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Updated Orthopedic Review | Dr Hutaif General Orthopedi -...

Approaches Orthopedic B Review | Dr Hutaif General Orth -...

23 Apr 2026 54 min read 165 Views
Master Orthopedic Approaches: SAESN Preferred Response Guide

Key Takeaway

This interactive board review contains 100 randomly selected orthopedic surgery questions with clinical images, immediate feedback, and detailed references.

Approaches Orthopedic B Review | Dr Hutaif General Orth -...

Comprehensive 100-Question Exam


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Question 1

A 45-year-old male sustains a 3-part proximal humerus fracture and is scheduled for open reduction and internal fixation via a deltopectoral approach. During the superficial dissection, the cephalic vein is encountered. Which of the following best describes the internervous plane of this approach and the recommended management of the cephalic vein to preserve its major venous tributaries?





Explanation

The deltopectoral approach utilizes the internervous plane between the deltoid (axillary nerve) and the pectoralis major (medial and lateral pectoral nerves). The cephalic vein is located within this interval. Standard orthopedic teaching recommends retracting the cephalic vein laterally with the deltoid muscle. This preserves the primary feeding veins which drain from the deltoid into the cephalic vein, thereby reducing postoperative deltoid swelling and venous congestion.

Question 2

A 32-year-old female undergoes a direct anterior (Smith-Petersen) approach to the hip for a peri-acetabular osteotomy. Which of the following describes the correct superficial internervous plane and the cutaneous nerve most at risk during this portion of the dissection?





Explanation

The Smith-Petersen (direct anterior) approach to the hip utilizes a superficial internervous plane between the sartorius (innervated by the femoral nerve) and the tensor fasciae latae (innervated by the superior gluteal nerve). The lateral femoral cutaneous nerve (LFCN) crosses over the sartorius approximately 2 cm distal to the ASIS and is at high risk of injury during the superficial dissection. Injury to the LFCN can result in meralgia paresthetica.

Question 3

An orthopedic surgeon is planning an approach to the radial head to perform an open reduction and internal fixation of a displaced fracture. The surgeon elects to use the Kocher approach. Between which two muscles is the internervous plane developed?





Explanation

The Kocher approach to the elbow and radial head utilizes the internervous plane between the anconeus (innervated by the radial nerve) and the extensor carpi ulnaris (innervated by the posterior interosseous nerve). In contrast, the Kaplan approach is slightly more anterior and utilizes the plane between the extensor digitorum communis (PIN) and the extensor carpi radialis brevis (radial nerve proper). The Kocher approach is generally considered safer for the posterior interosseous nerve, which stays further anteriorly in the supinator.

Question 4

During a primary total hip arthroplasty using a direct lateral (Hardinge) approach, the surgeon splits the gluteus medius and vastus lateralis. To avoid denervation of the anterior portion of the gluteus medius and tensor fasciae latae, the proximal splitting of the gluteus medius should not exceed what distance from the tip of the greater trochanter?





Explanation

The direct lateral (Hardinge) approach to the hip does not use a true internervous plane, as it splits the gluteus medius and vastus lateralis (both innervated by the superior gluteal nerve for the former, and femoral nerve for the latter, but the split is within the substance of the gluteus medius). The superior gluteal nerve courses from posterior to anterior and supplies the gluteus medius, gluteus minimus, and TFL. Its inferior branch runs approximately 3 to 5 cm proximal to the tip of the greater trochanter. Extending the split further proximal than 5 cm risks severing this nerve, leading to a postoperative Trendelenburg gait.

Question 5

A surgeon performs the proximal portion of the volar (Henry) approach to the forearm to expose the proximal radius. The internervous plane at this level is between which of the following muscles?





Explanation

The volar (Henry) approach to the forearm provides extensile exposure to the radius. Proximally, the internervous plane is between the brachioradialis (innervated by the radial nerve) and the pronator teres (innervated by the median nerve). Distally, the plane shifts to become between the brachioradialis and the flexor carpi radialis (median nerve).

Question 6

A 28-year-old male presents with an anterior column acetabular fracture. An ilioinguinal approach is planned. Once the external oblique aponeurosis and inguinal canal are opened, the iliopectineal fascia is identified. The 'middle window' of this approach is defined laterally by the iliopsoas/iliopectineal fascia and medially by the external iliac vessels. Which of the following structures is found within this middle window?





