Ilioinguinal Approach to the Acetabulum

(OBQ12.63) Which of the following describes the anatomic pathway of the ilioinguinal nerve?
Review Topic
1.

Perforates the posterior part of the transversus abdominis and divides the obliquus internus

2.

abdominis branching into a lateral and an anterior cutaneous branch

Pierces the obliquus internus and then accompanies the spermatic cord or round ligament through

3.

the superficial inguinal ring

Passes under the inguinal ligament and over the sartorius muscle into the thigh, where it divides

4.

into an anterior and a posterior branch

Travels outward on the psoas major, and passes through the deep inguinal ring and descends

5.

within the spermatic cord to the scrotum

Runs along the lower border of the twelfth rib and passes under the lateral lumbocostal arch

PREFERRED RESPONSE 2
The ilioinguinal nerve travels with the round ligament or spermatic cord through the superficial
inguinal ring. It does not pass through the deep inguinal ring, and therefore it only travels through
part of the inguinal canal.
The ilioinguinal nerve provides sensation to the upper inner thigh, groin, and perineum. It is
particularly at risk during the ilioinguinal approach to the acetabulum. During this approach, the
nerve can be found just proximal to the inguinal ligament after penetrating the abdominal wall when
releasing the muscular attachment.
Illustration A shows the pathways of the iliohypogastric, ilioinguinal, and genitofemoral nerves.
Incorrect Answers:
1-This describes the anatomy of the iliohypogastric nerve.
3-This describes the anatomy of the lateral femoral cutaneous nerve.
4-This describes the anatomy of the genitofemoral nerve.
5-This describes the anatomy of the subcostal nerve.

(OBQ10.28) While dissecting in the middle window of the ilioinguinal approach a nerve is
encountered entering the obturator foramen. Excessive retraction on this structure would result in
which of the following? Review Topic
1.

Lateral thigh numbness

2.

Weakness in knee extension

3.

Anterior thigh numbness

4.

Medial thigh numbness

5.

Weakness in hip flexion

PREFERRED RESPONSE 4
The obturator nerve is the largest nerve from the anterior divisions of the lumbar plexus, receiving
contributions from L2-4. The nerve courses through the psoas major, exiting on its medial aspect
and running along the lateral wall of the lesser pelvis until it enters the obturator foramen. It then
divides into an anterior and posterior division, supplying branches to the hip joint, adductor longus,
adductor brevis, gracilis, adductor magnus and sensory innervation the medial thigh. While in the
middle window of the ilioingunal approach, the lateral femoral cutaneous nerve (sensory innervation
to lateral thigh) and femoral nerve (sensory innveration to anterior thigh and motor innervation for
knee extension) will also be encountered and may be injured. Illustrations A and B demonstrate the
course and sensory innervation of the aforementioned nerves, respectively.
(OBQ08.58) When peforming the ilioinguinal approach, what lies between the external iliac vessels
and the lateral muscle window? Review Topic
1.

Sartorius muscle

2.

Iliopectineal fascia

3.

Round ligament

4.

Lateral femoral cutaneous nerve

5.

Corona mortis

PREFERRED RESPONSE 2
The ilioinguinal approach is typically used for anterior wall and column fracture of the acetabulum.
this question is essentially asking what separates the middle from the lateral windows. Mobilization
of the external iliac vessels and the iliopsoas (or iliopectineal fascia) creates the 3 windows of the
ilioinguinal approach: 1) Medial window: medial to external iliac artery & vein. 2) Middle window:
between external iliac vessels and the iliopsoas (or iliopectineal fascia) 3) Lateral window: lateral to
iliopsoas (or iliopectineal fascia). Note that some sources use the iliospoas as the structure that
separates the middle from the lateral windows; other sources use the iliopectineal fascia as the
structure that separates the middle from lateral windows.
The corona mortis (answer #5) is a normal variant; it is an anastomotic connection between the
external iliac and obturator arteries. If damaged in this approach, massive bleeding & death can
result. The lateral femoral cutaneous nerve (answer #4) crosses the inguinal crease close to the
ASIS (can be slightly medial to ASIS or, more commonly, 1-2 cm lateral) and, thus, may be seen in
the lateral aspect of the ilioinguinal approach. The femoral nerve (answer #3) gives branches that
supply muscles in the lateral muscular compartment.

