Applied surgical anatomy of forearm

ANTERIOR APPROACH ANTERIOR APPROACH TO RADIUS AND ITS TO RADIUS AND ITS APPLIED ANATOMYAPPLIED ANATOMY

INDICATIONS AND POSITIONINDICATIONS AND POSITION

ORIF of fracturesORIF of fractures Bone grafting and fixation of nonunion of radiusBone grafting and fixation of nonunion of radius Radial osteotomyRadial osteotomy Biopsy of tumorsBiopsy of tumors Excision of sequestra of chronic osteomyelitisExcision of sequestra of chronic osteomyelitis Exposure of bicipital tuberosityExposure of bicipital tuberosity

POSITION – supine , the arm on the arm board POSITION – supine , the arm on the arm board supinated with tourniquet.supinated with tourniquet.

LANDMARK AND INCISION: LANDMARK AND INCISION: the biceps tendon the biceps tendon which crosses the elbow joint medially to the which crosses the elbow joint medially to the brachioradialis muscle. The distal end of the incision is brachioradialis muscle. The distal end of the incision is the radial styloid process. the radial styloid process.

Inter-nervous plane Inter-nervous plane Superficial radial nerve Superficial radial nerve Radial arteryRadial artery

Proximal third dissectionProximal third dissection

MIDDLE THIRD DISSECTIONMIDDLE THIRD DISSECTION

DISTAL THIRD DISSECTIONDISTAL THIRD DISSECTION

ANTERIOR COMPARTMENTANTERIOR COMPARTMENT

Mobile wad to 3 muscles brachioradialis, Mobile wad to 3 muscles brachioradialis, extensor carpi radialis longus and brevisextensor carpi radialis longus and brevis

Flexor-pronator group 3 layersFlexor-pronator group 3 layers Inter-nervous planes:-Inter-nervous planes:-

1. B/W brachioradialis and FCR/ pronator 1. B/W brachioradialis and FCR/ pronator teresteres

for anterior approach to radiusfor anterior approach to radius

2. B/W FCU and FDS for ulnar nerve2. B/W FCU and FDS for ulnar nerve

3. B/W FCU and ECU for ulna3. B/W FCU and ECU for ulna

Brachioradialis action responsible for Brachioradialis action responsible for neutral positionneutral position

Recovering high radial nerve palsy is Recovering high radial nerve palsy is assessed by testing brachioradialisassessed by testing brachioradialis

Radial arteryRadial artery Superficial branch of radial nerve – Superficial branch of radial nerve –

sensory losssensory loss

painful neuroma.painful neuroma.

DEEP DISSECTIONDEEP DISSECTION Arcade of frohse in the substance of the Arcade of frohse in the substance of the

supinator musclesupinator muscle Post interosseous nerve syndromePost interosseous nerve syndrome Resistant tennis elbowResistant tennis elbow Pronator syndrome – mimics carpal tunnel Pronator syndrome – mimics carpal tunnel

syndrome but the muscles supplied by the syndrome but the muscles supplied by the ant interosseous nerve are spared.ant interosseous nerve are spared.

FDS, FPL, pronator quadratusFDS, FPL, pronator quadratus

POST INTEROSSEOUS NERVEPOST INTEROSSEOUS NERVE

Passes B/W the heads of the supinator Passes B/W the heads of the supinator muslemusle

Sometimes it may come in direct contact Sometimes it may come in direct contact with the periosteum of the neck of radiuswith the periosteum of the neck of radius

Supplies the extensor compartmentSupplies the extensor compartment Insertion of supinator is detached Insertion of supinator is detached

subperiosteally along with the nerve in the subperiosteally along with the nerve in the substance of the musclesubstance of the muscle

Posterior approach is safest for PINPosterior approach is safest for PIN Median nerve close proximity FDSMedian nerve close proximity FDS

POST INTEROSSEOUS NERVE POST INTEROSSEOUS NERVE SYNDROMESYNDROME

HENRY’S VOLAR AND DORSAL HENRY’S VOLAR AND DORSAL FACIOTOMYFACIOTOMY