Forearm 409

Forearm 9
Carlo Martinoli and Stefano Bianchi

CONTENTS
9.2
9.1 Introduction 409 Clinical and US Anatomy
9.2 Clinical and US Anatomy 409
9.2.1 Volar Forearm 409 Strong septal attachments of the antebrachial fascia
9.2.2 Dorsal Forearm 415 to the radius, the ulna and the interosseous mem-
9.2.3 Mobile Wad 417 brane divide the forearm into three distinct com-
9.3 Forearm Pathology 417 partments – volar, dorsal and the so-called mobile
9.3.1 Volar Forearm 419 wad – each of which house several muscles (Fig. 9.1).
9.3.1.1 Pronator Syndrome 419 The volar compartment (flexor compartment) con-
9.3.1.2 Anterior Interosseous Nerve Syndrome 419 tains eight muscles – the flexor pollicis longus, the
9.3.1.3 Other Compression Neuropathies 419
flexor digitorum profundus, the flexor digitorum
9.3.1.4 Penetrating Injuries 421
9.3.2 Dorsal Forearm and Mobile Wad 421 superficialis, the pronator teres, the palmaris longus,
the flexor carpi radialis, the flexor carpi ulnaris
References 423
and the pronator quadratus – and the most relevant
neurovascular structures of the limb, including the
median nerve along with its main divisional branch,
the anterior interosseous nerve, the ulnar nerve and
the ulnar artery. The dorsal compartment (extensor
compartment) houses eight muscles: the supinator,
9.1 the extensor pollicis brevis, the abductor pollicis
Introduction longus, the extensor pollicis longus, the extensor
indicis proprius, the extensor digitorum communis,
Although the soft tissue anatomy of the forearm is the extensor digiti minimi and the extensor carpi
complex due to the high number of muscles involved ulnaris. At the radial aspect of the forearm, three
in the spectrum of wrist and fingers movements, other muscles – the extensor carpi radialis brevis and
musculoskeletal pathology amenable to US exami- longus (extensors) and the brachioradialis (flexor)
nation is relatively uncommon in this area. Only a – form the so-called mobile wad. The superficial sen-
few specific conditions affecting the median nerve sory branch of the radial nerve and the radial artery
proximal to the carpal tunnel level merit separate run between the mobile wad compartment and the
consideration. volar compartment of the forearm. A basic review
of the compartmental normal and US anatomy of
the forearm with a description of the courses of the
radial, median and ulnar nerves is included here.

C. Martinoli, MD
Associate Professor of Radiology, Cattedra “R” di Radiologia
– DICMI – Università di Genova, Largo Rosanna Benzi 8, 16132
Genova, Italy
S. Bianchi, MD
Privat-docent, Université de Genève, Consultant Radiologist,
Fondation et Clinique des Grangettes, 7, ch. des Grangettes,
1224 Genève, Switzerland
9.2.1
Volar Forearm
The volar (anterior) compartment of the forearm
includes the flexor and pronator (antebrachial) mus-
cles. It can be divided by a transverse septum into
two layers: deep and superficial (Boles et al. 1999).
410 C. Martinoli and S. Bianchi

7 6
5
19
4
g cb
Volar c
f 8
R 17 R 1 2
da
MW 9
e
U 18
d
11
U
Dorsal
14 15 16

a b

Fig. 9.1a,b. a Schematic drawing of a transverse view through the right forearm showing the relationships of the volar (flexor)
and dorsal (extensor) compartments and the mobile wad (MW) with the radius (R) and ulna (U). b The position of the individual
muscles (see a for reference) is illustrated for each compartment. The volar compartment consists of deep and superficial layers
of muscles. In the deep layer, the flexor pollicis longus (1) and the flexor digitorum profundus (2) lie superficial to the bones and
the interosseous membrane and deep to the ulnar (a) and median (b) nerves. The superficial layer of the volar muscles includes
the flexor digitorum superficialis (4), the pronator teres (5), the palmaris longus (6), the flexor carpi radialis (7) and the flexor
carpi ulnaris (8). The dorsal compartment is smaller than the volar one and houses the supinator (9) and the abductor pollicis
longus (11) which lies in a deep position, and the more superficial extensor digitorum longus (14), extensor digiti minimi (15),
extensor carpi ulnaris (16). The mobile wad includes the extensor carpi radialis longus (17), extensor carpi radialis brevis (18)
and brachioradialis (19). The superficial branch (c) of the radial nerve runs between the dorsal compartment and the mobile
wad, whereas the posterior interosseous nerve (d) courses more posteriorly, inside the supinator muscle. Note the position of
the radial artery (g), the ulnar artery (f) and the anterior interosseous artery (e) relative to the adjacent muscles and nerves

