HyGuru USMLE Step 1

USMLE Musculoskeletal Review

100 Gross Anatomy Concepts
Rahul Damania, MD, FAAP
Thank You for Attending!
 Introduction | HyGuru
About Me:

PGY-5, Pediatric Critical Care

Co-Founder HyGuru

Passion for #MedEd – particularly USMLE Preparation

Rahul C. Damania, MD, FAAP

Disclaimer: this webinar is for educational purposes; not affiliated with USMLE, NBME, ECFMG
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active-recall fundamentals Content
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3. Questions?
Overview
Upper Extremity

Lower Extremity
Trunk & Upper Extremities
 • A neonate presents with fever. It is noted he is very
irritable. A sepsis workup is initiated. CSF needs to be
collected, what is the likely anatomical location for the
procedure?
• Between L3 and L5
• What meningeal layer?
• Subarachnoid space (dural sac ends at S2)
Lumbar Puncture • Anatomical landmarks:
• Supraspinous ligament
• Interspinous ligament
• Ligamentum flavum
• Meninges:
• Epidural space
• Dura Mater
• Arachnoid Mater
• Sub-arachnoid space
Lumbar Puncture
 • A 40 year old obese patient presents with back pain
that radiates down to the lower limb after lifting a box.
What reflexes may be diminished?
• Most likely region is the lumbar (L5 to S1)
• Reflexes review:
• S1-S2 à Achilles
• L3-L4 à Patellar
Herniated IV Disc • C5-C6 à Biceps
• C7 à Triceps
 • A 80 yo woman with acute onset of
back pain may have a compression
fracture causing what type of
abnormal curvature?
• Kyphosis
• Where is the most likely region of the vertebrae?
Spine Curvatures • Thoracic Spine

• A 9 month pregnant female or an

obese man may present with what
type of abnormal curvature?
• Lordosis
• Where is the most likely region of the vertebrae?
• Lumbar
 • After trauma (nerve damage)…
• A patient is unable to move his arms up to his
sides and has a flattened deltoid?
• Axillary nerve
• Location: surgical neck of the humerus
• Mechanism: anterior humerus dislocation
• A patient is unable to extend hand with resistance,
unable to grip appropriately?
Upper Limb & • Radial nerve
Fractures • Location: midshaft fracture of the humerus
• Other vignettes à crutches, drunk-arm over-chair
• Mechanism: compression of axilla, loss of sensation
on dorsal hand
• Has paresthesia and loss of sensation in the medial
portion of the hand?
• Ulnar nerve
• Location: fracture of medial epicondyle of humerus
• Think: ‘funny bone’
Nerve Anatomical Landmark Presentation Notes
Axillary (C5 and C6) Surgical neck of Abnormal Abduction, Relate to dislocation of
humerus and flattening of deltoid. humeral head.

Radial (C5 to T1) Midshaft of humerus Drunk or crutches boy Can present with
Lowest down in BP who now has wrist drop decreased grip strength
and loss of sensation to
posterior hand

Median (C6-C8, T1) Proximal: supracondylar Pope blessing when Thenar eminence
humerus fraction asked to flex fingers atrophy
Distal: (proximal lesion)
Carpal Tunnel Median claw when
asked to extend fingers
(distal lesion)
Ulnar (C8, T1) Proximal: medial FOSH Hypothenar eminence
epicondyle OK gesture when asked atrophy
Distal: hook of hamate to flex fingers (proximal
lesion)
Ulnar claw when asked
to extend fingers (distal
lesion)
 • A 45-year-old woman is found to have adenocarcinoma of
the left breast. Resection of the tumor is scheduled, and the
physician also plans to obtain samples of the draining
nodes. To find these nodes, a radiotracer is injected
adjacent to the tumor and images are obtained. The first
draining sentinel node in this patient is most likely found at
which of the following locations?
USMLE
a) Contralateral neck
Practice
b) Ipsilateral axilla
Question
c) Ipsilateral mediastinum

d) Ipsilateral supraclavicle

e) Medial contralateral breast

Lymphatic
Drainage of
Breast
 • Proximal lesion:
• Ask the patient to flex the fingers

