Dr. Ebraheim’s educational animated video describes surgical approaches for radius and ulna forearm fractures.
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At the end of the approaches, I am going to summarize all the common approaches and the interval between the muscles and which nerve supplies the muscles. Expose the ulna between the flexor carpi ulnaris and the extensor carpi ulnaris muscles. The ulna is subcutaneous. If you expose the distal third of the ulna, you then need to worry about the dorsal cutaneous branch of the ulnar nerve (it is about 5 cm proximal to the wrist joint). For the radius fractures, we can use the volar (Henry) approach or the dorsal (Thompson) approach. You begin the incision 1cm lateral to the biceps insertion and extend it distally to the radial styloid process. This is the classic Henry approach. The interval between the flexor carpi radialis and the brachioradialis muscles distally. When you go a little bit proximal, the interval will be between the pronator teres and the brachioradialis muscles. The brachioradialis is on the lateral side and the flexor carpi radialis distally, the pronator teres proximally is on the medial side (between them is the interval). This is the approach that is routinely used. This volar approach is good for fractures of the middle to distal third of the radius. This approach can also be used for fractures in the proximal third, however, some physicians like to use the Thompson dorsal approach in fractures of the proximal third. In general, if you go on the lateral border of the flexor carpi radialis sheath, you probably will be okay. If you go proximally with the Henry approach, you will go into the interval between the brachioradialis and pronator teres muscles. You need to protect the posterior interosseous nerve. The incision begins anterior to the lateral epicondyle and the interval is between the extensor carpi radialis brevis and extensor digitorum comminus muscles. The supinator is between these two muscles. Identify the posterior interosseous nerve as it exits the supinator muscle. You need to protect this nerve. In general, at the junction of the mid and upper third of the radial shaft, the posterior interosseous nerve is at risk. If you have trouble remembering this, and you are approaching the radius, the muscles in the volar approach are all median nerve innervated. You need to go between something median and the brachioradialis is on the side. The muscles on the dorsal aspect of the forearm and on the side are radial nerve innervated. Go between the median and radial nerves, whether you are up or down.
20 май 2019