The deep layer of muscles contains the flexor pol-
licis longus, the flexor digitorum profundus and the
pronator quadratus (Fig. 9.2a). The flexor pollicis
longus takes its origin from the anterior radius and
the interosseous membrane and continues down
in a distal tendon which passes deep to the flexor
retinaculum. Medial to it, the flexor digitorum pro-
fundus has a more extensive origin from the ulna
and the interosseous membrane. Distally, it divides
into four slips which pass deep to the tendons of the
flexor digitorum superficialis to reach the fingers.
These two muscles insert into the distal phalanx of
the thumb (flexor pollicis longus) and the second
through fifth fingers (flexor digitorum profundus).
The pronator quadratus muscle is the deepest of the
volar muscles and the only one that arises from the
ulna and inserts into the radius.
The superficial layer of volar muscles consists
of the flexor digitorum superficialis, the pronator
teres, the palmaris longus, the flexor carpi radialis
and the flexor carpi ulnaris (Fig. 9.2b,c). These mus-
cles take their origin from a strong common tendon
which arises from the medial epicondyle (see Chapter
8). The flexor digitorum superficialis, the larg-
est muscle of the superficial layer, consists of three
heads – humeral, ulnar and radial – which join at the
proximal forearm and continue distally in four distal
tendons that insert into the middle phalanx of the
second through the fifth finger. This muscle lies just
superficial to the flexor digitorum profundus. The
pronator teres is a short muscle which originates from
two proximal heads: a larger humeral, attached to the
medial epicondyle, and a smaller ulnar attached to
the coronoid process. Both pass obliquely across the
forearm to attach into the middle third of the medial
surface of the radius. The palmaris longus is a small
fusiform muscle which is absent on one or both sides
in approximately 12% of individuals (Reimann et al.
1944): its belly is located between the medial flexor
digitorum superficialis and the lateral flexor carpi
radialis. At the proximal forearm, this muscle con-
tinues into a long, slender and very superficial tendon
that attaches into the transverse carpal ligament. The
flexor carpi radialis and the flexor carpi ulnaris arise
at the medial epicondyle from the common flexor
tendon origin and descend the anterior compartment
of the forearm in a lateral (flexor carpi radialis) and
medial (flexor carpi ulnaris) position (Fig. 9.2b): they
continue into two long tendons which respectively
insert into the second metacarpal and the pisiform.
From the biomechanical point of view, the flexor digi-
torum superficialis flexes the proximal interphalan-
geal joint of the fingers, the pronator teres pronates
the forearm and aids in elbow flexion, and the three
more superficial muscles (palmaris longus, flexor
carpi radialis and flexor carpi ulnaris) flex the wrist.
 Forearm 411

5 Fig. 9.2a–c. Schematic drawings of a coronal view of

the muscles of the volar compartment of the fore-
arm from deep (a) to superficial (c). a The deep
layer includes the flexor pollicis longus (1) and the
7 6
flexor digitorum profundus (2), which have a wide
origin from the interosseous membrane, the radius
2 and the ulna. Their distal tendons pass superficial to
4 the pronator quadratus (3) before entering the carpal
1 8
tunnel. b Superficial to these muscles, the flexor
digitorum superficialis (4) is a broad muscle which
arises from the humerus, the ulna and the radius.
Its distal tendons are disposed in series over those
of the flexor digitorum profundus. c Over the flexor
digitorum superficialis, the pronator teres (5), the
palmaris longus (6), the flexor carpi radialis (7) and
the flexor carpi ulnaris (8) originate from the medial
epicondyle. While the pronator teres traverses the
3 proximal forearm obliquely to insert into the radius,
the other superficial muscles lie adjacent one to the
other and descend the forearm to continue in long
a b c distal tendons down to the wrist

Some anomalous muscles may be encountered in
the forearm, the two more common of which are the
anomalous palmaris and the Gantzer muscle. The
palmaris longus is one of the most variable muscles
in the human body, with an overall incidence of
anomalies of 9% (Reimann et al. 1944). Occasion-
ally, its muscle belly can be found in a central posi-
tion between discrete proximal and distal tendons
(digastric variant), or even distally. When located
distally, the muscle has a long proximal tendon,
an appearance resembling a “reversed” palmaris
(Schuurman and van Gils 2000). A palmaris with
double muscle bellies may also occur: in this latter
configuration, the two bellies – one proximal and
one distal – are separated by a central tendon lying
in between (Reimann et al. 1944). The Gantzer
muscle (found in approximately 52% of people) is
an accessory slip of the flexor pollicis longus which
arises from the medial epicondyle in 85% of cases
and has a dual origin from the epicondyle and the
coronoid process in the rest (Al-Quattan 1996).
It inserts onto the ulnar side of the flexor pollicis
longus and its tendon. Both anomalous palmaris
and Gantzer muscle may contribute to median and
anterior interosseous nerve compression.
The major nerves and vessels of the forearm are
located within or traverse the volar compartment
(Fig. 9.3). The median nerve enters the volar com-
partment passing between the superficial and deep
heads of the pronator teres muscle. It then crosses
the ulnar artery and proceeds toward depth to pass
below the fibrous arch formed by the flexor digito-
rum superficialis, the so-called “sublimis bridge”,
where it is closely apposed to the deep surface of
this muscle. At the middle forearm, the median
nerve runs in the midline, as its name indicates,
between the superficial flexor digitorum superfi-
cialis and the deep flexor digitorum profundus.
More distally, at the distal forearm, it becomes more
lateral and superficial to enter the wrist. Along its
course through the forearm, the median nerve pro-
vides motor function to the pronator teres, the flexor
carpi radialis, the flexor digitorum superficialis and
the palmaris longus. It also sends branches to the
proximal part of the flexor pollicis longus and the
flexor digitorum profundus. Approximately 5–8 cm
distal to the lateral epicondyle, the anterior interos-
seous nerve is a purely motor nerve which branches
off the median nerve at the level of the deep head of
the pronator teres. It travels along the anterior sur-
face of the interosseous membrane with the anterior
interosseous branch of the ulnar artery, between the
muscle bellies of the flexor pollicis longus and flexor
digitorum profundus, and then deep to the pronator
quadratus. This nerve supplies the flexor pollicis
longus, part of the flexor digitorum profundus (for
the index and middle finger) and the pronator qua-
dratus. After exiting the cubital tunnel, the ulnar
nerve enters the volar compartment of the forearm
passing on the anterior surface of the flexor digito-
rum profundus, under the flexor carpi ulnaris. At
the middle of the forearm, it is reached by the ulnar
412 C. Martinoli and S. Bianchi

