Approaches

Question 1

What is always in danger in the proximal third of the radius?

Answer 1

The PIN which is either in close contact with the bone or near to its periosteum as it spirals around the radius

Question 2

What is the patient position for a Henry’s approach to the forearm?

Answer 2

Supine, arm on arm board, tourniquet but do not fully exsanguinate, arm in supination

Question 3

What are the landmarks for a Henry’s approach to the forearm?

Answer 3

Biceps tendon, brachioradialis as part of the mobile wad (w ECRL+B) and radial styloid

Question 4

What is the start and finish points for the incision?

Answer 4

Anterior flexor crease of the elbow just lateral to the biceps tendon to the radial styloid in a straight line

Question 5

What is the internervous plane for a Henry’s approach?

Answer 5

Plane between brachioradialis (radial nerve) and FCR (distally) or pronator teres proximally which are both median nerve

Question 6

What is the superficial dissection in a Henry’s approach?

Answer 6

Deep fascia with the skin, medial border of BR and FCR. Start dissection distally and work proximally. Identify SRN on undersurface of BR. Ligate the leash of vessels from radial artery going to BR called recurrent radial artery. This enables lateral mobilisation of the BR.

Question 7

When doing a Henry’s approach, where do you look for the radial artery?

Answer 7

Beneath BR in the middle part of the forearm. May need to be mobilised medially for exposure.

Question 8

Where does the SRN run?

Answer 8

Under BR. Careful protection needed to avoid injury and painful neuroma

Question 9

What are the structures at risk in the superficial dissection of the Henry’s approach?

Answer 9

Lateral antebrachial cutaneous nerve, SRN, radial artery

Question 10

Henry’s approach proximal third deep dissection?

Answer 10

Follow biceps tendon to insertion and incise bursa to get to proximal shaft of radius. Incise the supinator along the line of insertion DO NOT SPLIT muscle. Continue subperiosteal dissection laterally.

Question 11

How do you protect the PIN in the deep dissection of the proximal third of the radius?

Answer 11

Full supination of the forearm to displace it posterior and laterally, avoid excessive traction during dissection, do not split supinator, no retractors on the posterior radial neck.

Question 12

What is the deep dissection middle third of radius in Henry’s approach?

Answer 12

Pronate arm to expose the insertion of PT. Detach PT and strip off bone medially, preserve as much attachment as possible. Also detaches some of FDS origin

Question 13

What is the deep dissection of distal third radius in Henry’s approach

Answer 13

Partially supinate forearm and incise the periosteum of the lateral aspect of the radius lateral to PQ and FPL then continue distally and lifting the muscles off medially

Question 14

What is the difference between a Henry’s approach and a modified Henry’s approach?

Answer 14

The modified Henry approach utilizes the interval between flexor carpi radialis tendon and the radial artery, whereas the classical Henry approach goes between brachioradialis and the radial artery. The modified approach is medial to the radial artery.

Question 15

What structures are at risk in the modified Henry’s approach?

Answer 15

Radial artery and palmar branch of the median nerve

Question 16

What are the structures at risk in the Henry’s approach to the forearm?

Answer 16

SRN, radial artery, recurrent radial artery, PIN

Question 17

What are the three practical internevous approaches to the anterior forearm?

Answer 17

1. Between radial and median nerves btw BR and FCR or PT
2. Between median and ulnar nerves btw FCU and FDS
3. Between ulnar nerve and PIN btw FCU and ECU

Question 18

What is the purpose of a posterolateral (Thompson) approach to the forearm?

Answer 18

Access radial shaft- particularly good for middle and distal thirds

Question 19

What are the landmarks for a posterolateral (Thompson) approach to the forearm?

Answer 19

Proximally the lateral epicondyle (won’t extend up to here), distally Lister’s tubercle

Question 20

What are the structures at risk in the superficial dissection of a posterolateral (Thompson) approach to the forearm?

Answer 20

Cephalic vein and SRN in the distal part of the incision

Question 21

What is the deep dissection for the middle third of the radius in the posterolateral (Thompson) approach to the forearm?

Answer 21

Distal starting point is the proximal crossing point of APL as it crosses obliquely from ulnar to radial. Develop plane beneath the muscle to retract and access radial shaft beneath
Proximally develop plane between the ECRB and EDC- this exposes supinator proximally and APL distally.
Then fully supinate the arm to protect PIN and allow for some lifting of supinator if required to access shaft

Question 22

How do you extend the posterolateral (Thompson) approach to proximal third?
NB CONSIDERABLE RISK TO PIN

Answer 22

Elevate supinator off it’s insertion on the radius- helped by supinating the forearm, need to protect the PIN- this can be identified by palpating for a bulge in supinator or making a small hole to visualise it.

Question 23

What is the approach for a DHS?

Answer 23

Appropriately consented and anaesthetised patient, supine on traction table, reduce fracture under image intensifier.
Straight lateral incision commencing just proximal to GT of about 10cm in length.
Blunt dissection down to iliotibial tract. Split fascia in line with incision, peel vastus off the intermuscular spetum and retract ventrally to expose shaft of femur