Approaches of forearm
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This document provides an overview of surgical approaches to the forearm bones - the radius and ulna. It describes the anterior and posterior approaches to the radius, including landmarks, incisions, planes of dissection, and dangers such as the posterior interosseous nerve. The approach to the ulna is also outlined. The goal is to expose the bones while protecting surrounding nerves and muscles through careful subperiosteal dissection in appropriate intermuscular planes.
Approaches of forearm
- 1. Anatomic Approach of Forearm Abdulrahman AlOmair R2
- 2. Objectives Indication. Position. Landmarks. Incision. Internervous plane. Superficial Surgical Dissection. Deep Surgical Dissection. Dangerous.
- 3. • The surgical anatomies of the two bones of the forearm differ significantly. The ulna has a subcutaneous border that extends for its entire length; the bone can be reached simply and directly without endangering other structures.
- 4. In contrast, the upper two thirds of the radius are enclosed by a sheath of muscles. All surgery in the upper third of the radius is complicated further by the posterior interosseous nerve, which winds spirally around the bone close to, if not in contact with, its periosteum.
- 5. Approaches I. Anterior Approach to the Radius . II. Posterior approach to the Radius. III. Approach to the Ulna.
- 6. Anterior Approach to the Radius Henry
- 7. • Open reduction and internal fixation of fractures • Bone grafting and fixation of fracture nonunions • Radial osteotomy • Biopsy and treatment of bone tumors • Excision of sequestra in chronic osteomyelitis • Anterior exposure of the bicipital tuberosity Uses
- 8. Position
- 11. Superficial Surgical Dissection -Incise the deep fascia of the forearm in line with the skin incision. -Identify the medial border of the brachioradialis muscle. -Distally : plane B/W brachioradilis and FCR. -Proximally : plane B/W brachioradialis and pronator teres.
- 12. Superficial Surgical Dissection -Dissection : from distal to proximal -Identify the superficial radial nerve running on the undersurface of the brachioradialis and moving with it. -The brachioradialis receives a number of arterial branches from the radial artery (called the recurrent radial artery) just below the elbow joint. Ligate this recurrent leash of vessels to make it easier to move the brachioradialis laterally
- 13. Deep Surgical Dissection Proximal third : Follow the biceps tendon to its insertion into the bicipital tuberosity of the radius. Just lateral to the tendon is a small bursa; incise the bursa to gain access to the proximal part of the shaft of the radius.
- 14. Deep Surgical Dissection The proximal third of the radius is covered by the supinator muscle, through which the posterior interosseous nerve passes on its way to the posterior compartment of the forearm
- 15. To displace the nerve laterally and posteriorly (away from the surgical area), fully supinate the forearm, exposing, at the same time, the insertion of the supinator muscle into the anterior aspect of the radius Deep Surgical Dissection
- 16. Next, incise the supinator muscle along the line of its broad insertion. Continue subperiosteal dissection laterally, stripping the muscle off the bone Deep Surgical Dissection
- 17. Lateral retraction of the muscle lifts the posterior interosseous nerve clear of the operative field, but be careful! Excessive traction may cause a neurapraxia of the nerve, and it recovers very slowly, taking up to 6 to 9 months. Finally, do not place retractors on the posterior surface of the radial neck, because they may compress the posterior interosseous nerve against the bone in patients whose nerve comes into direct contact with the posterior aspect of the radial neck. Deep Surgical Dissection
- 18. Middle third : Deep Surgical Dissection The anterior aspect of the middle third of the radius is covered by the pronator teres and flexor digitorum superficialis muscles.
- 19. Deep Surgical Dissection To reach the anterior surface of the bone, pronate the arm so that the insertion of the pronator teres onto the lateral aspect of the radius is exposed
- 20. Detach this insertion from the bone and strip the muscle off medially. Preserve as much soft tissue as you can compatible with accurate reduction and fixation of the fracture. Deep Surgical Dissection
- 21. Deep Surgical Dissection Distal third : Two muscles, the flexor pollicis longus and the pronator quadratus, arise from the anterior aspect of the distal third of the radius.
- 22. To reach bone, partially supinate the forearm and incise the periosteum of the lateral aspect of the radius lateral to the pronator quadratus and the flexor pollicis longus. Then, continue the dissection distally, retracting the two muscles medially and lifting them off the radius Deep Surgical Dissection
- 23. Dangers Posterior Interosseous Nerve is vulnerable as it winds around the neck of the radius within the substance of the supinator muscle. The key to ensuring its safety is to detach correctly the insertion of the supinator muscle from the radius. The insertion of the muscle is exposed completely only when the arm is supinated fully. Once the subperiosteal dissection is begun, the nerve is comparatively safe, but overzealous retraction still can lead to a neurapraxia
- 24. Superficial Radial Nerve Runs down the forearm under the brachioradialis muscle. It becomes vulnerable when the “mobile wad” of three muscles is mobilized and retracted laterally
- 25. radial artery Runs down the middle of the forearm under the brachioradialis muscle.
- 26. recurrent radial arteries a leash of vessels that arise from the radial artery just below the elbow joint
- 27. How to Enlarge the Approach The anterior approach provides complete access to the entire length of the radius. The approach can be extended distally to expose the wrist joint. Although it can be extended into an anterolateral approach to the elbow and humerus, such extension rarely is required.