e 19 c BT e
5
17 d BA b
d 18 4
b 9 H
c U
a
a
2 8 d

g 4
19 f b 4
c
g8
1 9 R 1,2
a
d U

h e

f b 3
a b c b
2,4
f 7 g8
c 3
a
R U

Fig. 9.3a–f. Schematic drawings of coronal (a–c) and transverse (d–f) views through the forearm
showing the main nerves (in black) and arteries (in white) and their relationships with surrounding
bones and muscles. a Basically, the forearm is crossed by three main neurovascular pedicles: ulnar,
central and radial. The ulnar pedicle is formed of the ulnar nerve (a) and the ulnar artery (g); the
central pedicle consists of the median nerve (b) and the anterior interosseous nerve (h), the latter
arising from it at the middle third of the forearm; the radial pedicle includes the superficial branch
of the radial nerve (c) and the radial artery (f). The course of the Martin–Gruber anastomosis is
indicated by a dashed line. At the elbow level, note the position of the brachial artery (e) and the
posterior interosseous nerve (d). b,c Main forearm muscles located b deep and c superficial to the
neurovascular bundles illustrated in a. Note the relationship of the nerves and arteries with the supi-
nator (9), the flexor pollicis longus (1), the flexor digitorum profundus (2), the pronator quadratus
(3), the flexor digitorum superficialis (4) and the flexor carpi ulnaris (8) muscles. d–f The relation-
ship of the nerves and arteries with the muscles of the forearm compartments is demonstrated at the
level of the elbow (a), the middle (b) and the distal (c) forearm. The individual anatomic structures
are indicated with the same numbers and letters used in Figs. 9.1 and 9.2. H, humerus; U, ulna; BA,
brachialis; BT, biceps tendon; R, radius

artery and its satellite veins. Thereafter, the nerve
and vessels proceed distally together, emerging on
the radial side of the flexor carpi ulnaris tendon,
between this tendon and the tendon of the flexor
digitorum superficialis for the little finger to enter
the Guyon canal. In the forearm, the ulnar nerve sup-
plies the flexor carpi ulnaris and the ulnar portion
of the flexor digitorum profundus. In up to 30% of
people, a crossover of fibers from the median nerve
to the ulnar nerve – the Martin–Gruber anastomosis
– occurs at the proximal forearm. This anastomo-
sis can be responsible of anomalous innervation of
intrinsic hand muscles and thus can lead to unclear
clinical presentation of some nerve entrapment syn-
dromes (Fig. 9.3a).
The two main arteries in the forearm are the radial
and the ulnar arteries, which are terminal divisions
of the brachial artery (Fig. 9.3). The ulnar artery tra-
vels through the volar compartment with the ulnar
nerve. It arises at the level of the neck of the radius,
just medial to the distal biceps tendon, and courses
deep to the “sublimis bridge” accompanied by the
median nerve. At the middle third of the forearm,
the ulnar artery traverses posterior to the median
 Forearm 413

nerve toward the medial side of the forearm, where
it reaches the ulnar nerve superficial to the flexor
digitorum profundus. More distally, it continues its
course on the radial side of the ulnar nerve down to
the Guyon canal.
The distal tendons, nerves and vessels are the best
US landmarks to recognize the individual muscles
located in the volar compartment. Transverse US
planes are essential to correctly distinguishing them.
At the proximal forearm, US scanning should start in
the antecubital fossa where the distal brachial artery
and the median nerve can be found along the medial
side of the distal biceps tendon (see Chapter 8). The
median nerve is identified based on its and well-
defined fascicular echotexture. Sweeping the probe
down over it, the median nerve and the ulnar artery
become gradually deep running in an echogenic
fat-filled cleavage plane under the humeral head
of the pronator teres (Fig. 9.4a). The ulnar head of
this muscle appears more distally than the humeral
head and is significantly smaller. Remember theat
the median nerves runs superficially to the ulnar
head while the ulnar artery passes deep to it. When
the nerve reaches the flexor digitorum superficialis,
it ceases to deepen. In this area, a thin hypoechoic
linear structure joining the humeral and ulnar heads
of the flexor digitorum superficialis can be seen cov-
ering it (Fig. 9.4b). This structure reflects the fibrous
arch (“sublimis bridge”) of the flexor digitorum
superficialis and should be examined carefully, as
a possible site of median nerve entrapment. At the
middle third of the forearm, the median nerve can
be easily recognized in the midline and represents a
useful key structure to separate the flexor digitorum
superficialis, which lies superficial to it, from the
flexor digitorum profundus, which lies in a deeper
position (Fig. 9.5a). Both muscles are wide muscles
occupying most of the volar compartment at the
middle and distal thirds of the forearm (Fig. 9.5b).
They are characterized by four flat intramuscular
tendons which appear as hyperechoic stripes and
are better individualized as scanning progresses
toward the wrist. The flexor carpi ulnaris and the
flexor carpi radialis are respectively located just
lateral and medial to them (Fig. 9.5b). Once identi-
fied the flexor digitorum profundus, the anterior
interosseous nerve and artery can be demonstrated
between it and the anterior aspect of the interosse-
ous membrane (Fig. 9.6). This membrane appears as
a thin hyperechoic layer joining the radius and the
ulna. The anterior interosseous nerve is a very small
hypoechoic dot-like structure consisting of one or
two fascicles located just superficial to the interos-
seous membrane, approximately midway between
the radius and the ulna. Once identified, the nerve
should be followed cranially on transverse planes up
to its confluence with the median nerve. To find the
ulnar nerve, a practical approach could be looking at
the ulnar artery (possibly switching the color Dop-
pler on) as it leaves the median nerve and traverses
the forearm to reach its medial side (Fig. 9.7a,b). At
the distal arm, the ulnar artery lies on the lateral
side of the ulnar nerve, covered by the flexor carpi
ulnaris muscle (Fig. 9.7c). In doubtful cases, one of

