internal carotid artery 59, (36) 60, 62–3, (250) 268
ligamentum teres (195) 208 internal cerebral veins (11) 46–7
hippocampus (17) 50 internal iliac artery (149) 169, (192) 206, (201) 211
Hoffa’s fat pad (222) 239 internal iliac vein (192) 206
hook of hamate (259) 272 internal jugular vein 59, (34) 59
horizontal fissure (pleura) (67) 96 internal mammary artery (81) 106, 107, (84) 108, (265)
Houston, valves of (186) 203 275
humerus (116) 136 internal oblique muscle (162) 178
anatomical neck 136, (257) 271 internal pudendal artery 203
capitulum (125) 141, (127) 142 interosseous arteries, forearm (128) 142
epicondyles 141, (127) 142 interosseous ligament 243
medulla (123) 140 interosseous membrane
olecranon fossa (126) 141, (247) 266 forearm (129) 143, (259) 272
Humphrey’s ligament (223) 240 leg (225) 241
Hunter’s canal (256) 271 interosseous sacroiliac ligament (262) 274
hydrocele (193) 207 interosseous talocalcaneal ligament (229) 244
hyoid bone (26) 55, (30) 57, (33) 59 interosseous muscles
hypoglossal nerve (9) 45, (37) 61 foot (230) 244
hypothenar eminence (133) 145 hand 146
hysterosalpingography (187) 204 interpeduncular cistern (13) 48, (22) 52
interspinous ligaments (1) 41
ileocolic artery 173, (258) 272 intertubercular groove (118) 137
ileum (151) 170 interventricular septum (89) 112
blood supply 173 intervertebral discs (91) 113–14
iliacus muscle (195) 208, (258) 272 intervertebral foramina 114, (150) 169
iliofemoral ligament (212) 232 intra-conal fat (16) 49
iliopsoas muscles (189) 205, (217) 236 intra-uterine contraceptive devices (185) 203
iliotibial tract 237, 240–1 ischial spine (184) 202
incisors (6) 44 ischioanal fossa 208, (218) 237
incisura (cardiac) (72) 100 ischiocavernosus muscle (194) 207, 208
incisura (stomach) (156) 174 ischiopubic ramus (251) 268
inferior alveolar artery and nerve 44 ischiopubic synchondrosis (213) 233
inferior colliculi 49, (20) 51, (20 & 21) 52 isthmus of fallopian tube 204
inferior epigastric artery (201) 211 isthmus of thyroid gland (34) 59
inferior gluteal artery 234
inferior mesenteric artery 171, (154) 172–3, (201) 211 jejunal branch, superior mesenteric artery (155) 173
inferior nasal concha (23) 53, (253) 269 jejunum (151) 170, 171, (258) 272
inferior petrosal sinus 47 Judet views 232
inferior rectal artery (186) 203 jugular foramen (9) 45
inferior rectus muscle (23) 53
inferior sagittal sinus (11) 46–7 kidney (147) 168, (161) 177, (165) 180, (185) 203
inferior vena cava (71) 99, (149) 169, (164) 179 renal pelvis (152) 171, 177
diaphragmatic hiatus 267 knee joint (219) 238, (222) 239, (223 & 224) 240–1, (252)
double (160) 176–7 269
infra-mammary skin fold (75) 102 child (220) 238
infrapatellar fat pad (222) 239
infraspinatus muscle (88) 111, (118) 137, (257) 271 labrum (of glenoid) (119) 138
infundibulum, fallopian tube 204 lambda 43
inguinal canal 236 lambdoid suture (5) 43, (10) 46
innominate bone 202, 233 lamina dura (7) 44
innominate line (2) 42 lamina papyracea (3) 42
insula (14) 48, (17) 50 laminae, vertebrae (87) 110, 170, (260) 273

