Volar Approach to Radius indications:

  • The Volar approach to radius also called Henry approach.
  • The Volar approach to radius offers an excellent, safe exposure of the radius, exposing the entire length of the bone.
  • The Volar approach to radius is used for:
    1. ORIF of proximal radius and radial shaft fractures.
    2. Radial osteotomy.
    3. Tumor/abscess biopsy and excision.
    4. Anterior exposure of bicipital tuberosity.
    5. Superficial radial nerve compression syndrome (Wartenberg Syndrome).
    6. Treatment of compartment syndrome of the forearm.

Position of the Patient

  • Place arm supine on table with arm board and supinate arm

Landmarks and Incision

  • Landmarks:
    1. Biceps tendon .
    2. Brachioradialis muscle.
    3. Styloid process of the radius.
  • Incision:
    • Make a straight incision from the anterior flexor crease of the elbow just lateral to the biceps tendon down to the styloid process of the radius.

Internervous plane

  • The Internervous plane for the Volar approach to radius is as following:
    • Proximally between:
      • Brachioradialis muscle: innervated by the radial nerve.
      • Pronator teres muscle: innervated by the  median nerve.
    • Distally between:
      • Brachioradialis muscle: innervated by the radial nerve.
      • Flexor Carpi Radialis (FCR) muscle: innervated by the median nerve.

Superficial dissection

  • Incise the deep fascia in line with skin incision,
  • Develop a plane between brachioradialis muscle and Flexor Carpi Radialis muscle distally.
  • Move proximal to develop plane between Pronator teres muscle and Brachioradialis muscle,
  • Identify the superficial radial nerve beneath Brachioradialis muscle,
  • Ligate the branches of the radial artery to aid lateral retraction of Brachioradialis muscle.

Deep dissection

  • 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 posterior interosseous nerve 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 sub-periosteal dissection laterally.
  • Deep dissection – middle third:
    • Pronate the forearm to bring the insertion of the pronator teres muscle, along the radial aspect of the radius, into view,
    • detach the pronator teres muscle insertion from bone and retract it 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 muscle and flexor pollicis longus muscle.

Approach Extension

  • The Volar approach to radius provides complete access to the entire length of the radius.
  • The Volar approach to radius can be extended distally to expose the wrist joint.

Dangers

  • The structure at risk during volar approach to radius include:
    1. 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 extensor muscles, known as posterior interosseous nerve entrapment syndrome.
      • Steps to protect the Posterior interosseous nerve include:
        • Dissecting supinator off radius sub-periostally.
        • 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.
    2. Superficial radial nerve:
      • It Runs down forearm under body of brachioradialis muscle.
      • Vulnerable to injury with manipulation of mobile wad of three.
      • Damage to it can cause a painful neuroma.
    3. Radial artery:
      • It Runs down middle of forearm under brachioradialis muscle.

The recurrent radial arteries are a leash of vessels arise from the radial artery below the elbow joint. They consist of two groups, anterior and posterior, which pass in front of and behind the superficial radial nerve, respectively, before entering the brachioradialis muscle. They must be ligated to allow mobilization of both the artery and the nerve.

References

  • Surgical Exposures in Orthopaedics book – 4th Edition
  • Campbel’s Operative Orthopaedics book 12th