This practice set contains high-yield board review questions covering key concepts in Surgical Anatomy & Approaches. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.
Question 321
Topic: Surgical Anatomy & Approaches
A 25-year-old male undergoes an open Latarjet procedure for recurrent anterior shoulder instability with 25% glenoid bone loss. Postoperatively, he complains of numbness over the lateral aspect of his forearm, but motor function of the biceps is intact. Which nerve is most likely injured, and what is its typical distance from the coracoid tip where it enters the conjoint tendon?
Correct Answer & Explanation
. Musculocutaneous nerve; 5 cm distal
Explanation
The musculocutaneous nerve typically enters the coracobrachialis approximately 5 cm (range 3-8 cm) distal to the coracoid tip. Injury can result in lateral forearm numbness (lateral antebrachial cutaneous nerve) and biceps weakness, though partial injuries may spare motor function.
Question 322
Topic: Surgical Anatomy & Approaches
When comparing the localized and diffuse forms of Pigmented Villonodular Synovitis (PVNS) regarding surgical outcomes, which of the following statements is most accurate?
Correct Answer & Explanation
. Diffuse PVNS has a significantly higher recurrence rate than localized PVNS after surgical excision
Explanation
Diffuse PVNS involves the entire synovial lining of the joint and has a notoriously high recurrence rate (ranging from 14% to 55%) even after extensive total synovectomy. Localized PVNS is much more amenable to complete excision and has a low recurrence rate.
Question 323
Topic: Surgical Anatomy & Approaches
A 22-year-old rugby player undergoes an open Latarjet procedure for recurrent anterior instability with 25% glenoid bone loss. Postoperatively, he exhibits weakness in elbow flexion and decreased sensation over the lateral aspect of his forearm. Which nerve was most likely injured during the procedure?
Correct Answer & Explanation
. Musculocutaneous nerve
Explanation
The musculocutaneous nerve enters the coracobrachialis approximately 3-8 cm distal to the coracoid process. It is at significant risk during retraction and coracoid mobilization in the Latarjet procedure, leading to biceps weakness and lateral forearm sensory deficits if injured.
Question 324
Topic: Surgical Anatomy & Approaches
A patient is undergoing an open Latarjet procedure. To safely dissect and mobilize the coracoid process, the surgeon must be mindful of the musculocutaneous nerve. On average, how far distal to the tip of the coracoid process does the musculocutaneous nerve enter the conjoint tendon?
Correct Answer & Explanation
. 5 to 8 cm
Explanation
The musculocutaneous nerve typically enters the coracobrachialis (part of the conjoint tendon) approximately 5 to 8 cm distal to the tip of the coracoid process. Dissection beyond 5 cm distal to the coracoid places the nerve at significant risk.
Question 325
Topic: Surgical Anatomy & Approaches
A resident is performing a distal femoral osteotomy for a valgus deformity. The CORA is located 10 cm proximal to the knee joint. The resident, attempting to avoid the joint, places both the osteotomy cut and the surgical hinge (ACA) 5 cm proximal to the knee joint (i.e., 5 cm distal to the true CORA). Based on Paley's principles, what is the MOST likely outcome of this surgical approach?
Correct Answer & Explanation
. C. An iatrogenic secondary translational deformity (ST) due to misplacement of the ACA and osteotomy relative to the CORA.
Explanation
Correct Answer: CThis scenario describes Paley's Osteotomy Rule Three: "The Iatrogenic Error (ACA and Osteotomy Elsewhere). The Rule:When the bone cut and the surgical hinge (ACA) are placed at the same level, but this level is remote from the true deformity apex (CORA), the result is an iatrogenic secondary translational deformity (ST)." The resident has placed both the osteotomy and the ACA at a level (5 cm proximal to the knee) that is remote from the true CORA (10 cm proximal to the knee). This will inevitably lead to an unintended and undesirable secondary translational deformity, meaning the mechanical axes will not be collinear.Incorrect Options:A. Pure angular correction with zero translation, as the osteotomy and hinge are at the same level.This is incorrect. Zero translation only occurs in Rule One, where the ACA and osteotomy areat the CORA. If they are at the same level but remote from the CORA, translation will occur.B. Angular correction with a planned, necessary translation at the osteotomy site.This describes Rule Two, where the ACA isat the CORAbut the osteotomy is elsewhere. In this case, the ACA is also elsewhere, making the translation iatrogenic and unplanned.D. A multiapical deformity requiring a second osteotomy.The problem described is a single-apical deformity with an incorrectly executed osteotomy, not a multiapical deformity.E. Collinear realignment of the mechanical axes with improved joint loading.This is the desired outcome of a correctly performed osteotomy (Rules One or Two). Rule Three, by definition, results in non-collinear axes and an iatrogenic translational deformity, which would not lead to improved joint loading.
