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Orthopedic Surgery Ultimate > Dangers & Planes > Flashcards

Dangers & Planes Flashcards

1
Q

internervous plane for lateral approach to the femur

A

none. this is a vastus split

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2
Q

dangers for lateral approach to the femur

A

1) numerous perforating vessels from the profunda femoris artery

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3
Q

internervous plane for posterolateral approach to the femur

A

between vastus lateralis and the lateral intermuscular septum

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4
Q

dangers for posterolateral approach to the femur

A

1) perforating arteries
2) superior lateral geniculate artery and vein

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5
Q

internervous plane for anteromedial approach to the distal femur

A

none

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6
Q

dangers for anteromedial approach to the distal femur

A

1) medial superior genicular artery - ligate to avoid hematoma formation
2) low fibres of vastus medialis attach to patella - make sure you take a small cuff of tendon so you can repair this later to prevent lateral subluxation of the patella

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7
Q

internervous plane for posterior approach to the femur

A

lateral intermuscular septum and biceps femoris

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8
Q

dangers for posterior approach to the femur

A

1) sciatic nerve medial to biceps
2) nerve to biceps enters very proximal and medial, so usually not a worry

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9
Q

internervous plane for minimal access approach to the distal femur

A

distally between vastus lateralis and biceps femoris

proximally, none, as you split vastus lateralis

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10
Q

danger for minimal access approach to the distal femur

A

1) superior genicular artery and veins need to be ligated

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11
Q

internervous plane for minimal access approach to proximal femur for intramedullary nailing

A

none

split fibres of glut max and glut med

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12
Q

danger for minimal access approach to proximal femur for intramedullary nailing

A

1) too lateral with your nail and you will get a varus deformity
2) too far medial and you will get an iatrogenic # of the femoral neck
3) superior gluteal nerve runnign through glut med 3-5 cm above the tip of GT

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13
Q

internervous plane for minimal access approach to retrograde intramedullary nailing of femur

A

none - you are just passing through medial retinaculum and synovium

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14
Q

danger for minimal access approach to retrograde intramedullary nailing of femur

A

1) infrapatellar branch of saphenous nerve should be distal to the incision
2) PCL on lateral aspect of medial femoral condyle may be damaged by reamers

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15
Q

internervous plane for arthorscopic approach to the knee

A

none

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16
Q

danger for arthorscopic approach to the knee

A

1) articular cartilage
2) meniscus

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17
Q

internervous plane for medial parapatellar approach to the knee

A

none

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18
Q

dangers for medial parapatellar approach to the knee

A

1) infrapatellar branch of the saphenous nerve
2) avulsion of the patella ligament during difficult dislocation

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19
Q

internervous plane for approach to medial meniscectomy

A

none

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20
Q

danger for approach to medial meniscectomy

A

1) infrapatellar branch of the saphenous nerve
2) popliteal artery posterior to joint capsule should be safe
3) coronary ligament if incision too distal
4) superficial medial ligament if incision too posterior
5) fat pad in anterior knee joint should be spared to prevent adhesions and maintain blood supply to patella
6) medial meniscus can be damaged during approach if incision too distal

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21
Q

internervous plane for medial approach to knee

A

none

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22
Q

danger for medial approach to knee

A

1) neuroma formation if infrapatellar branch of saphenous not buried in fat
2) saphenous vein in posterior corner of superficial dissection
3) medial inferior geniculate artery curves around the upper end of tibia
4) popliteal artery lies against posterior joint capsule in midline

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23
Q

internervous plane for approach to lateral meniscectomy

A

none

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24
Q

danger for approach to lateral meniscectomy

A

1) lateral inferior geniculate artery
2) LCL if too posterior with incision
3) lateral meniscus if too distal with incision

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25
Q

internervous plane for lateral approach to the knee

A

between IT band and biceps femoris

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26
Q

dangers for lateral approach to the knee

A

1) common peroneal nerve on posterior border of biceps
2) lateral superior geniculate artery between lateral gastrocs and corner
3) popliteus tendon within the joint posterolaterally
4) lateral meniscus if too distal with incision
5) coronary ligament if too distal with incision