MN
MN

HH
fds
a a
b
prt
v
fpl fdp

R R
U
a b

Fig. 9.4a,b. Median nerve in the pronator area. a,b Transverse 12–5 MHz US images obtained a at the level of the pronator teres
and b at the arcade of the flexor digitorum superficialis. a At the proximal forearm, the median nerve (arrow) passes under the
humeral (HH) head of the pronator teres muscle accompanied by the ulnar artery (a) and satellite veins (v). b A few centimeters
distally, the median nerve is seen running deep to the fibrous arcade (arrowheads) of the flexor digitorum superficialis (fds),
the so-called “sublimis bridge.” Deep to it, note the flexor digitorum profundus (fdp) and the flexor pollicis longus (fpl). The
pronator teres (prt) lies lateral to it. R, radius; U, ulna. The photograph at the right of the figure indicates probe positioning
over the course (dashed line) of the median nerve
414 C. Martinoli and S. Bianchi

fcr pl Fig. 9.5a,b. Volar compartment of the fore-

fcu
arm. a,b Transverse 12–5 MHz US images
fds obtained a just distal to the sublimis bridge
prt MN
and b, more caudally, at the middle third of
the forearm demonstrate the relationships
of the deep muscles – the flexor pollicis
fpl UN
fdp longus (fpl) and the flexor digitorum pro-
fundus (fdp) – with the superficial mus-
R cles – the pronator teres (prt), the flexor
a U carpi radialis (fcr), the flexor digitorum
superficialis (fds), the flexor carpi ulnaris
(fcu) and the palmaris longus (pl) – of the
pl volar forearm. The two layers of muscles
fcr are separated by a transverse hyperechoic
MN fds fcu cleavage plane (curved arrows) represent-
ing an extension of the antebrachial fascia
fds within which the median nerve (MN), the
UN ulnar nerve (UN) and the ulnar artery
fpl fdp (straight arrow) are found. From proximal
(a) to distal (b), observe the muscle belly
of the palmaris longus which continues
R in a thin superficial tendon. R, radius; U,
ulna. The photograph at the right of the
b U figure indicates probe positioning

RN MN
fds fcu

fpl fdp UN
AIN

MN
fds

fpl AIN
R fdp

a c U
Fig. 9.6a-c. Anterior interosseous nerve. a Schematic drawing of a coronal view of the elbow after removal of the distal tendon of
the biceps brachii (bb) the distal part of the brachialis (ba) and the superficial belly of the pronator teres muscle (prt) reveals the
course of the median nerve (arrow) in the pronator area and the origin of the anterior interosseous nerve (arrowheads) deep to
the flexor digitorum superficialis muscle (fds). b Schematic drawing of a transverse view through the middle forearm illustrates
the close relationship of the anterior interosseous nerve (AIN) with the anterior aspect of the interosseous membrane (arrow) and
the bellies of the flexor pollicis longus (fpl) and flexor digitorum profundus (fdp). The anterior interosseous nerve runs in a deeper
position compared with the median nerve (MN). Observe the ulnar nerve (UN) which courses between the flexor carpi ulnaris (fcu),
the flexor digitorum profundus (fdp) and the flexor digitorum superficialis (fds) muscles. RN, superficial sensory branch of the
radial nerve. c Transverse 12–5 MHz US images obtained over the volar compartment at the middle forearm reveal the respective
position of the median (MN) and anterior interosseous (AIN) nerves relative to the flexor digitorum superficialis (fds), the flexor
digitorum profundus (fdp), the flexor pollicis longus (fpl) and the interosseous membrane (arrows). R, radius; U, ulna
 Forearm 415

MN MN

UN
UN
a
R U b R U

MN

UN

Fig. 9.7a–c. Ulnar artery. a–c Transverse 12–5 MHz US images obtained
from a proximal to c distal reveal the ulnar artery (straight arrow)
which traverses the forearm leaving the median nerve (MN) to reach
the ulnar nerve (UN). R, radius; U, ulna. The photograph at the upper
right of the figure indicates probe positioning c R U

the best ways to identify the bellies of the superficial

flexors (flexor carpi radialis, flexor carpi ulnaris and a
palmaris longus) and the flexor pollicis longus is to 9
start scanning over their distal tendons and then 14
b
sweep the probe proximally on transverse planes.
The scanning technique to examine these tendons
and the pronator quadratus will be addressed later
(see Chapter 10). 16
11
15
12
9.2.2
Dorsal Forearm 10
13