(OBQ04.213) During an ilioinguinal approach to the pelvis, the lateral femoral cutaneous nerve is
seen. Which nerve roots supply this nerve? Review Topic
1.

L1-2

2.

L2-3

3.

L3-4

4.

L4-5

5.

L5-S1
PREFERRED RESPONSE 2
The lateral femoral cutaneous nerve (L2/3) is at risk of transection or traction injury with utilization of
the ilioinguinal approach to the acetabulum/pelvis. This structure is most commonly found 10-15mm
from the ASIS, passing underneath the inguinal ligament. Injury to this nerve is treated by sharply
transecting the nerve and burying the nerve ends to limit the symptoms of the eventual neuroma.
The ilioinguinal approach utilizes a Pfannesteil incision continuing laterally along the inguinal
ligament and finally along the iliac crest. The lateral window is lateral to the iliopsoas; the middle
window is between the iliopsoas and femoral vessels; the medial window is from midline to the
femoral vessels.
Illustration A shows a sketch of the ilioinguinal approach, with the lateral femoral cutaneous nerve
seen as it exits inferolaterally under the inguinal ligament.

Retroperitoneal (Anterolateral) Approach to the Lumbar

Spine
(SBQ09.58) Figure A demonstrates a cadaveric dissection of a retroperitoneal approach to the
lumbar spine. The aorta, L2 vertebral body, and L3 vertebral body are labeled. Which of the following
structures labeled 1-5 identifies the genitofemoral nerve?

1.

Number 1

2.

Number 2

3.

Number 3

4.

Number 4

5.

Number 5
PREFERRED RESPONSE 3
Number 3 represents the genitofemoral nerve.
The retroperitoneal approach to the lumbar spine is commonly used for anterior lumbar
corpectomies, fusions, and total disc replacements. The approach is usually performed from the left
as the aorta is more resistant to damage than the inferior vena cava (IVC). The bifurcation occurs
over the vertebral body of L4. Therefore, L4/5 discectomies are performed by working on the left
side of the aorta, while L5/S1 discectomies are performed by working between the bifurcation of the
common iliac vessels. Anatomic features which are important to identify include the genitofemoral
nerve, ureter, lumbar sympathetic chain, and lumbar segmental vessels.
Feigl et al performed an anatomic study looking at the effect of lumbar spondylosis on the anatomic
position of the lumbar sympathetic chain (LST). They found the LST entered the retroperitoneal
space at the level of the vertebral body of L2 in 62% of cadavers and showed the most consistent
relationship with the medial margin of the psoas muscle at intervertebral disc level L2/3. They
concluded degenerative changes can affect the anatomic position of the sympathetic chain.
Illustration A labels a cadaveric specimen. The sympathetic chain can be seen running down the
lateral aspect of the vertebral bodies and is labeled with the white arrows. The genitofemoral nerve
(GFN) runs along the surface of the the psoas muscles (PM). The lumbar segmental vessels branch
from the aorta roughly at the midpoint of the vertebral bodies (L5 = magenta, L4 = blue, L3 = green,
L2 = yellow). The intervertebral discs are shown in white and labeled b (L2/3), c (L3/4), and d (L4/5).
When working at L2 or above the renal arteries (LRV) must be identified.
Incorrect Answers:
Answer 1: Label 1 identifies the lumbar segmental vessels.
Answer 2: Label 2 identifies the sympathetic chain.
Answer 4: Label 4 identifies the psoas muscle.
Answer 5: Label 5 identifies the left renal vein.

(OBQ08.22) A surgeon is planning to place an anterior interbody device in the lumbar spine using a
retroperitoneal approach. A vertebral body is identified directly posterior to the bifurcation of the
aorta. What is the most likely level of this vertebral body? Review Topic

1.

