Anatomical Approach to Biopsy

Region specific approaches



- want to traverse one muscle / one compartment

- as a rule perform open biopsy through compartment the tumour is in

- keep away from NV bundle



- need to be done under guidance or by tumour centre


Anatomical guidelines to core biopsy PDF


Lower Limb




1.  Femoral head / neck

- lateral approach

- trans trochanteric

- avoid NV bundle and quadriceps


Proximal Femur TumourProximal femur biopsyFem neck biopsy


Proximal Femur Bony Tumour0001Proximal Femur Bony Tumour0002Proximal femur biopsy


2.  Subtrochanteric / femoral shaft

- lateral approach

- aim anterior or posterior to lateral intermuscular septum depending on compartment

- avoid rectus femoris / vastus intermedius

- ok to resect part of vastus lateralis or biceps femoris


Tumour Subtrochanteric FemurFemoral Shaft Bony LesionFemoral shaft biopsy


3.  Condyles

- medial: incision through vastus medialis

- lateral: anterior to vastus lateralis


Bony Lesion Lateral Distal FemurFem condyle biopsyFem condyle biopsy




1.  Lateral compartment soft tissue tumour

- lateral approach through ITB

- through vastus lateralis / anterior to lateral intermuscular septum


2.  Medial compartment soft tissue tumour

- medial approach through gracilis

- keep away from NV bundle


3.  Posterior compartment soft tissue tumour

- posterior approach / transmuscular


Popliteal fossa


Popliteal fossa / parosteal OS

- posterior approach

- go through hamstrings or gastrocnemius

- depending on whether lesion medial or lateral


Parosteal Osteosarcoma




Direct anterior


Patella Lytic Lesion


Tibia and fibular


Tibia: direct medial approach directly onto bone

Fibula: direct lateral or through peroneus, anterior to intermuscular septum


Proximal Tibial Lytic Epiphyseal Lesion XrayTibia biopsy 1


Tibial Shaft LesionTibia biopsy 2


Distal Fibular Lucent LesionTibia biopsy 3




1.  Proximal posterior compartment soft tissue tumour

- medial to tibia

- preserve anterolateral compartment


2.  Proximal anterolateral compartment soft tissue tumour

- direct approach through tibialis anterior

- will likely not be able to preserve CPN




1.  Head and neck

- medial approach between Tibialis anterior and Tibialis posterior


2.  Body

- lateral Ollier's approach between Peroneus tertius and Peroneus brevis




Direct lateral approach


Calcaneal Bony Lesion CTCalcaneal Bony Lesion MRI




Navicular / Medial cuneiform Direct medial
Cuboid Direct lateral
Intermediate cuneiform

Between EHL and EDC

Away from dorsalis pedis

Lateral cuneiform Lateral to EDC
Metatarsals / phalangeals Dorsal approach
Soft tissue tumour Medial or lateral as required


Metatarsal tumourSoft tissue sarcoma medial foot




Ewings pelvisAcetab Met


Iliac crest Ilioinguinal approach
Anterior column Watson - Jones through G medius
Posterior column Kocher - Lagenbeck through G maximus
Pubis Pfannenstiel approach
Ischium Posterior approach
Sacrum Direct posterior approach


Upper Limb




1.  Proximal humeral bony tumour

- direct lateral

- through deltoid muscle

- never deltopectoral (condemns patient to forequarter amputation)


Shoulder CSHumerus biopsy 1


2.  Shaft

- modified Henry

- lateral approach

- proximal: through deltoid

- distal: posterior to biceps, through brachialis


OS HumerusHumerus biopsy 2


3.  Distal humerus bony tumour

- lateral longitudinal to capitellum

- medial approach to trochlea

- both through brachialis


ABC elbow


Radius and Ulna


Radius Ulna
Proximal - posterolateral Olecranon - direct posterior
Shaft - direct lateral Ulna shaft - direct medial
Distal radius - direct lateral  


Brown tumour proximal radius


Ulna tumourUlna biopsy


GCT distal radiusDistal radius biopsy


Wrist / Hand


Carpus / metacarpal / phalanges - dorsal approach


Sarcoma Finger




Clavicle - direct subcutaneous




Acromion - deltoid split

Spine - transverse approach

Body - Judet posterior approach

Glenoid - posterior approach, through Teres major

Coracoid - deltopectoral approach