Question 326
Topic: Surgical Anatomy & Approaches
A 40-year-old patient requires a distal femoral osteotomy for a valgus deformity. The center of rotation of angulation (CORA) is identified within the epiphysis, making a direct osteotomy at this level technically challenging due to joint proximity and fixation concerns. The surgeon decides to perform the osteotomy more proximally in the metaphysis but ensures the angulation correction axis (ACA) is mathematically placed at the CORA. Referring to the provided image, which diagram set (i, ii, iii, or iv) best illustrates the expected outcome of this surgical approach, consistent with Paley's Rule Two?
Correct Answer & Explanation
. D. Diagram set (b), Roman numeral (iv)
Explanation
Paley's Rule Two states: 'When the ACA passes through the CORA, but the osteotomy is performed at a different level (either proximal or distal to the CORA), the mechanical axes will align perfectly, but the bone segments will translate.' The teaching case describes this as a common pragmatic approach when the CORA is in a difficult location. The image's 'Deformity Planning and Osteotomy Considerations' section for 'Opening Wedge Sequence' describes Rule 2 Variation (iv) as: 'Osteotomy line is distal to CORA, ACA is through the CORA. Result: 37ยฐ angular correction, no MAD, normal anatomic axis alignment of the distal tibia (though a cortical bump is present because of the level of osteotomy and obligatory translation), and normal ankle and knee joint orientation.' This perfectly matches the scenario described in the question, where the osteotomy is performed away from the CORA but the ACA is at the CORA, leading to correction with translation.
Question 327
Topic: Surgical Anatomy & Approaches
In the surgical treatment of a severe purulent infection of the radial bursa extending into the ulnar bursa, the surgeon must drain a 'horseshoe abscess.' Through which anatomical structure do these two bursae communicate in the distal forearm?
Correct Answer & Explanation
. Parona's space
Explanation
The radial bursa (housing the FPL tendon) and the ulnar bursa (housing the flexor tendons of the small digit) communicate proximally in the distal forearm via Parona's space. This space is located deep to the flexor digitorum profundus tendons and superficial to the pronator quadratus.
Question 328
Topic: Surgical Anatomy & Approaches
A 50-year-old patient presents with a recurrent lumbrical plus deformity after a previous lumbrical tenotomy. Intraoperative assessment confirms significant over-tensioning of the flexor digitorum profundus (FDP) tendon as the primary underlying cause. The surgeon decides to perform an FDP lengthening procedure. Which of the following statements accurately describes this technique and its implications?
Correct Answer & Explanation
. FDP lengthening is typically performed via a Z-plasty in the mid-palmar or forearm region, aiming to achieve appropriate tension without causing a quadriga effect.
Explanation
Correct Answer: CExplanation:The case provides specific details regarding FDP lengthening:Option C (Correct): The case states: 'Expose the FDP tendon well, typically in the mid-palmar or forearm region to gain sufficient length for a Z-plasty... Perform a Z-lengthening of the FDP tendon... The ideal tension is achieved when the affected digit can passively extend completely while maintaining a normal resting cascade, and can actively flex without paradoxical extension. A useful clinical test is to ensure the repaired FDP tendon allows the digit to passively extend fully without causing adjacent digits to flex prematurely (quadriga effect).' The image provided could represent such a Z-lengthening.Option A (Incorrect): The case states that 'simple lumbrical tenotomy... is the most effective and least morbid surgical intervention for established lumbrical plus deformity.' FDP lengthening is 'generally reserved for cases where... The primary etiology is clearly demonstrated to be iatrogenic overtensioning of the FDP tendon... or a simple lumbrical tenotomy has failed.'Option B (Incorrect): FDP lengthening is typically performed via a Z-plasty (longitudinal incision with a Z-shape or step-cut), not a simple transverse incision with a gap, which would be less stable and prone to gapping.Option D (Incorrect): The case explicitly states that FDP lengthening is 'More extensive surgery, longer recovery, higher risk of adhesions, and potential for flexor weakness if over-lengthened.' This contradicts the statement.Option E (Incorrect): The ideal tension ensures the digit can passively extend completelywithout causing adjacent digits to flex prematurely (quadriga effect). The option incorrectly states that it allows adjacent digits to flex prematurely.
