Updated: 12/6/2014

Dorsal Approach to Radius (Thompson)

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Indications
  • Access
    • provides exposure to posterior aspect of the radial shaft
  • Indications
    • ORIF of radial shaft fractures using extensor side of bone
    • access to the PIN as it passes through the arcade of Frohse for
      • nerve paralysis
      • resistant tennis elbow
    • radial osteotomy
    • osteomyelitis and bone tumor resection/biopsy
      
Internervous Plane
  • Proximally between 
    • ECRB (radial nerve)  
    • EDC (pin nerve) 
  • Distally between
    • ECRB (radial nerve)
    • EPL (pin nerve)  
   
Preparation
  • Position
    • place patient supine
      • if arm is abducted to the side on an arm board, the forearm should be pronated
      • if arm is adducted across the chest, the forearm should be supinated
   
Approach
  • Landmarks
    • Proximal
      • lateral epicondyle of the humerus
    • Distal
      • dorsoradial tubercle (Lister's tubercle)
  • Incision
    • starting point is anterior and distal to the lateral epicondyle of the humerus
    • straight or gently curved incision along the dorsolateral aspect of the forearm
    • be aware of superficial radial nerve and cephalic vein distally
    • end incision just distal and ulnar to Lister's tubercle
  • Superficial dissection
    • proximal third
      • incise fascia in line with skin incision using interval between ECRB and the EDC to reveal supinator
    • middle third
      • identify the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) emerging between ECRB and EDC 
    • distal third
      • undermine the APL and EPB tendons medially to identify plane between EPL and ECRB
  • Deep dissection 
    • proximal third
      • identify the insertion of supinator by turning arm into full supination
      • supination moves the PIN away from area of deep dissection 
      • incise insertion of supinator along radius and subperiosteally strip supinator off bone to expose proximal third of radius 
      • for more proximal exposures, two deep approaches exist to protect PIN: 
        • dissecting proximal to distal: 
          • detach origin of ECRB and ECRL from lateral epicondyle and identify and dissect PIN as it enters supinator muscle
        • dissecting distal to proximal: 
          • identify nerve as it exits supinator and dissect it proximally out of supinator substance
    • middle third
      • make incision along superior and inferior borders of APL and EPB
      • retract them off bone to expose middle third of radius
    • distal third
      • separating the ECRB and EPL will directly lead to the lateral border of the radius
      • part of the interosseous membrane may have to be removed to approach the radius
 


 




Dangers
  • Posterior interosseous nerve (branch of radial nerve)
    • injury usually from retraction
    • in 25% of patients the nerve actually touches the dorsal aspect of the radius
    • plates placed high on the dorsal surface may trap the nerve
    • PIN must be identified within the supinator muscle
  • Posterior interosseous artery
    • accompanies the PIN along the interosseous membrane in the proximal 1/3 of radius
 



 

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Questions (2)
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(OBQ04.214) The proximal aspect of the posterior approach (Thompson) to the radius involves what surgical interval? Review Topic

QID: 1319
1

Extensor carpi radialis brevis and extensor carpi radialis longus

6%

(93/1667)

2

Extensor carpi radialis brevis and extensor digitorum communis

66%

(1105/1667)

3

Supinator and brachioradialis

6%

(99/1667)

4

Extensor carpi radialis longus and brachioradialis

17%

(280/1667)

5

Extensor digitorum communis and brachioradialis

5%

(82/1667)

ML 3

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