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Surgical Anatomy & Approaches MCQs

Practice Set 27 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 521

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

Upper Extremity 2005 Practice Questions: Set 1 (Solved) - Figure 10

. passive physical therapy.
. musculocutaneous neurectomy and serial casting.
. musculocutaneous nerve block.
. lengthening of the biceps tendon.
. distraction arthroplasty.

Correct Answer & Explanation

. musculocutaneous neurectomy and serial casting.

Explanation

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.

Question 522

Topic: Surgical Anatomy & Approaches

A 21-year-old hockey player who has recurrent shoulder subluxations undergoes an anterior capsulorrhaphy under general anesthesia, and an interscalene block is used to relieve postoperative pain. At the 1-week follow-up examination, he reports loss of sensation over the lateral region of the shoulder and is unable to actively contract the deltoid muscle. The remainder of the examination is normal. What is the best course of action at this time?

. Early exploration and possible repair of the axillary nerve
. Urgent electromyography to assess for level of nerve injury
. Continued normal postoperative care and observation of the nerve injury
. Consultation with the anesthesiologist regarding a complication of the interscalene block
. MRI to evaluate for a possible hematoma compressing the neurovascular bundle

Correct Answer & Explanation

. Continued normal postoperative care and observation of the nerve injury

Explanation

The patient has an axillary nerve injury, which is relatively uncommon after surgery for instability. This type of injury generally is the result of a stretch injury rather than transection or a hematoma. Therefore, observation is indicated in the early postoperative period. After approximately 6 weeks, electromyography can be used to confirm and document the point of injury. Interscalene blocks can cause prolonged nerve injury but usually are not limited to the axillary nerve.

Question 523

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

The ascending branch of the lateral femoral circumflex artery crosses the gap between the tensor fascia lata and the sartorious and must be identified and ligated or coagulated. The other vessels are out of the field of dissection. 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.

Question 524

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?

Anatomy Board Review 2002: High-Yield MCQs (Set 4) - Figure 6

. Common iliac artery
. Superior gluteal artery
. Obturator artery
. Sciatic nerve
. External iliac vein

Correct Answer & Explanation

. Common iliac artery

Explanation

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.

Question 525

Topic: Surgical Anatomy & Approaches

Injury to which of the following structures has been reported following iliac crest bone graft harvest?

Spine Surgery 2000 Practice Questions: Set 1 (Solved) - Figure 5

. Superior gluteal artery from an anterior crest harvest
. Superior cluneal nerve from an anterior crest harvest
. Inferior gluteal artery from a posterior crest harvest
. Ilioinguinal nerve from a posterior crest harvest
. Lateral femoral cutaneous nerve from an anterior crest harvest

Correct Answer & Explanation

. Lateral femoral cutaneous nerve from an anterior crest harvest

Explanation

Injury to the lateral femoral cutaneous nerve and the ilioinguinal nerve have both been described with an anterior iliac crest bone graft harvest. The lateral femoral cutaneous nerve may be injured from retraction after elevating the iliacus muscle or from direct injury when the nerve actually courses over the crest. A posterior crest harvest can injure the superior gluteal artery if a surgical instrument violates the sciatic notch. Injury to the inferior gluteal artery has not been described; it leaves the pelvis below the piriformis muscle belly and should not be at risk even with a violation of the sciatic notch. Injury to the ilioinguinal nerve has been reported from vigorous retraction of the iliacus muscle after exposing the inner table of the anterior ilium. Cluneal nerve injury may occur with posterior crest harvest, particularly if the skin incision is horizontal or extends more than 8 cm superolateral from the posterior superior iliac spine. Kurz LT, Garfin SR, Booth RE Jr: Iliac bone grafting: Techniques and complications of harvesting, in Garfin SR (ed): Complications of Spine Surgery. Baltimore, MD, Williams and Wilkins, 1989, pp 323-341.

Question 526

Topic: Surgical Anatomy & Approaches

A 25-year-old woman undergoes surgical treatment of a displaced proximal humeral fracture via a deltopectoral approach. At the first postoperative visit, she reports a tingling numbness along the anterolateral aspect of the forearm. What structure is most likely injured?