Explanation

The ilioinguinal approach creates three surgical windows. The lateral window is lateral to the iliopsoas (contains the iliacus and lateral femoral cutaneous nerve). The middle window is between the iliopectineal fascia (lateral) and the external iliac vessels (medial); it contains the iliopsoas muscle and the femoral nerve. The medial window is medial to the external iliac vessels and provides access to the superior pubic ramus, the quadrilateral surface, and the retropubic space (Space of Retzius).

Question 7

During a modified Stoppa approach for a pelvic ring fracture, the surgeon elevates the peritoneum from the superior pubic ramus and quadrilateral plate. A significant vascular structure traversing vertically over the superior pubic ramus is encountered and must be ligated to prevent catastrophic hemorrhage. This structure is an anastomosis between which two vascular systems?





Explanation

The structure is the corona mortis (crown of death), which is an aberrant anastomosis between the external iliac system (specifically the inferior epigastric vessels) and the obturator system. It is present in approximately 30-40% of hemi-pelves and crosses over the superior pubic ramus at an average of 5-6 cm from the pubic symphysis. Ligation is critical during the modified Stoppa or ilioinguinal approach to prevent severe intrapelvic bleeding.

Question 8

A 40-year-old male sustains a midshaft humerus fracture requiring plate fixation. A posterior approach to the humerus is chosen. To safely identify and protect the radial nerve, the surgeon must know its reliable anatomical landmarks. The radial nerve typically crosses the posterior aspect of the humerus at approximately what distance proximal to the lateral and medial epicondyles respectively?





Explanation

The posterior approach to the humerus involves identifying the radial nerve as it passes through the spiral groove. A reliable anatomical landmark is that the radial nerve lies directly on the posterior aspect of the humerus approximately 14 cm proximal to the lateral epicondyle, and it crosses the medial intermuscular septum roughly 20 cm proximal to the medial epicondyle.

Question 9

Which of the following surgical approaches to the hip is accurately matched with its proper internervous plane?





Explanation

The Smith-Petersen approach uses a true internervous plane between the Sartorius (femoral n.) and the Tensor Fasciae Latae (superior gluteal n.). The Watson-Jones (anterolateral) approach utilizes the interval between the TFL and Gluteus Medius, which is not a true internervous plane since both are innervated by the superior gluteal nerve. The Hardinge approach involves a direct split of the Gluteus Medius and Vastus Lateralis, offering no internervous plane. The Kocher-Langenbeck splits the Gluteus Maximus.

Question 10

During a Kocher-Langenbeck approach for a posterior wall acetabular fracture, the short external rotators of the hip are tagged and tenotomized near their femoral insertion. Which muscle should be preserved or have its femoral insertion left intact to protect the main blood supply to the femoral head?





Explanation

The deep branch of the medial femoral circumflex artery (MFCA) provides the primary blood supply to the adult femoral head. It runs anterior to the quadratus femoris and posterior to the obturator externus. To protect the MFCA during a posterior approach, the quadratus femoris (or at least its inferior half) and the obturator externus should be preserved. Tenotomizing the piriformis and the triceps coxae (superior gemellus, obturator internus, inferior gemellus) is standard and safe.

Question 11

The anterior (Smith-Robinson) approach to the cervical spine allows access from C3 to T1. The internervous plane utilized in this approach lies between muscles innervated by which two nerves?





Explanation

The anterior approach to the cervical spine goes between the sternocleidomastoid muscle laterally (innervated by the spinal accessory nerve, CN XI) and the strap muscles medially (sternohyoid, sternothyroid, omohyoid), which are innervated by the ansa cervicalis. The recurrent laryngeal nerve is a critical structure at risk, particularly on the right side due to its more variable and oblique course.

Question 12

A surgeon is performing an open reduction and internal fixation of a distal tibia (pilon) fracture via a standard anterolateral approach. Which internervous plane is developed, and what nerve is directly at risk during the distal extent of this exposure?





Explanation

The anterolateral approach to the distal tibia and ankle joint is truly an approach between the tibia and the fibula, without a strict internervous plane since both the extensor digitorum longus and the peroneus tertius are supplied by the deep peroneal nerve. During the superficial dissection, the superficial peroneal nerve (specifically its intermediate dorsal cutaneous branch) crosses the operative field from medial to lateral and is at high risk of injury.

Question 13

During a posterolateral approach to the tibia to bone graft an ununited fracture, an internervous plane is developed. Which of the following accurately describes the muscle interval and nerve supply for this approach?





Explanation

The posterolateral approach to the tibia utilizes the true internervous plane between the posterior compartment muscles (lateral head of gastrocnemius, soleus, and FHL), which are all innervated by the tibial nerve, and the lateral compartment muscles (peroneus longus and brevis), which are innervated by the superficial peroneal nerve.

