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Question 721

Topic: Surgical Anatomy & Approaches

A surgeon performs a primary total hip arthroplasty using the direct anterior (Smith-Petersen) approach. Which of the following represents the correct superficial internervous plane utilized in this surgical approach?

. Between the sartorius (femoral nerve) and tensor fasciae latae (superior gluteal nerve)
. Between the gluteus medius (superior gluteal nerve) and vastus lateralis (femoral nerve)
. Between the rectus femoris (femoral nerve) and vastus lateralis (femoral nerve)
. Between the tensor fasciae latae (superior gluteal nerve) and gluteus medius (superior gluteal nerve)
. Between the adductor longus (obturator nerve) and gracilis (obturator nerve)

Correct Answer & Explanation

. Between the sartorius (femoral nerve) and tensor fasciae latae (superior gluteal nerve)


Explanation

The direct anterior approach to the hip utilizes a true internervous and intermuscular plane. The superficial interval is safely developed between the sartorius (supplied by the femoral nerve) and the tensor fasciae latae (supplied by the superior gluteal nerve).

Question 722

Topic: Surgical Anatomy & Approaches

A surgeon performs a THA using the direct anterior approach (DAA). This approach exploits a true internervous plane between which two muscles?

. Sartorius and rectus femoris
. Tensor fasciae latae and gluteus medius
. Sartorius and tensor fasciae latae
. Rectus femoris and vastus lateralis
. Gluteus medius and piriformis

Correct Answer & Explanation

. Sartorius and tensor fasciae latae


Explanation

The direct anterior approach utilizes the Smith-Petersen interval. This is a true internervous plane between the sartorius (innervated by the femoral nerve) and the tensor fasciae latae (innervated by the superior gluteal nerve).

Question 723

Topic: Surgical Anatomy & Approaches

During a direct anterior (Smith-Petersen) approach to the hip for a primary total hip arthroplasty, the superficial surgical dissection passes between which of the following internervous muscle intervals?

. Tensor fasciae latae and sartorius
. Gluteus medius and tensor fasciae latae
. Sartorius and rectus femoris
. Rectus femoris and vastus lateralis
. Gluteus maximus and gluteus medius

Correct Answer & Explanation

. Sartorius and rectus femoris


Explanation

The direct anterior approach utilizes the superficial internervous plane between the sartorius (innervated by the femoral nerve) and the tensor fasciae latae (innervated by the superior gluteal nerve).

Question 724

Topic: Surgical Anatomy & Approaches

Following a total hip arthroplasty via a posterior approach, a patient exhibits a foot drop and inability to extend the great toe, but plantar flexion and foot inversion remain intact. Which specific nerve division is most likely injured?

. Tibial division of the sciatic nerve
. Common peroneal division of the sciatic nerve
. Femoral nerve
. Superior gluteal nerve
. Obturator nerve

Correct Answer & Explanation

. Common peroneal division of the sciatic nerve


Explanation

The common peroneal division of the sciatic nerve runs laterally and is securely tethered at the fibular head, making it highly susceptible to stretch injury during hip lengthening or retractor placement. It innervates the dorsiflexors and toe extensors.

Question 725

Topic: Surgical Anatomy & Approaches

When performing a primary total hip arthroplasty via the direct anterior (Smith-Petersen) approach, the superficial internervous plane lies between muscles supplied by which of the following nerves?

. Superior gluteal and Femoral nerves
. Inferior gluteal and Femoral nerves
. Superior gluteal and Obturator nerves
. Femoral and Sciatic nerves
. Superior gluteal and Inferior gluteal nerves

Correct Answer & Explanation

. Superior gluteal and Femoral nerves


Explanation

The superficial internervous plane for the direct anterior approach is between the tensor fasciae latae (superior gluteal nerve) and the sartorius (femoral nerve).

Question 726

Topic: Surgical Anatomy & Approaches

A surgeon utilizing the direct anterior (Smith-Petersen) approach for total hip arthroplasty enters the hip joint through a specific internervous plane superficially. This plane lies between which two muscles?

. Sartorius and tensor fasciae latae
. Tensor fasciae latae and gluteus medius
. Gluteus medius and minimus
. Rectus femoris and vastus lateralis
. Gluteus maximus and medius

Correct Answer & Explanation

. Sartorius and tensor fasciae latae


Explanation

The direct anterior approach exploits the superficial internervous plane between the sartorius (innervated by the femoral nerve) and the tensor fasciae latae (innervated by the superior gluteal nerve).

