- See:
-
Plating Techniques:
-
Radial Shaft Fractures: Discussion:
- Discussion:
- dorsolateral approach is best suited to frxs of proximal & middle thirds of the radius as well as to address injury to proximal RU joint;
- advantages:
- much less soft tissue stripping is required with this approach (as compared to anterior approach), and patients can expect much more
rapid return of wrist and hand function;
- plate on the dorsal aspect of the proximal radius is less likely to produce mechanical block to pronation than if applied to the anterior surface;
- disadvantages:
- potential risk of injury to
PIN with proximal fractures;
- risk of tendonitis from fist and second wrist compartment tendons with distal fractures;
- Interneural Approach:
- interval between
ECRB (
Radial nerve) and
EDC (
PIN) (or
EPL distally);
- which is the same interval used in the
lateral approach to the elbow;
-
PIN must be identified & protected w/ this approach;
- exposing proximal third of radius is difficult because deep branch of
radial nerve traverses it w/ in
supinator;
- Surgical Technique:
-
arm position:
- pt is supine w/ shoulder abducted and the arm resting on hand table;
- arm is placed on arm board, w/ flexed elbow, & mid pronation of forearm;
-
incision:
- radial extensor group is palpated (mobile wad of Henry:
ECRL,
ECRB and
brachioradialis);
- incision is made on line extending from lateral epicondyle of humerus to radial styloid process, along dorsal border of mobile wad;
- alternatively, make skin incision over the proximal and middle thirds of radius along line 1.5 cm anterior to the lateral humeral epicondyle;
- when forearm is pronated, this line is virtually straight;
- expose lateral (radial) border of
extensor digitorum communis in the distal part of the incision;
- fascia between digital extensors and mobile wad is split;
- this interval is sometimes more apparent distally where outcropping muscles of the thumb cross over the radius;
-
surgical dissection:
- fascia between the
ECRB &
EDC is incised;
- in the distal 1/3,
APL and
EPB emerge obliquely;
- w/ careful dissection, separate both muscles from shaft of the radius, just sufficiently for a plate to be slipped beneath;
- proximally, identify
radial nerve before it enters
supinator and then emerges distally from the muscle;
- some surgeons prefer to identify the nerve distal to the supinator, where it lies in the 4th compartment;
- subperiosteal dissection of the supinator:
- bring the forearm into full supination, to bring its insertion into view;
- free muscle from bone subperiosteally from its insertion and reflect it either proximally or distally w/ nerve;
- reflect EDC ulnarly to expose
supinator muscle;
- develop an interval between
supinator &
ECRB;
-
APL is then visible, retract it distally and ulnarly to expose part of posterior surface of radius;
- continue dissection proximally between
EDC &
ECRB-
ECRL to lateral humeral epicondyle;
Vulnerability of the posterior interosseous nerve during proximal radius exposures.
Anatomical methods of approach in operations on the long bones of the extremities. JE Thompson. Ann Surg. Vol 68. 1918. p 309-329.
Surgical exposure of the dorsal proximal third of the radius: How vulnerable is the posterior interosseous nerve?
Strauch RJ, Rosenwasser MP, Glazer PA: J Shoulder Elbow Surg 5:342-346, 1996
The posterior interosseous nerve and the posterolateral approach to the proximal radius.