L2

2.

L3

3.

L4

4.

L5

5.

S1

PREFERRED RESPONSE 3
The level of the bifurcation of the great vessels can vary, but most commonly is located at or near
the L4 vertebral body. Direct anterior exposure of the L4-5 disc space usually requires lateral
retraction of the great vessels. Exposure of the L5-S1 disc space usually can be performed by
working in between the bifurcation of the aorta.
Hoppenfeld's Surgical Exposures states "The aorta divides on the anterior surface of the L4 vertebra
into the two common iliac arteries. Just below this bifurcation, the common iliac vessels divide in turn
at about the S1 level into the internal and external iliac vessels."
Khamanarong et al showed in a study of 197 cadavers that "the abdominal aorta descended and
bifurcated into two common iliac arteries at the level of L4 vertebra in 131 cases (70.1%), at the
fourth lumbar intervertebral disc in 23 cases (12.3%), and at the level of L5 vertebra in 33 cases
(17.6%).
Illustration A shows a cadaveric specimen. The bifurcation sits over the vertebral body of L4. The
sympathetic chain can be seen running down the lateral aspect of the vertebral bodies. The
genitofemoral nerve (GFN) runs along side the psoas muscles (PM) along with the ureter which is
not shown in this dissection. The lumbar segmental vessels branch from the aorta roughly at the
midpoint of the vertebral bodies (L5 = magenta, L4 = blue, L3 = green, L2 = yellow). When working
at L2 or above the renal arteries (LRV) must be identified.
(OBQ07.214) An MR aortogram is shown in Figure A. What structure is identified by the red arrow in
the coronal and axial views?

1.

hypogastric plexus

2.

superior mesenteric artery

3.

inferior mesenteric artery

4.

segmental lumbar artery

5.

sympathetic chain
PREFERRED RESPONSE 4
The segmental lumbar arteries branch directly off the aorta and run anterior to posterior along the
lateral border of the lumbar vertebrae. During a retroperitoneal approach to the spine it is important
to identify and tie off the segmental arteries to avoid excessive bleeding.
The sympathetic chain (5) runs longitudinal along the lateral aspect of the vertebral column. It would
not show up on an aortogram. The anatomic course of the artery shown in Figure A is not consistent
with the superior mesenteric artery, inferior mesenteric artery, or the hypogastic plexus.

Hip Direct Lateral Approach (Hardinge, Transgluteal)

(OBQ09.256) In a modified Hardinge (lateral) approach to the hip, what structure limits the proximal
extent of the gluteus medius split? Review Topic
1.

Superior gluteal nerve

2.

Inferior gluteal nerve

3.

Pudendal nerve

4.

Corona mortis

5.

Sciatic nerve
PREFERRED RESPONSE 1
The superior gluteal nerve enters the deep surface of the gluteus medius approximately 5 cm
proximal to the tip of the greater trochanter. Splitting the muscle, as in the Hardinge approach, has
been reported to cause injury to this nerve if the split is carried above 5 cm. A simple tag suture can
be placed at this level to prevent propogation of the split inadvertently during surgery.

(OBQ08.195) Which of the following approaches for total hip arthroplasty is reported to have the
lowest prosthetic dislocation rate? Review Topic
1.

Posterior approach with posterior soft tissue repair

2.

Anterolateral (Watson Jones)

3.

Direct lateral (Hardinge)

4.

Transtrochanteric

5.

