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Surgical Anatomy & Approaches MCQs

Practice Set 19 of 102

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 361

Topic: Surgical Anatomy & Approaches

A 35-year-old man has profound deltoid weakness after sustaining a traumatic anterior shoulder dislocation 6 weeks ago. Electromyographic (EMG) studies confirm an axillary nerve injury. Follow-up examination at 3 months reveals no recovery of function. What is the best course of action?

. Surgical repair of the Bankart lesion
. Exploration of the axillary nerve
. MRI neurography
. Repeat EMG studies
. Continued observation and physical therapy

Correct Answer & Explanation

. Surgical repair of the Bankart lesion

Explanation

DISCUSSION: Documenting the status of recovery at this time is appropriate; therefore, repeat EMG studies should be conducted to check for early signs of reinnervation.  Timing of nerve exploration in this setting is debated, with authors suggesting exploration if there is no sign of recovery at 6 to 9 months.REFERENCES: Perlmutter GS: Axillary nerve injury.  Clin Orthop 1999;368:28-36.Artico M, Salvati M, D’Andrea V, et al: Isolated lesions of the axillary nerves: Surgical treatment and outcome in twelve cases.  Neurosurgery 1991;29:697-700.Vissar CP, Coene LN, Brand R, et al: The incidence of nerve injury in anterior dislocation of the shoulder and its influence on functional recovery: A prospective clinical and EMG study.  J Bone Joint Surg Br 1999;81:679-685.Pasila M, Jarma H, Kiviluoto O, et al: Early complications of primary shoulder dislocations.  Acta Orthop Scand 1978;49:260-263.

Question 362

Topic: Surgical Anatomy & Approaches

A 25-year-old male involved in a motor vehicle accident sustains multiple injuries. He undergoes operative treatment for his humeral shaft fracture. Figures A and B show his preoperative and postoperative radiographs. The distal interlocks for this implant place which of the following nerves at risk?

. Radial
. Ulnar
. Anterior interosseous
. Axillary
. Musculocutaneous

Correct Answer & Explanation

. Radial

Explanation

With intramedullary (IM) nailing of the humerus, the distal anterior-to-posterior interlocking screws place the musculocutaneous nerve at high risk for injury as it goes through the coracobrachialis muscle and courses anteriorly along the brachialis (of which it innervates the medial half).Rupp et al performed a cadaveric study with IM nails utilizing either lateral-to-medial or anterior-to-posterior distal interlocking screws. They showed that anterior-to-posterior screws placed the musculocutaneous nerve at high risk, while lateral-to-medial screws placed the radial nerve at high risk as it courses laterally distally along the humerus.OrthoCash 2020

Question 363

Topic: Surgical Anatomy & Approaches
Bleeding is encountered while developing the internervous plane between the tensor fascia lata and the sartorius during the anterior approach to the hip. The most likely cause is injury to what artery?
. Ascending branch of the lateral femoral circumflex
. Superior gluteal
. Femoral
. Profunda femoris
. Medial femoral circumflex

Correct Answer & Explanation

. Ascending branch of the lateral femoral circumflex

Explanation

DISCUSSION: The ascending branch of the lateral femoral circumflex artery crosses the gap between the tensor fascia lata and the sartorius and must be identified and ligated or coagulated. The other vessels are out of the field of dissection. REFERENCES: Barrack RL, Booth RE Jr, Lonner JH, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, p 312. Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia, PA, JB Lippincott, 1984, p 304.

Question 364

Topic: Surgical Anatomy & Approaches
What approach should be chosen for the injury seen in Figure 67?
. Stoppa
. Hardinge
. Ilioinguinal
. Watson Jones
. Kocher-Langenbeck

Correct Answer & Explanation

. Kocher-Langenbeck

Explanation

Which of the following statements about the lateral femoral cutaneous nerve is true? It courses under the inguinal ligament.

Question 365

Topic: Surgical Anatomy & Approaches
The preferred surgical approach to the elbow of a child with an irreducible type III supracondylar distal humerus fracture and pulseless extremity is through which of the following muscle intervals?
. Pronator teres and the brachialis
. Pronator teres and the triceps
. Pronator teres and the biceps
. Brachioradialis and the biceps
. Brachioradialis and the brachialis

Correct Answer & Explanation

. Pronator teres and the brachialis

Explanation

DISCUSSION: In a type III supracondylar distal humerus fracture of the elbow, the brachial artery can become incarcerated, yielding a pulseless extremity. In this situation, closed reduction may not be effective; therefore, open management is often necessary. The preferred surgical approach to the brachial artery and to this fracture is the anterior approach to the cubital fossa. The lacertus fibrosus is incised, and the dissection is carried out between the brachialis (musculocutaneous nerve) and the pronator teres (median nerve), mobilizing the brachial artery. Once the brachial artery is mobilized, the anterior elbow joint capsule may be exposed. The interval between the brachialis and the biceps describes the anterolateral approach to the elbow more commonly used for exposure of the proximal aspect of the posterior interosseous nerve. The dissection interval between the brachioradialis and the pronator teres describes the proximal extent of the anterior approach to the radius. REFERENCES: Tubiana R, McCullough CJ, Masquelet AC: An Atlas of Surgical Exposures of the Upper Extremity. Philadelphia, PA, JB Lippincott, 1990, p 115. Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach, ed 2. Philadelphia, PA, Lippincott-Raven, 1992, p 119.

