Surgical Approaches And Applied Anatomy

• Surgical Approaches to the Radius

• Anterior Approach (Henry)
• The anterior approach to the radius was first described by Henry.
• It allows a wide exposure of the anterior surface of the radius and exposes the bone over its
entire length, if this is required.
• The approach can be extended across the elbow and into the hand.
• Care has to be taken not to harm the radial artery as it runs down the forearm under the
brachioradialis muscle with the superficial branch of the radial nerve.
• The posterior interosseous nerve is vulnerable during deep dissection proximally if the radial
neck needs to be accessed as the nerve winds round the radial neck within supinator muscle.
• The distal part of the approach is also used to access the distal radius for internal fixation of distal
radial fractures, and the approach can also be easily extended if more proximal exposure is required.
• Surgical Anatomy
• The anterior part of the forearm is basically subdivided into two groups of
muscles.
• Henry termed the group consisting of brachioradialis, extensor carpi radialis
longus, and extensor carpi radialis brevis as the mobile wad (32).
• These muscles define the lateral aspect of the proximal forearm and are
supplied by the radial nerve.
• The flexor-pronator group is found on the medial aspect and consists of
three muscular layers supplied by the median and ulnar nerves.
• Superficially, from lateral to medial, the pronator teres, flexor carpi radialis,
palmaris longus, and flexor carpi ulnaris muscles are found.
• The middle layer consists of flexor digitorum superficialis and the
deep layer of flexor digitorum profundus, flexor pollicis longus and,
more distally, pronator quadratus. To expose the forearm by a Henry
approach, the inter-nervous plane between the radial and median
nerves has to be found between the mobile wad, with brachioradialis
lying most medially and pronator teres proximally and flexor carpi
radialis distally in the flexor-pronator group.
After the interval between brachioradialis and flexor carpi radialis is
exposed and the radial artery retracted medially, supinator, pronator teres,
flexor pollicis longus, and flexor digitorum superficialis can be seen.
By continuing the dissection distally with the arm held in
pronation, the entire radius is exposed. The dissection should
be extraperiosteal in order not to strip the periosteum off the
bone.
• Surgical Technique
• The patient is placed supine on the operating table with the arm abducted on an arm board and the forearm
supinated. Before the incision is made the mobile wad, with its medial border adjacent to the biceps tendon, and
the styloid process of the radius should be palpated. A straight incision is made along the medial border of the
mobile wad. The length and axial location of the incision depends on where and to what extent the bone needs to
be exposed. The incision is carried down to the fascia while protecting the lateral cutaneous nerve. The fascia is
incised and the inter-nervous plane between the radial and median nerves is developed. The radial artery lies just
beneath, or just ulnar to the brachioradialis. It is exposed and retracted medially. The superficial branch of the
radial nerve is retracted laterally (Fig. 27-7). Care has to be taken not to harm this nerve because it has a tendency
to develop painful neuromata (Table 27-3).
• Further dissection depends on what length of bone needs to be exposed to reduce and fix the fracture. In the
middle third of the radius pronation of the arm exposes the insertion of P.973
•
pronator teres. Its tendon is detached from proximal to distal in order not to split the muscle. The flexor pollicis
longus, pronator quadratus, and/or supinator muscles are also partially detached from their origin in order to
provide adequate exposure to insert the plate. In general muscles should be detached extra-periosteally and the
periosteum left intact where possible.
• To gain access to the proximal third of the radius, the supinator muscle
has to be partially or totally detached from the bone. The deep branch
of the radial nerve, the posterior interosseous nerve, passes through
supinator on its way to the dorsal compartment of the forearm. To
avoid damage to this nerve the forearm is held in supination (Fig. 27-
8). This maneuver is important as it exposes the insertion of supinator.
It also displaces the nerve laterally and posteriorly away from the
operative field. The muscle is then detached extra-periosteally and
retracted laterally. The supinator, with the posterior interosseous nerve,
must be handled with caution, especially when using retractors as it is
easy to put excessive traction on the nerve.
• More proximally the dissection should always be carried out on the
lateral side of the biceps tendon for anatomic reasons and not just to
stay away from the radial artery and the median nerve. The radial
recurrent vessels are ligated if necessary.
• In the distal two-thirds the radius is mainly covered by flexor pollicis
longus and pronator quadratus muscles. When extending the
exposure to the distal end of the radius (Fig. 27-9), the surgeon must
be aware that the radial artery is relatively fixed distally where it
passes posteriorly after giving off the superficial palmar branch
 From AO
• Introduction
• The anterior (Henry) approach offers good exposure of the whole
length of the radius.
• The length of the incision depends on the extent of exposure needed.
• The Henry approach in the proximal forearm might result in a
more obvious scar.
• The landmarks for the skin incision are:
• Proximally: the biceps tendon which crosses the front of the elbow joint,
medial to the brachioradialis muscle.
• The distal landmark is the radial styloid process.
• The brachioradialis muscle is part of the mobile wad, comprising the
brachioradialis and the extensors carpi radialis brevis and longus.
This illustration shows the extents of the incisions for the anterior approaches to the proximal third middle third
distal third of the radial shaft.
Superficial dissection
The superficial muscular dissection is similar for all three parts of the Henry anterior
approach, illustrated here for the proximal third.

