Neuromuscular Anatomy of Volar Aspect of the Forearm

The antebrachial fascia is a continuation of the brachial fascia. The

antebrachial fascia surrounds the musculature of the forearm and divides it into
mobile wad, volar, and dorsal compartments. Fascia surrounds the individual
muscles and provides strong septal attachments to the radius, ulna, and
interosseous membrane. If the fascia is incomplete, some communication between
compartments maybe permitted.

Volar Muscles

The volar compartment contains the flexor and pronator muscles. A

transverse septum divides the muscles into deep and superficial groups. The deep
group consists of the flexor digitorum profundus and the flexor pollicis longus,
which flex the phalanges, and the pronator quadratus, which pronates the forearm.
An accessory slip of the flexor pollicis longus, Gantzer’s muscle, may be present
as a large discrete muscle in 45% of individuals. All muscles of the deep
compartment originate on the radius or ulna. The superficial group contains the
flexor carpi ulnaris, palmaris longus, flexor carpi radialis, and flexor digitorum
superficialis, which flex the hand and wrist, and the pronator teres, which pronates
the forearm and aids in elbow flexion.

Neurovascular Structures

Several nerves are located within or traverse the volar compartment: the
median nerve and its branch, the anterior interosseous nerve, the ulnar nerve, and
the deep branch of the radial nerve. The major vessels of the forearm are also
within this compartment.

Median Nerve

The median nerve and the brachial artery enter the volar compartment in
the antecubital fossa. The median nerve travels under the bicipital aponeurosis, or
lacertus fibrosis, a strong membranous band that reaches inferiorly across the
antecubital fossa to join the deep fascia covering the flexor muscles. The nerve
passes between the deep and superficial heads of the pronator teres and descends
distally. It passes deep in relation to the fibrous arch formed by the flexor
digitorum superficialis and is closely bound to the deep surface of this muscle by
its fascial sheath. The median nerve becomes more superficial and enters the
carpal tunnel at the wrist. The median nerve innervates the pronator teres, the
flexor carpi radialis, the palmaris longus, and the flexor digitorum superficialis. It
supplies branches to proximal portions of the flexor pollicis longus and flexor
digitorum profundus. The brachial artery branches to form the radial and ulnar
arteries, which travel with the superficial radial nerve and the ulnar nerve,
respectively.

Anterior Interosseous Nerve

The major branch of the median nerve is the anterior interosseous nerve.
At a point 5–8 cm distal to the lateral epicondyle, at the level of the deep head of
the pronator teres, the anterior interosseous nerve branches off and travels with the
anterior interosseous artery, anterior to the interosseous membrane. It dives deep
in relation to the pronator quadratus before terminating at the wrist. The anterior
interosseous artery is a branch of the common interosseous artery, which is a
branch of the ulnar artery. The anterior interosseous nerve innervates the flexor
pollicis longus, the lateral portion of the flexor digitorum profundus, and the
pronator quadratus.

Ulnar Nerve

The ulnar nerve enters the forearm between the medial epicondyle and the
ulnar head of the flexor carpi ulnaris and travels between the two heads of the
flexor carpi ulnaris in the superficial volar compartment. It then courses between
the flexor carpi ulnaris and the flexor digitorum profundus, where it is joined by
the ulnar artery. In the distal forearm, the ulnar nerve lies on the volar side of the
pronator quadratus, becomes superficial and lateral to the flexor carpi ulnaris, and
is on the volar side of the flexor retinaculum where it crosses the wrist. The ulnar
nerve provides motor function to two muscles in the forearm: the flexor carpi
ulnaris and the medial portion of the flexor digitorum profundus.
The Deep Radial Nerve

The deep radial nerve innervates the extensor carpi radialis brevis and the
supinator. In approximately 70% of the population, the deep radial nerve then
passes into the volar compartment, through the supinator, and into the dorsal
compartment In the remaining 30%, the nerve passes via the arcade of Frohse
(proximal fibrous border of the supinator) rather than through the belly of the
supinator. Now known as the posterior interosseous nerve, the deep radial nerve
travels with the posterior interosseous artery between the superficial and deep
compartments.