Question 366

Topic: Surgical Anatomy & Approaches
The quadrilateral space in the shoulder contains which of the following structures?
. Axillary nerve and posterior humeral circumflex artery
. Axillary artery and radial nerve
. Axillary artery and axillary nerve
. Recurrent suprascapular nerve and artery
. Profunda brachii artery

Correct Answer & Explanation

. Axillary nerve and posterior humeral circumflex artery

Explanation

The quadrilateral space of the shoulder is formed laterally by the humerus, proximally by the subscapularis (and teres minor viewed from posterior), distally by the teres major, and medially by the long head of the triceps. The posterior humeral circumflex artery and axillary nerve pass through it.

Question 367

Topic: Surgical Anatomy & Approaches
A 25-year-old right-hand dominant professional baseball pitcher complains of posteromedial right elbow pain that is worsened by throwing. He also reports occasional paresthesias in his small and ring finger after lengthy bullpen sessions. On examination, he is tender along the medial olecranon and complains of pain when extending the elbow > 20° of extension. He has negative valgus stress, moving valgus stress, and milking maneuver tests. He is stable to varus stress, chair rise, and lateral pivot shift tests. Radiographs reveal a small osteophyte along the posteromedial border of the olecranon. What is the most likely diagnosis?
. Valgus extension overload
. Varus posteromedial rotatory instability (VPMRI)
. Valgus posterolateral rotatory instability (VPLRI)
. Olecranon bursitis

Correct Answer & Explanation

. Valgus extension overload

Explanation

The patient has valgus extension overload. This is a spectrum of pathologies, often seen in pitchers, that begins with posteromedial impingement between the medial olecranon and posterior trochlea during forceful elbow extension. As a result, a medial olecranon osteophyte is typically the first notable imaging finding. As pathology increases, there can be progressive damage to the medial collateral ligament (MCL), degeneration of the radiocapitellar articulation, and neuritis of the ulnar nerve. VPMRI is often associated with a large anteromedial coronoid fracture and posterior band MCL rupture. VPLRI occurs when the lateral collateral ligament complex is ruptured. Olecranon bursitis presents with focal swelling or a fluid collection over the posterior aspect of the olecranon.

Question 368

Topic: Surgical Anatomy & Approaches

Figures 1 and 2 are the radiographs of a 24-year-old male wrestler who underwent surgery for recurrent shoulder dislocations using coracoid autograft. At his first postoperative visit, the patient complains of decreased sensation on the lateral aspect of his forearm. The patient’s symptoms are most likely due to injury of the

. axillary nerve.
. musculocutaneous nerve.
. median nerve.
. radial nerve.

Correct Answer & Explanation

. musculocutaneous nerve.

Explanation

The patient has undergone a Latarjet procedure as shown in the radiographs. After harvesting the coracoid graft, care must be taken to not place too much tension on or dissect excessively near the musculocutaneous nerve. The nerve is encountered 5 cm distal to the coracoid as it enters the conjoint tendon. The lateral antebrachial cutaneous nerve is the terminal branch of the musculocutaneous nerve and; therefore, injury can cause decreased sensation in the lateral forearm.

Question 369

Topic: Surgical Anatomy & Approaches
A 32-year-old man has a closed oblique displaced fracture at the junction of the lower and middle third of the humeral shaft and a complete radial nerve palsy. Closed reduction is performed and is felt to be acceptable. Management of the radial nerve palsy should consist of
. exploration and repair of the radial nerve if clinical findings or electromyographic studies show no improvement at 2 to 3 weeks.
. exploration and repair of the radial nerve if clinical findings or electromyographic studies show no improvement at 14 weeks.
. transfer of the pronator teres to the extensor carpi radialis brevis if clinical findings or electromyographic studies show no improvement at 14 weeks.
. immediate exploration and repair of the radial nerve, along with internal fixation with a plate and screws.
. immediate exploration and repair of the radial nerve, along with internal fixation with an intramedullary nail.

Correct Answer & Explanation

. exploration and repair of the radial nerve if clinical findings or electromyographic studies show no improvement at 14 weeks.