Develop the interval between the brachioradialis (mobile wad) and flexor carpi radialis
muscles.
The radial artery lies deep to the brachioradialis in the middle part of the forearm and between
the tendons of brachioradialis and flexor carpi radialis distally.
It can be identified by its two venae comitantes, which run alongside it.
 The arterial branches arising from the lateral side of the radial
artery are identified by slipping a finger underneath them,
lateral to the artery.
These are largely the recurrent branches and those to the
“mobile wad”.
These branches should be ligated in order to retract the artery
medially.
The superficial radial nerve runs under the brachioradialis
muscle on the lateral aspect of the radial artery and
should be retracted laterally.
Deep dissection: proximal third

The supinator muscle covers the lateral aspect of the proximal

radius.
The posterior interosseous nerve (also known as deep branch
of the radial nerve) lies within the substance of the supinator
muscle.
The forearm should be fully supinated to displace the posterior
interosseous nerve away from the surgical field
The supinator muscle is then incised along its most medial
edge, and gently elevated from the bone surface only to the
extent that it is necessary for the required exposure. The plate
is inserted deep to the elevated supinator muscle.
Note: Make sure that the plate is seated on the bone without
any soft-tissue interposition. In rare cases, the posterior
interosseous nerve itself is identified. In such cases it is
recommended that the position of the nerve in relationship to
the plate be noted and later documented in the operation
report.
Deep dissection: middle third

The forearm should be fully pronated to expose the lateral

border of the pronator teres muscle and its insertion.

Note: Sometimes it will be necessary to partially detach the

pronator teres from the radius. Whenever possible, preserve at
least some of its insertion.
The forearm is then again supinated and the exposure of the
bone is completed by any necessary elevation of the flexor
pollicis longus and, more distally, pronator quadratus.
• Deep dissection: distal third (modified Henry approach)

• Note: where exposure is likely to be confined to the distal radius only,

the following modified Henry approach is preferred by some
surgeons.
 The modified Henry approach utilizes the interval between
flexor carpi radialis tendon and the radial artery, whereas the
classical Henry approach goes between brachioradialis and the
radial artery. The modified approach is medial to the radial
artery.

Note: The radial artery and the palmar branch of the median
nerve are vulnerable during this approach.
The radial artery is retracted laterally and the flexor carpi
radialis is retracted in a medial direction. The pronator
quadratus muscle is then exposed by retracting medially the
muscle belly of the flexor pollicis longus.
 Exposure of the bone is completed by incision of the lateral
and distal edges of pronator quadratus muscle leaving a small
lateral cuff on the radius to allow for subsequent repair.
This now allows elevation of the muscle belly from the anterior
aspect of the distal radius.
• Anterior approach (Henry)

