Below is a stretch-and-challenge MCQ of clinically applied thoracic anatomy addressing learning outcomes of both the Anatomical Society of Great Britain and Northern Ireland’s “Anatomical Society core regional anatomy syllabus for undergraduate medicine” and the MRCS Part A Basic Science syllabus.  Best of luck!

Reference: Smith, C et al. (2015). The Anatomical Society core regional anatomy syllabus for undergraduate medicine.  Journal of Anatomy. Available here when last accessed 7th Oct 2019.

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Thorax Anatomy - Part Two

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Question 1
Which of the following definitions best match the unique anatomic classification of ribs 1-7?
A
Directly articulate with the costal margin
B
Directly articulate their heads with the manubrium sternii
C
Are embedded into the substance of the quadratus lumborum
D
Are embedded into the substance of the quadratus lumborum
E
Articulate with the sternum directly through costal cartilage
Question 2
Which of the following structures does rib four not articulate with directly?
A
T3
B
T4
C
T5
D
Sternum
E
Costal cartilage
Question 3
A costal tubercle articulates with
A
A vertebral spinous process
B
The costal groove
C
A vertebral transverse process
D
The neck of the rib
E
The adjacent rib tubercle
Question 4
The costal groove does not contain
A
Anterior intercostal artery of T7
B
Posterior intercostal vein of T7
C
Anterior rams of T7
D
Posterior intercostal artery of T7
E
Dorsal ramus of T7
Question 5

Stem 1 of 4

Read the following vignette:
Following a fall onto outstretched upper limbs, a 67YOF presents with intermittent sharp pain in her unilateral left brachium and discolouration of her hand.

Which structure was most likely fractured to result in the presentation?
A
Sternal body
B
Manubrium
C
C7 vertebra
D
Rib 1
E
Clavicle
Question 5 Explanation: 
A fracture of rib 1, a border of the thoracic outlet, is commonly responsible for thoracic outlet syndrome. The symptoms listed above are some of the more common presentations, and in elder women the incidence is more likely.
Question 6

Stem 2 of 4

Which of the following best match the definition of the rib articulating with C7 and T1?
A
The least curved costal body
B
No tubercles present
C
The attachment point of the scalene anterior
D
One articular facet on the head
E
Three articular facets on the head
Question 6 Explanation: 
This is describing the "atypical" first rib.
Question 7

Stem 3 of 4

Which of the following structures are not at immediate risk in the patient with the previously defined falls fracture?
A
Sympathetic chain
B
T1 anterior ramus
C
Superior intercostal artery
D
Lung apex
E
Recurrent laryngeal nerve
Question 7 Explanation: 
The neck of rib one is crossed by the sympathetic chain, superior intercostal artery and T1 as it joins the brachial plexus.
Question 8

Stem 4 of 4

The patient was acutely breathless after the fall.  On examination, reduced lung sounds were heard in the apex of the unilateral lung field.  Which of the following best explains this presentation?
A
A rib fragment rupturing the posterior intercostal artery arcade
B
A lesion to the sympathetic chain at T1
C
Chronic anxiety
D
A haemopneumothorax
E
Air entry into the potential pleural space
Question 8 Explanation: 
At the apex of the lung, with reduced breath sounds, this is likely to be a pneumothorax. Although a haemothorax is also a potential, there were no further signs indicating bleeding or vessel rupture and no mention was made to the inferior portion of the lung field to confirm.
Question 9
A cyclist is thrown from his bike and lands bluntly on his right side, back face down. He sustains multiple lower rib fractures on the unilateral side of fall. Which of the following structures may a general surgeon immediately clamp to arrest bleeding of the ruptured organ in theatre?
A
Inferior vena cava
B
Oesophageal venous plexus
C
Vertebral venous plexus
D
Gastroduodenal ligament
E
Gastroepiploic foramen
Question 9 Explanation: 
See the Pringle manoeuvre for more information on surgically arresting bleeding to the liver.
Question 10
Which rib fractures are not likely to cause splenic rupture? Choose two answers ...
A
8th
B
9th
C
10th
D
11th
E
12th
Question 10 Explanation: 
The surface anatomy of the spleen classically is stated as anterior to the posterior surfaces of the 9-11th ribs, left side.
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