Explanation

In patients who have radial nerve dysfunction associated with a closed humeral fracture, nerve function usually will return to normal without surgical exploration. If clinical findings or electromyographic studies show no improvement at 3 months, surgical exploration and repair can be performed. Tendon transfers are performed if nerve repair is deemed unsuccessful.

Question 370

Topic: Surgical Anatomy & Approaches
The sartorius muscle is innervated by which of the following nerves?
. Femoral
. Obturator
. Superior gluteal
. Inferior gluteal
. Ilioinguinal

Correct Answer & Explanation

. Femoral

Explanation

The femoral nerve enters the thigh behind the inguinal ligament, lying on the surface of the iliopsoas muscle lateral to the femoral artery and vein. The nerve divides into numerous muscular and cutaneous branches in the femoral triangle. The first motor branch (sometimes two branches) is to the sartorius. There is a variable branch to the pectineus. Subsequent branches go to the rectus femoris and then the vastus muscles in variable order. The last motor branch is to the articularis genu. The muscular branches can be injured in anterior approaches to the hip, especially the middle window of the ilioinguinal approach.

Question 371

Topic: Surgical Anatomy & Approaches
When harvesting an iliac crest bone graft from the posterior approach, what anatomic structure is at greatest risk for injury if a Cobb elevator is directed too caudal?
. Sciatic nerve
. Cluneal nerves
. Inferior gluteal artery
. Superior gluteal artery
. Sacroiliac joint

Correct Answer & Explanation

. Superior gluteal artery

Explanation

DISCUSSION: If a Cobb elevator is directed caudally while stripping the periosteum over the iliac wing, it will encounter the sciatic notch. Although this puts the sciatic nerve at risk, the first structure encountered is the superior gluteal artery. Because it is tethered at the superior edge of the notch, it is very vulnerable to injury and can then retract inside the pelvis, making it difficult to obtain hemostasis. The inferior gluteal artery exits the sciatic notch below the piriformis and is more protected. The cluneal nerves are at risk only if the incision extends too anteriorly, and the sacroiliac joint can be entered while harvesting the graft.

Question 372

Topic: Surgical Anatomy & Approaches

What neurovascular structure is at greatest risk when creating a proximal anterolateral elbow arthroscopy portal? Review Topic

. Lateral antebrachial cutaneous nerve
. Radial nerve
. Posterior interosseous nerve
. Median nerve
. Brachial artery

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve

Explanation

The radial nerve is 4 to 7 mm from the anterolateral portal, which is placed 1 cm anterior and 3 cm proximal to the lateral epicondyle. The posterior interosseous nerve can lie 1 to 14 mm from the portal site.

Question 373

Topic: Surgical Anatomy & Approaches
  • Which of the following surgical approaches to the hip is associated with the highest incidence of heterotopic ossification?
. Ilioinguinal
. Extended iliofemoral
. Combined ilioinguinal and Kocher-Langenbeck (posterior)
. Kocher-Langenbeck (posterior)
. Kocher-Langenbeck (posterior) with trochanteric osteotomy

Correct Answer & Explanation

. Ilioinguinal

Explanation

Significant extopic bone formation results from a combination of initial trauma to the gluteal muscle mass and surgical exposure of the lateral surface of the pelvis. Extensile (extended iliofemoral or triradiate) approaches are associated with the highest incidence of ectopic bone formation, whereas the ilioinguinal approach is rarely associated with this complication. Many of the fractures described in this chapter require a posterolateral or extensile approach in order to achieve acceptable fracture reduction. When these approaches must be used, local measures may be helpful in reducing the incidence of heterotopic ossification. Debridement of devitalized muscle, particularly the gluteus minimus, has been shown to limit the extent of ectopic bone formation.Prevention:incision choice: ilioinguinal if possibleradiationindocin (give pepcid with it)

Question 374

Topic: Surgical Anatomy & Approaches
In a retroperitoneal approach to the lumbar spine, what nerve is commonly found on the psoas muscle?
. Ilioinguinal
. Iliohypogastric
. Genitofemoral
. Obturator
. Femoral

Correct Answer & Explanation

. Genitofemoral

Explanation

The genitofemoral nerve and the sympathetic plexus consistently lie on the ventral surface of the psoas muscle. The ilioinguinal and iliohypogastric nerves are the most superior branches of the lumbar plexus and emerge along the upper lateral border of the psoas muscle traveling toward the quadratus lumborum. Both the obturator and femoral nerves are deep and lateral to the psoas muscle.