Similar to the volar compartment, the muscles of

the dorsal (posterior) compartment of the forearm,
can be arbitrarily divided in two layers: deep and
superficial. The deep muscles include the supina-
tor, the extensor pollicis brevis, the abductor pollicis
longus, the extensor pollicis longus and the extensor
indicis proprius (Fig. 9.8a). The anatomy of the supi-
nator muscle and its relationships with the posterior
interosseous nerve has already been described (see
Chapter 8). The remaining four muscles take their
origin from the posterior aspect of the radial and
ulnar shaft and from the interosseous membrane
distal to the position of the supinator muscle. They
insert into the metacarpal (abductor pollicis longus),
a b
Fig. 9.8a,b. Schematic drawings of a coronal view of the a deep
and b superficial muscles of the dorsal compartment of the
forearm. a The deep layer of muscles includes the supinator
(9), consisting of two heads – superficial (a) and deep (b) – and,
more distally, the abductor pollicis longus (11), the extensor
pollicis brevis (10), the extensor pollicis longus (12) and the
extensor indicis proprius (13). These latter muscles originate
from the posterior aspect of the radial and ulnar shaft and the
interosseous membrane. b In a more superficial position, the
extensor digitorum communis (14), the extensor digiti minimi
(15) and the extensor carpi ulnaris (16) are found arising from
the lateral epicondyle of the humerus
416 C. Martinoli and S. Bianchi

the proximal (extensor pollicis brevis) and the distal
phalanx (extensor pollicis longus) of the thumb, and
the middle and distal phalanx of the index finger
(extensor indicis proprius) respectively. From lateral
to medial, the abductor pollicis longus is the largest
and most superficial muscle of the group. Close to
it, the extensor pollicis brevis lies in a more distal
position and is partially covered by the abductor.
The extensor pollicis longus is larger and its tendon
is longer than the brevis. Finally, the extensor indicis
proprius is narrow and elongated, and lies medial
to and alongside the extensor pollicis longus. Apart
from the abductor pollicis longus which abducts and
extends the thumb, the other deep extensors act to
extend the phalanges. From lateral to medial, the
extensor muscles of the superficial layer include the
extensor digitorum communis, the extensor digiti
minimi and the extensor carpi ulnaris (Fig. 9.8b). In
association with the extensor carpi radialis brevis,
these muscles share a proximal strong tendon that
originates from the lateral epicondyle of the humerus
(see Chapter 8). The extensor digitorum longus and
extensor digiti minimi insert onto the middle and
distal phalanges of the four medial fingers (exten-
sor digitorum longus) and the little finger (extensor
digiti minimi). The extensor carpi ulnaris inserts
distally into the base of the fifth metacarpal. On the
whole, the superficial extensor muscles are inner-
vated by distal branches of the radial nerve (posterior
interosseous nerve). As a functional part of the long
head of the triceps, the anconeus muscle has already
been described in Chapter 8.
As a rule, an accurate and systematic US exami-
nation of the dorsal muscles of the forearm should
begin at the level of the wrist, where their indi-
vidual tendons are easily distinguished within the
six compartments. Then, US scanning should be
performed by shifting the transducer upward to
depict the myotendinous junction and the belly of
the appropriate muscle to be evaluated. This “ret-
rograde” technique is particularly helpful, even for
the experienced examiner, to increase confidence on
establishing the identity of the forearm muscles. At
the middle third of the dorsal forearm, the muscle
bellies of the superficial and deep layers are divided
by a transverse hyperechoic septum (Fig. 9.9). More
deeply, the hyperechoic straight appearance of the
interosseous membrane and the profile of the radial
and ulnar shafts separate the dorsal compartment
from the volar compartment (Fig. 9.9).

a
b

Edc Edm
Ecu
Apl Epl
Epb

R U
b Volar
Fig. 9.9a,b. Dorsal compartment of the forearm. a Proximal and b distal transverse 12–5 MHz US images obtained at the middle
third of the forearm reveal the two layers of extensor muscles located over the posterior aspect of the interosseous membrane
(arrowheads) and seperated by a transverse hyperechoic septum (arrows). From lateral to medial, the superficial layer of mus-
cles includes the extensor digitorum communis (Edc), the extensor digiti minimi (Edm) and the extensor carpi ulnaris (Ecu),
whereas the deep layer houses the abductor pollicis longus (Apl), the extensor pollicis brevis (Epb) and the extensor pollicis
longus (Epl). R, radius; U, ulna. The photograph at the upper right of the figure indicates probe positioning

