10/2/22, 11:59 PM Ovid: Operative Techniques in Orthopaedic Surgery

Editors: Wiesel, Sam W.

Title: Operative Techniques in Orthopaedic Surgery, 2nd Edition

Copyright ©2016 Lippincott Williams & Wilkins

> Table of Contents > Volume 3 > Part 6 - Hand, Wrist, and Forearm > Section II - Radius and Ulna Fractures and Dislocations > Chapter 4 -
Open Reduction and Internal Fixation of Diaphyseal Forearm Fractures > SURGICAL MANAGEMENT > Approach > TECHNIQUES > ▪ Posterior
Approach to the Radius

▪ Posterior Approach to the Radius

The posterior approach is typically used for proximal- or middle-third radius shaft fractures. Extensile exposure of
the entire proximal and middle thirds of the radius is described in the following text.

An incision is drawn from the lateral epicondyle of the humerus to Lister tubercle and centered on the fracture.

The incision length typically approximates one-third the length of the radius centered at the fracture (TECH
FIG 2A).

Blunt dissection is performed down to the level of the fascia, and small fasciocutaneous flaps are elevated.
Perforating fasciocutaneous vessels can usually be seen and cauterized with a needle-tip cautery.

Proximally, the interval lies between the white, thick tendinous band of the extensor digitorum communis
tendon at the confluence of the extensor mass and the muscle belly of the extensor carpi radialis brevis just
anterior to it (TECH FIG 2B).

It is important to identify the tendinous origin of the extensor digitorum communis, as the radial portion of the
lateral collateral ligament complex of the elbow lies directly deep to it.

The fascia is incised just anterior to the white, thick tendinous band, and a Freer elevator is used to elevate
the muscle fibers off the septum.

The deep facial layer is then carefully opened with scissors in a distal to proximal direction revealing the
supinator muscle, identified by the changing direction of muscle fibers proximal/posterior to distal/anterior
(TECH FIG 2C).

The PIN enters the supinator approximately 90 degrees to the orientation of its muscle fibers. By lifting the
radial wrist extensors and brachioradialis off of the supinator with a blunt retractor, one can frequently identify
the PIN entering the supinator.

Alternatively, the PIN is identified distally and traced proximally through the supinator (TECH FIG 2D,E).

In the middle third of the radius, the abductor pollicis longus and extensor pollicis brevis are identified and
elevated off the radius sharply for exposure.

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TECH FIG 2 • Posterior approach to the radius. A. Extensile exposure (lateral humeral epicondyle to Lister
tubercle). B. Proximal interval is located between extensor digitorum communis (EDC) and extensor carpi
radialis brevis (ECRB). C. The deep fascia of ECRB and EDC has been divided, and the oblique fibers of the
supinator are now visualized. The posterior interosseous nerve (PIN) can be seen entering supinator
perpendicular to its fibers. (continued)

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TECH FIG 2 • (continued) D. The supinator has been partially divided to reveal the PIN coursing through its
substance. The radial head is seen proximally and the radius fracture is seen distally. E. A 3.5-mm locking
compression plate has been applied to the proximal radius. In this case, only two screws of proximal fixation
were available, therefore locking screws were used. F. Pre and postoperative radiographs demonstrating bridge
plating of this comminuted proximal radius fracture. A 3.5-mm locking plate was utilized. Proximally, the plate
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placement must be scrutinized to avoid impingement during forearm pronosupination. In our experience, this
fracture is at significant risk for infection and nonunion. Acute bone grafting was not performed secondary to
concern for infection.

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