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27
Q

internervous plane for posterior approach to the knee

A

none

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28
Q

danger for posterior approach to the knee

A

1) medial sural cutaneous nerve travelling lateral to the small saphenous vein
2) tibial nerve
3) common peroneal nerve
4) small saphenous vein
5) popliteal vessels

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29
Q

internervous plane for lateral approach to distal femur for ACL repair

A

vastus lateralis and biceps femoris

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30
Q

danger for lateral approach to distal femur for ACL repair

A

1) peroneal nerve posterior to biceps
2) lateral superior geniculate artery must be ligated
3) popliteal artery if plane does not stay subperiosteal

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31
Q

danger (2) for anterior approach to iliac crest

A
  1. ASIS insertion of inguinal ligament
  2. crest of ilium should be left for cosmesis
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32
Q

danger (3) for posterior approach to iliac crest

A
  1. cluneal nerves start 8 cm lateral to PSIS
  2. sciatic nerve if you go too far inferior to sciatic notch
  3. superior gluteal artery travels by the sciatic notch, proximal to piriformis
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33
Q

danger (1) for anterior approach to pubic symphysis

A
  1. bladder
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34
Q

danger (3) for anterior approach to SI joint

A
  1. LFCN arises 2 cm distal to ASIS and is often sacrificed in this approach
  2. sacral nerve roots if: i) go too medial with dissection; ii) put a homan in a foramina; iii) put more than 1 screw in the anterior sacrum
  3. large nutrient vessels enter the anterior ileum - use bone wax
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35
Q

danger (4) for posterior approach to the SI joint

A
  1. IGN is in the deep surface of glut max
  2. SGN in is the deep surface of glut med
  3. sacral nerve roots may be injured by inaccurate screws
  4. IGA/SGA run with their respective nerves
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36
Q

danger (7) for inguinal approach to the acetabulum

A
  1. FN on iliopsoas
  2. LFCN 2 cm distal to ASIS (usually divided)
  3. femoral/external iliac vessels
  4. inferior epigastric A/V need to be ligated
  5. spermatic cord
  6. bladder
  7. corona mortis on lateral superior rami
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37
Q

plane for posterior approach to the acetabulum

A

none - glut max is split

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38
Q

danger (3) for posterior approach to the acetabulum

A
  1. avoid vigorous retraction of SERs to protect sciatic nerve
  2. IGA/IGN leave pelvis inferior to piriformis
  3. SGA/SGN leave pelvis superior to piriformis
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39
Q

plane for anterior (Smith-Petersen) approach to the hip

A

superficial: between sartorius and TFL
deep: between rectus femoris and glut med

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40
Q

danger (3) for anterior (Smith-Petersen) approach to the hip

A
  1. LFCN lies on sartorius
  2. FN lies over hip joint medial to rectus femoris
  3. must ligate ascending branch of lateral femoral circumflex artery
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41
Q

plane for anterolateral (Watson-Jones) approach to the hip

A

none really, but just don’t dissect to the origin of TFL - where it is innervated

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42
Q

danger (4) for anterolateral (Watson-Jones) approach to the hip

A
  1. FN injury with aggressive medial retraction
  2. FA/FV damage if retraction through iliopsoas
  3. profunda femoris lies on iliopsoas
  4. femoral shaft prone to # with dislocation maneuvers when there is an incomplete capsulotomy
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43
Q

plane for lateral approach to the hip

A

none - split glut med and vastus lateralis

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44
Q

danger (4) for lateral approach to the hip

A
  1. SGN runs between glut med and min 3-5 cm rostral to GT
  2. FN runs on psoas, so anterior retractors should only be placed on bone
  3. FA/FV run medial to nerve but could be injured if retraction too medial
  4. transverse branch of the lateral femoral circumflex artery must be ligated as vastus lateralis is cut.
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45
Q