9.2.3
Mobile Wad
The mobile wad, which is also referred to as the
radial group of forearm muscles, contains two wrist
extensors (the extensor carpi radialis brevis and the
extensor carpi radialis longus) and a forearm flexor
(the brachioradialis). These muscles lie in a radial
position compared with the ventral and the dorsal
muscles of the forearm (Fig. 9.10). The extensor carpi
radialis longus and the brachioradialis are the most
superficial and lateral. Both arise from the supra-
condylar ridge of the humerus and the lateral inter-
muscular septum, more cranially than the extensor
carpi radialis brevis. The brachioradialis is a large
muscle forming the lateral boundary of the cubital
fossa (Fig. 9.10a). Distally, it inserts onto the lateral
surface of the distal end of radius, just proximal to
the radial styloid. Although acting as a flexor of the
elbow, the brachioradialis is innervated by the radial
nerve, like an extensor muscle. Partially covered
by the brachioradialis, the extensor carpi radialis
longus lies between it and the extensor carpi radialis
brevis (Fig. 9.10). The extensor carpi radialis brevis
arises more distally than the longus and is partially
overlapped by it. The tendons of the extensor carpi
radialis muscles pass through the anatomic snuff-
box to insert into the dorsal aspect of the base of
the second (longus) and third (brevis) metacarpals.
Both muscles extend and abduct the wrist joint. The
US scanning technique to examine the muscles of
the mobile wad does not differ significantly from
that used for the dorsal compartment (Fig. 9.11).
The superficial sensory branch of the radial nerve
and the radial artery are located between the mobile
wad compartment and the volar compartment of
the forearm (Fig. 9.3a). After branching off the main
trunk of the radial nerve, the superficial radial nerve
initially travels with the radial artery deep to the bra-
chioradialis. It then passes between that muscle and
the extensor carpi radialis longus to emerge from
under the lateral boundary of the brachioradialis
(Fig. 9.12a). At the distal forearm, this nerve pierces
the antebrachial fascia and becomes subcutaneous,
providing sensory innervation for the dorsum of the
hand, the first web space and the proximal phalanges
of the three radial fingers (Fig. 9.12b,c). While cros-
ing the fascia, the radial nerve can be compressed in
the scissoring of the brachioradialis and the extensor
carpi radialis longus during pronation and supina-
tion of the forearm. At this site, dynamic US can show
transverse sliding of the nerve during pronation and
supination movements. The radial artery is located
Forearm 417
18
19
17
a b
Fig. 9.10a,b. Schematic drawings of a coronal view of the
mobile wad compartment of the forearm illustrated a with-
out and b with removal of the brachioradialis muscle. a The
brachioradialis (19) is a large palpable muscle arising from the
supracondylar ridge of the humerus and the lateral intermus-
cular septum which continues distally with a long and strong
tendon. b More deeply, the extensor carpi radialis brevis (17)
and the extensor carpi radialis longus (18), the first arising
from the lateral epicondyle, the second from the supracondy-
lar ridge of the humerus, descend in the forearm in association
with the brachioradialis
more lateral and superficial compared with the ulnar
artery. Initially, it is covered by the brachioradialis
and then becomes more superficial at the middle and
distal thirds of the forearm, where it runs between the
brachioradialis and the flexor carpi radialis tendons.
9.3
Forearm Pathology
Similar to the arm, musculoskeletal pathology affect-
ing muscles and tendons is uncommon in the fore-
arm and, for the most part, should derive from open
wounds, contusion or penetrating trauma. Although
unusual, there are some peculiar pathologic condi-
tions affecting the median nerve in the proximal fore-
arm as well as its main divisional branch, the anterior
interosseous nerve, which may give rise to pain in
the volar aspect of the forearm and weakness of the
innervated flexor muscles. These conditions include
pronator syndrome and anterior interosseous nerve
syndrome. To the best of our knowledge, the latter
is the only one which has received attention in the
imaging literature.
418 C. Martinoli and S. Bianchi

BrRad
Ecrb
Ecrl
a
H Br
a

Fig. 9.11a–c. Mobile wad compartment

Ecrb BrRad of the forearm. a–c Series of transverse
Ecrl 12–5 MHz US images obtained at the
elbow and the proximal forearm from
a a proximal to c distal reveal the bulk
of muscles of the mobile wad, consist-
R ing of the brachioradialis (BrRad), the
extensor carpi radialis longus (Ecrl)
b
and the extensor carpi radialis brevis
(Ecrb). The relationships of these mus-
cles with the posterior interosseous
SH nerve (arrowhead), the superficial sen-
Ecrb sory branch of the radial nerve (arrow),
the radial artery (a) and the superficial
DH (SH) and deep (DH) heads of the supi-
nator muscle are shown. Br, brachialis;
DH R H, humerus; R, radius; U, ulna. The pho-
U tograph at the upper right of the figure
c indicates probe positioning

BrRad
* * ECRL

R R
R
a b c

Fig. 9.12a–c. Superficial branch of the radial nerve. a–c Series of transverse 15–7 MHz US images obtained at the distal forearm
from a proximal to c distal. a The superficial radial nerve (arrow) courses just deep to the antebrachial fascia (arrowhead)
between the brachioradialis muscle (BrRad) and tendon (asterisk) and the extensor carpi radialis longus (ECRL). b More dis-
tally, it crosses the fascia and c moves to the subcutaneous tissue. R, radius. The photograph at the right of the figure indicates
probe positioning

