First FRCR Anatomy Questions and Answers UsmanShaikh InterventionalRadiologyFellow,RoyalLiverpool UniversityHospital,Liverpool,UK JohnCurtis ConsultantRadiologist,UniversityHospitalAintree, Liverpool,UK RebeccaHanlon ConsultantRadiologist, UniversityHospitalAintree,Liverpool,UK DavidWhite ConsultantRadiologist, UniversityHospitalAintree,Liverpool,UK AndrewDunn ConsultantRadiologist, RoyalLiverpoolUniversityHospital,Liverpool,UK AndrewHealey ConsultantPaediatricInterventionalRadiologist, AlderHeyChildren’sHospital,Liverpool,UK JaneBelfield ConsultantRadiologist,RoyalLiverpoolUniversityHospital,Liverpool,UK ElizabethKneale RadiologyRegistrar, UniversityHospitalAintree,Liverpool,UK PeterDangerfield UniversityofLiverpool, Liverpool,UK HilaryFewins ConsultantRadiologist, LiverpoolHeartandChestHospital,Liverpool,UK Downloaded from Cambridge Books Online by IP 121.246.53.177 on Tue Apr 10 14:22:00 BST 2012. http://ebooks.cambridge.org/ebook.jsf?bid=CBO9781139087384 Cambridge Books Online © Cambridge University Press, 2012 CAMBRIDGE UNIVERSITY PRESS Cambridge,NewYork,Melbourne,Madrid,CapeTown, Singapore,SãoPaulo,Delhi,MexicoCity CambridgeUniversityPress TheEdinburghBuilding,CambridgeCB28RU,UK PublishedintheUnitedStatesofAmericaby CambridgeUniversityPress,NewYork www.cambridge.org Informationonthistitle:www.cambridge.org/9781107679498 #U.Shaikh,J.Curtis,R.Hanlon,D.White,A.Dunn,A.Healey,J.Belfield,E.Kneale, P.DangerfieldandH.Fewins2012 Thispublicationisincopyright.Subjecttostatutoryexception andtotheprovisionsofrelevantcollectivelicensingagreements, noreproductionofanypartmaytakeplacewithout thewrittenpermissionofCambridgeUniversityPress. Firstpublished2012 PrintedintheUnitedKingdomattheUniversityPress,Cambridge AcataloguerecordforthispublicationisavailablefromtheBritishLibrary LibraryofCongressCataloging-in-PublicationData FirstFRCRanatomy:questionsandanswers/JohnCurtis...[etal.]. p.;cm. Includesindex. ISBN978-1-107-67949-8(Paperback) I. Curtis,John,1963– [DNLM: 1. Anatomy–CaseReports. 2. Anatomy–ExaminationQuestions. 3. Radiology–CaseReports. 4. Radiology–ExaminationQuestions. QS18.2] 616.07057076–dc23 2011034134 ISBN978-1-107-67949-8Paperback CambridgeUniversityPresshasnoresponsibilityforthepersistenceor accuracyofURLsforexternalorthird-partyinternetwebsitesreferredto inthispublication,anddoesnotguaranteethatanycontentonsuch websitesis,orwillremain,accurateorappropriate. Everyefforthasbeenmadeinpreparingthisbooktoprovideaccurateandup-to-date informationwhichisinaccordwithacceptedstandardsandpracticeatthetimeof publication.Althoughcasehistoriesaredrawnfromactualcases,everyefforthasbeen madetodisguisetheidentitiesoftheindividualsinvolved.Nevertheless,theauthors, editorsandpublisherscanmakenowarrantiesthattheinformationcontainedhereinis totallyfreefromerror,notleastbecauseclinicalstandardsareconstantlychangingthrough researchandregulation.Theauthors,editorsandpublishersthereforedisclaimallliability fordirectorconsequentialdamagesresultingfromtheuseofmaterialcontainedinthis book.Readersarestronglyadvisedtopaycarefulattentiontoinformationprovidedbythe manufacturerofanydrugsorequipmentthattheyplantouse. Downloaded from Cambridge Books Online by IP 121.246.53.177 on Tue Apr 10 14:22:00 BST 2012. http://ebooks.cambridge.org/ebook.jsf?bid=CBO9781139087384 Cambridge Books Online © Cambridge University Press, 2012 Contents Foreword pagevii Preface ix Introduction 1 Examination 1: Questions 3 Examination 1: Answers 23 Examination 2: Questions 31 Examination 2: Answers 51 Examination 3: Questions 58 Examination 3: Answers 78 Examination 4: Questions 85 Examination 4: Answers 105 Examination 5: Questions 113 Examination 5: Answers 133 Examination 6: Questions 141 Examination 6: Answers 161 Examination 7: Questions 167 Examination 7: Answers 187 Examination 8: Questions 193 Examination 8: Answers 213 v Downloaded from Cambridge Books Online by IP 121.246.53.177 on Tue Apr 10 14:22:27 BST 2012. http://ebooks.cambridge.org/ebook.jsf?bid=CBO9781139087384 Cambridge Books Online © Cambridge University Press, 2012 Foreword Knowledge and understanding of human anatomy