Question 727

Topic: Surgical Anatomy & Approaches

During a direct anterior approach for a total hip arthroplasty, the patient sustains a nerve injury resulting in localized numbness over the anterolateral aspect of the thigh. Which nerve was most likely injured?

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

Correct Answer & Explanation

. Lateral femoral cutaneous nerve


Explanation

The lateral femoral cutaneous nerve is at high risk during the direct anterior approach (Smith-Petersen interval). Injury results in paresthesias or numbness over the anterolateral thigh.

Question 728

Topic: Surgical Anatomy & Approaches

During a direct anterior approach for total hip arthroplasty, the surgeon develops the superficial surgical interval. Between which two nerve territories does this true internervous plane lie?

. Femoral nerve and Superior gluteal nerve
. Femoral nerve and Obturator nerve
. Superior gluteal nerve and Inferior gluteal nerve
. Sciatic nerve and Femoral nerve
. Superior gluteal nerve and Sciatic nerve

Correct Answer & Explanation

. Femoral nerve and Superior gluteal nerve


Explanation

The direct anterior (Smith-Petersen) approach utilizes the internervous plane between the sartorius (innervated by the femoral nerve) and the tensor fasciae latae (innervated by the superior gluteal nerve).

Question 729

Topic: Surgical Anatomy & Approaches

When utilizing the direct anterior approach for total hip arthroplasty, the internervous plane is established between muscles supplied by which of the following pairs of nerves?

. Femoral nerve and superior gluteal nerve
. Femoral nerve and obturator nerve
. Superior gluteal nerve and inferior gluteal nerve
. Sciatic nerve and inferior gluteal nerve
. Femoral nerve and sciatic nerve

Correct Answer & Explanation

. Femoral nerve and superior gluteal nerve


Explanation

The direct anterior approach uses the internervous plane between the sartorius (femoral nerve) and the tensor fasciae latae (superior gluteal nerve).

Question 730

Topic: Surgical Anatomy & Approaches

During a direct anterior approach for a total hip arthroplasty, the surgeon develops the superficial internervous plane. Which of the following nerves innervates the muscle that forms the medial boundary of this surgical interval?

. Superior gluteal nerve
. Femoral nerve
. Inferior gluteal nerve
. Obturator nerve
. Sciatic nerve

Correct Answer & Explanation

. Femoral nerve


Explanation

The superficial interval for the direct anterior (Smith-Petersen) approach is between the tensor fasciae latae (laterally) and the sartorius (medially). The sartorius is innervated by the femoral nerve.

Question 731

Topic: Surgical Anatomy & Approaches

During a direct anterior approach for a total hip arthroplasty, the surgeon utilizes the internervous plane between which of the following muscles?

. Gluteus medius and tensor fasciae latae
. Tensor fasciae latae and sartorius
. Sartorius and rectus femoris
. Rectus femoris and vastus lateralis
. Adductor longus and gracilis

Correct Answer & Explanation

. Tensor fasciae latae and sartorius


Explanation

The direct anterior (Smith-Petersen) approach to the hip exploits the internervous plane between the tensor fasciae latae (superior gluteal nerve) and the sartorius (femoral nerve). This allows access to the joint without detaching muscle insertions.

Question 732

Topic: Surgical Anatomy & Approaches

The posterior interosseous nerve (PIN) enters the posterior compartment of the forearm by passing between the two heads of which muscle?

. Pronator teres
. Flexor carpi ulnaris
. Supinator
. Extensor carpi radialis brevis
. Brachioradialis

Correct Answer & Explanation

. Supinator


Explanation

The PIN, a continuation of the deep branch of the radial nerve, enters the posterior compartment of the forearm by passing through the arcade of Frohse between the superficial and deep heads of the supinator muscle.

Question 733

Topic: Surgical Anatomy & Approaches

A 16-year-old male undergoes a deltopectoral approach for a proximal humerus fracture. Aggressive medial retraction of the conjoined tendon places which of the following nerves at highest risk of injury?

. Axillary nerve
. Radial nerve
. Median nerve
. Musculocutaneous nerve
. Suprascapular nerve

Correct Answer & Explanation

. Musculocutaneous nerve


Explanation

The musculocutaneous nerve typically enters the coracobrachialis muscle 5 to 8 cm distal to the coracoid process. Vigorous medial retraction of the conjoined tendon during a deltopectoral approach can stretch and injure this nerve.

Question 734

Topic: Surgical Anatomy & Approaches

The corona mortis, which is at risk of iatrogenic injury during an ilioinguinal approach to the acetabulum, is typically an anastomotic connection between the obturator vessels and which of the following?