Review
Median Nerve:
Pope blessing when
asked to flex fingers
Ulnar Nerve:
OK gesture when
asked to flex fingers
 • Distal lesion:
• Ask the patient to extend the fingers

Ulnar Nerve:
Ulnar claw

Review

Median Nerve:
Median claw aka ape
hand
 Smith Fracture Colles Fracture
• Get hit ventrally
• Get dorsally hit at at the wrist when
Distal Radius the wrist when it
Fractures it is extended
is flexed.
• Buzz word is
• Fragment gets dinner fork
displaced
anteriorly. • “Curved
forearm”
Dinner Fork
 • Distal radius fractures:
• Smith
‘Fall on the • Colles
outstretched
hand’ for the • Carpal fractures:
USMLE • Scaphoid:
• USMLE clues:
• Tenderness in the anatomic snuff box
• X-ray clear, however patient at risk for
avascular necrosis
• Hamate:
• USMLE clues:
• Ulnar nerve damage
• Forearm fractures:
• Radial head fracture
 • A 60-year-old man has tenderness in the region distally
between the tendons of the extensor pollicis longus and
extensor pollicis brevis (anatomical snuffbox) after falling
on the palm of his right hand. A fracture of which of the
following carpal bones is most likely in this patient?

• (A) Hamate

USMLE • (B) Lunate

Practice • (C) Scaphoid
Question • (D) Trapezium

• (E) Triquetrum
 • A child is on the playground and falls. He is holding his arm
in an inferolateral placement. What is the likely diagnosis?
• Clavicle Fracture

FOSH
 • A patient presents after trauma. He is
noted to have decreased resistance
with his arms outstretched, adducted
and thumbs pointed down. What is
the likely affected structure?
• Supraspinatus muscle
Rotator Cuff
• What is the likely innervation?
• Suprascapular nerve
• How many degrees of
abduction is the supraspinatus
muscle responsible for?
• 0 to 15 degrees.
 • 0 - 15 degrees
• Supraspina
tus
• 15 - 90 degrees
• Deltoid
Rotator cuff • 90 - 180 degrees
abduction • Trapezius
• Serratus
anterior
 • A painter has increased
pain when lifting his
arm above his head. He
has pain underneath
the acromion. MRI is
Subacromial
bursitis shown. What is the
likely diagnosis?
• Subacromial
bursitis
 • A 40 yo plumber reports left elbow
swelling for the past few months. The
Elbow swelling was worsened and became
Pathology more painful. He has redness near his
elbow. No fever. Elbow is tender to
palpation. What is the likely
diagnosis?
• Olecranon bursitis
 Lateral
• Tennis. Medial
• Common • Golf.
Elbow extensor • Common
tendon. flexor tendon
Pathology
• Pt plays • Medial
tennis and it epicondyle
hurts when • Hand-trick
he is opening
a door.
 • A child is in the park. He is playing and is noted to have
trauma after he was pulled up by the arm by his family
member to avoid oncoming traffic. What is the liley
diagnosis?
• Nursemaid’s elbow
• Annular ligament tear at the radial neck

Elbow
Pathology
 • A patient presents after getting cut by an
electrical saw. He is noted to have an injury
to the brachial artery at the cubital fossa.
What is the structure medial to the affected
brachial artery?