is a key element of medical training,whetheritisatanundergraduateoratapostgraduatelevel.Thisisparticu- larlysoininterpretingradiologicalimages.Agoodradiologistrequiresmanydiffer- ent skills and competences, but right up there at the top of the list is a detailed knowledgeofanatomyrelevanttoradiology.Overrecentyearsithasbecomeappar- entthattheknowledgeofanatomyacquiredatmedicalschoolandinspecialtiesprior to entry to radiology training is variable and the Royal College of Radiologists hasmadeitoneofitsprioritiestosetthestandardofradiologicalanatomicalknow- ledge that all radiologists should achieve. Theoretically, knowledge of anatomy should be possible to acquire as a radiology trainee passes through the modular training, but many involved in training have realized that this on its own is not sufficient.Acurriculumandanappropriateformofassessmentarerequiredtoensure consistency,andthereisgoodevidencethattheneedtopassanexamdriveslearning. The recently introduced anatomy curriculum and the First Part FRCR anatomy examinationareintendedtoachievethisend. Radiologicalimages,particularlycross-sectionalimages,arealsoanexcellentway of teaching anatomy to medical students, and more and more medical schools are taking advantage of this facility, as are specialties where anatomy is essential for practicewithinthatparticularareaofmedicine.Theexcitingdevelopmentsinmolecu- lar and functional imaging mean that it is now even more important to be able to localize a particular function to a particular anatomical structure, and this is only possiblewithanexcellentunderstandingandknowledgeofanatomy. A key element of a modern curriculum is that students should undertake regular formativeassessmenttoallowthemtoevaluatetheirownprogressandidentifytheir trainingneedsandthatpartofthisshouldbeself-assessment.Thereareanumberof resourcesavailabletoachievethisandamongstthemarebooksproducedspecifically forthispurpose,web-basedmaterialandtheradiology–integratedtraininginitiative (R-ITI)e-learningdatabase(e-LD). DrDavidRMLindsellFRCR vii Downloaded from Cambridge Books Online by IP 121.246.53.177 on Tue Apr 10 14:22:39 BST 2012. http://dx.doi.org/10.1017/CBO9781139087384.001 Cambridge Books Online © Cambridge University Press, 2012 Preface The reintroduction of an anatomy section heralded a welcome return to the part 1 FRCR examination. Anatomy is the main cornerstone on which radiology rests and without a good grounding, being an effective radiologist is impossible. Clinicians oftencalluponradiologiststoguidethemwithanatomyinadditiontosteeringthem towardsbetterdiagnosisandmanagementoftheirpatients. Our aim with this book was much more than a simple pre-examination self- assessment text. From its inception, we wanted to write a text that would prove equally as useful after the part 1 FRCR examination and therefore endeavoured to include radiological ‘pearls’ that would serve the radiologist well throughout his or her career. Similarly a non-radiologist reading the text would derive significant benefitin theirparticular field. The authors havechosen theseclinical ‘pearls’,from withintheir own susbspecialties, rather than purelydidacticinformation thatmight beobtainedinotherstandardtextbooks. The cases in this book very closely match the standard type of cases likely to be encounteredintheactualanatomysectionoftheexamination. Self-assessment gives immediate feedback to the reader which is often lacking in larger texts. Furthermore it gives a framework for further reading in the various subspecialties. We also believe that this text will be invaluable to medical students, foundationdoctorsandspecialisttraineesinsurgeryandmedicine. We would like to thank all of the contributing authors for their hard work in diligentlyputtingquestionstogetherandfortheirsharedwisdom. UsmanShaikh JohnCurtis June2011 ix Downloaded from Cambridge Books Online by IP 121.246.53.177 on Tue Apr 10 14:22:59 BST 2012. http://dx.doi.org/10.1017/CBO9781139087384.002 Cambridge Books Online © Cambridge University Press, 2012 Introduction Atthetimeofwriting,theanatomysectionofthepart1FRCRexaminationconsistsof 