Lymphatic Drainage — MCQs

10 questions

Which of the following statements regarding axillary lymph nodes is incorrect?

Lymph vessels which drain the posterior 1/3rd of the tongue:

In obstruction of the second part of the axillary artery, the anastomosis between which arteries will maintain the blood supply to the upper limb?

What is the most common site of lymphangiosarcoma?

Which lymph nodes drain the skin and fascia of the great toe?

Lympho-venous anastomosis is done for

All are true about the triangle marked green except:

Which of the following is not intracapsular -

Name the muscle marked as colour blue in the extensor compartment of forearm. (Recent NEET Pattern 2019)

Q10Medium

What is true about the blood supply of the scaphoid bone?

Lymphatic Drainage Indian Medical PG Practice Questions and MCQs

Question 1: Which of the following statements regarding axillary lymph nodes is incorrect?

A. Posterior group lies along subscapular vessels
B. Lateral group lies along lateral thoracic vessels (Correct Answer)
C. Apical group is terminal lymph nodes
D. Apical group lies along axillary vessels

Explanation: ***Lateral group lies along lateral thoracic vessels*** - The **lateral group** of axillary lymph nodes is located along the **axillary vein**, receiving lymph primarily from the upper limb [1]. - The **lateral thoracic vessels** are associated with the central and posterior groups of axillary lymph nodes, not the lateral group. *Posterior group lies along subscapular vessels* - The **posterior (subscapular) group** of axillary lymph nodes is indeed located along the **subscapular vessels**. - This group receives lymph from the posterior wall of the trunk and the posterior shoulder region. *Apical group is terminal lymph nodes* - The **apical group** (also known as the subclavian group) is considered the **terminal lymph nodes** of the axilla. - Lymph from all other axillary nodes eventually drains into the apical group before continuing to the supraclavicular nodes and then into the subclavian lymphatic trunk [2]. *Apical group lies along axillary vessels* - The **apical group** of axillary lymph nodes is situated in the apex of the axilla, superior to the pectoralis minor muscle, and lies in close proximity to the **axillary vessels** [1]. - This location allows it to receive lymph from other axillary groups and drain into the supraclavicular lymph nodes.

Question 2: Lymph vessels which drain the posterior 1/3rd of the tongue:

A. Submental node
B. Submandibular node
C. Preauricular node
D. Jugulodigastric node (Correct Answer)

Explanation: ***Jugulodigastric node*** - The **jugulodigastric node** (also known as the principal node of Küttner) is a prominent deep cervical lymph node that drains lymphatic fluid directly from the **posterior 1/3rd of the tongue**. - Its strategic location at the junction of the internal jugular vein and the posterior belly of the digastric muscle makes it a primary drainage site for malignant lesions of the posterior tongue. *Submental node* - The **submental nodes** primarily drain the central part of the lower lip, the floor of the mouth, and the tip of the tongue. - They do not receive lymphatic drainage from the posterior third of the tongue. *Submandibular node* - The **submandibular nodes** drain most of the anterior two-thirds of the tongue, excluding the tip, as well as the oral cavity structures like the floor of the mouth and gingivae. - They are not the primary drainage site for the posterior third of the tongue. *Preauricular node* - **Preauricular nodes** (also known as parotid lymph nodes) are located in front of the ear and drain the temporal region, outer ear, and eyelids. - They have no direct lymphatic drainage connection to any part of the tongue.

Question 3: In obstruction of the second part of the axillary artery, the anastomosis between which arteries will maintain the blood supply to the upper limb?

