Unit review

Bring the unit together

Start with the case synthesis, answered in 4 separate parts, then work through mixed case-based questions. Every answer explains the clue that matters and why the closest alternative fails.

Case synthesis

Bringing it together: a blow to the temple

A 19-year-old cricketer, batting without a helmet, is struck on the left temple by the ball. He is dazed for a moment, then talks normally and walks off the field. Forty minutes later he has a severe headache, vomits and becomes drowsy. CT shows a fracture of the side wall of the skull about two finger-widths above the zygomatic arch, and a collection of blood inside the skull beneath it.

  1. 1. The bones

    The fracture is at the pterion. Which bones meet there?

  2. 2. The vessel

    Which vessel lies just deep to the bone at this point?

  3. 3. The opening

    Through which opening had that vessel entered the cranial cavity?

  4. 4. The collection

    Where does the blood collect, and why did he seem well at first?

Answer all 4 parts to see how they connect.Netter p.11–12Netter p.19–20OpenStax · Sutures of the skull; Middle cranial fossa

Mixed case review

Morphology, mechanism and application. Some items need two sections at once.

0 of 16 correct
  1. Q1Bone and side in the anterior viewConnects 1 + 2 + 6OpenStax · Zygomatic bone

    A photograph of a dry skull is taken from directly in front. A healed fracture line crosses the prominence of the cheek on the left-hand side of the photograph.

    Which bone was fractured?

  2. Q2The 14 facial bonesConnects 2 + 3OpenStax · Facial bones of the skullNetter p.13–14

    Revising the facial skeleton, a student writes: two maxillae, two zygomatic bones, two nasal bones, two lacrimal bones, two palatine bones, two inferior nasal conchae and the mandible. The total comes to 13.

    Which facial bone is missing from the list?

  3. Q3Sagittal suture, bregma and lambdaConnects 1 + 3OpenStax · Sutures of the skullNetter p.11–12

    After a fall, a CT reconstruction of the vault seen from above shows a fracture that has opened up a suture. The widened suture runs along the midline, between the two parietal bones.

    Which suture is it, and where does it begin and end?

  4. Q4Anterior cranial fossa, cribriform plate and olfactory bulbConnects 4 + 5OpenStax · Anterior cranial fossa; Ethmoid boneNetter p.19–20

    A small tumor rests on the cribriform plate of the ethmoid, beside the crista galli. To reach it from above, the surgeon lifts the part of the brain that lies on this part of the floor of the skull.

    Which fossa is this, which lobe is lifted, and what lies directly on the plate?

  5. Q5Orbital floor, maxillary sinus and infraorbital foramenConnects 3 + 4 + 5OpenStax · The orbit; Maxillary bone; Paranasal sinusesNetter p.9–10

    A squash ball strikes a player in the eye. The rim of the orbit is intact, but CT shows orbital fat bulging into the air space below the orbit. The skin of the cheek and upper lip on that side is numb.

    Which wall of the orbit has given way, and where does the affected nerve reach the face?

  6. Q6Foramen ovale, V3 and the side in the internal base viewConnects 1 + 5 + 6Netter p.19–20OpenStax · Middle cranial fossa

    On a specimen of the internal cranial base, held with the face toward the top, a tumor has enlarged the largest of the three openings in the greater wing of the sphenoid on the left-hand side. The patient has numbness of the lower lip and chin and weak chewing on one side.

    Which structure is compressed, and on which side of the patient?

  7. Q7Internal acoustic meatus: CN VII with CN VIIIConnects 4 + 5Netter p.19–20OpenStax · Posterior cranial fossa

    A 48-year-old woman has had slowly worsening hearing loss and ringing in the right ear, with unsteadiness. Now the right side of her face is weak. MRI shows a mass widening an opening on the back slope of the petrous part of the right temporal bone.

    Which opening is it, and which nerves does it carry?

  8. Q8Jugular foramen: CN IX, X and XIConnects 4 + 5Netter p.19–20Netter p.133–134

    A patient has a hoarse voice, difficulty swallowing and a weak shrug of the left shoulder. The tongue moves normally and hearing is normal. Imaging shows a single small tumor at the base of the skull on the left.

    At which opening does the tumor most likely lie?

  9. Q9Stylomastoid foramen: where the facial nerve leavesConnects 3 + 5 + 6OpenStax · Temporal boneNetter p.19–20

    A deep cut just below the ear, between the back edge of the ramus of the mandible and the mastoid process, leaves the whole of one side of the face paralyzed. Hearing and balance are normal.

    Through which opening had the injured nerve just left the skull, and between which landmarks does that opening lie?

  10. Q10Sella turcica, hypophyseal fossa and sphenoidal sinusConnects 3 + 4Netter p.15–16OpenStax · Sphenoid bone; Paranasal sinuses

    A surgeon removes a pituitary tumor through the nose. The instruments pass backward through the nasal cavity and open one air sinus. The roof of that sinus is the floor of the hollow in which the gland sits.

    Which sinus is opened, and what is the hollow called?

  11. Q11Condylar process and the temporomandibular jointConnects 3 + 6Netter p.21–22, 25–26OpenStax · Mandible

    After a punch to the chin a patient has pain in front of the right ear and cannot open the mouth fully. A radiograph shows a fracture through the narrow neck below the rounded head of the mandible.

    Which process is broken, and with what does its head articulate?

  12. Q12Inferior alveolar nerve: mandibular foramen to mental foramenConnects 3 + 5Netter p.21–24OpenStax · Mandible

    Before filling a lower molar a dentist injects local anesthetic beside the opening on the inner surface of the ramus of the mandible. Within minutes the lower teeth on that side are numb, and so is the skin of the lower lip and chin.

    What explains the numb lip and chin?

  13. Q13Internal carotid artery, carotid canal and foramen lacerumConnects 4 + 5Netter p.133–134Netter p.19–20OpenStax · Carotid canal; Foramen lacerum

    A fracture of the cranial base runs along the petrous part of the right temporal bone to its tip. The team is concerned about the large artery that travels inside this part of the bone on its way to the brain.

    Which description of that artery's route is correct?

  14. Q14Choosing a view: the midsagittal sectionConnects 1 + 4 + 6Netter p.13–14BodyParts3D

    You want one picture that shows the bony nasal septum, the sella turcica with the sinus beneath it, and the slope of bone running down to the foramen magnum.

    Which preset do you open, and how is it oriented on this specimen?

  15. Q15Superior orbital fissure versus optic canalConnects 4 + 5Netter p.19–20OpenStax · Middle cranial fossa

    After a fall onto the outer part of the brow, a patient's right upper eyelid droops, the right eye barely moves in any direction, and the skin of the right forehead is numb. Vision in the right eye is normal.

    A fracture through which opening best explains these findings?

  16. Q16Hard palate: maxillae in front, palatine bones behindConnects 3 + 4OpenStax · Maxillary bone; Palatine boneNetter p.17–18

    During the repair of a cleft palate the surgeon lifts the lining of the mouth from the back quarter of the bony palate, on each side of the midline.

    Which pieces of bone are exposed?

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Timed practice