Question 14

The classic posterior approach to the shoulder joint requires developing an internervous plane between the infraspinatus and teres minor. What are the respective nerve supplies to these muscles?





Explanation

The posterior approach to the shoulder develops an internervous plane between the infraspinatus (innervated by the suprascapular nerve) and the teres minor (innervated by the axillary nerve). Care must be taken not to injure the axillary nerve, which exits the quadrangular space just inferior to the teres minor.

Question 15

A distal humerus fracture is treated using a posterior approach with an olecranon osteotomy. During the approach, the ulnar nerve is identified and mobilized. The ulnar nerve enters the forearm between the two heads of which muscle?





Explanation

The ulnar nerve runs through the cubital tunnel posterior to the medial epicondyle. As it transitions into the proximal forearm, it passes between the humeral and ulnar heads of the flexor carpi ulnaris (FCU) muscle.

Question 16

A surgeon uses the posteromedial approach to the ankle for fixation of a posterior malleolus fracture. The dissection takes place posterior to the medial malleolus. To safely access the posterior tibia, the surgeon must retract the neurovascular bundle. Which of the following represents the correct order of structures passing behind the medial malleolus, from anterior/medial to posterior/lateral?





Explanation

The correct sequence of structures passing behind the medial malleolus is remembered by the mnemonic 'Tom, Dick, And Very Nervous Harry': Tibialis posterior, flexor Digitorum longus, posterior tibial Artery, posterior tibial Vein, tibial Nerve, and flexor Hallucis longus.

Question 17

During a lateral extensile approach to the calcaneus for open reduction and internal fixation of a displaced intra-articular fracture, a full-thickness subperiosteal flap is elevated. Which nerve is most at risk in the proximal and posterior portion of the vertical limb of this incision?





Explanation

The lateral extensile approach involves an L-shaped incision. The vertical limb is placed halfway between the fibula and the Achilles tendon. The sural nerve runs in close proximity to the small saphenous vein in this region and crosses the posterior aspect of the lateral malleolus. It is at direct risk during the incision and elevation of the corner of the full-thickness flap.

Question 18

When exposing the entire length of the radius via the volar (Henry) approach, the supinator must be detached to expose the proximal third of the radius. To safely detach the supinator without injuring the posterior interosseous nerve, how should the forearm be positioned during the detachment?





Explanation

During the proximal Henry approach, the supinator is elevated to expose the proximal radius. The posterior interosseous nerve (PIN) runs within the substance of the supinator. By fully supinating the forearm, the insertion of the supinator moves laterally and anteriorly, which safely rotates the PIN away from the surgical field. The muscle can then be safely elevated subperiosteally from medial to lateral.

Question 19

An anterolateral approach to the femur is performed for the treatment of a proximal third shaft fracture. The surgeon develops the plane between the rectus femoris and the vastus lateralis. Which structure crosses this surgical interval proximally and must be protected or ligated?





Explanation

The anterolateral approach to the femur utilizes the interval between the rectus femoris and the vastus lateralis (both innervated by the femoral nerve, so no true internervous plane). Proximally, the descending branch of the lateral femoral circumflex artery and vein cross this interval obliquely. They must be identified, isolated, and ligated to allow adequate retraction and to prevent significant bleeding.

Question 20

A surgeon is utilizing an extensile posterior approach to the knee to manage a complex popliteal artery injury and posterior tibial plateau fracture. As dissection proceeds through the popliteal fossa, the surgeon must be aware of the relationship of the neurovascular structures. From superficial/lateral to deep/medial, what is the anatomical arrangement in the central popliteal fossa?





Explanation

In the popliteal fossa, the structures are arranged such that the Tibial Nerve is the most superficial and lateral. Deep and slightly medial to the nerve is the Popliteal Vein. The deepest and most medial structure against the joint capsule is the Popliteal Artery. Mnemonic: N-V-A from superficial/lateral to deep/medial.

Question 21

A surgeon is performing an anterolateral approach (Watson-Jones) to the hip for a femoral neck fracture.

What is the internervous plane for the superficial dissection of this approach?





Explanation

The Watson-Jones approach utilizes the plane between the Tensor fasciae latae (TFL) and Gluteus medius. Note that this is not a true internervous plane, as both muscles are innervated by the superior gluteal nerve.

Question 22

During a posterior approach to the shoulder, the internervous plane is developed between the infraspinatus and teres minor. Which of the following correctly pairs these muscles with their respective innervations?





