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Surgical Anatomy & Approaches MCQs

Practice Set 20 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 381

Topic: Surgical Anatomy & Approaches

Sciatic nerve

. The sciatic nerve is in the posterior compartment of the thigh and can be palpated at the midpoint between the ischial tuberosity and the greater trochanter when the hip is flexed.
. The obturator nerve is in the medial compartment of the thigh. The femoral nerve is in the anterior compartment of the thigh.
. The peroneal (common peroneal) nerve bifurcates into the deep peroneal and the superficial peroneal nerves which lie in the anterior and lateral compartments of the leg, respectively.

Correct Answer & Explanation

. The sciatic nerve is in the posterior compartment of the thigh and can be palpated at the midpoint between the ischial tuberosity and the greater trochanter when the hip is flexed.

Explanation

(999) Q1-1306:The principal thrombogenic stimulus leading to the production of venous thromboembolic disease during total hip arthroplasty occurs at which time:

Question 382

Topic: Surgical Anatomy & Approaches

During an anterior intrapelvic (Stoppa) approach for the fixation of an acetabular fracture, massive hemorrhage is encountered from a vessel located over the posterior aspect of the superior pubic ramus. This bleeding is most likely due to an injury to an anastomosis between which two vascular systems?

. Internal pudendal and inferior gluteal
. External iliac (or inferior epigastric) and obturator
. Internal iliac and internal pudendal
. Femoral and deep circumflex iliac
. Superior gluteal and internal iliac

Correct Answer & Explanation

. Internal pudendal and inferior gluteal

Explanation

The corona mortis ('crown of death') is a common vascular anastomosis between the external iliac or inferior epigastric vessels and the obturator vessels (a branch of the internal iliac system). It is located on the posterior aspect of the superior pubic ramus and is highly vulnerable during anterior pelvic approaches.

Question 383

Topic: Surgical Anatomy & Approaches

During an anterior intrapelvic (modified Stoppa) approach for an acetabular fracture, significant hemorrhage occurs while dissecting over the superior pubic ramus. This is most likely due to an injury to the 'corona mortis,' which represents an anastomosis between which two vessels?

. Internal pudendal artery and external iliac vein
. External iliac artery and obturator vein
. Obturator artery and internal iliac vein
. External iliac system and obturator system
. Superior gluteal artery and inferior epigastric artery

Correct Answer & Explanation

. Internal pudendal artery and external iliac vein

Explanation

The corona mortis is a vascular anastomosis between the external iliac (or inferior epigastric) vessels and the obturator vessels. It is located on the posterior aspect of the superior pubic ramus and is at high risk during the Stoppa approach.

Question 384

Topic: Surgical Anatomy & Approaches

A 26-year-old female undergoes hip arthroscopy for labral repair. Postoperatively, she reports numbness over the perineum and medial thigh, as well as transient sexual dysfunction. Which nerve was most likely compressed by the perineal post during traction?

. Lateral femoral cutaneous nerve
. Pudendal nerve
. Sciatic nerve
. Obturator nerve
. Femoral nerve

Correct Answer & Explanation

. Lateral femoral cutaneous nerve

Explanation

Pudendal nerve neuropraxia is a well-known complication of hip arthroscopy caused by compression against a poorly padded or malpositioned perineal post. It typically presents with groin, perineal, and genital numbness or dysfunction.

Question 385

Topic: Surgical Anatomy & Approaches

The anterolateral approach to the distal tibia is frequently utilized for pilon fractures. This approach utilizes an internervous plane between muscles innervated by which two nerves?

. Superficial peroneal and deep peroneal nerves
. Deep peroneal and tibial nerves
. Superficial peroneal and sural nerves
. Femoral and deep peroneal nerves
. Tibial and superficial peroneal nerves

Correct Answer & Explanation

. Superficial peroneal and deep peroneal nerves

Explanation

The anterolateral approach utilizes the internervous plane between the lateral compartment (fibularis tertius, innervated by the superficial peroneal nerve) and the anterior compartment (extensor digitorum longus, innervated by the deep peroneal nerve).