• Apart from possible reattachment of pronator quadratus, the anterior

deep tissues are left unrepaired. Some subcutaneous sutures are
inserted in order to relieve tension on the skin closure. Wound
drainage, either with a closed or an open system, is used. Skin closure
is accomplished using interrupted or running sutures, or skin staples.
n certain instances, for example with marked forearm
swelling, the wound may have to be left open. There are
different techniques to overcome such difficulties (e.g., elastic
closure, vacuum assisted closure, petroleum jelly gauze, skin
substitute, etc.)
• Dorsolateral Approach (Thompson)
• This approach was originally described by Thompson in 1918: it provides access
to the posterior aspect of the radius (33). It is particularly suited for fractures of
the middle third of the radius. In our experience the approach is less well suited
if extension to the distal third or the proximal third of the radius is required. In
the distal third the abductor pollicis longus and extensor pollicis brevis muscles
cross the surgical field. Although it is technically possible to tunnel the plate
under the muscles after carefully lifting the muscles from their origins, we
consider that the potential morbidity of this approach is too great. In the
proximal third the approach is limited by supinator muscle with the enclosed
posterior interosseous nerve. The dorsolateral approach requires exposure of the
posterior interosseous nerve as it exits the supinator canal. brevis and longus.
• The approach may be useful in posterior interosseous nerve palsy when the nerve
needs to be explored. If this is the case, the supinator canal can be split in order to
expose the entire length of the nerve.[pa[jf4]Surgical Anatomy[cmThe posterior
muscles of the forearm can be split into three groups. On the radial side the mobile
wad (32) consists of brachioradialis and extensor carpi longus and brevis. The mobile
wad is supplied by the radial nerve. On the ulnar aspect of the forearm, the superficial
extensors comprise extensor digitorum communis, extensor digiti minimi, extensor
carpi ulnaris, and anconeus. The anconeus muscle does not extend the wrist but is an
important dynamic stabilizer of the elbow. While the three extensor muscles are
supplied by the posterior interosseous nerve the neural pedicle of anconeus originates
directly from the radial nerve and travels in the triceps muscle to enter anconeus
proximally deep to the lateral epicondyle. There are five deep muscles, three of which
supply the thumb, these being abductor pollicis longus and extensor pollicis
• The remaining two deep muscles are supinator and extensor indicis.
All the deep muscles are supplied by the posterior interosseous nerve.
Two inter-nervous planes can be found on the posterior aspect of the
forearm, although they are not inter-nervous planes between two
different nerves as they consist of planes between two branches of the
radial nerve. There is a proximal inter-nervous plane between the
mobile wad (radial nerve) and extensor digitorum communis
(posterior interosseous nerve). A second internervous plane is found
between extensor carpi ulnaris (posterior interosseous nerve) and
anconeus (branch of radial nerve). This is generally called the Kocher
interval and is used to access the radial head.
• The critical step in the dorsolateral approach is to identify and preserve
the posterior interosseous nerve. The nerve is protected in the mass of
supinator when the muscle is detached from the bone and retracted as it
mainly travels within the substance of the muscle. However, in 25% of
patients, the posterior interosseous nerve actually runs extra-
periosteally (34,35) and is potentially at risk if the supinator is detached
and retracted P.975
•
without prior identification and dissection of the nerve. Therefore, deep
dissection of the proximal radius should always include prior
identification of the posterior interosseous nerve.
After incising the deep fascia, the interval between the
extensor carpi radialis brevis and the extensor digitorum
communis muscles should be identified.
• Surgical Technique[cmThe patient is placed supine on the operating table with the arm
abducted on an arm board and the forearm pronated. Before the incision is made the mobile
wad of Henry, the lateral epicondyle of the humerus, and Lister's tubercle are palpated. The
skin is incised from the lateral epicondyle along the ulnar border of the mobile wad to Lister's
tubercle, the length of the skin incision depending on the location of the fracture. The incision
is deepened down to fascia which is incised in line with the skin incision. The interval between
extensor carpi radialis brevis and extensor digitorum comminus is developed and followed
distally to where abductor pollicis longus crosses (Figs. 27-10 and 27-11). If it is difficult to
find the interval between the muscles, it can also be developed from distal to proximal where
the abductor pollicis longus and extensor pollicis brevis cross. More proximally, the common
apponeurotic origin of extensor carpi radialis brevis and longus is split, revealing the
underlying supinator muscle (Fig. 27-12). Distal to abductor pollicis longus and extensor
pollicis brevis, the interval between extensor carpi radialis brevis and extensor pollicis longus
is developed which exposes the extraperiosteal posterolateral aspect of the distal radius
The interval between extensor carpi radialis brevis and