Question 329
Topic: Surgical Anatomy & Approaches
A hand surgeon is reviewing the literature on lumbrical plus deformity to prepare for a complex case. The literature consistently emphasizes the standard surgical approach and its rationale. Which of the following statements accurately reflects the consensus in current hand surgery literature regarding the primary surgical intervention for established lumbrical plus deformity?
Correct Answer & Explanation
. Simple lumbrical tenotomy at its origin from the FDP tendon is the most effective and least morbid intervention, with functional loss generally well-compensated.
Explanation
Correct Answer: CExplanation:The 'Summary of Key Literature / Guidelines' section clearly outlines the standard surgical approach:Option C (Correct): The case states: 'The overwhelming consensus in current hand surgery literature is that simple lumbrical tenotomy at its origin from the FDP tendon is the most effective and least morbid surgical intervention for established lumbrical plus deformity... The loss of a single lumbrical's specific function is generally well-compensated by other intrinsic muscles, and the functional gain from improved FDP excursion is significant.'Option A (Incorrect): FDP lengthening is described as 'a more involved procedure and is generally reserved for cases where... The primary etiology is clearly demonstrated to be iatrogenic overtensioning of the FDP tendon... or a simple lumbrical tenotomy has failed.' It is not the preferred initial procedure for all cases.Option B (Incorrect): Lumbrical advancement/recession is described as 'Less commonly performed as the primary solution for established lumbrical plus' and 'Technically more demanding, higher risk of recurrence.'Option D (Incorrect): EDC tendon transfer to the FDP is not mentioned as a standard treatment for lumbrical plus deformity.Option E (Incorrect): Arthrodesis is a joint fusion procedure, typically reserved for severe, painful arthritis or instability, not for correcting a dynamic tendon imbalance like lumbrical plus. The goal is to restore motion, not eliminate it.
Question 330
Topic: Surgical Anatomy & Approaches
A 35-year-old patient presents with a pure angular varus deformity of the distal tibia. Pre-operative planning identifies the Center of Rotation of Angulation (CORA) 5 cm proximal to the ankle joint. The surgeon plans a corrective osteotomy to achieve perfect alignment without any translation of the bone segments. According to Paley's Three Rules of Osteotomy, which of the following surgical approaches is most appropriate?
Correct Answer & Explanation
. Perform the osteotomy and place the hinge exactly at the CORA.
Explanation
Correct Answer: CThe text describes Paley's Osteotomy Rule 1: 'If the osteotomy (the bone cut) and the ACA (the hinge) pass through the CORA, the deformity will correct with pure angulation. The mechanical axes of the proximal and distal segments will perfectly align without any translation (displacement) of the bone ends. This is the ideal scenario for most simple deformities.' To achieve perfect alignment without translation, both the osteotomy cut and the hinge must be placed precisely at the CORA.Option A is incorrectbecause placing the osteotomy away from the CORA, even with the hinge at the CORA, would result in translation (Paley's Rule 2).Option B is incorrectfor the same reason as Option A; placing the osteotomy away from the CORA results in translation.Option D is incorrectbecause placing both the cut and the hinge away from the CORA would result in a new translation deformity and a zigzag appearance (Paley's Rule 3).Option E is incorrectbecause a double-level osteotomy is typically used for double-level deformities or to distribute correction, not for a pure angular deformity where the CORA is clearly identified at a single level, especially when the goal is pure angulation without translation.
Question 331
Topic: Surgical Anatomy & Approaches
Before the widespread adoption of Paley's principles, a surgeon performed an osteotomy based on a subjective visual assessment of a patient's genu varum, without precise angular measurements or mechanical axis analysis.
According to the case, what was a common outcome of osteotomies planned based on intuition and subjective visual assessment in the pre-Paley era?
Correct Answer & Explanation
. Unpredictable outcomes and iatrogenic secondary deformities.
Explanation
Correct Answer: CThe case explicitly contrasts the pre-Paley era with the current systematic approach: 'Before the widespread adoption of Paley's principles of deformity correction, osteotomies were often planned based on intuition and subjective visual assessment, leading to unpredictable outcomes and iatrogenic secondary deformities.' This highlights the significant problem that Paley's method aimed to solve by introducing precision and standardization. The other options describe desirable outcomes that were oftennotachieved in the pre-Paley era due to the lack of a systematic approach.
Question 332
Topic: Surgical Anatomy & Approaches
During a transperitoneal approach to the L5-S1 interspace, care must be taken to protect the superior hypogastric plexus from injury. Which of the following techniques reduces the risk of neurologic injury?