9.3.1
Volar Forearm
9.3.1.1
Pronator Syndrome
Pronator syndrome is an insidious entrapment neu-
ropathy of the median nerve in the proximal volar
forearm. In this syndrome, the compression may
occur either in the area where the nerve traverses
deep to the lacertus fibrosus of the biceps, or as it
crosses between the two heads of the pronator teres,
or as it passes under the fibrous arch (sublimis bridge)
of the flexor digitorum superficialis. Hypertrophy of
the pronator teres, aberrant fibrous bands connecting
the pronator teres to the tendinous arch of the flexor
digitorum superficialis or the flexor carpi radialis
with the ulna, direct trauma and forearm–elbow
fractures have been reported as the possible causes.
The main clinical features of this uncommon and
somewhat controversial clinical entity are aching in
the proximal volar forearm or distal arm, typically
exacerbated by repetitive pronation and supination
movements paresthesias in one or more of the radial
three and a half fingers and weakness of the flexor pol-
licis and abductor pollicis longus with intact forearm
pronation. Nocturnal pain (so typical of carpal tunnel
syndrome) is usually not seen in these patients. Dia-
gnosis of pronator syndrome is essentially based on
clinical signs and symptoms and should be conside-
red seriously when median nerve disturbances are
not relieved after carpal tunnel release. The role of
diagnostic imaging has not yet been assessed in this
neuropathy. US could reinforce the likelihood that
a pronator syndrome is present, when asymmetry
of the pronator teres (the belly of the affected side
larger than the contralateral side) and local flatte-
ning, distortion and an abnormal course of the nerve
between the heads of the pronator or beneath the
arcade of the flexor digitorum superficialis are seen
(Fig. 9.13). Initial treatment of pronator syndrome is
conservative because many patients recover over the
course of a few months. In the remaining patients,
surgical decompression of the nerve below the elbow
(possibly associated with carpal tunnel release) is
successful in many cases.
9.3.1.2
Anterior Interosseous Nerve Syndrome
The entrapment of the anterior interosseous nerve in
the forearm, a condition also known as the Kiloh–
Forearm 419
Nevin syndrome (Kiloh and Nevin 1952), occurs
where the nerve branches off the median nerve, in
proximity to the pronator teres and the tendinous
bridge connecting the heads of the flexor digitorum
superficialis (Stern 1984). The anterior interosseous
nerve may be compressed alone or together with the
main trunk of the median nerve by a variety of condi-
tions, such as fibrous bands arising from the pronator
teres and the flexor digitorum superficialis, hyper-
trophied anomalous muscles (Gantzer muscle) and
accessory tendons from the flexor digitorum superfi-
cialis to the flexor pollicis longus. Similar to pronator
syndrome, an isolated anterior interosseous neuropa-
thy leads to pain in the volar forearm and difficulty
in performing pinching movements with the digits
(formation of a triangle instead of a circle with the
first two digits) and handwriting. The thenar muscles
are spared and there is no sensory loss (Fig. 9.14a).
Muscle weakness is typically limited to the flexor
pollicis longus, the flexor digitorum profundus to the
index finger (middle finger also involved in 50% of
cases), and the pronator quadratus (Fig. 9.14a). Diffe-
rential diagnosis includes brachial plexus lesion and
selective injury to the fibers of the median nerve at the
elbow or in the arm that are destined to become the
anterior interosseous nerve. In general, US examina-
tion of the anterior interosseous nerve is inconclusive
in the absence of a mass because this nerve is too
small and located deeply in the forearm. In rare cases,
however, the nerve and its fascicles may appear swol-
len compared with the contralateral side (Fig. 9.14c).
Besides direct nerve assessment, US diagnosis of an
overt anterior interosseous neuropathy may be sug-
gested by loss in bulk and increased reflectivity of
the innervated muscles: the flexor pollicis longus, the
flexor digitorum profundus and the pronator qua-
dratus (Fig. 9.14d) (Grainger et al. 1998; Hide et al.
1999; Martinoli et al. 2004).
9.3.1.3
Other Compression Neuropathies
Because of their free, unconstricted course, the
radial and ulnar nerves are rarely compressed in
the forearm. A reported site of compression of the
sensory branch of the radial nerve is its point of
emergence between the tendons of the brachiora-
dialis and the extensor carpi radialis longus in the
distal forearm. Repeated pronation and supination
of the forearm is believed to be contributory to
positional impingement of the nerve in the scisso-
ring of these two tendons. From the biomechanical
420 C. Martinoli and S. Bianchi

a
prt
*
d
br
*
*
a e

a
a
prt prt
prt
prt
b c f

Fig. 9.13a–f. Pronator syndrome in a patient with persisting symptoms of median neuropathy irradiated to the volar forearm
and wrist after carpal tunnel release. a Transverse 12–5 MHz US image obtained at the elbow level, over the medial edge of
the humeral trochlea (asterisk) demonstrates a flattened median nerve (arrow) presenting with an abnormal medial course
between the pronator teres (prt) and the brachialis (br). a, brachial artery. b More distally, in the pronator area, transverse
12–5 MHz US image shows the flattened median nerve (arrow) coursing between the two heads of the pronator teres (prt).
The nerve lies more medially than expected and not so closely associated with the ulnar artery (a). This anomaly suggested
positional entrapment of the median nerve in the pronator area. c Contralateral normal side. Note the rounded cross-sectional
profile of the normal median nerve (arrow) which runs adjacent to the ulnar artery (a). prt, pronator teres. d,e Transverse
d T1-weighted and e fat-suppressed T2-weighted MR images of the elbow confirm flattening of the median nerve (arrow)
which appears slightly hyperintense in the T2-weighted sequence. Asterisk, medial edge of the humeral trochlea. f Schematic
drawing of a coronal view of the elbow after removal of the distal tendon of the biceps brachii (bb), the brachialis muscle and
the superficial belly of the pronator teres (prt) reveals the abnormal course of the median nerve (arrows) in the pronator area
described in this particular case. Arrowheads, brachial artery

point of view, the nerve is anchored by fascia at this
site and cannot adjust its position as the adjacent
tendons do. Patients complain of pain and burning
sensation over the dorsoradial aspect of the forearm,
which increase in intensity with palmar flexion
and ulnar deviation of the wrist or quick repea-
ted pronation and supination movements. More
distally, the entrapment of the sensory branch of
the radial nerve may occur around the radial aspect
of the wrist, so-called Wartenberg syndrome (see
Chapter 10). On the mid-distal forearm, ulnar nerve
compression may occur from casts positioned for
wrist fractures or may be related to direct injuries,
including contusion trauma (from a direct blow)
or penetrating wounds. In contusion trauma, there
may be discrepancy between severity of clinical pic-
ture and normal electrodiagnostic studies. Tinel’s
sign is usually positive on the ulnar aspect of the
forearm. US can assess whether a nerve abnormality
(fusiform neuroma) exists at the lesion site and may
help the clinician to decide which is the most appro-
priate treatment (conservative vs. operative) to be
instituted. In the area between the pronator and the
carpal tunnel, the median nerve may occasionally be
compressed by space-occupying masses (i.e., lipo-
mas, ganglion cysts) or anomalous muscles. Among
them, a reversed palmaris can produce a mass effect
on the flexor tendons and the median nerve at the
distal forearm (Depuydt et al. 1998). In these cases,
US is an ideal means to reveal dynamic impingement
of the median nerve by the anomalous muscle at rest
and during contraction (Fig. 9.15).
 Forearm 421

