The Hip: Preservation, Replacement and Revision

Anterior Approach to the Radial Shaft: (Henry)

- See:
       - Anterolateral Approach to Forearm
       - Forearm Flexors
       - Plating Techniques
       - Radial Shaft Fractures: Discussion

- Discussion:
     - anterior approach of Henry utilizes interval between brachioradialis (radial nerve) & pronator teres (or FCR distally, which are innervated by the median nerve);
     - this approach is often used for fractures of the radial shaft, (more often used for fractures in the distal half rather than proximal half);
     - disadvantages:
           - use of anterior approach (with anterior placement of the plate) may result in block to pronation in proximal third fractures;
           - anterior approach requires at least moderate stripping of soft tissues from bone, resulting in delayed return of wrist and hand function;

- Surgical Dissection:  

- Incision:
     - w/ forearm supinated, begin longitudinal incision at point just lateral & proximal to biceps tendon (at the flexor crease of the elbow) extend it distally in forearm along medial border of brachioradialis towards the radial styloid;
     - expose the biceps tendon by incising deep fascia on its lateral side;
            - incise biciptial bursa, which lies in angle between lateral margin of biceps tendon & the radius;
     - then divide deep fascia of forearm in line w/ skin incsion, taking care to protect the radial vessels;
     - fascia is incised between brachioradialis & FCR;
     - preserve lateral cutaneous nerveantebrachial lateral nerve which lies subcutaneously;
     - superficial branch of the radial nerve lies along undersuface of the brachioradialis, which is protected by lateral retraction of the BR;
     - proximal exposure:
            - Henry approach can also be modified to allow exposure to the anterior elbow and proximal radius;
            - if more proximal exposure is required, then dissect between the brachioradialis and the brachialis (radial nerve will lie between these muscles);
            - the exposure can be further extended w/ the anterior approach to the humerus;

- Isolation of the Radial Artery:
     - the radial artery is best identified distally and followed proximally;
     - once the distal artery has been found, the brachioradialis & superficial radial nerve are retracted radially revealing the proximal portion of the radial artery;
     - radial artery lies beneath brachioradialis in middle part of forearm, and lies close to medial edge of wound;
            - artery may have to be mobilized & retracted medially to achieve satisfactory exposure of deeper muscular layer;
            - it runs w/ two venae comitantes, which remain prominent if limb is not exsanguated before the tournequet is applied;
     - because the radial artery is vulnerable during mobilization of brachioradialis, its branches to the brachioradialis must be ligated (bipolar cautery);
            - proximal mobilization of the brachioradialis requires ligation of the recurrent radial artery;

- Deep Dissection:
    - BR is retracted laterally and the pronator teres is retracted medially;
           - flex elbow to right angle to allow more complete retraction of brachioradialis & radial carpal extensor to expose supinator;
           - brachioradialis is supplied by several branches of radial artery which are ligated;
           - superficial branch of the radial nerve lies along undersuface of the brachioradialis, which is protected by lateral retraction of the BR;
     - more distally, the dissection procedes between the brachioradialis and the FCR which is also retracted medially (along w/ the pronator);

- Dissection of the Forearm Muscles Off the Radius:
    - supinator:
           - proximally, fibers of supinator are identified as are fibers of pronator teres which will be seen more distally passing over supinator in opposite direction;
           - proximally, supinator is incised at its insertion on radius, and subperiosteally stripped from radius;
           - supination of the forearm displaces the PIN laterally, away from operative field;
                  - supinator insertion should be exposed in full supination & detached from radius as close as possible to the bone;
                  - through an incision starting at the flexor crease of elbow & following medial border of brachioradialis belly distally toward the lower forearm;
           - supinator is then is reflected laterally together w/ deep branch of radial nerve (PIN) w/ in its substance (lateral retraction protects the PIN);
           - for more proximal exposure, begin dissection of the supinator origin just lateral to the biceps tendon;
                  - isolate & ligate leash of Henry  & subperiosteally strip supinator from its insertion;
    - FDS:
           - the FDS insertion begins just distal to the bicipital tuberosity and is ulnar to the supinator;
    - pronator teres:
           - in middle third, insertion of pronator teres muscle is preserved if possible;
           - if dissection is required, pronate the arm to better expose its insertion;
    - FPL & PQ

Vulnerability of the posterior interosseous nerve during proximal radius exposures.

Anatomic considerations for the anterior exposure of the proximal portion of the radius.

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Tuesday, January 15, 2013 10:04 am