plane for posterior approach to the hip

A

none - split the fibres of glut max

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46
Q

danger (2) for posterior approach to the hip

A
  1. sciatic nerve emerging from beneath piriformis
  2. IGA emerging under piriformis
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47
Q

plane for the medial approach to the hip

A

superficial: between longus and gracillus
deep: between brevis and magnus

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48
Q

danger (3) for the medial approach to the hip

A
  1. anterior ON lies on OE and brevis
  2. posterior ON goes through OE and lies on magnus
  3. MFCA passes around medial and distal to psoas tendon
49
Q

internervous plane for anterior approach to ankle

A

use the intermuscular plane between EHL and EDL

50
Q

dangers for anterior approach to ankle

A

cutaneous branches of superficial peroneal nerve

deep peroneal nerve

anterior tibial artery

51
Q

dangers for approaches to medial malleolus

A

anterior - saphenous nerve, long saphenous vein

posterior - tom, dick and very nervous harry

both - vascularity of bone fragments

52
Q

dangers for posteromedial approach to ankle

A

posterior tibial artery

tibial nerve

53
Q

internervous plane for posterolateral approach to the ankle

A

peroneus brevis and FHL

54
Q

dangers for posterolateral approach to ankle

A

short saphenous vein

sural nerve

55
Q

dangers for the lateral approach to the lateral malleolus

A

sural nerve

terminal branches of peroneal artery lying on the medial surface of the distal fibula

56
Q

internervous plane for anterolateral approach the ankle hindfoot

A

between peroneals and extensors

57
Q

dangers for anterolateral approach to the ankle and hindfoot

A

deep peroneal nerve

anterior tibial artery

58
Q

internervous plane for lateral approach to hindfoot

A

peroneus tertius and peroneal tendons

59
Q

dangers for lateral approach to hindfoot

A

exposures here are notorious for skin necrosis

60
Q

dangers for lateral approach to the posterior talocalcaneal joint

A

sural nerve

61
Q

dangers for lateral approach to calcaneus

A

sural nerve

soft tissue necrosis a risk

62
Q

danger for dorsomedial approach to MTP joint

A

tendon of EHL

tendon of FHL

63
Q

danger for dorsal approach to the metatarsophalangeal joints (other than 1st)

A

long extensor tendon

plantar nerves and vessels lie deep to transverse metatarsal ligament between the metatarsal heads

64
Q

danger for approach to the dorsal web spaces

A

dorsal cutaneous nerve

take care to protect plantar neurovascular bundle

65
Q

danger for anterior approach to the clavicle

A

1) brachial plexus
2) subacromial artery and vein immediately inferior to clavicle - avoid inferior dissection

66
Q

internervous plane for anterior approach to shoulder joint

A

between deltoid and pecs

67
Q

danger for anterior approach to shoulder joint

A

1) MSK nerve as it enters the coracobrachialis 5-8 cm distal to corocoid
2) cephalic vein

68
Q

internervous plane for anterolateral approach to the AC joint and subacromial space

A

none - delt is detached

69
Q

danger for anterolateral approach to the AC joint and subacromial space

A

1) axillary nerve runs deep to delt 7 cm below the acromion
2) acromial branch of the coracoacromial artery must be ligated just under the delt as you approach

70
Q

internervous plane for lateral approach to proximal humerus

A

none - split delt

71
Q

danger for lateral approach to proximal humerus

A

1) axillary nerve 7 cm below acromion travelling transversely under delt

*note that the minimally invasive lateral approach is also available with 2 incisions, but the key is ID the axillary nerve and go deep to it*

72
Q

internervous plane for posterior approach to the shoulder joint

A

between teres minor and infraspinatus

73
Q

danger for posterior approach to the shoulder joint

A

1) axillary nerve as it runs through quadrangular space beneath teres minor
2) suprascapular nerve passes around the base of the spine of scapula
3) posterior circumflex humeral artery runs with axillary nerve