280
large intestine (153) 172 breast 101

Index
laryngopharynx (32) 58 mediastinum (68) 97, (77) 103
larynx (33) 59
cartilages (26) 55, (27) 56 Magendie, median aperture of (20) 51
lateral circumflex femoral artery (214) 234 magnetic resonance imaging
lateral mass of atlas (31) 58 bone marrow 111
lateral meniscus (223) 240 gleno-humeral joint (119) 138
lateral pterygoid muscle (36) 60 heart (261) 273
lateral sulcus (sylvian fissure) (13 & 14) 48, (17) 50 intervertebral discs 114
lateral ventricles, temporal horns (16) 49 orbit (16) 49
latissimus dorsi muscle (249) 267 pelvis (246) 266
left atrium (254) 270 sacroiliac joint (199) 210
appendage (80) 106, (82) 107 shoulder (120) 138
left brachiocephalic vein 267, (254) 270 uterus (197) 209
left colic artery 173 male pelvis 202, (251) 268, (264) 275
left gastric artery (78) 104, (249) 267 malleoli (227) 242, (255) 270
left hepatic artery (152) 171 mamillary body (20) 51–2
lentiform nucleus (19) 51 mammography (74) 101, (75) 102
lesser omentum (254) 270 mandible (253) 269
lesser sac (158) 175 angle (26) 55
lesser tubercle, humerus (116) 136 condylar process (6) 44, (8) 45, (254) 269
lesser wing of sphenoid bone (10) 46 coronoid process (3) 42, (253) 269
levator ani muscle (196) 208, (199) 210 orthopantomograms (6) 44
lienorenal ligament (158) 175 mandibular canal (6) 44
ligament(s), thoracic spine 113 manubriosternal joint (73) 100, 101
ligament of Bigelow (212) 232 manubrium (73) 100, 101, (92) 114
ligament of Humphrey (223) 240 marrow (87) 110–11
ligament of ovary (192) 206 massa intermedia, thalamus (20) 51
ligament of Treitz 171 masseter muscle (36) 60
ligamentum arteriosum (79) 104, 105 mastoid air cells (1) 41, (10) 46, (253) 269
ligamentum flavum (1) 41, 113 maxillary ostium see inferior nasal concha
ligamentum nuchae (91) 113 maxillary sinus (1) 41, (3) 42, (23) 53
ligamentum teres, hip (195) 208 McRae’s line (35) 60
limbic system 50 meati, nose (23) 53
linea alba (162) 178 Meckel’s cave (25) 54–5
linea aspera (256) 271 medial genicular artery (221) 239
lines, edges vs, pleural reflections 98 medial intermuscular septum, thigh 237
lingula, bronchi supplying (85) 109 medial pterygoid muscle (36) 60
liver (147) 168, (158) 175, 178–9 medial tibial plateau (219) 238
caudate lobe (164) 179 medial tibial spine (219) 238
neonatal (149) 169 median aperture of Magendie (20) 51
segments (155) 173 median arcuate ligament 267
lobes (lung) (67) 96 median nerve (133) 145, (257) 271
long saphenous vein (216) 235, (224) 240, 241, (227) median sacral crest (189) 205
242 mediastinum (64 & 65) 94
long thoracic nerve (265) 275 lymph nodes (68) 97, (77) 103
longitudinal ligaments (167) 181, 182 pleural reflections (69) 98
cervical spine (1) 41 mediastinum testis (193) 206
thoracic spine 113 medulla, humerus (123) 140
lumbar spine (150) 169–70, (262) 274 membranous urethra (188) 204
lumbo-sacral junction (148) 169, 170 meninges 49
transverse processes (148) 168 menisci (knee) (223) 240
lumbarization, S1 vertebra (148) 169 meniscofemoral ligament, anterior (223) 240
lumbo-sacral joint (186) 203, (251) 268 mesentery 172
lumbrical muscles (135) 146 mesorectal fascia (198) 209
lunate (130) 143, (132) 144 metacarpals (134) 145, (259) 272
lung (67) 96 metaphyses (125) 141
bronchopulmonary segments 104–5, 109 tibia (220) 238
oblique fissure (72) 100, (85) 109 metatarsals (255) 270
right middle lobe (89) 112 midbrain (16) 49
lymph nodes middle colic artery 173
axillary (75) 102, 115 middle ear (24) 54