Cubital • Median nerve

Fossa • Contents of the cubital fossa:
• Lateral to medial:
• Biceps brachii tendon
• Brachial artery
• Median nerve
• Covered by the bicipital
aponeurosis
 • Secretary who feels numb in her fingers mostly at
night?
• What is the diagnosis?
• Carpal Tunnel
• What nerve is compressed?
• Median nerve
• Where is she going to have paresthesia?
Wrist • Lateral 3.5 digits.
Pathology • Remember: poor opposition, and could
be due to lunate dislocation
• Other vignettes:
• Hypothyroidism
• Pregnancy
 • A cyclist presents with numbness and tingling in the hand.
He is noted to be unable to grip a piece of paper between
his thumb and pinky. PE shows numbness in his medial 2
fingers. What is the likely affected structure?
• Ulnar nerve
• Compression of the ulnar nerve at the wrist
• Relate which bony structure?
• Hook of the hamate.
Wrist
Pathology
 Upper Lower
• Excessive
• Upper limb
angle between
Brachial neck &
pulled up
Plexus shoulder • TOS
• Birth injury • Claw/Ape
• Erb Duchenne • Horner
Syndrome
• C5-C6
 • What is the nerve plexus?
• C5-C6
• What are the muscles affected?
• Deltoid
• Infraspinatus
• Biceps brachii
Erb • How is the waiter’s tip described?
Duchenne • Adducted
• Medially rotation
Palsy • Extended and Pronated
 • What is the nerve plexus?
• C8-T1
• What are the muscles affected?
• Lumbricals
• Interosseus
• Thenar
• How is the lesion described?
Klumpke’s • Ape hand
Paralysis • Claw hand
• Horner’s syndrome
 • A 25 yo F presents with L arm pain. She says that after she
cooks, she has decreased mobility of her L arm, and her
extremity is pale and cool to the touch. She has been a non-
smoker and has a normal lipid profile. What is the likely
diagnosis?
• Thoracic outlet syndrome
Lower
Brachial
Plexus
Lesion
 • A patient is unable to abduct the arm above the horizontal.
When pressing on the wall, a protrusion from the posterior
mid back is noted. Which muscle is likely implicated?
• Long thoracic nerve à serratus anterior.
• Common vignettes:
• Stab wounds, axillary node dissection after
mastectomy.

Winged Scapula
Hand
Innervation
for the
USMLE
 • A patient has a STEMI with troponin elevation. He is
emergently taken to the cath lab for PCI. What is the path
of cannulation from the femoral artery?
• Femoral artery à external iliac à common iliac à
aorta à coronary artery

Cardiac
Catheterization
Lower Extremities
 • An elderly female presents after a fall in the nursing hope.
She is noted to have pain in the groin area, and on exam
her left femur is shorter than her right, and is laterally
rotated. What is the likely diagnosis?
• Femoral neck fracture.
• What is the likely vascular complication if left untreated?
• Disruption of the medial circumflex femoral artery
Femoral à avascular necrosis.
Fractures
 • A patient presents with back pain that radiates down to the
lower limb after lifting a box. What embryological structure
is the herniated disc most likely derived from?
• Notochord which becomes nucleus pulposis.
• He now presents with weakened hip extension and knee
flexion. What is the likely structure affected?
• Sciatic nerve
Sciatic • Responsible for hip extension and knee flexion
Nerve Injury
 • Passenger in a rear end collision hits her knees on the
dashboard. On exam her leg is now shortened and medially
rotated. What is the underlying deformity?
• Posterior hip dislocation
• Mechanism: Femoral head is taken out of the acetabular
head à ischium is fractured à ischiofemoral ligament is
torn.
Hip • Exam will show shortened and medially rotated extremity
Dislocation • Patients may have foot drop as sciatic nerve also branches
into the common peroneal and anterior tibial nerve.
 • A 17 yo male presents after being hit by a car in the parking
lot. He has a high stepping gait and there is a large
contusion with point tenderness to the proximal right leg.
What is the likely nerve affected?
• Common peroneal nerve
• PED:
• Peroneal everts and dorsiflexes

Foot Drop
 • Fibular Neck Fractures can lead to common peroneal
nerve injury

Foot Drop
 • 63 yo man presents with difficulty walking after receiving a
gluteal steroid injection for refractory OA. He is noted to have
leaning towards his right side when walking. When asked to
stand on his right leg, his left hip tilts downward. What is the
likely injured nerve?
• Superior gluteal nerve
• Muscle that are affected?
• Gluteus Medius
• Gluteus Minimus
Trendelenburg gait • Ability to pull the pelvis up and abduction of thigh lost.
Trendelenburg
Gait