Posterior approach without posterior soft tissue repair

PREFERRED RESPONSE 3
The direct lateral (Hardinge) approach has been cited to have the lowest associated dislocation rate
of the options provided. The metanalysis by Masonis and Bourne found a dislocation rate for 14
studies involving 13000 total hips was 1.27% for the transtrochanteric approach, 3.23% for the
posterior approach (3.95% without posterior repair and 2.03% with posterior repair), 2.18% for the
anterolateral approach, and 0.55% for the direct lateral approach. Eight studies involving 2455
primary total hip arthroplasties evaluated postoperative limp. However, the article also found that the
incidence of postoperative limp was 4% to 20% for patients who had the lateral approach and 0% to
16% for patients who had the posterior approach. The article by Kwon et al found the lowest
dislocation rate with direct lateral (0.43%) followed by anteroalateral (0.7%) and posterior with soft
tissue repair (1.01%). The article by Farrell et al reviewed 27,004 patients and found the use of a
posterior approach (p = 0.032) to be associated with a significantly increased odds ratio for the
development of a postoperative motor nerve palsy.

Hip Posterior Approach (Moore or Southern)

(OBQ09.218) Where is the origin of the muscle located between the anterior acetabulum and iliac
vessels? Review Topic
1.

Anterior superior iliac spine

2.

Obturator foramen

3.

Anterior inferior iliac spine

4.

Pubic tubercle

5.

Lumbar transverse processes

PREFERRED RESPONSE 5
The psoas muscle serves to protect the iliac vessels from retractors/instruments anterior to the
acetabulum, and this muscle originates off the transverse processes of L1-L5. The referenced article
by Skaggs et el found that the iliac vessels were on average 1 cm away from the iliopsoas at the
level of the pelvic brim, but could be as close as 4mm in children. They also found that the
neurovascular structures were on average 3.1 cm away from the iliopsoas at the level of its insertion
at the lesser trochanter.

(OBQ07.59) The medial femoral circumflex artery and first perforating branch of the profunda
femoris artery anastamose at which of the following locations? Review Topic
1.

Medial to the gluteus medius insertion

2.

Medial to the gluteus maximus insertion

3.

Anterior to the adductor magnus

4.

Within the gluteus minimus muscle belly

5.

Medial to the ischial tuberosity

PREFERRED RESPONSE 2
The medial femoral circumflex artery is the primary blood supplier to the adult femoral head. This
artery anastamoses with the first perforating branch of the profunda femoris just medial to the
gluteus maximus insertion. This is important, as sectioning the gluteus maximus tendon during
posterior approaches can put both of these vessels (and the anastamosis) at risk.
(OBQ04.94) A 57-year-old female with degenerative hip arthritis has questions regarding miniincision total hip arthroplasty (THA) with comparison to traditional THA. Which of the following
statements is true regarding the mini-incision technique? Review Topic
1.

Reduced rate of hip dislocation

2.

Increased hip range motion at 1 year

3.

No significant difference in hip function at 1 year

4.

Less chance of surgical complications

5.

Less chance of limping at 1 year

PREFERRED RESPONSE 3
Mini-incision THA has not been shown to have any clinical benefit in terms of hip function at long
term followup. Proponents of this technique claim less soft tissue damage may allow for faster
recovery. Digioia et al, looked at mini-incision THA vs standard THA using navigation. Although limp,
distance walked, and stair function was better at 6 months with mini-incision THA, there were no
significant differences in pain, function, or motion at 1 year.

Volar Approach to Radius (Henry)

(OBQ11.66) A 47-year-old male punches through a glass window and suffers a deep laceration that
severs his brachioradialis muscle at the mid-forearm. What nerve is most likely injured? Review
Topic
1.

Posterior interosseous nerve

2.

Ulnar nerve

3.

Superficial radial nerve

4.

Anterior interosseous nerve

5.

Medial antebrachial cutaneous nerve

PREFERRED RESPONSE 3
The radial nerve splits at the level of the elbow joint into deep and superficial branches. The deep
branch passes between the two heads of the supinator and continues to the wrist as the posterior
interosseous nerve. The superficial branch of the radial nerve pierces the dorsal fascia and
accompanies the radial artery down the forearm along the dorsal side of the brachioradialis, as
shown in Illustration B. Therefore, a laceration that severs the brachioradialis would most likely injure
the superficial radial nerve. It is a purely sensory nerve that supplies sensation to the dorsal aspects
of the thumb, index, middle, and radial half of the ring fingers, as shown in Illustration A.
Incorrect Answers:
Answer 1: The PIN passes between the two heads of the supinator and then travels on the dorsal
aspect of the interosseous membrane (see Illustration C).
Answer 2: The ulnar nerve splits the two heads of the FCU and then travels on the ulnar side of the
forearm under the FCU.
Answer 4: The anterior interosseous nerve is a branch of the median nerve that travels along the
volar interosseous membrane between the FPL and FDP.