281
 middle meningeal artery ovarian ligament (192) 206
Index

foramen spinosum and (8) 45 ovary (192) 206

pterion and 43
middle rectal artery (186) 203 palate 51
minor fissure (pleura) (67) 96 see also soft palate
minor papilla 181 palmar aponeurosis (135) 146
mitral valve (69) 98, (89) 112, (261) 273 palmar arches (128) 142, (259) 272
moderator band, right ventricle (89) 112 palmar digital arteries (135) 146
Morison’s pouch (160) 176, 177 pancreas (157) 174, (164) 179, (248) 267
musculocutaneous nerve (257) 271 pancreas divisum (166) 180, 181
mylohyoid muscle (32) 58 pancreatic duct 181
myometrium (190) 205, (191) 206, (246) 266 papilla of Vater (ampulla of Vater) (151) 171, 181
junctional zone (197) 209 papillary muscles (83) 108, (261) 273
parahippocampal gyrus (17) 50
nasolacrimal duct 53 paranasal sinuses (1) 41, 51, (23) 53
nasopharynx (32) 58 parapharyngeal space (36) 60
natal cleft (198) 209, (251) 268 pararectal fat (198) 209
navicular (231) 245, 270 paratracheal lymph nodes (68) 97
neonate paratracheal stripe (65) 95
abdomen (149) 169 parotid gland (36) 60–1
brain (14) 48, (15) 49 pars interarticularis (150) 169, 170
chest (70) 99 patella (219) 238, (252) 269
nerve roots see spinal nerve roots ossification (220) 238
neural arch of atlas (31) 58 pectineal line (183) 202
neural foramina (intervertebral foramina) 114, (150) 169 pectoralis major muscle (75) 102, (92) 114, (93) 115, 138
nipple (75) 102 pectoralis minor muscle (88) 111, (93) 115
non-coronary sinus (82) 107 pedicles, vertebrae (87) 110, (253) 269
nose (23) 53 cervical (30) 57
inferior concha (23) 53, (253) 269 lumbar (148) 168, 170
nucleus pulposus 113–14 thoracic (70) 99
peduncles, cerebellar (13) 48, (21) 52, (25) 54–5, (90) 112
oblique fissure (lung) (72) 100, (85) 109 pelvi-ureteric junction (161) 177, (185) 203
oblique muscles, eye (23) 53 pelvic diaphragm 208, 209
obturator artery (264) 275 pelvic floor (urogenital diaphragm) 204, (196) 208
obturator externus muscle (194) 207 pelvicalyceal system (161) 177
obturator foramen (183) 202, 236 pelvis
obturator internus muscle (195) 208, (199) 210, (264) 275 bony (183) 202, (212) 232, 233
obturator nerve (217) 236, (264) 275 child (213) 233
obturator vein (264) 275 female 202, (185) 203, (196) 208
occipito-frontal view, structures shown (2) 42 male 202, (251) 268, (264) 275
occipito-mental view, structures shown (3) 42 MRI (246) 266
odontoid process (dens) 55, (27 & 28) 56, (31) 58 penile urethra (188) 204
oesophageal hiatus 267 penis (184) 202, (194) 207
oesophagus (32) 58, (77) 103, (78) 104, (91) 113, (260) 273 perianal fistula 208
olecranon fossa, humerus (126) 141, (247) 266 pericardium 109
olecranon process, ulna (126) 141, 142 periodontal membranes (7) 44
orbit (23) 53 perirectal fascia (198) 209
magnetic resonance imaging (16) 49 perirectal fat (198) 209
occipito-mental view (3) 42 perirenal fat 177
oropharynx 58, (37) 61 peritoneum 174, 175
orthopantomograms (6) 44 Perkins line 233
ossification peroneal retinaculum (228) 243
ASIS and AIIS 232 peroneus brevis muscle 243
coracoid process of scapula (70) 99 peroneus longus muscle (225) 241, (227) 242, 243, (229)
femur (220) 238 244, 245
head 235 peroneus tertius muscle 243
forearm (127) 142 petrosal sinuses 47
hand (134) 145 petrous ridge (2) 42, (4) 43, 46
patella (220) 238 phalanges, fingers (134) 145
ostiomeatal complex (23) 53 phrenic nerve (66) 95, (80) 106, (86) 110
ovarian artery (201) 211 phrenicocolic ligament (157) 174
see also gonadal artery physes, fingers (134) 145