Question 386

Topic: Surgical Anatomy & Approaches

When utilizing an extended deltopectoral approach for open reduction internal fixation of a complex proximal humerus fracture, the axillary nerve is at risk inferiorly. What is the average distance from the lateral edge of the acromion to the axillary nerve as it crosses the humerus?

. 2 cm
. 6 cm
. 10 cm
. 14 cm
. 18 cm

Correct Answer & Explanation

. 2 cm

Explanation

The axillary nerve wraps around the surgical neck of the humerus approximately 5 to 7 cm distal to the lateral edge of the acromion. Care must be taken not to place retractors or plate screws blindly in this danger zone.

Question 387

Topic: Surgical Anatomy & Approaches

A 31-year-old man sustained an unstable closed left posterior hip dislocation in a motorcycle accident. A postreduction radiograph is shown in Figure 51a. 3-D CT scans are shown in Figures 51b and 51c. What is the optimal surgical approach that will allow for the most appropriate treatment?

. Surgical hip dislocation (“Berne” approach)
. Watson-Jones approach
. Smith-Peterson approach
. Kocher-Langenbeck approach
. Extensile iliofemoral approach

Correct Answer & Explanation

. Surgical hip dislocation (“Berne” approach)

Explanation

The radiograph and CT scans show a posterior wall acetabular fracture with an associated femoral head fracture. As is the case in most of these injuries, the femoral head fracture is located on the anterior aspect of the femoral head. Surgical dislocation with a trochanteric flip osteotomy as described by Solberg and associates and Henle and associates allows for exposure and treatment of the posterior wall fracture as well as surgical dislocation for treatment of the femoral head fracture. A Smith-Peterson approach or Watson-Jones approach would allow for anterior exposure and may help to address the femoral head fracture, but not the posterior wall fracture. A Kocher-Langenbach approach would allow exposure of the posterior wall fracture, but not the femoral head fracture. An extensile iliofemoral approach is unnecessary for this injury pattern.

Question 388

Topic: Surgical Anatomy & Approaches
During an open reduction internal fixation of a humerus fracture using the posterior approach, a surgeon can identify the posterior antebrachial cutaneous nerve and trace it proximally to which of the following nerves?
. Ulnar
. Musculocutaneous
. Radial
. Median
. Axillary

Correct Answer & Explanation

. Radial

Explanation

The posterior antebrachial cutaneous nerve branches from the radial nerve in the axilla. It extends distally to innervate the skin on the back of the arm. Gerwin et al recommended identifying the nerve first when approaching the humerus from the posterior shaft. It can be traced proximally to safely identify the radial nerve before any proximal exposure of the shaft is done.

Question 389

Topic: Surgical Anatomy & Approaches
What structure has been described as having a risk of injury with retractor placement on the sacrum during combined acetabular-pelvic ring surgery using the Stoppa approach with a lateral window?
. External iliac artery
. Obturator nerve
. Corona mortis
. L5 nerve root
. Ilioinguinal nerve

Correct Answer & Explanation

. L5 nerve root

Explanation

DISCUSSION: Care must be taken when placing a retractor on the anterior aspect of the sacrum, as the L4 and L5 nerve roots are both at risk. The L5 nerve root is 10 mm medial to the sacroiliac joint at the pelvic brim.

Question 390

Topic: Surgical Anatomy & Approaches

The direct anterior approach (Smith-Petersen) to the hip is increasingly popular for total hip arthroplasty. This approach utilizes a true internervous and intermuscular plane. Deep dissection occurs between which of the following muscles?

. Gluteus medius and tensor fasciae latae
. Rectus femoris and gluteus medius
. Sartorius and tensor fasciae latae
. Gluteus maximus and gluteus medius
. Pectineus and adductor longus

Correct Answer & Explanation

. Gluteus medius and tensor fasciae latae

Explanation

The direct anterior approach utilizes an internervous plane. Superficial dissection is between the sartorius (femoral nerve) and the tensor fasciae latae (superior gluteal nerve). The deep dissection continues between the rectus femoris (femoral nerve) and the gluteus medius (superior gluteal nerve).