Question 375

Topic: Surgical Anatomy & Approaches
The posterior approach to the proximal radius uses what intermuscular interval?
. Extensor carpi radialis brevis and extensor digitorum communis
. Extensor carpi radialis longus and extensor digitorum communis
. Extensor digitorum communis and extensor pollicis brevis
. Brachioradialis and flexor carpi radialis
. Anconeus and extensor carpi ulnaris

Correct Answer & Explanation

. Extensor carpi radialis brevis and extensor digitorum communis

Explanation

Knowledge of intermuscular and internervous planes allows safe exposures throughout the body. The posterior (Thompson) approach to the proximal forearm uses the interval between the extensor carpi radialis brevis and extensor digitorum communis. The anterior (Henry) approach to the proximal forearm uses the interval between the brachioradialis and the flexor carpi radialis.

Question 376

Topic: Surgical Anatomy & Approaches
A patient has a humeral shaft fracture and is scheduled to undergo open reduction and internal fixation with a plate. What surgical approach will provide the greatest amount of exposure?
. Modified posterior approach with elevation of the medial and lateral heads of the triceps
. Posterior triceps-splitting approach
. Posterior triceps-splitting approach with radial nerve mobilization
. Posteromedial approach
. Lateral approach with radial nerve mobilization

Correct Answer & Explanation

. Modified posterior approach with elevation of the medial and lateral heads of the triceps

Explanation

DISCUSSION: The modified posterior approach with elevation of the medial and lateral heads of the triceps can provide exposure of 94% of the humeral shaft. The traditional posterior triceps-splitting approach exposes 55% of the humeral shaft. REFERENCES: DeFranco MJ, Lawton JN: Radial nerve injuries associated with humeral fractures. J Hand Surg Am 2006;31:655-663. Gerwin M, Hotchkiss RN, Weiland AJ: Alternative operative exposure of the posterior aspect of the humeral diaphysis with reference to the radial nerve. J Bone Joint Surg Am 1996;78:1690-1695.

Question 377

Topic: Surgical Anatomy & Approaches

During an ilioinguinal approach for fixation of the anterior pelvic ring, brisk bleeding is encountered as the dissection is extended along the superior pubic ramus approximately 5 cm from the midline. What structure has most likely been injured?

. A branch of the femoral artery
. An anastomosis between the external iliac artery and obturator artery
. An anastomosis between the external iliac and femoral artery
. Internal iliac artery
. External iliac artery

Correct Answer & Explanation

. A branch of the femoral artery

Explanation

The corona mortis, or "crown of death," is a common anatomic variant that consists of an anastomosis between the obturator and the external iliac or inferior epigastric arteries or veins. Its reported incidence is over 80%. It is located behind the superior pubic ramus at a variable distance from the symphysis pubis (3 cm to 9 cm). It is at risk during surgical approaches to the anterior pelvic ring. If accidentally cut, the vessel can retract making control of hemorrhage difficult.

Question 378

Topic: Surgical Anatomy & Approaches

During establishment of an anterior portal for hip arthroscopy, what structure is at greatest risk for injury? Review Topic

. Lateral femoral cutaneous nerve
. Femoral nerve
. Femoral artery
. Superior gluteal nerve
. Sciatic nerve

Correct Answer & Explanation

. Lateral femoral cutaneous nerve

Explanation

The anterior portal for hip arthroscopy is approximately 6 cm distal to the anterior superior iliac spine, penetrating the muscle belly of the sartorius and the rectus femoris before entering through the anterior capsule. The lateral femoral cutaneous nerve is divided into three or more branches at the level of this portal and may be injured during portal placement. The femoral nerve and artery are more medial and at less risk. The superior gluteal and sciatic nerves are posterior and not at risk with an anterior portal.

Question 379

Topic: Surgical Anatomy & Approaches
The brachialis muscle is innervated by what two nerves?
. Radial and musculocutaneous
. Lateral and medial brachial cutaneous
. Axillary and medial and lateral pectoral
. Radial and ulnar
. Ulnar and musculocutaneous

Correct Answer & Explanation

. Radial and musculocutaneous

Explanation

The brachialis is innervated by two nerves: medially, the musculocutaneous nerve; laterally, the radial nerve. The muscle is split longitudinally to approach the humerus anteriorly.

Question 380

Topic: Surgical Anatomy & Approaches

During a direct anterior approach for total hip arthroplasty, the surgeon develops the superficial internervous plane. The ascending branches of the lateral femoral circumflex artery are typically encountered and must be ligated. These vessels cross the operative field between which two muscles?

. Sartorius and Tensor fasciae latae
. Rectus femoris and Tensor fasciae latae
. Gluteus medius and Tensor fasciae latae
. Adductor longus and Gracilis
. Iliopsoas and Pectineus

Correct Answer & Explanation

. Sartorius and Tensor fasciae latae

Explanation

The direct anterior approach (Smith-Petersen) utilizes the true internervous plane between the Sartorius (femoral nerve) and the Tensor fasciae latae (superior gluteal nerve). The ascending branches of the lateral femoral circumflex artery cross this interval transversely and must be identified and ligated to prevent significant postoperative hematoma.

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