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Anterior Approach to the Radial Shaft: (Henry)

- See:
       - Anterolateral Approach to Forearm
       - Forearm Flexors
       - Plating Techniques
       - Radial Shaft Fractures: Discussion

- Discussion:
     - anterior approach of Henry utilizes interval between brachioradialis (radial nerve) & pronator teres (or FCR distally, which are innervated by the median nerve);
     - this approach is often used for fractures of the radial shaft, (more often used for fractures in the distal half rather than proximal half);
     - disadvantages:
           - use of anterior approach (with anterior placement of the plate) may result in block to pronation in proximal third fractures;
           - anterior approach requires at least moderate stripping of soft tissues from bone, resulting in delayed return of wrist and hand function;

- Surgical Dissection:  

- Incision:
     - w/ forearm supinated, begin longitudinal incision at point just lateral & proximal to biceps tendon (at the flexor crease of the elbow) extend it distally in forearm along medial border of brachioradialis towards the radial styloid;
     - expose the biceps tendon by incising deep fascia on its lateral side;
            - incise biciptial bursa, which lies in angle between lateral margin of biceps tendon & the radius;
     - then divide deep fascia of forearm in line w/ skin incsion, taking care to protect the radial vessels;
     - fascia is incised between brachioradialis & FCR;
     - preserve lateral cutaneous nerveantebrachial lateral nerve which lies subcutaneously;
     - superficial branch of the radial nerve lies along undersuface of the brachioradialis, which is protected by lateral retraction of the BR;
     - proximal exposure:
            - Henry approach can also be modified to allow exposure to the anterior elbow and proximal radius;
            - if more proximal exposure is required, then dissect between the brachioradialis and the brachialis (radial nerve will lie between these muscles);
            - the exposure can be further extended w/ the anterior approach to the humerus;

- Isolation of the Radial Artery:
     - the radial artery is best identified distally and followed proximally;
     - once the distal artery has been found, the brachioradialis & superficial radial nerve are retracted radially revealing the proximal portion of the radial artery;
     - radial artery lies beneath brachioradialis in middle part of forearm, and lies close to medial edge of wound;
            - artery may have to be mobilized & retracted medially to achieve satisfactory exposure of deeper muscular layer;
            - it runs w/ two venae comitantes, which remain prominent if limb is not exsanguated before the tournequet is applied;
     - because the radial artery is vulnerable during mobilization of brachioradialis, its branches to the brachioradialis must be ligated (bipolar cautery);
            - proximal mobilization of the brachioradialis requires ligation of the recurrent radial artery;

- Deep Dissection:
    - BR is retracted laterally and the pronator teres is retracted medially;
           - flex elbow to right angle to allow more complete retraction of brachioradialis & radial carpal extensor to expose supinator;
           - brachioradialis is supplied by several branches of radial artery which are ligated;
           - superficial branch of the radial nerve lies along undersuface of the brachioradialis, which is protected by lateral retraction of the BR;
     - more distally, the dissection procedes between the brachioradialis and the FCR which is also retracted medially (along w/ the pronator);

- Dissection of the Forearm Muscles Off the Radius:
    - supinator:
           - proximally, fibers of supinator are identified as are fibers of pronator teres which will be seen more distally passing over supinator in opposite direction;
           - proximally, supinator is incised at its insertion on radius, and subperiosteally stripped from radius;
           - supination of the forearm displaces the PIN laterally, away from operative field;
                  - supinator insertion should be exposed in full supination & detached from radius as close as possible to the bone;
                  - through an incision starting at the flexor crease of elbow & following medial border of brachioradialis belly distally toward the lower forearm;
           - supinator is then is reflected laterally together w/ deep branch of radial nerve (PIN) w/ in its substance (lateral retraction protects the PIN);
           - for more proximal exposure, begin dissection of the supinator origin just lateral to the biceps tendon;
                  - isolate & ligate leash of Henry  & subperiosteally strip supinator from its insertion;
    - FDS:
           - the FDS insertion begins just distal to the bicipital tuberosity and is ulnar to the supinator;
    - pronator teres:
           - in middle third, insertion of pronator teres muscle is preserved if possible;
           - if dissection is required, pronate the arm to better expose its insertion;
    - FPL & PQ

Vulnerability of the posterior interosseous nerve during proximal radius exposures.

Anatomic considerations for the anterior exposure of the proximal portion of the radius.

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