. Medial cord of the brachial plexus
. Radial nerve
. Median nerve
. Axillary nerve
. Musculocutaneous nerve

Correct Answer & Explanation

. Musculocutaneous nerve

Explanation

Sensation along the anterolateral aspect of the forearm is supplied by the lateral antebrachial cutaneous nerve, the terminal branch of the musculocutaneous nerve. The musculocutaneous nerve can be injured by proximal humeral fractures or dislocations, and is also at risk during surgical exposure if excessive retraction is placed on the conjoint tendon. The musculocutaneous nerve enters the conjoint tendon 1 cm to 5 cm distal to the coracoid process. McIlveen SJ, Duralde XA, D'Alessandro DF, et al: Isolated nerve injuries about the shoulder. Clin Orthop 1994;306:54-63.

Question 527

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

Sports Medicine 2001 Practice Questions: Set 3 (Solved) - Figure 10

. acetabular labrum.
. zona orbicularis.
. iliofemoral ligament.
. acetabular pulvinar.
. retinacular vessels.

Correct Answer & Explanation

. acetabular labrum.

Explanation

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. 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.

Question 528

Topic: Surgical Anatomy & Approaches

A 6-year-old boy falls on an outstretched hand. Radiographs of the elbow are shown below:

On physical examination, the child is unable to flex the interphalangeal joint of the thumb. Which nerve is most likely injured?

. Ulnar nerve
. Radial nerve
. Anterior interosseous nerve
. Posterior interosseous nerve
. Musculocutaneous nerve

Correct Answer & Explanation

. Anterior interosseous nerve

Explanation

The inability to flex the interphalangeal joint of the thumb indicates an injury to the flexor pollicis longus (FPL), which is innervated by the Anterior Interosseous Nerve (AIN). AIN neuropraxia is the most common nerve injury associated with extension-type supracondylar humerus fractures.

Question 529

Topic: Surgical Anatomy & Approaches

A 6-year-old child falls onto an outstretched hand resulting in the injury shown.

Which nerve is most commonly injured in extension-type supracondylar humerus fractures with posteromedial displacement of the distal fragment?

. Anterior interosseous nerve (AIN)
. Ulnar nerve
. Radial nerve
. Musculocutaneous nerve
. Axillary nerve

Correct Answer & Explanation

. Radial nerve

Explanation

In extension-type supracondylar fractures, the distal fragment displaces posteriorly. If it displaces posteromedially, the proximal fragment's sharp metaphysis is driven anterolaterally, thereby placing the radial nerve at the highest risk of injury. Conversely, posterolateral displacement of the distal fragment drives the proximal spike anteromedially, putting the median nerve (specifically the AIN) and brachial artery at risk.

Question 530

Topic: Surgical Anatomy & Approaches

Which of the following surgical approaches for total hip arthroplasty (THA) uniquely utilizes a true internervous and intermuscular plane, dissecting superficially between the tensor fasciae latae and the sartorius, and deeply between the gluteus medius and the rectus femoris?

. Direct anterior approach (Smith-Petersen)
. Anterolateral approach (Watson-Jones)
. Direct lateral approach (Hardinge)
. Posterior approach (Moore/Southern)
. Posterolateral approach

Correct Answer & Explanation

. Direct anterior approach (Smith-Petersen)

Explanation

The direct anterior (Smith-Petersen) approach exploits a true internervous plane. Superficially, the plane is between the sartorius (femoral nerve) and the tensor fasciae latae (superior gluteal nerve). Deeply, the plane is between the rectus femoris (femoral nerve) and the gluteus medius/minimus (superior gluteal nerve). The anterolateral (Watson-Jones) plane is between the TFL and gluteus medius (both superior gluteal nerve, thus not internervous). The direct lateral approach splits the gluteus medius and vastus lateralis.

Question 531

Topic: Surgical Anatomy & Approaches

During an ilioinguinal approach to the acetabulum, massive bleeding occurs while dissecting over the superior pubic ramus near the symphysis. The injured vessel, commonly referred to as the 'corona mortis,' typically represents an anastomosis between the obturator artery and which of the following?

. Internal pudendal artery
. Superior gluteal artery
. Inferior epigastric or external iliac artery
. Femoral artery
. Deep circumflex iliac artery

Correct Answer & Explanation

. Inferior epigastric or external iliac artery

Explanation

The 'corona mortis' (crown of death) is an anatomical variant describing an anastomosis between the obturator system and the external iliac or inferior epigastric system. It is located on the posterior aspect of the superior pubic ramus. Injury to this vessel during pelvic or acetabular surgery (like the ilioinguinal or Stoppa approaches) can lead to severe, difficult-to-control hemorrhage.

