ANATOMICAL BASIS OF DORSA FQREAR P

Based on Posterior Interosseous Vessels

P. BAYON and R. W. H. PHO

From the Hand Surgery Unit, Department of Orthopaedic Surgery, National University of Singapore

Injection studies on 35 upper limbs with neoprene latex were carried out and the limbs carefully
dissected to observe the vascular contribution of the posterior interosseous branches of the
dorsal forearm, the transverse anastomosis between anterior and posterior interosseous vessels
and the calibre of the vessel. The findings indicated that a fascia-cutaneous flap based on septo-
cutaneous branches of the posterior interosseous artery can be raised as a reversed forearm
for resurfacing after skin loss in the hand.

The versatility of the radial forearm flap has been well-
documented (Montandon et al., 1984) and (Braun et
al.,1985). It is easy to harvest, safe, reliable and can be
used either as a pedicled or free flap. Its greatest
drawback is the sacrifice of one major artery supplying
the hand. Timmons (1986) has reported the
complications at the donor site following the use of
radial forearm flaps.
The aim of our study was to explore the anatomical
basis of using the dorsal skin flap of the forearm based
on the posterior interosseous artery and its branches.
Anatomy
On the posterior aspect of the forearm, the posterior
interosseous artery runs in the septum between extensor
carpi ulnaris and extensor digitorum communis and
minimi. The artery provides branches to the muscles and
also to the lower part of the ulna (McCormack et
a1.,1953; Backhouse, 1981). The septo-cutaneous
branches rise vertically and reach the overlying skin
(Manchot, 1983). The posterior interosseous artery ends
on the dorsal aspect of the carpus where it participates in
the dorsal carpal arch (Fig. 1).
Above the level of the wrist-joint, it receives a
transverse anastomosis from the dorsal branch of the
anterior interosseous artery. This branch crosses the
interosseous membrane at the upper border of the
quadratus pronatus (Zancolli and Angrigiani, 1988).
A fascia-cutaneous flap, distally based on the septo-
cutaneous arteries of the posterior interosseous artery
and reverse-flow irrigated by the dorsal branch of the
anterior interosseous artery via the transverse
anastomotic artery, can be raised as a reverse dorsal
forearm flap, after division of the posterior interosseous
arteries proximally.
Method
Injection studies were carried out in 35 upper limbs of
cadavers, severed at the level of the scapula-humeral
joint.
Received: 17 July 1987
Professor R. W. H. Pho, Depvtment of Orthopaedic Surgery,
Lower Kent Ridge Road, Singapore OS1 1.
The injection was performed at the level of the axillary
artery in all the specimens, using 15 cm long catheter
cannulated down to mid-arm. Th were injected with
50 ml of a mixture of Neoprene latex coloured with green
tattoo dye.
Before injection of Neoprene latex, a flush of
formalin solution was injected into the vessels to clear all
clots. A transverse incision was made at the tip of the
middle finger to allow better diffusion of the latex.
At the time of injection of Neoprene latex, a tight
ligature was applied proximally at the level of
amputation to prevent retrograde oozing of latex.
Distally, once latex had reached the finger-tip, a strong
tie was applied around the middle finger. These
precautions are needed to ensure better filling of the
vessels with Neoprene latex.
The limb was then placed in a refrigerator for at least
three days, after which the specimens we
dissected to obtain the following observati
1. The frequency of the transverse ~~a$tomot~c artery
and its calibre.
2. The length of the pedicle and the possible extension of
the flap.
3. The number of septo-cutaneous branches and their
locations.
4. The relationship of the flap to the following nerves:
(a) the pedicle of the flap with the termmal motor
branches of the posterior interosseous nerve.
(b) the size of the flap with the sensory branches of
the radial nerve and the dorsal branch of the ulnar
nerve.
(c) the sensory branches of the dorsum of the forearm
snpplying the flap.
Findings
Frequency of the transverse Q~asto~otic artery
It was found to be rather constant in our 35 dissected
specimens. It was missing only once and in ther case,
its diameter was considered too small transfer
purpose. In one specimen, two small parallel transverse
National University Hospital,
vessels were found. Further details are given in Table 1.