Explanation

The posterior approach to the shoulder uses the true internervous plane between the infraspinatus (supplied by the suprascapular nerve) and teres minor (supplied by the axillary nerve).

Question 23

A direct lateral (Hardinge) approach is used for a total hip arthroplasty. The gluteus medius is split during the approach. To avoid denervating the anterior portion of the gluteus medius and tensor fasciae latae, the proximal split should not extend beyond what distance from the tip of the greater trochanter?





Explanation

The superior gluteal nerve innervates the gluteus medius, minimus, and TFL. Its branches traverse the deep surface of the gluteus medius approximately 3 to 5 cm proximal to the tip of the greater trochanter. Splitting the muscle beyond 5 cm places the nerve at significant risk.

Question 24

A surgeon utilizes the volar (Henry) approach to the forearm to plate a middle-third radial shaft fracture.

During the deep dissection in the proximal third of the forearm, the supinator muscle must be elevated from the radius. To minimize risk to the posterior interosseous nerve (PIN), how should the supinator be managed?





Explanation

In the proximal third of the volar Henry approach, the posterior interosseous nerve (PIN) runs within the supinator. The muscle should be detached from its insertion on the radius and reflected ulnarly, carrying the PIN with it to protect it. Supination of the forearm moves the PIN further laterally, away from the surgical field.

Question 25

When performing an ilioinguinal approach for an acetabular fracture, the middle window is defined by which of the following boundaries?





Explanation

The ilioinguinal approach creates three windows. The lateral window is lateral to the iliopsoas. The middle window is between the iliopsoas/femoral nerve laterally and the external iliac vessels medially (separated by the iliopectineal fascia). The medial window is medial to the external iliac vessels.

Question 26

In the modified Stoppa approach for anterior intrapelvic access, which of the following structures must often be identified and ligated on the superior pubic ramus to prevent catastrophic bleeding?





Explanation

The corona mortis is a venous and/or arterial anastomosis between the external iliac (or inferior epigastric) and obturator vessels. It is located on the posterior aspect of the superior pubic ramus and is at significant risk during the Stoppa approach, necessitating careful identification and ligation.

Question 27

During a deltopectoral approach to the shoulder, the conjoined tendon is identified attaching to the coracoid process.

Which of the following structures makes up the conjoined tendon, and what nerve is most at risk if retractors are placed aggressively medial to it?





Explanation

The conjoined tendon consists of the short head of the biceps brachii and the coracobrachialis. The musculocutaneous nerve enters the coracobrachialis approximately 5-8 cm distal to the coracoid process and is highly susceptible to traction injury with vigorous medial retraction.

Question 28

A posterolateral (Kocher) approach is performed on the elbow for radial head replacement.

Which ligament is most at risk of iatrogenic injury if the origin of the extensor mass on the lateral epicondyle is aggressively elevated anteriorly?





Explanation

The lateral ulnar collateral ligament (LUCL) originates on the lateral epicondyle and inserts on the supinator crest of the ulna. It acts as the primary restraint to posterolateral rotatory instability (PLRI) of the elbow. If the dissection is taken too far anteriorly or distally off the lateral epicondyle, the LUCL can be severed, leading to iatrogenic PLRI.

Question 29

The posterolateral approach to the distal tibia (often used for posterior malleolus fractures) exploits the internervous plane between which two muscle groups?





Explanation

The posterolateral approach to the ankle utilizes the internervous plane between the peroneal muscles (supplied by the superficial peroneal nerve) and the flexor hallucis longus (supplied by the tibial nerve). Retraction of the FHL medially also protects the posterior tibial neurovascular bundle.

Question 30

A surgeon uses the medial approach to the knee to perform an opening wedge high tibial osteotomy. The superficial medial collateral ligament (sMCL) is located deep to which of the following structures?





Explanation

The superficial MCL lies deep to the pes anserinus tendons (sartorius, gracilis, semitendinosus) at its distal tibial insertion. The pes must often be retracted or elevated to fully expose the distal aspect of the sMCL and medial tibia.

Question 31

During a Smith-Petersen (anterior) approach to the hip,

the deep dissection involves working between the rectus femoris and the gluteus medius/minimus. Which blood vessels typically cross this field and require ligation to mobilize the rectus femoris safely?





Explanation

In the deep interval of the Smith-Petersen approach (between the rectus femoris and gluteus medius/minimus), the ascending branch of the lateral femoral circumflex artery (often termed the 'vascular leash of Henry') crosses the field transversely and must be ligated to gain full access to the hip joint capsule.

