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Indications
  • Access
    • provides exposure to the volar aspect of the radial shaft
  • Indications
    • ORIF of proximal radius and radial shaft fractures
    • radial osteotomy
    • tumor/abscess biopsy and excision
    • anterior exposure of bicipital tuberosity
    • superficial radial nerve compression syndrome (Wartenberg Syndrome)
     
Internervous Plane
  •  Proximally between:
    • brachioradialis (radial nerve)  
    • pronator teres (median nerve)
  • Distally between:
    • brachioradialis (radial nerve)
    • FCR (median nerve)
 
Preparation
  •  Position
    • place arm supine on table with armboard and supinate arm
   
Approach
  • Incision
    • longitudinal incision
      • begin just lateral to biceps tendon on flexor crease of elbow
      • end at radial styloid process

  • Superficial dissection
    • 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 of the radial artery to aid lateral retraction of BR

  • Deep dissection - proximal third
    • 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 of its broad insertion and continue subperiosteal dissection laterally

  • Deep dissection - middle third
    • 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

  • Deep dissection - distal third
    • 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


   

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Dangers
  • 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
    • injury
      • injury leads to a neuropraxia that takes 6-9 months to resolve
  • 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
   



 

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