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 P. BAPQN AND R. W. H. PHO
I’\

Ext. Carpi Ulnaris

,w ----Ext. Digiti tfinimi
Horos Br. of PIN -~ 1,d
sensory Isr. of PIU-- Ext. Digitorum Lcngus
Posterior Interosseous Art
Septocutaneous Br. of PIA .~ Abd. Poll&is Longus

-Ext. Pollicis Brevis

Dorsal Br. of AIA ---------. PoZlicis Longus

Transverse Anastomotic Artery --- Ext. Indicis Proprius

Interosseous Uembrane-----------
Anterior Interosseous Artery ------------ - Pronator Quadratus
- Radial Vessels
-- Ulnar Vessels

AXA - Anterior Interosseous Artery

PIA - Posterior Interosseous Artery
PIN - Posterior Interosseous Nerve
Ext. - Extessor
Abd. - Abductor
Br. - Branch

Fig. 1 Anatomy of the interosseous arteries.

TABLE 1
Transverse anastomotic
braacb

Diameter
2.5 -2.Omm = 5
2.0 - 1.5mm = 12
1.5 - l.Omm = 15
\( l.Omm = 2
Absent = 1

Origin (Reference: Above the wrist joint)

2.6 - 4.2cm : Average 3.4cm

Termination
2.3 - 3.5 cm : Average 2.6 cm
Length
1.2 - 3.7 cm : Average 2.3 cm

Pedicle: origin and length

The origin of the pedicle determines the pivot point of
Fig. 2 Pedicle of the dorsal forearm flap. A: Dorsal transverse
the flap (Fig. 2). It is given by the origin of the transverse anastomotic arch. B: The portion of posterior interosseous
anastomotic artery from the dorsal artery of the anterior artery just above the transverse anastomosis.
interosseous artery, which crosses the interosseous
membrane at the upper border of pronator quadratus.
TABLE 2
The pedicle includes the dorsal transverse anastomotic Lengthof the pedicle(see
Fig. 2)
branch (A in Fig. 2) and a segment of posterior
interosseous artery (B in Fig. 2) just above the junction Length Range Average
with the transverse branch. The highest upper limit of
Segment A 1.2 - 3.7 2.3 cm
this segment, allowing the longest pedicle, is given by the Segment B 4.1 - 5.9 5.2 cm
level of the first medium-sized perforator, otherwise the Total 5.1 - 8.3 7.1 cm
vascularity of the flap could be compromised. The 2.6 - 4.2 3.4cm
Pivot point level
average length of the pedicle is 7.1 cm (Table 2).

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 ANATOMICAL BASIS OF DORSAL FOREARM FLAP

Septo-cutaneous branches TABLE 4

Distribution of different sizes of perforators
The distribution of the septo-cutaneous vessels was
studied in 33 flaps (Table 3). There are numerous small Size Number Range A uerage by flap

perforators with varying diameters (Table 4). The Large 29 o-2 0.85
location of the two medium and one large-sized septo- Medium 61 1-3 1.97
Small 79 1-5 2.32
cutaneous branches of the posterior interosseous artery
above the wrist joint have been determined as the main
contributing vessels to a dorsal forearm flap which
TABLE 5
branch out at varying levels above the transverse Average levels of the medium and large size p~r~or~~~rs
anastomic vessel (Table 4). The number, the size and the (from the w&t joint)
location of perforators originating from the last 15 cm of
Perforators Range
the posterior interosseous vessels have been determined
(cml
(Table 5). Above this limit, we think the dissection of the
proximal part of the intermuscular septum would 1st medium size 5.8 - 8.6 7.4
2nd medium size 7.6 - 10.9 9.1
interfere too much with the motor branches of the Large size 8.9 - 12.7 11.2
posterior interosseous nerve.
TABLE 3
Posterior interosseous artery
septo-cutaneous perforators
in the lowest 15 cm of the forearm
Distribution of septo-cutaneousperforators
Below ! At ) Above
the level of the transverse anastomosis

c
,o 0 4 21 0
P 1 11 12 0
0
b 2 18 0 0
B 3 0 0 0
B 4 0 0 7
$ 5 0 0 16
9 6 0 0 08
z I 0 0 02