Question 391

Topic: Surgical Anatomy & Approaches

During a direct anterior (Smith-Petersen) approach for total hip arthroplasty, the surgeon performs deep dissection between the sartorius and tensor fasciae latae. Which nerve is at greatest risk of iatrogenic injury if dissection is carelessly carried too superficially in this interval?

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

Correct Answer & Explanation

. Femoral nerve

Explanation

The lateral femoral cutaneous nerve (LFCN) is highly vulnerable during the superficial dissection of the direct anterior approach. It courses over the sartorius and can be injured, leading to meralgia paresthetica.

Question 392

Topic: Surgical Anatomy & Approaches

A 45-year-old male with end-stage avascular necrosis undergoes a primary total hip arthroplasty. The surgeon uses the direct anterior (Smith-Petersen) approach. Which of the following nerve injuries is most specifically associated with the superficial dissection of this approach?

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

Correct Answer & Explanation

. Superior gluteal nerve

Explanation

The direct anterior approach uses the internervous plane between the tensor fasciae latae (superior gluteal nerve) and the sartorius (femoral nerve). The lateral femoral cutaneous nerve courses superficially over the sartorius and is at highest risk during the superficial dissection.

Question 393

Topic: Surgical Anatomy & Approaches

A surgeon is performing a primary THA via the direct anterior (Smith-Petersen) approach. During the deep dissection between the tensor fasciae latae and sartorius, a vascular bundle is routinely encountered crossing the field that must be ligated to prevent excessive bleeding. This bundle represents branches of which of the following arteries?

. Medial femoral circumflex artery
. Lateral femoral circumflex artery
. Superior gluteal artery
. Inferior gluteal artery
. Obturator artery

Correct Answer & Explanation

. Medial femoral circumflex artery

Explanation

The ascending branches of the lateral femoral circumflex artery reliably cross the internervous plane of the direct anterior approach. Ligation or cauterization is necessary to maintain hemostasis.

Question 394

Topic: Surgical Anatomy & Approaches
When harvesting iliac crest bone graft during a posterior spinal decompression and fusion, injury to what structure can result in painful neuromas or numbness over the skin of the buttocks?
. Ilioinguinal nerve
. Superior gluteal nerve
. Superior cluneal nerves
. Iliohypogastric nerves
. Lateral femoral cutaneous nerve

Correct Answer & Explanation

. Superior cluneal nerves

Explanation

DISCUSSION: The superior cluneal nerves (L1, L2, and L3) are most at risk when harvesting iliac crest bone graft during a posterior decompression and fusion. These nerves pierce the lumbodorsal fascia and cross the posterior iliac crest, beginning 8 cm lateral to the posterior superior iliac spine.

Question 395

Topic: Surgical Anatomy & Approaches
In the anterior forearm approach to the distal radius (Henry approach), the radial artery is located between what two structures?
. Flexor carpi radialis tendon and flexor digitorum superficialis muscle
. Flexor carpi radialis and brachioradialis tendons
. Flexor carpi radialis and palmaris longus tendons
. Brachioradialis and flexor pollicis longus tendons
. Brachioradialis tendon and flexor digitorum superficialis muscle

Correct Answer & Explanation

. Flexor carpi radialis and brachioradialis tendons

Explanation

DISCUSSION: The standard approach to the volar aspect of the distal radius is the Henry approach. Following incision of the skin and subcutaneous tissues, the forearm fascia is incised. The radial artery and venae comitantes lie in the interval between the tendons of the flexor carpi radialis muscle and the brachioradialis muscle. This interval is developed, and the radial artery and veins are retracted in a radial direction.