74
Q

internervous plane for anterior approach to the humeral shaft

A

proximally between pec and delt

distally between medial and lateral fibres of brachialis

75
Q

danger for anterior approach to the humeral shaft

A

1) radial nerve - vulnerable at 2 spots - spiral groove and anterior compartment of distal third of arm between brachialis and brachioradialis
2) axillary nerve running under deltoid 7 cm distal to acromion
3) anterior humeral circumflex artery
4) lateral ante-brachial cutaneous nerve medial to brachialis

*note that this can also be done via two small minimally invasive incisions

76
Q

danger for anterolateral approach to the distal humerus

A

1) ID the radial nerve and protect it

77
Q

internervous plane for posterior approach to the distal humerus

A

none - separate heads of triceps

78
Q

danger for posterior approach to the distal humerus

A

1) radial nerve between medial and lateral head of triceps
2) ulnar nerve as in passes posteromedially
3) profunda brachii artery with radial nerve

79
Q

internervous plane for lateral approach to distal humerus

A

none - between triceps and brachioradialis

80
Q

dangers for lateral approach to distal humerus

A

1) radial nerve pierces lateral intermuscular septum in distal third of arm

81
Q

danger for minimal access approach for humeral nailing

A

1) axillary nerve 7 cm below the acromion under deltoid
2) brachial artery medial to proximal humerus
3) median nerve with brachial artery
4) supraspinatus tendon is partially incised - take care when drilling not to cause more damage

82
Q

danger for posterior approach to the elbow

A

1) ulnar nerve must be ID’d
2) median nerve lies anterior to distal humerus
3) radial nerve if you do too far proximal
4) brachial artery lies with median nerve
5) realign olecranon with great care after osteotomy

83
Q

internervous plane for medial approach to the elbow

A

proximally between brachialis and triceps

distally between brachialis and pronator teres

84
Q

danger for medial approach to the elbow

A

1) ulnar nerve
2) median nerve - careful when retracting PT and the flexors

85
Q

internervous plane for anterolateral approach to the elbow

A

proximally between brachialis and brachioradialis

distally between brachioradialis and PT

86
Q

danger for antrolateral approach to the elbow

A

1) radial nerve and its 3 branches in proximal forearm
2) PIN in supinator near neck of radius
3) LCNF - retract with skin medially
4) recurrent branches of radial artery must be ligated to mobilize the brachioradialis

87
Q

internervous plane for anterior approach to the cubital fossa

A

distally between brachioradialis and PT

proximally brachioradialis and brachialis

88
Q

danger for anterior approach to the cubital fossa

A

1) LCNF - find between biceps and brachialis
2) radial artery lies immediately deep to bicipital aponeurosis
3) PIN vulnerable as it winds around the neck of radius within supinator

89
Q

internervous plane for posterolateral approach to the radial head

A

between anconeus and ECU

90
Q

danger for posterolateral approach to the radial head

A

1) PIN is in the supinator and also on radial neck opposite the bicipital tuberosity
2) radial nerve - open joint laterally, not anteriorly

91
Q

internervous plane for anterior approach to radius

A

between brachioradialis and FCR/PT

92
Q

danger for anterior approach to the radius

A

1) PIN around neck of radius and within supinator
2) superficial radial nerve under brachioradialis
3) radial artery vulnerable during mobilization of brachioradialis and near the biceps tendon
4) recurrent radial arteries must be ligated to properly mobilize the brachioradialis

93
Q

internervous plane for approach to ulna

A

between ECU and FCU

94
Q

dangers for approach to ulna

A

1) ulnar nerve travels throught the two head and then under FCU on FDP
2) ulnar artery travels just radial to the nerve

95
Q

internervous plane for posterior approach to the radius

A

ECRB and ED proximally

ECRB and EPL distally

96
Q

danger for posterior approach to the radius

A

1) PIN - 25% of people have a PIN that touches the radius opposite the bicipital tuberosity - so protect it by stripping supinator subperiosteally

97
Q

internervous plane for dorsal approach to the wrist

A

none

use intermuscular plane between ECRB and ECRL

98
Q

danger for dorsal approach to wrist

A

1) superficial radial nerve emerges from under brachioradialis just proximal to wrist joint
2) radial artery crosses wrist laterally - stay below periosteum and it will be hard to damage