Question 532

Topic: Surgical Anatomy & Approaches

During an anterior intrapelvic (modified Stoppa) approach for the fixation of an acetabular fracture, the surgeon encounters significant bleeding from a vascular anastomosis situated over the superior pubic ramus.

What two main vessels typically form this specific anastomosis (Corona Mortis)?

. Obturator artery and internal iliac artery
. Superior gluteal artery and external iliac artery
. Inferior epigastric artery and obturator artery
. Internal pudendal artery and inferior gluteal artery
. External pudendal artery and medial circumflex femoral artery

Correct Answer & Explanation

. Inferior epigastric artery and obturator artery

Explanation

The corona mortis ('crown of death') is a vascular anastomosis between the external iliac and internal iliac vascular systems. Specifically, it connects the inferior epigastric artery or vein (from the external iliac system) to the obturator artery or vein (from the internal iliac system). It is located on the posterior aspect of the superior pubic ramus, approximately 4-7 cm from the pubic symphysis, and is at high risk of iatrogenic injury during the modified Stoppa or ilioinguinal approaches.

Question 533

Topic: Surgical Anatomy & Approaches

A 45-year-old male is undergoing an ilioinguinal approach for the treatment of an anterior column/posterior hemitransverse acetabular fracture.

During the dissection of the retropubic space (Space of Retzius), brisk arterial bleeding is encountered approximately 5 cm from the symphysis pubis, located posterior to the superior pubic ramus. Injury to which of the following structures is the most likely source of this hemorrhage?

. Internal pudendal artery
. Inferior epigastric artery
. Anastomosis between the external iliac and obturator vessels
. Lateral femoral circumflex artery
. Superior gluteal artery

Correct Answer & Explanation

. Anastomosis between the external iliac and obturator vessels

Explanation

The source of bleeding in this location is the 'corona mortis,' which is an anastomotic connection between the external iliac (or inferior epigastric) system and the obturator system. It traverses the superior pubic ramus at an average distance of 5 to 6 cm from the pubic symphysis. Surgeons must carefully dissect the posterior aspect of the superior pubic ramus and ligate these vessels during the ilioinguinal or intrapelvic approaches to avoid catastrophic hemorrhage.

Question 534

Topic: Surgical Anatomy & Approaches

A 65-year-old male is undergoing a total hip arthroplasty via the direct anterior approach. Which of the following best describes the deep internervous plane utilized during this approach?

. Between sartorius and tensor fasciae latae
. Between rectus femoris and gluteus medius
. Between gluteus medius and minimus
. Between tensor fasciae latae and gluteus medius
. Between pectineus and psoas

Correct Answer & Explanation

. Between sartorius and tensor fasciae latae

Explanation

The direct anterior (Smith-Petersen) approach to the hip utilizes a superficial and a deep internervous plane. The superficial plane is between the sartorius (innervated by the femoral nerve) and the tensor fasciae latae (innervated by the superior gluteal nerve). The deep interval is between the rectus femoris (femoral nerve) and the gluteus medius (superior gluteal nerve).

Question 535

Topic: Surgical Anatomy & Approaches

A trauma surgeon is performing an ilioinguinal approach to the anterior pelvis for the fixation of an anterior column acetabular fracture. During dissection over the superior pubic ramus, brisk arterial bleeding is encountered. This bleeding is most likely originating from an anastomosis between the obturator vessels and branches of which of the following?

. Internal iliac artery
. External iliac or inferior epigastric artery
. Superior gluteal artery
. Internal pudendal artery
. Deep circumflex iliac artery

Correct Answer & Explanation

. External iliac or inferior epigastric artery

Explanation

The 'corona mortis' (crown of death) is an important vascular anastomosis located over the posterior aspect of the superior pubic ramus, approximately 5-6 cm lateral to the pubic symphysis. It connects the obturator system (internal iliac system) with the external iliac or inferior epigastric vessels. It is vulnerable to injury during anterior pelvic approaches and can cause significant hemorrhage.

Question 536

Topic: Surgical Anatomy & Approaches

A patient presents with a midshaft humerus fracture and a concomitant complete radial nerve palsy. The fracture is closed and treated nonoperatively in a functional brace. At 12 weeks, there is no clinical or electromyographic (EMG) evidence of radial nerve recovery, and the fracture is healing well. What is the most appropriate next step in management?