Lesion is contralateral to the

side o the hip that drops
 • Iliohypogastric nerve:
• A patient presents after
abdominal surgery with
burning pain near the site of
the incision. It radiates to the
Lower inguinal and suprapubic
Extremity region. What is the likely
Nerves affected nerve?
• Iliohypogastric nerve
• Motor innervation to the
transversus abdominis & internal
oblique
Iliohypogastric
nerve
 • Genitofemoral nerve:
• A patient presents after
laparoscopic surgery for
cryptorchid testes. Post-
operatively, the patient is
Lower noted to have an absent
Extremity cremasteric reflex. What is the
Nerves likely nerve implicated?
• Genitofemoral nerve
• Motor: cremaster muscle (sensory:
anterior thigh, beneath the inguinal
ligament and scrotum)
Genitofemoral
nerve
 • Lateral femoral cutaneous nerve:
• A patient presents to PCP with
weight gain over 20 years. He
is noted to have BMI 30. He
complains of intermittent
Lower anterior and lateral thigh
Extremity tingling especially during work
Nerves days at the construction site.
What is the likely nerve
implicated?
• Lateral femoral cutaneous nerve
• Sensory: anterior and lateral thigh.
Lateral Femoral
Cutaneous
 • Obturator nerve:
• A patient presents after pelvic
teratoma resection. She is
noted to have medial thigh
sensation altered and
Lower decreased adduction. What is
Extremity the likely nerve implicated?
Nerves • Obturator nerve
• Sensory to medial thigh
• Motor to adductors, gracilis, pectineus
• Other vignette:
• Anterior hip dislocation
Obturator
 • An obese female presents with medial knee pain. She has
tenderness to palpation over the anteromedial proximal
tibia. Radiograph shows no fracture. MRI is shown. What is
the likely diagnosis?
• Pes Anserine Bursitis

Bursitis
Obturator
Nerve
 • Femoral Nerve:
• A child presents to the PICU. He is noted to need
central access via cannulation of the femoral vein
at the inguinal ligament. Multiple attempts to
pass the catheter are tried until finally a vein is
accessed. Three days later he is noted to have
decreased leg extension, and a diminished
patellar reflex. What is the likely nerve which is
Lower implicated?
Extremity • Femoral nerve (L2-L4)
• Motor: quadriceps, sartorius
Nerves • Sensory to anterior thigh
Femoral
Nerve
 • Tibial Nerve:
• A patient presents with a cystic fluid collection on
the posterior portion of the knee. He is unable to
plantar flex or curl his toes inward. Would this
patient have issues with inversion or eversion?
• Inversion
• Tibial nerve is motor to plantaris (TIP)
• It is also sensory to the sole of the foot
Lower
Extremity
Nerves

Vignette on penetrating trauma

 Tibial nerve runs through
the tarsal tunnel

Tibial Nerve
 • A patient presents with difficulty in climbing stairs. It is
noted that the patient is unable to get up from the
examiner chair as well. The patient has PMH significant for
posterior hip dislocation. Which nerve may be implicated?
• Inferior gluteal nerve
• Motor to the gluteus maximus

Inferior
gluteal nerve
 • A female presents with urinary incontinence. She is 2 weeks
post giving birth to baby boy. Chart review notes a
procedure involving “anesthetic being injected medial to
the ischial spine near the sacrospinus ligament.” Which of
the following nerves may be implicated?
• Pudendal (S2-S4)
• Motor: external urethral and anal sphincters
• Sensory: perineum
Pudendal
nerve
 • During a study of bladder function, a healthy 20-year-old
man drinks 1 L of water and delay. Which of the following
muscles permits his voluntary control of micturition?