99
Q

internervous plane for volar approach to the wrist

A

none

100
Q

danger for volar approach to the wrist

A

1) palmar cutaneous branches of median arise 5 cm proximal to wrist joint run on ulnar side of FCR befor crossing flexor retinaculum
2) motor branch of median nerve
3) superficial palmar arch crosses plam at level of outstretched thumb - cut flexor retinaculum only under direct vision

101
Q

danger for volar approach to ulnar nerve

A

1) ulnar nerve at 2 locations - during approach through FCU and during detachment of volar carpal ligament

102
Q

danger for posterior approach to the lumbar spine

A

1) segmental arteries between TPs near facet joints
2) dorsal rami between TPs near facet joints
3) ID nerve roots individually
4) venous plexi around nerves and on floor of canal
5) iliac vessels anterior to vertebral body if you puncture annulus fibrosis

103
Q

which muscles might you encounter during posterior approach to the lumbar spine?

A

superficial = lat. dorsi.

deep = sacrospinalis, multifidus and rotatores

104
Q

danger for transperitoneal approach to the lumbar spine

A

1) presacral nerve plexi - can use retroperitoneal saline injection to assist
2) midline sacral artery
3) lumbar vessels carefully dissectedand ligated to access great vessels
4) ureters must be mobilized laterally

105
Q

dangers for retroperitoneal approach to lumbar spine

A

1) presacral nerve plexus should mobilize medial with peritoneum
2) ureters should mobilize medial with peritoneum
3) sympathetic chain on lateral vertebral body
4) segmental arteries and veins if you go above L5

106
Q

dangers for anterolateral approach to lumbar spine

A

1) sympathetic chain on lateral vertebral body wall
2) genitofemoral nerve on anteromedial surface of psoas
3) segmental arteries and veins (must tie off)
4) vena cava if approaching from R side
5) ureter - retract with peritoneum

107
Q

danger for posterior approach to the cervical spine

A

1) don’t traction cord
2) venous plexus bleeding around cord
3) do not enter transverse foramen
4) 3rd occipital nerve lateral to skin incision

108
Q

danger for posterior approach to C1/C2 specifically

A

1) do not retract cord near C1/2!
2) C2 and C3 occipital nerves are lateral to this field
3) vertebral artery crosses the field superior to C1

109
Q

which vertebrae can you access with anterior approach to C-spine?

A

C3-T1

110
Q

anatomical landmark for C2-3

A

jaw line

111
Q

anatomical landmark for C4-5

A

thyroid cartilage

112
Q

anatomical landmark for C6

A

cricoid cartilage

113
Q

internervous plane for anterior approach to the cervical spine

A

none superficial, however, between SCM and neck strap muscles intermediate and between R and L longus colli muscles deep

114
Q

danger for anterior approach to the cervical spine

A

1) protect recurrent laryngeal nerve by placing retractors medial to longus colli
2) avoid sympathetic chain by subperiosteal midline dissection
3) avoid dissecting out to TP
4) avoid self-retainers near carotid sheath
5) take care not to lose the inferior thyroid artery behind the carotid sheath
6) do not extend this approach

115
Q

internervous plane for Wiltse approach to the spine

A

none. however, intermuscular plane between multifidus and longissimus

116
Q

danger for posterolateral approach to the thoracic spine

A

1) intercostal arteries often damaged - this is okay, but bleeding must be controlled with ties
2) if dissection is too intensive you can enter the central canal
3) pleural tears require chest tubes

117
Q

danger for anterior approach to thoracic spine

A

1) intercostal arteries are vulnerable at 2 points: during rib resetion and vertebral body approach
2) expand the lungs every 30 min

118
Q

dangers for posterior approach in scoliosis

A

) posterior rami emerge between TPs

2) segmental arteries emerge between TPs

Orthopedic Surgery Ultimate (88 decks)

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