Sixth edition
APPLETON & LANGE REVIEW OF
ANATOMY .
Royce Lee Montgomery, PhD Professor Department of Cell and Developmental Biology School of Medicine University of North Carolina Chapel Hill, North Carolina
Kurt Ogden Gilliland, PhD Department of Cell and Developmental Biology School of Medicine University of North Carolina Chapel Hill, North Carolina
Appleton & Lange Reviews/McGraw-Hill Medical Publishing Division New York Chicago San Francisco Lisbon London Madrid Mexico City Milan New Delhi San Juan Seoul Singapore Sydney Toronto
Appleton & Lange Review of Anatomy, Sixth Edition Copyright © 2003 by The McGraw-Hill Companies, Inc. All rights reserved. Printed in the United States of America. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a data base or retrieval system, without the prior written permission of the publisher. Previous editions copyright © 1995, 1989, by Appleton & Lange; copyright © 1982, 1978, 1974, by Arco Publishing, Inc. 1 2 3 4 5 6 7 8 9 0 VNH VNH 0 9 8 7 6 5 4 3 2 ISBN: 0-07-137727-1
Notice Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work. Readers are encouraged to confirm the information contained herein with other sources. For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recommendation is of particular importance in connection with new or infrequently used drugs.
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This book was set in Palatino by Circle Graphics. The editors were Catherine W. Johnson and Lester A. Sheinis. The production supervisor was Lisa Mendez. The cover designer was Aimée Nordin. The indexer was Alexandra Nickerson. Von Hoffmann Graphics, Inc., was printer and binder. This book was printed on acid-free paper. Library of Congress Cataloging-in-Publication Data Montgomery, Royce L. Appleton & Lange review of anatomy / Royce L. Montgomery, Kurt Ogden Gilliland.—6th ed. p. ; cm. Rev. ed. of: Appleton & Lange review of anatomy for the USMLE Step 1 / Royce L. Montgomery, Gerald A. Montgomery. © 1995. Includes bibliographical references. ISBN 0-07-137727-1 (alk. paper) 1. Human anatomy—Examinations, questions, etc. 2. Physicians—Licenses—United States—Examinations—Study guides. I. Title: Appleton & Lange review of anatomy. II. Title: Review of anatomy. III. Gilliland, Kurt Ogden. IV. Montgomery, Royce L. Appleton & Lange review of anatomy for the USMLE Step 1. V. Title. [DNLM: 1. Anatomy—Examination Questions. QS 18.2 M788a 2003] QM32 .M65 2002 611′.0076—dc21 2002016672 International Edition ISBN 0-07-121248-5 Copyright © 2003. Exclusive rights by The McGraw-Hill Companies, Inc., for manufacture and export. This book cannot be reexported from the country to which it is consigned by McGraw-Hill. The International Edition is not available in North America.
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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1. The Back . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Answers and Explanations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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2. The Upper Limb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Answers and Explanations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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3. The Thorax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Answers and Explanations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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4. The Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Answers and Explanations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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5. The Pelvis and Perineum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Answers and Explanations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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6. The Lower Limb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Answers and Explanations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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7. The Head and Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Answers and Explanations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Introduction
If you are planning to prepare for the United States Medical Licensing Examination (USMLE) Step 1, then this book is designed for you. Here, in one package, is a comprehensive review resource with over 600 examination type anatomy multiple-choice questions with referenced explanations of each answer. This introduction provides specific information on the USMLE Step 1, information on question types, question-answering strategies, and various ways to use this review.
THE UNITED STATES MEDICAL LICENSING EXAMINATION STEP 1
Each of the chapters contains single-best answer multiple choice questions. In some cases, a group of two or three questions may be related to a situational theme. In addition, some questions have illustrative material (e.g., line illustrations of anatomy) that require understanding and interpretation on your part. Moreover, questions may be of three levels of difficulty: rote memory, memory question that requires more understanding of the problem, and a question that requires both understanding and judgment. In view of the fact that the USMLE Step 1 is moving toward the judgment, critical-thinking type question, we have attempted to write this review with this emphasis.
The United States Medical Licensing Examination Step 1 is a one-day computerized examination consisting of approximately 400 questions to test your knowledge in the basic sciences. It contains multiplechoice questions organized within three dimensions. Each dimension is weighted; however, the projected percentages for these dimensions are subject to change from exam to exam. The three dimensions are: (1) System, (2) Process, and (3) Organizational Level. The application materials illustrate the percentage breakout and offer you a detailed content outline to aid you in your review.
One Best-Answer-Single Item Question. The majority of the questions are posed in the A type, or “one best answer single item” format. This is the most popular question format in most exams. It generally contains a brief statement, followed by five options of which only ONE is entirely correct. The options on the USMLE are lettered A, B, C, D, and E. Although the format for this question type is straightforward, the questions can be difficult because some of the distractors may be partially right. The instructions you will see for this type of question will generally appear as below:
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Question Formats
The style and presentation of the questions have been fully revised to conform with the United States Medical Licensing Examinations. This will enable you to familiarize yourself with the types of questions to be expected and provide practice in recalling your knowledge in each format. Following the answer to each question, a reference to a particular and easily available text is provided for further reference and reading.