. Internal iliac vessels
. Superior gluteal vessels
. Inferior epigastric vessels
. Internal pudendal vessels
. Deep circumflex iliac vessels

Correct Answer & Explanation

. Inferior epigastric vessels


Explanation

The corona mortis is an anastomosis between the external iliac system (specifically the inferior epigastric vessels) and the obturator vessels. It crosses the superior pubic ramus and is highly vulnerable during anterior pelvic approaches.

Question 735

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

. splinting for 1 to 2 weeks, followed by a humeral fracture brace.
. intramedullary nailing.
. exploration of the radial nerve and intramedullary nailing.
. exploration of the radial nerve and a humeral fracture brace.
. exploration of the radial nerve and open reduction and internal fixation with plates and screws.

Correct Answer & Explanation

. splinting for 1 to 2 weeks, followed by a humeral fracture brace.


Explanation

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. Ring D, Chin K, Jupiter JB: Radial nerve palsy associated with high-energy humeral shaft fractures. J Hand Surg Am 2004;29:144-147.

Question 736

Topic: Surgical Anatomy & Approaches

A 45-year-old man requires ORIF of a displaced posterior wall acetabular fracture via a Kocher-Langenbeck approach. To minimize iatrogenic injury to the sciatic nerve during retraction, how should the ipsilateral lower extremity be positioned intraoperatively?

. Hip flexed and knee flexed
. Hip flexed and knee extended
. Hip extended and knee flexed
. Hip extended and knee extended
. Hip abducted and knee extended

Correct Answer & Explanation

. Hip extended and knee flexed


Explanation

During a Kocher-Langenbeck approach, the sciatic nerve is at high risk from retractor tension. Extending the hip and flexing the knee minimizes tension on the nerve, reducing the risk of a stretch injury.

Question 737

Topic: Surgical Anatomy & Approaches

During an ilioinguinal approach for the fixation of an anterior column acetabular fracture, the surgeon operates in the middle window. Which of the following structures defines the medial border of this surgical window?

. Iliopectineal fascia
. Iliopsoas muscle
. Femoral nerve
. External iliac vessels
. Conjoint tendon

Correct Answer & Explanation

. Iliopectineal fascia


Explanation

The middle window of the ilioinguinal approach is bordered laterally by the iliopectineal fascia and medially by the external iliac vessels. This window provides access to the pelvic brim, quadrilateral plate, and superior pubic ramus.

Question 738

Topic: Surgical Anatomy & Approaches

During an ilioinguinal approach for an anterior column acetabular fracture, brisk arterial bleeding is encountered near the superior pubic ramus approximately 5 cm from the pubic symphysis. This bleeding is most likely arising from an anastomosis between which of the following vessel pairs?

. Internal iliac and external pudendal vessels
. External iliac and obturator vessels
. Internal pudendal and superior gluteal vessels
. Inferior epigastric and internal pudendal vessels

Correct Answer & Explanation

. Inferior epigastric and internal pudendal vessels


Explanation

The corona mortis is a critical vascular anastomosis between the external iliac (or inferior epigastric) system and the obturator vessels. It is found traversing the superior pubic ramus and is highly vulnerable during anterior pelvic and acetabular approaches.

Question 739

Topic: Surgical Anatomy & Approaches

A 32-year-old man is involved in a high-speed motor vehicle collision and sustains a displaced posterior wall acetabular fracture with a posterior hip dislocation.

Following emergent closed reduction of the hip, CT imaging confirms a large, single-piece posterior wall fragment. Which of the following surgical approaches is most appropriate for definitive fixation?

. Ilioinguinal approach
. Kocher-Langenbeck approach
. Modified Stoppa approach
. Smith-Petersen approach
. Extended iliofemoral approach

Correct Answer & Explanation

. Kocher-Langenbeck approach


Explanation

The Kocher-Langenbeck approach is the standard approach for isolated posterior wall and posterior column acetabular fractures. It allows direct visualization and buttress plating of the posterior wall.

Question 740

Topic: Surgical Anatomy & Approaches

When utilizing the ilioinguinal approach for an anterior column acetabular fracture, the surgeon must identify and ligate the 'corona mortis'. This structure represents an anastomosis between the obturator vessels and the:

. Internal pudendal vessels
. Superior gluteal vessels
. External iliac or deep inferior epigastric vessels
. Femoral vessels
. Internal iliac vessels

Correct Answer & Explanation

. External iliac or deep inferior epigastric vessels


Explanation

The corona mortis is an important vascular anastomosis crossing the superior pubic ramus. It connects the obturator vessels with the external iliac or deep inferior epigastric vessels and can cause massive hemorrhage if torn.