282
pia mater 49 rectum (153) 172, (186) 203, (199) 210, (246) 266

Index
pisiform (131) 144, (133) 145 rectus abdominis muscle (162) 178, (196) 208
pituitary fossa (35) 60 rectus femoris muscle (183) 202, (212) 232, 237
plantar aponeurosis (230) 244 rectus muscles, eye (23) 53
plantaris muscle 245 rectus sheath 178
pleura (67) 96, (85) 109 recurrent laryngeal nerve (80) 106, (90) 112
pleural reflections, mediastinum (69) 98 red nucleus (22) 52, 53
pneumatization, paranasal sinuses (1) 41 renal artery (161) 177
pons (13) 48, (25) 54–5, (35) 60 renal pelvis (152) 171, 177
pontine cistern (13) 48 renal sinus (165) 180
popliteal artery (221) 238, 239 renal veins (154) 172, (157) 174
popliteal trifurcation 239 rete testis (193) 206, 207
popliteus muscle (222) 239 retro-areolar ducts (74) 101, (75) 102
popliteus tendon (219) 238, (222) 239 retromandibular veins (36) 60, 61
porta hepatis 179 retroperitoneal space 177
portal triads 180 ribs 113
portal vein (149) 169, (159) 176, (163) 178, 179 cervical 55, (68) 97
porto-systemic anastomoses 176 first (29) 57, (65) 95
posterior communicating arteries (16) 49 right atrial appendage (83) 108
posterior descending coronary artery (76) 102, 103, (81) right colic artery 173
106, 107 right portal vein (159) 176
posterior fontanelle 43 roots of teeth (7) 44
posterior longitudinal ligament, cervical spine (1) 41 rostrum, corpus callosum (18) 50
posterior renal fascia (160) 176, 177 rotator cuff 137, (121) 139, (257) 271
posterior tibial artery (221) 238, 239, (225) 241 rugae 174
pouch of Douglas (197) 209
pregnancy, ultrasound (191) 206 sacralization, L5 vertebra (148) 169
presacral space (186) 203, (246) 266 sacroiliac joint (184) 202, (189) 205, (199) 210, (213) 233,
presacral vertebra (148) 168 (262) 274
prevertebral soft tissues (27) 56 sacrum (184) 202
profunda brachii (deep brachial artery) (122) 139, (123) ala (212) 232, (251) 268
140 canal (189) 205
profunda femoris artery (214) 234 foramina (199) 210
prostate (195) 208, 210, (200) 210, (264) 275 lumbo-sacral junction (148) 169, 170
prostatic urethra (188) 204, (200) 210 unfused joint (189) 205
psoas major muscle (147) 168, 169, (160) 176, (165) 180 sagittal suture (4) 42
pterion (5) 43 sail sign 99
pubic symphysis (184) 202, (213) 233 Santorini, duct of (166) 180, 181
pubic tubercle (186) 203 saphenous nerve 271
pulmonary arteries (64) 94, (69) 98, 105, (84) 108, (86) sartorius muscle 237, (251) 268, (256) 271
110 scalene muscles (39) 62
aberrant 103 scalenus anterior muscle 105, (90) 112–13, (92) 114
interlobar (80) 106 scapho-lunate joint (131) 144
segmental (67) 96 scaphoid (130) 143, (132) 144, (134) 145
pulmonary veins (69) 98, (79) 104, 105, (84) 108, (86) 110 scapula (29) 57, (66) 95, (70) 99
pulp cavities, teeth (7) 44 acromion process (116) 136, (121) 139
putamen (19) 51 coracoid process (70) 99, (117) 137, (120) 138
pyloric antrum, stomach (151) 170, 174 spine (38) 61, (71) 99, (117) 137, (121) 139
pyramids, renal (165) 180 sciatic nerve (217) 236
segmental pulmonary arteries (67) 96
quadrangular space 139 segments
quadriceps femoris muscle 237 bronchopulmonary 104–5, 109
kidney 177
radial artery (128) 142, (129) 143 liver (155) 173
radial collateral ligament (247) 266–7 semicircular canals (24) 54
radial head (127) 142 semimembranosus muscle 237
radial nerve (123) 140, (129) 143, (257) 271 seminal vesicle (198) 209, (200) 210, (264) 275
radial tuberosity (125) 141 semitendinosus muscle 237
radial vein (124) 140, (129) 143 septa (cardiac)
radiculomedullary arteries 182 interatrial (82) 107
radius, styloid process (130) 143 interventricular (89) 112
recto-uterine pouch (197) 209 septum pellucidum (18) 50, (250) 268