. Continued observation for another 3 months
. Tendon transfers
. Surgical exploration of the radial nerve
. Magnetic resonance imaging of the cervical spine
. Ultrasound-guided nerve block

Correct Answer & Explanation

. Surgical exploration of the radial nerve

Explanation

Radial nerve palsy associated with a closed humeral shaft fracture is initially managed expectantly. If there are no clinical or electromyographic signs of spontaneous recovery by 3 to 4 months post-injury, surgical exploration of the radial nerve is indicated.

Question 537

Topic: Surgical Anatomy & Approaches

A 45-year-old woman requires open reduction and internal fixation for a volar Barton's fracture of the distal radius. The surgeon utilizes the standard volar Henry approach. Distally, this approach develops an internervous plane between which two structures?

. Flexor carpi ulnaris (FCU) and flexor digitorum superficialis (FDS)
. Flexor carpi radialis (FCR) and the radial artery
. Flexor carpi radialis (FCR) and brachioradialis (BR)
. Brachioradialis (BR) and extensor carpi radialis longus (ECRL)
. Abductor pollicis longus (APL) and extensor pollicis brevis (EPB)

Correct Answer & Explanation

. Flexor carpi radialis (FCR) and brachioradialis (BR)

Explanation

The classic volar Henry approach to the distal radius utilizes the internervous plane between the flexor carpi radialis (FCR, innervated by the median nerve) and the brachioradialis (BR, innervated by the radial nerve). The radial artery is mobilized radially along with the brachioradialis to protect it while exposing the pronator quadratus and the underlying radius.

Question 538

Topic: Surgical Anatomy & Approaches

A 6-year-old boy falls from monkey bars and sustains a completely displaced extension-type supracondylar humerus fracture. Radiographs show the distal fragment is displaced posterolaterally. Based on this displacement pattern, which neurovascular structure is at the greatest risk of injury?

. Radial nerve
. Ulnar nerve
. Anterior interosseous nerve
. Musculocutaneous nerve
. Axillary nerve

Correct Answer & Explanation

. Anterior interosseous nerve

Explanation

In extension-type supracondylar fractures, the direction of distal fragment displacement predicts the structure at risk. Posterolateral displacement of the distal fragment results in the proximal fragment being driven anteromedially, stretching the median nerve (specifically the Anterior Interosseous Nerve branch) and brachial artery. Conversely, posteromedial displacement drives the proximal fragment anterolaterally, endangering the radial nerve.

Question 539

Topic: Surgical Anatomy & Approaches

A 42-year-old male sustains a high-energy distal tibia pilon fracture.

An anterolateral surgical approach is planned for open reduction and internal fixation. During this approach, which nerve is at greatest risk of iatrogenic injury as it crosses the operative field?

. Sural nerve
. Deep peroneal nerve
. Superficial peroneal nerve
. Saphenous nerve
. Tibial nerve

Correct Answer & Explanation

. Superficial peroneal nerve

Explanation

The anterolateral approach to the distal tibia uses the internervous plane between the superficial peroneal nerve (lateral compartment) and deep peroneal nerve (anterior compartment). The superficial peroneal nerve crosses the surgical field from medial to lateral as it travels distally over the ankle, placing it at high risk of iatrogenic injury.

Question 540

Topic: Surgical Anatomy & Approaches

A 35-year-old male sustains an anteroposterior compression (APC) type II pelvic ring injury.

During anterior ring fixation via an ilioinguinal approach, massive hemorrhage is encountered posterior to the superior pubic ramus. Which anomalous anatomical connection represents the classic 'corona mortis'?

. External iliac artery to internal pudendal artery
. External iliac artery or inferior epigastric artery to the obturator artery
. Internal iliac artery to superior gluteal artery
. Internal pudendal artery to inferior epigastric artery
. Internal pudendal artery to obturator artery

Correct Answer & Explanation

. External iliac artery or inferior epigastric artery to the obturator artery

Explanation

The 'corona mortis' (crown of death) refers to a vascular anastomosis between the obturator and external iliac (or inferior epigastric) vascular systems. It is located posterior to the superior pubic ramus at a variable distance (average 5-6 cm) from the symphysis pubis and can cause life-threatening hemorrhage if inadvertently disrupted during anterior pelvic ring surgery (ilioinguinal or Stoppa approaches).

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