A. Dorsal scapular artery and subscapular artery (Correct Answer)
B. Anterior and posterior circumflex humeral arteries
C. Posterior circumflex humeral and circumflex scapular arteries
D. Suprascapular and anterior circumflex humeral arteries

Explanation: Dorsal scapular artery and subscapular artery - This anastomosis forms part of the scapular anastomosis, which is crucial for collateral circulation around the shoulder joint and axillary artery. - The dorsal scapular artery (a branch of the subclavian artery, or occasionally the deep branch of the transverse cervical artery) connects with the subscapular artery (a branch of the third part of the axillary artery) and its circumflex scapular branch, bypassing the obstruction [1]. - This provides effective collateral circulation when the second part of the axillary artery is obstructed. Anterior and posterior circumflex humeral arteries - These arteries originate from the third part of the axillary artery and primarily supply the humeral head and surrounding shoulder joint [1]. - While they anastomose around the surgical neck of the humerus, they are distal to an obstruction in the second part of the axillary artery and do not provide an alternative blood supply around the obstruction. Posterior circumflex humeral and circumflex scapular arteries - The posterior circumflex humeral artery is distal to the obstruction, originating from the third part of the axillary artery. - Although the circumflex scapular artery (a branch of the subscapular artery) participates in the scapular anastomosis, its anastomosis with the posterior circumflex humeral artery would still be affected by an occlusion in the second part of the axillary artery as they are both branches distal to the obstruction. Suprascapular and anterior circumflex humeral arteries - The suprascapular artery (from the thyrocervical trunk) contributes to the scapular anastomosis and is proximal to the obstruction, supplying the supraspinatus and infraspinatus muscles. - However, the anterior circumflex humeral artery arises from the third part of the axillary artery and is distal to an obstruction in the second part, so their anastomosis would not effectively bypass the blockage.

Question 4: What is the most common site of lymphangiosarcoma?

A. Liver
B. Spleen
C. Post-mastectomy lymphedema of the arm (Correct Answer)
D. Retroperitoneum

Explanation: ***Post-mastectomy lymphedema of the arm*** - Lymphangiosarcoma is a rare, aggressive malignancy that most commonly arises in the setting of **chronic lymphedema**, particularly following **radical mastectomy** for breast cancer [1]. - The chronic lymphedema, often in the arm, creates a microenvironment conducive to the development of this vascular malignancy, known as **Stewart-Treves syndrome**. *Liver* - While the liver can be a site of various primary and metastatic cancers, it is not the most common location for **lymphangiosarcoma**. - Primary liver cancers are typically **hepatocellular carcinoma** or **cholangiocarcinoma**. *Spleen* - The spleen is rarely a primary site for any sarcoma and is not typically associated with the development of **lymphangiosarcoma**. - Splenic involvement usually indicates metastatic disease or a primary **lymphoid malignancy**. *Retroperitoneum* - The retroperitoneum can be a site for various soft tissue sarcomas, such as **liposarcoma** or **leiomyosarcoma** [2]. - However, it is not the most common primary site for **lymphangiosarcoma**, which has a strong predilection for areas of chronic lymphedema. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. (Basic Pathology) introduces the student to key general principles of pathology, both as a medical science and as a clinical activity with a vital role in patient care. Part 2 (Disease Mechanisms) provides fundamental knowledge about the cellular and molecular processes involved in diseases, providing the rationale for their treatment. Part 3 (Systematic Pathology) deals in detail with specific diseases, with emphasis on the clinically important aspects., pp. 125-126. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, p. 1222.

Question 5: Which lymph nodes drain the skin and fascia of the great toe?

A. Superficial inguinal lymph nodes (Correct Answer)
B. External iliac lymph nodes
C. Internal iliac lymph nodes
D. Deep inguinal lymph nodes

Explanation: ***Superficial inguinal lymph nodes*** - The **superficial inguinal lymph nodes** are responsible for draining lymph from the skin and fascia of the lower limb, including the **great toe**. [1] - They are located in the superficial fascia below the inguinal ligament and receive lymphatic vessels associated with the **great saphenous vein**. *External iliac lymph nodes* - The external iliac lymph nodes drain structures within the **pelvis** and receive lymph from the **deep inguinal lymph nodes**, not directly from the skin of the great toe. - They are located along the external iliac artery and vein. *Internal iliac lymph nodes* - The internal iliac lymph nodes primarily drain lymph from the **pelvic organs** and the **perineum**. - They do not directly receive lymphatic drainage from the great toe or the superficial lower limb. *Deep inguinal lymph nodes* - The deep inguinal lymph nodes are located deeper, medial to the **femoral vein**, and receive lymph mainly from the deep structures of the lower limb. - While they eventually drain into the external iliac nodes, they do not directly drain the superficial skin and fascia of the great toe.