MN
fds

fpl
fdp
R
AIN
a b U

fds
MN MN
fpl fdp fds
fpl
fdp
R
R AIN
c d

Fig. 9.14a–d. Anterior interosseous nerve syndrome in a young woman with previous contusion trauma at the volar forearm
and inability to perform pinching movements with the thumb and the index as shown in a. b Transverse 10–5 MHz US image
obtained through the middle forearm demonstrates abnormally swollen fascicles (arrowheads) of the anterior interosseous
nerve (AIN) over the interosseous membrane. Note the loss in bulk and increased reflectivity (arrows) of the flexor digitorum
profundus (fdp) and flexor pollicis longus (fpl) muscles. Such changes are not appreciated in the flexor digitorum superficialis
(fds) MN, median nerve; R, radius; U, ulna. c Corresponding fat-saturated T2-weighted transverse MR image shows the swollen
hyperintense nerve. d Normal contralateral side. Surgery revealed the entrapment of the anterior interosseous nerve (AIN) by
a fibrous band arising from the flexor digitorum superficialis

9.3.1.4 be wounded at the same time by such trauma. In

Penetrating Injuries
Except for major trauma with fractures and exten-
sive laceration of soft tissues, there are no specific
musculoskeletal disorders affecting tendons and
muscles (such as overuse injuries, compartment
syndromes and tears) in the forearm. The main
nerves are covered by large muscle bellies (i.e., the
flexor carpi ulnaris for the ulnar nerve, the flexor
digitorum superficialis for the median nerve, the
brachioradialis for the radial nerve) for the majo-
rity of their course and, therefore, are somewhat
protected from external trauma. In general, the
critical area for nerve and tendon injuries is the
distal forearm where these structures become
more superficial and are, therefore, exposed to
penetrating wounds (Fig. 9.16, 9.17). Nevertheless,
deep open trauma caused by sharp objects or glass
fragments may reach and damage tendons and
nerves everywhere. Often, two or more contiguous
structures (i.e., ulnar nerve and ulnar artery) may
general, the smaller the damaged structure, the
most likely it will be completely sectioned by a
penetrating wound. Differentiation between com-
plete and partial tears of muscles and tendons is
easily accomplished with US because a significant
retraction of the torn tendon ends usually takes
place when the lesion is complete.
9.3.2
Dorsal Forearm and Mobile Wad
Owing to a differential diagnosis list which mainly
includes wrist problems (i.e., de Quervain disease
and Wartenberg neuropathy), the most important
tendinopathy of the mobile wad compartment
affecting the tendons of the extensor carpi radialis
brevis and longus as they traverse the components
of the first dorsal extensor tendon compartment,
so-called intersection syndrome, will be discussed
in Chapter 10.
422 C. Martinoli and S. Bianchi

fcr

fds ft ft
fpl
fdp
pq
c
R pq
b

fcr fds
ft *
*
a d e

fcr

* *
f g

Fig. 9.15a–g. Reversed palmaris muscle and carpal tunnel syndrome. a Photograph of a woman presenting with a fusiform soft
tissue lump (arrowheads) in the volar wrist and clinical symptoms of carpal tunnel disease. The lump increases in size and stiff-
ness while clenching the fist. b Transverse and c longitudinal 12–5 MHz US images over the mass reveal an additional muscle belly
(white arrows) over the flexor digitorum superficialis muscle (fds) and tendons (ft), reflecting a reversed palmaris. In a, observe
the median nerve (open arrow) and other adjacent deep muscles, the flexor pollicis longus (fpl), the flexor digitorum profundus
(fdp) and the pronator quadratus (pq). R, radius. d Transverse 12–5 MHz US image over the anomalous muscle obtained during
contraction. Active contraction leads to an increased thickness of the muscle belly. This change can be easily palpated at physical
examination and would lead to compression on the underlying median nerve (arrow). Note tenosynovial effusion (asterisks) in
the sheath of the flexor tendons (ft) and the normal flexor carpi radialis tendon (fcr). e Transverse 12–5 MHz US image obtained
at the proximal forearm demonstrates a long thin tendon (arrowheads) of the palmaris instead of the muscle belly. The anomalous
tendon is located superficial to the flexor digitorum superficialis. f Axial T1-weighted and g sagittal fat-suppressed T2-weighted
MR images reveal the anomalous reversed palmaris (arrows), a hyperintense appearance of the median nerve (arrowheads) in the
T2-weighted sequence and fluid effusion (asterisks) in the flexor tendon sheath reflecting tenosynovitis

Radius
a b d

Fig. 9.16a–d. Flexor carpi radialis tendon tear. a Photograph of a boy complaining of weakness of wrist flexion and a soft tissue
lump (white arrows) on the volar aspect of the wrist after receiving a penetrating wound (open arrow) in the middle forearm
by a sharp object. b Longitudinal and c transverse 12–5 MHz US images over the distal lump reveal a retracted tendon end
(arrows) of the flexor carpi radialis which appears swollen and diffusely hypoechoic. d At the level of the wound, transverse
12–5 MHz US image demonstrates an empty sheath (arrowheads) of the flexor carpi radialis tendon
 Forearm 423

a
R
a

a Fig. 9.17a–d. Complete tear of the superficial branch

R of the radial nerve by a glass wound. a–c Series of
b transverse 12–5 MHz US images of the middle third
of the forearm obtained a proximal to, b at the level
of and c distal to the cut line. In a, note the superfi-
cial course of the radial nerve (straight arrow) which
runs closely associated with the radial artery (a). In
b and c, two adjacent neuromas are found connected
a with the proximal (white arrowhead) and distal (open
R arrowhead) stumps of the severed nerve. R, radius. d
Photograph shows the cut line (arrow) at the middle
c d third of the forearm.

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