283
 serratus anterior muscle (79) 104, 275 pyloric antrum (151) 170, 174
Index

sesamoid bones straight sinus (11) 46–7

of thumb (130) 143, 144 strap muscles 59, (260) 273
plantar (230) 244 stripes, pleural reflections 98
Shenton’s line (212) 232 stylohyoid ligaments 57
short saphenous vein 241 styloid process
shoulder radius (130) 143
MRI (120) 138 ulna (131) 144, (259) 272
trans-scapular view (117) 137 sub-carinal lymph nodes (68) 97
sigmoid colon (153) 172 sub-phrenic space (258) 272
sigmoid sinus 47 subacromial space (121) 139
silhouette sign 94 subarachnoid cisterns
sino-atrial node artery (76) 102, 107 ambient cistern (12) 47
sino-tubular junction (83) 108 pontine cistern (13) 48
sinus venosus 267 subarachnoid spaces, neonates (15) 49
sinuses of Valsalva 108 subclavian artery (39) 62, (72) 100, (79) 104, 105, 107
skull (1) 41 aberrant 103, (88) 111
base (8) 45 subclavian vein (39) 62
lines (35) 60 subdural haemorrhage 49
child (5) 43 subfertility 204
Towne’s view (4) 43 subsartorial canal (256) 271
small-bowel follow-through (151) 170–1 subscapularis muscle (88) 111, (118) 137, (120) 138, (257)
soft palate (18) 50, 51 271
soft tissues subscapularis tendon (93) 115
plain radiographs (184) 202, (251) 268 substantia nigra (22) 52, 53
prevertebral (27) 56 subtalar joint (226) 242, (229) 244
soleal line 269 superficial cerebral veins (15) 49
soleus muscle 245, (252) 269 superficial circumflex iliac artery (214) 234
spermatic cord (194) 207, (217) 236 superficial femoral artery (214) 234, 271
sphenoid bone, lesser wing (10) 46 superficial palmar arch (128) 142, (259) 272
sphenoid sinus (1) 41, (18) 50 superior colliculi 49, (20) 51, (22) 52, (20 & 21) 52
sphincter of Oddi 181 superior medullary velum (35) 60
sphincters superior mesenteric artery 171, (154) 172, (155) 173,
anus (194) 207 272
urethra (196) 208 superior mesenteric vein (155) 173
spinal accessory nerve (90) 112 superior oblique muscle (eye) (23) 53
spinal cord (167) 181–2 superior orbital fissure (2) 42
upper cervical (37) 61 superior petrosal sinus 47
spinal nerve roots superior rectal artery (186) 203
brachial plexus 114 superior sagittal sinus (11) 46–7, (15) 49
cervical (39) 62, (260) 273, (263) 274 superior vena cava (64) 94
ganglia (91) 113 double (249) 267
lumbar (262) 274 suprarenal gland (adrenal gland) (156) 174, (164) 179
sacral (199) 210, (246) 266, 274 suprarenal vein 179
spinous processes, vertebrae (66) 95 supraspinatus muscle (38) 61, (121) 139, (257) 271
C4 (26) 55 supraspinous ligament (1) 41
C7 (27) 56 surgical neck, humerus (116) 136
spleen (254) 270 suspensory ligament of ovary (192) 206
splenic artery (152) 171 suspensory ligaments of Cooper (74) 101
splenic vein (159) 176 sutures, skull 43
splenium, corpus callosum (18) 50 see also named sutures
splenius muscle (38) 61 swallowing 61
splenorenal ligament (158) 175 swimmer’s view (29) 57
stations, mediastinal lymph nodes 97 sylvian fissure (13 & 14) 48, (17) 50
sternocleidomastoid muscle (34) 59, (37 & 38) 61, (39) 62, symphysis pubis (184) 202, (213) 233
(92) 114, (260) 273 synovial fluid, gleno-humeral joint (119) 138
sternocostal joints (73) 100, 101
sternohyoid muscle 59, (260) 273 taeniae coli (148) 168
sternothyroid muscle 59, (260) 273 talocalcaneal joint (226) 242
sternum (73) 100, 101, (92) 114 talocalcaneal ligament (229) 244
stomach (147) 168, 174 talofibular joint (229) 244
fundus (71) 99, (78) 104, 174 talotibial joint (228) 243

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talus (226) 242 basal foramina and (8) 45