Question 6: Lympho-venous anastomosis is done for

A. Cystic hygroma
B. Malignant lymphoedema
C. Lymphoid cyst
D. Filarial lymphoedema (Correct Answer)

Explanation: ***Filarial lymphoedema*** - **Lympho-venous anastomosis (LVA)** is a microsurgical technique used to bypass damaged lymphatic vessels and directly connect lymphatic channels to small veins. This procedure is primarily effective in treating **lymphedema due to lymphatic obstruction**, such as that caused by filarial infection. - In **filarial lymphoedema**, the lymphatic obstruction leads to accumulation of lymph fluid. LVA helps to restore lymphatic drainage, reducing limb swelling and improving symptoms, particularly in the early stages of the disease. *Cystic hygroma* - A **cystic hygroma** is a congenital lymphatic malformation, typically treated by surgical excision, sclerotherapy, or laser ablation. - It involves abnormally dilated lymphatic spaces and doesn't usually benefit from LVA, as the primary issue is malformation rather than obstruction requiring a bypass. *Malignant lymphoedema* - **Malignant lymphoedema** (secondary to cancer or its treatment) is often complicated by active tumor burden, radiation fibrosis, or extensive nodal involvement. - While LVA might be considered in carefully selected cases, its efficacy can be limited due to underlying cancer and the diffuse nature of the lymphatic damage, making it a less common primary indication compared to filarial lymphedema. *Lymphoid cyst* - A **lymphoid cyst** is a localized collection of lymph, often treated by aspiration, sclerotherapy, or surgical excision. - It is not a widespread lymphatic drainage disorder that would necessitate a bypass procedure like lympho-venous anastomosis.

Question 7: All are true about the triangle marked green except:

A. Localised pain in this area after fall on outstretched hand indicates fracture of scaphoid
B. Cephalic vein in this area is used to make Ciminobrescia fistula in hemodialysis
C. Medial border is formed by tendon of abductor pollicis longus and extensor pollicis brevis (Correct Answer)
D. Superficial branch of radial nerve runs to provide innervation to 3.5 digits

Explanation: ***Medial border is formed by tendon of abductor pollicis longus and extensor pollicis brevis*** - This statement is incorrect because the **medial border of the anatomical snuffbox** is formed by the tendon of the **extensor pollicis longus**. - The **lateral border** of the anatomical snuffbox is formed by the tendons of the **abductor pollicis longus** and **extensor pollicis brevis**. *Localised pain in this area after fall on outstretched hand indicates fracture of scaphoid* - The anatomical snuffbox is a crucial site for palpating the **scaphoid bone**, which is frequently fractured in falls on an **outstretched hand**. - **Tenderness in the anatomical snuffbox** following such an injury is a strong clinical indicator of a scaphoid fracture, even if initial X-rays are negative. *Cephalic vein in this area is used to make Ciminobrescia fistula in hemodialysis* - The anatomical snuffbox region provides access to the **cephalic vein**, which is a common site for creating an **arteriovenous fistula (AV fistula)**, also known as a Cimino-Brescia fistula. - An AV fistula connects the radial artery to the cephalic vein, providing robust venous access for **hemodialysis**. *Superficial branch of radial nerve runs to provide innervation to 31/2 digits* - The **superficial branch of the radial nerve** traverses the anatomical snuffbox region to provide **sensory innervation** to the dorsal aspect of the lateral 3.5 digits (thumb, index finger, middle finger, and radial half of the ring finger) as well as the associated dorsal hand. - This nerve is susceptible to injury in this area due to its superficial location.