Relationship with nerves

The posterior interosseous nerve is deep as it enters the
dorsal compartment of the proximal one third of the
forearm but becomes more superficial as it proceeds
Fig. 3 The relationship of posterior interosseous nerve and posterior
distally (Fig. 3). At the upper third of the forearm, the interosseous vessels.
posterior interosseous artery crosses the nerve which is
already in the compartment (Fig. 4). At or just above this
level, the posterior interosseous nerve is supplying motor
branches for extensor carpi ulnaris, extensor digitorum
communis and minimi: it also gives a sensory branch to
the carpus and the motor branches for each of the four
muscles of the deep layer of the dorsal compartment of
the forearm (A.P.L., E.P.B., E.P.L. and E.I.P.)
The sensory branch to the carpus does not follow the
posterior interosseous artery at its end, but goes more on
the radial side, passing between E.P.B and E.P.L.,
reaches the dorsal branch of the anterior interosseous
artery and follows it down to the carpus.
The last motor branches of the posterior interosseous
nerve follow the posterior interosseous artery in the
septum just deep to it, but very close to it. These
branches are very tiny and come in the following order:
branch to A.P.L., then to E.P.B., then E.P.L. and last to
E.I.P. The last two branches are situated 1 to 2mm Fig. 4 In upper third of forearm, posterior interosseous nerve
(arrow) lies deep to posterior interosseous vessels and sends
beneath the artery and are the most vulnerable during branches (arrows) to extensor carpi ulnaris and extensor
dissection of the pedicle. digitorum communis.

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 P. BAYON AND R. W. H. PHO

Sensory innervation of forearm and the hand

The skin of the dorsum of the forearm is innervated by
the posterior antebrachial cutaneous nerve and by
branches coming from medial and lateral antebrachial
cutaneous nerves.
The posterior antebrachial cutaneous nerve can be
identified during the dissection and can be harvested to
give sensation to the flap.
The cutaneous branches of radial nerve and the dorsal
cutaneous branch of the ulnar nerve are close to the
dissection of the flap in the most distal part of the
dorsum of the forearm, nearly at the level of the wrist
joint (Fig. 5). Provided the distal limit of the flap is not
too low, there is no risk of damage to these nerves: it
should be 3 to 4cm above the wrist joint.
Fig. 5 In distal third of forearm, both radial nerve (top arrow) and
These nerves are also quite lateral and if the flap is not dorsal branch of ulnar nerve (bottom arrow) may be damaged
too large, they are unlikely to be encountered during the in raising of large distal flap.
dissection.

Discussion

Vessel diameter
In assessing the calibre of the vessels, we found that
although a constant amount of liquid was injected and
the viscosity of the liquid was always about the same, we
could not guarantee that the pressure of filling of the
vessels was uniform and had not altered the diameter of
the perforators and the transverse anastomotic branch.