- 28. Posterior Approach to the Radius
- 29. Uses -Open reduction and internal fixation of radial fractures (the approach provides access to the extensor side of the bone -Treatment of delayed union or nonunion of fractures of the radius -Access to the posterior interosseous nerve; decompression of the nerve. -Radial osteotomy -Treatment of chronic osteomyelitis of the radius Biopsy and treatment of bone tumors
- 30. Position
- 33. Superficial Surgical Dissection Incise the deep fascia in line with the skin incision. Identify the space between the extensor carpi radialis brevis and the extensor digitorum communis. This gap is more obvious distally, where the abductor pollicis longus and the extensor pollicis brevis emerge from between the two muscles.
- 34. Continue the dissection proximally, separating the two muscles to reveal the upper third of the shaft of the radius, which is covered by the enveloping supinator muscle. Superficial Surgical Dissection
- 35. Below the abductor pollicis longus and the extensor pollicis brevis, identify the intermuscular plane between the extensor carpi radialis brevis and the extensor pollicis longus. Separating the two muscles exposes the lateral aspect of the shaft of the radius Superficial Surgical Dissection
- 36. Deep Surgical Dissiction Two methods exist for successfully identifying and preserving this nerve as it traverses the muscle.
- 37. Deep Surgical Dissiction Proximal to distal :Detach the origin of the extensor carpi radialis brevis and part of the origin of the extensor carpi radialis longus from the lateral epicondyle and retract these two muscles laterally. Next, identify the posterior interosseous nerve proximal to the proximal end of the supinator muscle by palpating the nerve
- 38. Deep Surgical Dissiction Distal to proximal: Identify the nerve as it emerges from the supinator. Note that it emerges about 1 cm proximal to the distal end of the muscle. Now, follow the nerve proximally through the substance of the muscle, taking care to preserve all muscular branches.
- 39. When the nerve has been identified and preserved successfully, fully supinate the arm to bring the anterior surface of the radius into view. Detach the insertion of the supinator muscle from the anterior aspect of the radius. Strip the supinator off the bone subperiosteally to expose the proximal third of the shaft of the radius Deep Surgical Dissiction
- 40. Middle third : Deep Surgical Dissiction Two muscles, the abductor pollicis longus and the extensor pollicis brevis, blanket this approach as they cross the dorsal aspect of the radius before heading distally and radially across the middle third of the radius.
- 41. To retract them off the bone, make an incision along their superior and inferior borders. Then, they can be separated easily from the underlying radius and retracted either distally or proximally, depending on the exposure that is required Deep Surgical Dissiction
- 42. Distal third : Deep Surgical Dissiction Separating the extensor carpi radialis brevis from the extensor pollicis longus already has led directly onto the lateral border of the radius
- 44. How to Enlarge the Approach Local measures : To widen the plane between the extensor carpi radialis brevis and extensor digitorum communis muscles, detach the origin of the extensor carpi radialis brevis from the common extensor origin on the lateral epicondyle of the humerus.
- 45. Extensile measures : How to Enlarge the Approach The approach can be extended to the dorsal side of the wrist It can be extended proximally to expose the lateral epicondyle of the humerus .These extensions, however, rarely are required.
- 46. Approach to the Ulna
- 47. Uses - Open reduction and internal fixation of ulnar fractures. - Treatment of delayed union or nonunion of ulnar fractures. - Osteotomy of the ulna. - Treatment of chronic osteomyelitis. - Treatment of the fibrous anlage of the ulna in cases of ulnar clubhand. - Ulnar lengthening (in Kienböck's disease). - Ulnar shortening (in cases of distal radial malunion).
- 48. Position
- 51. Superficial Surgical Dissection Beginning in the distal half of the incision, incise the deep fascia along the same line as the skin incision; continue the dissection down to the subcutaneous border of the ulna
- 52. Even though the bone feels subcutaneous in its middle third, the fibers of the extensor carpi ulnaris muscle nearly always have to be divided to reach the bone. In the region of the olecranon, the flexor carpi ulnaris and anconeus muscles run along the plane of dissection. The plane still is an internervous plane, because the anconeus is supplied by the radial nerve and the flexor carpi ulnaris is supplied by the ulnar nerve. Superficial Surgical Dissection
- 53. Deep Surgical Dissection Incise the periosteum over the ulna longitudinally. Continue the dissection around the bone in a subperiosteal plane to reveal either the flexor or the extensor aspects of the bone, as needed
- 54. Dangers Ulnar Nerve Travels down the forearm under the flexor carpi ulnaris, lies on the flexor digitorum profundus.
- 55. The nerve is safe as long as the flexor carpi ulnaris is stripped off the ulna subperiosteally. If the dissection strays into the substance of the muscle, however, the nerve may be damaged. Because the nerve is most vulnerable during very proximal dissections, it should be identified as it passes through the two heads of the flexor carpi ulnaris before the muscle is stripped off the proximal fifth of the bone Ulnar Nerve
- 56. Ulnar Artery Travels down the forearm with the ulnar nerve, lying on its radial side. Therefore, it also is vulnerable when dissection of the flexor carpi ulnaris is not carried out subperiosteally
- 57. How to Enlarge the Approach Local Measures The approach described provides excellent exposure of the entire bone and cannot be enlarged usefully by local measures.
- 58. Extensile Measures How to Enlarge the Approach The approach cannot be extended usefully distally. It can be extended over the olecranon and up the back of the arm, however, either to expose the elbow joint through an olecranon osteotomy or to approach the posterior aspect of the distal two thirds of the humerus.
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