extensor digitorum is developed.
• In the proximal two-thirds of the forearm, deep dissection to expose the bone
involves identification and protection of the posterior interosseous nerve. In the
proximal third the nerve can be identified where it exits supinator. If access to
the radial nerve is required, the nerve is dissected through the substance of
supinator while preserving its motor branches. Once the nerve is identified, the
forearm is supinated to expose the anterior insertion P.976
•
of supinator where it is detached extra-periosteally. The muscle can then be
retracted to gain access to the proximal radius (Fig. 27-14). To undertake deep
dissection distally into the middle third of the forearm, abductor pollicis longus
and extensor pollicis brevis have to be detached extraperiosteally from the
underlying radius and mobilized proximally and distally to gain access to bone
Further dissection of the interval proximally with splitting the
aponeurotic origin of the extensors reveals supinator and the
posterior interosseous nerve as it leaves the arcade of Frohse.
• Surgical Approach to the Ulna
• Exposure of the shaft of the ulnar is the most straightforward approach in the forearm. It permits
exposure of the entire length of the bone. The approach relies on the plane between flexor and
extensor carpi ulnaris. Careful dissection has to be carried out distally where the dorsal branch of the
ulna nerve crosses the interval.
• Surgical Anatomy
• On the medial side the ulna is covered by flexor and extensor carpi ulnaris. Extensor carpi ulnaris is
the most medial muscle supplied by the posterior interosseous nerve and flexor carpi ulnaris is the
most medial muscle supplied by the ulnar nerve. The two muscles therefore form the borders of the
inter-nervous plane used to approach the ulna. The ulnar nerve runs underneath flexor carpi ulnaris
between flexor digitorum superficialis and profundus with the ulnar artery on its lateral side.
Proximally, the nerve is fixed to flexor carpi ulnaris as it leaves the sulcus ulnaris and enters the flexor
muscle between its humeral and ulnar origins. The ulnar nerve divides into four branches distally, one
of which is the dorsal branch which runs across the surgical field distally. It may be encountered if
dissection is continued to the distal end of the ulna.
Development of the interval between extensor carpi radialis
brevis and extensor pollicis longus reveals the radius distal to
extensor pollicis brevis. Proximally, the nerve can be mobilized
where it exits supinator if required. The posterior interosseous
nerve should be identified and protected throughout the whole
procedure.
• Surgical Dissection
• The patient is placed supine on the operating table with the arm abducted on an arm board. The forearm is held
in a neutral position and the arm flexed at the elbow. Alternatively, the arm may be placed across the chest. For
isolated fractures of the ulna a lateral decubitus position with the arm on an arm rest P.977
•
offers the best option. Before the incision is made the subcutaneous border of the ulna is palpated along its entire
length and the surgeon can usually palpate the fracture. The incision is centered over the fracture site and is made
longitudinally slightly anterior or posterior to the palpable subcutaneous crest. The length of the incision depends
on the degree of exposure that is required. The incision is deepened down to fascia which is incised in line with
the skin incision. Distally, care must be taken to identify and protect the dorsal branch of the ulnar nerve which
passes onto the dorsal surface of extensor carpi ulnaris. The plane between extensor and flexor carpi ulnaris is
developed to expose the underlying bone extraperiosteally. At the level of the olecranon the anconeus is found on
the extensor side instead of extensor carpi ulnaris. The muscles are detached extraperiosteally depending on
whether access to the anterior or posterior aspects of the bone is required. Anteriorly flexor carpi ulnaris has to be
retracted carefully as the ulnar nerve and the ulnar artery run underneath between flexor digitorum superficialis
and profundus. If the bone is exposed extraperiosteally by detaching and retracting flexor carpi ulnaris together
with flexor digitorum profundus, the neurovascular structures are not endangered
After identification of the posterior interosseous nerve, the
forearm can be supinated in order to release supinator, which
then exposes the proximal radius.
Pearls and Pitfalls of Surgery of Radius and Ulna Diaphyseal Fractures

Pearls
Anterior Approach (Henry)
The anterior approach is an extensile approach.
Avoid damage to the posterior interossoeus nerve by supinating the forearm.
Proximal dissection should be lateral to biceps tendon.
Dorsolateral Approach (Thompson)
Most suitable for fractures in the middle third of the forearm.
In 25% of patients the posterior interosseous nerve is in an extraperiosteal location.
Ulna Approach
Allows exposure of the entire length of the bone.
Pitfalls
Anterior Approach
The radial artery is vulnerable under brachioradialis.
The posterior interosseous nerve can be damaged during proximal dissection.
Damage to the superficial nerve may cause painful neuromata.
Dorsolateral Approach
The dorsolateral approach is not extensile and proximal and distal exposure is difficult.
If used for proximal fractures, the posterior interosseous nerve must be exposed.
Ulna Approach
Ulna nerve damage may occur in distal dissection.