Answer 5: The medial antebrachial cutaneous nerve is a subcutaneous sensory nerve that travels on
the volar ulnar aspect of the forearm over the FDS.

OBQ10.165) A 58-year-old female undergoes right elbow arthroscopy for loose body removal and
debridement. During the case, the anterior capsule of the elbow is violated while the arthroscopic
shaver is being used through an anterolateral portal. A clinical photograph demonstrating the
patients post-operative physical exam deficits is shown in Figure A. Which structure labeled in Figure
B has most likely been damaged?

(OBQ04.237) Which of the following describes the internervous plane of the direct lateral approach
to the hip? Review Topic
1.

Between femoral nerve and superior gluteal nerve

2.

Between superior gluteal nerve and inferior gluteal nerve

3.

Between superior gluteal nerve and sciatic nerve

4.

No true internervous plane as the dissection splits a muscle innervated by the superior gluteal

5.

nerve
No true internervous plane as the dissection splits a muscle innervated by the inferior gluteal nerve

PREFERRED RESPONSE 4
The direct lateral approach (Hardinge) splits the fibers of the gluteus medius which is innervated by
the superior gluteal nerve. With this approach, there is no true internervous plane. After incising the
fascia lata, the fibers of the gluteus medius are split as are the fibers of the vastus lateralis. The
transverse branch of the lateral circumflex artery is often cut as the vastus lateralis is mobilized and
must be cauterized during the dissection.
The anterior approach employs the interval between the sartorius/rectus femoris (femoral nerve) and
TFL/gluteus medius (superior gluteal nerve).
The posterior approach utilizes the interval between the gluteus maximus (inferior gluteal nerve) and
the gluteus medius (superior gluteal nerve). No true internervous plane exists with this approach as
the gluteus maximus is split in the line of its fibers and it is supplied by the inferior gluteal nerve.
However, the muscle is not typically denervated if one keeps the split less than 5cm proximal to the
tip of the greater trochanter, as this theoretically limits damage to the inferior gluteal nerve.

(OBQ10.165) A 58-year-old female undergoes right elbow arthroscopy for loose body removal and
debridement. During the case, the anterior capsule of the elbow is violated while the arthroscopic
shaver is being used through an anterolateral portal. A clinical photograph demonstrating the
patients post-operative physical exam deficits is shown in Figure A. Which structure labeled in Figure
B has most likely been damaged?

1.

2.

3.

4.

5.

None of the identified structures have been damaged

PREFERRED RESPONSE 3
The clinical photograph demonstrates loss of finger extension and partial loss of wrist extension, the
result of a posterior interosseus nerve (PIN) palsy. The PIN is at risk of iatrogenic damage when
performing surgery on volar aspect of the proximal forearm. This is particularly a concern during
elbow arthroscopy when working through a distally placed anterolateral portal. The PIN supplies the
wrist and finger extensors with the exception of ECRL which is innervated by the radial nerve
proximal to the bifurcation. Injury to the radial nerve (choice 1) would result in complete loss of wrist
extension. Injury to the superficial radial nerve (choice 2) would result in sensory deficits only. The
supinator (choice 4) is innervated by the PIN, but loss of supinator function would not result in the
clinical photograph provided.
(OBQ09.25) When approaching a proximal diaphyseal radius fracture via the Henry approach
(volar), the forearm is supinated to minimize injury to what structure? Review Topic

1.

Ulnar nerve

2.

Median nerve

3.

Posterior interosseus nerve

4.

Lateral antebrachial cutaneous nerve

5.