DIRECTIONS (Question 1): Each of the numbered items or incomplete statements in this section is followed by answers or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each case. An example of this question type is: 1. An obese 21-year-old woman complains of increased growth of coarse hair on her lip, chin,
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Introduction
chest, and abdomen. She also notes menstrual irregularity with periods of amenorrhea. The most likely cause is (A) (B) (C) (D) (E)
polycystic ovary disease an ovarian tumor an adrenal tumor Cushing’s disease familial hirsutism
In the question above, the key word is “most.” Although ovarian tumors, adrenal tumors, and Cushing’s disease are causes of hirsutism (described in the stem of the question), polycystic ovary disease is a much more common cause. Familial hirsutism is not associated with the menstrual irregularities mentioned. Thus, the most likely cause of the manifestations described can only be “(A) polycystic ovary disease.”
. STRATEGIES FOR ANSWERING ONE BEST ANSWER-SINGLE ITEM QUESTIONS 1. Remember that only one choice can be the correct answer. 2. Read the question carefully to be sure that you understand what is being asked. Pay attention to key words like “most.” 3. Quickly read each choice for familiarity. (This important step is often not done by test takers.) 4. Go back and consider each choice individually. 5. If a choice is partially correct, tentatively consider it to be incorrect. (This step will help you eliminate choices and increase your odds of choosing the correct answer.) 6. Consider the remaining choices and select the one you think is the answer. At this point, you may want to quickly scan the stem to be sure you understand the question and your answer. 7. If you do not know the answer, make an educated guess. Your score is based on the number of correct answers, not the number you get incorrect. Do not leave any questions unanswered. 8. The actual examination is timed for an average of 60 seconds per question. It is important to be thorough to understand the question, but it is equally important for you to keep moving.
Answers, Explanations, and References
In each of the sections of this book, the question sections are followed by a section containing the answers, explanations, and references to the questions. This section (1) tells you the answer to each question; (2) gives you an explanation/review of why the answer is correct and background information on the subject matter; and (3) tells you where you can find more indepth information on the subject matter in other books and/or journals. We encourage you to use this section as a basis for further study and understanding. If you choose the correct answer to a question, you can then read the explanation (1) for reinforcement and (2) to add to your knowledge about the subject matter (remember that the explanations usually tell not only why the answer is correct, but also why the other choices are incorrect). If you choose the wrong answer to a question, you can read the explanation for a learning/reviewing discussion of the material in the question. Furthermore, you can note the reference cited (e.g., “Joklik et al, pp 103–114”), look up the full source in the bibliography at the end of the section (e.g., “Joklik WK, Willett HP, Amos DB. Zinsser’s Microbiology. 20th ed. Norwalk, Conn: Appleton & Lange; 1992”), and refer to the pages cited for a more in-depth discussion.
SPECIFIC INFORMATION ON THE STEP 1 EXAMINATION
The official source of all information with respect to the United States Medical Licensing Examination Step 1 is the National Board of Medical Examiners (NBME), 3930 Chestnut Street, Philadelphia, PA 19104. Established in 1915, the NBME is a voluntary, nonprofit, independent organization whose sole function is the design, implementation, distribution, and processing of a vast bank of question items, certifying examinations, and evaluative services in the professional medical field. Please contact the NBME or visit the USMLE web site (www.usmle.org) for information on exam registration and scoring.
CHAPTER 1
The Back Questions
DIRECTIONS (Questions 1 through 40): Each of the numbered items or incomplete statements in this section is followed by answers or by completions of the statements. Select the ONE lettered answer or completion that is BEST in each case. 1. The vertebral column does all of the following EXCEPT (A) (B) (C) (D)
protect the spinal cord and spinal nerves support the weight of the body provide a pivot for the head play an important role in posture and locomotion (E) form the main part of the appendicular skeleton
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2. Which of the following is NOT a distinctive characteristic of a typical cervical vertebra? (A) The body is small and wider from side to side than anteroposteriorly. (B) The vertebral foramen is large and triangular. (C) The transverse processes contain transverse foramina. (D) The articular processes contain superior facets directed inferoanteriorly. (E) The spinous processes are short and bifid. 3. Which of the following is NOT a distinctive characteristic of a typical thoracic vertebra? (A) The body is heart-shaped. (B) The vertebral foramen is triangular and larger than in cervical and lumbar vertebrae.
(C) The transverse processes are long and strong and extend posterolaterally. (D) The articular processes contain superior facets directed posteriorly and slightly laterally. (E) The spinous processes are long and slope posteroinferiorly. 4. Which of the following is a distinctive characteristic of a typical lumbar vertebra? (A) The body is massive and kidney-shaped when viewed superiorly. (B) The vertebral foramen is circular and smaller than those of cervical and lumbar vertebrae. (C) The transverse processes are long and slender and contain mammillary processes. (D) The articular processes contain accessory processes. (E) The spinous processes are long and slope posteroinferiorly. 5. Which of the following is true regarding the intervertebral disc between the C1 and C2 vertebrae? (A) Its annulus fibrosus is composed of concentric lamellae of fibrocartilage. (B) It does not contain a nucleus pulposus as other intervertebral discs do. (C) It is thicker than other intervertebral discs. (D) It acts like a shock absorber in response to axial forces. (E) There is no intervertebral disc between the C1 and C2 vertebrae.