The size of the flap

The length of the flap is determined by the levels of its
upper and lower borders. The distal limit of the flap
must be at a distance from the wrist joint, to avoid
damage to the sensory branches of the ulnar and the
radial nerves (Fig. 6). Above this level, the bed consists
of muscles of the musculo-tendinous junction; therefore
split skin graft has better chance to take.
The aim is to provide a long pedicle to the flap. The
first medium-sized perforator gives the distal limit of the
flap; it is an average 7.4cm above the wrist joint. There
is an obvious balance between the length of the pedicle
and the level of the distal limit of the flap.
The proximal limit can be placed at least at the level of
the highest medium or large sized septo-cutaneous
branch. There is no risk of necrosis of the tip of the flap
if the limit of it is extended 2 or 3 cm more proximally. If
a larger area of fascia can be harvested, incorporating
the skin, the proximal limit of the flap can be extended
5 cm higher.
The other determining factor of extension of the flap
is in the relationship of the posterior interosseous nerve
with its artery. The most distal motor branches are
particularly vulnerable during dissection of the artery,
and impairment of active extension of the thumb and
index finger may result.
Fig. 6 Distally based dorsal forearm flap with dorsal branch of
anterior interosseous artery through transverse anastomotic
branch.
Based on these studies, the maximal length of the flap
is 10 cm. As regards the width of the flap, its ulnar
border should not go beyond the ulna. This allows
3.5 cm proximally and 2.5 cm distally from the centre of
the forearm. The radial border of the flap is only limited
by the quality of perfusion of the flap on this side: 3 to
4cm seems to be reasonable. This would give a flap of
width 5 to 7cm.
The pedicle of the flap
The posterior interosseous artery and the transverse
anastomotic branch are accompanied by venae
comitante. The drainage is by reverse flow along the
superficial and deep venous system and may not be
adequate, so venous anastomosis may be indicated.
The pivot point is given by the origin of the transverse
anastomotic artery from the dorsal branch of the
arterior interosseous artery. Although there is risk in

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 ANATOMICAL BASIS OF DORSAL FOREARM FLAP
b c
Fig. 7 Application of flap to cover: (a) dorsum of hand (b) volar aspect of hand (c) thumb.
mobilising the pedicle beyone this point, the pedicle can
be shifted to some extent either to the radial or to the
ulnar aspect of the dorsum of the forearm. This is
important if one wishes to use the flap to cover a defect
on the volar aspect of the distal forearm.
Extra length of the pedicle can only be taken from the
free segment of the posterior interosseous artery above
the junction with the transverse anastomotic branch, but
the inconvenience of a long free segment is to reduce the
number of perforators to the flap. It seems reasonable
not to go over a limit, which is the first medium-sized
perforator. Below this limit, there is no risk in sacrificing
one or two small perforators.
Application of the flap
The flap can be used to cover dorsal defects of the wrist
or the hand level (Fig. 7).
The distal end of the pedicle can easily reach the
dorsum of the hand 1 to 3 cm below the radio-carpal
joint. Once totally elevated and in its maximal
dimension, the flap can be extended distally to the
middle part of the first phalanx of the digits or of the
thumb, or to the first web-space.
If the flap is to cover the volar aspect of the distal
forearm, the flap can be passed either underneath the
extensor tendons of the digit and be placed radially, or
underneath E.C.U. and be based ulnarly.
Posterior interosseous nerve
The terminal part of this nerve has been used as a donor
site for a nerve graft. If the nerve is harvested with the
accompanying interosseous vessels, it can be used as a
vascularised nerve graft.
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Extensor indicisproprius as a free ~us~~~~~transer
This muscle is partly vascularised by perforating
branches of the volar branch of the arterior
interrosseous artery and partly by the posterior
interosseous artery. We have not seen branches coming
from the transverse anastomosis. The innervation of the
muscle comes from the posterior interosseous nerve by
its most distal motor branch, so it is possible to use the
posterior interosseous vessels and its vascular bundle to
E.I.P. as a free vascularised muscular transfer.
Acknowledgments
We are grateful to the Shaw Foundation and tbe Lee Foundation and the
Singapore Turf Club for their donations to the Microsurgery Research Fund to
make this project possible.
We would like to thank Mr. S. H. Tow for the photography, Mr. Robert Ng for
the technical help, Miss Mak Tsui Mei for the illustrations and Miss Karen Teng
for typing the manuscript.
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