Question 396

Topic: Surgical Anatomy & Approaches
Which of the following is considered the preferred approach to resect a lesion in the posterior one third of the proximal humerus?
. Triceps splitting
. Deltoid splitting
. Between the lateral head of the triceps and the deltoid muscle
. Between the long head of triceps and the deltoid muscle
. Between the long head of triceps and the teres major

Correct Answer & Explanation

. Between the lateral head of the triceps and the deltoid muscle

Explanation

DISCUSSION: At least 8 cm of the posterior aspect of the proximal region of the humeral diaphyseal cortex can be exposed through the interval between the lateral head of the triceps and the deltoid muscle. No nerves or blood vessels need to be exposed in the dissection. The deltoid muscle is innervated by the axillary nerve and the triceps muscle by the radial nerve. This is a true internervous plane. REFERENCE: Berger RA, Buckwalter JA: A posterior surgical approach to the proximal part of the humerus. J Bone Joint Surg Am 1989;71:407-410.

Question 397

Topic: Surgical Anatomy & Approaches
During the ilioinguinal approach to the pelvis, the corona mortis artery must be identified and ligated if present. The corona mortis artery joins the external iliac artery with which other major artery?
. Pudendal
. Deep iliac circumflex
. Hypogastric
. Obturator
. Testicular

Correct Answer & Explanation

. Obturator

Explanation

DISCUSSION: The "corona mortis" (translated as “crown of death”) artery is a vascular variant that joins the external iliac and the obturator artery as it crosses the superior pubic ramus. The corona mortis can be injured in superior ramus fractures and iatrogenically while plating pelvic ring injuries using the ilioinguinal approach.

Question 398

Topic: Surgical Anatomy & Approaches
  • Which of the following nerves supply the muscles on each side of internervous plane identified when performing the anterior (Smith-Petersen) approach to the hip?
. Femoral and obturator nerves
. Femoral and superior gluteal nerves
. Femoral and lateral femoral cutaneous nerves
. Obturator and superior gluteal nerves
. Obturator and lateral femoral cutaneous nerves

Correct Answer & Explanation

. Femoral and obturator nerves

Explanation

The anterior (Smith-Peterson) approach to the hip utilizes the superficial internervous plane between the sartorius (femoral nerve) and the tensor fascia lata (superior gluteal nerve). The deep internervous plane is between the rectus femoris (femoral nerve) and the gluteus medius (superior gluteal nerve).

Question 399

Topic: Surgical Anatomy & Approaches
The safest surgical approach to the insertion of the tibial posterior cruciate ligament uses the interval between which of the following muscles?
. Semimembranosus and medial gastrocnemius
. Semimembranosus and semitendinosus
. Medial and lateral gastrocnemius
. Lateral gastrocnemius and biceps femoris tendon
. Popliteus and lateral gastrocnemius

Correct Answer & Explanation

. Semimembranosus and medial gastrocnemius

Explanation

Discussion: Burks and Schaffer described an approach to the tibial insertion of the posterior cruciate ligament that uses the interval between the semimembranosus and the medial gastrocnemius. The medial gastrocnemius muscle is retracted laterally and protects the neurovascular bundle.

Question 400

Topic: Surgical Anatomy & Approaches
  • Which of the following nerves lying between the gluteus medius and minimus is at risk for injury in a lateral approach to the hip?
. Femoral
. Obturator
. Inferior gluteal
. Superior gluteal
. Lateral femoral cutaneous

Correct Answer & Explanation

. Femoral

Explanation

Femoral nerve is located in the anterior neurovascular bundle which does not lie between the gluteus medius minimus. Obturator arises from lumbar plexus supplies and runs with the adductor muscles. Inferior gluteal runs with the posterior neurovascular bundle which do not lie between these muscles. The lateral femoral cutaneous arises inferior and medial to the ASIS which is anterior and medial to this area as well.The direct lateral approach (Transgluteal approach). No true intervenous plane (“split the fibers” of the gluteus medius “distal to the point where the superior gluteal nerve supplies the muscle”). “Do not (split) more than 3 cm above the upper boarder of the trochanter.”

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