Question 32

A posterior approach to the humerus is selected for open reduction and internal fixation of a distal third humerus fracture. The radial nerve is identified in the spiral groove. Approximately how far proximal to the lateral epicondyle does the radial nerve piece the lateral intermuscular septum to pass from the posterior to the anterior compartment?





Explanation

The radial nerve pierces the lateral intermuscular septum approximately 10 cm proximal to the lateral epicondyle. It crosses the posterior aspect of the humerus approximately 20 cm proximal to the medial epicondyle and 14 cm proximal to the lateral epicondyle.

Question 33

An anterior approach to the cervical spine (Smith-Robinson) is performed at the C5-C6 level. The dissection passes medial to the carotid sheath and lateral to the visceral axis (trachea/esophagus). Which of the following fascial layers must be divided to enter the retropharyngeal space and access the longus colli muscles?





Explanation

After splitting the platysma (superficial fascia) and passing the investing fascia, the dissection retracts the pretracheal fascia/visceral structures medially and the carotid sheath laterally. The prevertebral fascia lies immediately anterior to the longus colli muscles and the cervical spine and must be incised to expose the vertebral bodies.

Question 34

A direct posterior approach is chosen to access the posterior malleolus. The patient is prone. Which of the following nerves is at greatest risk during the superficial surgical dissection of the posterolateral approach to the distal tibia?





Explanation

The sural nerve runs parallel and lateral to the Achilles tendon in the posterolateral aspect of the ankle. It is superficial and highly vulnerable during the superficial dissection of the posterolateral approach to the distal tibia/ankle.

Question 35

In the Kaplan approach (anterolateral) to the proximal radius,

the internervous plane is developed between the extensor digitorum communis (EDC) and the extensor carpi radialis brevis (ECRB). Why is this approach considered to have a higher risk of neurologic injury compared to the Kocher approach?





Explanation

The Kaplan approach (between ECRB and EDC) places the posterior interosseous nerve (PIN) at higher risk because the PIN lies closer to the Kaplan interval (more anterior) as it enters the supinator. The Kocher approach (between Anconeus and ECU) is more posterior, making it safer for the PIN, although the LUCL is at higher risk in the Kocher approach.

Question 36

When performing an extensile lateral approach to the calcaneus for a displaced intra-articular fracture, a full-thickness subperiosteal flap is created. Which of the following structures is explicitly preserved and elevated within this full-thickness flap?





Explanation

The extensile lateral approach to the calcaneus requires a 'no-touch' full-thickness flap to avoid skin necrosis. The flap includes the skin, subcutaneous tissue, sural nerve, peroneal tendons, and the calcaneofibular ligament (CFL), all of which are elevated anteriorly and superiorly together as a single tissue block off the lateral wall of the calcaneus.

Question 37

An anterolateral (Watson-Jones) approach is utilized. The deep dissection requires identification of the capsule. During this deep dissection, which muscle must frequently be detached from the anterior aspect of the greater trochanter to optimize exposure of the femoral neck?





Explanation

In the Watson-Jones approach (between TFL and Gluteus medius), access to the superior capsule and femoral neck is often obstructed by the gluteus minimus. Its anterior fibers are typically detached from the greater trochanter and retracted superiorly to fully expose the hip capsule.

Question 38

A volar approach to the wrist is performed for carpal tunnel release.

The palmar cutaneous branch of the median nerve must be protected. What is its typical anatomical course in relation to the main median nerve and surrounding structures at the wrist crease?





Explanation

The palmar cutaneous branch of the median nerve typically originates about 5 cm proximal to the wrist crease, on the radial side of the median nerve. It runs distally in the interval between the palmaris longus (PL) and the flexor carpi radialis (FCR), passing superficial to the transverse carpal ligament. Carpal tunnel incisions are placed ulnar to the PL to avoid it.

Question 39

During a medial approach to the tibia to access the entire shaft, what is the structure at risk that runs parallel to the medial border of the tibia, particularly in the distal half of the leg?





Explanation

The saphenous nerve and great saphenous vein run superficially along the medial aspect of the leg, closely following the medial border of the tibia. They are the primary superficial structures at risk during a medial approach to the tibial shaft.

Question 40

A surgeon performs the Ludloff (medial) approach to the hip for an open reduction of a pediatric developmental dysplasia of the hip.

What is the deep internervous plane utilized in this approach?





Explanation

The Ludloff medial approach to the hip exploits the superficial plane between the adductor longus (obturator nerve) and pectineus (femoral nerve). The deep plane continues between the adductor brevis (obturator nerve) and the pectineus (femoral nerve) to access the lesser trochanter and inferior hip capsule.

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