Radial nerve
PREFERRED RESPONSE 3
The Henry approach is the volar approach to the forearm. The internervous plane is pronator teres
(median) and brachioradialis (radial nerve). The arm should be supinated to move the PIN away
from the surgical field. Conversely, in the Thompson (posterior) approach to the forearm, the forearm
should be pronated to move the PIN away from the surgical field.

Posterior Approach to the Acetabulum (KocherLangenbeck)

(OBQ11.266) Figure A is a cadaver specimen where a posterior approach to the hip has been performed
after removal of part of the Gluteus maximus muscle. Which of the following choices correctly
identifies structures A, B, and C in Figure A?

1.

A: Gluteus minimus, B: Piriformis tendon, C: Sacrospinous ligament

2.

A: Piriformis tendon, B: Superior gemellus tendon, C: Sacrospinous ligament

3.

A: Gluteus minimus, B: Piriformis tendon, C: Sacrotuberous ligament

4.

A: Piriformis tendon, B: Quadratus femorus tendon, C: Sacrotuberous ligament

5.

A: Gluteus minimus, B: Superior gemellus tendon, C: Sacrotuberous ligament

PREFERRED RESPONSE 3
In Figure A, the arrow labeled A is pointing to the Gluteus minimus muscle, B is pointing to the
tendon of the piriformis muscle, and C is pointing to the sacrotuberous ligament (Illustration A).
These are all important landmarks and points of identification during a posterior approach to the hip.
Illustrations B and C demonstrate the relationship of the ischial spine and ischial tuberosity in
relation to the hip joint and the associated ligaments. The superior gemellus originates from the
ischial spine.
(OBQ10.48) Which of the following structures exits distal to the anatomic landmark identified in
Figure A

1.

Sciatic nerve

2.

Superior gluteal artery

3.

Piriformis tendon

4.

Inferior gluteal artery

5.

Obturator internus

PREFERRED RESPONSE 5
The arrow points to the ischial spine and is the site of attachment of the sacrospinous ligament
which anatomically divides the greater and lesser sciatic notches.
The following structures pass through the greater sciatic notch:
1. Piriformis muscle
2. Sciatic nerve
3. Inferior gluteal nerve and artery

4. Internal pudendal nerve, artery, and vein

5. Nerve to obturator internus muscle
6. Nerve to quadratus femoris
7. Posterior cutaneous nerve of the thigh
The following structures pass through the lesser sciatic nothc:
1. Tendon of obturator internus
2. Nerve to obturator internus
3. Pudendal nerve
4. Internal pudendal artery
Illustration A shows these structures.

(OBQ06.257) All of the following structures pass below the piriformis through the greater sciatic
foramen EXCEPT: Review Topic
1.

pudendal nerve

2.

sciatic nerve

3.

inferior gluteal nerve

4.

obturator nerve

5.

inferior gluteal artery

PREFERRED RESPONSE 4
The pudendal nerve, sciatic nerve, inferior gluteal nerve, and inferior gluteal artery all exit the sciatic
foramen. The obturator nerve does not exit the sciatic foramen. The greater sciatic foramen is
bounded as follows: anterolaterally by the greater sciatic notch of the illium, posteromedially by the
sacrotuberous ligament, inferiorly by the sacrospinous ligament and ischial spine, and superiorly by
the anterior sacroiliac ligament. It is partially filled up by the piriformis which leaves the pelvis
through it. The following structures make their exit from the pelvis through the greater sciatic
foramen above the piriformis: superior gluteal vessels and superior gluteal nerve. Below the
piriformis the following structures exit: inferior gluteal vessels, inferior gluteal nerve, internal
pudendal vessels, pudendal nerve, sciatic nerve, posterior femoral cutaneous nerve, nerve to
obturator internus, and nerve to quadratus femoris.
The obturator nerve originates from the L2, L3, and L4 nerve roots, exits the pelvis through the
obturator foramen, innervates the gracilis, adductors (longus, brevis, magnus), and provides
sensation to the inferomedial thigh.