Correct Answer & Explanation
. Vertical midline incision of the posterior peritoneum, reflecting the prevertebral tissues beginning at the margin of the left iliac vein and extending toward the right iliac vein
Explanation
DISCUSSION: Retrograde ejaculation is the sequela of superior hypogastric plexus injury. This structure needs protection, especially during anterior exposure of the L5-S1 disk space. Only blunt dissection should be used, and use of monopolar electrocautery should be avoided. If possible, preserve and retract the middle sacral artery. Once the iliac veins are isolated, blunt dissection is begun along the course of the medial edge of the left iliac vein, reflecting the prevertebral tissues toward the patientโs right side. The dissection goes from left to right because the parasympathetic plexus is more adherent on the right side. REFERENCE: Transperitoneal midline approach to L4-S1, in Watkins RG (ed): Surgical Approaches to the Spine, ed 1. New York, NY, Springer Verlag, 1983, pp 123-129.
Question 333
Topic: Surgical Anatomy & Approaches
A patient wakes up with a foot drop following open reduction internal fixation of a posterior wall/posterior column acetabular fracture. What position of the leg causes the highest intraneural pressure in the sciatic nerve?
Correct Answer & Explanation
. hip flexion to 90, knee extension
Explanation
DISCUSSION: Borrelli et al examined the intraneural pressure of the sciatic nerve with the hip and knee in various different positions. They found that the "sciatic nerve appeared to exceed published critical thresholds for alterations of blood flow and neural function only when the hip was flexed to 90 degrees and the knee was fully extended." As a result, the leg is typically positioned with the hip in extension (or minimal flexion) and the knee in about 90 degrees of flexion when performing acetabular surgery via a posterior approach.
Question 334
Topic: Surgical Anatomy & Approaches
Figure 44 shows the AP radiograph of the hip of a patient who underwent screw fixation of the acetabulum. Which of the following structures is at least risk for injury during screw placement in the acetabular component?
Correct Answer & Explanation
. Common iliac artery
Explanation
DISCUSSION: Acetabular screws are inserted to supplement fixation. The acetabular component can be divided into four quadrants. Anatomic studies have shown that screws placed in the anterior superior and anterior inferior quadrants of the cup may injure the external iliac vein and obturator artery, respectively. Posterior superior and posterior inferior placement (in screws greater than 25 mm) may injure the sciatic nerve or the superior gluteal artery. The common iliac artery is proximal to the acetabulum and is at least risk for injury from acetabular screw placement. REFERENCE: Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 207-215.
Question 335
Topic: Surgical Anatomy & Approaches
Which of the following nerves is most commonly injured during revision surgery following a Bristow procedure?
Correct Answer & Explanation
. Musculocutaneous
Explanation
Because of the previously transferred bone block of coracoid and short arm flexors, the musculocutaneous nerve often scars along the anteroinferior glenohumeral capsule. Mobilization of this tissue places the nerve at greatest risk. The axillary nerve is also potentially at risk, but this is nonspecific to prior surgery, particularly the Bristow procedure.
Question 336
Topic: Surgical Anatomy & Approaches
A 72-year-old woman who sustained a cerebrovascular accident 9 months ago now has a fixed elbow flexion contracture of 80 degrees. Management should consist of
Correct Answer & Explanation
. musculocutaneous neurectomy and serial casting.
Explanation
DISCUSSION: A flexion contracture of the elbow is commonly seen in hemiplegic patients following cerebrovascular accidents. Spasticity and myostatic contracture of the joint are both causative factors. In patients with a flexion deformity of less than 90 degrees, musculocutaneous neurectomy is recommended, followed by serial casting to treat any residual deformity. At 9 months after injury, physical therapy will not significantly improve motion. Nerve blocks may be used in the early stages of recovery to facilitate therapy and serial casting. REFERENCE: Waters RL, Keenan ME: Surgical treatment of the upper extremity after stroke, in Chapman MW (ed): Operative Orthopedics. Philadelphia, PA, JB Lippincott, 1988, vol 2, pp 1449-1450.
Question 337
Topic: Surgical Anatomy & Approaches
A 20-year-old woman sustained the closed injury shown in Figures 49a and 49b in a motor vehicle accident. Examination reveals that this is an isolated injury; however, she has a complete radial nerve palsy. Management should consist of
Correct Answer & Explanation
. intramedullary nailing.
