Approaches
Anterior Approach to Radius
Posterior Approach to Radius
Approach to the Ulna
Anterior Approach to Radius / Henry
Indications
- ORIF of radius fractures
- bone grafting of non unions
- radial osteotomy
Technique
Position
- arm table
- tourniquet
Incision
- avoid full exsanguination to see vascular structures more easily
- supinate forearm
- straight incision from flexion crease just lateral to biceps tendon down to radial styloid
Internervous plane
- proximally between brachioradialis / BR and pronator teres / PT (median nerve)
- distally between the BR (radial nerve) and FCR (median nerve)
Superficial Dissection
- proximally between PT and BR
- distally between FCR and BR
- begin distal and work proximally
- superficial radial nerve deep to BR / retract radially with BR
- recurrent leash of Henry from the radial artery to BR just below elbow joint need to be ligated
- radial artery beneath the BR in middle of wound and runs with two vena commitante
- may need to be mobilised and retracted medially particularly proximally and distally
Deep Dissection
Proximal Third
- follow biceps tendon to insertion on bicipital tuberosity
- just lateral to tendon is bicep bursa
- incise bursa to access proximal radius
- radial artery superficial and medial to tendon
- fully supinate the forearm to expose the supinator and protect the PIN
- incise supinator along insertion on radius and lift subperiosteally (anterior oblique line)
- reflect from medial to lateral
- 25% of patients: PIN in contact with radial neck / thus take care with retractors
Middle third
- anterior aspect covered by PT and FDS
- insertion of PT into radius exposed by pronating forearm
- detach PT from insertion along with FDS subperiosteally
Distal third
- FPL and Pronator Quadratus arise from the anterior aspect of distal third of radius
- incise periosteum of radius just lateral to PQ and FPL
- subperiosteally dissect medially off radius
- this protects Median Nerve
Dangers
- PIN
- superficial radial nerve
- radial artery
- recurrent radial artery (anterior and posterior groups lie either side of radial nerve)
Posterior Approach to Radius / Thompson approach
Concept
- between ECRB and EDC proximally
- between ECRB and EPL distally
Indications
- ORIF of radial fractures
- non union of radial fractures
- decompression of PIN
Technique
Position
- supine with pronated forearm to expose the dorsal surface
Incision
- from point just anterior to the lateral epicondyle to Lister's tubercle on dorsal radius
Intermuscular plane
- proximally is between the ECRB and EDC (PIN)
- distally the plane is between the ECRB and EPL (PIN)
Superficial Dissection
- deep fascia split in line of the skin incision
- identify plane between ECRB and EDC
- more obvious distally where the APL and EPB separate the two muscles
- upper 1/3 contains the supinator at the base
- proximal 1/3 then centres on exposure of the PIN between the two heads of supinator
- PIN emerges 1cm proximal to distal edge of supinator
- divides into branches to the extensor compartment
Proximal to Distal PIN exposure
- detach origin of the ECRB and part of ECRL
- locate the PIN proximally and dissect out distally
Distal to Proximal PIN exposure
- identify nerve as emerges from supinator and follow proximal
- protecting all branches
Deep Dissection
- once protected fully supinate the forearm to expose the supinator fully
- strip the supinator subperiosteally to expose the proximal radius
- in the middle 1/3 the APL and EPB blanket the approach as they cross the radius radially
- they are mobilised by incising the superior and inferior borders
- the distal 1/3 is exposed with subperiosteal dissection
Dangers
- 25% of cases have the PIN in touch with the radial shaft and so must be exposed
- the nerve is protected with the supinator and reflected
Extension
- proximally to expose the lateral epicondyle
- distally as the posterior approach to the wrist
Approach to the Ulna
Indications
- ORIF of Ulna fractures
- treatment of delayed or non union of ulnar fractures
- osteotomy of Ulna
- ulnar lengthening / shortening
Approach
Position
- place arm across chest of the supine patient
Incision
- linear longitudinal incision along the subcutaneous border of the ulna
Internervous plane
- between the ECU and FCU
- attach via shared aponeurosis onto subcutaneous border of the ulna
- cannot be separated at origin
- fibers of ECU usually detached from the aponeurosis
Dissection
- deep fascia incised along line of skin incision
- continue to subcutaneous border of the ulna
- proximally dissect between the Anconeus and FCU
- periosteum incised longitudinally
- in proximal 1/5 part of triceps insertion released
Dangers
- the ulnar nerve lies on FDP deep to FCU
- safe as long as FCU stripped subperiosteally
- in proximal dissections (1/5) should be identified between the two heads of FCU prior to stripping
- ulnar artery also at risk
- this incision also able to be extended proximally as posterior approach to humerus