00 20digitalimages presented on acomputer witha19 monitor.Eachimagehasfive questionsattached,labelleda–e.Youwill have75minutes toanswer atotalof one- hundredquestions. TheimagespresentedareDICOMimages,whichhavebeenconvertedintoj-pegs or tiffs in order to allow annotated symbols to be applied. These images are then convertedbackintoDICOManduploadedontoanOsiriXdatabase.Itisabsolutely essentialtofamiliarizeyourselfwiththissoftwarepriortotheexamination.Itshould be noted that the OsiriX software is only available for Apple Macs and not on IBM PCs.Thereishoweveropportunitypriortothestartoftheexaminationtomanipulate sampleimages.Theanswersaretobewrittenintoabooklet. There is further information regarding the examination available on the Royal CollegeofRadiologistswebsitewww.rcr.ac.ukwhichshouldbepartofyouressential revision.Therearealsosamplequestionsandanswerstoaccess. Thebasicsaretrueforanyexaminationbutneedtobereiteratedhere. This is not an examination to be taken lightly. The anatomy learned at medical school may be far removed from radiological anatomy in the workplace. However, more and more medical schools are using radiological anatomy to educate their undergraduates.Anatomyhasbeen‘broughttolife’intheworkplacebyradiologists. AgoodwayoflearninganatomyistositatyourPACSworkstation.Ononescreen put up a patient's chest radiograph with a CT scan of the thorax on the adjacent screen.ScrollingthroughtheCTstudyallowseasierexplanationoftheproductionof interfacesseenonthechestradiograph.Thisappliesequallyaswellwiththeabdom- inal radiograph and CT of the abdomen and pelvis. The anatomy tested in the examination is not beyond the scope of most of the basic radiology atlases and thereforearegularconsistentapproachtorevisionisadvised. Theexaminationisnotnegativelymarkedandthereforetheremustbeananswerin everybox. An easy way to lose marks is not stating the side of the labelled structure, for instance,rightlateralventricle.Forthepurposesofthisbook,iftherecanonlybeone side(e.g.imageofarightknee)thenforeaseofreadingthesidehasnotbeenincluded intheanswer. Eachpersonhasadifferentapproachtorevisionandifyoupreferonlinelearning then there are a number of websites providing radiological e-learning options. AlthoughanumberofthesewebsitesareAmerican,andthereforenotgearedtowards the part 1 FRCR examination, there is a degree of overlap and these sites are well worth a visit. The Radiology – Integrated Training Initiative (R-ITI) should not be overlookedasitcontainsusefulinformationandiswrittenbylike-mindedpeopleto whowouldsettheanatomyexamination.Otherwebsitesthatourtraineeshavefound usefulinclude: http://www.radiologyanatomy.com/index.php http://www.info-radiologie.ch/index-english.php http://www.meddean.luc.edu/lumen/MedEd/GrossAnatomy/x_sec/mainx_sec. htm http://radiologytutorials.com/ 1 Downloaded from Cambridge Books Online by IP 121.246.53.177 on Tue Apr 10 14:23:13 BST 2012. http://dx.doi.org/10.1017/CBO9781139087384.003 Cambridge Books Online © Cambridge University Press, 2012 n http://web.mac.com/rlivingston/Eycleshymer/Welcome.html o ti http://www.rad.washington.edu/academics/academic-sections/msk/teaching- uc materials/radiology-anatomy-teaching-modules/ d o r There are a number of anatomy courses now run as preparation prior to sitting the t n examination.Similartomocktestsinbookstheytutoryouinkeyanatomywithtipsto I avoid simple mistakes. Their one-day format provide focussed revision and they serveasausefuladjunct. 2 Downloaded from Cambridge Books Online by IP 121.246.53.177 on Tue Apr 10 14:23:13 BST 2012. http://dx.doi.org/10.1017/CBO9781139087384.003 Cambridge Books Online © Cambridge University Press, 2012 Examination 1: Questions Case 1.1 A B C D QUESTION WRITEYOURANSWERHERE (a) Namethestructure labelledA. (b) Namethestructure labelledB. (c) Namethestructure labelledC. (d) Namethestructure labelledD. (e) Whichnormal variantispresent onthisimage? 3 Downloaded from Cambridge Books Online by IP 121.246.53.177 on Tue Apr 10 14:49:24 BST 2012. http://dx.doi.org/10.1017/CBO9781139087384.004 Cambridge Books Online © Cambridge University Press, 2012