Index
tarsal bones (231) 245, (255) 270 trigone parietale 96
teeth (7) 44, (28) 56 triquetral (134) 145
orthopantomogram (6) 44 triradiate cartilage, acetabulum (213) 233
temporal horns, lateral ventricles (16) 49 trochlea (127) 142
temporal lobe see anterior temporal lobe true pelvic floor (urogenital diaphragm) 204, (196)
temporalis muscle (36) 60 208
temporomandibular joint (254) 269 tubercle of intercondylar eminence (219) 238
tennis elbow 141 tunica vaginalis (193) 207
tensor fascia lata muscle (218) 237, (251) 268 turbinates, inferior nasal (23) 53, (253) 269
tentorium cerebelli (21) 52
teres major muscle (121) 139, (257) 271, (265) 275 ulna (126) 141, (129) 143, (132) 144
teres minor muscle (121) 139, (257) 271 coronoid process (126) 141, (247) 266
testicular artery (201) 211 styloid process (131) 144, (259) 272
see also gonadal artery ulnar artery (128) 142, (133) 145
testicular vein (258) 272 ulnar collateral ligament (247) 266–7
testis (193) 206–7 ulnar nerve (133) 145, (257) 271
thalamus (19) 51 ulnar vein (124) 140, (133) 145
massa intermedia (20) 51 ultrasound
thenar eminence 145, (135) 146 common femoral vein 235
third ventricle (12) 47 female reproductive tract (190) 205, (191) 206
thoracic duct (77) 103 ovary (192) 206
thoracic spine (29) 57, (87) 110–11, (91) 113, (156) 174 portal veins 179
three column principle, lumbar spine 170 testis (193) 206–7
thumb, sesamoid bones (130) 143, 144 umbilical artery (149) 169
thymus 95, (70) 99 umbilical vein (149) 169, (159) 176
thyrohyoid membrane 55 uncinate process, pancreas 179
thyroid cartilage (26) 55, (33) 59 ureter 177, 203
thyroid gland (34) 59 urethra (188) 204, (195 & 196) 208
blood supply 270 prostatic (188) 204, (200) 210
tibia (219) 238 urogenital diaphragm 204, (196) 208
condyles (252) 269 uterus (190) 205
malleoli (255) 270 MRI (197) 209
paediatric (220) 238 uvula (263) 274
tuberosity (222) 239
tibial nerve 236 vagina (187) 204, (190) 205, (196) 208
tibialis anterior muscle (228) 243, (231) 245 fornices 209, (246) 266
tibialis posterior muscle (225) 241, (227) 242–3, 245 vagus nerve (78) 104, (86) 110
tibiofemoral space 238 valves (cardiac) (69) 98, (254) 270, (261) 273
Tom, Dick and Harry (mnemonic) 243 aortic (69) 98, (83) 108, (254) 270
Tom, Harry and Dick (mnemonic) 243 mitral (69) 98, (89) 112, (261) 273
Towne’s view, skull (4) 43 tricuspid (89) 112
trachea (66) 95, (72) 100, (249) 267 valves, venous (124) 140
tracheal rings (33) 59, (34) 59 valvulae conniventes 171
tracheobronchial lymph nodes (68) 97 vas deferens (193) 207
trans-scapular view, shoulder (117) 137 vastus lateralis muscle (218) 237
transverse colon (153) 172, (159) 176 vastus medialis muscle (256) 271
transverse fissure (85) 109 veins 235, 267
transverse ligament, atlas (31) 58 valves (124) 140
transverse processes venous pumps 269
cervical vertebrae (30) 57 venous sinuses, skull (11) 46–7
lumbar vertebrae (148) 168 see also transverse venous sinus
transverse venous sinus (4) 42 ventral duct of Wirsung 181
transversus abdominis muscle (162) 178 ventral spinal nerve roots 273
trapezium (132) 144, (133) 145 ventricles (brain)
trapezius muscle (38) 61, 113, (93) 115, (257) 271 lateral ventricles, temporal horns (16) 49
trapezoid (bone) (131) 144, (133) 145 third ventricle (12) 47
trapezoid component, coracoclavicular ligament (116) see also fourth ventricle
136 ventricles (heart) (64) 94
triangular cartilage 143–4, (131) 144 moderator band (89) 112
tricuspid valve (89) 112 vermis (21) 52
trigeminal nerve (25) 54–5 vertebra prominens (27) 56

285
 vertebrae wisdom teeth (7) 44
Index

cervical (26) 55, (30) 57 Wrisberg’s ligament (223) 240

laminae (87) 110, 170, (260) 273 wrist (130) 143–4
lumbar (150) 169–70 adolescents (259) 272
presacral (148) 168
thoracic (87) 110–11, (91) 113, (156) 174 xiphisternal joint 101
see also pedicles; spinous processes
vertebral artery (30) 57, (37) 61, (40) 62 Y-Y line (213) 233
vesico-ureteric junction (185) 203
vestibular nerve (24) 54 zygoapophyseal joints (27) 56, (91) 113, (150) 169
vocal cords 55, 59 zygoma, frontal process (8) 45
zygomatic arch (3) 42
Wirsung, duct of 181

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