The Forearm

• 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.
• 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.
• Three surgical approaches to the forearm are described in this
chapter, all of which allow for the complete exposure of bone.
• In nearly every case, only part of the approach is required.
Relationship of radial nerve to brachialis and supinator muscles. In the cubital fossa, lateral to the
brachialis, the radial nerve divides into deep (motor) and superficial (sensory) branches. The deep branch
penetrates the supinator muscle and emerges in the posterior compartment of the forearm as the posterior
interosseous nerve. It joins the artery of the same name to run in the plane between the superficial and the
deep extensors of the forearm.
• The anterior approach to the radius is one of the classic extensile
approaches, relying on subperiosteal dissection for protection of
the posterior interosseous nerve.
• The posterior approach to the radius also makes use of an
internervous plane, but still requires identification and preservation
of the posterior interosseous nerve.
• The approach to the ulna cuts directly onto its subcutaneous border.
• The anatomy of the anterior approach to the radius, the approach to
the ulna, and the anatomy of the posterior compartment of the
forearm are considered separately.
• Because of the critical importance of the posterior interosseous
nerve, its course is described in both anatomic sections.
• Anterior Approach to the Radius
• The anterior approach offers an excellent, safe exposure of the radius,
exposing the entire length of the bone.
• Exposing the proximal third of the radius endangers the posterior
interosseous nerve.
• By stripping the supinator muscle off the radius subperiosteally and using
it to protect the nerve, however, the anterior approach avoids this danger.
• Still, great care must be taken in positioning retractors, because the nerve
actually may touch the bone at the level of the distal portion of the neck of the
radius, opposite the bicipital tuberosity, and posteriorly placed retractors can
compress it against the bone.
• The approach first was described by Henry, and his name usually is
associated with it.
• The uses of the anterior approach include the following:
• Open reduction and internal fixation of fractures2
• 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
• Treatment of compartment syndrome
• Position of the Patient
• Place the patient supine on the operating table, with the arm on
an arm board. Place a tourniquet on the arm, but do not
exsanguinate it fully before inflating the tourniquet. Venous
blood left in the arm makes the vascular structures easier to
identify. Finally, supinate the forearm (Fig. 4-1).
• Landmarks and Incision
• Landmarks
• Palpate the biceps tendon, which is a long, taut structure that crosses the front of the
elbow joint just medial to the brachioradialis muscle.
• Palpate the brachioradialis, which is a fleshy muscle that arises with the extensor carpi
radialis longus and brevis muscles from the lateral epicondyle of the elbow.
• The three muscles form a “mobile wad” of muscle that runs down the lateral aspect of the
supinated forearm.
• Palpate the styloid process of the radius.
• Note that this bony process is truly lateral when the hand is in the anatomic (supinated)
position.
• The styloid process is the most distal part of the lateral side of the radius.
• Incision
• Make a straight incision from the anterior flexor crease of the elbow just lateral to the
biceps tendon down to the styloid process of the radius.
• The length of the incision depends on the amount of bone that needs to be exposed
Make a straight incision on the anterior part of the
forearm, from the flexor crease on the lateral side of
the biceps down to the styloid process of the radius.
• Internervous Plane
• Distally, the internervous plane lies between the
brachioradialis muscle, which is innervated by the radial
nerve, just proximal to the elbow joint, and the flexor carpi
radialis muscle, which is innervated by the median
nerve.
• Proximally, the internervous plane lies between the
brachioradialis muscle, which is innervated by the radial
nerve, and the pronator teres muscle, which is innervated
by the median nerve.
• Superficial Surgical Dissection
• Incise the deep fascia of the forearm in line with the skin incision.
• Identify the medial border of the brachioradialis as it runs down
the forearm, and develop a plane between it and the flexor carpi
radialis distally.
• More proximally, the plane lies between the pronator teres and
brachioradialis muscles (Fig. 4-4).
• Note that the medial border of the brachioradialis is surprisingly far
across the forearm.
• At the level of the elbow the brachioradialis extends almost halfway
across the forearm.
• Begin dissection distally and work proximally.
• 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 (Fig. 4-5).
• Take care to ligate these vessels and not avulse them, as avulsion is
a potent cause of postoperative hematoma formation.
• Many vessels are present and all will need to be ligated and divided
to allow the brachioradialis to be mobilized laterally.