• A. Coccygeus

• B. Detrusor

• C. External Urethral Sphincter

USMLE
• D. Internal Urethral Sphincter
Practice
Question • E. Obturator Internus
 • A female presents with a globular swelling at the hip
region. She states that the bulge worsens when coughing
or straining. What is the likely anatomical region which is
superior to this pathology?
• Hernia protrudes through the femoral ring à
inferior to the inguinal ligament
• Femoral ring is medial to the femoral vein
• Obturator artery vulnerable to injury during repair

Hernia
Direct vs. Indirect inguinal Hernia
INFERIOR
EPIGASTRIC
ARTERIES

Direct Indirect
• Directly into the • Passes thru deep
abdomen inguinal ring
(medial to (lateral to vessels)
vessels) • Usually right (1/3)
• Old man bilateral
• NOT in scrotum • Young male (0-3)
• IN scrotum
 • A 6-year-old boy has a large intra-abdominal mass in the
midline just above the symphysis pubis. During an
operation, a cystic mass is found attached to the umbilicus
and the apex of the bladder. Which of the following is the
most likely diagnosis?

• Hydrocele

USMLE • Meckel cyst

Practice • Meckel diverticulum
Question • Omphalocele

• Urachal cyst
 • A 3629-g (8-lb) male newborn is delivered at term. During
the initial examination, urine is found to be leaking from
the umbilicus. This patient most likely has an abnormality
of which of the following fetal structures?

• (A) Umbilical arteries

• (B) Umbilical vein

USMLE • (C) Urachus
Practice • (D) Urogenital sinus
Question • (E) Urorectal septum
 • A 55-year-old man who has alcoholic cirrhosis is brought to
the emergency department because he has been vomiting
blood for 2 hours. He has a 2-month history of abdominal
distention, dilated veins over the anterior abdominal wall,
and internal hemorrhoids. Which of the following veins is
the most likely origin of the hematemesis?

USMLE • (A) Inferior mesenteric veins

Practice • (B) Left gastric vein

Question • (C) Periumbilical veins

• (D) Superior rectal vein

• (E) Superior vena cava

Esophageal varices

Left Gastric Vein Azygous Vein

(portal (systemic
contribution) contribution)
Umbilical varices

Superior and
Paraumbilical
inferior epigastric
veins
veins
(portal
(systemic
contribution)
contribution)
Rectal varices

Superior rectal Inferior rectal

vein vein
(portal (systemic
contribution) contribution)
 • Runner who is limping after rising in the AM, he says he has
pain on his heel and foot. On exam he has point tenderness
to the calcaneus. X-ray shows a heel spur, no fracture.
Diagnosis?

• Plantar fasciitis
• Inflammation of the plantar
Foot aponeurosis
Attaches to the medial tubercle of
Pathology the calcaneus.
 • A 23-year-old female college basketball player presents in
Sports Clinic after she felt a "pop" in her knee after coming
down with a rebound. To examine the patient, you have her
lie down on the table with her knees flexed 90 degrees.
With your hand around her knee you are able to draw the
tibia toward you from underneath the femur. Likely
affected structure?

Knee • Anterior Cruciate Ligament Tear

Pathology • Soccer player complains of her knee giving out after she fell
on her knee flexed. Her leg is able to be forced backwards
relative to the femur after grasping the tibia from a 90 deg
angle. Likely affected structure?
• Posterior cruciate ligament tear.
 • Football player gets tackled in the lateral side of the knee
while running in the red-zone. There are multiple injuries
which make up this complex. What are likely pathologies?
• MCL, ACL, LATERAL MENISCUS.
• Medial meniscus originally described.
• Remember the MCL prevents hyper-abduction of
leg at the knee and extension of leg at the knee.
• A patient is noted to have excess varus laxity at the knee.
Knee What is the likely structure implicated?
LCL tear
Pathology •
• LCL prevents hyper adduction of leg at the knee
• A 65-year-old female presents with complaints of
intermittent knee pain and locking for the past 4 weeks.
Her symptoms are aggravated when twisting or squatting.
On physical exam there is a mild effusion. Diagnosis?
• Meniscus tear.
• McMurrays test
MCL and LCL
tears

Citation: Le, Tao. First Aid 2020.

 • A basketball player has ‘rolled’ his ankle – he is noted to
have a high-ankle sprain. Which ligament is most likely
affected?
• Anterior Inferior Talofibular ligament
• Due to over-inversion and supination of foot

Ankle Sprain