Explanation
DISCUSSION: Lacerated radial nerves are associated with open humeral fractures. All open humeral fractures with radial nerve palsy should be managed with radial nerve exploration and skeletal stabilization. Closed humeral fractures with associated radial nerve palsy usually have an intact nerve with neurapraxia. Most of these patients recover without surgical treatment. If the patient has multiple injuries, skeletal stabilization may be indicated to improve mobilization. For an isolated closed humeral fracture with a radial nerve palsy, the treatment of choice is splinting for 1 to 2 weeks, followed by a humeral fracture brace. REFERENCES: Ring D, Chin K, Jupiter JB: Radial nerve palsy associated with high-energy humeral shaft fractures. J Hand Surg Am 2004;29:144-147. Foster RJ, Swiontkowski MF, Bach AW, et al: Radial nerve palsy caused by open humeral shaft fractures. J Hand Surg Am 1993;18:121-124.
Question 338
Topic: Surgical Anatomy & Approaches
A 38-year-old woman fell from a ladder onto her right hip. The radiographs and CT scan are shown in Figures 52a through 52d. What is the best surgical approach for this fracture?
Correct Answer & Explanation
. Ilioinguinal
Explanation
DISCUSSION: The fracture is an associated both column fracture. The best approach for this fracture is the ilioinguinal. The Kocher-Langenbeck is best for posterior injuries to the acetabulum and some transverse fractures. The iliofemoral alone is limited to high anterior column injuries. The extended iliofemoral and triradiate approaches, although useful for this fracture, have a higher rate of complications. REFERENCES: Letournel E: The treatment of acetabular fractures through the ilioinguinal approach. Clin Orthop Relat Res 1993;292:62-76. Matta JM: Operative treatment of acetabular fractures through the ilioinguinal approach: A 10-year perspective. Clin Orthop Relat Res 1994;305:10-19.
Question 339
Topic: Surgical Anatomy & Approaches
What complication is more likely following excessive medial retraction of the anterior covering structures during the anterolateral (Watson-Jones) approach to the hip?
Correct Answer & Explanation
. Quadriceps weakness
Explanation
DISCUSSION: The femoral nerve is the most lateral structure in the anterior neurovascular bundle. The femoral artery and vein lie medial to the nerve. Retractors placed in the anterior acetabular lip should be safe, although neurapraxia of the femoral nerve may occur if retraction is prolonged or forceful leading to quadriceps weakness. The femoral artery and nerve are well protected by the interposed psoas muscle. Damage to the lateral femoral cutaneous nerve, causing numbness over the anterolateral thigh, can occur while developing the interval between the tensor fascia latae and sartorious in the anterior (Smith-Petersen) approach but less likely in the Watson-Jones approach. Superior gluteal injury and accompanying abductor insufficiency may occur during excessive splitting of the glutei during the direct lateral (Hardinge) approach. Foot drop secondary to sciatic injury is more common with a posterior exposure or posterior retractor placement. REFERENCES: Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia, PA, JB Lippincott, 1984, p 325. Anderson JE: Grantโs Atlas of Anatomy, ed 7. Baltimore, MD, Lippincott Williams & Wilkins, 1978, pp 4-17, 4-18.
Question 340
Topic: Surgical Anatomy & Approaches
A 39-year-old competitive cyclist sustains an injury to her left hip in a fall. Gadolinium arthrography, with an accompanying MRI scan, is shown in Figure 31. A cleft, or defect, identified by the arrow, indicates a detachment of the:
Correct Answer & Explanation
. acetabular labrum.
Explanation
DISCUSSION: The area indicated by the arrow represents gadolinium contrast extending into a separation between the lateral labrum and its acetabular attachment. This can be a traumatic detachment, but occasionally a cleft may be present as a normal variant of the labral morphology. The capsular attachment of the iliofemoral ligament is peripheral to the labrum. The pulvinar is the common name applied to the fat and overlying synovium contained within the acetabular fossa above the ligamentum teres. The zona orbicularis is a circumferential thickening of the capsule around the femoral neck, and the retinacular vessels travel within the capsular synovium up the femoral neck to supply the femoral head. REFERENCES: Petersilge CA, Haque MA, Petersilge WJ, Lewin JS, Lieberman JM, Buly R: Acetabular labral tears: Evaluation with MR arthrography. Radiology 1996;200:231-235. Czerny C, Hofmann S, Neuhold A, et al: Lesions of the acetabular labrum: Accuracy of MR imaging and MR arthrography in detection and staging. Radiology 1996;200:225-230. Byrd JWT: Indications and contraindications, in Byrd JWT (ed): Operative Hip Arthroscopy. New York, NY, Thieme, 1998, pp 7-24.
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