Question 8: Which of the following is not intracapsular -

A. Olecranon fossa
B. Lateral epicondyle (Correct Answer)
C. Coronoid fossa
D. Radial fossa

Explanation: **Lateral epicondyle** - The **lateral epicondyle** is an extracapsular structure, sitting superior and lateral to the capitulum and serving as an attachment site for the **radial collateral ligament** and the **common extensor tendon**. - Its position outside the joint capsule means it does not directly articulate within the synovial space of the elbow joint. *Olecranon fossa* - The **olecranon fossa** is a deep depression on the posterior aspect of the **distal humerus** that accommodates the **olecranon process** of the ulna during full elbow extension. - It is located within the joint capsule, allowing the olecranon to articulate freely within the joint. *Coronoid fossa* - The **coronoid fossa** is an anterior depression on the **distal humerus** that receives the **coronoid process** of the ulna during elbow flexion. - This fossa is located within the joint capsule, facilitating the articulation of the ulna with the humerus. *Radial fossa* - The **radial fossa** is a shallow depression on the anterior surface of the distal humerus, superior to the capitulum, that accommodates the **head of the radius** during elbow flexion. - It is located within the joint capsule, enabling smooth movement between the radius and the humerus.

Question 9: Name the muscle marked as colour blue in the extensor compartment of forearm. (Recent NEET Pattern 2019)

A. Extensor carpi radialis
B. Brachioradialis (Correct Answer)
C. Extensor digitorum
D. Extensor carpi ulnaris

Explanation: ***Brachioradialis*** - The **brachioradialis** muscle is a prominent superficial muscle in the lateral compartment of the forearm, shown in **blue** in the diagram, originating from the **lateral supracondylar ridge of the humerus** and inserting into the **radial styloid process**. - It primarily functions to **flex the elbow** and helps to bring the forearm into a midprone position. *Extensor carpi radialis* - The extensor carpi radialis muscles (longus and brevis) are located deep to the brachioradialis and extend the wrist, often distinguishable by their more distal insertion on the **metacarpals**. - They are typically not the most superficial and most lateral muscle spanning the entire forearm length as depicted in blue. *Extensor digitorum* - The **extensor digitorum** is located more medially than the brachioradialis and its tendons diverge to attach to the four medial fingers, a configuration not shown by the blue muscle. - This muscle is responsible for **extending the medial four digits**. *Extensor carpi ulnaris* - The **extensor carpi ulnaris** is situated on the **ulnar side** of the forearm, furthest from the blue-highlighted muscle, and its primary action is **wrist extension and ulnar deviation**. - It would be found along the posterior medial aspect of the forearm, not in the relatively lateral position shown in blue.

Question 10: What is true about the blood supply of the scaphoid bone?

A. Mainly through the ulnar artery
B. Major supply from the ventral surface
C. Major supply from the dorsal surface (Correct Answer)
D. Proximal supply in antegrade fashion

Explanation: The scaphoid is the most commonly fractured carpal bone [1], and its unique vascular anatomy is a high-yield topic for NEET-PG. [2] ### **Explanation of the Correct Answer** The scaphoid receives approximately **70–80% of its blood supply from the dorsal carpal branch of the radial artery**. These vessels enter the bone through the **dorsal ridge** (non-articular surface) and supply the proximal two-thirds of the bone via **retrograde flow**. This makes the dorsal surface the primary site of vascular entry. ### **Analysis of Incorrect Options** * **Option A:** The blood supply is derived almost exclusively from the **radial artery**, not the ulnar artery. * **Option B:** While some minor vessels enter the distal tubercle on the volar (ventral) side, the **major** supply is dorsal. * **Option C (Correct):** As stated, the dorsal carpal branch of the radial artery is the dominant source. * **Option D:** The blood supply to the proximal pole is **retrograde** (distal-to-proximal). There is no direct antegrade supply to the proximal pole, which is why it is highly susceptible to ischemia. [2] ### **Clinical Pearls for NEET-PG** * **Retrograde Blood Flow:** Because the vessels enter distally and travel proximally, a fracture at the **waist of the scaphoid** often severs the blood supply to the proximal fragment. [1] * **Avascular Necrosis (AVN):** The proximal pole is the most common site for AVN (Preiser’s disease is idiopathic AVN, but post-traumatic AVN is more common). [2] * **Anatomical Snuffbox:** Tenderness here is pathognomonic for a scaphoid fracture. * **Non-union:** Due to the precarious retrograde supply, scaphoid fractures have a high risk of non-union and delayed healing. [2]

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