Anterior approach to the forearm (Henry)

Surgical Interval is between Pronator Teres (median n.) and Brachioradialis (rad n.) proximally and between Brachioradialis (radial n.) and FCR (median n.) distally.

internervous plane

Incise the deep fascia in line with skin incision

Develop a plane between BR and FCR distally

Move proximal to develop plane between PT and BR

Identify the superficial radial nerve beneath BR

Ligate the branches

Follow the biceps tendon to its insertion on the bicipital tuberosity

Radial to the insertion of biceps tendon incise the bursa to gain access to the proximal part of radius (radial artery which runs along the ulnar side of the biceps tendon)

Fully supinate the forearm to displace the PIN radially and bring the origin of the supinator muscle into the anterior aspect of the radius

Incise the supinator muscle along the line if its broad insertion and continue subperiosteal dissection laterally

pronate the forearm to bring the insertion of the pronator teres, along the radial aspect of the radius, into view

detach the pronator insertion from bone and retract medially

partially supinate the forearm

dissect the periosteum off the lateral aspect of the distal third of the radius, lateral to the pronator quadratus and flexor pollicis longus

Posterior interosseous nerve

the posterior interosseous nerve enters the supinator muscle beneath a fibrous arch known as the arcade of Frohse.

the arch is formed by the thickened edge of the superficial head of the supinator muscle.

compression of the nerve at this point produces paralysis or dysfunction of the extensors known as posterior interosseous nerve entrapment syndrome

step to protect the PIN include

dissecting supinator off radius subperiostally

do not place retractors on posterior surface of radial neck

avoid excessive radial retraction of supinator

supinating the forearm to move PIN away from the surgical field

Superficial radial nerve

runs down forearm under body of brachioradialis

vulnerable with manipulation of mobile wad of three

damage to it can cause a painful neuroma

Radial artery

runs down middle of forearm under brachioradialis