• The radial artery lies beneath the brachioradialis in the middle
part of the forearm; therefore, it is quite close to the medial edge
of the wound.
• It runs with its two venae comitantes, which remain prominent if the
limb is not exsanguinated before the tourniquet is applied.
• Often, the artery may have to be mobilized and retracted medially
to achieve adequate exposure of the deeper muscular layer,
particularly at the upper and lower ends of the approach (see
Fig. 4-5).
• The superficial radial nerve, which is a sensory nerve in the forearm,
also runs under cover of the brachioradialis muscle.
• Preserve the nerve, because damage to it may create a painful
neuroma at the operative site (see Fig. 4-5).
• It is retracted laterally with the brachioradialis muscle.
Incise the fascia and develop the plane between the brachioradialis and the
flexor carpi radialis.
A leash of vessels from the radial artery supplies the brachioradialis. The vessels must be
ligated to mobilize the brachioradialis laterally. Retract the superficial branch of the radial
nerve with the brachioradialis muscle.
• 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. Because the radial artery lies superficial and
just medial to the tendon at this point, deepen the wound on the
lateral side of the biceps tendon (Fig. 4-6).
• 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.
• The posterior interosseous nerve is the single most important
structure left vulnerable by this approach. 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
(Fig. 4-7).
• Next, incise the supinator muscle along the line of its broad
insertion. Ensure that the muscle is detached by dividing its
insertion and not by splitting the muscle. Continue subperiosteal
dissection laterally, stripping the muscle off the bone (see Fig.
4-7). 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 (about 25%
of all patients).
Deep to the brachioradialis and the flexor carpi radialis are the supinator
muscle, the pronator teres, the flexor digitorum superficialis, and, most
distally, the pronator quadratus.
• Middle Third
• The anterior aspect of the middle third of the radius is covered
by the pronator teres and flexor digitorum superficialis muscles.
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 (Fig. 4-8; see Fig. 4-6). 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. This maneuver
detaches the origin of the flexor digitorum superficialis from the
anterior aspect of the radius as well (Fig. 4-9).
• Distal Third
• Two muscles, the flexor pollicis longus and the pronator
quadratus, arise from the anterior aspect of the distal third of
the radius. 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
With the patient's arm in the supinated position, resect the origin of the supinator. Reflect the muscle laterally. Leave
the posterior interosseous nerve in the muscle's substance. The radial nerve enters the supinator through the
arcade of Frohse (inset). Turning the forearm upward moves the nerve laterally, away from the operative field. The
origin of the supinator muscle is easier to identify if the surgeon stays lateral to the biceps tendon and locates the
bursa between it and the supinator.
Turn the arm downward to identify the pronator teres muscle. Resect it
along its insertion on the lateral aspect of the radius.
Continue dissection distally to uncover the distal part of the radius. Leave the
periosteum intact.
With the arm in partial supination, remove the flexor pollicis longus and the
pronator quadratus from the bone to expose the entire radius from its proximal to
distal end.
• Dangers
• Nerves
• The 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 (see
Figs. 4-7, inset, and 4-13).
• The 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 (see Fig. 4-5). The superficial radial nerve is
vulnerable to neurapraxia if it is retracted vigorously. Take great care, therefore,
when retracting the nerve and warn your patients preoperatively that temporary
paresthesia in the distribution of the superficial branch of the radial nerve may
occur in the early postoperative phase.
• Vessels
• The radial artery runs down the middle of the forearm under the
brachioradialis muscle. It is vulnerable twice during the anterior
approach to the radius:
• During mobilization of the brachioradialis. Protection depends
on recognizing the artery. Its two accompanying venae
comitantes are the best surgical guide, because the artery is
surprisingly small after a tourniquet has been used (see Fig. 4-
5).
• In the proximal end of the wound, as the artery passes to the
medial side of the biceps tendon. Damage to the artery at that
level can be avoided by remaining lateral to the tendon (see
Fig. 4-13).
• The recurrent radial arteries are a leash of vessels that arise
from the radial artery just below the elbow joint. They consist of
two groups, anterior and posterior, which pass in front of and
behind the superficial radial nerve, respectively, before entering
the brachioradialis muscle. They must be ligated to allow
mobilization of both the artery and the nerve